Every finding on record at St. John's Health Care Corporation

Based on observations, interviews, and record review conducted during a Recertification Survey from 06/02/2025 to 06/09/2025, the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for three (3) (Residents #120, #213 and #222) of seven (7) residents reviewed. Specifically, Resident #120 was observed with debris underneath multiple fingernails and eating food items with their hands. Resident #213 was observed over several days with greasy hair and the facility was unable to provide evidence of the resident getting their hair washed for the prior month. Resident #222 was observed with untrimmed overgrown mustache hair going into their mouth which they reported made them feel shameful about themselves and did not want visitors to see them in that state. This resulted in actual psychosocial harm to Resident #222 that was not immediate jeopardy. The findings include: The facility policy Standards of Care dated 01/19/2024, documented for staff to shave men's facial hair and ear hair minimally on shower day or per the residents' choice. Additionally, to clean resident's hands before and after meals, inspect fingernails for cleanliness and need for trimming, and to provide nail care as needed. If a resident declines or refuses any or all portions of care and attempts to re-approach are unsuccessful, the nurse should write a note in the resident's chart. 1. Resident #222 had diagnoses that included repeated falls, congestive heart failure, and weakness. The Minimum Data Set (a resident assessment tool) dated 04/24/2025, documented the resident was cognitively intact, their vision was severely impaired, and they required assistance with personal hygiene. Resident #222's Comprehensive Care Plan dated on 05/22/2025, documented the resident had a self-care deficit related to decreased mobility and loss of vision and preferred to be clean, neat and dressed appropriately. The Key to Care (care plan used by Certified Nursing Assistants) dated 05/30/2025, documented the resident required assistance with dressing and grooming. During an observation and interview on 06/02/2025 at 10:30 AM, Resident #222 had a significant amount of facial hair growing into their mouth. In an immediate interview, the resident stated they had asked for a shave weeks ago and was told by staff that they would get to it soon, but no one ever comes back. The resident said they would like to be shaved weekly, but they were blind and depended on staff. There was an aide that kept on top of it, but they were no longer at the facility and care had decreased due to staff turnover. During an observation and interview on 06/03/2025 at 9:23 AM, Resident #222's mustache remained long with hair hanging over their upper lip and their neck hair more than an inch long. The resident said their mustache hair went into their mouth, and they asked their aide (name unknown) yesterday for a shave and were told they would call downstairs to speak with the barber. The resident said they were told that they were on the schedule to see the in-house barber on 06/21/2025, but they did not want to wait until then because their hair had grown too long. The resident said they were not used to having so much hair on their face and neck. During observations and interviews on 06/04/2025 at 1:00 PM, Resident #222 was eating lunch in their room and remained unshaven. The resident stated they again asked a staff member (name unknown) to shave them but still had not been shaved. The resident said they hated that the hair from their mustache was in their mouth, and they did not want to be seen that way. The resident said they looked like a bum and thought they should get a shave at least every two (2) weeks. When interviewed at 3:18 PM, Resident #222 stated it bothered them when they had to go out because they were used to being clean shaven, and this was not like them. During an observation and interview on 06/05/2025 at 10:30 AM, Resident #222 remained unshaved. The resident stated they did ask their aide, who is new, for a shave today and hope they are better than the others. During an interview on 06/05/2025 at 11:45 AM, Certified Nurse Assistant #4 said Resident #222 required more help due to their visual impairment and that they were not assigned to care for them due to the rotating schedule, but that shaving was usually performed on the unit by staff. Certified Nurse Assistant #4 said the resident's mustache should never grow to the point of going inside the mouth and if a resident requested a shave and they were too busy to complete this, staff should pass the request to the evening shift. If the evening shift could not assist, staff should make sure the request was completed the following day. Certified Nurse Assistant #4 said the resident should never have to wait several days to be shaved and that 06/21/2025 (appointment with the barber) was too long of a wait. During an interview on 06/05/2025 at 12:41 PM, the Director of Nursing said Resident #222 should have received a shave long ago and nursing staff on the unit should have provided it and not waited for them to see the barber. The Director of Nursing said that due to the resident not being able to shave themselves, staff should have offered it that day or the following day. During an interview on 06/09/2025 at 2:46 PM, Nurse Practitioner #2 said they were familiar with Resident #222 and that they did not think it was good that the resident's hair grew so long that they were ashamed. Nurse Practitioner #2 said the resident usually had some facial hair, but not an excessive amount and were unsure why the staff did not assist the resident with shaving since it was an easy fix and could be completed on the unit. 2. Resident #120 had diagnoses including glaucoma (increased pressure in the eyes that damages the eye nerves causing blindness), dysphagia (difficulty swallowing), and heart failure. The Minimum Data Set, dated [DATE] documented Resident #120 was cognitively intact, visually impaired, required setup assistance with eating, and was dependent (on staff) for personal hygiene and bathing. Review of the Key to Care dated 06/03/2025 revealed Resident #120's first choice for bathing was a bed bath which was scheduled weekly on the Friday day shift. The Key to Care documented the resident required one staff assistance with grooming and needed set-up assistance with meals. During an observation and interview on 06/02/2025 at 12:15 PM, Resident #120 was in bed eating lunch. Dark brown debris was observed underneath the fingernails of multiple nails on the resident's left hand. The resident picked up multiple food items off their tray with their left hand placing them in their mouth. Resident #120 stated they were completely blind in one (1) eye, partially blind in the other and wished they had more help (from staff) with eating. During an interview on 06/05/2025 at 10:23 AM, Certified Nursing Assistant #11 said they assist residents with nail care as needed. During an interview on 06/05/2025 at 11:27 AM, Licensed Practical Nurse #7 stated Resident #120 was legally blind and required setup help with meals. Licensed Practical Nurse #7 stated they had never seen Resident #120 use a fork (even for items that required one) and they had seen the resident pick up food with their hands. During an interview on 06/09/2025 at 9:22 AM, Licensed Practical Nurse Manager #1 said nail care should be done on residents' shower (bathing) days and as needed when they are dirty. Licensed Practical Nurse Manager #1 stated they were not aware Resident #120 was using their hands (to eat) and if there was debris underneath their fingernails, nail care should be done. 3. Resident #213 had diagnoses including anxiety, dementia, and macular degeneration (a progressive eye disease causing vision loss). The Minimum Data Set, dated [DATE] revealed Resident #213 had moderately impaired cognitive function and required maximum assistance with bathing and showering. Review of the Key to Care dated 05/01/2025 revealed Resident #213 preferred bed baths and was scheduled for them on Wednesday's day shift. During an observation and interview on 06/02/2025 at 9:33 AM, Resident #213 hair was unwashed and greasy. In an immediate interview, Resident #213 said their hair was last washed a couple months ago when they had it cut. Review of a handwritten document titled Beauty Salon and signed by Beautician #1 revealed that on 05/01/2025 at 1:00 PM, Resident #213 had a shampoo, cut, set and a manicure. In a nursing progress note dated 06/04/2025, Licensed Practical Nurse #8 documented that Resident #213 had received a bed bath, but did not include if the resident's hair had been washed. Review of Resident #213's electronic medical record did not include any documented evidence the resident had gotten their hair washed since 05/01/2025. During an observation and interview on 06/09/2025 at 10:43 AM, Resident #213's hair remained unwashed and greasy. In an immediate interview Resident #213 again stated it had been a while since they had their hair washed. During an interview on 06/09/2025 at 10:46 AM, Licensed Practical Nurse #8 said residents' hair was supposed to be washed on their shower (bath) days and if a resident did not get up for a shower, staff could use a shower cap (to wash hair). Licensed Practical Nurse #8 stated they saw Resident #213 earlier and their hair looked flat and said I guess you can say greasy. During an interview on 06/09/2025 at 11:07 AM, Certified Nursing Assistant #10 said it was hard to wash resident's hair when the residents received bed baths because they did not have basins to put their head (hair) in. Certified Nursing Assistant #10 said they document hair washing in the electronic medical record, under personal hygiene but it does not specifically include hair washing. Certified Nursing Assistant #10 stated they were not sure when Resident #213's hair was last washed because they had never been assigned to the resident on their designated shower (bath) day. During an interview on 06/09/2025 at 11:16 AM, Assistant Director of Nursing #3 said if a resident received a bed bath their hair could be washed via a shower cap or by going to the hairdresser. Assistant Director of Nursing #3 stated documentation of hair washing should be included as part of the resident's shower (bath) day documentation unless the resident went to the hairdresser. 10 NYCRR 415.12(a)(3)

