Every finding on record at Riverside Center for Rehabilitation and Nursing

Based on observation and interviews conducted during the survey, the facility failed to provide food and drink that were palatable, attractive, and at a safe and appetizing temperature. Specifically, for three (4) of the three (4) meals reviewed (Breakfast meal 04/09/2026 and two (2) Lunch meals) on 04/06/2026 and 4/10/2026. Specifically, food and drinks were not served at a palatable and appetizing temperature or taste. Findings Include: Facility policy titled Resident Meal Service, reviewed 04/2026, documented the facility would provide each resident with nourishing, palatable, and attractive meals. Residents who refuse meals were to be offered an alternative meal off the facility alternative meal list. Residents were to be provided with a variety of food and liquid items. Meal tickets were to be checked for accuracy prior to serving residents. Observation: During a meal sampling on 04/06/2026 at 12:28 PM, a sample of three (3) plates were observed from the South unit dining room steam table. The lunch service was observed, and the results were as follows: The cauliflower appeared dry, no gravy or seasonings were offered. Plate one (1) was missing the pork gravy and the penne with marinara, plate two (2), mechanical soft diet, was missing the soft salad and pudding, and plate three (3) was missing the cauliflower and tossed salad. During a meal tray sampling on 04/09/2026 at 9:21 AM, Resident #50's breakfast tray was tested, and a replacement tray was provided. The breakfast tray was tested for taste and temperature, and the results were as follows: Condiments were missing from tray. Milk 62.6 degrees Fahrenheit, Juice 64.4 degrees Fahrenheit, Bacon 108.9 degrees Fahrenheit, and Pancakes 112.5 degrees Fahrenheit. During a meal tray sampling on 04/10/2026 at 12:36 PM, Resident #50's lunch tray was tested, and a replacement tray was provided. The lunch tray was tested for taste and temperature, and the results were as follows: Condiments were missing from tray. Coffee 119.8 degrees Fahrenheit, Milk 59.7 degrees Fahrenheit, Juice 57.2 degrees Fahrenheit, [NAME] Pasta Bake 167 degrees Fahrenheit with bland unappetizing taste, Squash 129 degrees Fahrenheit, and Applesauce 60 degrees Fahrenheit with bland unidentifiable taste. Interviews: During an interview on 04/06/2026 at 10:34 AM, Resident #50 stated they were served cold tatter tots and soup for dinner the night before. They had asked for their food to be heated and were told it could not be heated. They stated they then asked for a sandwich, when they received the sandwich, they could not decide what it was therefore they did not eat it. During an interview on 04/06/2026 at 10:52 AM, Resident #34 stated the food was not good. They did not regularly eat the food from the facility. They did not get what they ordered and the quantity of food they received was small. During a subsequent interview on 04/10/2026 at 8:30 AM, Resident #34 stated they did not get dinner the night before. They were served tacos and beans, when they were supposed to get a cheeseburger. They could not have spicy foods. They stated they had asked for a different meal, which they never received. During an interview on 04/06/2026 at 11:15 PM, Resident #76 stated the food was not good and portions sizes were small. They stated they had received a full plate of rice for dinner at one time. They generally asked for sandwiches for most of their meals because the food the facility served was always cold and tasted bad. During the Resident Council interview on 04/07/2026 at 2:00 PM, it was stated that the food was not good. They felt the food choices they received where choices most people would not want, such as a frequent offering of lima beans. Vegetables and fruit were never fresh, always frozen or canned. The food was not severed at the right temperature and meal tickets were not accurate to what was received on the plates or trays. During an interview on 04/09/2026 at 2:40 PM, Regional Operational Director #1 stated they were currently hiring dietary staff including a new cook for the facility. They were working with current staff to ensure the residents received meals that matched their meal tickets. During a subsequent interview on 04/14/2026 at 10:08 AM, they stated they had implemented a new refrigeration process of storing drinks for residents after they were prepared for the mealtime and before they were served to the residents. During an interview on 04/10/2026 at 1:00 PM, Licensed Practical Nurse #2 stated residents complained about the food in the facility. The food lacked taste and was served in small portions. 10 New York Code of Rules and Regulations 483.60(d)(1)-(2)

Based on observation and interviews conducted during the survey, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards. Specifically, unwrapped or contained pork was thawed in still water that contained carrots floating on the water surface, items were stored in the refrigerators without being labeled or dated with an open or preparation date, beverages were prepared and placed in walk in freezer for cooling, and personal food was stored the small slide open top freezer. Findings Include: Facility Policy titled CCS Food Storage Criteria (undated) documented Storage Guidelines. Refrigerator storage documented items were to be labeled and unlabeled items were to be discarded. Freezer storage was for long term storage and not for cooling foods. All food items were to be checked for the Use by or best before date, and that date was to be honored even if the items did not appear to be spoiled. During a tour of the facility kitchen on 04/06/2026 at 10:05 AM, the following was observed:A small bag of mixed frozen fruit was unlabeled in the small slide open top freezer in the kitchen prep area next to the prep sink. The dry storage area contained 12 loaves of bread with a discard date of 04/05/2026 and six (6) packages of rolls with a discard date of 03/29/2026. The walk-in refrigerator contained Two (2) prepared salads containing cooked eggs, a package of pre sliced cheese, and a package of lunchmeat wrapped in plastic wrap on a shelf that was not labeled with open or discard date. There were opened mayonnaise and relish containers that were not labeled with an open or discard date. In the small refrigerator located in the kitchen there were prepared fruit cups and puddings that were unlabeled. There was one (1) tray of room temperature unlabeled prepared applesauce cups in the prep area of the kitchen. During an observation on 04/06/2026 at 10:29 AM, in the kitchen prep sink, there was free floating solid pork approximately one 1 inch thick in a large metal bowl noted to be thawing in standing water, diced carrots were noted to be floating in the water and pork was not secured in a bag or packaging.During an observation 04/07/2026 at 11:40 AM, a tray prepared beverages in cups were in the walk-in freezer. During an observation on 04/14/2026 at 10:08 AM, a loaf of bread was on a shelving unit in the kitchen prep area and had a discard date of 04/05/2026. During an interview on 04/06/2026 at 10:20 AM, Regional Operational Director #1 stated the Food Service Director #2 had resigned from their position prior to the state agency entrance and had discussed with them the appropriate way to thaw meat products. During an interview on 04/06/2026 at 10:05 AM, Food Service Director #1 stated they were doubling as a cook because there were only three (3) staff members on. All beverages and snacks that were in the refrigerators were prepared earlier that day and they did not have a chance to label them. The applesauce in the kitchen prep area was also prepared that day for the nurse's medication passes, they had not had a chance to label them either. They identified the small bag of frozen fruit located in the small open top freezer as an employee's who sometimes places their food in there. They stated they reminded the employee frequently that they could not place personal food in the kitchen freezers. They stated their delivery arrived that morning, the pork was the alternative meal, and they had to thaw the pork so it could be cooked and served for lunchtime. During a subsequent interview on 04/07/2026 at 11:40 AM, they stated the beverages in the freezer were being kept cold for the lunch meal. During an interview on 04/06/2026 at 10:20 AM, Regional Operational Director #1 stated they were currently hiring dietary staff including a cook for the facility. They stated all prepared food items should be labeled with a date, and they would discard any items that were not. They stated open containers of condiments in the refrigerator should be labeled with an open date and discarded after five (5) days of opening. For bread products, they labeled them with a discard date, the items should be discarded on that date, however there was also a best buy date on the original packaging that they sometimes used. 10 New York Code of Rules and Regulations 483.60(i)(1)-(2)

Based on resident observation, record reviews and staff interviews during the survey, the facility failed to ensure that the accuracy of the Minimum Data Set data submitted for one resident. The Minimum Data Set assessment did not accurately reflect the residents' conditions for one (1) of 19 residents reviewed. Specifically, Resident #11 diagnosed with Contractures, documented on the Quarterly Minimum Data Set dated 3/11/2026 no impairment to the upper or lower extremities. This resulted in misrepresentation of the resident's status during the assessment period. Findings include: Resident #11 was admitted to the facility on [DATE] with a diagnosis Contracture (the abnormal, often permanent shortening and stiffening of muscles, tendons, skin, or other soft tissues, leading to restricted joint movement and potential deformity), Left Wrist Contracture and Contracture of Muscle multiple sites. The Activities of Daily Living/Mobility Comprehensive Care Plan dated 7/07/2026 documented the resident was dependent and required a Hoyer Lift for transfers, Splint/brace. During an observation on 04/10/2026 9:05 AM Resident #11 was observed lying in bed supine, with their head of the bed elevated, leaning toward the wall. Their left hand was drawn up near their chest with their wrist arcing downward. The History and Physical dated 11/07/2025 documented Resident #11 with left sided Hemiplegia (paralysis of one side of the body). The Physical Therapy Evaluation and Plan of Treatment dated 2/26/2026 documented History/Complexities of Left Hemiparesis (partial weakness on one side of the body)/ Hemiplegia, prior treatment on contracture management and positioning. The Musculoskeletal System Assessment documented right and left lower extremity range of motion impaired. Functional Limitations Present due to Contracture. Clinical Impressions included Left Hemiplegia, Contractures of left lower extremity. The Occupational Therapy Evaluation and Plan of Treatment dated 3/4/2026 decreased range of motion and contractures. The Quarterly Minimum Data Set, dated [DATE] documented under section GG: No Impairment to Upper Extremity, No Impairment to Lower Extremity. Interview: During an interview on 4/10/2026 at 2:50 PM, Licensed Practical Nurse #2 stated Resident # 11's contracture started in the hospital and they continued to contract at the facility. During an interview on 4/13/2026 at 3:41 PM, Director of Rehabilitation # 1 stated Resident #11 came in with the beginning contracture elbow, wrist and hand. It was already contracted. Resident #11 came in November of 2025 and went back to the hospital for a month. The resident has a splint for the left hand and wrist that was to be worn as tolerated, the staff should have been putting it on Resident #11 every day. During a telephone interview on 4/14/2026 at 11:06 AM, Minimum Data Set Coordinator #1 stated they completed the Minimum Data Set quarterly dated 3/11/2026 for Resident #11. They looked over the Nursing Progress Notes, Comprehensive Care Plan and Therapy notes and this is how they obtained the information for the Minimum Data Set. If there was a discrepancy they would reach out to the facility directly. They stated they should have utilized the contracture on the Minimum Data Set and they could see in Resident #11's record that the resident had a contracture on the left wrist from February 2026 acute visit progress note. 10 New York Codes, Rules, and Regulations 415.11

