Every finding on record at Renaissance Rehabilitation And Nursing Care Center

Based on record review and interviews, the facility failed to ensure each resident was free from verbal and mental abuse. This was evident for one of three residents reviewed for abuse (Resident #1). Specifically, on 01/25/2026, Certified Nurse Assistant #1 used vulgar/foul language and screamed at Resident #1 while providing care. This incident caused Resident #1 to experience mental distress which resulted in actual harm to Resident #1 that was not Immediate Jeopardy.The undated facility policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property documented that an owner, licensee, administrator, licensed nurse, employee or volunteer of a nursing home shall not physically, mentally or emotionally abuse, mistreat or neglect a resident. Under abuse definition section 'A.' Abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse. Verbal abuse is further defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, disability. Mental abuse includes but is not limited to humiliation, harassment, threats of punishment or deprivation. Resident #1 had diagnoses that included anoxic brain damage (a severe injury caused by a total lack of oxygen to the brain causing brain cells to die within minutes), hemiplegia (paralysis of one entire side of the body) following other cerebrovascular disease (problems with blood flow to the brain) affecting right dominant side, contracture of muscle right and left hand. The Quarterly Minimum Data Set (a resident assessment tool) dated 12/09/2025 documented Resident #1 had unclear speech, was sometimes understood, was cognitively intact and dependent on staff for all activities of daily living: eating, oral hygiene, toileting, showering and dressing upper and lower body. Resident #1 had a Care Plan dated 01/21/2025 entered by the social worker with a focus Potential for Victimization: Due to medical, cognitive, mood and/or behavioral status). Resident #1 has the potential to be a victim while a resident in a skilled nursing setting related to: medical status, diagnosis of traumatic brain injury, and other which is defined as unable to easily verbalize. The long-term goal was Resident #1 would be free of being a victim of abuse, neglect, or resident-to-resident incident throughout routines. Interventions were listed as Resident #1 will be encouraged to engage in daily routines, meaningful conversations, activities of preference, psych consultations, and hobbies to foster growth, healthy relationships, and positive engagement while a resident at the facility. The internal Accident and Incident report dated 01/25/2026 documented that at approximately 3:15 PM, Resident #1 was receiving care from Certified Nurse Assistant #1. They were witnessed by other staff members to be handling Resident #1 in a rough manner and vocalizing in loud tones characterized as screaming. Per Resident #1's report, Certified Nurse Assistant #1 used ice cold water to provide hygienic care. At the time of the occurrence, Resident #1's family was on the phone with an open line. The Registered Nurse Supervisor #1 reported to the scene and Certified Nurse Assistant #1 was removed from the environment immediately and care was provided by other staff. Certified Nurse Assistant #1 left the facility and was subsequently notified that they would be suspended pending the outcome of the investigation. A Registered Nurse assessment yielded data supporting emotional upset and anger; there was no indication of physical injury. The Medical Director was made aware of the incident and followed up with no new orders. A follow up skin check three days later yields no new injury, bruising, discoloration, report of pain or other negative psychical manifestation of the event. Statements collected from staff on duty support the allegation as stated by Resident #1 regarding being handled roughly and being subjected to loud, disruptive and agitated vocalizations. The allegation of abuse is substantiated. Review of a handwritten internal Accident and Incident statement dated 01/25/2026 at 3:15 PM by Registered Nurse #1 documented Resident #1 accused Certified Nurse Assistant #1 of abuse and reported that Certified Nurse Assistant #1 was physically rough when doing care, was screaming about having to do care, and used ice cold water. Registered Nurse #1 documented that they saw Certified Nurse Assistant #1 rolling Resident #1 back and forth roughly and that staff heard and saw Certified Nurse Assistant #1 yelling. There is a follow up undated, untimed typed page signed by Registered Nurse #1 included in the incident report. It documented that they were called to the unit shortly after 3:00 PM to address a certified nurse assistant screaming. They intervened and advised Certified Nurse Assistant #1 to exit Resident #1's room and to stop screaming. Certified Nurse Assistant #1 left the room, and they finished providing care to Resident #1. Resident #1's representative was on the phone during the entire exchange. Registered Nurse #1 stated that at about 5:00 PM, they went back to get a statement from Resident #1 and Resident #1 was still on the phone with Resident #1's representative. Registered Nurse #1 stated that Resident #1 told them that Certified Nurse Assistant #1 had come in the room, was loud and was in their face, that they used cold water to clean them, Certified Nurse Assistant #1 started yelling, and that they got upset and yelled back. There is no documented evidence that local law enforcement was called by the facility. Review of the handwritten statement by Certified Nurse Assistant #1 dated 01/25/2026, revealed that the nurse wanted them to change Resident #1, they said they would if the nurse went with them, and they said they would. They gathered the supplies and went into Resident #1's room. The Resident's representative was on the phone on speaker and asked Certified Nurse Assistant #1 why they were in the room, and Certified Nurse Assistant #1 replied that they were there to change Resident #1. Resident #1's representative told them that the resident did not want them in there and then verbally berated them. Certified Nurse Assistant #1 stepped out and called out to the nurse to come to the room and help them and the nurse replied they would, but they never did. In the written statement, Certified Nurse Assistant #1 documented that by the time they were almost done changing Resident #1, Certified Nurse Assistant #2, the nurse they expected would assist them, and another nurse all came to the room. When they were all there outside the room, Certified Nurse Assistant #1 documented in their statement that they all started in on them saying Resident #1 said for you to go. Certified Nurse Assistant #1 also wrote in their statement that they mentioned that Certified Nurse Assistant #2 had told them earlier that all certified nurse assistants were to take care of Resident #1 regardless of how Resident #1 behaves. Certified Nurse Assistant #1 further documented that in their defense the nurse should have come into the room with them when they first asked them then none of this would have happened. Review of the handwritten statement by Certified Nurse Assistant #2 dated 01/25/2026 documented as follows, on Sunday they were working on unit 1 during the 7:00 AM to 3:00PM shift floating to unit 2 for the 3:00 PM to 11:00 PM shift, before they even got up on the unit, the nurse texted stating can you go to unit 2, Certified Nurse Assistant #1 wants to go home. They went upstairs and heard screaming coming from Resident #1's room so they entered and told Certified Nurse Assistant #1 that they can leave because it was evident that they were very upset. They replied f*** you I ain't going, you said everyone is allowed to change them. Even though Resident #1 was scared and saying don't touch me get out of my room, they still continued to do care tossing the resident left to right as they put on a depend (adult brief), loudly cursing and arguing. Resident #1 was very shaken up by what was going on, the nurse (Registered Nurse Supervisor #1) tried to calm Certified Nurse Assistant #1, but they were still irate. They were arguing with Resident #1's representative that was on the phone, going back and forth, while trying to give care to Resident #1. They finally left very upset. Afterward, Resident #1 was very scared at the way they were treated by Certified Nurse Assistant #1. After full chart review there is no documented evidence of a complete nursing assessment, psychiatric referral or follow-up with a medical provider after this incident occurred. During an interview on 04/29/2026 at 1:15 PM Resident #1's representative stated that day when they were on the phone, the aide (Certified Nurse Assistant #1) came in and they could tell on the phone that they had an attitude. They stated they heard a smack but did not know the location, and they heard the staff cursing. During an interview on 04/29/2026 at 1:16 PM, Resident #1 reported Certified Nurse Assistant #1) smacked them and used a racial slur. Resident #1 stated they have been nervous, and they jump when staff comes into the room. They stated there was no consultation afterwards. Resident #1 stated that sometimes when they receive care it is one aide and sometimes it is two. Resident #1 stated they do not feel safe in the facility. Sometimes they are scared, and they will call downstairs for someone to assist them. During a telephone interview on 04/29/2026 at 2:58 PM, Certified Nurse Assistant #1 they stated on that day they had to float but usually worked on unit 2, the Alzheimer's dementia unit. They stated they were arrested, and they are being falsely accused. Certified Nurse Assistant #1 stated that it is a public record they are falsely accused of striking Resident #1 in the face. They did not know they were being accused until the troopers came to their house. They stated they are not sure who made the accusation. They stated that they knew that Resident #1's representative was on the phone. Certified Nurse Assistant #1 stated that the facility never informed them of why they were terminated, that it was vague. They thought they were terminated because they said f*** you to the nurse after they made them go in the room to provide care alone. They stated that Resident #1's representative was on the phone but there was no video proof. It was the day of the blizzard there were only two aides and Resident #1 has been a problem since they got there. There was an incident before this of Resident #1 accusing a different aide of hitting them and they were not suspended. This other aide, who recently left the facility, contacted them when they saw the story on the news and offered to write a statement for them. They implemented a 2-aide policy because Resident #1 refused care from certain aides and then they were down to only one aide that could provide care to them. Certified Nurse Assistant #1 stated that on the day of the incident, Registered Nurse #1 had allowed the only other aide to leave the facility, during a snow emergency, to get food, and they stated that they were not going to provide care to Resident #1 by themselves. Certified Nurse Assistant #1 stated that they were told to get started and they (Registered Nurse #1) would come in to assist them. Certified Nurse Assistant #1 stated that they tried to get the nurse to come in and assist them with care because Resident #1's representative and Resident #1 were yelling. Certified Nurse Assistant #1 stated that Registered Nurse #1 snapped at them and told them to go in and provide care and that they would be in soon, and shortly thereafter multiple staff appeared and everyone started screaming at them. Certified Nurse Assistant #1 stated that they said f*** you to Registered Nurse #1 and to the aide that was supposed to assist them with care. Certified Nurse Assistant #1 stated that Resident #1 was frustrated because they had not been changed all day. During an interview on 04/29/2026 at 4:25 PM, Certified Nurse Assistant #2 stated Resident #1 has a controlling behavior on the phone, yelling, screaming, and cursing on the phone, and on the day of the incident, Resident #1 was acting like that with the certified nurse assistants. Certified Nurse Assistant #2 stated on the day of the incident, they were on unit 1 from 7:00 AM to 3:00 PM and were moved to unit 2 at 3:00 PM. Certified Nurse Assistant #2 stated that when they arrived on unit 2 they went to Resident #1's room and found Certified Nurse Assistant #1, Resident #1, and a person that was engaged in a phone call with Resident #1, all screaming at each other. Certified Nurse Assistant #2 stated they noted that Certified Nurse Assistant #1 was upset so they stated that they would finish providing care to Resident #1 and told Certified Nurse Assistant #1 that they could leave. Certified Nurse Assistant #1 was saying to Resident #1 I need to change you and Resident #1 was asking Certified Nurse Assistant #1 to get out their room. Certified Nurse Assistant #1 was midway through changing Resident #1 when other nursing staff arrived and Registered Nurse #1 told Certified Nurse Assistant #1 to leave Resident #1's room. Certified Nurse Assistant #1 complied and left the room. Certified Nurse Assistant #2 stated that they were not sure if Resident #1 was seen by psychiatry after the incident. Certified Nurse Assistant #2 stated that the police were at the facility the next morning. Certified Nurse Assistant #2 stated they were surprised when the incident was reported on the news and that the report stated that Certified Nurse Assistant #1 had hit Resident #1. Certified Nurse Assistant #2 stated that they never saw Certified Nurse Assistant hit Resident #1 and Resident #1 never told them that Certified Nurse Assistant #1 had hit them. Certified Nurse Assistant #2 stated that after the incident they thoroughly checked Resident #1's body and did not find any visible marks. During an interview with Registered Nurse #1 on 05/01/2026 at 3:45 PM, they stated that they started as the Director of Nursing on 03/24/2026, but prior to that they were hired for infection control. They stated that since they live close, they would be willing to come in over the weekend. They stated they were there when the incident with Resident #1 occurred. Registered Nurse #1 stated that they saw Certified Nurse Assistant #1 being very unprofessional, they did not see a hit. Certified Nurse Assistant #1 was in the resident's room, Resident #1 was uncovered, and Certified Nuse Assistant #1 was rolling the resident back and forth. Registered Nurse #1 stated that from inside the room, Certified Nurse Assistant #1 was yelling out into the hallway I am already F-ing in here I am going to finish the F-in care. Registered Nurse #1 stated that they were trying to de-escalate the situation. They stated that another certified nurse assistant came into the room. Resident #1 was upset and was distraught and nervous. Registered Nurse #1 stated that this incident was their first time meeting Resident #1, and that Resident #1's representative was on the phone the whole time. Registered Nurse #1 talked with Resident #1's representative on the phone, and they said they heard the aide screaming and cursing and that Resident #1 had said to them on the phone that Certified Nurse Assistant #1 was being really rough and washing them with cold water. Registered Nurse #1 stated that they were not aware if Resident #1 was seen by psychiatry services yet, but that it should be evaluated as quickly as possible. Registered Nurse #1 stated they did know that the social worker saw Resident #1 to discuss the event and that they would consider that to be a mental health evaluation, not a psychiatric evaluation. Registered Nurse #1 did not recall if there were any changes to the care plan at that time. Registered Nurse #1 stated that the social worker would be the staff to update the care plan in the system. During a telephone interview with Registered Nurse #2 on 05/26/2026 at 2:30 PM they stated they knew Resident #1, that they were the Director of Nursing at the time of the incident, and that it had occurred during a snowstorm. They stated that what they knew was that no one had called them that evening, even though they were the Director of Nursing, they stated that the facility had since fired them claiming that they were unavailable. They stated that Registered Nurse #1 was the only registered nurse in the building because of the snow. Registered Nurse #2 stated they had heard that Resident #1 had said they were slapped but were unsure who they said it to. Registered Nurse #2 stated that they knew they had to report it. They stated that Resident #1 told the police, and they were not sure why no one else called the police, they were not sure if it was their family that had made the call, and they were unsure when the police showed up. Registered Nurse #2 stated that because Resident #1 said they had been slapped, they had to report it. Registered Nurse #2 stated that at the time neither they nor Registered #1 knew anything about the reporting system. They stated that Registered Nurse #1 called the Department of Health and made the report over the phone, and that they knew the incident was in the newspaper. Registered Nurse #2 stated that Registered Nurse #1 had assessed Resident #1 and that there was no psychiatrist to assess the resident. During a telephone interview with the Medical Director on 05/26/2026 at 3:48 PM, they stated that they did not get any call regarding the incident, but they heard about it randomly one day during rounding sometime the following week. They stated that Resident #1 was being followed by a different medical provider who saw the resident on 02/08/2026. The Medical Director stated that they think they should have been called and would have liked to have been notified of the incident. The Medical Director stated that they were not aware this incident made it to the local news. 10NYCRR 415.4(b)(1)(i)