Based on observations, interviews and record review conducted during the Recertification Survey from 06/02/2025 to 06/09/2025, the facility failed to ensure residents with indwelling urinary catheters (a tube inserted into the bladder to drain urine) received the care and services to manage the urinary catheter for two (2) (Resident #112 and #222) of four (4) residents reviewed. Specifically, Resident #112 had a urinary catheter that was not consistently secured to prevent tension resulting in a genital injury. Additionally, Resident #112's Comprehensive Care Plan did not include the presence of a urinary catheter or interventions for appropriate care of the urinary catheter to prevent complications. Resident #222 had a urinary catheter that was observed not secured appropriately to prevent complications. Additionally, the urinary catheter drainage bag (a collection bag attached to the catheter that the urine drains into) was observed on multiple occasions lying on the floor without a barrier. This resulted in actual harm to Resident #112 that is not Immediate Jeopardy. The findings include: The facility policy Insertion and Maintenance of Indwelling and Intermittent Catheters dated 09/18/2024, documented to maintain the closed system and straight gravity drainage by positioning the drainage bag below the level of the bladder, to position the catheter over the top of the leg to prevent occlusion and to secure the tubing (catheter) with a strap to prevent pulling. 1. Resident #112 had diagnoses that included Parkinson's disease (progressive brain disorder that slowly destroys memory and thinking skills), urinary retention (inability to fully or partially empty the bladder), and benign prostatic hyperplasia (enlarged prostate). The Minimum Data Set (a resident assessment tool) dated 05/09/2025 revealed Resident #112 was moderately impaired of cognitive function and had an indwelling urinary catheter. Review of Resident #112's Comprehensive Care Plan dated 04/24/2025 revealed the resident had a focus area of self-care performance deficit related to use of a urinary catheter. The Comprehensive Care Plan did not include any interventions related to the care of the catheter to prevent complications. Physician orders dated 03/11/2025 documented to ensure the urinary catheter was secured to the resident with a securement device (device that secures the catheter tubing to the resident's leg to prevent tension on the catheter and subsequent injury or dislodgement) every shift. In a late entry nursing progress note dated 05/24/2025 at 10:30 PM for 05/23/2025, Licensed Practical Nurse #10 documented that Resident #112 had removed their fully inflated urinary catheter during the prior evening shift and the tip of the resident's penis was observed to be split (an open wound) and a new urinary catheter was inserted. The progress note did not include if the medical team had been notified of the resident's injury at the time. In a nursing progress note dated 05/27/2025 at 7:06 AM, Registered Nurse #1 documented Resident #112 was bleeding from the penis, that the penile split was worse than before, and the on-call (medical provider) was notified. In a medical progress note dated 05/27/2025 at 12:32 PM, Nurse Practitioner #2 documented Resident #112 was evaluated for hematuria (blood in the urine) and an ulceration (a break in the skin) from the catheter through the shaft of the resident's penis. Nurse Practitioner #2 documented that the meatus (the opening in the tip of the penis that the catheter is inserted through) was eroded through into the shaft due to the presence of the urinary catheter and that there is now a securement device in place. Nurse Practitioner #2 documented Resident #112 had a stage three (3) (full thickness skin loss) pressure ulcer to the shaft of their penis from the urinary catheter. Triad cream (medicated paste used to treat pressure ulcers) would be ordered, and to ensure that a securement device was in place and to ensure to position the catheter, so it did not cause further trauma. In a nursing progress note dated 05/29/2025 at 10:25 PM, Licensed Practical Nurse #11 documented Resident #112's penis had split further, there was blood in the resident's brief and the supervisor was notified. In a medical progress note dated 05/30/2025 at 3:13 PM, Nurse Practitioner #1 documented Resident #112 was seen for a pressure area to the penis from the urinary catheter and per nursing, due to the resident's positioning, the urinary catheter had been pressing and pulling on their penis, which created an open area/slit in their urethra (passageway between the bladder and the external part of the body that allows urine to flow out). On exam, Nurse Practitioner #1 documented that Resident #112 did not have a leg securement device on and there was an open slit of the urethra where the urinary catheter tube was. Nurse Practitioner #1 documented they advised nursing to position the catheter carefully to avoid tension to the area with use of a leg securement device and pillows to position the resident's legs. There was no documented evidence the care plan was updated to include Nurse Practitioner #1's recommendations and orders. During an observation and interview on 06/05/2025 at 4:35 PM with Licensed Practical Nurse #11 and Certified Nursing Assistant #10, a securement device was affixed to Resident #112's right inner thigh. Licensed Practical Nurse #11 stated the securement device prevents a urinary catheter from pulling (create tension). The resident had an open wound on the underside of the penis. During an interview on 06/06/2025 at 11:07 AM, Licensed Practical Nurse #8 stated to prevent a catheter from pulling, there were securement devices (straps or adhesive holders) around a resident's leg. Licensed Practical Nurse #8 stated an order was not needed for a securement device and every resident (with a catheter) should have them put on automatically. Licensed Practical Nurse #8 stated prior to the penile injury, Resident #112 did have a securement device, but it was the wrong one and the resident's urinary catheter was incorrectly positioned coming up over the top of their incontinence brief and at times under the securement device (instead of accurately positioned through it). Licensed Practical Nurse #8 said the day the injury was noted, staff said Resident #112 had pulled out the catheter but when they came in, the whole catheter was full of blood, and they felt the issue was due more to a lack of education about the care and of positioning of urinary catheters. During an interview on 06/09/2025 at 10:07 AM, Nurse Practitioner #1 said to prevent skin breakdown from urinary catheters, orders should include checking the resident's skin, looking for leaking or retention, and catheter flushes. Nurse Practitioner #1 stated if there was associated skin breakdown, barrier cream should be used and leg straps (securement devices) in place to assist with catheter positioning. Nurse Practitioner #1 said securement devices were standard interventions unless the resident had a reason for not having it. Medical providers usually order the securement devices, but it is also a nursing intervention that they could put in on their own (without an order). Nurse Practitioner #1 stated Resident #112 had rubbing from the urinary catheter that caused their urethra to split, and when they saw the resident on 05/30/2025, the injury had gotten worse and there was no leg strap (securement device) in place. Nurse Practitioner #1 stated Nurse Practitioner #2 talked to the nursing staff on 05/27/2025 about not having a securement device in place and wrote in their progress note to ensure one was in place. Nurse Practitioner #1 said Resident #112 has had an ongoing order for a securement device since 03/11/2025. Nurse Practitioner #1 stated it was tough to say if the injury could have been prevented, but having a securement device in place could have resolved the injury or prevented the injury from getting worse. During an interview on 06/09/2025 at 11:16 AM, Assistant Director of Nursing #3 stated to prevent skin breakdown from a urinary catheter, a securement device should be used to keep the catheter/tubing from pulling. Assistant Director of Nursing #3 stated they were unaware Resident #112 had a penile injury from their urinary catheter. After review of Resident #112's medical progress notes in the electronic medical record, Assistant Director of Nursing #3 said the resident had an injury to the penis that could have occurred when the resident pulled out their urinary catheter. They were unaware that the resident had not had a securement device in place. Assistant Director of Nursing #3 stated interventions related to care of the urinary catheter were not on Resident #112's care plan and should have been. 2. Resident #222 had diagnoses including urinary retention, acute kidney failure, and chronic kidney disease. The Minimum Data Set, dated [DATE], revealed the resident was cognitively intact and had an indwelling urinary catheter. Resident #222's Comprehensive Care Plan, dated 05/22/2025, documented the resident required an indwelling urinary catheter related to urinary retention and staff were to assist with catheter care and use a leg bag (drainage bag that can be secured to the resident's leg and under clothing) when out of bed. The Comprehensive Care Plan did not include the use of a securement device to prevent complications. Physician orders dated 04/18/2025 documented urinary catheter care per facility policy. In a nursing progress note dated 06/01/2025, Licensed Practical Nurse #14 documented Resident #222's indwelling urinary catheter was replaced after being dislodged, hematuria was noted, and the Registered Nurse Supervisor was notified. During an observation on 06/05/2025 at 10:30 AM, Resident #222 was sitting in their wheelchair in their room. Their urinary catheter drainage bag was lying on the floor without a barrier under it. During an interview on 06/05/2025 at 11:45 AM, Certified Nurse Assistant #4 said the catheter drainage bag should hang from the bed frame and never be on the floor and if it touched the floor, it was considered contaminated and should be changed. During an observation on 06/05/2025 at 12:12 PM, Resident #222's urinary catheter drainage bag remained lying directly on the floor without a barrier under it and a small corner of the drainage bag was underneath the wheel of the resident's wheelchair. The floor was stained with dirt, had scrambled eggs on it and was sticky with an unknown substance. The catheter tubing was coiled around the resident's left ankle and there was no securement device in place at this time. During an interview on 06/05/2025 at 12:41 PM, the Director of Nursing said urinary catheter drainage bags should never be on the floor and should be hung on the bed frame and below the bladder. If found on the floor, the bag should be replaced or disinfected. During an observation and interview on 06/05/2025 at 3:52 PM, Licensed Practical Nurse #3 entered Resident #222 room with the surveyor and stated there was no securement device on the resident's urinary catheter. Licensed Practical Nurse #3 immediately applied one and stated they had received training on properly securing the catheter tubing so the catheter would remain in place and not get dislodged. During an interview on 06/06/2025 at 9:56 AM, Certified Nurse Assistant #5 said when performing care on Resident #222, they ensured the securement device was in place on the resident's leg, because when it is not there, the urinary catheter could come out. Certified Nurse Assistant #5 said a few days prior they noticed the securement device was not in place and the drainage bag was hanging lower than normal, so they reported it to the nurse and shortly after they were notified that the resident's urinary catheter had come out. During an interview on 06/09/2025 at 9:18 AM, with the Director of Nursing and Assistant Director of Nursing #2, the Director of Nursing stated residents with indwelling urinary catheters, especially with a history of catheter dislodgement, should have a securement device in place to stabilize the catheter tubing. The Director of Nursing said nursing orientation covered indwelling urinary catheter care and staff should ensure that securement devices are in place. 10 NYCRR 415.12(d)(1)