Number of residents sampled: 19Number of residents cited: 1 Based on record reviews and interviews, the facility failed to obtain a Level II evaluation recommended by the Pre-admission Screening and Resident Review. Specifically, for Resident #55, a Level II evaluation was not obtained in the presence of significant mental illness. Findings include: Resident #55 The policy and procedure titled Pre-admission Screening and Resident Review (PASARR, revised 04/2026, stated a positive Level I screen required an additional evaluation of the individual by the state designated authority, the Level II review must be completed prior to admission to the facility. Resident #55 was admitted to the facility with diagnoses of bipolar disorder (a chronic mental health condition characterized by extreme mood swings, alternating between intense highs and lows causing significant disruption to daily life), chronic hepatitis (persistent liver inflammation lasting longer than six months), and urinary tract infection (a bacterial infection of the urinary system). The Minimum Data Set (an assessment tool), dated 3/26/2026, documented the resident was understood, could understand others, and was moderately cognitively impaired. The Pre-admission Screening and Resident Review, dated 2/29/2024, recommended a Level II evaluation through positive (yes) answers to the following questions: Question 23: Does this person have a serious mental illness? Question 33: A: Level II mental illness evaluation by a designated mental health review entity. There were no Level II evaluations completed for this resident. During an interview on 4/14/2026 at 10:15 AM, Director of Social Services #1 stated they had made a mistake and hadn't read the Pre-admission Screening and Resident Review to the end of the document, where a Level II evaluation had been recommended. 10 New York Codes, Rules, and Regulations 415.11(e)

Based on observations, record reviews and interviews during survey, the facility failed to develop and implement person-centered comprehensive care plans for residents in accordance with professional standards for two (2) (Residents #3 and #34) of 19 residents reviewed for comprehensive care plans. Specifically, there was no comprehensive care plan to address Resident #3's dementia diagnosis and, separately, to address Resident #34's use of a Continuous Positive Airway Pressure machine. Findings include: The policy and procedure titled Care Planning, revised 4/2026, stated the comprehensive care plan should describe the resident's medical, nursing, physical, mental, and psychological needs and preferences and how the facility will assist in meeting these needs and preferences. Resident #3 Resident #3 was admitted to the facility with the diagnoses of sepsis (a life-threatening medical emergency caused by an improper, extreme bodily response to infection, leading to potential organ damage, shock, and death), vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, damaging tissue) with other behavioral disturbance (dementia-related problem behaviors often stemming from unmet needs, pain, or condition including agitation, aggression, wandering, repetition, suspicion, and social withdrawal), and chronic pain syndrome (a condition where pain lasts longer than 3-6 months, often persisting beyond the expected healing time and accompanied by psychological issues like depression, anxiety, and insomnia). The Minimum Data Set (an assessment tool) dated 3/4/2026 documented the resident usually understood others, was sometimes understood by others, and was severely cognitively impaired. A review of the comprehensive care plans for Resident #3 documented there was no comprehensive care plan to address the resident's dementia diagnosis. During an interview on 04/10/2026 at 11:00 AM, Director of Nursing #1 stated there should be a care plan for dementia. During an interview on 04/10/2026 at 11:09 AM, Assistant Director of Nursing #1 stated there should be care plans for any issues with a resident and a dementia resident should have had a care plan addressing the issue. Resident #34 Resident #34 was admitted to the facility with diagnoses of hypertension (a chronic condition where blood flows through arteries at a consistently high pressure damaging vessels over time), chronic obstructive pulmonary disease (a progressive, incurable lung disease that blocks airflow, making it hard to breathe), and obstructive sleep apnea (a common, serious disorder where the throat muscles relax, causing repeated airway collapse and breathing pauses during sleep). The Minimum Data Set, dated 11/05/2025, documented the resident was understood, could understand others, and was cognitively intact. During an observation on 04/06/2026 at 10:52 AM, a Continuous Positive Airway Pressure (CPAP) machine was observed at the resident's bedside. During an observation on 04/10/2026 at 9:19 AM, a Continuous Positive Airway Pressure machine was observed at the resident's bedside. The History and Physical dated 11/07/2025 documented the diagnosis of obstructive sleep apnea and encouraged the resident to continue the use of Continuous Positive Airway Pressure machine. It documented the resident may experience/aggravate their headaches if not used. The comprehensive care plan titled Risk for Compromised Respiratory Status, dated 11/05/2025, did not include the use of a Continuous Positive Airway Pressure machine. During an interview on 04/10/2026 at 11:09 AM, Assistant Director of Nursing #1 stated there should have been care plans for any issues with a resident. 10 New York Codes, Rules, and Regulations 415.11(c)(1) Based on observations, record reviews and interviews, the facility failed to develop and implement person-centered comprehensive care plans for residents in accordance with professional standards for two (2) (Residents #3 and #34) of 19 residents reviewed for comprehensive care plans. Findings include: The policy and procedure titled Care Planning, revised 4/2026, stated the comprehensive care plan should describe the resident's medical, nursing, physical, mental, and psychological needs and preferences and how the facility will assist in meeting these needs and preferences. Resident #3 Resident #3 was admitted to the facility with the diagnoses of sepsis (a life-threatening medical emergency caused by an improper, extreme bodily response to infection, leading to potential organ damage, shock, and death), vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, damaging tissue) with other behavioral disturbance (dementia-related problem behaviors often stemming from unmet needs, pain, or condition including agitation, aggression, wandering, repetition, suspicion, and social withdrawal), and chronic pain syndrome (a condition where pain lasts longer than 3-6 months, often persisting beyond the expected healing time and accompanied by psychological issues like depression, anxiety, and insomnia). The Minimum Data Set (an assessment tool) dated 3/4/2026 documented the resident usually understood others, was sometimes understood by others, and was severely cognitively impaired. A review of the comprehensive care plans for Resident #3 documented there was no comprehensive care plan to address the resident's dementia diagnosis. During an interview on 04/10/2026 at 11:00 AM, Director of Nursing #1 stated there should be a care plan for dementia. During an interview on 04/10/2026 at 11:09 AM, Assistant Director of Nursing #1 stated there should be care plans for any issues with a resident and a dementia resident should have a care plan addressing the issue. Resident #34 Resident #34 was admitted to the facility with diagnoses of hypertension (a chronic condition where blood flows through arteries at a consistently high pressure damaging vessels over time), chronic obstructive pulmonary disease (a progressive, incurable lung disease that blocks airflow, making it hard to breathe), and obstructive sleep apnea (a common, serious disorder where the throat muscles relax, causing repeated airway collapse and breathing pauses during sleep). The Minimum Data Set, dated 11/05/2025, documented the resident was understood, could understand others, and was cognitively intact. During an observation on 04/06/2026 at 10:52 AM, a Continuous Positive Airway Pressure (CPAP) machine was observed at the resident's bedside. During an observation on 04/10/2026 at 9:19 AM, a Continuous Positive Airway Pressure machine was observed at the resident's bedside. The History and Physical dated 11/07/2025 documented the diagnosis of obstructive sleep apnea and encouraged the resident to continue the use of Continuous Positive Airway Pressure machine. It documented the resident may experience/aggravate their headaches if not used. The comprehensive care plan titled Risk for Compromised Respiratory Status, dated 11/05/2025, did not include the use of a Continuous Positive Airway Pressure machine. During an interview on 04/10/2026 at 11:09 AM, Assistant Director of Nursing #1 stated there should be care plans for any issues with a resident. 10 New York Codes, Rules, and Regulations 415.11(c)(1)

Based on observation, record review and interview during the survey, the facility failed to ensure that a resident received necessary treatment and care in accordance with professional standards of practice for one (1) of 19 residents reviewed for quality of care. Specifically, Resident #11 had a physician-ordered splint for their left wrist and hand. On 4/10/2026 at 9:05 AM and 12:15 PM, Resident #11 was observed without the splint. This placed the resident at risk for decline in physical functioning. Finding is: Resident #11 was admitted to the facility with a diagnoses including nontraumatic intracerebral hemorrhage in hemisphere (spontaneous bleeding within the brain tissue, often leading to significant neurological deficits), stiffness of other specified joint, muscle weakness, and left wrist contracture and contracture of Muscle multiple sites (the abnormal, often permanent shortening and stiffening of muscles, tendons, skin, or other soft tissues, leading to restricted joint movement and potential deformity). The Minimum Data Set (an assessment tool) dated 12/02/2025 documented [NAME] cognitive impairment. The Activities of Daily Living/Mobility Comprehensive Care Plan dated 04/08/2026 documented Activities of Daily Living/ Mobility Interventions including Splint/Brace- Refer to Physicians Order for details: Left Resting Hand Splint as tolerated. The resident was dependent for transfers and required a Hoyer Lift for transfers. During an observation on 04/10/2026 9:05 AM Resident #11 was observed lying in bed on their back, with the head of the bed elevated, leaning toward the wall. Their left hand was drawn up near their chest with the wrist arcing downward. Resident #11 was not wearing a splint to the left wrist, hand or arm. During an observation on 04/10/2026 12:15 PM Resident #11 was observed sitting bedside in their positioning chair, alert and non-verbal. The resident's left hand was observed without a hand splint. The Physicians Order dated 03/27/2026 documented an order for a left resting hand splint to be applied every day during the day shift as tolerated. The Certified Nursing Assistant Accountability dated 04/06/2026- 04/13/2026 lacked documentation of a left had splint being applied. The Occupational Therapy Evaluation and Plan of Treatment dated 03/4/2026 documented the resident presented with left upper extremity pain, increased tone, decreased range of motion and contractures. Current orthotic device to be determined. During an interview on 04/10/2026 at 2:40 PM, Certified Nursing Assistant #8 stated they were assigned to Resident #11. They stated the resident was in so much pain when they were getting mechanically moved out of bed in the morning, they did not want to hurt the resident more by applying the splint. Certified Nursing Assistant # 8 stated that they did not report to the nurse that they did not put the residents' splint on. During an interview on 04/10/2026 at 2:45 PM, Licensed Practical Nurse # 6 stated they were assigned to Resident #11 and were not notified by any staff that Resident # 11 needed their splint applied. They stated they had tried to put it on the resident in the past, and if they could not get the hand splint on, they would notify therapy. During an interview on 04/13/2026 at 3:41 PM, Director of Rehabilitation # 1 stated Resident #11 was not currently receiving therapy and had a splint for the left hand and wrist that was to be worn as tolerated. They further stated staff should be putting it on Resident #11 every day. 10 New York Codes, Rules, and Regulations 415.12