Based on record review, and interviews conducted during survey, the facility failed to ensure adequate supervision and implementation of an identified intervention for two of three residents (Resident #9 and Resident #8) reviewed for accidents. Specifically, on 03/15/2025, Resident #9 who required two-person assistance for bed mobility was provided with one staff assist by a certified nurse assistant which resulted in a fall from bed and Resident #9 sustained a fracture to their right hip. On 11/26/2025, Resident #8, who was severely cognitively impaired and required close supervision for ambulation, walked unassisted and without monitoring and fell and fractured their right hip. These incidents resulted in actual harm to Resident #9 and Resident #8 that was not Immediate Jeopardy.The facility assessment last reviewed 12/12/2025 documented in a chart addressing resident support/care needs on page five for activities of daily living that the goal is to foster a dignified environment that maximizes residents' autonomy, enhances their quality of life, and ensures their safety and comfort during these essential activities. In the same assessment, related to mobility and fall/fall with injury prevention the facility assessment documented that the facility implemented comprehensive care practices aimed at contracture prevention and management, ensuring that residents retain their range of motion and physical comfort.The undated facility policy titled Abuse, Neglect Mistreatment and Misappropriation of Resident Property under Section 'G' defined what constitutes an injury of unknown origin. An injury should be classified as an injury of unknown source when both of the following conditions are met: The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident.The undated facility policy Accident/Incident Prevention and Management documented that it is the policy of the facility to promote and maintain a safe environment, and to maintain reports and surveillance of all resident's accidents and incidents. On page one, this policy defines an avoidable accident as an accident that occurred because the facility failed: to implement interventions, including adequate supervision, consistent with a resident's needs, goals, plan of care, and current standards of practice in order to reduce the risk of an accident.Resident #9 was admitted with diagnoses that include fusion of spine site unspecified, personal history of healed traumatic fracture, and chronic pain syndrome.The Annual Minimum Data Set (a resident assessment tool) dated 02/17/2025 documented that Resident #9 was cognitively intact. Resident #9 had functional ability limitations documented as being dependent on staff for most/all activities of daily living like: toileting, showering, upper and lower body dressing. According to the Centers for Medicare & Medicaid Services (CMS) coding guidelines, an activity is defined as Dependent (Code 01) if: A caregiver must complete the entire activity for the resident (total staff assistance); or the assistance of two or more helpers is required to safely complete the activity (multiple helpers).Resident #9's Care Plan with focus Activities of Daily Living (ADL)s: bathing, dressing, personal hygiene, toileting, and feeding, date entered 10/27/2022, documented that resident required assistance of one staff with activities of daily living as follows: bathing, dressing, toileting, personal hygiene, and feeding. Goals: resident will have these needs met as evidenced by neat clean well-groomed appearance daily. Interventions: assist with bathing, dressing, grooming, toileting needs, provide privacy. Assist with feeding needs at all meals, monitor and record intakes.Resident #9's Care Plan with focus Fall Risk entered 10/26/2023: Resident is at increased risk for fall related to: sympathetic dystrophy (an older term for Complex Regional Pain Syndrome - a rare, chronic, and severe neurological condition characterized by intense burning or aching pain, swelling, and changes in the skin, bones, and joints of an affected limb). Goals: Resident will have no serious injury related to falls entered on 01/12/2025. Interventions entered 10/27/2022: call bell in reach at all times, keep needed items in reach, keep room well-lit and clutter free, remind and encourage resident to call for assistance. A note attached to this care plan dated 02/19/2023 documented care plan reviewed, no negative outcome no fall since last quarter, continue Plan of Care (POC).Resident #9's Care Plan with focus Activities of Daily Living (ADL)s: transfers, bed mobility, ambulation devices and equipment: Geri chair transfers: total dependence of two, Hoyer lift, Bed Mobility: total dependence of two Ambulation: non ambulatory, total dependence of one Geri chair on and off unit. Active effective date 10/27/2022 entered on 03/26/2025 by Director of Physical Therapy. Goals: Resident will maintain maximum comfort and positioning while in bed. Interventions: Assist with transfers ambulation, and bed mobility as recommended. Encourage participation in activities of daily living care. Praise and provide positive reinforcement for completed task. Use task segmentation (specify).Review of the facility's internal Accident and Incident report dated 03/15/2025 by Certified Nurse Assistant #7 on their handwritten employee investigative statement documented that they were doing patient care on Resident #9, they turned them on their left side to adjust the pad underneath Resident #9 and rolled them on their left side. While they were adjusting the pad, Resident 9's right leg jerked forward and pulled their body weight forward off the bed and onto the floor. They informed the charge nurse and supervisor of the fall.Review of an untitled, undated and unsigned page in the packet provided by the facility as part of the internal incident report documented the date of the incident as 03/15/2025 at 9:00 PM. The summary of the incident documented that Certified Nurse Assistant #7 was rendering care and turned Resident #9 on their left side facing the door to adjust the pad underneath the resident, their legs were parallel (right leg was on top of the left leg), while Certified Nurse Assistant #7 was adjusting the pad the resident's right leg jerked with spastic movement which pulled resident's body weight to dangle off the bed causing resident to slide off the bed and fall onto the floor. The certified nurse assistant documentation revealed that the resident required total assist by two person in bed mobility and toilet care. Certified Nurse Assistant #7 acknowledged not following the plan of care requiring two-person assist. An x-Ray was done on 03/16/2025 and revealed resident moderate arthritic changes of the knee with distal femur fracture (broken leg bone just above the knee joint). Conclusion: Resident was transferred to a hospital for further evaluation and was admitted for right femur fracture. Certified Nurse Assistant #7 was given disciplinary notice and education to follow plan of care.Review of the note written by Physical Therapist #1 on 02/22/2025 at 1:59 PM documented late entry for 02/11/2025 Interdisciplinary Quarterly Screen for Physical Therapy: patient screened by physical therapy and does not demonstrate any decline from baseline levels. Patient refuses to get out of bed most days. Bilateral Shepard's hooks required for bed mobility. Bed Mobility: total dependance of two. Transfers: total dependence by Hoyer. Ambulation: non-ambulatory. Locomotion on/off unit: total dependence by Geri Chair. No physical therapy evaluation required at this time.The standard monthly progress note started on 03/04/2025 and entered on 03/30/2025 written by the Medical Director documented history of present illness (HPI): Resident #9 with past medical history (PMHx) (listing all the resident's current diagnoses), Patient was seen today for monthly medication renewal. No complaints on examination. History of change since last assessment: Over the past month no falls, hospitalization. Started on famotidine (a histamine H2-receptor blocker that reduces stomach acid production). Change in Mobility: No. The note continues with the review of systems.Review of a nursing note dated 03/15/2025 at 10:58 PM Resident #9 was reported to have rolled out of bed onto the floor while being changed around 9:00 PM. Resident with complaint of severe pain to their right knee. Nurse on unit 2 administered Tylenol 650mg as ordered right now for pain with moderate relief. No other visible injuries and no other complaints of pain. Nurse Practitioner notified and ordered x-ray of the right knee. Vital signs every shift for three days and skin assessment every shift for three days. Review of nursing note dated 03/16/2025 at 2:43 AM Resident #9 alert and verbal; makes needs known, pupils equal and reactive to light, vital signs stable, hematoma noted on right forehead and front of forehead, supervisor made aware, supervisor stated doctor was made aware. Call light in reach.Review of a nursing note dated 03/16/2025 at 2:56 AM documented resident complains of right knee pain, ice applied with some relief. Resident alert and verbal.Review of a nursing note dated 03/16/2025 at 2:55 PM neurological checks and skull x-ray per Nurse Practitioner.Review of a nursing note dated 03/16/2025 at 11:28 PM type: correction. Resident x-ray shows R (right) femur fracture. Resident will be transferred to emergency room, family made aware.During an interview with the Administrator on 05/20/2026 at 3:15 PM, they stated there are challenges with staffing and some days they are okay. The Administrator stated in the 30 days of the month of November 2025, there were 19 falls The Administrator stated they are working to find reasons for the falls, ways to prevent them, and are trying to determine what times of day they occur. The Administrator stated that the staff are trained with the yearly mandatory training. The Administrator stated that they do not believe the falls are related to low staffing but stated sometimes more staffing could help. The Administrator stated that they need to work on ensuring that call lights are answered promptly, and toileting is done as necessary.During a telephone interview with the Medical Director on 05/26/2026 at 3:48 PM, they stated that they did not have details of how or why Resident #9 fell, just that they had wound up with a hip fracture and there was an order for the resident to be transferred to the hospital. They stated that Resident #9 could not walk at all, and they did not know how they had fallen. They stated Resident #9 was very unsteady on their feet. The Medical Director stated that they usually want to know if they need to be evaluated in the emergency room, their goal is to get them to the hospital. They stated to prevent future falls; the details would be important. The Medical Director stated that they did not know if it was a care plan violation.Resident # 8 was admitted with diagnoses of history of falling, primary generalized (osteo) arthritis (protective cartilage that cushions the ends of the bones wears down over time) and chronic pain.The Minimum Data Set, dated [DATE] indicates that for sit to stand and for walking 10 feet, further defined as the ability to walk at least 10 feet in a room, corridor or similar space. Resident #8 required supervision or touching assistance, further defined as helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity, and the assistance may be provided throughout the activity or intermittently.Review of Fall Risk Care Plans with active effective date of 08/04/2022 documented Resident #8 is at increased risk for fall related to: muscle weakness, 06/10/2024 status post fall no injury. 09/19/2024 status post fall laceration to forehead. 10/09/2024 status post fall, and 11/26/2025 status post fall. Goals were listed as follows: Resident will have no falls, and resident will have no fall related injuries. Interventions dated 08/04/2022 included: call bell in reach at all times, keep needed items in reach, gripper socks to feet at HS (hour of sleep), keep room well-lit and clutter free, remind and encourage resident to call for assistance, and keep resident in areas of increased visibility. The list of interventions continues. A new intervention added on 12/26/2022 was round on the resident at 7:00 PM to see if needs are met. More interventions added and/or updated on 06/10/2024 included monitor for decreases in vision, monitor for episodes of restlessness agitation or increase in unsafe behaviors, and maintain safe environment at all times. After each fall there are updates to the care plan. On 06/10/2024 status post fall, redirect resident from standing in front of the elevator. On 07/17/2024 status post fall transfer to hospital to rule out head injury, laceration to side of forehead, and neurological checks as per protocol. On 09/18/2024 status post fall, close monitoring by staff when resident is out of bed. Interventions added on 10/10/2024 included offer nap times after breakfast and get resident up before lunch served. Last intervention noted with effective date 11/28/2025 documented 11/26/2025 status post fall, neurological checks as per protocol, vital signs every shift for three days, stat (immediate) bilateral hip x-ray per doctor, keep in bed until x-ray result arrives, rehabilitation screen, pain management as ordered. A note was attached to the care plan documenting, after the last fall to assess resident on the floor, sitting position, complaints of pain on lower extremity hips, no external rotation noted, notified Medical Director, ordered bilateral hip x-rays, Tylenol given for pain, notified family, left message to call back.Review of the internal facility Accident and Incident report dated 11/26/2025 revealed the first page is a check-off list with 25 items, none of which are marked. The second page of this unnumbered packet indicated the resident name (for Resident #8), time of 4:30 PM, location of event is hallway, that resident baseline prior to event was ambulatory and wheelchair, and the event is described as resident got up from wheelchair and walked in hallway, lost balance and fell to floor. Safety/Preventative devices in place at time of incident per Care Plan: marked off as no and Safety/Preventative devices present at time of event: handwritten as no. The charge nurse that signed this page is signed by Licensed Practical Nurse #2 and Certified Nurse Assistant #5. Resident representative was notified at 5:10 PM and Medical Director notified at 5:14 PM. The provider instructions were listed as x-rays of bilateral hips, the entry is signed by a nurse supervisor, but the signature is illegible. The third page contained no resident name, documented the resident's most current mental status and diagnoses and indicated that the resident had a cognitive deficit as well as perceptual impairment noted as impaired sense of balance and poor safety awareness. The last time Resident #8 was observed was in the dining room at 4:00 PM, they were sitting in their wheelchair, indicating the resident got up walked into hallway lost balance fell. Witness statement by Licensed Practical Nurse #2 documented that they last saw Resident #8 at lunch, that the resident was on their assignment and that at the time of the incident, they heard a thud from the north hallway, saw the resident on floor, paged the supervisor and got vitals. Certified Nurse Assistant #5 documented in their witness statement that when they last saw Resident #8 it was afternoon, that the resident was on their assignment and that they were later informed of the accident/fall by a nurse.The facility Investigative Synopsis typed up on letterhead, undated and untimed, documented that on 11/26/2025, the facility received report that Resident #8 was found on the floor in the north hallway of Unit 2. The event was reported by Licensed Practical Nurse #2, who discovered the resident on the floor at approximately 5:00 PM. Nursing administration was notified immediately. According to the initial incident report, the resident was found on the floor near the north hallway after apparently losing their balance while ambulating. The fall was unwitnessed. The resident was able to verbalize what happened, reporting that they were going to the dining room and slipped and fell. An injury assessment was performed, and the resident complained of pain in both hips. X-ray orders were placed according to the provider notification. The event is documented as being discovered by Licensed Practical Nurse #2 and their narrative is they turned and found the resident on the floor in the north hallway, they saw the resident on the floor and paged the supervisor and got vitals. This document further indicated that the resident's [NAME] fall risk evaluation prior to the fall was 19, indicating they were a high risk for falls. The contributing factors included intermittent confusion, balance impairment, prior falls and medications affecting stability. The conclusion documented that based on the facts gathered, the evidence does not support abuse, neglect, mistreatment, or misappropriation of property and the rationale is that the fall was unwitnessed, but all available evidence was consistent with the resident losing their balance while ambulating independently. The administrator at the time of the event signed this document with the conclusion that the investigation supports that this incident was an accidental fall related to the resident's impaired balance and high fall risk, not the result of abuse, neglect or mistreatment.An interview on 05/20/2026 at 11:23 AM with Licensed Practical Nurse #2, stated on 11/26/2025, Resident #8 was walking and fell. They were coming out of the community room and fell in the hallway. It was after dinner and they thought the resident had already eaten. They were walking, they were not given a walker. They had a wheelchair, because they needed something to sit in. They repeated that Resident #8 did not have a walker, they were not sure if they had fallen prior, and they did not know when the last fall occurred. Licensed Practical Nurse #2 stated that Resident #8 would always walk, does not know about their care plans. Licensed Practical Nurse #2 does not normally work on unit 2. When they called the supervisor on the day of the incident, they advised that they had found Resident #8 on the floor, but they did not see them fall. Licensed Practical Nurse #2 stated that Resident #8 is not capable of telling you what caused their fall, they have dementia. Licensed Practical Nurse #2 stated that the fall was unwitnessed. Licensed Practical Nurse #2 was not sure that on that day during change of shift they were made aware of who can and cannot walk alone. Licensed Practical Nurse #2 stated that close supervision means that if Resident #8 is in the dayroom a staff person should be with them so that if they try and get up and walk they can be assisted back to the wheelchair or staff can walk with them. Licensed Practical Nurse #2 stated they did not know Resident #8's care plan said this, and they were not sure if there had been someone in the day room. Licensed Practical Nurse #2 stated they were in the hallway, Resident #8 did not walk past them. They heard a noise when Resident #8 fell to the floor, they turned and looked down the hall and saw Resident #8 on the floor.An interview on 05/20/2026 at 11:39 AM with the Director of Rehabilitation, they revealed that before Resident #8 fell, they were getting Occupational Therapy and Physical Therapy. They stated that Resident #8's function prior to the fall, was indicated to be contact guard handheld assist, they were very confused, and they would try to self-transfer. The Director of Rehabilitation stated that Resident #8 should not have been walking around by themself. The Director of Rehabilitation stated that to communicate the details of the abilities and limitations of the residents to the units, they fill out a rehabilitation recommendation form that is given to the Director of Nursing and this would be linked to the certified nurse assistant documentation, so they can see what residents can do and cannot do. The Director of Rehabilitation stated that at the time of the incident, the rehabilitation recommendation was given to the Director of Nursing, and they would record the residents' ability levels. The Director of Rehabilitation stated that they have no way of making sure that nursing is following their recommendations and recording the residents' ability levels. The Director of Rehabilitation stated that residents with dementia or advanced dementia would not use a walker appropriately. The Director of Rehabilitation stated that when Resident #8 was in the dining room and stood up, someone should have redirected them, and if they felt like walking someone should have held their hand and walked with them, they should not have walked alone. The Director of Rehabilitation stated that they have seen a decline in Resident #8's abilities.During an interview on 05/20/2026 at 12:03 PM with Certified Nurse Assistant #5, they stated they did not know Resident #8 well prior to the fall. They stated that Resident #8 needs a lot of assistance with everything, such as feeding and getting dressed, and once on their feet, they are very unsteady and can only walk short distances. Certified Nurse Assistant #5 stated when Resident #8 wanders around they know that they need to be with them, so they ask someone to get Resident #8's wheelchair. Certified Nurse Assistant #5 stated there are times when Resident #8 will get out of bed, leave their room, and walk down the hallway. They stated, when this happens, I walk them back to their room, or I will get a chair, or a wheelchair, and sometimes they have Resident #8 sit by the nurses' station. Certified Nurse Assistant #5 stated they know that they have to monitor Resident #8, as the last thing they want is for them to fall. Certified Nurse Assistant #5 stated they are aware of which residents should not walk by themselves, it is in their care plans, they see it on Sigma (electronic medical record), and since the unit usually has the same staff, staff know the residents' abilities. Certified Nurse Assistant #5 stated there are still days Resident #8 has the strength and enough willpower to get up and start walking.During a telephone interview with the Medical Director on 05/26/2026 at 3:48 PM, they stated they knew about Resident #8's fractured hip because they got a call on the weekend and they had the facility send the resident to the hospital because of the fall and the report that the resident had a shortened leg. The Medical Director stated they were not given the details of what led to the fall. The Medical Director stated that to determine how well a resident can ambulate, normally a Physical Therapy assessment is conducted to identify the abilities and limitations of the resident. The Medical Director stated that a resident that requires supervision should not be walking alone, and someone should be next to them. The Medical Director stated that they were not told that Resident #8 often stood up on their own and at times would walk down the hall. The Medical Director stated that if they had known and were aware of all regarding Resident #8, further evaluation might have been needed to determine if closer supervision was warranted, and they might have considered one-to-one supervision.10 NYCRR 415.4(b)