Based on observations, interviews, and record review conducted during a Recertification Survey from 06/02/2025 to 06/09/2025, for one (1) (Resident #28) of one (1) resident reviewed, the facility did not ensure the interdisciplinary team determined the resident's right to self-administer medications was clinically appropriate. Specifically, there were multiple observations of unsecured medications left at Resident #28's bedside and the resident had not been assessed for their ability to self-administer medications. Additionally, there was no medical order or comprehensive care plan in place to address the self-administration of medications. The finding is: The facility policy Self-Administration of Medications, last reviewed 10/07/2008, included residents may self-administer medication when it has been determined by the interdisciplinary care team that the practice is safe. The interdisciplinary team will meet to determine the safety and appropriateness of the resident to self-administer medication. The physician writes an order for self-administration. The nurse will take the container to the resident's room and give them complete instructions for taking the medication. Medication will be kept in a locked drawer or other secured area. Resident #28 had diagnoses including chronic obstructive pulmonary disease (lung disease that blocks airflow making it difficult to breath), nasal congestion, and acute bronchitis (inflammation of the tubes that carry oxygen to the lungs). The Minimum Data Set (a resident assessment tool), dated 05/02/2025, documented the resident was cognitively intact. Review of active medical orders as of 06/05/2025 included the following: Breo Ellipta 100-25 microgram inhalation one (1) puff inhale orally once daily for chronic obstructive pulmonary disease, fluticasone 50 micrograms nasal spray two (2) sprays in both nostrils once daily for allergies, and Mouth Kote Spray give two (2) sprays orally three times daily for dry mouth. There was no medical order for Resident #28 to self-administer medications. The current Comprehensive Care Plan on 06/05/2025 did not include measurable goals and/or interventions addressing Resident #28's ability to safely self- administer medications. During an observation and interview on 06/02/2025 at 11:37 AM, a Breo Ellipta inhaler (a steroid medication) and fluticasone (a steroid medication) 50 micrograms were on Resident #28's bedside table. There was no nurse in sight. Resident #28 stated they took their medications independently. During an observation on 06/04/2025 at 9:22 AM, a Breo Ellipta inhaler was on Resident #28's bedside table. There was no nurse in sight. During an observation and interviews on 06/04/2025 at 11:13 AM, Mouth Kote dry mouth spray was on Resident #28's nightstand. Resident #28 stated the medication had been in their room for a while. Licensed Practical Nurse #4 stated the mouth spray was considered a medication and the Mouth Kote, Breo Ellipta, and fluticasone were not supposed to be left at the bedside. Licensed Practical Nurse #4 stated they overlooked the medications before. During an interview on 06/05/2025 at 10:57 AM, Licensed Practical Nurse #12 stated they had passed medications to Resident #28 on 05/31/2025 and saw the Breo Ellipta inhaler and fluticasone nasal spray at the bedside. Resident #28 liked to have their medications at the bedside, but did not have a medical order for it. During an interview on 06/05/2025 at 12:57 PM, the Director of Nursing stated the facility did not have residents who self-administered their medications and a nurse would have to ensure Resident #28 could take medications independently. Resident #28 should know what their medications were for, demonstrate their ability to take them safely, the medications should be secured, and a medical order and care plan should be in place. The Director of Nursing stated staff had been educated about leaving medications at the bedside unsupervised, and if medications were found, they should be removed immediately. 10 NYCRR 415.12(l)(1)

Based on interviews and record review conducted during the Recertification Survey and complaint investigations (NY00352162 and NY00356860) from 06/02/2025 to 06/09/2025 for 6 (Residents #23, #27, #93, #210, #313, #721) of 14 residents reviewed, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment were reported to the New York State Department of Health in accordance with state law. Specifically, Resident #23 and #721 both had multiple unwitnessed falls including one with a major injury. Resident #27 had multiple bruises on their face of unknown origin. Resident #210 was observed by staff engaging in potential sexual abuse towards Resident #93. Resident #313 had an unwitnessed fall with a major injury and subsequently passed away within two (2) days. None of the identified incidents had been reported to the New York State Department of Health. The findings include but not limited to: The facility policy Abuse Prevention and Incident Investigation, dated October 2024, documented the facility will investigate any allegation of abuse, mistreatment, neglect, or injuries of unknown origin. If potential abuse, mistreatment, or neglect was suspected, the Assistant Director of Nursing or the Director of Nursing would submit an online report to the Department of Health within two (2) hours of making the determination. 1. Resident #210 had diagnoses including dementia, Alzheimer's disease, and heart failure. The Minimum Data Set (a resident assessment tool), dated 05/16/2025, included the resident had moderate cognitive impairment and had physical behavior symptoms directed towards others. Review of the Comprehensive Care Plan, dated 05/08/2025, revealed Resident #210 had impaired cognitive function and a behavior problem related to inappropriate language and touching. In a nursing progress note dated 06/05/2025 at 7:35 PM, Licensed Practical Nurse #13 documented a Certified Nursing Assistant reported that Resident #210 was in the dining room seated on the edge of their wheelchair with their legs open in front of Resident #93. Resident #210 had their shorts pulled to the side exposing and touching Resident #93's leg with their genitals. The facility was unable to provide documentation that the allegation of sexual abuse was reported to the New York State Department of Health within the two-hour timeframe and could not provide statements from staff obtained within the two-hour timeframe that would rule out alleged sexual abuse. During an interview on 06/09/2025 at 10:46 AM, the Director of Nursing stated the facility was unable to substantiate sexual abuse as the incident was initially reported as Resident #210's genitals touching Resident #93's leg. However, after staff interviews it was identified that Resident #210 had just sat next to Resident #93 with their pants unzipped. The Director of Nursing stated they did not report the incident within the two-hour timeframe as they wanted to get as many facts as possible and when they had discussed the incident with the Administrator, they did not believe the incident needed to be reported. 2. Resident #23 had diagnoses including dementia, cerebral infarction (stroke-blood flow to the brain is blocked), and dysarthria (difficulty speaking). The Minimum Data Set, dated [DATE], included the resident had severe cognitive impairment and required staff assistance with bed mobility, standing, transferring, and was unable to ambulate ten (10) feet independently. Review of the Comprehensive Care Plan, dated 12/04/2024, revealed Resident #23 was at high risk for falls, required staff assistance with care and transfers due to weakness, often attempted to self-transfer and ambulate, and needed to be reminded to wait for assistance. Review of an Incident Report, dated 03/16/2025, documented Resident #23 was found on the floor next to their bed lying on their left side. Resident #23 complained of pain to their left hip and had a skin tear on their left elbow. Resident #23 was documented as having been incontinent of bowel and bladder and had stated that they fell trying to go to the bathroom. In a nursing progress note dated 03/16/2025, Registered Nurse #5 documented Resident #23 had an unwitnessed fall. X-rays revealed a left hip fracture and the resident was hospitalized . The incident was not reported to the New York State Department of Health. 3. Resident #27 had diagnoses including dementia, adult failure to thrive, and chronic obstructive pulmonary disease. The Minimum Data Set, dated [DATE], included the resident had severe cognitive impairment and required staff assistance with all care. Review of the Comprehensive Care Plan, dated 06/10/2024, revealed Resident #27 was on hospice, had impaired cognitive function, was at high risk for falls, had limited physical mobility, and required assistance from staff for transfers and ambulation. In a nursing progress note dated 08/16/2024, Registered Nurse #3 documented a visitor noticed bruising to Resident #27's face and told a Licensed Practical Nurse. Registered Nurse #3 documented there were purple bruises to the chin, above the lip, and under the resident's right and left eyes. Registered Nurse #3 documented it was not known how the bruises occurred and the resident was unable to answer any questions. The facility was unable to provide documentation that an investigation had been completed to rule out abuse, neglect, and/or mistreatment, and the injury of unknown origin was not reported to the New York State Department of Health. 