Based on observation, record review, and interviews during the survey, the facility failed to ensure residents received adequate supervision for one (1) (Resident #16) of eight (8) residents reviewed. Specifically, Resident #16 was assessed to have a high risk for falls, severely impaired cognition, and a history of falls. Resident #16 was care planned to be in a supervised area when out of her room. This resident was left unattended in a day room and fell on [DATE].Findings include:Resident #16 was admitted to the facility with a diagnosis of unspecified dementia with other behavioral disturbance (a form of cognitive decline where the specific type of dementia is not identified, accompanied by behavioral and psychological symptoms that affect daily functioning), Vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, damaging tissue). The Minimum Data Set (an assessment tool) dated 03/23/2026 documented that the resident usually understood others, was sometimes understood by others, and was severely cognitively impaired.Care Plan dated 09/09/2022 documented the resident was at risk for falls, had a history of falls, and poor safety awareness. Interventions included to keep the resident in a supervised area when out of bed, in the hallway.During an observation on 04/06/2026 at approximately 10:30 AM, a resident was yelling for help in the day room, a loud noise was heard, and Resident #16 was lying on the floor face down, in front of their wheelchair. No staff were around. The surveyor yelled for assistance. Licensed Practical Nurse #1 came to the room, then left to get assistance. Registered Nurse #1 came to assess the resident. Certified Nurse Aide #1 came into the day room with the Hoyer lift. Registered Nurse #1 assessed resident #16, Physician Assistant #1 came into the room, assisted Registered Nurse #1 with assessing the resident, then staff started to move the resident off the floor.Resident #16 was taken to their room and placed in bed.During an interview on 04/06/2026 at 11:20 AM, Registered Nurse #1 said Resident #16 needed to be in the front day room.During an interview on 04/06/2026 at 11:25 AM, Licensed Practical Nurse #1 stated the resident was usually in the front day room or in the hallway near the nurses' station.During an interview on 04/13/2026 at 9:12 AM, Certified Nurse Aide #1 stated a supervised area would be in front of the nursing station or in the first common room.During an interview on 04/13/2026 at 9:13 AM, Certified Nurse Aide #3 stated a supervised area would be in front of the nursing station.During an interview on 04/13/2026 at 9:16 AM, Certified Nurse Aide #4 stated a supervised area would be the dining room, activities, nursing station, anywhere staff were or would walk by.10 New York Codes, Rules and Regulations 483.25(d)(2)

Based on observation, interview and record review during the survey, the facility failed to provide appropriate treatment and services for a clinically justified indwelling urinary catheter, provide adequate oversight and maintain proper infection control practices for one (1) of 2 residents (Resident # 26). Specifically, Resident #26 was observed on 04/10/2026 at 8:32 AM with a urinary drainage bag on the floor and not utilizing a leg bag as indicated, staff interviews revealed the staff considered the resident independent in changing the leg bag. This deficient practice placed the resident at increased risk for contamination and infection. Findings Include: The Catheter Care Policy and Procedure last reviewed date 4/2026 documented the procedure for Catheter Care and the responsible disciplines as the Certified Nursing Assistant, Licensed Practical Nurse and Registered Nurse. The Changing Urinary Drainage Bag Policy dated 10/2002, last reviewed 04/2026; documented changing of the urinary drainage bags/leg bags is performed by licensed nursing personnel only and is performed appropriately to prevent complications caused by the presence of an indwelling urethral catheter. The steps to the procedure were outlined in the policy including; cleanse connection site between catheter and drainage tubing with alcohol wipe prior to opening system, placing the drainage bag into a clean plastic bag for storage. Resident #26 was admitted to the facility with a diagnosis of Parkinson's Disease (progressive neurological disorder that primarily affects movement), Vascular Dementia (a type of cognitive decline caused by reduced or blocked blood flow to the brain) moderate with psychotic disturbances, Flaccid Neuropathic Bladder (type of bladder dysfunction caused by nerve damage). The Minimum Data Set (an assessment tool) dated 02/21/2026 documented the resident was cognitively intact and required Partial/Moderate assistance for toileting hygiene and personal hygiene, and was independent with sit to stand, chair/bed transfer, and requires set up or clean-up assistance with toilet transfer. Resident # 26 was observed on 04/10/2026 at 8:32 AM in the dining room sitting in a wheelchair. The resident was noted with a urinary catheter tubing coming out the left pant leg with a urinary collection bag attached (covered) lying on the floor. The tubing was observed to have cloudy contents. Upon observation of the area there was no place to hang the bag. This 04/10/2026 at 8:32 AM observation continued. At 8:48 AM, Licensed Practical Nurse #2 asked the Resident #26 if they had the leg bag on. Resident #26 stated yes, they thought they did. The Physician's Order dated 09/06/2025 documented an order for a Foley Catheter, change to leg bag when out of bed, foley catheter to bedside bag every day on days and evenings shifts. The Bladder Alteration Comprehensive Care Plan dated 12/31/2024 documented the resident would perform their own care of changing their foley bag to leg bag changes. The Comprehensive Care Plan noted the resident did not ring for assistance. The active Certified Nurse Aide Care Plan documented the resident had a catheter and a leg bag in AM. During an interview on 04/10/2026 at 9:00 AM, Certified Nurse Aide #8 stated they work 7:00 AM - 3:00 PM and they were assigned to the resident for the day, however they did not see the resident yet today. They stated Resident # 26 wore a leg bag on day shift and could put it on themself. They further stated they did not assist with Resident #26's catheter today. During an interview on 04/10/2026 at 8:50 AM, Certified Nurse Aide #7 stated they had cared for Resident # 26 in the past. They stated the resident was pretty much independent and like to do their own foley. If the resident asked for help, they would help them. During an interview on 04/13/2026 at 1:00 PM, Assistant Director of Nursing #1 stated the resident should not be changing their catheter drainage bag to the leg beg on their own and they would follow up on this. During an interview on 04/13/2026 at 3:20 PM, Director of Nursing #1 stated they preferred staff to apply the residents' leg bag. The staff should not expect the resident to change it themselves. The residents do not apply their own leg bags for infection control reasons, and it could put them at risk of urinary tract infections if not done properly. 10 New York Codes, Rules, and Regulations 415.12 (d) (1)

Based on observation, record review, and interviews during the survey, the facility failed to ensure appropriate respiratory care and services were provided for 1of 2 residents (Resident # 34) reviewed for Respiratory Care. Specifically, Resident # 34 had a diagnosis of Obstructive Sleep Apnea (a sleep disorder characterized by repeated interruptions in breathing during sleep) and required the use of a Continuous Positive Airway Pressure (CPAP) machine (a device that delivers a constant stream of pressurized air to keep the airways open during sleep, used to treat sleep apnea). The medical record had no documented evidence of a necessary physician's order and had no documented evidence of an implemented care plan to address the resident's need for CPAP therapy and equipment maintenance. Interview of the Resident and Staff revealed the resident did not receive assistance with required equipment maintenance , resulting in the resident going without use of the device for approximately two (2) weeks, placing the resident at risk of complications related to untreated sleep apnea. Findings Include: The Continuous Positive Airway Pressure (CPAP)/Bi-PAP Policy and Procedure dated 07/1999 and last revised 4/2026 documented the purpose of the policy was to provide specific guidelines for safe set-up and use of the Continuous Positive Airway Pressure (CPAP). Residents who require the use of Continuous Positive Airway Pressure (CPAP) machine will have the mask applied and the machine cleaned according to manufacturer guidelines to prevent respiratory complications. Regular cleaning of the machine will be performed to decrease the risk of respiratory illness. The procedure included to obtain a physician's order. Resident # 34 was admitted to the facility with diagnoses of Obstructive Sleep Apnea (a sleep disorder characterized by repeated interruptions in breathing during sleep), Chronic Obstructive Pulmonary Disease (lung disease causing restricted airflow and breathing problems), Chronic Pulmonary Embolism (blood clots persist in the pulmonary arteries), and Migraine (neurological disorder with intense headache). The Minimum Data Set (Resident Assessment Tool) dated 02/26/2026 documented that the resident was cognitively intact. During an observation on 04/06/2026, resident's bedside stand was observed with Continuous Positive Airway Pressure (CPAP) on it, tubing, and mask lying open. During an interview at this time, the Resident reported they required assistance turning it on. During an observation on 04/10/2026 at 8:30 AM, Resident # 34 was observed awake, alert and orientated lying in bed. A Continuous Positive Airway Pressure (CPAP) machine was observed on the bedside stand with tubing and mask open to air. The Resident stated they needed to clean it, and they had to take the machine into the bathroom and wash it. They had not used it in two (2) weeks because it needed to be cleaned. The Physicians Orders were reviewed and lacked a physician's order for Continuous Positive Airway Pressure (CPAP) and settings. The History and Physical dated 11/07/2025 documented a diagnoses Obstructive Sleep Apnea, the resident is encouraged to continue the Continuous Positive Airway Pressure (CPAP), because not using this machine may aggravate her headaches. The Risk for Compromised Respiratory Status Care Plan dated 11/05/2025 documented monitoring of respiratory status and lacked documented evidence of Continuous Positive Airway Pressure (CPAP) intervention. During an interview on 04/10/2026 at 11:15 AM, Licensed Practical Nurse #6 stated they were assigned to the resident, who had a Continuous Positive Airway Pressure (CPAP) bedside. They further stated that they did not do anything with the machine because it was the residents' own machine. Licensed Practical Nurse #6 looked at the computer then stated they did not administer it because there was no physician's order for it. During an interview on 04/10/2026 at 11:25 AM, Licensed Practical Nurse #2 they did not know Resident #34 had a Continuous Positive Airway Pressure (CPAP) that the resident or staff never said a word about it. Licensed Practical Nurse #2 stated there was not a physician's order for the Continuous Positive Airway Pressure (CPAP) but there should be. During an interview on 04/10/2026 at 11:35 AM, Medical Doctor #1 stated Resident # 34 had a diagnosis of morbid obesity and sleep apnea. They stated if the residents were using Continuous Positive Airway Pressure (CPAP) at home, it was likely to continue usage at the facility. They stated they wrote a note in the medical record on 11/05/2025 that indicated the resident should continue using the Continuous Positive Airway Pressure (CPAP) while at the facility and if the resident had not been using the Continuous Positive Airway Pressure (CPAP) for two (2) weeks, they may not get a restful sleep and feel more tired. They further stated Resident # 34 also had a history of headaches and may also experience more headaches if not using the Continuous Positive Airway Pressure (CPAP). The Medical Doctor #1 stated they were not aware the resident had not been using the Continuous Positive Airway Pressure (CPAP) for two (2) weeks. During an interview on 4/13/2026 at 3:25 PM, Director of Nursing #1 stated the nurse or the Certified Nursing Assistant was responsible for cleaning the Continuous Positive Airway Pressure (CPAP). 10 New York Codes, Rules, and Regulations 415.12 (k) (6)