Based on record reviews and interviews conducted during a Survey, the facility did not ensure for three of six residents (Resident #1, Resident #8, and Resident #9) that were reviewed for abuse and falls, that all alleged violations involving abuse and injuries were reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegations involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey agency, in accordance with State law through established procedures. Specifically, on 03/15/2025, Resident #9 while receiving assistance for bed mobility fell out of bed and sustained a fracture to their right hip. On 11/26/2025, Resident #8, who required close supervision for ambulation, walked unassisted and without monitoring and fell and sustained a fracture to their right hip. On 01/25/2026, Resident #1 while receiving care was subjected to vulgar/foul language and was screamed at by a certified nurse assistant. The facility's undated policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property defined mental abuse as including but not limited to humiliation, harassment, threats of punishment or deprivation and defined neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. According to their policy immediately means as soon as possible but ought not to exceed 24 hours after discovery of the incident. Their policy further documented that if the injury is unexplained (i.e., fracture), and if the findings of abuse are substantiated (physical, verbal, sexual, financial exploitation), and if there is caregiver neglect (i.e., care plan not followed resulting in resident injury), or if a therapeutic error results in injury a report must be made to the facility designated State Agency within 24 hours (or per state guidelines) of the initial findings. Resident #9 was admitted with diagnoses of fusion of spine site unspecified, personal history of healed traumatic fracture, and chronic pain syndrome. Resident #9 had an annual minimum data set (a resident assessment tool) dated 02/17/2025 that documented that the resident was cognitively intact. Resident #9 had functional ability limitations documented as being dependent on staff for most/all activities of daily living like: toileting, showering, upper and lower body dressing. According to the Centers for Medicare & Medicaid Services (CMS) coding guidelines, an activity is defined as Dependent (Code 01) if: A caregiver must complete the entire activity for the resident (total staff assistance); or the assistance of two or more helpers is required to safely complete the activity (multiple helpers).Resident #9's Care Plan with focus Fall Risk entered 10/26/2023: Resident is at increased risk for fall related to (r/t): sympathetic dystrophy (an older term for Complex Regional Pain Syndrome - a rare, chronic, and severe neurological condition characterized by intense burning or aching pain, swelling, and changes in the skin, bones, and joints of an affected limb). Goals: Resident will have no serious injury related to falls entered on 01/12/2025. Interventions entered 10/27/2022: call bell in reach at all times, keep needed items in reach, keep room well lit and clutter free, remind and encourage resident to call for assistance. A note attached to this care plan dated 02/19/2023 documented care plan reviewed, no negative outcome no fall since last quarter, continue Plan of Care (POC).Review of an untitled, undated and unsigned page in the packet provided by the facility as part of the internal incident report documented the date of the incident as 03/15/2025 at 9:00 PM. The summary of the incident documented that Certified Nurse Assistant #7 was rendering care and turned Resident #9 on their left side facing the door to adjust the pad underneath the resident, their legs were parallel (right leg was on top of the left leg), while Certified Nurse Assistant #7 was adjusting the pad the resident's right leg jerked with spastic movement which pulled resident's body weight to dangle off the bed causing resident to slid off the bed and fall onto the floor. certified nurse assistant documentation showed that resident required total assist by two person in bed mobility and toilet care. Certified Nurse Assistant #7 acknowledged not following the plan of care requiring two person assist. An x-Ray was done on 03/16/2025 and revealed resident sustained moderate arthritic changes of the knee with distal femur fracture (broken leg bone just above the knee joint). Conclusion: Resident was transferred to a hospital for further evaluation and was admitted for right femur fracture. Certified Nurse Assistant #7 was given a disciplinary notice and education to follow plan of care.Review of chart indicates this incident was never reported to the New York State Department of Health.Resident # 8 was admitted with diagnoses of history of falling, primary generalized (osteo) arthritis and chronic pain.The Minimum Data Set, dated [DATE] indicates that for sit to stand and for walking 10 feet, further defined as the ability to walk at least 10 feet in a room, corridor or similar space, Resident #8 required supervision or touching assistance, further defined as helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity, and the assistance may be provided throughout the activity or intermittently.Review of Fall Risk Care Plans with active effective date of 08/04/2022 documented Resident #8 is at increased risk for fall related to: muscle weakness, 06/10/2024 status post fall no injury. 09/19/2024 status post fall laceration to forehead. 10/09/2024 status post fall, and 11/26/2025 status post fall. Goals were listed as follows: Resident will have no falls, and resident will have no fall related injuries.The facility Investigative Synopsis typed up on letterhead, undated and untimed, documented that on 11/26/2025, the facility received report that Resident #8 was found on the floor in the north hallway of unit 2. The event was reported by Licensed Practical Nurse #2, who discovered the resident on the floor at approximately 5:00 PM. Nursing administration was notified immediately. According to the initial incident report, the resident was found on the floor near the north hallway after apparently losing their balance while ambulating. The fall was unwitnessed. The resident was able to verbalize what happened, reporting that they were going to the dining room and slipped and fell. An injury assessment was performed, and the resident complained of pain in both hips. X-ray orders were placed according to the provider notification. The event is documented as being discovered by Licensed Practical Nurse #2 and their narrative is they turned and found the resident on the floor in the north hallway, they saw the resident on the floor and paged the supervisor and got vitals. This document further indicated that the resident's [NAME] fall risk evaluation prior to the fall was 19, indicating they were a high risk for falls. The contributing factors included intermittent confusion, balance impairment, prior falls and medications affecting stability. The conclusion documented that based on the facts gathered, the evidence does not support abuse, neglect, mistreatment, or misappropriation of property and the rationale is that the fall was unwitnessed, but all available evidence was consistent with the resident losing their balance while ambulating independently. The administrator at the time of the event signed this document with the conclusion that the investigation supports that this incident was an accidental fall related to the resident's impaired balance and high fall risk, not the result of abuse, neglect or mistreatment. During an interview on 05/20/2026 at 11:39 AM the Director of Rehabilitation stated that before Resident #8 fell, they were getting Occupational Therapy and Physical Therapy. They stated that Resident #8's function prior to the fall was indicated to be contact guard handheld assist, they were very confused, and they would try to self-transfer. The Director of Rehabilitation stated that Resident #8 should not have been walking around by themself. The Director of Rehabilitation stated that to communicate the details of the abilities and limitations of the residents to the units, they fill out a rehabilitation recommendation form that is given to the Director of Nursing and this would be linked to the certified nurse assistant documentation, so they can see what residents can do and cannot do. Director of Rehabilitation stated that at the time of the incident, the rehabilitation recommendation was given to the Director of Nursing, and they would record the residents' ability levels. The Director of Rehabilitation stated that they have no way of making sure that nursing is following their recommendations and recording the residents' ability levels. The Director of Rehabilitation stated that residents with dementia or advanced dementia would not use a walker appropriately. The Director of Rehabilitation stated that when Resident #8 was in the dining room and stood up, someone should have redirected them, and if they felt like walking someone should have held their hand and walked with them, they should not have walked alone. The Director of Rehabilitation stated that they have seen a decline in Resident #8's abilities. Review of chart indicates this incident was never reported to the New York State Department of Health.Resident #1 had diagnoses that included anoxic brain damage (a severe injury caused by a total lack of oxygen to the brain causing brain cells to die within minutes), hemiplegia (paralysis of one entire side of the body) following other cerebrovascular disease (problems with blood flow to the brain) affecting right dominant side, contracture of muscle right and left hand. The Quarterly Minimum Data Set (a resident assessment tool) dated 12/09/2025 documented Resident #1 had unclear speech, was sometimes understood, was cognitively intact and dependent on staff for all activities of daily living: eating, oral hygiene, toileting, showering and dressing upper and lower body. Resident #1 had a Care Plan dated 01/21/2025 entered by the social worker with a focus Potential for Victimization: Due to medical, cognitive, mood and/or behavioral status. Resident #1 has the potential to be a victim while a resident in a skilled nursing setting related to: medical status, diagnosis of traumatic brain injury, and other, which is defined as unable to easily verbalize. The long-term goal was Resident #1 would be free of being a victim of abuse, neglect, or resident-to-resident incident throughout routines. Interventions were listed as Resident #1 will be encouraged to engage in daily routines, meaningful conversations, activities of preference, psych consultations, and hobbies to foster growth, healthy relationships, and positive engagement while a resident at the facility. The internal Accident and Incident report dated 01/25/2026 documented that at approximately 3:15 PM, Resident #1 was receiving care from Certified Nurse Assistant #1. They were witnessed by other staff members to be handling Resident #1 in a rough manner and vocalizing in loud tones characterized as screaming. Per Resident #1's report, Certified Nurse Assistant #1 used ice cold water to provide hygienic care. At the time of the occurrence, Resident #1's family was on the phone with an open line. The Registered Nurse Supervisor #1 reported to the scene and Certified Nurse Assistant #1 was removed from the environment immediately and care was provided by other staff. Certified Nurse Assistant #1 left the facility and was subsequently notified that they would be suspended pending the outcome of the investigation. A Registered Nurse assessment yielded data supporting emotional upset and anger; there was no indication of physical injury. The Medical Director was made aware of the incident and followed up with no new orders. A follow up skin check three days later yields no new injury, bruising, discoloration, report of pain or other negative psychical manifestation of the event. Statements collected from staff on duty support the allegation as stated by Resident #1 regarding being handled roughly and being subjected to loud, disruptive and agitated vocalizations. The allegation of abuse is substantiated. Review of the chart and the incident report revealed that the Nurse Supervisor on the day of the incident called a phone number to report the incident. However, it is indicated in iQIES that the phone number called was to the Justice Center, and the Nurse Supervisor left a message but did not leave a return phone number. The review also revealed that the facility never called local law enforcement, and that local law enforcements' arrival at the facility on the day following the incident was because the Resident #1's representative had called them. 10 New York Codes, Rules, and Regulations 415.4(b)(1)(i)

Based on record reviews and interviews conducted during a Survey the facility did not revise or update a resident care plan after a significant change was noted in the resident's psychosocial and physical wellbeing. This was noted for three of three residents (Resident #9, Resident #4, and Resident #1) reviewed for care planning. Specifically, on 02/02/2025 Resident #9 had a fall from bed and care plan for falls was never updated; on 11/20/2025 at 5:24pm Physical Therapist #1 documented that Resident #4 was voicing suicidal ideation upon evaluation, and this information was never addressed and there was no update to the care plan for Psychosocial well-being; and on 01/25/2026 after an incident of abuse Resident #1 voiced that they did not feel safe, and there was no update to the potential for victimization care plan. The facility policy titled Comprehensive Care Plan Policy last reviewed/revised defined significant change in condition as a decline or improvement requiring an updated assessment and care plan revision. This policy further documented that the care plan must be updated when risk increases or new problems arise, and following falls, hospitalization, skin issues, behaviors, infections, or adverse events.Resident #4 was re-admitted with diagnoses that included, but were not limited to, unspecified fracture of right femur, peripheral vascular disease and anxiety disorder. An admission minimum data set (a resident assessment tool) dated 10/29/2025 documented the resident had a brief interview of mental status score of 15, indicating no cognitive impairment. Progress note dated 11/20/2025 at 5:48pm written by Physical Therapist #1 documented resident.voicing suicial ideations upon evaluation. Social Worker and Director of Rehabilitation made aware. Resident also noted with left heel erythema. Nurse made aware and heel booties applied to both heels after optimal positioning in bed. Physician's History and Physical dated 11/21/2025 indicted psychiatric normal. No further documentation noted regarding depression or suicidal ideations.Review of care plans with focus of observe for changes in behavior due to alteration of self-image revised effective date of 11/10/2025. Review of care plan for psychosocial well-being listed problem as changes in lifestyle/daily routine in community with an active effective date of 11/09/2025. Review of care plan for psychotropic drug use: anxiety, state resident is on alprazolam: related to diagnosis of anxiety with an active effective date of 10/20/2025. There are no care plans for depression, or for suicidal ideation.During an interview with the Director of Social Work on 05/01/2026 at 9:01am they stated they have a role in psychosocial admission assessment. They stated they can do some of the nurse related items in a care plan meeting. When talking about Resident #4 they stated they remembered a care plan for delusions, and that if they had known about the statement they would have talked with Resident #4.During an interview on 05/01/2026 at 3:45pm with the current Director of Nursing they stated they did not know about the suicidal comment made by Resident #4, but had they known the next step would be to do a Patient Health Questionnaire-9 (PHQ9 is a multipurpose instrument for screening, diagnosing, monitoring and measuring the severity of depression) and a Generalized Anxiety Disorder (GAD) follow up and then update the emotional well being care plan. Resident #9 was admitted with diagnoses that include fusion of spine site unspecified, personal history of healed traumatic fracture, and chronic pain syndrome. The Annual Minimum Data Set (a resident assessment tool) dated 02/17/2025 documented that Resident #9 was cognitively intact. Resident #9 had functional ability limitations documented as being dependent on staff for most/all activities of daily living like: toileting, showering, upper and lower body dressing. According to the Centers for Medicare & Medicaid Services (CMS) coding guidelines, an activity is defined as Dependent (Code 01) if: A caregiver must complete the entire activity for the resident (total staff assistance); or the assistance of two or more helpers is required to safely complete the activity (multiple helpers). Review of the facility's internal Accident and Incident report dated 03/15/2025 by Certified Nurse Assistant #7 on their handwritten employee investigative statement documented that they were doing patient care on Resident #9, they turned them on their left side to adjust the pad underneath Resident #9 and rolled them on their left side. While they were adjusting the pad, Resident 9's right leg jerked forward and pulled their body weight forward off the bed and onto the floor. They informed the charge nurse and supervisor of the fall. Review of an untitled, undated and unsigned page in the packet provided by the facility as part of the internal incident report documented the date of the incident as 03/15/2025 at 9:00 PM. The summary of the incident documented that Certified Nurse Assistant #7 was rendering care and turned Resident #9 on their left side facing the door to adjust the pad underneath the resident, their legs were parallel (right leg was on top of the left leg), while Certified Nurse Assistant #7 was adjusting the pad the resident's right leg jerked with spastic movement which pulled resident's body weight to dangle off the bed causing resident to slide off the bed and fall onto the floor. The certified nurse assistant documentation revealed that the resident required total assist by two person in bed mobility and toilet care. Certified Nurse Assistant #7 acknowledged not following the plan of care requiring two-person assist. An x-Ray was done on 03/16/2025 and revealed resident moderate arthritic changes of the knee with distal femur fracture (broken leg bone just above the knee joint). Conclusion: Resident was transferred to a hospital for further evaluation and was admitted for right femur fracture. Certified Nurse Assistant #7 was given disciplinary notice and education to follow plan of care. Resident #9's Care Plan with focus Activities of Daily Living (ADL)s: bathing, dressing, personal hygiene, toileting, and feeding, date entered 10/27/2022, documented that resident required assistance of one staff with activities of daily living as follows: bathing, dressing, toileting, personal hygiene, and feeding. Goals: resident will have these needs met as evidenced by neat clean well-groomed appearance daily. Interventions: assist with bathing, dressing, grooming, toileting needs, provide privacy. Assist with feeding needs at all meals, monitor and record intakes. Resident #9's Care Plan with focus Fall Risk entered 10/26/2023: Resident is at increased risk for fall related to: sympathetic dystrophy (an older term for Complex Regional Pain Syndrome - a rare, chronic, and severe neurological condition characterized by intense burning or aching pain, swelling, and changes in the skin, bones, and joints of an affected limb). Goals: Resident will have no serious injury related to falls entered on 01/12/2025. Interventions entered 10/27/2022: call bell in reach at all times, keep needed items in reach, keep room well-lit and clutter free, remind and encourage resident to call for assistance. A note attached to this care plan dated 02/19/2023 documented care plan reviewed, no negative outcome no fall since last quarter, continue Plan of Care (POC).During an interview on 05/26/2026 at 1:13pm with The Medical Director they stated they do not normally attend care plan meetings, they occur in the afternoons, and they are usually there in the mornings to do their rounds. They stated if there is something they need to sign, or if they receive notice, they can speak with the family, or if there are some concerns, they can be involved in the care plan meetings. They stated the social workers arranged the meetings. The Medical Director stated daily care is not brought to their attentionResident #1 had diagnoses that included anoxic brain damage (a severe injury caused by a total lack of oxygen to the brain causing brain cells to die within minutes), hemiplegia (paralysis of one entire side of the body) following other cerebrovascular disease (problems with blood flow to the brain) affecting right dominant side, contracture of muscle right and left hand. The Quarterly Minimum Data Set (a resident assessment tool) dated 12/09/2025 documented Resident #1 had unclear speech, was sometimes understood, was cognitively intact and dependent on staff for all activities of daily living: eating, oral hygiene, toileting, showering and dressing upper and lower body.Resident #1 had a Care Plan dated 01/21/2025 entered by the social worker with a focus Potential for Victimization: Due to medical, cognitive, mood and/or behavioral status. Resident #1 has the potential to be a victim while a resident in a skilled nursing setting related to: medical status, diagnosis of traumatic brain injury, and other, which is defined as unable to easily verbalize. The long-term goal was Resident #1 would be free of being a victim of abuse, neglect, or resident-to-resident incident throughout routines. Interventions were listed as Resident #1 will be encouraged to engage in daily routines, meaningful conversations, activities of preference, psych consultations, and hobbies to foster growth, healthy relationships, and positive engagement while a resident at the facility.The internal Accident and Incident report dated 01/25/2026 documented that at approximately 3:15 PM, Resident #1 was receiving care from Certified Nurse Assistant #1. They were witnessed by other staff members to be handling Resident #1 in a rough manner and vocalizing in loud tones characterized as screaming. Per Resident #1's report, Certified Nurse Assistant #1 used ice cold water to provide hygienic care. At the time of the occurrence, Resident #1's family was on the phone with an open line. The Registered Nurse Supervisor #1 reported to the scene and Certified Nurse Assistant #1 was removed from the environment immediately and care was provided by other staff. Certified Nurse Assistant #1 left the facility and was subsequently notified that they would be suspended pending the outcome of the investigation. A Registered Nurse assessment yielded data supporting emotional upset and anger; there was no indication of physical injury. The Medical Director was made aware of the incident and followed up with no new orders. A follow up skin check three days later yields no new injury, bruising, discoloration, report of pain or other negative psychical manifestation of the event. Statements collected from staff on duty support the allegation as stated by Resident #1 regarding being handled roughly and being subjected to loud, disruptive and agitated vocalizations. The allegation of abuse is substantiated.During an interview on 05/01/2026 at 3:45pm with the current Director of Nursing they stated they know that the Social Worker met with Resident #1. The Director of Nursing stated that they would consider that meeting to be a mental health evaluation not a psychiatric evaluation. The Director of Nursing stated that they do not recall if there were any changes made to the care plan at that time. The Director of Nursing stated that the social worker would be the staff to update the care plan in the system. The Director of Nursing also stated that the social worker may have put a care plan in place requiring that two certified nurse assistants provide care to Resident #1. 10NYCRR 415.11(c)(2)(i-iii)