4. Resident #313 had diagnosis including Alzheimer's disease, heart failure, and anxiety disorder. The Minimum Data Set, dated [DATE], documented the resident had severe cognitive impairment, required staff assistance with standing and transferring, and was dependent on staff for ambulation. Review of the Comprehensive Care Plan, dated 01/08/2025, revealed the resident had impaired cognitive function, was a high risk for falls, had limited physical mobility, and required assistance from staff for transfers and ambulation. In a progress note dated 03/27/2025, Physician #1 documented Resident #313 had an unwitnessed fall on 03/24/2025 resulting in a large hematoma (bleeding and swelling under the skin) to the left side of their forehead. On 03/26/2025, the resident developed a sudden change in condition with hypoxia (low oxygen levels in the body), tachypnea (rapid respiratory rate), and tachycardia (rapid heart rate); the family was notified, comfort measures were requested, and the resident passed away. The facility was unable to provide documentation that an investigation had been completed to rule out abuse, neglect, and/or mistreatment, and the incident was not reported to the New York State Department of Health. During an interview on 06/06/2025 at 12:55 PM, the Assistant Director of Nursing #3 stated that the Assistant Director of Nurses or the Director of Nursing are responsible for reporting allegations of abuse to the New York State Department of Health. Assistant Director of Nursing #3 stated that they were unsure of which incidents should be reported and needed to review the facility policy. During an interview on 06/09/2025 at 10:46 AM, the Director of Nursing stated either they, the Assistant Director of Nursing, or the Nurse Managers were responsible for reporting incidents. Without completed investigations to rule out abuse, neglect, or mistreatment, they would not know if the incidents should have been reported to the New York State Department of Health. The Director of Nursing stated there was a break in the facility's system. 10 NYCRR 415.4(f)(1-4)

Based on interviews and record review conducted during the Recertification Survey and complaint investigations (NY00352162 and NY00356860) from 06/02/2025 to 06/09/2025 for 4 (Residents #23, #27, #313, #721) of 14 residents reviewed, the facility did not ensure that incidents were thoroughly investigated to rule out abuse, neglect, or mistreatment. Specifically, the facility was unable to provide documented evidence (including statements from all involved staff members or potential witnesses) that the following incidents were thoroughly investigated to rule out abuse, neglect, or mistreatment. Residents #23 and #721 had multiple unwitnessed falls with one fall resulting in a major injury for each resident. Resident #27 had multiple bruises to their face of unknown origin. Resident #313 had an unwitnessed fall with a hematoma (bleeding and swelling under the skin) to their forehead and subsequently passed away within two (2) days. The findings include: The facility policy Abuse Prevention and Incident Investigation, dated October 2024, documented the facility will investigate any allegation of abuse, mistreatment, neglect, or injuries of unknown origin. An investigation would be started immediately that included a Registered Nurse assessment, interviews conducted with the resident and all staff on duty at the time of the alleged incident, and witness statements completed. The Assistant Director or Director of Nursing would complete a thorough review of the resident ' s medical record. 1. Resident #23 had diagnoses including dementia, cerebral infarction (blockage of blood flow to the brain), and dysarthria (difficulty speaking). The Minimum Data Set (a resident assessment tool), dated 05/09/2025, included the resident had severe cognitive impairment and required staff assistance with bed mobility, transfers, and ambulation. Review of the Comprehensive Care Plan, dated 12/04/2024, revealed Resident #23 was at high risk for falls, had impaired cognitive function, and required staff assistance with care and transfers due to weakness. In a nursing progress note, dated 03/16/2025 at 8:20 AM, Registered Nurse #5 documented they received a call from the floor nurse who reported Resident #23 had an unwitnessed fall. Resident #23 had gotten out of bed and fell onto the floor. Initially Resident #23 had no complaints and the only injury noted was a skin tear on left elbow. Registered Nurse #5 had advised that staff could get the resident off the floor and placed in bed. Upon examination, Registered Nurse #5 noticed that left leg was longer than right leg and resident had left hip pain. X-ray of the hip revealed a hip fracture. Review of an Incident Report, dated 03/16/2025, documented Resident #23 was found on the floor next their bed lying on their left side. Resident #23 complained of pain to their left hip. Resident #23 was documented as having been incontinent of bowel and bladder and had been trying to go to the bathroom and fell. The facility was unable to provide documentation that a thorough investigation (including staff statements at the time of the incident) had been completed to rule out abuse, neglect, and/or mistreatment. 2. Resident #27 had diagnoses including dementia, adult failure to thrive, and chronic obstructive pulmonary disease. The Minimum Data Set, dated [DATE], included the resident had severe cognitive impairment. Review of the Comprehensive Care Plan, dated 06/10/2024, revealed Resident #27 was on hospice, had impaired cognitive function, was at high risk for falls, had limited physical mobility, and required assistance from staff for transfers and ambulation. In a nursing progress note dated 08/16/2024, Registered Nurse #3 documented a visitor noticed bruising to Resident #27's face and told a Licensed Practical Nurse. Registered Nurse #3 documented the sizes of purple bruises to the chin, above the lip, and under the resident's right and left eyes. Registered Nurse #3 documented it was unknown how the bruises were made and the resident was unable to answer any questions. The facility was unable to provide documentation that any investigation had been completed to rule out abuse, neglect, and/or mistreatment. 3. Resident #313 had diagnosis including Alzheimer's disease, heart failure, and anxiety disorder. The Minimum Data Set, dated [DATE], included the resident had severe cognitive impairment and required staff assistance for transfers and ambulation. Review of the Comprehensive Care Plan, dated 01/08/2025, revealed Resident #313 had impaired cognitive function, was at high risk for falls, had limited physical mobility, and required assistance from staff for transfers and ambulation. In a medical progress note, dated 03/27/2025, Physician #1 documented Resident #313 sustained a fall on 03/24/2025 with a large hematoma to their forehead and on 03/26/2025 developed a sudden change in condition with hypoxia (low oxygen levels in the body), tachypnea (rapid respiratory rate), and tachycardia (rapid heart rate). The family was notified, elected comfort measures, and the resident passed away on 03/26/2025. The facility was unable to provide documentation that any investigation had been completed to rule out abuse, neglect, and/or mistreatment. During an interview on 06/05/2025 at 10:47 AM, the Director of Nursing stated that the facility did not have any completed investigations for the accident and injury reports requested and that they had over 1,700 investigations that they were going through from the previous administration. In a follow-up interview on 06/09/2025 at 10:46 AM, the Director of Nursing stated if there was an unwitnessed fall or an injury of unknown origin, an investigation should be completed going back 48-72 hours including statements from staff. The Director of Nursing stated without an investigation, it would be hard to rule out abuse, neglect, or mistreatment and that there was a break in the facility's system. 10 NYCRR 415.4(g)(1-3)

Based on observations, interviews, and record review conducted during the Recertification Survey from 06/02/2025 to 06/09/2025, the facility did not ensure that person-centered comprehensive care plans were developed and/or implemented to address the resident's medical, physical, mental, and psychosocial needs for 7 (Residents #10, #110, #112, #122, #127, #199, and #236) of 40 residents reviewed. Specifically, Resident #10 had a diagnosis of diabetes and the comprehensive care plan did not include measurable goals or interventions related to diabetes. Resident #110 had a history of post-traumatic stress disorder, a history of suicide attempts, and a history of falls with injuries. The comprehensive care plan did not include measurable goals and interventions related to post-traumatic stress disorder, a history of suicide attempts, or falls. Resident's #112 had current pressure ulcers, a seizure disorder, a diagnoses of deep vein thrombosis (blood clot) requiring injectable anticoagulant (blood thinner) medication, a heart condition, and an indwelling urinary catheter. Their comprehensive care plan did not include measurable goals and interventions related to pressure ulcers, an indwelling urinary catheter, or deep vein thrombosis requiring anticoagulant therapy or a seizure disorder. Resident #122 had pressure ulcers and no Comprehensive Care Plan with goals and interventions. Resident's #127 and #199 had diagnoses of epilepsy (seizure disorder) requiring anticonvulsant (medications used to prevent seizures) injections and their comprehensive care plans did not include measurable goals and interventions related to seizures and anticonvulsant medication. Resident #236 had a history of chronic constipation and medication refusals and the comprehensive care plan did not include measurable goals and interventions related to these issue. The findings include but are not limited to the following: The facility policy Care Plan: Comprehensive Care Plan, dated January 2025, documented an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's needs is developed for each resident. The clinical team, in coordination with the resident and/or his/her family or representative, develops and maintains a comprehensive care plan for each resident that identifies the highest level of well-being the resident may be expected to attain. Each resident ' s comprehensive care plan is designed to incorporate identified problem areas, risk factors associated with identified care areas, residents' strengths, expressed wishes regarding care and treatment goals, timetables and objectives in measurable outcomes, professional services responsible for each element of care, and reflect currently recognized standards of practice for care areas and conditions. 