Number of residents sampled: 5Number of residents cited: 1The policy and procedure titled Physician Orders, revised 12/2025, stated orders for medications must include Name and strength of the drug,Number of doses, start and stop date, and/or specific duration of therapy;Dosage and frequency of administration;Clinical condition or symptoms for which the medication is prescribed;Any interim follow-up requirements.The policy and procedure titled Medication Administration, revised 12/2025, stated medications must be administered in accordance with the order. Resident #3 was admitted to the facility with the diagnoses of sepsis (a life-threatening medical emergency caused by an improper, extreme bodily response to infection, leading to potential organ damage, shock, and death), vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, damaging tissue) with other behavioral disturbance (dementia-related problem behaviors often stemming from unmet needs, pain, or condition including agitation, aggression, wandering, repetition, suspicion, and social withdrawal), and chronic pain syndrome (a condition where pain lasts longer than three to six 3-6 months, often persisting beyond the expected healing time and accompanied by psychological issues like depression, anxiety, and insomnia). The Minimum Data Set (an assessment tool) dated 3/04/2026 documented the resident usually understood others, was sometimes understood by others, and was severely cognitively impaired. The Physician's Order dated 11/20/2025 documented oxycodone HCl tablet 10 milligrams one (1) tablet by mouth as needed, pain from November 18 as needed limit one time (once) for chronic pain syndrome. The December 2025 Medication Administration Record documented oxycodone HCl 10 milligrams was administered as needed on 12/02/2025 at 4:26 AM, 12/03/2025 at 2:15 AM, 12/04/2025 at 1:27 AM, 12/09/2025 at 6:33 AM, 12/12/2025 at 10:13 PM, and 12/26/2025 at 11:00 AM. The January 2026 Medication Administration Record documented oxycodone HCl 10 milligrams was administered as needed on 01/06/2026 at 2:22 AM, 01/12/2026 at 4:14 AM, 01/16/2026 at 6:37 AM, 01/20/2026 at 4:32 PM, and 01/24/2026 4:56 AM. The February 2026 Medication Administration Record documented oxycodone HCl 10 milligrams was administered as needed on 2/01/2026 at 12:39 am and 5:00 PM, 2/.07/2026 at 3:30 AM, 2/14/2026 at 3:25 AM, 2/16/2026 at 4:00 AM, and 2/23/2026 at 5:20 PM. The March 2026 Medication Administration Record documented oxycodone HCl 10 milligrams was administered on 03/01/2026 at 10:55 AM, 03/07/2026 at 2:36 AM, 03/09/2026 at 2:38 AM, 03/14/2026 at 2:30 AM, 03/15/2026 at 2:21 AM, 03/18/2026 at 2:11 AM, 03/22/2026 at 10:57 AM, 03/25/2026 at 1:49 AM, 03/27/2026 at 11:09 AM, 03/28/2026 at 2:23 AM, 03/29/2026 2:48 AM, and 03/30/2026 at 4:12 AM. The April 2026 Medication Administration Record documented oxycodone HCl 10 milligrams was administered as needed on 04/01/2026 at 3:00 AM, 04/06/2026 at 2:54 AM, 04/08/2026 at 2:14 AM. During an interview on 04/10/2026 at 11:00 AM, Director of Nursing #1 stated this was a medication error and they did not know why the order was not put in with a stop date or why the error was not caught. During an interview on 04/13/2026 at 9:20 AM, Licensed Practical Nurse #1 stated they were told verbally that the order was once a day as needed for pain. They stated they did not read the entered order closely. They stated there was no system in place to check new orders for accuracy. During an interview on 04/13/2026 at 1:00 PM, Assistant Director of Nursing #1 stated when a new order was put into the system, it required a co-signer: another nurse to check the order for accuracy. 10 New York Codes, Rules, and Regulations 415.12(m)(2)

Based on observation, record review, and interviews during the recertification survey, the facility did not ensure each resident was treated with respect and dignity and cared for in a manner and in an environment that promoted maintenance or enhancement of their quality of life, recognizing each resident's individuality for 2 (North and South Units) of 2 units reviewed for dignity. Specifically, the facility did not ensure residents were treated in a dignified manner during mealtime when facility staff referred to residents' as feeders to describe residents requiring assistance with feeding, and the term bib to describe clothing protectors, and by placing clothing protectors on residents in the South Dining Room without determining whether the residents wanted them, and for Resident #20, the facility did not ensure privacy and dignity were provided when faciity staff performed blood glucose monitoring on 07/11/23. This was evidenced by: Finding 1: The facility did not ensure residents were treated in a dignified manner at mealtime, when staff used the term feeder to describe residents who required assistance with feeding on the North Unit on 07/06/2023 and on the South Unit on 07/11/2023. The Policy and Procedure (P&P) titled Quality of Life - Dignity, reviewed 05/2023, documented staff would speak respectfully to residents at all times, including addressing the resident by their name of choice, and not labeling them by their room number, diagnosis, or care needs. During a dining observation on 07/06/23 at 12:11 PM, a staff member in the North Unit Dining Room was heard referring to a table of residents as feeders. During an observation/interview on 07/11/23 at 12:45 PM, Licensed Practical Nurse (LPN) #3 stated all the lunch trays on the unit had been passed, except for the feeders. The feeders were the residents who needed to be fed; this was what these residents were called. They stated they supposed the residents should not be called feeders, since that was not very dignified; they should be referred to as residents who require assistance with feeding instead. During an interview on 07/11/23 at 12:50 PM, the Director of Nursing (DON) stated they heard LPN #3 refer to the resident who needed assistance with feeding as feeders. They cringed when they heard this, as this was a resident dignity issue and staff should not be calling the residents feeders. During an interview on 07/12/23 at 11:32 AM, Resident Assistant (RA) #1 stated part of their role included helping to pass meal trays with the Certified Nurse Aids (CNAs) at mealtimes. Part of maintaining resident dignity at mealtime included referring to residents by their first name, and not using terms like feeders, and not to use the term bib to describe clothing protectors. During an interview on 07/12/23 at 11:45 AM, CNA #5 stated at mealtime, staff should be calling residents by their names and not using terms like feeder or bib to describe clothing protectors to help ensure they were maintaining resident dignity. Additionally, clothing protectors should not be placed on residents without their consent or telling the resident what was happening if they were unable to consent. During an interview on 07/12/23 at 12:01 PM, LPN #4 stated residents should be called by either their name or their preferred name at mealtime. Terms like feeder should not be used by the staff; they have heard this term used by staff before. During an interview on 07/12/23 at 12:17 PM, Registered Nurse Unit Manager (RNUM) #1 stated residents who required feeding assistance should not be referred to using terms like feeders; instead, they should be referred to by their name. The term bib should not be used to refer to clothing protectors. Clothing protectors should be offered to residents, not placed on their bodies without their consent or being told the clothing protector was going to be placed. Finding #2 The facility did not ensure residents were treated in a dignified manner at mealtime, when staff placed clothing protectors on the resident without asking, referred to the clothing protectors as bibs when placing them on the residents and used the term feeder to describe residents who required assistance with feeding on the South Unit on 07/06/2023 and 07/07/2023 The Policy and Procedure (P&P) titled Quality of Life - Dignity, reviewed 05/2023, documented staff would speak respectfully to residents at all times, including addressing the resident by their name of choice, and not labeling them by their room number, diagnosis, or care needs. During an observation on 07/06/2023 at 12:34 PM, Registered Nurse (RN) #3 placed clothing protectors on 7 residents on the South Unit who were gathered in the main dining room waiting for their lunch trays. RN #3 did not ask the residents about their preference regarding wearing a clothing protector prior to placing the clothing protector on the residents. During an observation on 07/06/2023 at 12:45 PM. CNA #3 placed a clothing protector on a male resident while stating I'm going to put your bib on! During an observation on 07/07/2023 at 12:36 PM, staff assisted residents with placing clothing protectors on the residents gathered in the dining room. Staff asked 10 of 24 residents if they wanted a clothing protector placed on them. During an interview on 07/07/2023, at 2:47 PM, the Licensed Practical Nurse Manager (LPNUM) stated the residents should always be asked if they want a clothing protector placed on them. Staff placing the clothing protector or giving any care should explain prior to providing the care and should not refer to the clothing protectors as bibs. Staff have received education on this at hire and annually. Finding 3: The facility did not ensure privacy and dignity was maintained for a resident and other residents present while blood glucose monitoring was performed during a group activity in a main area on 07/11/23. The Policy and Procedure titled Quality of Life - Dignity dated 5/23 documented staff shall maintain an environment in which confidential clinical information is protected. The Policy and Procedure titled Quality of Life - Dignity dated 5/23 stated staff shall promote, maintain, and protect resident privacy including bodily privacy during assistance with personal care and during treatment procedures. A Fingerstick (FS) for blood glucose monitoring was not performed in a private area away from other residents on 07/11/23. During an observation on 07/11/23 at 11:35 AM, Licensed Practical Nurse (LPN) #3 was observed collecting a fingerstick from a resident from the South Unit in the main activity room in front of other staff and residents during a group activity. None of the residents attending the group activity were asked if they objected to the interruption of the group activity for the personal care treatment performed by LPN #3. During an interview on 7/11/23 at 11:45 AM, LPN #3 stated they had performed the Blood Glucose for Resident #20 during the group activity because it was always done that way. LPN #3 stated they had never been told it was not acceptable to perform the FS's and administration of insulin when residents were at group activities. LPN #3 stated we always do that. The LPN stated they had drawn up the residents insulin and were ready to administer it in the common area and had discarded it because this surveyor had stopped them. During an interview on 7/11/2023 at 12:01 PM, LPNUM #! stated the FS and administration of insulin was to be done in a private area. If a resident is in a common area like the dining room or activities the resident is to be removed from the area and brought to their room or a private screened area to have the procedure or medication administered. LPN #3 should have either removed Resident #20 from the area or waited until the resident was done with the activity. Meal trays had not come up yet and there was no reason LPN #3 should have done either the FS or rushed administering the insulin. It wasn't proper and was not the policy of the facility to disrupt other residents group activities. During an interview on 7/11/2023 at 2:46 PM, the DON stated there was no immediate need to administer the Fingerstick while all residents were participating in a group activity. The residents privacy should have been the focus and had not. Finding #4 The facility did not ensure residents were treated with dignity and respect on the South Unit when staff referred to residents needing assistance with feeding as feeders. During an observation on 7/11/2023 at 12:45 PM, the staff were delivering meal trays to residents who were eating in their rooms and Licensed Practical Nurse (LPN) #3 stated all the meal trays were passed except for the Feeders. During an interview on 7/11/2023 at 12:45 PM, LPN #3 stated the residents that need to be fed are called Feeders, when asked why residents needing assistance would be called feeders? LPN #3 stated, well I guess the residents should not be called feeders, that is not very dignified, they should be referred to as residents who need feeding assistance. During an interview on 7/11/2023 at 12:50 PM, the Director of Nursing (DON) acknowledge that they heard LPN #3 refer to the residents who needed assistance with feeding as feeders from down the hall. The DON said they cringed because residents should not be referred to by the level of care required, residents deserve to be treated with dignity and respect, and staff reeducation will be provided. Finding #5 The facility did not ensure Residents #'s 21 and #60, dignity and privacy were maintained when their urinary catheter bags were not covered or placed in an area where the catheter bag could not be seen by others. The Policy and Procedure titled Catheter Care dated 5/18/23 stated a dignity bag is to be placed over the catheter drainage bag to ensure dignity is maintained for the resident. The Policy and Procedure titled Quality of Life - Dignity dated 5/23 stated staff shall promote, maintain, and protect resident privacy and promote dignity and assist residents as needed by helping the resident to keep urinary catheter bags covered. Resident #21 Resident #21 was admitted to the facility with the diagnoses obstructive and reflux uropathy, quadriplegia and dementia. The Minimum Data Set (MDS - an assessment tool) dated 6/19/23 documented resident had mildly impaired cognition, was sometimes understood and usually understood others. During an observation on 7/6/23 at 11:12 AM, the resident's urinary catheter drainage bag was uncovered and hanging off the side of the bed facing the door. The privacy curtain was noted to end before the top of the bed, leaving the catheter bag visible from the door even with the curtain pulled around the bed. During an interview on 7/12/23 at 1:48 PM, LPN #4 stated privacy bags are needed for the urinary catheter bags to maintain a resident's dignity. During an interview on 7/12/23 at 1:53 PM Registered Nurse (RN) #1 stated privacy bags are needed for the urinary catheter bags. 10 NYCRR 415.5(a)