Based on record reviews and interviews conducted during a Survey (2809204), the facility did not ensure that two of three residents reviewed for behavioral health (Resident #4 and Resident #1) were assessed and provided necessary services after making a suicidal statement and having a traumatic incident. Specifically, on 11/20/2025 at 5:24pm Physical Therapist #1 documented that Resident #4 was voicing suicidal ideation upon evaluation; and on 01/25/2026 Resident #1 experienced a situation and voiced that they did not feel safe.In the facility assessment last revision dated 11/17/2025 under Mental Health and Behavior it documented that the facility is dedicated to effectively managing medical conditions and medication-related issues that may contribute to psychiatric symptoms and behavioral challenges. This involved thorough assessment and ongoing monitoring to identify underlying factors influencing residents' mental health. The facility assessment further documented that to ensure the delivery of high-quality, safe, and effective care at all times that the facility is equipped with a diverse array of resources and further lists Behavioral and Mental Health Providers.In the facility policy titled Psychiatry and Psychology Services last revision 5/2025 documented that the facility would provide, arrange for or refer residents to psychiatric and psychological services sufficient to meet the mental and psychological needs identified through comprehensive assessment. This policy defines a psychiatrist as a physician licensed in New York State with specialty training in psychiatry, and a psychologist is an individual licensed by the New York state Education Department under article 153 of the education law. Resident #4 was re-admitted with diagnoses that included, but were not limited to, unspecified fracture of right femur, peripheral vascular disease, and anxiety disorder. An admission minimum data set (a resident assessment tool) dated 10/29/2025 documented the resident had a brief interview of mental status score of 15, indicating no cognitive impairment. Progress note dated 11/20/2025 at 5:48pm written by Physical Therapist #1 documented resident.voicing suicial ideations upon evaluation. Social Worker and Director of Rehabilitation made aware. Resident also noted with left heel erythema. Nurse made aware and heel booties applied to both heels after optimal positioning in bed. Physician's History and Physical dated 11/21/2025 indicted psychiatric normal. No further documentation noted regarding suiciadal ideations. Medication orders were as follows: alprazolam 0.5mg give 1 tablet by mouth four times a day start date 11/19/2025 for diagnosis anxiety disorder due to known physiological condition. Order written by Medical Director;escitalopram 5mg give 1 tablet by mouth once daily start date 11/19/2025 for diagnosis major depressive disorder, single episode, mild. Order written by Medical Director;mirtazapine 15mg give 7.5mg by mouth once dialy start date 03/27/2026 for diagnosis depression, unspecified and anxiety disorder unspecified. Order written by Medical Director. Review of care plans Observe for changes in behavior due to alteration of self image revised effective date of 11/10/2025. Review of care plan for psychosocial well being listed problem as changes in lifestyle/daily routine in community with an active effective date of 11/09/2025. Review of care plan for psychotropic drug use: anxiety state resident is on alprazolam: related to diagnosis of anxiety with an active effective date of 10/20/2025. There are no care plans for depression, or for suicidal ideation. During an interview on 04/30/2026 at 2:56pm with Registered Nurse #3 they stated that were hired to be the unit manager for unit 1, but that at the moment they are covering both units and float all over. They stated they were never told about the suicial statement that Resident #4 made but that if a resident makes a statement the protocol is to take away any belt and or shoe laces and provide a tap bell. Registered Nurse #3 stated that a nurse and a doctor need to be made aware. During an interview on 05/01/2026 at 10:58am with Physical Therapist #1 they reviewed and read their note about Resident #4. They explained that DOR is Director of Rehabilitation and SW is Social Worker. They stated that they did not tell a nurse on the unit about the statement Resident #4 made because they cannot always find a nurse. They explained that they sometimes seek staff at a higher level, and then they usually find someone to tell. Physical Therapist #1 stated that Resident #4 stated that basically they didn't want to live anymore. Physical Therapist #1 stated that the resident had pulmonary issues, anxiety, and depression, and it was holding them back in their rehabilitation, and they were afraid. They stated Resident #4 is doing so much better walking 10 feet now, and they have been in rehabilitation for a long time. When Resident #4 made the comment Physical Therapist #1 stated they listened and told them that things are going to get better. They stated that they see them almost every day and ask how they are feeling. Physical Therapist #1 stated Resident #4 has been weepy with them off and on and that they try and listen and encourage them. Physical Therapist #1 was not sure if they were at the facility the next day to follow up, but they told their director. They stated that they did not try to tell the Director of Nursing because they are not always available, they do not have their email, and they understood that the Director of Rehabilitation would inform the Director of Nursing. Physical Therapist #1 stated that when Resident #4 made the statement they didn't think they were going to do anything, adding that if someone feels that low, they want them to get the help they need, and Resident #4 struggles with a lot of depression and anxiety. Physical Therapist #1 stated if someone had seen or assessed Resident #4, they would have expected to find a note, but they did not recall specifically looking for a note about Resident #4's comment. They were not aware if there was a psychiatric provider at the facility in November. Physical Therapist #1 stated they do not do suicide assessments, and the protocol is to tell a supervisor or social worker, and they will notify the appropriate staff. Review of chart for Resident #4 revealed that no staff member ever did a psychiatric assessment before or after Resident #4 made the commemt. During an interview with the Administrator on 05/20/2026 at 3:15pm they were told that the Medical Director was doing medication gradual dose reduections and they believed they would also be doing any necessary psychiatric assessment, but they were not sure what information was provided to the Medical Director. The Administrator stated that if there were a psychaitric emergency they would send Resident #4 out to hospital. The Administrator stated they have been without a psyciatric provider for approximately 7 to 8 months. Resident #1 had diagnoses that included anoxic brain damage (a severe injury caused by a total lack of oxygen to the brain causing brain cells to die within minutes), hemiplegia (paralysis of one entire side of the body) following other cerebrovascular disease (problems with blood flow to the brain) affecting right dominant side, contracture of muscle right and left hand. The Quarterly Minimum Data Set (a resident assessment tool) dated 12/09/2025 documented Resident #1 had unclear speech, was sometimes understood, was cognitively intact and dependent on staff for all activities of daily living: eating, oral hygiene, toileting, showering and dressing upper and lower body. Resident #1 had a Care Plan dated 01/21/2025 entered by the social worker with a focus Potential for Victimization: Due to medical, cognitive, mood and/or behavioral status. Resident #1 has the potential to be a victim while a resident in a skilled nursing setting related to: medical status, diagnosis of traumatic brain injury, and other, which is defined as unable to easily verbalize. The long-term goal was Resident #1 would be free of being a victim of abuse, neglect, or resident-to-resident incident throughout routines. Interventions were listed as Resident #1 will be encouraged to engage in daily routines, meaningful conversations, activities of preference, psych consultations, and hobbies to foster growth, healthy relationships, and positive engagement while a resident at the facility. The internal Accident and Incident report dated 01/25/2026 documented that at approximately 3:15 PM, Resident #1 was receiving care from Certified Nurse Assistant #1. They were witnessed by other staff members to be handling Resident #1 in a rough manner and vocalizing in loud tones characterized as screaming. Per Resident #1's report, Certified Nurse Assistant #1 used ice cold water to provide hygienic care. At the time of the occurrence, Resident #1's family was on the phone with an open line. The Registered Nurse Supervisor #1 reported to the scene and Certified Nurse Assistant #1 was removed from the environment immediately and care was provided by other staff. Certified Nurse Assistant #1 left the facility and was subsequently notified that they would be suspended pending the outcome of the investigation. A Registered Nurse assessment yielded data supporting emotional upset and anger; there was no indication of physical injury. The Medical Director was made aware of the incident and followed up with no new orders. A follow up skin check three days later yields no new injury, bruising, discoloration, report of pain or other negative psychical manifestation of the event. Statements collected from staff on duty support the allegation as stated by Resident #1 regarding being handled roughly and being subjected to loud, disruptive and agitated vocalizations. The allegation of abuse is substantiated. Review of chart revealed that there was no psychiatric assessment for Resident #1 after the incident. Resident # 1 did have psychiatric assessments in their chart. On 01/23/2025, was the first assessment and it noted no change in medication regime. On 03/10/2025 the same provider assessed the resident and suggested Resident #1 start Lexapro 5mg for generalized anxiety disorder and also increase their melatonin for sleep. The same provider did a follows up assessment on 03/21/2025 with no new recommendations, and saw Resident #1 on 06/10/2025, and again on 07/04/2025. At the end of the 07/04/2025 assessment the provider indicated that Resident #1 should have another follow up assessment in 4 to 6 weeks. That next follow up assessment did not occur. A new provider started and saw Resident #1 on 04/20/2026. During an interview on 04/29/2026 at 1:16pm Resident #1 reported the aide smacked them and called them a nigger. Resident #1 stated they have been nervous, and they jump when staff comes into the room. They stated there was no consultation afterwards. Resident #1 stated that sometimes when they receive care it is provided by one aide and sometimes it is provided by two aides. Resident #1 stated sometimes they are scared, and they will call downstairs for someone to assist them. Resident #1 stated they do not feel safe in the facility. During a telephone interview with the Medical Director on 05/26/2026 at 3:48 PM, they stated that they did not get any call regarding the incident, but they heard about it randomly one day during rounding sometime the following week. They stated that Resident #1 was being followed by a different medical provider who saw the resident on 02/08/2026. The Medical Director stated that they think they should have been called and would have liked to have been notified of the incident. The Medical Director stated that they were not aware this incident made it to the local news. 10NYCRR 415.15(b)(2)(iii)

Based on record review and interviews during an abbreviated survey (2582016, 2579539, 2574633), the facility did not ensure sufficient nursing staffing to attain or maintain the well-being of each resident. Specifically, upon review of the staffing schedule for multiple days on all three shifts and for each floor for July and August 2025, the facility did not provide adequate numbers of Certified Nurse Aides to meet the needs of the residents.The findings are: The undated facility Staffing Policy documented the facility shall have sufficient staff to provide nursing and related services to attain or maintain the highest practicable, physical, mental and psychosocial well-being of each resident. The facility shall further assure that staffing levels enable each resident to receive treatments, medications, diets and other health services in accordance with individual care plans. The Facility assessment dated [DATE], and last reviewed by the Quality Assurance and Improvement Committee on 8/22/24 documented the staffing plan. The Staffing Plan- Staffing Guidelines documented there would be a minimum of 11 Certified Nurse Aides for the day and evening shifts, and a minimum of six (6) Certified Nurse Aides for the night shift. A review of the staffing schedules for July 2025 and August 2025 documented the facility did not meet the minimum of 11 Certified Nurse Aides on day or evening shifts for 62 of 62 days, and did not meet the minimum of six (6) Certified Nurse Aides on the night shift for 58 of 62 days. During an observation on 10/29/25 at 9:55 AM on second floor foul odors were noted coming from residents' rooms. There were approximately eight residents in the day room at tables. There was no staff supervising or interacting with residents. During an observation on 10/30/25 at 10:26 AM, in the first floor dining room, no staff were present and six residents were unsupervised.During an observation on 10/30/25 at 10:30 AM, there was a strong smell of urine on second floor and twenty residents were observed in bed. During an interview on 10/29/25 at 10:17AM, Resident #1 stated call bells went off all the time and it took a long time to get a bell answered. They stated on the weekend bells rang constantly, meals were always cold, and they did not get showers regularly. They stated the Charge Nurses were aware and did not do anything about it. They stated that sometimes there were no nurses on the second floor and a nurse would have to come up from another unit to give out medications. During an interview on 10/28/25 at 10:15 AM, Certified Nurse Aide #2, working on the second floor, stated there were five (5) Certified Nurse Aides working today but there were times when there were three (3) Certified Nurse Aides or less and that was not enough to get the work done. They stated residents had to stay bed longer or not get out of bed when short staffed. They stated they had two residents to shower today and would try hard to get it done but was not sure it would happen. They stated the facility was aware that there was a staffing problem. During an interview on 10/29/25 at 9:57 AM, Certified Nurse Aide#10, who was working on the second floor, stated today there were four (4) Certified Nurse Aides, and they were taking care of about 12-13 residents each. They stated they had two showers to give but had not given them as they had four residents to feed. They stated they used to have seven (7) Certified Nurse Aides on the schedule and that was what they needed to get residents out of bed, complete all cares and have a Certified Nurse Aide to supervise the day room. When there was not enough Certified Nurse Aides on the unit it limited the number of residents they were able to get out of bed, shower, and take to activities. When they had only two Certified Nurse Aides, residents were stuck in their rooms, and it was impossible to get the residents into chairs for activities. They stated it also took a long time to feed everyone. During an interview on 10/29/25 at 10:37 AM Certified Nurse Aide #3 stated when staffing was lower than five (5), they could not complete their assigned work. They stated it was hard to do showers, answer call bells, and find help for transfers requiring a mechanical lift. During a follow up interview on 10/30/25 at 10:30 AM, Certified Nurse Aide#3 stated there were only three Certified Nurse Aides working on the unit. The plan was to work with the other Certified Nurse Aide to get residents ready for the day. At this time, they were still getting residents out of bed and making the toileting changes that were started at 7:00 AM. They stated they had eight (8) residents that required a mechanical lift for transfers and one (1) or two (2) more showers to give.During an interview on 10/30/25 at 10:36AM, Registered Nurse#6 stated they were giving meds on two sides today. They stated they were also assisting the Certified Nurse Aides as there were three (3) working. They stated they were constantly stopped and asked for help to get residents out of bed or to help with turning. They stated they could not get the medications passed out in a timely manner and residents got their medications late. They stated they were unable to get assessments done and care plans were often left incomplete. They stated some days there was only one Certified Nurse Aide.During an interview on 10/29/25 at 11:21 PM the Staffing Coordinator stated they did not have the staff to meet the staffing goals. They tried agency staffing but it was not a reliable source, and agencies did not have the structure or disciplinary model. They stated staffing was a challenge and they got help and direction from the Director of Nursing. They staffed units by need and not census and were aware there were days when they were below the minimum. The facility has offered incentives to get staff to work. They stated the evening shift has a lot of day workers working doubles. They are constantly working on recruitment but felt the surrounding areas are concentrated with nursing homes.During an interview on 10/29/25 at 11:38AM the Director of Nursing stated they were working with the Staffing Coordinator to get extra staff in the building, but it was difficult. They stated they came in on off hours to help out. Recruitment was ongoing and the Administration was aware of the problem. The staff in the building knew they needed to prioritize their work to get all tasks done. They stated four (4) Certified Nurse Aides should be enough to get things done.During an interview on 10/28/25 at 2:15PM, the Corporate Administrator stated they were the Administrator at the facility until June 2025. At that time another corporate staff was helping with administrative tasks such as the Facility Assessment and kept it current. The Facility assessment dated [DATE] was the current working document and was used to drive all activities and minimal staffing needed to care for all residents. They stated the Facility Assessment was an important document and someone should have gone over this with the new administrator.During an interview on 10/30/25 at 1:55 PM, the Administrator stated they were aware there was staffing problems but did not know the role of the Facility Assessment as a tool used to determine the number of staff needed. They stated the facility was recruiting. 10NYCRR 415.13(a)(1)(i-iii)

Based on observation, interview, and record review conducted on an abbreviated survey (2582016, 2579539, 2574633), the facility did not ensure that a Registered Nurse was on duty for at least 8 consecutive hours a day, 7 days a week for four (4) of nine (9) weekends reviewed from 07/01/25 through August 31,2025. Specifically, no Registered Nurse worked during the 24-hour period on the following weekends 7/5/25 to 7/6/25, 7/12/25 to 7/13/25, 7/19/25 to 7/20/25 and 8/2/25 to 8/3/25. Additionally, during the times when no Registered Nurse was scheduled, two (2) residents (Resident #4 and #6) fell, another sustained a burn (Resident #7), and they were not assessed by qualified staff (registered nurse, physician or nurse practitioner) (See F684).Findings included:The undated facility Staffing Policy documented the facility will have sufficient staff to provide nursing and related services to attain or maintain the highest practicable physical mental and psychosocial well-being of each resident. The facility shall further assure that staffing levels enable each resident to receive treatments, medications, diets and other health services in accordance with individual care plans.The Facility assessment dated [DATE] documented staffing goals which included the Director of Nursing as a full-time Registered Nurse, two full-time Registered Nurse Managers, three (3) full-time Registered Nurse Supervisors for evenings and weekends, and six (6) Licensed Practical Nurses for day shift, five (5) for evening shift and (3) three for night shift.The facility staffing was reviewed from 7/1/2025 through 8/31/25. During this time there was no documentation of a Registered Nurse on duty for at least 8 consecutive hours a day on the weekends of 7/5/25 to 7/6/2025, 7/12/25 to 7/14/25, 7/19/25 to 7/20/25, and 8/2/25 to 8/3/25. On these weekends, the facility had no registered nurse in the building for periods of 36 to 48 hours. Review of the facility Accident/Incident log documented on 7/19/2025, Resident #4 fell out of bed, sustained a bloody nose, and was put back to bed without being assessed by a Registered Nurse. On 7/19/2025 Resident #6 fell out of bed, complained of hip pain and was not assessed. On 8/2/2025, Resident #7 was observed with a burn on their thigh and was not assessed by qualified staff until 8/4/2025 when seen by the wound care physician. During an interview on 10/29/25 at 11:21 AM the Staffing Coordinator stated they did not have the staff to meet the goal of the Facility Assessment. There were times when there was no Registered Nurse scheduled in a twenty-four-hour period and the Director of Nursing was made aware of the situation. The Director of Nursing would be available to cover any day where a Registered Nurse was needed. The staffing Coordinator stated that the weekend dates of 7/7/25, 7/6/25, 7/9/25, 7/12/25, 7/19/25 and 8/2/25 would be covered by the Director of Nursing. They did not keep a record of days the Director of Nursing was in the facility filling in for Registered Nurses or have documentation the Director of Nursing was added to the weekend schedule.During an interview on 10/29/25 at 11:38 AM the Director of Nursing stated they were the back up when a Registered Nurse was not scheduled. When there was not a Registered Nurse, the Licensed Practical Nurse would call them when there was a problem, and they would offer guidance over the phone. They stated they did not write notes and did not not have any other documentation they were on duty during this time. During an interview on 10/30/25 at 1:55 PM the Administrator stated when a Registered Nurse was not present in the building during an incident, the expectation was that the Director of Nursing or a Corporate Registered Nurse would report to the facility as soon as possible to assess resident. They also stated that a nurse from sister facility nearby could also be requested to go to the facility to assess a resident. The Administrator stated they were aware that there were days when a Registered Nurse was not available to work in the facility, especially on weekends or night shift and was working to increase Registered Nurses at the facility. 10NYCRR 415.13(b)(1)