1. Resident #112 had diagnoses that included epilepsy, atrial fibrillation (irregular and/or rapid heart rhythm), urinary retention (inability to empty the bladder) requiring an indwelling urinary catheter, deep vein thrombosis, and pressure ulcers. The Minimum Data Set (a resident assessment tool), dated 05/09/2025, included Resident #112 had an indwelling urinary catheter and several pressure ulcers. Current physician's orders, dated 04/01/2025 to 06/01/2025, revealed that Resident #112 received anti-seizure medication daily, anticoagulant medications twice daily, heart medications three times daily, wound care treatments twice daily, and an indwelling urinary catheter. Resident #112 current Comprehensive Care Plan, reviewed on 06/05/2025, did not include that the resident had actual pressure ulcers, or any goals or interventions related to pressure ulcers, and did not include any interventions related to the care of the resident's indwelling urinary catheter. Additionally, the Comprehensive Care Plan did not address Resident #112's seizure disorder, heart conditions, or the presence of deep tissue thrombosis with associated interventions or medications to monitor. During observations on 06/03/2025 at 10:09 AM, 06/02/2025 at 9:56 AM, and 06/05/2025 at 4:32 PM Resident #112 had an indwelling urinary catheter, a gauze dressing on their left foot, and a pressure wound to their right buttock. During an interview on 06/09/2025 at 11:16 AM, Assistant Director of Nursing #3 stated they were responsible for creating and revising resident care plans on the unit. Assistant Director of Nursing #3 said medications such as anticonvulsants and anticoagulants should be included on the comprehensive care plan, and interventions related to the urinary catheter and actual pressure ulcers should be but were not. 2. Resident #110 had diagnoses including post-traumatic stress disorder, depression, and anxiety. The Minimum Data Set, dated [DATE], documented the resident was cognitively intact, reported feeling down, depressed or hopeless, received anti-depressant medications, and had diagnoses including depression and post-traumatic stress disorder. Review of Resident #110's Comprehensive Care Plan, last revised on 05/28/2005, revealed no information related to the resident's diagnoses of post-traumatic stress disorder, anxiety, or depression and no individualized goals or interventions for management of. The Comprehensive Care Plan included use of psychotropic medications but did not include any non-pharmacological interventions. Review of the current Key to Care of our Elders (care plan used by the Certified Nursing Assistants for daily care) with a print date of 06/05/2025 did not include any individualized goals or interventions for staff to utilize related to depression, anxiety, or post-traumatic stress disorder. Review of a telepsychiatry note, dated 03/18/2025, revealed Resident #110 suffered from chronic insomnia, that the resident became tearful while discussing their past trauma, their depression, and dealing with current stressors such as their inability to walk. The note included the resident stated that they had insomnia due to nightmares and a related history of emotional and sexual abuse as a child and that they had two suicide attempts as a young adult. During an interview on 06/09/2025 at 8:44 AM, the Assistant Director of Nursing #3 stated Resident #110's Comprehensive Care Plan should include the post-traumatic stress disorder, abuse history, psychiatric involvement, psychological counseling services, and non-pharmacological interventions to address these concerns. During an interview on 06/09/2025 at 9:52 AM, Social Worker #1 stated nursing staff are responsible for care planning and that Resident #110 has a significant history that should be care planned for. 3. Resident #10 had diagnoses including diabetes, coronary artery disease, and anxiety. The Minimum Data Set, dated [DATE], documented the resident was cognitively intact and received insulin injections on seven of seven days in the look back period. Physician's orders dated 04/08/2025 included insulin injections three times of day for diabetes. Review of Resident #10's current Comprehensive Care Plan on 06/04/2025 revealed no problem area, goals, or interventions for staff related to the resident's diabetes. During an interview on 06/05/2025 at 9:41 AM, Licensed Practical Nurse Clinical Coordinator #1 stated they, along with the Registered Nurse Manager #1, are responsible for developing the comprehensive care plans. They stated the comprehensive care plan for Resident #10 should have a problem area developed for diabetes with goals and interventions. 4. Resident #199 had diagnoses including epilepsy, dementia, and anxiety. The Minimum Data Set, dated [DATE], documented the resident had severe cognitive impairment and received an anticonvulsant medication. Active orders as of 06/06/2025 included Resident #199 was on phenytoin (anticonvulsant medication) three times a day (start date of 04/08/2024). Resident #199's current Comprehensive Care Plan, reviewed on 06/04/2025, revealed no problem area, goals, or interventions related to epilepsy/seizures or medications to monitor. During an interview on 06/05/2025 at 9:34 AM, Registered Nurse Manager #1 stated they and Licensed Practical Nurse Clinical Coordinator #1 were responsible for developing the comprehensive care plans. Registered Nurse (Nurse Manager) #1 stated Resident #199's comprehensive care plan should include problem areas with goals and interventions related to epilepsy/seizures. During an interview on 06/06/2025 at 11:20 AM, the Director of Nursing stated a resident with a diagnosis of epilepsy/seizures receiving an anticonvulsant medication should have a problem area with goals and interventions developed on the Comprehensive Care Plan. They stated the facility has identified issues with the comprehensive care plans and are in the process of correcting those problems. 5. Resident #236 had diagnoses that included constipation, major depressive disorder, and anxiety disorder. The Minimum Data Set, dated [DATE], documented the resident was cognitively intact, was always incontinent of bowel, and exhibited behaviors related to refusal of care and medications. Active physician's orders as of 06/06/2025 included Metamucil daily for constipation and oxycodone every six (6) hours as needed for pain. Review of the Medication Administration Record from 05/01/2025 to 06/07/2025 revealed Resident #236 had refused their scheduled dose of Metamucil nine (9) times. Review of the May 2025 Medication Administration Record for May 2025 revealed Resident #236 had received oxycodone 22 times throughout the month. During an interview on 06/02/2025 at 10:59 AM, Resident #236 stated they had been constipated for over a week, they lay in bed daily, and do not like to get up. During an observation and interview on 06/04/2025 at 3:28 PM, Resident #236 was lying in bed with three (3) beverages at their bedside, including prune juice. The Resident stated it was their routine to have a bowel movement once every week. Resident #236 stated they did not like to get out of bed. During an interview on 06/04/25 03:51 PM, Certified Nurse Assistant #3 stated Resident #236 refused to get out of bed, did not like to participate in activities, and did not have frequent bowel movements. Review of the current Comprehensive Care Plan revealed no issues, goals, or interventions related to chronic constipation. Additionally, the Comprehensive Care Plan did not include the resident's goals or interventions for the resident's refusal to get out of bed daily and risks involved. During an interview on 06/06/2025 at 3:46 PM, Clinical Lead Licensed Practical Nurse #2 stated Resident #236 should be care planned for constipation, especially since they often refused their Metamucil and did not like to get out of bed despite encouragement. During multiple interviews on 06/06/2025 at 11:20 AM and on 06/09/2025 at 9:27 AM and at 10:46 AM, the Director of Nursing stated a resident with a diagnosis of diabetes and receiving insulin should have a problem area with goals and interventions developed in their comprehensive care plan, and a resident with epilepsy/seizure disorder should have the problem area identified with goals and interventions. The Director of Nursing stated the unit in which Resident #236 resided did not have a nurse manager or a consistent Clinical Lead Nurse, and that was whose responsibility it was to ensure that care plans were implemented and revised as needed. The Director of Nursing stated Resident #236's care plan should have included the resident was at risk for constipation due to their refusal of cares and medications and infrequent bowel movements. The Director of Nursing also stated the Comprehensive Care Plan for Resident #110 should have included all of the concerns related to their psychiatric diagnoses. They stated the facility has identified issues with the comprehensive care plans and are in the process of correcting those problems. 10 NYCRR 415.11(c)(1)

Based on observations, interviews, and record review conducted during the Recertification Survey from 06/02/2025 to 06/09/2025, the facility did not ensure that all drugs and biologicals were stored and/or labeled in accordance with currently accepted professional principles and regulations for six (6) of nine (9) medication carts and two (2) of six (6) medication rooms reviewed. Specifically, on Reservoir Three residential unit, there were pre-poured unlabeled medications for multiple residents and multiple unlabeled loose pills inside several medication carts, multiple medication cups containing several pills and medication creams left on top of the unsupervised medication cart, and the medication cart keys were left on top of the cart unattended. Additionally, there were expired medicated dressings in the Reservoir Three medication storage room. On Reservoir Five Unit, there was a narcotic medication stored in the top drawer of the medication cart (under one lock versus two). On [NAME] Two Unit, there was a narcotic medication in the top drawer of the medication cart. On [NAME] One Unit, there was an opened, undated insulin pen, multiple loose, unlabeled pills, and an insulin pen labeled Do not use after 05/28/2025 in a medicatin cart. On [NAME] Three Unit and South Six Unit, there were multiple loose, unlabeled pills in several medication cart drawers. On South Five Unit, there were multiple loose, unlabeled pills and expired medications in a medication cart and a box of expired syringes in the medication storage room. Additionally, an insulin pen was observed left unattended on a dining room table on [NAME] Two unit, with residents, unlicensed staff, and visitors nearby for approximately 37 minutes. This is evidenced by but not limited to the following: Review of the Medication Administration policy, dated 04/04/2024, revealed for staff to lock medication carts whenever left unattended or out of sight. Each nurse is responsible to obtain the medication cart keys from the previous shift and be kept on your person. Keep all medications in the appropriate storage area in the medication room, in the medication carts or in the Omnicell (locked medication storage unit) until ready to administer. Insulin pens/vials must be stored in the medication room refrigerator prior to opening. Controlled substances (narcotic medications) will be stored in the Omnicell and may be accessed by a licensed nurse for any routine doses for one medication pass at a time. Once accessed, all controlled substances MUST be locked in the lockbox within the medication cart. All medications that are stored in the medication cart must remain in the cart until ready to pour for administration. Once poured, medication blister pack, bottle, etc., must be returned to the appropriate spot in the medication cart. 1. During an observation and interview on the Reservoir Three Unit on 06/04/2025 at 1:25 PM in the medication storage room, there were six (6) expired petroleum wound dressings with expiration dates as old as September 2023. 