Based on observation and interviews during the recertification survey dated 07/06/23 through 07/12/23, the facility did not provide effective housekeeping services on two (2) of 2 resident units and the core area. Specifically, floors were soiled with dirt next to walls, in corners, along door thresholds, and where door frames meet the floor in room #'s 117-N, 113-S, 115-S, 117-S, and #121-S, and in the corridors on the North Unit, South Unit, and Core Area; the floors were soiled with dirt in the activities room and activities room office, South Unit nurse station, social worker office, South Unit Nurse Manager office, and South Unit utility closet; ceiling tiles were water-stained in room #'s 106-N, 107-N, 105-S, 112-S, and the South Unit supply room, the North Unit Clean Workroom, and the physical therapy room; 17 corridor floor tiles were cracked by room [ROOM NUMBER]-N, 5 floor tiles were cracked by room [ROOM NUMBER]-N, and 2 corridor floor tiles were cracked by room [ROOM NUMBER]-S; the privacy curtain between for Resident #43 was stained with a black opaque dried spot approximated 8-inches by 10-inches in size; the privacy curtain between bed A and bed B in room [ROOM NUMBER]-N was soiled with 4 black stain spots; black smudge marks were found on the wall in room #s 105-N, 111-N, 112-S, and 115-S, the Mother [NAME] Room, the Empire Room, and on both sides of the corridor by room #s 104-N, 119-N, and #120-N; the wall in the Adirondack Room was splattered with a liquid food stain; the coving base peeling off outside room #s 105-N and 120-N; old tape was found on the bathroom doors in room #s 111-N and 113-N; ceiling paint was peeling in shower #2 on the South Unit; and the sink in the South Unit utility closet was heavily soiled with a black build-up. This is evidenced as follows: North Unit During observations on 07/06/23 at 10:03 AM through 12:52 PM, the corridor floor was soiled with dirt next to walls, in corners, along door thresholds, and where door frames meet the floor; black marks were found on the walls in the Mother [NAME] Room, the Empire Room, and on both sides of the corridor by room #s 104-N, 119-N, and 120-N; the coving base peeling off outside room #s 105-N and #120-N. During observations on 07/07/23 at 9:28 AM, ceiling tiles were water-stained in room [ROOM NUMBER]-N and the Clean Workroom. During observations on 07/11/23 at 9:27 AM, the floors were soiled with dirt in corners and next to walls in resident room [ROOM NUMBER]-N; smudge marks were found on the wall in room #'s 105-N and #111-N; old tape was found on the bathroom doors in room #s 111-N and 113-N; a bathroom ceiling tile was water-stained in room [ROOM NUMBER]-N; and 17 corridor floor tiles were cracked by room [ROOM NUMBER]-N and 5 floor tiles were cracked by room [ROOM NUMBER]-N. During an observation on 07/12/23 at 10:41 AM, the privacy curtain between bed A and bed B in room [ROOM NUMBER]-N was soiled with 4 black stain spots. South Unit During observations on 07/06/23 at 10:24 AM, the corridor floor was soiled with dirt next to walls, in corners, along door thresholds, and where door frames meet the floor. During observations on 07/07/23 at 9:28 AM, ceiling paint was peeling in shower #2; one ceiling tile was water-stained in both room [ROOM NUMBER]-S and the supply room; the wall in the Adirondack Room was splattered with a liquid food stain; the floors were soiled with dirt in the nurse station, social worker office, nurse manager office, and utility closet; the sink in the utility closet was heavily soiled with a black build-up. During observations on 07/11/23 at 9:28 AM, the floors were soiled with dirt in corners and next to walls in resident room #s 113-S, 115-S, 117-S, and 121-S; smudge marks were found on the wall in room #s 112-S and 115-S; a bathroom ceiling tile was water-stained in room [ROOM NUMBER]-S; 2 corridor floor tiles were cracked by room [ROOM NUMBER]-S. During observations on 07/07/23 at 9:43 AM, again on 07/10/23 at 9:48 and 10:41 AM, and again 07/11/23 at 9:27 AM, the privacy curtain for resident #43 was stained with a black opaque dried spot approximated 8-inches by 10-inches in size. During an interview on 07/10/23 at 10:41 AM, Resident #43 stated that this privacy curtain has been dirty for months Core Area During observations on 07/06/23 at 10:24 AM, the corridor floors were soiled with dirt next to walls, in corners, door thresholds, and where door frames meet the floor in the service hallway to the kitchen. During observations on 07/07/23 at 9:28 AM, the floors were soiled with dirt in the activities room and activities room office, and a ceiling tile was water-stained in the physical therapy room. Interviews During an interview on 07/11/23 at 10:25 AM, the Maintenance Director, when asked for documentation on replacing floor tiles, presented the document titled Maintenance Department QA Weekly Status Report and dated 06/02/23 through 06/30/23 which record identified maintenance projects within the facility but do not document that replacing cracked floor tiles have been identified. During an interview on 07/11/23 at 11:37 AM, the Director of Nursing stated that the privacy curtains could easily drag over food and stain the curtains due to the short length. During an interview on 05/26/22 at 10:02 AM, the Assistant Administrator (AA) stated that the facility will re-educate housekeeping staff on thoroughly cleaning the floors and walls. The AA stated that the ceiling tiles, privacy curtains, and cracked floor tiles found are being replaced, and the facility is looking into replacing the floors. 483.10(i)(3); 10 NYCRR 415.5(h)(4)

Based on observation and interviews during the recertification survey dated 07/06/23 through 07/12/23, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, in the main kitchen, the automatic dishwashing machine (dish machine) was not functioning; the facility did not have chemical sanitizer to manually wash and sanitize food contact surfaces (sanitizer), such as cups; the microwave oven, shelving, and kitchen drawers were soiled with food particles; and the walk-in refrigerator floor and dry storage area floor were soiled with dirt including in the corners and next to walls. In the North Unit Kitchenette, the inside of the refrigerator door and cupboards were soiled with food particles. In the South Unit Kitchenette, the cupboards were soiled with food particles, and a bottle labeled [NAME] multi surface cleaner + disinfectant with a warning on the label not to swallow, was stored in a cupboard above paper drinking cups located on the countertop below. This is evidenced as follows: During observations on 07/06/23 at 9:39 AM, in the main kitchen, the dish machine was not functioning, the microwave oven, shelving, and kitchen drawers were soiled with food particles, and the walk-in refrigerator floor and dry storage area floor were soiled with dirt including in the corners and next to walls. In the North Unit Kitchenette, the inside of the refrigerator door and cupboards were soiled with food particles. In the South Unit Kitchenette, the cupboards were soiled with food particles, and a bottle labeled [NAME] multi surface cleaner + disinfectant with a warning on the label not to swallow, was stored in a cupboard above paper cups (a food contact surface) located on the countertop below. During an interview on 07/06/23 at 9:50 AM, the Food Service Director stated that a sensor in the automatic dishwashing machine hasn't been working for about a week, a work order has been filed, and the repair vendor will be contacted again. The Food Service Director stated that in the interim, the facility has been using paper products and manually washing cups. When asked to check the concentration of sanitizer, the Food Service Director stated that they did not have any sanitizer as the sanitizer was not ordered on time. During an interview on 07/06/23 at 10:33 AM, the Assistant Administrator (AA) stated that the repair of the dishwashing machine, lack of sanitizer, cleaning items, and improper storage of cleaning chemicals will be investigated immediately. The AA stated the dish machine repair vendor had been in the building and fixed one problem, the current problem had arisen since, and the vendor will be back today (07/06/23). The AA stated that currently, there is not an explanation as to why the facility ran out of chemical sanitizer. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14