Based on observations, record review and interviews during an abbreviated survey (2582016, 2579539, 2574633), the facility did not ensure residents received treatment and care in accordance with professional standards of quality for three of three residents (Residents #7, #6, and #4) reviewed for quality of care. Specifically, 1) Resident #7 was not assessed timely by a registered nurse after being observed with three open wounds on the left thigh; 2) there was no documented evidence that Resident #6 with complaint of pain was assessed by a registered nurse prior to being transferred from the floor to bed after an unwitnessed fall; and 3) there was no documented evidence that Resident #4 was assessed by a registered nurse prior to being transferred from the floor to bed after an unwitnessed fall. The findings include: An untitled policy dated 10/02/2024 revealed when it is determined that a resident has had an accident or incident according to policy definition the nurse must notify the nursing supervisor immediately of the unusual event. The nurse/nursing supervisor is responsible to evaluate the resident for injury to determine whether the resident may or may not be moved, if there is any suspicion for major injury which may be worsened/exacerbated by moving the resident, they must be stabilized and remain in place until emergency medical services arrive to assume care, with non-disruptive measures employed for comfort as practicable. If the nursing supervisor deems the resident may be moved, maximal support will be used, and the resident will be placed into bed for a full body audit and vitals collected. The attending physician will be notified to receive orders for treatment, in the event the attending physician cannot be reached, the medical director will be notified of the resident's condition. 1) Resident #7's diagnoses included paranoid schizophrenia, neurocognitive disorder with Lewy bodies and hypertensive disorder. The 07/28/2025 quarterly Minimum Data Set documented Resident #7 had moderate cognitive impairment, was independent with eating, and self-propelled in a wheelchair. The 08/02/2025 Accident and Incident Report written by Licensed Practical Nurse #8 documented Certified Nurse Aide #11 reported Resident #7 was found with three open areas on the left hip (four (4) x thee (3) centimeters upper, five (5) x two (2) centimeters middle, and three (3) x three (3) centimeters lower). The physician was notified at 10:45 PM on 08/02/2025. The 08/02/2025 statement written by Licensed Practical Nurse #8 documented Resident #7 stated they burned themselves with hot black coffee a few days ago. The undated Post Accident Incident Pain and Skin Observation Report written by Registered Nurse #6 documented Resident #7 had three open areas on the left hip. There was no documented evidence in the electronic medical record or in the accident/incident report documenting that Resident #7 was assessed timely by a registered nurse after the open hip wounds were identified. The 08/03/2025 nursing progress note Licensed Practical Nurse #8 documented the resident was reported to have three (3) open areas on left hip, upper four (4) x three (3) centimeters, middle five (5) x two (2) centimeters and lower three (3) x three (3) centimeters. The physician was notified. The area was cleansed with normal saline, and triple antibiotic ointment and dry protective dressing were applied. The resident stated they burned themself with coffee a few days ago but did not recall when. The resident has been witnessed putting a cup with black hot coffee and no lid next to their body when in the wheelchair. The resident's sister was notified. Suggested obtaining a metal coffee mug with lid and cup holder for the wheelchair to prevent further incident. Review the staffing schedule documented no Registered Nurse was on duty from 08/02/2025 at 7:00 AM until 08/03/2025 7:00 PM. The 08/04/2025 nursing progress note written Licensed Practical Nurse #13 documented the resident was seen by the wound care physician for evaluation of the left hip burn. Silvadene and a dry protective dressing to be applied every day and as needed. During an interview and observation on 10/30/2025 at 9:36 AM, the Director of Nursing stated Licensed Practical Nurse Supervisor #8 was on duty when Resident #7's wounds were observed. They stated a Registered Nurse was not in the facility from 7:08 AM on 08/02/2025 until 5:44 PM on 08/03/2025. They stated the registered nurse who presented to the facility on [DATE] should have been informed of the wounds during verbal shift report and upon review of the supervisor report and should have immediately assessed Resident #7. During an interview on 10/30/2025 at 11:30 AM, Licensed Practical Nurse #8 stated they were working as a supervisor on 08/02/2025 from 7 PM to 7 AM and contacted the Director of Nursing, Regional Director of Nursing, Administrator, medical doctor and other supervisors via group text to report Resident # 7's wounds. During a follow-up interview on 10/30/2025 at 11:41 AM, the Director of Nursing stated they received a group text message on 08/03/2025 at 6:36 AM and 6:37 AM from Licensed Practical Nurse #8 informing the group of Resident #7's wounds. They stated they did not respond to the group text chat and that the only response to the text message was from the Administrator who stated they would order Resident #7 a coffee mug with a lid and holder for the wheelchair. They stated they should have responded to the text and followed up with a phone call to discuss the incident and provide an assessment. During an interview on 10/30/2025 at 1:55 PM the Administrator stated they received a group chat text message on 08/03/2025 at 6:36 AM from Licensed Practical Nurse #8 to report the incident involving Resident #7. They stated they responded at 7:23 AM indicating they would order a coffee mug with lid for Resident #7. The Administrator stated when a registered nurse was not present in the building during an incident, the expectation was that the Director of Nursing, a corporate registered nurse or a registered nurse from a nearby sister facility would be requested to report to the facility to assess resident/s. They stated that Resident #7 not being assessed by a registered nurse immediately was due to lack of clinical oversight. During an interview on 11/04/2025 at 4:25 PM, the Medical Director stated they were contacted by Licensed Practical Nurse #8 via group text on 08/03/2025 at 6:36 AM. The Medical Director stated the expectation was that video assessments be utilized when a registered nurse was not in the building to assess. They stated the video assessment could be completed by Director of Nursing or Medical Director. They stated they did not conduct a video assessment for Resident #7 on 08/02/2025 and was unaware if the Director of Nursing conducted a video assessment. 2) Resident #6 diagnoses included metabolic encephalopathy (a neurological condition,) Dysphagia (difficulty swallowing), and Lupus (an autoimmune disorder). The admission Minimum Data Set (an assessment tool) dated 07/22/2025 documented Resident #6 had moderately impaired cognition and was dependent on staff for all activities of daily living. The resident had one (1) fall documented. The 07/20/2025 Accident and Incident Report written by Licensed Practical Nurse #8 documented the resident was found on the floor next to their bed. Resident # 6 complained of hip pain. Medical Doctor was notified, and x-rays were ordered. The 07/20/2025 at 7:00 AM progress note written by Licensed Practical Nurse #8 documented the resident was reported to be on the floor next to their bed. Medical Doctor was notified, x-rays were ordered, and Tylenol was administered for pain. There was no documented evidence in the 07/20/2025 through 07/24/2025 nurse progress notes that an assessment was done by a registered nurse after the 07/20/2025 fall. The staffing schedule dated 7/20/2025 documented there was not a Registered Nurse working from 7 AM on 7/19/25 until 7 AM on 7/20/25. During an observation and interview on 10/30/2025 at 10:45 AM Resident #6 was in bed with two (2) staff providing incontinence care. Resident #6 was alert but did not recall the fall. During an Interview on 10/30/2025 at 11:40 AM, Licensed Practical Nurse #8 stated if there was no registered nurse in the building they could facetime the Director of Nursing. They stated they did not remember specifics but stated they would not get the resident off the floor without a registered nurse assessment. They stated they completed the Accident and Incident Report and were unsure why there was no documentation of a registered nurse assessment. During an interview on10/30/25 at 12:56 PM the Director of Nursing stated they usually completed the investigation for unwitnessed falls. They stated they did not recall this specific event and were unsure if a registered nurse assessed the resident prior to them being returned to bed. They stated if a registered nurse assessed the resident a note should have been written. They stated a supervisor should have written a note, and a registered nurse assessment should have been completed. They stated nurses should have written notes for three (3) days after the fall. They did not know why this was not done. 3) Resident #4 had diagnoses that included dementia, depression and anxiety. The 07/07/2025 quarterly Minimum Data Set documented Resident #4 had severe cognitive impairment and received maximal assistance for bed mobility and transfers. The 05/19/2025 care plan titled Fall Risk documented keep items in reach, gripper socks to feet at bedtime, keep room well-lit and clutter free, keep resident in areas of increased visibility, bed in lowest position. The 07/19/2025 Accident/Incident Report documented the resident was observed lying on the floor on the left side along the right side of the bed with what appeared to be blood coming from the left nostril. The resident was assisted off the floor and transferred to bed with staff assistance of two persons. The physician and family were notified at 6:00 PM. Follow up for 72 hours and observe for signs and symptoms of injury such as ecchymosis, pain, swelling and a change in mentation or behavior. There was no documented evidence in the nursing progress notes from 07/19/2025 through 07/29/2025 that a registered nurse assessed Resident #4 prior to the resident being transferred from the floor to the bed. There was no documented evidence that 72-hour post fall monitoring was conducted and/or treatment was put in place to address Resident #4's bloody nose. The staffing dated 7/19/25, documented on the second floor Licensed Practical Nurse #12 worked 7 AM -7 PM, Licensed Practical Nurse #13 worked 7 AM to 2 PM and Licensed Practical Nurse#14 worked 7 PM -11PM. Licensed Practical Nurse Supervisor #8 worked 7 PM on 7/19/25 to 7 AM on 7/20/25. There were no Registered Nurses scheduled to work from 7 AM on 7/19/25 until 7 AM on 7/20/25. During this time Resident#4 was found on the floor in their room on 7/19/25 at 6 PM with a bloody nose. During an interview on 11/6/25 at 10:20AM, Certified Nurse Aide #11 stated they found the resident on the floor. They stated they knew they could not move the resident and told Licensed Practical Nurse #12. They stated the resident was transferred back to bed by Licensed Practical Nurse #12 and Licensed Practical Nurse #8. They stated there were no other nurses that came to see the resident. During an interview on 10/30/25 at 11:55AM, Licensed Practical Nurse #12 stated the process was to call the Director of Nursing. Licensed Practical Nurse #12 stated they did not recall speaking with the director of nursing regarding Resident #4's fall. They stated they often communicated with the Director of Nursing via text. They stated they had not seen the Director of Nursing come to the facility to assess residents after fall/s. During an interview on 10/30/25 at 11:31AM, Licensed Practical Nurse Supervisor #8 stated they were working at the time of Resident #4's fall. They stated the process was to call the Director of Nursing, the Medical Director, and corporate nurse if there was a fall in the building after hours. They stated many times there were no registered nurses working at the facility when residents had falls. They stated they did not remember a registered nurse being in the building to conduct an assessment at the time of Resident #4's fall. During an interview on 10/29/2025 at 11:38AM, the Director of Nursing stated they were the backup when there were no registered nurses in the building. They stated they did not come to the facility to assess residents, instead the nurses called them with problems, and they provide guidance and support over the phone. They stated they did not write notes after speaking to nurses about incidents. They stated they were not aware of Resident #4's 07/19/2025 fall until 07/21/2025. They stated they had an in-service with the nurses to remind them they needed to call them about falls in the facility. During a follow up interview on 10/30/2025 at 12:56 PM the Director of Nursing stated they now remembered being notified by the nurse about the fall. They stated they did not write a note or an assessment because they had a lot of things on their mind. 10NYCRR 415.12

Based on observation, interview, and record review conducted during the abbreviated survey (2574633), the facility did not ensure each resident received adequate supervision consistent with resident's needs to prevent accidents for one (1) of three (3) residents (Resident #7) reviewed for accidents. Specifically, Resident #7 sustained an upper left lateral thigh burn on 04/12/2025 after they spilled a hot beverage. The facility did not thoroughly investigate the accident and implement interventions to prevent reoccurrence. Subsequently, Resident #7 sustained second degree burns on the left upper thigh on 08/04/2025 after placing their hot cup of coffee next to their thigh while self-propelling in their wheelchair. Additionally, the facility did not report either burn incident to the New York State Department of Health.The findings included:An untitled facility policy last dated 10/02/2024 documented: It is the policy of the Facility to promote and maintain a safe environment, and to maintain reports and surveillance of all resident's accidents and incidents. The purpose is to investigate and document all accidents and incidents and develop corrective measures to prevent reoccurrence. The Director of Nursing/designee is to review initial information with Administrator to determine if there had been a care plan violation or other criteria to prompt a report to Department of Health such as suspicion of abuse, with appropriate follow-through per prevailing regulation and best practice. Nursing will review the completed report with the Interdisciplinary team in Morning Report and discuss outcomes of investigation including causative/contributory factors, efforts to prevent recurrence, care plan updates and any necessary resident or employee education needs.1) Resident #7's diagnoses included paranoid schizophrenia, neurocognitive disorder with Lewy bodies and hypertensive disorder.An Annual Minimum Data Set completed 04/28/2025 documented Resident #7 had moderate cognitive impairment, required set-up/clean up assistance with eating, and self-propelled in a wheelchair. An Accident and Incident report dated 04/12/2025 completed by Licensed Practical Nurse Supervisor #15 documented Resident #7 was found with two blisters on left thigh which Resident #7 stated they received when they spilled hot chocolate on 04/11/2025.The nursing progress note completed by Licensed Practical Nurse #15 dated 04/12/2025 at 6:55 PM, documented they were notified by Licensed Practical Nurse #16 that Resident #7 had blisters to left lateral upper thigh. The resident stated I spilled hot cocoa on myself during dinner last night and I didn't tell anyone. The Nurse Practitioner was notified and wound care notified. New orders included vitals every shift for three (3) days and to cleanse area with DermaKlenz (wound cleanser), apply Silvadene (cream to prevent and treat infection) to blisters and cover with boarder gauze daily. Certified Nurse Aide #14's written statement dated 4/12/2025 documented while doing morning cares on Resident #7, they noticed two blisters on the resident's left thigh. They stated the resident told them it happened yesterday (4/11/2025) while drinking hot chocolate. Certified Nurse Aide #14 documented they notified the nurse. A Post-Incident Skin assessment dated [DATE] by Registered Nurse #6 documented a burn blister on left thigh. The 04/12/2025 Accident / Incident report was signed off by the Director of Nursing on 4/14/2025 and documented the resident had poor safety awareness, was educated on appropriate safe handling of hot beverages and there was no evidence of abuse/neglect. The report did not include an investigation to determine how abuse was ruled out or a root cause analysis to prevent further recurrence. Additionally, there was no documented evidence the burns were reported to the New York State Department of Health.The resident comprehensive care plan was updated on 04/14/2025 documented a blister to the left hip. Interventions included to refer for follow-up with the wound care team, perform wound care rounds weekly, assess characteristics of ulcer daily during treatment care and document findings weekly, apply local treatments as ordered by physician, monitor food consumption, and dietary education regarding use of hot chocolate cup, dietary referral. A dietary note dated 04/14/2025 completed by the Registered Dietician documented they were informed by nursing that Resident #7 spilled hot chocolate on themselves over the weekend. They encouraged the resident to consume all hot liquids during meals or ensure hot liquids had a lid to reduce risk of spills. No further updates were made to the resident's care plan with interventions to prevent reoccurrence. The Certified Nurse Aide Kardex (care instructions) did not document any instructions for hot beverage management or increased supervision with hot beverages.An Accident and Incident report dated 08/02/2025, completed by Licensed Practical Nurse #8 documented Certified Nurse Aide #11 reported Resident #7 was found with three open areas on left hip. Resident #7 stated they burned themself with hot coffee a few days ago. The Accident/Incident report documented the 3 open areas measured 4 X 3 centimeters, 5 x 2 centimeters, and 3 x 3 centimeters. The physician was notified at 10:45 PM on 8/2/25 and no instructions were documented. New interventions put into place at the time of event included a coffee mug with lid and cupholder. The Accident & Incident Report was signed off by the Director of Nursing and the Administrator on 8/11/2025 and documented the wound on hip was related to poor safety awareness and handling of coffee cup. There was not an investigative summary to determine if the accident was avoidable or a root cause analysis.The 08/03/2025 nursing progress note Licensed Practical Nurse #8 documented the resident was reported to have three (3) open areas on left hip. The physician was notified. The area was cleansed with normal saline, and triple antibiotic ointment and dry protective dressing were applied. The resident stated they burned themself with coffee a few days ago but did not recall when. The resident had been witnessed putting a cup with black hot coffee and no lid next to their body when in the wheelchair. Licensed Practical Nurse #8 suggested obtaining a metal coffee mug with lid and cup holder for the wheelchair to prevent further incident. A wound care physician's note dated 8/4/2025 at 12 PM, documented the resident was seen for 2nd degree burns to left hip.The care plan updated 08/17/2025 (2 weeks after the incident) titled Skin Integrity: left hip blister documented: Resident has skin breakdown related to 08/02/2025 left hip blister. Interventions included: apply local treatments as ordered by physician. Assess characteristics of ulcer daily during treatment care and document findings weekly. Assess for pain, effectiveness of pain medication as per physician order. Monitor for signs and symptoms of infection (increased redness, warmth, drainage, foul odor, etc). Perform wound care rounds weekly. Refer for follow-up with the wound care team, rehab screen, supervision during meals. There were no further interventions to address burn prevention and the lidded cup was not added to the care plan until 10/29/2025.During an observation on 10/30/2025 at 10:55 AM, Resident #7 was observed self-propelling in hallway on Unit 2. A metal, reusable coffee cup with lid and cup holder was observed on right arm of wheelchair. During an interview on 10/30/2025 at 1:55 PM, the Administrator stated the facility expectation would be that the Director of Nursing review Accident and Incident Reports for completion and ensure that a root cause analysis included in the investigation. The Administrator stated they sign-off on completed Accident and Incident Reports and check for completion. They stated they were not aware if a root cause analysis was completed for the 08/02/2025 incident involving Resident #7. The Administrator stated that accidents/incidents involving a burn should be reported to the NYSDOH within two hours and that the facility did not notify the NYSDOH. They stated the Administrator or Director of Nursing was responsible for reporting and was not sure why they did not report.During an interview with the Director of Nursing on 10/30/25 at 9:36 AM they stated a Licensed Practical Nurse Supervisor #8 was present when Resident #7's burns/blisters were observed on 8/2/2025 and completed an Accident / Incident Report. Upon review of the Accident and Incident report during the interview, the Director of Nursing stated a root cause analysis was not completed for the accident/incident. They stated a root cause analysis should have been completed by the Director of Nursing or other facility staff. During a follow-up telephone interview on 11/19/2025 at 1:30 PM, the Director of Nursing stated they not informed of the accident on 04/12/2025 and should have been as there was no Registered Nurse in the building on 04/12/2025. The Director of Nursing stated they reviewed the Accident and Incident Report on 04/14/2025. They stated they did not complete a root cause analysis or investigation including the circumstances leading up to Resident #7 being burned or location of where the burn occurred. The Director of Nursing stated residents received hot fluids with their meal trays and could also request hot fluids from staff during other times. They stated the kitchen staff monitored the temperature of hot fluids delivered to units and the unit staff did not check temperatures. Thick cups were used for hot beverages with plastic covers which should be used all the time. They stated that if staff observed a resident ambulating or propelling in their wheelchair with an uncovered hot liquid, staff would assist the resident and by carrying the cup or obtaining a lid. During the interview, the Director of Nursing reviewed the electronic medical records and stated the only intervention put in place after the 04/12/2025 accident was resident education. They could not locate any further interventions to prevent reoccurrence. They stated they were aware that a recommendation was made by Registered Dietician to include a lid with beverages for Resident #7 and that the recommendation was not entered into the Resident care plans or the Certified Nurse Aide task records until 10/29/2025. The Director of Nursing stated facility staff, including dietary, nursing and management discussed the lid use recommendation during morning report after the incident. They were not aware how this intervention would have been discussed with Certified Nurse Aide staff since it was not added to their tasks by nursing until 10/29/2025 (five months after the first burn and 2 months after the second burn). They were unaware why a portable cup with lid was not put in place after the 04/12/2025 accident. The Director of Nursing stated they or the Administrator would be responsible for informing the Department of Health of resident burn. They stated the Department of Health should have been notified and were unaware why the notification did not occur. During an interview with Licensed Practical Nurse #15 on 11/19/2025 at 2:32 PM they stated they recalled being notified by unit staff on 04/12/2025 that Resident #7 had blisters on left upper thigh. They stated they spoke to Resident #7 who stated they had spilled hot cocoa on the evening of 04/11/2025. Licensed Practical Nurse #15 stated they notified the Nurse Practitioner by phone and received orders for treatment. They did not recall if there was a Registered Nurse in the building on 04/12/2025 or if they contacted the Director of Nursing. They stated they were not aware of any interventions that were put in place after the incident to prevent reoccurrence. They stated staff monitored for lids during tray pass and in the dining room. If a resident was observed in the hallway carrying hot fluids, they would be redirected to sit and complete the hot liquid or the Certified Nurse Aide would carry the hot fluid to the resident's room. They stated they were not aware of the supervision needs for Resident #7 who was very independent.10NYCR 483.25 (d)(1)(2)

Based on observations, record review, and interviews conducted during an Abbreviated Survey (2579539), the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain personal hygiene for one (1) of three (3) residents reviewed for activities of daily living. Specifically, Resident #3 was dependent on staff assistance for bathing and did not consistently receive showers twice per week per the resident's care plan and preference. The findings include: The policy and procedures on Activities of Daily Living/Maintain Abilities, revised 09/11/2024, stated that the facility was responsible for creating an environment that individualized each resident's quality of life. Staff across all shifts and departments were expected to understand and support principles of quality of life and honor each resident's preferences, choices, values, and beliefs. The facility also ensured residents were given appropriate treatment and services to maintain or improve their ability to perform activities of daily living. Resident #3 was admitted with diagnoses including cerebrovascular disease, dysarthria, and asthma. The admission Minimum Data Set assessment, dated 01/23/2025, documented the resident had intact cognition. For preferences for customary routine and activities, it was documented as very important for Resident #3 to choose between a tub bath, shower, bed bath, or sponge bath. Resident #3 was dependent on staff to complete bathing, and transfers for bathing and showering. The comprehensive care plan for activities of daily living dated 01/20/2025 documented interventions to provide showers twice per week as per the resident's preference. The 7/31/2025 Resident Nursing Instructions (care instructions for direct care staff) documented to shower on Tuesday and Friday evenings (initiated 01/24/2025). The July 2025 Certified Nurse Aide accountability documentation for the 3PM to 11PM shift, documented the resident received 5 of 9 showers for the month. The August 2025 Certified Nurse Aide accountability documentation for the 3PM to 11PM shift, documented the resident received 3 showers for the month. During an observation on 10/29/2025 at 11:50 AM, the resident was in bed not wearing a shirt and wearing an adult brief as the sheet was off the resident's body. The resident was interviewed during the observation and stated they did not always get showers when they should. During an interview on 10/30/2025 at 9:10 AM, the Staff Development Licensed Practical Nurse stated the resident usually told the staff when they wanted their shower, and the resident did not refuse their showers. During an interview on 10/30/2025 at 1:57 PM, Certified Nurse Aide #2 stated there was a time when the resident reported they did not receive a shower on the 3 PM-11 PM shift. During an interview on 10/30/2025 at 2:32 PM, the Director of Nursing stated they observed a pattern on the 3-11 and 11-7 shifts in which the Certified Nurse Aides were not documenting the care provided. The Director of Nursing stated the supervisor should review the Kiosk to confirm that documentation was completed. 10 NYCRR 415.12 (a)(3)