2. During an observation on the Reservoir Three Unit on 06/04/2025 at 10:14 AM, Licensed Practical Nurse #4 walked away, out of sight of the medication cart. The cart was unlocked, and the keys were left on top of the cart. An unlabeled medication cream was in a small medication cup and another unlabeled medication cup that contained approximately 20 loose pills were left unsupervised on top of the cart. 3. During an observation and interview on the Reservoir Three Unit on 06/05/2025 at 9:47 AM, multiple pre-poured medications in multiple medication cups and multiple loose pills were found in the top drawer of a medication cart. Another drawer contained spilled liquid and powder. During an interview at this time, Licensed Practical Nurse #16 stated it was difficult to clean the drawer due to the spills being there for so long. Licensed Practical Nurse #16 stated that they pre-pour medications to ensure that the residents get their medications because they have to share a medication cart with another nurse and do not always have the keys. Licensed Practical Nurse #16 stated sometimes staff store the medication cart keys in a box on the side of the cart (in an open compartment where plastic spoons are stored). Licensed Practical Nurse #16 stated that they knew the keys should not be left on the cart, but there is only one set of keys. 4. During an observation and interview on the Reservoir Five Unit on 06/05/2025 at 10:46 AM, a half tablet of oxycodone (a narcotic pain medication) was stored in the top drawer of the medication cart (not double locked). During an interview at this time, Licensed Practical Nurse #12 stated that when they came on shift, they did not receive medication keys when they arrived. Licensed Practical Nurse #12 stated they were unaware the narcotic pill was in the drawer and was obviously pulled on the previous shift and not wasted (when a resident received only half a pill). Licensed Practical Nurse #12 stated this has happened before when the nurse who pulled the medication (removed the medication from the narcotic cupboard) and should waste the half tablet not used with a second nurse present but does not. 5. During an observation and interview on the [NAME] Two Unit on 06/05/2025 at 11:32 AM, a blister pack labeled oxycodone containing a half tablet stored in the medication cart drawer (not double locked). During and interview at this time, Licensed Practical Nurse #8 stated they were unable to put the narcotic in the locked box on the medication cart because the key was broken. Licensed Practical Nurse #8 stated they had just floated to [NAME] Two Unit that day. 6. During an observation on the [NAME] Two Unit dining room on 06/05/2025 at 12:27 PM, an insulin pen (an injectable medication) was sitting on the dining table near Resident #61 and a second resident. At 1:04 PM, Licensed Practical Nurse #15 entered the dining room, administered medications to another resident and saw the insulin pen and removed it. There were 16 residents and two (2) family members in the dining room throughout the observation. During an interview on 06/05/2025 at 1:06 PM, Licensed Practical Nurse #15 stated they had administered Resident #61's insulin in the dining room and should not have left the insulin pen on the dining room table. During an interview on 06/05/2025 at 1:07 PM, the Director of Nursing stated they were not aware that nurses were pre-pouring medications and should not be. They had thought there was an extra set of medication cart keys so that all nurses could access the medications. The Director of Nursing stated nurses should ensure the medications are secured and in their original packaging. The Director of Nursing stated the night shift nurse should clean the medication carts and get rid of expired medications and all nurses are responsible for cleaning their carts at the start of their shift. The Director of Nursing stated there should never be narcotics in the drawers of a medication cart and should be double locked. They should not be taken out of the Omnicell until the nurse is ready to administer the medication. The Director of Nursing said if a narcotic needed to be wasted (resident only received half a pill), the nurse should find a second nurse and properly waste the narcotic and never leave it in the cart improperly secured. 10 NYCRR 415.18(d) 10 NYCRR 415.18(e)(1-4)

Based on observations, interviews, and record review conducted during the Recertification Survey from 06/02/2025 to 06/09/2025 for 8 (Reservoir 3rd, 5th, and 6th floors, [NAME] 1st floor, and South 2nd, 3rd, 5th, and 6th floors) of 20 resident use floors, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, there were dirty microwaves, a dirty refrigerator, outdated milk cartons, and a potentially hazardous food was not held at proper temperatures. The findings are: During an observation on 06/02/2025 at 9:20 AM, the interior of the microwave in the Reservoir 6th floor dining room was heavily soiled with food debris, crumbs, and splatter. During an immediate interview the Facilities Director stated that they think environmental services were supposed to clean them (the microwave). During an observation on 06/02/2025 at 10:00 AM, the interior of the microwave in the Reservoir 5th floor dining room was heavily soiled with food debris, crumbs, and splatter. During an observation on 06/02/2025 at 10:42 AM, the interior of the microwave in the Reservoir 3rd floor dining room was heavily soiled with food debris, crumbs, and splatter. During observations on 06/02/2025 at 1:20 PM, there was an extremely swollen half gallon of whole milk (partially used) marked sell by April 10 (2025), and a half gallon of fat free milk marked sell by March 23 (2025) located in the 6th floor South dining room. The cartons of milk were voluntarily discarded by a maintenance staff member. During an observation on 06/02/2025 at 1:47 PM, the interior of the microwave in the South 5th floor dining room was heavily soiled with food debris, crumbs, and splatter. During observations on 06/02/2025 at 2:12 PM, the following items were in the refrigerator in the 3rd floor South dining room: multiple unopened half pints of whole milk dated 4/19, 4/12, 5/18, and 5/28 and multiple half pints of 1% milk dated 4/10, 4/13, 4/17, 5/10, 5/20, 5/29, and one with no date. During an immediate interview a maintenance staff member stated that to their knowledge it (rotating stock and maintaining the dining room refrigerators) was the responsibility of dining services. During observations on 06/03/2025 at 9:44 AM, there were brown, yellow, and red spills in the interior of the 2nd floor South dining room refrigerator. Additionally, the interior of the microwave was heavily soiled with food debris, crumbs, and splatter. Record review of the facility policy/procedure for meal delivery times included breakfast on the 3rd floor South was at 7:40 AM. During observations and interview on 06/04/2025 at 9:58 AM on the 3rd floor South dining room Certified Nurse Assistant #1 removed a breakfast tray from a stainless-steel caddy to deliver to a resident. The Surveyor requested Certified Nurse Assistant #1 to obtain the temperature of the 1% milk, using a facility digital food service thermometer. Certified Nurse Assistant #1 obtained a temperature of 73.5 degrees Fahrenheit. Certified Nurse Assistant #1 stated the breakfast trays arrived on the unit around 7:45 AM. During an interview on 06/04/2025 at 10:02 AM, Assistant Director of Nursing #1 stated meal trays should be delivered to the resident within 30 minutes of their arrival on the units if possible. Director of Nursing #1 then instructed Certified Nurse Assistant #2 to serve the remaining residents the fluids from the trays, but not the food until someone from dietary department could check if the food was safe to serve. During an observation on 06/04/2025 at 10:03 AM, Certified Nurse Assistant #2 served Resident #50 orange juice and 1% milk (the milk that had been temped at 73.5). Resident #50 was observed to take a small sip of the milk, and then pushed the 1% milk aside. During observations and interview on 06/04/2025 at 10:12 AM, Dining Director #1 stated the South 3 floor breakfast trays left the kitchen at 7:20 AM. Dining Director #1 then obtained the temperature of a carton of 1% milk, using a facility digital food service thermometer, from a tray that had not yet been served to a resident. The temperature obtained was 74 degrees Fahrenheit. The Dining Director #1 stated milk should be served at 40 degrees Fahrenheit or below. They said milk that is served at 70 degrees Fahrenheit or higher is considered in the danger zone with risk of food-borne bacterial growth. During an observation on 06/04/2025 at 1:15 PM, the interior of the microwave in the [NAME] 1st floor dining room kitchenette was heavily soiled with food debris, crumbs, and splatter. 10 NYCRR: 415.14(h) 10 NYCRR: Subparts 14-1.30, 14-1.31(a), 14-1.40(a), 14-1.95, 14-1.110(d)