Based on interview and record review it was determined that the facility did not designate one or more individual(s) as the infection preventionist(s) (IP)(s) responsible for the facility's IPCP. Specifically, the facility did not ensure there was a designated individual as their Infection Control Preventionist from April 28 th to July 7th, 2023. This was evidenced by: The Infection Control Policy and Procedure date 5/15/2023, documented the following: 1 The facility will ensure that an adequate Infection control program is in place for the prevention and control of infections. 2. The Infection Control Nurse (ICN) will investigate and implement methods and procedures to control the spread of infection. 3. The ADON/IP (Assistant Director of Nursing/Infection Preventionist) will complete facility surveillance and review at facility QUPI meetings. 4. The ADON/IP will periodically assess staff adherence to Infection Control Guidelines. 5. The ADON/IP will compile and maintain statistics of all nosocomial infections. 6. The ADON/IP will collaborate with all departments in education programs. 7. The ADON/IP will act as a resource for all departments when infection control issues should arise. The Facility's previous Infection Preventionist's (ICP) last day in the facility was April 28 th, 2023. The Facility's current Infection Preventionist/ Director of Nursing (DON) completed the Infection Preventionist training on April 28 th, 2023. The Facility's current ICP was the Acting Assistant Director of Nursing (ADON) who was also the Registered Nurse Unit Manager (RNUM) for the North Unit and was unaware that they were the ICP. During an interview on 07/07/2023 at 1:17 PM, the Director of Nursing (DON) stated the ADON/ICP/RNUM #1 was the person who kept track of the infections requiring isolation in the facility. During an interview on 07/07/2023 at 1:57 PM, LPNUM #1 stated the last ICP RN had left in April 2023 and believed the DON and RNUM #1 were doing the infection control together. During an interview on 07/07/2023 at 2:36 PM, RNUM #1 stated they were not the ICP for the facility. During a re-interview on 07/12/2023 at 11:20 AM, RNUM #1 stated they were now aware that they were the ICP. RNUM #1 had been the ADON for a short time and then became the RNUM for the North Unit when the RN hired left without notice. The previous DON was the ICP and nurse educator but left in April 2023. Another nurse was hired in that position but did not stay and they asked me to do the interim ICP position with the DON helping. RNUM #1 was unable to give the date of the completion of ICP modules. During an interview o 07/07/2023 at 12:58 PM, the DON stated they had no ICP certification and were doing the best they could. During an interview 07/12/2023 at 1:27 PM, the Facility's Administrator stated they had only been at the facility a short time and were not sure who covered the Infection Control Preventionist (ICP) position once the previous person left in April 2023. 10NYCRR 415.19 (a)

Based on observation and interviews during the recertification survey dated 07/06/23 through 07/21/23, the facility did not equip bedrooms to assure full visual privacy for each resident on two (2) of 2 resident units. Specifically, the privacy curtain for resident #21 was partially pulled and allowed the resident's urinary catheter bag to be seen from the opened door (a dignity bag was not provided); the urinary catheter bag would still be seen if the privacy curtain was fully pulled as the curtain extended about 3/4 the distance from the ceiling; the distance between the floor and the bottom of the privacy curtains in all semi-private rooms on the North Unit and South Unit was 22-inches of open space between floor and bottom of privacy curtain; and the distance between the top of bed B in room [ROOM NUMBER]-N, when in the lowest position, and the bottom of the privacy curtain was 6-inches. This is evidenced as follows: During an observation on 07/06/23 at 11:12 AM, the privacy curtain for Resident #21 was partially pulled and allowed the resident's urinary catheter bag to be seen from the opened door (a dignity bag was not provided); the urinary catheter bag would still be seen if the privacy curtain was fully pulled as the curtain extended about 3/4 the distance from the ceiling. During an observation on 07/10/23 at 10:41 AM, the privacy curtains in the semi-private rooms on the South Unit extended approximately 4 to 5-inches of open space above low bed position. During observations on 07/11/23 at 9:27 AM, when measured, the distance between the floor and the bottom of the privacy curtains in all semi-private rooms on the North Unit and South Unit was 22-inches of open space between the floor and bottom of privacy curtains. During an observation on 07/12/23 at 10:29 AM, when measured, the distance between the top of bed B in room [ROOM NUMBER]-N, when in the lowest position, and the bottom of the privacy curtain was 6-inches of open space. During an interview on 07/12/23 at 10:33 AM, the Maintenance Director stated that the facility is purchasing new privacy curtains that extend closer to the floor for every room. During an interview on 07/11/23 at 11:37 AM, the Director of Nursing stated that the privacy curtains had been recently changed and that agreed that they are too short for adequate privacy, [NAME] noticed that the curtains were too short. During an interview on 07/12/23 at 11:19 AM, the AA stated that the facility acknowledged that the privacy curtains are not the correct length and new curtains have already been ordered. 10 NYCRR 415.29(c), 713-3.4 (b)(7)

Based on observation, record review, and interviews during the recertification survey dated 07/06/23 through 07/12/23 the facility did not maintain a pest-free environment and an effective pest control program on one (1) of 2 units, the Core Area, and the administration areas. Specifically, small black flies were noted by the elevator in the Core Area, in the corridor by room #s 101-N, 109-N, and 112-N; and the North Unit Nurse Manager was swatting at a fly in their office. This is evidenced as follows: During observations on 07/06/23 at 12:28 PM, small black flies were found when exiting the elevator onto the second floor Core Area and in the Board Room (the Board Room is the surveyor meeting space). During observations on 07/06/23 10:02 AM, a small black fly was observed flying in the corridor by room [ROOM NUMBER]-N; the North Unit Nurse Manager was swatting at a fly in their office; and a small black fly flew out of the restroom across from room [ROOM NUMBER]N. During an observation on 07/07/23 08:33 AM, a small black fly was found in the North Unit corridor between room #s 112-N. During observations on 07/12/23 at 9:07 AM and 10:03 AM, small black flies were found in the Board Room. During an observation on 07/12/23 at 12:48 PM, small black flies were found in the Women's Locker room. The document titled [NAME] Valley Pest Control, Inc. Service Report dated 06/13/23, 05/19/23, 04/13/23, 03/10/23, 2/10/23, 01/25/23, and 01/05/23 documented that observations were not noted of nor was the facility treated for small black flies. During an interview on 07/12/23 at 10:12 AM, the Maintenance Director stated that the maintenance department had not received verbally or through the facility electronic work order system, of any issues with flies. During an interview on 07/12/23 at 11:28 AM, the Assistant Administrator stated that the pest control vendor will be contacted immediately. 10 NYCRR 415.29(j)(5)