Based on observations, record review, and interviews conducted during an Abbreviated Survey (2579539) from 10/28/2025 to 10/30/2025, the facility did not ensure that residents were provided with appropriate treatment and services to achieve or maintain as much bladder and bowel function as possible for one (1) (Resident #3) of three (3) residents reviewed for activities of daily living. Specifically, Resident #3 was admitted with occasional incontinence of urine and bowel, was not provided services to maintain or improve incontinence. The resident expressed their preference not to wear adult briefs, was not trialed on a toileting program, and their incontinence episodes increased. The findings include: The policy and procedures on Activities of Daily Living/Maintain Abilities, revised 09/11/2024, stated that the facility was responsible for creating an environment that individualized each resident's quality of life. Staff across all shifts and departments were expected to understand and support principles of quality of life and honor each resident's preferences, choices, values, and beliefs. The facility also ensured residents were given appropriate treatment and services to maintain or improve their ability to perform activities of daily living. Resident #3 was admitted with diagnoses including cerebrovascular disease, dysarthria, and asthma. The admission Minimum Data Set assessment tool, dated 01/23/2025, documented the resident had intact cognition and was dependent on staff to complete toileting hygiene, bathing, and transfers for bathing and showering. The resident had an external catheter, was occasionally incontinent of urine (less than 7 episodes of incontinence during the 7-day look back period) and occasionally incontinent of bowel (one episode of bowel incontinence). The comprehensive care plan for urinary incontinence dated 01/20/2025 documented goals included the resident would be maintained on a toileting program to promote dignity and prevent skin breakdown. Interventions included to monitor for redness or skin breakdown during toileting or diaper changes every 2 to 4 hours. The care plan for Incontinence Prevention dated 01/20/2025 documented the resident was at risk for episodes of incontinence. Goals included the resident would maintain continence to ability with interventions. Interventions included utilize clothing that is easily removed to facilitate toileting, physical therapy/occupational evaluation and treatment as needed, and provide incontinence briefs. There were no updates to the care plan for continence after 1/20/2025. The quarterly Minimum Data Set assessment tool, dated 07/21/2025, documented the resident had intact cognition and was dependent on staff for toilet transfers. The resident had no urinary appliance, was frequently incontinent of urine ( 7 or more episodes of urinary incontinence, but at least one episode of continent voiding) and always incontinent of bowel (no episodes of continent bowel movements). The Minimum Data Set also documented a trial of a toileting program had not been attempted on admission/entry or reentry or since urinary incontinence was noted. The 7/31/2025 Resident Nursing Instructions (care instructions for direct care staff) documented the resident was incontinent and interventions were incontinence briefs, urinal, condom catheter initiated on 1/20/2025 with no updates. For Bowel Continence it documented continent with no updates since 1/20/2025. Toilet Use was documented as the resident was total dependence with one person assist, was incontinent of urine (starting 1/20/25) and incontinent of bowel (changed on 3/1/25), toilet type was bedpan or incontinence briefs. The care card was updated on 7/28/2025 to assist with toileting needs and provide incontinent care every 3 to 4 hours and as needed. During an observation on 10/29/2025 at 9:10 AM, the resident was observed in bed while Certified Nurse Aide #2 was providing care. During a telephone interview on 10/29/2025 at 10:23 AM, Resident #3's family member stated the resident wore adult briefs and it was not good for their skin. The family member stated the resident was assisted to the toilet when the resident was out on pass with the family. During an observation on 10/29/2025 at 11:50 AM, the resident was in bed not wearing any shirt and wearing an adult brief as the sheet was off the resident's body. The resident was interviewed during the observation they stated when they needed help, they yelled for staff to assist by calling, nurse! nurse! Staff did not answer, and they would be incontinent. They did not like wearing the brief and would like to be assisted to the toilet. They stated that when they went to visit their family, they did not wear adult briefs and used the toilet. The resident stated the staff were aware of their preference to be assisted to the toilet; they had told the certified nurse aides and nurses, but they did not listen to them. During an interview on 10/30/2025 at 1:08 PM, Certified Nurse Aide #2 stated that the resident transferred with two assistants, could stand and was capable of being toileted. They also stated at times they did not have the staff to assist the resident. During an interview on 10/30/2025 at 1:27 PM, Registered Nurse #6 stated that the resident had not been on a toileting program. During an interview on 10/30/2025 at 1:57 PM, the Director of Rehabilitation stated that the resident could request to sit on the toilet and that the rehab team did not recommend that the resident not be toileted. They stated toileting schedules were the responsibility of nursing to implement. During an interview on 10/30/2025 at 2:12 PM, the Nurse Practitioner stated that if the resident was aware of when they needed to go to the bathroom, then the resident should be trialed with voiding and could use a bedside commode. The Nurse Practitioner also stated that they did not know the resident's full capacity but would have physical therapy re-evaluate the resident for toileting need. During an interview on 10/30/2025 at 2:32 PM, the Director of Nursing stated Resident #3 was not on a voiding program and the resident was not a candidate for a voiding program because they require two assistants for transfers. 10 NYCRR 415.12 (d)(2)

Based on interview and record review conducted during an abbreviated survey (2582016) the facility did not ensure that pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals) met the needs of each resident for one (1) (Resident #1) of three (3) residents reviewed for medications., Specifically, Resident #1 was not administered six (6) doses of eszopiclone to treat insomnia. The finding include:Resident #1 had diagnoses that included bipolar disorder, Lupus anticoagulation syndrome, and insomnia.An admission Minimum Data Set, (an assessment tool) dated 08/08/2025 documented the resident's cognition was intact. The resident received hypnotic medication daily.The policy titled Administering Medications dated 03/2025, documented if a medication is missing / unavailable, the overflow/extra medication supply storage in the med room should be checked. if it is not there, the emergency box should be checked to see if it is present. If it is not present the nurse should call the Medical Doctor/Nurse Practitioner for a hold order, document and call the pharmacy on the whereabouts and when the delivery will be, or an alternative that is available as stock or in the emergency drug box inventory. Monitor for potential effects of medication not given based on diagnoses being treated. Report all unusual events to nursing management promptly. A Physician order dated 09/15/2025 documented eszopiclone three (3) milligrams, one (1) tablet daily at bedtime for insomnia.The October 2025 Medication Administrator Record documented eszopiclone was not administered on 10/11/2025-10/16/2025. The nurse documented in the comment section of the Medication Administration Record on order on 10/11/2025-10/13/2025, on 10/15/2025 it was documented as unavailable on 10/14/2025 and 10/16/2025 the medication administration record had no documentation. The nurse progress notes from 10/11/2025-10/16/2025 did not document the sleeping medication was unavailable or not given.A Grievance report dated 10/17/2025, included an undated letter, addressed to the Director of Nursing, from the resident documenting they had not received their sleep medication. The Director of Nursing met with the resident regarding their concern and explained to the resident why the medication was not available for six (6) nights. The medication required prior insurance authorization. The insurance authorization had been obtained on 10/16/2025 for the medication and the medication was dispensed to the facility on [DATE]During an interview on 10/29/2025 at 9:25 AM, Resident #1 stated they were unable to get eszopiclone (sleep medication) for almost a week. They were unaware if the physician was notified but were told they had no sleep medication in the emergency medication box.During an interview on 10/29/2025 at 10:55 AM, Licensed Practical Nurse # 1 stated Resident #1 had a physician order for eszopiclone three (3) milligrams every night at bedtime for insomnia. The medication was unavailable in the facility. They notified the supervisor. They did not attempt to call the medical provider or the pharmacy to obtain the medication or obtain an order for an alternative sleep medication. During an interview on 10/29/2025 at 11:30 AM, the Director of Nursing stated the resident told them about not receiving eszopiclone for several days. A grievance was filed, and an investigation was conducted, and shared with the resident. The pharmacist advised the Director of Nursing the medication was not sent as it required prior approval from the insurance company. The Director of Nursing had called the Medical Provider who offered the resident Trazadone after the fifth missed dose, which the resident declined. The Director of Nursing stated they spoke with the pharmacy consultant and the pharmacy obtained the insurance approval, and the medication was delivered on 10/17/2025. They stated the medication nurse should have called the medical provider and or the pharmacy to obtain an alternative medication to help the resident sleep. They did not recall the pharmacy informing them of the need to obtain insurance approval and were unaware the medication would not have been delivered to the facility. The Director of Nursing stated they had not obtained prior approval in the past and thought it was the pharmacy's responsibility.During an interview with on 10/29/2025 at 12:03PM, the Nurse Practitioner stated if a medication was unavailable, they would expect either the nurse or the pharmacy to notify them. They were away in October during this time so they would have expected a medical provider would have been called.During an interview on 10/29/2025 at 2:15 PM, the physician stated they were made aware the resident did not get eszopiclone as ordered after six (6) doses were missed. They stated if they had been notified when the medication ran out, they could have ordered the resident an alternative sleep medication. During an interview on 10/30/2025 at 1:45 PM, the pharmacy representative stated the Director of Nursing notified them the resident had not received eszopiclone from 10/11/2025-10/16/2025. They stated they thought the pharmacy had notified the facility that this medication required insurance authorization prior to the medication being refilled and sent to the facility. The pharmacy representative was unsure who notified the facility, or when the facility was notified. They stated the pharmacist obtained the authorization from the insurance company for the eszopiclone, so the medication could be sent to the facility.10NYRCC 415.18 (a)

Based on observation, record review and interview conducted during the recertification and abbreviated surveys (NY00352254 and NY00340278) from 9/5/24 to 9/13/24, it was determined the governing body did not establish and implement policies regarding the management and operation of the facility to ensure regulatory compliance. Specifically, the large elevator was not working consistently since the spring of 2024 and the facility did not ensure the Quality Assurance Performance Improvement committee developed and implemented an appropriate plan of action to address identified issues related to the large elevator being out of service. Findings include: The facility policy, 'Elevator Breakdown-Single Car Operation' last review April 2024 documented during downtime of one elevator car, the facility will continue to operate with as little impact as possible to resident convenience, quality of life, and provision of services. The Administrator and Maintenance Director/designee must be notified immediately upon awareness of elevator outage event with identification of specific elevator car that is not operational. Downtime of larger elevator car will potentially impact meal delivery, evacuation processes, and movement of larger items that exceed the capacity of the smaller elevator car. The fire department will be made aware of the single car operation situation to manage emergency response in the event of a fire call and to plan for any necessary non fire evacuation of the upper level of the building during which the elevator would be used. If the larger elevator car is non-operational dietary services will modify delivery of meals by use of transport cards that can fit on the smaller elevator stairwell modifications are in place to accommodate safe transport of bariatric residents by stretcher between levels admission criteria during large elevator car downtime will be adjusted to defer bariatric admissions. Facility staff members were aware that the large elevator was shut down, but no quality assurance measures were put in place to identify or address the issue and ensure clinical staff and residents were educated on interventions/plan to address the problem. The facility could not provide any documentation of interventions/plans that were put in place to address the issue No evidence of a Quality Assurance Performance Improvement plan action to address identified issues related to the large elevator being out of service was documented. (See F865) On 9/13/24 at 9:10 AM during an interview, the facility owner/ operator stated they were aware of the broken large elevator. The facility owner/ operator stated they believed the broken large elevator was a topic in Quality Assurance Performance Improvement meetings because in Quality Assurance Performance Improvement meetings, they discussed the issues in the facility, but they were not sure if that occurred. They stated they did not go to any Quality Assurance Performance Improvement meetings. In reference to having created a plan during the shut-down of the large elevator, the facility owner/operator stated they have people that work for them that do that. The facility owner operator stated they believed the staff were maintaining the food temperatures for the residents during the period that the large elevator has been shut down. The facility owner operator stated they were not aware that live music did not occur. They stated they had alternative activities in the building. They stated they did not think the broken elevator negatively impacted the residents. The facility owner/operator stated the large elevator had issues for last couple of months but did not get shut down totally until the summertime. They stated the technician came in several times, but parts were not readily available. They stated the elevator technician company was having staffing problems, and they kept extending the dates the job would be completed. They stated they were originally told the elevator would be fixed by mid-August. They stated they were not sure how many weeks it was shut down. They stated the small elevator was working, and the fire department was made aware of the situation. The facility owner operator stated that emergency transports and evacuation transports were addressed. They stated they did not think they jeopardized the safety or health of the residents due to the broken large elevator. 10 NYCRR 415.26

Based on observation, record review and interview conducted during the recertification and abbreviated surveys (NY00352254, NY00345799 and NY00340278) from 9/5/24 to 9/13/24, the facility did not ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. This was evident for the entire facility. Specifically, the large elevator was out of order since the spring of 2024. The findings are: The facility policy, 'Elevator Breakdown-Single Car Operation' last review April 2024 documented during downtime of one elevator car, the facility will continue to operate with as little impact as possible to resident convenience, quality of life, and provision of services. The Administrator and Maintenance Director/designee must be notified immediately upon awareness of elevator outage event with identification of specific elevator car that is not operational. Downtime of larger elevator car will potentially impact meal delivery, evacuation processes, and movement of larger items that exceed the capacity of the smaller elevator car. The fire department will be made aware of the single car operation situation to manage emergency response in the event of a fire call and to plan for any necessary non fire evacuation of the upper level of the building during which the elevator would be used. If the larger elevator car is non-operational dietary services will modify delivery of meals by use of transport cards that can fit on the smaller elevator stairwell modifications are in place to accommodate safe transport of bariatric residents by stretcher between levels admission criteria during large elevator car downtime will be adjusted to defer bariatric admissions. The Resident Council Meeting notes dated 3/12/24 documented the residents would like to have outdoor activities when the weather gets warmer. The Resident Council Meeting notes dated 5/7/24 documented the parts of the elevator have been ordered. On 9/5/24 at 9:15 AM, the large elevator was observed with a sign posted, 'Out of Order'. On 9/5/24 at 4:42 PM, 2 large linen carts were observed near the elevator. Activity Aide #6 stated, 'We use those to bring meal trays onto the unit because the big meal truck does not fit into the small elevator'. On 9/5/24 at 4:45 PM, Activity Aide #7 was observed on the lobby level near the elevators, removing resident meal trays from the large, insulated meal truck and loading them onto linen carts. When asked, Activity Aide #7 stated, 'We do that because the big meal truck does not fit in the small elevator'. On 9/5/24 at 5:30 PM during an interview, [NAME] Supervisor #1 reviewed the temperatures taken from a meal tray and stated those temperatures were within the danger zone. They stated it is a transportation issue. They stated foods are checked for safe temperatures in the kitchen 3 times during dinner tray service at 4:45 PM, 5:15 PM, and 5:45 PM. They stated the facility has a large food truck which can withstand the heavy weight of china plates which can be heated to retain food temperatures, and the food truck is also insulated, but the large food truck is not being used to bring meal trays upstairs because it does not fit into the small elevator. They stated that because the large elevator is broken, trays are currently being brought to the units on un-insulated linen carts which cannot withstand the heavy weight of the china plates which can be heated to keep food hot. They stated they have not been checking food temperatures on the units since the large elevator was shut down because they did not have time and wanted to get the resident's trays to the residents as fast as possible. On 9/5/24 at 5:36 PM during an interview, the Food Service Director agreed that the food temperatures reviewed taken from the meal tray were in the danger zone. The Food Service Director stated they agreed with [NAME] Supervisor #1's statements regarding foods being served in the danger zone. The Food Service Director stated that the large elevator has been out of service for some time. The Food Service Director stated they are not sure who is responsible for the problem of serving foods within safe temperatures, stated it is probably a combination of the broken large elevator and not having enough staff on the unit to pass the trays timely. They stated they have not been checking food temperatures on the units since the large elevator was shut down because they did not have time. They stated they had wanted to get the resident's trays to the residents as fast as possible. On 9/5/24 at 5:46 PM during an interview, the Administrator stated they were not aware that food is being served in the danger zone. They stated they were not aware of any dietary staff taking food temperatures on the units. They stated the elevator has been broken since April. They stated that the technician came last week but they are waiting for parts. They stated that is the only company that works on this type of elevator. On 9/6/24 at 1:00 PM during an interview, the Director of Maintenance stated the large elevator was jamming a dozen times a day starting in April, the elevator technician came out but did not have the parts available to repair the problem. The Director of Maintenance stated the large elevator was out of order since mid-July. They stated they called other elevator repair companies, but they would not have been able to do the repair any faster than [NAME] Inc. so the facility chose [NAME] Inc. for the repair. They stated the parts have been very difficult to obtain because the elevator parts became obsolete in 1969, and now the parts need to be retrofitted. On 9/11/24 at 5:35 PM the survey team observed two Emergency Medical Technicians bringing a stretcher into the small elevator. The Emergency Medical Technicians were observed lifting the head of the stretcher to approximately 45 in order to fit the stretcher into the small elevator. The Emergency Medical Technician lowered the head of the stretcher as much as possible and the head of the stretcher remained at approximately a 45 angle. On 9/11/24 at 5:35 during an interview, the Emergency Medical Technician stated the stretcher could not go flat inside the small elevator and demonstrated at such. On 9/11/24 at 6:02 PM during an interview, the Director of Activities stated that approximately 10 residents were eating lunch in the main dining room on the main floor before the large elevator was shut down. On 9/12/24 at 8:35 AM during an interview with the Director of Maintenance and a review of documentation of communication between the Director of Maintenance and the elevator installation and repair company, the Director of Maintenance stated that at beginning of April, the large elevator door was not closing properly 2-3 times daily and if the door did not close, the elevator would not move, and the Director of Maintenance further stated that the technician determined the problem was the speed reducer, but it would take a long time to receive the part, the Director of Maintenance stated they found the part on E-Bay but the elevator repair company did not approve installation of a used part. The Director of Maintenance provided: -Text messages dated May 13 and May 21 from the Director of Maintenance to elevator repair company asking for follow-up. The Director of Maintenance stated that some phone calls ensued to try to establish a plan for repair, which were undocumented. -An invoice dated June 21st to elevator repair company and a check dated July 3rd. -A text message dated July 12 requesting follow-up shipping date of part. -A letter dated July 15th notifying the families of the broken main elevator. -A text message dated July 29th requesting follow-up shipping date of part. The elevator repair company replied they were unsure of part arrival date and would not have a technician until 3rd week of August. -An email from elevator repair company dated August 12th documented elevator repair company came to facility to begin demolition of large elevator door. -A text message dated August 14 asking elevator repair company why the technician was not at the facility today. Reply from elevator repair company unsure of when technician will be back. -A text message dated August 15th askingelevator repair company for follow-up. -A text message dated August 22nd asking elevator repair company for follow-up. -A text message dated August 23rd from elevator repair company stating they will come after hours to complete the work due to lack of technicians. -A text messages dated August 29th and 30th from the Director of Maintenance asking elevator repair company for follow-up with possible completion date. -A text message dated August 30th from elevator repair company documenting the need for additional parts which are on order. -A text message dated September 4th asking elevator repair company for follow-up. Reply from elevator repair company documented they did not have the correct wiring diagram. -A text message dated September 5th asking elevator repair company for follow-up. -A text message dated September 11th from elevator repair company documented need a new transformer. On 9/12/24 at 7:04 PM, during a record review with the Director of Activities of the April, May, June, July, August, and September activity schedules documented that the concert activity was cancelled on April 25, May 9, May 16, May 23rd, June 6th, June 13th, June 20th in 2024. The Director of Activities stated that concert activities were cancelled in April, May, and June and concert activities were not scheduled for July 18th and 25th because the large elevator was shut down. On 9/13/24 at 9:10 AM during an interview, the facility owner /operator stated they were aware that the large elevator was out or order. They stated the large elevator had issues for last couple of months but did not get shut down totally until the summertime. They stated they had the technician come in several times, but parts are not readily available. They stated elevator repair company dominates the region and was having staffing problems, and they keep extending the dates the job will be completed. They stated they were originally told the elevator would be fixed by mid-August. They stated they were not sure how many weeks it was shut down. 10 NYCRR 415.29(f)(1-7)