Based on observations, interviews, and record review conducted during the Recertification Survey from 06/02/2025 to 06/09/2025 for one (1) (Resident #61) of 32 residents reviewed for dining, the facility did not ensure residents were treated with respect, dignity, and care in a manner and in an environment that promoted maintenance or enhancement of quality of life. Specifically, Resident #61 was observed having their blood sugar (measuring the amount of sugar in a blood sample from a finger-prick) tested and received an insulin injection and medications in the dining room with several residents, staff, and visitors present. The finding is: Resident #61 had diagnoses including diabetes, end stage renal (kidney) disease, and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). The Minimum Data Set (a resident assessment tool), dated 05/23/2025, documented the resident was cognitively intact and received daily insulin injections. During an observation and interview on 06/04/2025 at 11:57 AM, Registered Nurse #6 entered the dining room during the lunch meal and approached Resident #61 who was seated at a table in the corner of the room with another resident. There were 10 residents, a hospice staff, and two family members in the dining room at the time. Registered Nurse #6 told Resident #61 they needed to get their blood sugar, proceeded to take the resident's blood sugar, and shared the test results prior to leaving the dining room. During an interview at this time, Resident #61 stated Registered Nurse #6 always takes their blood sugar in the dining room and it makes them mad because the nurse interrupts their meal to take their blood sugar and give them medicine. Resident #61 stated the nurse also administered their insulin shots in the dining room during meals with other residents around. Resident #61 stated that a lot of the nurses often take blood sugars and give insulin injections and medications to people in the dining room. During an observation on 06/04/2025 at 12:13 PM, Registered Nurse #6 returned to the dining room and approached Resident #61 with pills in a medication cup, water, and an insulin pen. Registered Nurse #6 instructed the resident to lift their shirt (exposing their stomach) and proceeded to inject the insulin into the resident's stomach. Registered Nurse #6 administered eye drops and left the filled medication cup with the resident and walked away. During an interview on 06/05/2025 at 12:27 PM, Resident #61 stated the nurse took their blood sugar in the dining room and tried to give them medications, but they told the nurse they would not take them until after they ate. During an interview on 06/05/2025 at 1:06 PM, Licensed Practical Nurse #15 stated they have administered Resident #61's insulin in the dining room. Licensed Practical Nurse #15 stated medications, blood sugars, and insulins were given in the dining room because there is a big rush to take residents to activities. They stated that taking blood sugars and administering insulin in the dining room is not dignified for the residents and they try to catch residents in their rooms. Licensed Practical Nurse #15 stated they did not previously ask Resident #61 to go to a private location to test their blood sugar or to give the insulin. During an interview on 06/06/2025 at 12:52 PM, Registered Nurse #6 stated they do not usually give medications in the dining room, but Resident #61 had come back from dialysis and usually leaves the floor quickly, so they gave it to them in the dining room (on 06/04/2025). During an interview on 06/09/2025 at 11:29 AM, the Director of Nursing stated nurses should not administer medications in the dining room and residents should not be interrupted during meals. 10 NYCRR 415.3(d)(1)(i)

Based on observations, interviews, and record review conducted during the Recertification Survey from 06/02/2025 to 06/09/2025, it was determined for 1 (Resident #120) of 32 residents reviewed for dining and 1 (Resident #222) of 2 residents reviewed for call bell accessibility, the facility did not ensure that a resident received services with reasonable accommodation of the resident's needs and preferences. Specifically, Resident #120 who was visually impaired reported to facility staff they needed assistance during meals. The resident was observed eating independently and there was no documented evidence the facility followed-up with the resident's request. Resident #222 was observed on several occasions without their call device within reach. The finding is: 1. Resident #120 had diagnoses including glaucoma (disease of the eye that can cause blindness), dysphagia (difficulty swallowing), and disorientation. The Minimum Data Set (a resident assessment tool), dated 04/21/2025, revealed Resident #120 was cognitively intact, visually impaired, and required setup assistance with eating. Review of the current Comprehensive Care Plan revealed Resident #120 was legally blind (revised on 04/26/2025), was on a regular consistency diet with thin liquids, on aspiration precautions (revised on 06/05/2025), and preferred to stay in bed and eat meals in their room with supervision and touch assist as needed (revised on 04/15/2025). Review of the Key To Care (care plan used by Certified Nursing Assistants for daily care), dated 06/03/2025, revealed Resident #120 needed set-up assistance with meals and was on aspiration precautions. Review of current physician's orders, dated 04/21/2025, included a regular diet, regular texture, thin liquids, and aspiration precautions. In a Nutrition/Dietary Note dated 05/14/2025, Dietician #1 documented Resident #120 stated they needed more assistance with eating their meals and would eat most meals in their room. Dietician #1 documented that the Clinical Coordinator was made aware of Resident #120's request. Review of an e-mail sent on 05/14/2025 at 1:34 PM from Dietician #1 to Licensed Practical Nurse Manager #1 and Registered Nurse Manager #2, Dietician #1 documented a request for Resident #120 to be changed to assistance with meals (per resident request). The resident was observed during lunch laying almost flat in bed, and staff stated the resident will put their head back as desired. Dietician #1 documented Resident #120 had significant weight loss over the previous three (3) months. Review of interdisciplinary progress notes, dated 05/15/2025 to 06/09/2025, did not include documented evidence of any follow-up on Resident #120's request for more assistance with meals. During an observation and interview on 06/02/2025 at 12:15 PM, Resident #120 was in bed with their lunch tray in front of them. Resident #120 asked where their plate and water cup was, and stated they were blind in one eye and partially blind in the other. Resident #120 stated they wished they had more assistance with eating and picked up a piece of food with their hand which had brown debris underneath the fingernails. During an observation and interview on 06/04/2025 at 12:10 PM, unit nursing staff were delivered and set up Resident #120's lunch tray in the resident's room, and then exited the room. At 12:14 PM, Resident #120 had pie frosting on their fingers. Resident #120 stated they did not know where their food or drink were, and the resident was feeling around the tray for the items. During an interview on 06/04/2025 at 12:45 PM, Certified Nursing Assistant #9 stated residents would verbally tell them what level of assistance they needed, and it would also be on the Key to Care. During an observation and interview on 06/04/2025 at 12:50 PM, Certified Nursing Assistant #11 picked up Resident #120's lunch tray which appeared untouched. Certified Nursing Assistant #11 stated Resident #120 does not eat much no matter how much the staff try. Certified Nursing Assistant #11 stated the assigned staff document how much the resident consumed and that Resident #120 consumed less than 25 percent of their meal. During an interview on 06/04/2025 at 12:58 PM, Licensed Practical Nurse #7 stated per the resident's care plan, they required set-up assistance and was on aspiration precautions. During a follow-up interview on 06/05/2025 at 11:27 AM, Licensed Practical Nurse #7 stated Resident #120 did not like to eat a lot, would consume at most 50 percent (of their meals), and they would encourage the resident to eat. Licensed Practical Nurse #7 stated they had not seen Resident #120 eat any food items that required a utensil. They stated Resident #120 did not need staff assistance to eat and had not heard the resident required more assistance than setup. During an interview on 06/04/2025 at 3:43 PM, Dietician #1 stated they sent an email to Licensed Practical Nurse Manager #1 and Registered Nurse Manager #2 on 05/14/2025 at 1:34 PM, requesting the resident's care plan changed to include for staff to assist with meals at the resident's request. During an interview on 06/05/2025 at 11:56 AM, Speech Language Pathologist #1 stated Resident #120 could eat independently, but needed verbal cueing (from staff) during meals to find things as the resident would get frustrated when unable to find things (food items or drinks). During an interview on 06/09/2025 at 9:22 AM, Licensed Practical Nurse Manager #1 stated Resident #120 was not totally dependent on staff during meals, would opt to not have staff in their room, and would often change their mind about things. Licensed Practical Nurse Manager #1 stated Resident #120's Key to Care included set-up with meals. Licensed Practical Nurse Manager #1 stated they recalled receiving an e-mail from a dietician about Resident #120 requesting more assistance with meals, and they had a conversation with the resident (could not recall when) during which the resident stated they would let staff know if they wanted assistance with meals. Licensed Practical Nurse Manager #1 stated they were not aware Resident #120 had asked for more assistance (again) and they would change the care plan. During an interview on 06/09/2025 at 9:57 AM, Certified Nursing Assistant #9 stated Resident #120 previously use utensils, but they noticed the resident started using their fingers. During an interview on 06/09/2025 at 12:54 PM, the Director of Nursing stated if a resident voiced the need for more assistance with meals, staff should help. 2. Resident #222 had diagnoses including repeated falls, weakness, and hypotension (low blood pressure). The Minimum Data Set, dated [DATE], documented the resident was cognitively intact, frequently incontinent of bowel, and required substantial assistance from staff with toileting. Review of the facility policy Care: Standards of Care, last reviewed 01/19/2024, included to ensure the call bell is within reach and clipped to a place the resident could reach it. Review of the Comprehensive Care Plan (dated 05/22/2025) and the Keys to Care (care plan used by the Certified Nurse Assistants) (dated 05/30/2025) documented Resident #222 was at risk for falls related to gait (walking pattern)/balance problems, a history of falls, and being legally blind. Interventions included, but were not limited to, ensure the resident's call bell was within reach and respond promptly to the resident's requests for assistance. During an observation and interview on 06/05/2025 at 12:12 PM, Resident #222 was sitting in their room and their call bell was on the floor. Resident #222 stated they did not know where it was, and when they needed to call for help, they self-propelled into their bathroom to pull the call light hanging on the wall. During an observation and interview on 06/06/2025 at 9:36 AM, Resident #222 was sitting in their wheelchair in their room and their call bell was hanging from the wall, behind the resident's shelf, and out of reach. Resident #222 stated they could not find it and often did not know