Based on record review and interviews during an abbreviated survey (Case #NY00295832), the facility did not ensure that the resident environment remained as free of accident hazards as possible for one (Resident #5) out of 4 residents reviewed for accident hazards. Specifically, for Resident #5, the facility did not ensure the resident received hot beverages in a cup/mug with a lid and handles in accordance with the resident's care plan and after the resident had had an incident where they sustained a burn due to spilling hot food on themself. Additionally, the facility did not ensure that temperatures of beverages made with hot water were obtained, recorded and monitored for safe serving temperatures that were not too hot. The findings include: The Policy and Procedure (P&P) titled, Accident/Incidents Reporting, Investigating and Implementing Corrective Action, last revised February 2022, read in pertinent part, it is the policy of the facility to promptly investigate any accident or incident and initiate measures to prevent recurrence. The policy defined accidents/incidents as an unexpected, unintended event that can cause a resident bodily injury. Examples of accidents/incidents included burns. The P&P titled, Final Temperature Policy, last revised 2/15/23, read in pertinent part that the intent of the policy was to ensure food is cooked and maintained at safe palatable temperatures. The procedure included that hot beverages should be heated to greater than 140 degrees Fahrenheit (F). The policy did not include a maximum temperature for safe consumption of hot beverages. The P&P titled, Hot Food Policy, undated, read that the kitchen will assure that hot foods are held so that all parts of the food meet current temperature regulations for hot holding. The procedure included that potentially hazardous foods must be held and served at 135 degrees F or above or at the temperature dictated by local health regulations. The policy did not include a [NAME] temperature for safe consumption of hot beverages. should it? if so add to the DPS During an interview on 2/15/23 at 2:09 PM, the facility's Food Services Director (FDS) stated the facility did not have a policy and/or procedure which detailed how facility/staff ensured hot beverages were not served at a temperature that was too hot for safe consumption/could cause harm if spilled on a resident. An email correspondence from the Nursing Home Administrator (NHA) on 2/17/23 at 9:10 AM, documented the facility did not have a policy and procedure for serving hot beverages and monitoring for temperature that were not too hot for safe consumption. Review of an article published in Journal of Food and Science titled, A Review of Hot Beverage Temperatures: Satisfying Consumer Preference and Safety, dated 7/19/19 retrieved from https://doi.org/10.1111/1750-3841.14699 on 2/17/23, read, Hot beverages are served ubiquitously in the food-service industry as well as at residences and other venues. Coffee and tea beverages, in particular, are brewed at temperatures that are sufficiently high to cause immediate and serious risk for scald injuries. On the other hand, numerous research studies have been performed to identify the preferred consumption temperatures for hot beverages. The outcome of these mutually reinforcing studies is that the preferred drinking temperatures are significantly below the often-encountered brewing temperatures of 200 degrees F. Consequently, there is great need to distinguish brewing temperatures from serving temperatures. Serving consumers beverages at very high temperatures is not only unnecessary (from a preference standpoint) but also unsafe. An appropriate range for service temperatures is 130 to 160 degrees F. Resident #5 Resident #5 was admitted to the facility with the diagnoses of chronic obstructive pulmonary disease, hypertension and peripheral vascular disease. The Minimun Data Set (MDS-an assessment tool) dated 1/9/2023 documented the resident usually understands others and makes self understood and usually understands others. The Care Plan titled Activities of Daily Living Function (ADL) dated 6/26/19 documented Resident #5 required assistance with personal care related to the diagnosis of dementia. The ADL care plan documented Resident #5 was able to feed themselves after set-up assistance and required assistance with fluid intake. Interventions included that all meals should be supervised, and staff were to provide the resident with two handled mugs with lids and food in separate bowls. On 5/20/22, the care plan was updated to include that a dycem mat (non-slip mat) should be placed under food bowls during meals. The Care Plan for Activities of Daily Living Function updated on 2/7/23 by the Registered Dietician (RD) documented staff should provide supervision and one (1) person assistance with meals, and to provide a two (2) handled mug with lid and separate bowls for food items. The facility's Investigation Report dated 5/11/22 documented at approximately 12:45 PM on 5/11/22, Resident #5 was eating lunch in the dining room when they attempted to scoop pureed food out of their bowl, the bowl slipped off the table and the contents landed on the resident's right thigh. Resident #5 stated, it's hot and facility staff immediately intervened by administering first aid measure. The report documented the resident had a reddened area on their right thigh as a result of the incident which developed into a blister within twenty-four (24) hours. The facility investigation found that there was no care plan violation as the resident was care planned to be able to feed themselves with close supervision and support. The investigation read that during the evening shift on 5/11/22 at approximately 10:25 PM, the reddened area on the resident's thigh began to blister and the physician was notified. The area was cleaned with wound cleanser, silver sulfadiazine (cream used to treat burns)) was applied and covered with a loose-fitting bandage. Resident #5 was seen for follow up by their provider and a new treatment order for acetaminophen was prescribed for pain management. Resident #5 was documented to have no indicators of pain. The temperature of the tray line for that date documented the meal was noted to be 170 degrees, which was within the appropriate range. The findings of the investigation concluded there were no care plan violations found, however, the incident met the criteria for reporting to the state Department of Health. A Medical Provider Progress Note dated 5/12/22 documented Resident #5 was seen for a burn sustained to their thigh. The note included that per nursing staff, food had slipped off a plate and into their lap. The progress note documented Resident #5's thigh had a ten (10) by eight (8) centimeters pink area, and the perimeter was raised with a small vesicle (blister) present, apply Xeroform (non-adherent wound dressing) daily and monitor for drainage, may apply a cool compress as needed for pain/discomfort, Tylenol 650 milligrams (mg) every six (6) hours as needed for pain, monitor for signs or symptoms of infection and notify provider. A Nursing Progress Note dated 5/16/22 documented Resident #5 continued to have a ten (10) by five (5) centimeter light pink area to right inner thigh, skin was intact, no drainage noted, treatment provided as ordered, and Resident #5 was not showing signs of discomfort or pain during the assessment. During an observation on 2/15/23 at 11:55 AM, Resident #5 was seated in the dining room waiting for lunch service. The resident was served a hot chocolate in a regular mug that did not have a lid or double handles. The meal ticket on the table next to the resident documented the resident required a dycem mat (non-slip mat) placed under their meal bowls and the resident required a two handled sippy cup with spout. Resident #5 received supervision and assistance from nursing staff throughout the meal. At 12:46 PM, the resident was left seated at the dining table without supervision while nursing staff assisted other residents from the dining room. The hot chocolate was still in front of the resident at this time. Review of the facility's final temperature log revealed hot water used to make hot beverages was not recorded in the log. Review of the food and beverage temperature log on 2/14/23, did not include documentation that temperatures were recorded for coffee or hot water. Review of the lunch meal food and beverage temperature log, dated 2/15/23, did not include documentation that temperatures were recorded for the water that was used to make hot chocolate, therefore, whether the hot chocolate was served within the parameters of a safe serving temperature could not be determined. During an interview on 2/15/23 at 1:29 PM, the RD stated they were aware of the incident on 5/11/22, when Resident #5 spilled hot food from their bowl onto their thigh. The RD stated, following the incident, a dycem (non-slip) mat was added under the resident's bowls to prevent them from spilling. The RD stated two handled cup with a lid were added to the resident's care plan prior to the incident. Resident #5 could feed themself with supervision and assistance from staff with beverages. They said the resident should be served beverages in a two (2) handled cup with a lid. The RD said the two handled cups with lid were utilized to help prevent the resident from spilling on themself. The RD stated the resident's meal ticket included that the resident required two handled cups with lids for beverages. They said the facility had cups available with two handles and a lid that should be utilized to serve hot beverages to the resident. The RD stated a cup with a lid would be provided when serving for hot beverages to prevent accidents. During an interview on 2/15/23 at 2:09 PM, the Food Services Director (FSD) said the brewing machine at the facility brewed hot beverage to a temperature of 200 degrees fahrenheit (F). The FSD stated coffee was served between 165 to 180 degrees F. The FSD stated the kitchen staff would brew hot beverages ahead of the mealtime to allow for them to cool. The FSD stated said once the hot beverage temperatures were obtained in the kitchen, they would not have the temperature taken again once it was on the unit. The FSD stated all hot beverage temperatures should be taken and recorded in the facility log which included coffee and hot water used to make tea, hot chocolate or other hot beverages. They said the facility's temperature log did not have a space to record hot water temperatures, however, they intended to change the log to include them. The FSD said, we don't know that it (the temperature) has gotten down to the 160-to-180-degree temperature range once hot beverages were brought to unit for service. The FSD stated facility had two (2) handled cups with lids available for use with hot beverages for residents who required them. The FSD stated the facility had just purchased fifty (50) new adaptive cups. They said in the facility the kitchen staff did not serve the residents. During an interview on 2/15/23 at 3:20 PM, Licensed Practical Nurse (LPN) #3 said Resident #5 should have beverages served to the them in a cup with a lid. They said they would have some concerns that the resident could spill a hot beverage down the front of themselves if served in a cup without a lid. LPN #3 said that would be a hazard for the resident. They said they did not know what a safe serving temperature would be for hot liquids. LPN #3 stated the temperatures for hot beverages was taken in the kitchen ahead of mealtime after it was brewed. LPN #3 stated the person feeding (the resident) should be able to feel the cup to determine if the beverage had sufficient cooled to be safe for serving, however beverage temperatures were not taken a second time on the unit before service to determine what the actual temperature was before service. During an interview on 2/16/23 at 11:25 AM, the Lead Cook (LC) said hot beverages were brewed ahead of time to allow for time for cooling before serving to residents. The LC stated hot water and coffee should have the temperature taken and recorded in the food and beverage temperature log, however, there was not a space on the temperature log to record the temperature of hot water. The LC stated they would obtain temperatures of all food and beverages before they left the kitchen. The LC stated the facility had sippy cups that were designed for hot liquids and that was what should be used for serving Resident #5 and was what should have been used for the resident's safety. The LC stated a safe serving temperature for hot beverages would be 160 degrees F or below. The LC stated residents who required specialized cups, utensils, feeding equipment was listed on the resident's meal ticket. They said they cared for the residents and their safety. During an interview on 2/16/23 at 12:13 PM, Registered Nurse (RN) #1 said they were next to Resident #5 when they spilled the contents on their bowl on themself during the lunch meal on 5/11/23. They said they heard the resident call out and saw that the soup had fallen on their lap. RN #1 stated they immediately brought the resident into a nearby bathroom, assisted to undress the resident and determined that the hot contents had landed on the resident's right thigh. RN #1 stated they discovered a reddened area. RN #1 stated the burned area resolved quickly. RN #1 stated Resident #5 utilized special cups for drinking that should have a lid and two handles. RN #1 stated the facility had specialized cups for hot beverages with two handles and a lid that should be used to prevent accidents and was easier for the resident handle. During an interview on 2/16/23 at 3:00 PM, LPN #4 stated Resident #5 was provided sippy cups for their beverages. LPN #4 stated the cups should have a lid and staff should always ensure the lid was secured tightly and that the lid was intended for the cup. They said hot beverages served in a cup without a lid could potentially cause an accident/ harm to the resident. They said if a resident was served a beverage in a cup other than one specifically ordered for their needs, it could be spilled on them and cause a burn, it could choke them or could go into the airways. There was number of hazards that could result. During a follow up interview on 2/17/23 at 3:16 PM, the FSD stated they had added a space for hot water temperatures on the facility food and beverage temperature log. The FSD stated kitchen staff should be taking the temperature of all food and beverages and recording the temperature in the log. The FSD stated all staff had received training on taking food and beverage temperatures. During the follow up interview, the FDS said safe serving temperature would be below 160 degrees F. The FSD stated the facility did not have a policy and/or procedure that states that a safe serving temperature should be below at or below 160 degrees F. During an interview on 2/28/23 at 12:01 PM, the Director of Nursing (DON) said they were not working at the facility when the incident occurred when Resident #5 spilled hot soup on themself. They said Resident #5's care plan included that the resident should be served beverages in a cup/mug with handles and a lid. The DON stated the intervention of an adaptive drinking cup/mug was typically initiated for residents who had difficulty with gripping beverages. The DON stated hot beverages should be served in a mug with a lid if required for the specific resident's needs for to promote safety. The DON stated kitchen staff would take the temperature of hot beverages in the kitchen prior to service but was unsure whether the temperature of hot beverages was taken again on the unit right before service to ensure that they had cooled sufficiently to be within in safe serving parameters. The DON stated hot beverages were made prior to the meals in order to allow for time for the beverages to cool down. 10 NYCRR 415.12(h)(2)