Based on observation, record review, and interview during the recertification and abbreviated surveys (NY00346428), conducted 9/5/24 to 9/13/24, the facility did not ensure each resident remained as free of accident hazards as possible for 4 of 5 residents (#35, #161, #18, and #87) reviewed for accidents. Specifically, 1) Resident #161 had falls on 6/29/24 and 7/4/24, was on an anticoagulant (blood thinner) medication and there was no documented evidence of neuro-checks following falls on 6/29/24 and 7/4/24 and the resident was not sent to the hospital for evaluation, 2) Resident #35's shepherd's hook/enabler rail was loose and not functionable for over one month, 3)Resident #18 had a fall on 8/2/2024 and sustained a hip fracture and the fall care plan was not updated with new interventions to prevent recurrence of falls, and 4) Resident #87 had falls with major injuries on 2/8/24, 2/29/24 and 5/8/24 and the fall care plan was not updated with new interventions to prevent recurrence of falls. Findings include: The policy and procedure titled Resident Falls last revised September 2023 documented each resident fall will be managed in a manner that maximizes well being and safety including assessment for injury with appropriate follow up. The follow up procedure determines the causative/contributive factors, root cause, interventions to prevent recurrence, or in the event that recurrence is highly likely means to prevent major injury from falls. The undated facility Accident/Incident Prevention and Management policy documented it is the policy of Renaissance Rehabilitation and Nursing Care Center to promote and maintain a safe environment and develop corrective measures to prevent reoccurrence. 1. Resident #35 had diagnoses which included personal history of transient ischemic attack, flaccid hemiplegia affecting left non-dominant side, and obesity due to excess calories. The 8/13/2024 Minimum Data Set Assessment documented the resident had intact cognition, and was dependent for bed mobility (rolling left to right). The comprehensive care plan titled: Activities of Daily Living: transfer, bed mobility, ambulation (last updated 5/23/23) documented the Resident required assistance with activities of daily living tasks secondary to cerebrovascular accident with left hemiplegia. Resident is dependent with transfers requiring assistance of 2 staff via mechanical hoyer lift. Resident required extensive assist of 1 for mobility and was non-ambulatory. Interventions included to Assist with transfers and bed mobility as recommended. Bilateral shepherd hooks to bed, encourage participation in activities of daily living care. On 9/05/24 at 10:20 AM, 9/06/24 at 10:20 AM, 09/09/24 at 10:14 AM, and 9/10/24 at 10:38AM, Resident #35's shepherd's hook/enabler rail on the right side of the bed was observed to be loose and not functionable. On 09/05/24 at 10:20 AM during an observation and brief interview with Resident #35, the shepherd's hook/enabler rail on resident's right side was observed to be loose. Resident #35 stated that the shepherd's hook/enable rail had been loose for over a month, and they were not able to utilize side rail to turn and reposition or push themselves up in bed. Resident #35 stated they had informed numerous unit staff members of the defective shepherd's hook/enabler rail and that the facility maintenance checked it over a month earlier but did not complete a repair. Resident #35 stated the broken shepherd's hook/enable rail affected their daily bed mobility by making it difficult to turn and reposition, reach for items on side table, and move up in bed and during cares. Resident #35 stated the Certified Nurse Aides observed the broken shepherd's hook/enable rail device daily during cares daily. On 09/10/24 at 11:27 AM during an interview, Licensed Practical Nurse #4 stated that Resident #35 had not discussed a loose shepherd's hook/enable with them and that Resident #35 had only reported television issues in the past. Licensed Practical Nurse #4 stated that right sided shepherd's hook/enabler rail was functional to their knowledge, and they were not aware of device being loose. They stated that the last time they assisted with cares with the resident was over a month ago and that the Certified Nurse Aide provided care to Resident #35. On 09/10/24 at 03:15 PM during an interview, the Regional Director of Maintenance and Life Safety stated they just became aware of Resident #35 broken shepherd's hook/enabler today (9/10/24). Regional Director of Maintenance stated about a month ago (no official date), a member of maintenance team was verbally informed of loose rail by staff on the second floor and they assessed rail. Regional Director of Maintenance stated that the plan to repair side rail required the resident to be taken out of bed so full repair could take place. They stated at the time of assessment, the maintenance staff tightened rails as much as possible with Resident #35 in the bed. Regional Director of Maintenance stated the staff on the second floor were made aware that full repair could only take place if Resident #35 was not present in the bed. Regional Director of Maintenance was not aware why follow up and permanent repair was not made and stated it could be related to recent staff changes in Maintenance Department and communication deficit between Maintenance staff and Second Floor Unit nursing staff. On 09/11/24 at 10:54 AM during an interview Certified Nurse Aide #17 stated they verbally reported to a member of the Maintenance team (name unknown) over a month ago that Resident #35's shepherd's hook/enabler was loose and not functionable. They stated that a member of the Maintenance Department observed shepherd's hook/enabler rail in resident room the same day, tightened bolts but it was never fully repaired. Certified Nurse Aide #17 reported that the member of the Maintenance team verbally reported that Resident #35 would need to be out of bed for the full repair and that Unit Manager was aware of this information. On 09/12/24 at 05:04 PM a review was conducted of the second floor Maintenance Binder there was no record of maintenance request for shepherd's hook/enabler rail repair request from 1/2024 to present date. 2. Resident #161 was admitted with diagnoses which included status post left above knee amputation, osteomyelitis, and rheumatoid arthritis. The fall assessment dated [DATE] documented a score of 12 that indicated that Resident #161 was at high risk for falls. The 5/18/24 physician orders documented that Resident #161 was to receive Eliquis (blood thinner medication) 2.5 mg twice a day. The 5/21/24 Fall Care Plan documented Resident #161 is at increased risk for falls related to: 6/18/24 status post fall no apparent injuries, complained of neck pain at 2:05 AM, neck x-ray result showed no compression deformities, mild degree of osteopenia, mild degree of spondylosis. Noted old bruise on forehead fading away, 6/29/24 s/p fall, no apparent injuries, 7/4/24, s/p fall redness to right side of forehead. The following were documented as interventions: 6/18/24 s/p fall provide positioning wedge cushion; 6/29/24 keep bed in lowest position, neuro checks q shift, fall monitoring x 3 days, bilateral floor mats, scoop mattress overlay provided; 7/4/24 s/p fall hourly check x 24 hour. The 6/14/24 Quarterly Minimum Data Set Assessment (a resident assessment tool) documented Resident #161 had intact cognition. The assessment further documented lower extremity impairment on one side. Resident #161 received dependent assistance with chair and bed transfers. The assessment documented Resident #161 had no falls since admission or prior assessment and did not receive rehab services. The 6/29/24 Accident/Incident Report documented resident unable to describe incident. Resident observed laying on her left side on floor in room beside bed. No apparent injuries on assessment. No mental status change, range of motion within normal limits. The following were documented as interventions: Keep bed in lowest position, floor mats for both sides of bed. Neuro checks each shift and fall monitoring for 3 days post fall. The 7/4/24 Accident/Incident Report documented resident stated she fell out of bed. Resident found lying on floor mat next to bed, resident hoyered back unto bed after assessment, no injuries, no bleeding. The following were documented as interventions: Call bell within reach, safety matts, bed in lowest position, hourly check x 24 hours. There was no documented evidence of neuro checks being done following the falls on 6/29/24 and 7/4/24. Additionally, there was no documented evidence in the electronic medical record to indicate hourly checks were put in place for 24 hours as per care plan after the fall on 7/4/24. On 09/10/24 at 11:31 AM, Certified Nurse Aide #10 stated after the falls, Resident #161 was put in a geri chair and they used floor mats. Certified Nurse Aide #10 stated Resident #161 was always climbing out of bed saying they were going home. On 9/12/24 at 11:46 AM, Registered Nurse Unit Manager #2 stated after a fall they immediately assess resident, get their vitals and call the physician and family. Registered Nurse Unit Manager #2 stated if there was no Registered Nurse overnight, the Licensed Practical Nurse would assess resident. Registered Nurse Unit Manager #2 stated if the resident hit their head from a fall there was nothing different they would do. If there were no injuries, the resident would not be sent out to the hospital. Registered Nurse Unit Manager #2 stated if a resident was on anticoagulant they would notify doctor and doctor would determine if the anticoagulant should be held. Registered Nurse Unit Manager #2 stated it was the same protocol as any other fall. The doctor would order neuro-checks for 3 days and the nurses should write a progress note. Registered Nurse Unit Manager #2 stated the physician was called and they did not order to send Resident #161 to hospital, stated the physician knew the medications Resident #161 was on. When asked, Registered Nurse Unit Manager #2 stated they did not remind the physician that Resident #161 was on an anticoagulant medication. Registered Nurse Unit Manager #2 stated they usually did hourly checks which would be listed on the Medication Administration Record and they would have to check it every hour. Registered Nurse Unit Manager #2 stated they did hourly checks for 24 hours for the fall on 7/4/24, but was never given a paper log to document the hourly checks, and acknowledged it was not documented in the Medication Administration Record or Treatment Administration Record for June and July of 2024. Registered Nurse Unit Manager #2 stated they trie to remind the doctors but sometimes their suggestions were not welcomed. On 09/12/24 at 1:04 PM, the Director of Nursing stated when a resident had a fall and was on an anticoagulant medication, they did not necessarily send the resident to the hospital; it depended on the severity of injury. The Director of Nursing stated they would evaluate the resident. Director of Nursing stated if there was a change in mentation or vitals signs they might send the resident out. The Director of Nursing stated the resident had no change in mentation and the final decision was made by the physician or nurse practitioner whether or not to send the resident to the hospital. The Director of Nursing stated the neuro checks was the way they monitor mentation and acknowledged there was no documented evidence of neuro checks or hourly checks for monitoring in Resident #161's electronic medical record. The Director of Nursing stated if the nurse practitioner did not put in the order for neuro checks or monitoring then it would not populate in the either the Treatment Administration Record or the Medication Administration Record for the nurses to do. The Director of Nursing stated the nurses should remind the Nurse Practitioner if the resident is on an anticoagulant medication after a fall, so the order gets put in for neuro checks. 3. Resident #18 was admitted to the facility with diagnoses which included vascular dementia, chronic obstructive pulmonary disease, and muscle weakness. The 5/7/24 Quarterly Minimum Data Set Assessment (a resident assessment tool) documented Resident #18 had a moderately impaired cognition. The assessment further documented no impairments on the upper or lower extremities. Resident #18 received supervision with chair and bed transfers. The assessment documented Resident #18 was continent of bowel and bladder. A fall risk assessment dated [DATE] documented a score of 11 documenting a high fall risk. A review of the Accident/ Incident Report dated 8/2/2024 documented Resident # 18 was found on their back close to the bathroom door. Urine was on the floor. The resident stated they slid in their own urine on the way to the bathroom. Abrasion to face, 8/10 pain to the right hip. New intervention put in place at the time of the event included encourage resident to call for assistance. A Nursing progress Note dated 8/3/24 at 11:36 AM documented Resident #18 complained on nausea and right hip pain, Nurse Practitioner ordered to give Zofran 4 mg tablet for nausea and transfer to the hospital. A review of the nursing progress note dated 8/4/2024 at 12:37 am documented writer spoke with nurse at the hospital, per nurse, Resident # 18 was diagnosed with a right hip fracture and will have intramedullary nail femur surgery in the morning. A fall risk assessment dated [DATE] documented a score of 12 that is a high fall risk. The Fall Risk Care Plan had no documented evidence of any new interventions added to the care plan after the fall on 8/2/24. The last two interventions were dated 5/24/24. The interventions included to place the bed in the lowest position and resident to be toileted at night. On 09/05/24 at 02:30 PM during an observation and brief interview, Resident #18's room was cluttered with trash on the floor (cups, empty med cup, paper). Nasal cannula tubing was observed on the floor at the bedside. The call bell was not in reach. Resident #18 stated they had a recent fall while trying to go to the bathroom and after the fall they had to go to the hospital. On 09/10/24 at 11:31 AM Resident #18 was observed in the bed with head of bed elevated. Resident's right leg was resting on the wheelchair located near the foot of the right side of the bed and their left leg was on the bed. The call bell was not in reach. Surveyor handed Resident# 18 the call bell and staff from OT assisted the resident to the middle of the bed. On 09/10/24 at 11:38 AM during an interview, Resident #18 stated they are aware that they need assistance to get back in bed. They attempted to transfer themself back to bed because they were uncomfortable in the chair. They stated when they ring their call bell it takes a time for someone to come. Resident #18 stated the day of their fall they attempted to go to the bathroom independently. They stated they made it near the bathroom when they fell and hit the right side of their head and had pain in the right side of their hip. Resident #18 stated they do not use the call bell because it takes so long that they give up and do what they need to do for themself. They stated that sometimes there is only one person on for the whole unit. On 09/12/24 at 11:50 AM during an interview, Licensed Practical Nurse #4 stated they worked in the facility for 7 years. They stated they are not familiar with the care plan for Resident #18. They stated in the past, Resident #18 attempted to get out of bed without help. Licensed Practical Nurse #4 stated that during a medication pass and at various times throughout the day they will monitor Resident #18 for safety per their nursing judgment, although there were no current orders to do so. Surveyor asked Licensed Practical Nurse #4 if Resident #18 had any recent falls. Licensed Practical Nurse #4 stated they are not aware of Resident #18 having recent falls, but after reviewing Resident #18 medical record, Licensed Practical Nurse #4 stated the resident had a fall and fractured the right hip in August. Licensed Practical Nurse # 4 stated they can not recall any new interventions put in place to prevent Resident # 18 after the fall in August from falling again. On 09/12/24 at 12:06 PM during an interview, Certified Nurse Aide #17 stated that in the electronic medical record (Sigma Care) the system identified how to care for Resident #18. Certified Nurse Aide #17 stated the resident had hip surgery and they need to be careful with the transfer of the resident. Surveyor asked Certified Nurse Aide #17 about new interventions put in place for Resident #18 afetr the fall in August. They stated they transfer with the assist of 2 staff, they need to do safety checks on them every 1-2 hours which is documented in the Certified Nurse Aide instructions. 10 NYCRR 415.12(h) 45478 50815

Based on observations and interviews conducted during the recertification survey from [DATE] to [DATE], the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, meat, mashed potatoes, milk, and super shake were not maintained within the acceptable temperature range for food safety during a dinner observation on [DATE]. Additionally, perishable foods were not labeled and dated and nonperishable foods were expired during observations in the kitchen. The undated facility policy, Dietary Department -Food Temperatures documented it is the policy of the dietary department to take temperatures of all food items served to residents before the tray line begins. All parts of potentially hazardous foods requiring cooking will be heated to at least 170 F with the exception of poultry, pork, and roast beef. All poultry, poultry stuffing, stuffed meats, and stuffing containing meat will be heated so all parts are at least 165 F with no interruption of the cooking process. Pork and food containing pork is to be heated so all parts of the food are at least 150 F. Rare roast beef and/or rare beef steaks are to be heated to an internal temperature of 130 F. Proper labeling and dating of each item. left over foods will be used within 3 days. The entire mass of all precooked, refrigerated, potentially hazardous food that is to be reheated is to be heated rapidly to 165 F or above and held above 140 F until served. Potentially hazardous foods requiring refrigeration will be stored and served at a temperature not exceeding 45 F. It is the responsibility of the cook preparing the meal to take temperatures of all the food items served to residents. The temperatures will be recorded before each meal is served on a form designed for this purpose. A chart of correct serving and cooking temperatures is attached to the recording form to guide the cook in ensuring the food is at the proper temperature. The in-service, 'Modified elevator usage' signed by staff on [DATE] included documentation that test tray temperatures are to be taken on unit each meal this is repeated until each unit is served. On [DATE] at 9:15 AM during the initial tour of the kitchen in the walk-in refrigerator, a 2-liter container of liquid eggs was open with no date of when it was opened, a one-liter plastic container half filled with a white- yellow substance was observed with no label, and was undated, and two loaves of sliced white bread were observed on the counter undated. On [DATE] at 9:30 AM during an interview, the Food Service Director stated the egg salad should have a preparation date and a discard date, the liquid eggs should have an open date. The Food Service Director stated that consuming expired food can lead to food poisoning. On [DATE] at 4:42 PM, 2 large linen carts were observed near the elevator. Activity Aide #6 stated, 'We use those to bring meal trays onto the unit because the big meal truck does not fit into the small elevator'. On [DATE] at 4:45 PM, Activity Aide #7 was observed on the lobby level near the elevators, removing resident meal trays from the large, insulated meal truck and loading them onto linen carts. When asked, Activity Aide #7 stated, 'We do that because the big meal truck does not fit in the small elevator'. On [DATE] at 5:20 PM, the surveyor requested food temperatures to be checked on a dinner meal. Registered Nurse Unit Manager #1 checked temperatures on meal tray. The temperature of the meat was 109 degrees, the temperature of mashed potatoes was 116 degrees, the temperature of reduced fat milk and super- shake was 48 degrees. Registered Nurse Unit Manager #1 stated they did not know why the cold foods were not cold enough and the hot foods were not hot enough. On [DATE] at 5:30 PM during an interview, the [NAME] Supervisor #1 reviewed the temperatures taken from the meal tray and stated those temperatures were within the danger zone. On [DATE] at 5:36 PM during an interview, the Food Service Director agreed that the food temperatures reviewed taken from the meal tray were in the danger zone. On [DATE] at 5:46 PM during an interview, the Administrator stated they were not aware that food was being served in the danger zone. They stated they were not aware if staff had been checking food temperatures on the units. On [DATE] at 10:00 AM during the follow up tour of the emergency supply area, ten twelve-ounce bags of gravy mix were observed with an expiration date of [DATE]. On [DATE] at 10:00 AM, during an interview the Food Service Director stated the gravy mix was expired. 10 NYCRR 415.14(h) 44673