Based on record review and interviews during an abbreviated survey (Case #NY00284583), the facility did not ensure the resident's right to be free from abuse for 1 (Resident #2) of 3 residents reviewed. Specifically, the facility did not ensure that Resident #2 who was bed bound and paralyzed on one side of their body was free from sexual abuse the night of 10/9/2022, when Resident #3 who had severely impaired cognition wandered into their room while they slept touched them in their crotch and then their breast. Subsequently, the incident triggered memories of previous sexual assault and they suffered sleep deprivation as they kept their eyes on the door. Resident #2 was fearful the resident would come back again. This resulted in psychosocial harm that was not immediate jeopardy as defined by the Centers for Medicare and Medicaid Services Psychosocial Outcome Severity Guide. This was evidenced by: The Policy and Procedure (P&P) titled Freedom from Abuse, Neglect, and Mistreatment dated 7/19/2021, and last reviewed on 3/4/2022 documented the purpose was to ensure that residents in the facility were free from abuse, neglect, or exploitation. It defined sexual abuse, as non-consensual sexual contact of any type. Resident #2: Resident #2 was admitted with diagnoses of hemiplegia (paralysis) following a cerebral infarction (stroke) affecting their right side, depression, and a mood disorder. The Minimum Data Set (MDS-an assessment tool) dated 10/6/2021 documented the resident was cognitively intact. Review of the Comprehensive Care Plan (CCP) for Trauma Survivor dated 1/13/2020 and updated on 10/11/2021 at 11:06 AM documented the resident revealed a history of unwanted sexual contact and had restarted with counseling services. Resident #3: Resident #3 was admitted with diagnoses of dementia, cancer, and heart failure. The MDS dated [DATE] documented Resident #3 had severely impaired cognition and could make themselves understood and understood others. The CCP for Elopement Risk/Wandering dated 8/13/2021 documented the resident would self-propel in the hall and was noted to wander without purpose or intent and staff were to redirect them out of other's rooms. The CCP was updated on 10/10/2021 and interventions to include frequent checks were immediately implemented to ensure Resident #3 was in their room. On 10/11/2021, a staff person was assigned to sit outside the resident's room to ensure Resident #3's whereabouts. On 10/12/2021, Resident #3 was moved to another room and a door alarm was placed on their door. The facility Accident & Incident (A&I) Report dated 10/10/2021 at 8:00 PM, written by Registered Nurse Supervisor (RNS) #1, documented Resident #2 reported a man with gray hair and in a wheelchair (Resident #3) entered their room and touched their crotch. Resident #3 was removed but came back about a half hour later and touched Resident #2's breast. Resident #2 called for help and the Resident #3 was removed from their room. Immediate interventions implemented for Resident #2 to prevent further incident was their door was kept closed and frequent surveillance of the resident's room to ensure safety. The Nursing Note dated 10/10/2021 (untimed) for Resident #2, written by RNS #1, documented the resident's door was closed per resident's permission. Nursing assessment was completed and there were no signs or symptoms of physical injury observed and Resident #2 did not have any complaints of pain or discomfort from the event. Resident #2's door remained closed with frequent room checks. Review of Resident #2's medical record revealed there was no documented evidence that the facility assessed the resident for psychological symptoms (increased anxiety) after the incident was reported on 10/10/2021 at 6:57 PM until 10/11/2021 when Resident #2 was seen by the Nurse Practitioner. Review of Training Nurse Aide (TNA) #2's undated written statement documented that, on 10/9/2021 TNA #2 went into Resident #2's room and Resident #2 wanted to speak to a supervisor. The TNA #2 told Licensed Practical Nurse (LPN) #2, and LPN #2 went into Resident #2's room. Resident #2 did not report anything to the TNA #2. Review of LPN #2's statement dated 10/10/2021 (untimed) documented that on Saturday night 10/9-10/10/2021 on the 11-7 shift at around 2:00 AM they saw Resident #3 wheeling themselves out of Resident #2's room. LPN #2 told Resident #3 they were not allowed in there and told them to stay out in the hallway or in their room. Sometime later the LPN #2 saw Resident #3 in the doorway of Resident #2's room. At that time the LPN #2 apologized to Resident #2 and again asked Resident #3 to stay out of their room and redirected them. Resident #2 did not tell LPN #2 about the incident when they went into Resident #2's room and removed Resident #3 from the doorway. Review of the Nurse Practitioner (NP) #1's note dated 10/11/2021 (untimed), documented Resident #2 reported that they were inappropriately touched by another resident (identified by staff as Resident #3) on 10/9/2021. Resident #2 was very upset and only felt safe in their room and wanted their door closed at all times. Resident #2 refused examination, cried, and revealed a history of rape. Resident #2 reported increased anxiety and was unable to sleep. A new order was written for the resident to be given lorazepam 0.25 milligrams (mg) twice daily for two weeks for anxiety and to restart behavioral therapy. Review of the Social Worker (SW) #1's note dated 10/11/2021 (untimed), documented a resident (identified by staff as Resident #3) entered Resident #2's room in the night-time while sleeping and inappropriately touched their genital area and the resident (Resident #2) was concerned that it could happen again. SW #1 visited with Resident #2 daily to monitor how they were doing emotionally. Review of a Psychological Evaluation dated 10/13/2021, written by Licensed Master of Social Worker (LMSW-Counselor) #1, documented Resident #2 presented with a report of unwanted sexual touching by another resident who wandered into their room. Resident #2 reported acute anxiety and depression. Cognitive status was intact. Resident #2's mood in session presented as appropriate to the session dialogue and included a range of expressed emotion. LMSW #1 documented they worked with Resident #2 in support of mood and psychological recovery from the recent incident. LMSW #1 documented the resident stated their goal was to feel safe. LMSW #1 documented Resident #2's mood was sad and anxious and had risk factors such as sleep disturbance, mobility impairment and the resident's condition resulted in significant impairment in psychological function. During an interview on 10/26/2022 at 11:20 AM, Resident #2 stated they were in a dead sleep and awoke to cold hands that touched their groin and the top of their leg. Resident #2 stated that Resident #3 did not get inside of their brief and screamed at Resident #3 to leave and put the call bell on. TNA #2 came and took Resident #3 out of their room. Resident #2 stated they were able to get back to sleep but about a half hour later they awoke to Resident #3 touching their breast. Resident #2 stated they screamed for Resident #3 to get out of their room and put the call bell on. The staff removed Resident #3. Resident #2 stated that at the time they were afraid and felt unsafe especially because Resident #3 was able to get to them a second time. Resident #2 stated they did not know what to do and felt like no one was doing anything about the incident and did not say anything to the staff about what had occurred. Resident #2 stated that after all this was their room where they should feel safe but instead, they felt vulnerable and defenseless. Resident #2 stated they were afraid to fall asleep for fear that Resident #3 would come back and did not tell anyone until the next evening when they confided in RNS #1 of what occurred. Resident #2 stated they told RNS #1 they wanted their door closed at all times. Resident #2 stated they spoke with SW #1 about the incident with Resident #3 and told them how anxious and unsafe they felt, and SW #1 told Resident #2 that a staff person would sit outside their door until Resident #3's room could be changed. Resident #2 stated they were somewhat relieved when Resident #3's room was changed. Resident #2 stated eventually a stop sign was placed across their doorway. Resident #2 stated this incident triggered bad memories of when they were sexually assaulted as a youth. Resident #2 stated a person had the right to feel safe in their own place and this incident made them feel very vulnerable and defenseless. Resident #2 stated the doctor prescribed lorazepam 0.25 mg to help calm their nerves and they resumed counseling which also helped. During an interview on 10/26/2022 at 3:49 PM, SW #1 stated that they became aware of the incident on Monday, 10/11/2022 at morning report and that they went to visit Resident #2 to provide support. SW #1 stated Resident #2 was observed to be anxious. Resident #2 cried and reported they felt uneasy after the incident. SW #1 stated Resident #2 complained of having difficulty sleeping and was worried it would happen again. SW #1 stated Resident #3' s room was located directly across from Resident #2's room. SW #1 stated they visited daily on 1:1 basis with Resident #2 and that counseling services were re-established with LMSW #1, and they were started on an anti-anxiety medication. During an interview on 11/1/2022 at 2:30 PM, RNS #1 stated that on 10/10/2021 they were on duty and Resident #2, confided in them that the night before Resident #3 came in their room and touched them inappropriately. RNS #1 stated that they assessed Resident #2 with no physical findings, there was no bruising or marks noted on the resident's body including their peri-area. Resident #2 did not have any tenderness or pain and they notified Medical Doctor (MD) #1 and there were no new orders. RNS #1 stated that they did not assess for psychological symptoms, but the resident wanted to have their door kept closed because they were afraid that Resident #3 might enter again. RNS #1 stated they checked throughout the shift to make sure the door was shut. During an interview on 11/23/2022 at 10:00 AM, MD #1 stated that RNS #1 called them the night of the incident and told them that Resident #3 wandered into Resident #2's room and touched them inappropriately and RNS #1 assessed the resident and told them there was no physical harm. MD #1 stated they did not give any new orders since there was no physical harm and could not recall if the resident's psychological status was discussed. During an interview on 11/23/2022 at 2:30 PM, the Administrator (ADM) stated Resident #2 was assessed by the NP and a new order for lorazepam was started. During an interview on 12/9/2022 at 10:55 AM, LPN #2 stated they were on duty and recalled Resident #3 coming out of Resident #2's room and told Resident #3 you can't be in there. LPN #2 stated sometime later they saw Resident #3 again in the hallway heading into Resident #2's room and told them don't go in there and redirected them out and recalled Resident #2 asked to keep them out of their room. LPN #2 stated Resident #3 wandered during the night shift. 10 NYCRR 415.4(b)(1)(i)

Based on record review and interviews during an abbreviated survey (Case #NY00289583) the facility did not ensure an allegation of abuse was reported to the New York State Department of Health (NYSDOH) no later than 2 hours after the allegation was made for 1 (Resident #2) of 3 residents reviewed for abuse. Specifically, for Resident #2, the facility did not ensure an allegation of sexual assault made on 10/10/2021 at 6:57 PM was reported to the NYSDOH within 2 hours after the allegation was made. The facility reported the allegation on 10/11/2021 at 10:45 AM, 15 hours later than when the allegation was made. This is evidenced by: The Policy and Procedure (P&P) titled Freedom from Abuse, Neglect, and Mistreatment dated 7/19/2021, and last reviewed on 3/4/2022 documented all allegations of abuse, with or without injury fall into the immediate reporting category, imprudent to allow delay in reporting of any abuse. Allegations of abuse will be reported immediately, but no later than 2 hours after the allegation is made. Allegations of neglect or exploitation will be reported to the Administrator immediately, but not later than 2 hours after forming the suspicion if the events that caused suspicion result in serious bodily injury. Or not later than 24 hours if the events that caused the suspicion do not result in serious bodily injury. Resident #2 was admitted with diagnoses of stroke, diabetes, and a mood disorder. The Minimum Data Set (MDS-an assessment tool) dated 10/6/2021 documented the resident was cognitively intact. Resident #3 admitted [DATE] diagnoses of dementia, cancer, and heart failure. The MDS dated [DATE], documented the resident had severely impaired cognition, could make themselves understood and understood others. The Nursing Home Intake Form documented the alleged incidents occurred on 10/9/2021 at 11:00 PM, and was submitted to the NYSDOH by the facility on 10/11/2021 at 10:45 AM. During an interview on 10/26/2022 at 4:55 PM, the Administrator (ADM) stated they did not recall when they were notified but were supposed to report an allegation of sexual abuse within 2 hours to the NYSDOH. The ADM stated that they did not report the alleged incident to the NYSDOH or law enforcement. During an interview on 11/1/2022 at 2:30 PM, Registered Nurse Supervisor (RNS) #1 stated that they were supposed to notify the Administration right away and the NYSDOH within 2 hours for allegations of abuse. RNS #1 stated they became aware of the allegation of abuse on 10/10/2021 at 6:57 PM, and notified the Administrator at 8:00 PM. The RNS did not report the allegation of abuse to the NYSDOH. 10 NYCRR 415.4(b)(2)

Based on interviews and record review, during an abbreviated survey (NY 944), the facility failed to develop and implement policies and procedures (P&P) to ensure proper precautions to prevent the spread of COVID-19 by unvaccinated staff. Specifically, P&Ps did not include a contingency plan for staff not fully vaccinated or with exemptions for COVID-19, there was no procedure for staff to apply for medical exemptions, and no procedure for tracking and securely documenting staff vaccinations including staff with medical/religious exemptions or temporary delays. This was evidenced by: The facility P&P titled, COVID 19 Action Plan dated 2/21/2022, did not include a contingency plan for staff not fully vaccinated for COVID-19 that addressed actions and consequences the facility would take for staff who indicated they would not get vaccinated and did not qualify for an exemption. Other than precautions of wearing an N95 mask, and social distancing from peers for staff who had medical or religious exemptions, there was no further directives of precautions the facility could take. There was no procedure for staff to apply for a medical exemption. The P&P did not include procedures for tracking and securely documenting staff vaccinations including staff with medical/religious exemptions or a process to track and securely document delayed staff vaccination for clinical precautions/considerations. During an interview on 3/23/ at 4:03 PM, the Administrator stated there was only the one packet for COVID-19 P&P and that was what was provided to the surveyor. The Administrator stated there were no other P&Ps for COVID-19. The Administrator stated they were familiar with the P&P, and it contained a contingency plan, and the process by which the facility tracked staff vaccinations, exemptions, and temporary delays. 10 NYCRR 415.19(a)(1-3)