Based on observation, interview, and record review conducted during the recertification survey from 9/5/2024 to 9/13/24, the facility did not ensure residents' right to a safe, clean, comfortable and homelike environment. This was evident during environmental observations of resident Units 1 and 2. Specifically, on Unit 2, resident rooms were observed with sticky floors, garbage receptacles overflowing, garbage was strewn the floor, and soiled adult briefs were observed lying on floor; and on Unit 1, the floor near the nursing station and in front of the elevator was littered with garbage, and appeared stained and the Unit 1 dining room floor was observed with dried spills of coffee, and breakfast trays were still on tables at 12:35 PM. The findings are: During observations on 09/05/24 on Unit 1, at 10:12 AM debris was on floors by the Unit 1 nursing station with straws, paper, caps to bottles, and other particles of dust or dirt. The floor by nursing station in front of elevator appeared stained and dirty. At 12:35 PM, the Unit 1 dining room floor was observed with dried spills of coffee, and breakfast trays left on tables after residents had completed their meals. During observations on 09/05/24 of resident room [ROOM NUMBER]: - at 10:07 AM, a soiled adult brief was observed lying on the floor to the left side of the resident bed and the floor had garbage thrown on it and was sticky. - at 11:08 AM, the resident was sitting on the side of the bed and a soiled adult brief and garbage were still present on the floor. - at 12:22 PM, a strong smell of urine was noticed and the resident was sitting at bedside eating lunch; a soiled adult brief remained on the floor. During observations on 09/05/24 of resident room [ROOM NUMBER]: - at 10:20 AM, the floor was littered with garbage, and the garbage receptacle was overflowing. The sink area was soiled with tan stains and littered with resident clothing and debris. - at 12:27 PM, garbage was strewn on the floor, empty cans, empty food containers, the garbage receptacle was full and overflowing, and the floor was sticky. During an interview on 09/05/24 at 12:08 PM, Certified Nurse Aide #16 stated that morning care had not been completed for all residents on their assignment due to them being overwhelmed with 30 residents to provide morning care for, as well as feed and assist with housekeeping. Certified Nurse Aide #16 stated facility was chronically understaffed and they did as much as possible during their shift but had difficulty completing all tasks. During an interview on 09/13/24 12:00 PM with Administrator, they stated facility had sufficient housekeeping staff but felt they could benefit from additional training and oversight. They stated that they were in the process of hiring a new Maintenance Director. They stated that housekeeping staff was available 7:00 AM-3:00 PM shift and 3:00 PM-11:00 PM shift. 10 NYCRR 415.29

Based on record review and interviews conducted during the recertification and abbreviated surveys (NY00352254 and NY00340278) from 09/05/24 to 9/13/24, the facility did not ensure that there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, upon review of the actual staffing from April 1, 2024 through June 30, 2024 and August 9, 2024 through September 9, 2024 on all three shifts for each unit, the facility did not provide adequate nurse staffing to meet the needs of the residents on multiple occasions during each of the months reviewed, based on the Facility-Wide Assessment. The findings are: The Facility-Wide assessment dated [DATE] and reviewed by the Quality Assurance Agency/Quality Assurance and Performance Improvement committee on 8/22/24, stated the below facility resources were needed to provide competent resident support and care daily and during emergencies: Facility-Wide Assessment Staffing Plan: Licensed Nurses providing administrative direction, supervision and direct care: Director of Nursing: 1 Registered Nurse full time days. Assistant Director of Nursing 1 Full time equivalent. Registered Nurse Manager: 2 full time equivalents. RN Supervisors: evenings and weekends: 3 full time equivalents. Licensed Practical Nurse Medication Nurses 7:00 AM-7:00 PM and 7:00 PM to 7 AM: 4-6 Full time equivalents daily. Direct care Staff: Certified Nurse Aides: 6-8 for days, 6-8 for evenings, 4-6 for nights. The facility actual staffing sheets from April 1st through June 30, 2024, August 9, 2024 through September 9, 2024 and the Facility Assessment for residents to direct care nursing staff ratios, documented the facility was understaffed 18 out of 30 days in April, 2024, 24 out of 30 days in May, 2024, and 22 out of 30 days in June, 2024 in nursing staff. During a Resident Council meeting on 09/09/24 at 11:15 PM, one resident stated they waited 4 hours for a response to their call bell and another resident stated that there was no staff to be found at 11:30 PM. Another resident stated the facility was short staffed. During an observation and brief interview on 09/05/24 at 9:55 AM, Resident #81 was observed in bed with trash on right side of bed and wheelchair positioned at the left side of the foot of the bed. Resident #81 stated they had been waiting to get out of bed since 7:30 AM. They rang the call bell and a staff came and shut the call bell off. During an observation on 09/05/24 at 10:07 AM, Resident #66 had a soiled adult brief lying on floor at left side of their bed. The Resident's floor was soiled and sticky. During an interview with Resident #62's family member on 09/05/24 at 11:03 AM, they stated they were informed by nursing staff that when they were short staffed, they could not get residents out of bed. The family member stated Resident #62 was in bed for an entire week. During an interview on 09/05/24 at 11:33 AM, Resident #32 stated they need assistance with shaving, but sometimes the facility was too short staffed. During an observation on 09/05/24 at 11:34 AM with Director of Nursing present, Resident #78 was observed with feces on their hands, on the tray table, and on the floor along with a torn adult brief. The Resident's room smelled of urine and feces. During an observation on 09/05/24 at 11:49 AM, Resident #4 was observed sitting on the side of their bed wearing a pajama top and had soiled diaper. A soiled pajama bottom was observed on the floor. During an observation on 09/05/24 at 12:22 PM, Resident #66's room had a strong smell of odor while eating the Resident was eating lunch. A soiled adult brief was observed on the floor. During an observation and brief interview on 09/05/24 at 12:37 PM, Resident #38 was in bed, wearing a gown, eating lunch. Resident stated they liked to get out of bed but staff frequently told them there was not enough staff to assist them to get out of bed because they required 2 staff assist and a Hoyer lift for transfers. Resident #38 stated they thought they had not gotten out of bed in about a week. During an observation and brief interview on 9/06/24 at 09:58 AM, Resident #38 was lying in bed wearing a gown. Resident #38 stated they wanted to get out of bed but there was not enough staff to assist them. During an interview on 09/06/24 at 10:53 AM, Resident #35 stated they often waited extended periods of time to get changed. During an observation and interview 09/10/24 at 11:38 AM, Resident #18 stated they need assistance to get back in bed. They stated they attempted to self-transfer back to bed because they were uncomfortable in the chair. Resident #18 stated when they ring their call bell it takes a while for someone to come. During a brief interview on 09/05/24 at 12:08 PM with Certified Nurse Aide #16, they stated morning cares were not completed for Resident #45 and Resident #66 before 11:45 AM due to the Certified Nurse Aide being overwhelmed with 30 residents to provide morning cares for and assist residents with breakfast and lunch. Certified Nurse Aide #16 stated they were also requested to assist with housekeeping on the floor during their shift. They stated reason for cares being delayed and assignment of 30 residents was due to a call-out which was not re-staffed by the facility. They stated this occurred at least a few times a month and that staffing shortage had been a chronic concern within the facility. They stated they had difficulty completing their assigned resident care tasks when the facility was short staffed and that some tasks were not completed. They stated overtime was requested frequently. During an interview 09/06/24 at 03:35 PM, Resident #106 complained that staff took a long time to respond to call bells, especially at night. Resident #106 also reported that they recently fell when self-transferring after no staff responded to call bell. During an interview on 9/9/24 at 12:13 PM, the Director of Nursing stated that due to difficulties with nursing staffing between 3 PM to 7 PM, most of the Resident's medications were ordered to be administered at 7 PM. During an interview on 09/10/24 at 11:08 AM, Certified Nurse Aide #18 stated that there were frequently shifts where the facility was understaffed. They stated there were usually 3-4 aides assigned to second floor unit during 7:00 AM-3:00 PM shift, but that sometimes staffing could be as low as two Certified Nurse Aides covering second floor with a resident census of about 50 residents. Certified Nurse Aide #18 stated when staffing was low they had approximately 30 residents assigned to them. They stated resident cares were completed when staffing was low, but were delayed, including assisting residents with meals and answering call bells. They stated overtime was requested frequently. During an interview on 09/10/24 at 11:43 AM, Licensed Practical Nurse #4 stated the facility was frequently not staffed sufficiently. They stated they were requested to work overtime frequently. During an interview on 09/13/24 at 10:30 AM, Registered Nurse Unit Manager #2 stated four Certified Nurse Aides were the optimal amount needed for the unit but there were frequently shifts where there were only 2 to 3 Certified Nurse Aides assigned. They stated that in addition to their role and duties as Unit Manager, they were also responsible for medication administration, providing treatments to residents, assisting with cares when licensed practical nurses and certified nurse aides staffing was low. They stated they had difficulty entering or updating resident care plans as a result of low staffing. They stated that some weeks they were not able to work on resident care plans at all. They stated their assigned hours at hire were to 8:30 AM to 4:00 PM however, they usually were required to work from 7:30 AM-approximately 6:00 PM due to call outs or to have a Registered Nurse in building. They frequently had to cover other floor units to provide medication administration due to short staffing, often resulting in late medication administration. Registered Nurse Unit Manager #2 stated they were frequently contacted when not on duty via phone or text with questions or requested to work overtime by the Director of Nursing. They stated staffing at weekends was especially difficult and the facility was short-staffed frequently on Saturdays or Sundays, especially for Registered Nurses. During an interview on 09/13/24 at 10:52 AM, the Staffing, Human Resources and Payroll Coordinator stated staffing minimums were based on recommendations from facility report and New York State requirements and based on resident census. They stated nursing staffing has been a challenge for the facility over recent years. The facility does not utilize staffing agencies. They did in past and did not feel it benefited facility. They stated from Monday to Friday, there is always a Registered Nurse in the building and weekends usually have a Registered Nurse during the 7:00 PM to 7:30 AM shift. The Staffing Coordinator stated that callouts are handled by contacting all staff who are not working to offer extra shifts and that bonuses/incentives are offered to staff who agree to cover shifts. They will also offer bonuses/incentives to a staff member who is currently working to stay for an additional shift. The Staffing Coordinator stated they have had concerns from staff bought to their attention in the past about staffing shortages. They stated they have not had staffing concerns from families or residents. The Staffing Coordinator stated they are continuously trying to recruit new hires in nursing and dietary and that the main barrier to hiring is related to competition in area. The Staffing Coordinator stated the facility offers incentives and bonuses to entice new hires. Exit interviews are held when a staff member resigns and efforts are made to retain staff. Coordinator stated they have made recent progress with hiring in nursing and dietary aide staff. During an interview on 09/13/24 at 11:25 AM, the Director of Nursing stated staffing schedules are reviewed with the Staffing Coordinator daily. They stated that staffing can be challenging, and they are aware of areas of concern on Payroll Based Journal reports. They stated a Registered Nurse is present in building Monday to Friday and most weekends during 7:00 PM to 7:30 AM shift. The Director of Nursing acknowledged there have been shifts in which there was no Registered Nurse in building after review of staffing logs. They stated that any emergency that occurs when a Registered Nurse is not in the building would be called into facility Nurse Practitioner who is on call 24 hours, 7 days a week, the Director of Nursing and the Medical Director. All falls with major injury would be sent to hospital. They stated that Registered Nurses serving as Unit Managers are often also responsible for medication administration and treatments due to short staffing. The Director of Nursing stated they are aware that resident cares are often completed late or not completed when Certified Nurse Aide staffing is low. They stated the Licensed Practical Nurses and Registered Nurses would assist with cares during low staffing and that due to this, updates to care plans can sometimes be delayed. The Director of Nursing stated that they assist with entering/updating resident care plans when this occurs, which is frequently. The Director of Nursing stated that there are challenges with recruiting Certified Nursing Aides, nursing and dietary staff. They stated housekeeping is adequately staffed. The Director of Nursing stated that the facility hired two Assistant Directors of Nursing over the last year and the facility was not able to retain these hires. Exit interviews were completed and they stated that workload was a presenting factor in deciding not to continue employment. They stated that the facility does not have a staffing waiver and does not utilize staffing agencies. They stated efforts are in place in increase hiring of all nursing staff and dietary employees with bonuses and incentives offered. Overtime is used frequently, and incentives are used to encourage staff members to accept overtime. During an interview on 09/13/24 at 12:00 PM, the Administrator stated that staffing was challenging. The Administrator stated they were not sure if there was a Registered Nurse in the building at least 8 hours, 7 days a week. They stated that there was a Registered Nurse in building Monday through Friday days and most nights and weekends. They stated that emergencies that occurred when a Registered Nurse was not in building would be called in to the facility Nurse Practitioner who is on call 24 hours a day, 7 days a week and / or Director of Nursing who will assess emergency verbally and provide instructions. They stated that the facility continues to recruit for all levels of nursing staff. The Administrator stated call outs are attempted to be restaffed by the Staffing Coordinator or Director of Nursing and by offering overtime with incentives or reassigning staff from another floor to cover. The Administrator stated they believe facility is adequately staffed but would always want more employees. They stated that the facility does not use agency staff and that the facility could benefit from using agencies, however the decision not to utilize agency was made by Facility Corporate leadership prior to the Administrator's hire. The Administrator stated facility has sufficient housekeeping staff but feels they could benefit from additional training and oversight. They stated the facility is in process of hiring a new maintenance director. The Administrator stated Dietary Department is short-staffed as well and stated that the Staffing Coordinator continues to try to recruit through Indeed and friends and family. Administrator stated they feel that staffing shortages may affect resident care in terms of wait time and that the employees work hard to cover deficits. 415.13(a)(1)(i-iii)

Based on record review and interviews conducted during the recertification survey from 9/5/24 to 9/13/24, it was determined that the facility did not use the services of a Registered Nurse for at least eight consecutive hours per day, seven days per week per the regulations. Specifically, the facility was unable to provide documented evidence that a Registered Nurse had worked 4/12/24, 4/13/24, 4/27/24, and 5/18/24. Findings include: Review of the nurse staffing reports (report posted to inform residents and visitors of the number and hours of nursing staff working) for dates 4/1/24 through 6/30/24 and 8/9/24 through 9/9/24 provided by the facility Staffing, Human Resources and Payroll Coordinator, the facility did not have a Registered Nurse assigned to staffing for the facility's three shifts on 4/12/24, 4/13/24, 4/27/24, and 5/18/24. During an interview on 09/13/24 at 10:52 AM with the Staffing, Human Resources and Payroll Coordinator, they stated staffing minimums were based on recommendations from the Facility Report and New York State requirements and based on resident census. They stated nursing staffing has been a challenge for the facility over recent years. The facility does not utilize staffing agencies. Staffing agencies were utilized in the past and the facility did not feel agency use was beneficial. The Staffing Coordinator stated that from Monday to Friday, there is always a Registered Nurse in the building. Weekends usually have a Registered Nurse during the 7:00PM to 7:30AM shift. The Staffing Coordinator stated that callouts are handled by contacting all staff who are not working to offer extra shifts and that bonuses/incentives are offered to staff who agree to cover shifts. During an interview on 09/13/24 at 11:25 AM with the Director of Nursing, they stated staffing schedules are reviewed with the Staffing Coordinator daily. They stated that staffing can be challenging. They stated a Registered Nurse is present in building Monday to Friday and most weekends during 7:00PM to 7:30AM shift. The Director of Nursing acknowledged there have been shifts in which there was no Registered Nurse in building after review of staffing log during interview. They stated that any emergency that occurs when a Registered Nurse is not in building would be called in to the facility Nurse Practitioner who is on-call 24 hours,7 days a week, Director of Nursing and Medical Director. All falls with major injury would be sent to hospital. During an interview on 09/13/24 at 12:00 PM with the Administrator, they stated that staffing is challenging. The Administrator stated they were not sure if there was a Registered Nurse in the building at least 8 hours, 7 days a week. They stated that there is a Registered Nurse in building Monday through Friday days and most nights and weekends. They stated that emergencies that occur when a Registered Nurse is not in building would be called in to the facility Nurse Practitioner who is on call 24 hours a day, 7 days a week and / or Director of Nursing who will assess emergency verbally and provide instructions. They stated that facility continues to recruit for all levels of nursing staff. 10NYCRR 415.13(b)(1)

Based on record review and interview conducted during the recertification survey from 9/5/24 to 9/13/24, the facility did not ensure certified nursing aide performance reviews were completed at least once every 12 months for 5 of 5 Certified Nurse Aides ( #8, #19, #20, #21, #22) reviewed. The findings are: During an interview on 09/09/24 03:45 PM with Director of Nursing/Staff Educator, they stated they are responsible for documentation of the Certified Nurse Aide annual performance reviews. The Director of Nursing/Staff Educator, was provided with a random sample of five Certified Nurse Aides, and documentation of their annual performance appraisals was requested. Review of Certified Nurse Aides (#8, #19, #20, #21 and #22) dates of hire provided by the facility, revealed all five of the Certified Nurse Aides had been working at the facility for more than one year. The Director of Nursing stated they have not completed annual performance appraisals for the Certified Nursing Aides since they started employment in November 2022. The Director of Nursing was not able to provide documentation of annual performance appraisals for the five randomly sampled Certified Nurse Aides. During an interview on 09/10/24 11:08 AM with Certified Nurse Aide #18, they stated they have been employed since 2019 and do not recall annual performance appraisals being completed in recent years. During an interview on 09/13/24 12:00 PM, the Administrator stated the facility is currently recruiting to hire an Assistant Director of Nursing which will enable the Director of Nursing to ensure the completion of annual performance reviews. 10NYCRR 415.26 (c)(2)(iii)