where it was. The resident then self-propelled to the wall where their call light was hanging, moved their bedside table, and began to stand independently from their wheelchair to reach for the call bell. During an observation on 06/06/2025 at 9:38 AM, the Minimum Data Set Manager entered Resident #222's room and asked the resident if they could get them anything. The resident told them they would like to have their call bell in reach. The Minimum Data Set Manager reached over to the wall, pulled the call light from behind the shelf, draped it over the resident's bed, and told the resident they should have a clip to secure their call light to the bed and they would get them one. During an interview on 06/06/2025 at 9:39 AM, the Minimum Data Set Manager stated they did not think Resident #222 could have accessed their call light alone and it was difficult for them to reach it. The Minimum Data Set Manager stated the call bell should be clipped to the bed or somewhere in reach. With the resident being visually impaired, they should not have to stand up from their wheelchair to get it from behind the shelf and risk falling. The Minimum Data Set Manager stated the resident should never have to go in their bathroom to use the call bell and staff should make sure it is within reach before leaving the room. During an interview on 06/06/2025 at 9:56 AM, Certified Nurse Assistant #5 stated they encouraged Resident #222 to call for help when they needed to go to the bathroom, and in the past they had caught the resident just in time, trying to get up from their wheelchair to toilet themself even though they required assistance. Certified Nurse Assistant #5 stated when the resident could not find their call light, they would go in the bathroom to use the call light. During an interview on 06/09/2025 at 9:18 AM with Assistant Director of Nursing #2 and the Director of Nursing, the Director of Nursing stated the call light should always be in reach. 10 NYCRR 415.5(e)(1)

Based on observations, interviews and record review conducted during the Recertification Survey from 06/02/2025 to 06/09/2025, the facility did not ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (1) (Resident #24) of four (4) residents reviewed for catheters. Specifically, there was no documented evidence that care of Resident #24's nephrostomy tube (tube inserted directly into the kidney through the skin to drain urine) was completed as ordered by the medical team. The findings include: The facility policy Nephrostomy Tube Care dated 06/09/2023, included irrigation of a nephrostomy tube could only be performed by a registered nurse, and to document the amount and type of liquid used and whether or not a complete return (of instilled fluid) was obtained. Resident #24 had diagnoses including chronic kidney disease, aphasia (a communication disorder that affects a person's ability to speak, understand, read, and write), and renal calculus (kidney stones). The Minimum Data Set (a resident assessment tool) dated 04/18/2025 revealed Resident #24 had severely impaired cognitive skills and had an indwelling catheter (nephrostomy tube). Review of Resident #24's current Comprehensive Care Plan dated 05/23/2024 revealed the resident had a nephrostomy tube with interventions including nephrostomy care per orders. Physician orders dated as active orders as of 06/09/2025 documented to flush the nephrostomy tube with five (5) milliliters of normal saline every day shift, must be done by a registered nurse (RN), to empty the nephrostomy tube (collection bag) and record the output every shift and to contact the nursing supervisor if no (urine) output. Review of the Treatment Administration Records dated 05/01/2025 through 06/09/2025 revealed no documented evidence that the nephrostomy tube was flushed as ordered on 17 of 40 opportunities. Additionally, there was no documented evidence that on 18 of 118 opportunities the urine output was monitored and recorded, and on three (3) opportunities, zero (0) urine output was recorded and no documented evidence that a registered nurse supervisor had been notified as ordered. During an observation and interview with Licensed Practical Nurse #9 on 06/09/2025 at 10:59 AM Resident #24 was lying in bed with their right-sided nephrostomy tube draining a clear yellow urine into a collection bag. Licensed Practical Nurse #9 said they could empty the nephrostomy tube (collection bag), but only registered nurses could flush the nephrostomy tubes. Licensed Practical Nurse #9 stated they check the nephrostomy tube and empty it twice a shift, and it was flushed once a day. Licensed Practical Nurse #9 said the registered nurses know when the nephrostomy tube needed to be flushed because it would be part of the Medication/Treatment Administration Record. Licensed Practical Nurse #9 stated if they did not see a registered nurse (on the unit), they would call the nursing supervisor (to come and flush the nephrostomy tube). During an interview on 06/09/2025 at 11:16 AM, Assistant Director of Nursing #3 said licensed nurses could provide nephrostomy tube care but they would have to check the policy to see who could flush it. Assistant Director of Nursing #3 said whoever flushed the nephrostomy tube should document that it was done and if an order was omitted (not done) there should be documentation as to why. Assistant Director of Nursing #3 said if the licensed practical nurse read the order on the Treatment Administration Record that a registered nurse had to flush the nephrostomy tube, the licensed practical nurse should notify a registered nurse. During a follow-up interview at 12:04 PM, Assistant Director of Nursing #3 said there were no nursing supervisors on the day shifts because there were registered nurse managers and clinical coordinators in the facility, and the onus would be on the licensed practical nurse to contact one of the registered nurses to flush the nephrostomy tube. Assistant Director of Nursing #3 said they were the nursing leader covering the unit and they did not know Resident #24 had a nephrostomy tube nor had they ever flushed it. During an interview on 06/09/2025 at 12:54 PM, the Director of Nursing said registered nurses were responsible for flushing nephrostomy tubes, and if a licensed practical nurse was assigned to the resident, they should notify the clinical coordinator or nurse manager (if a registered nurse) or find a registered nurse in the building to do it. The Director of Nursing said if no documentation (on the Medication/Treatment Administration Record) they would have to assume it was not done. 10 NYCRR 415.12

Based on observations, interviews, and record review conducted during a Recertification Survey from 06/02/2025 to 06/09/2025, for one (1) (Residents #2) of one (1) resident reviewed, the facility did not provide special eating equipment for a resident who required it to maintain or improve the resident's ability to drink independently. Specifically, Resident #28 was observed on multiple occasions without their two-handled cup as recommended by Occupational Therapy. The resident said it was difficult for them to consume beverages without it. The finding includes: An undated facility policy, Tray Line Procedure documented in part meal service will be changing to a tray line system. All food will be prepared and plated in the main kitchen, then sent up on trays to be distributed to the residents. It will be the responsibility of nursing staff to pass the meal trays and help with meal set up, including opening containers for drinks and pouring into cups as needed. If adaptive equipment is missing, call the kitchen to ask for the missing piece of equipment. If the kitchen does not have the item, check the resident's room, wheelchair, bags, or the kitchen areas to see if it was left on the floor somewhere. If the item is missing, please notify the Dietitian, Therapy, or Nurse Manager to request new equipment be ordered. Therapy will order the adaptive equipment and deliver it to dining. Resident #28 had diagnoses including constipation, chronic pain, and depression. The Minimum Data Set (a resident assessment tool) dated 05/02/2025, documented the resident was cognitively intact and required set-up assistance with meals. Review of Resident #28's Comprehensive Care Plan, last revised on 02/19/2025, revealed the resident had a potential nutritional problem related to a therapeutic diet and staff were to encourage the resident to use their adaptive utensils and cup with meals. The Key to Care (care plan used by Certified Nurse Assistants) last revised on 05/30/2025 included providing a two-handled mug with a lid. During an observation on 06/05/2025 at 9:44 AM, Resident #28's meal tray was observed before being taken to the resident. The meal tray included a weighted spoon and fork and two clear, disposable, plastic cups. During an observation and interview on 06/05/2025 at 10:24 AM, Resident #28's meal ticket did not have their two-handled cup listed. Resident #28 said they were not supposed to have the plastic cups on their tray and were supposed to have cups with handles to help them drink independently, but often did not receive them. Resident #28 said when they received regular plastic cups, they would squeeze the cup while trying to grip it and spill the beverage all over themselves. During an interview on 06/05/2025 at 3:42 PM, Physical Therapist #1 said per their record, Resident #28 was not currently receiving therapy services. When occupational therapy recommended a two-handled cup, it was communicated to the kitchen and should be listed on the meal ticket. During an observation on 06/06/2025 at 9:23 AM, Resident #28 had their meal tray in front of them with one clear, disposable, plastic cup on it and there was no two- handled cup on their meal tray. In the corner of the room, on the resident's nightstand was a plastic two-handled cup positioned behind the resident out of their reach and did not look clean. During an observation on 06/06/2025 at 9:26 AM, Assistant Director of Nursing #1 entered Resident #28's room to ask if the resident had their two-handled cup. Resident #28 told them the only cup they had was the one that had been in the corner on their nightstand all week. During an interview on 06/06/2025 at 9:30 AM, Assistant Director of Nursing #1 said Resident #28 should have a two-handled cup and that it should be on their meal tray at each mealtime and the resident should not be using a cup that had been sitting in the room. The Assistant Director of Nursing #1 said if the resident chose to keep the cup in their room, staff should ensure at least every shift that the cup was clean to drink out of. The Assistant Director of Nursing #1 said the cup in the resident's room did not look clean, was not within their reach, and should be indicated on the resident's meal ticket so the kitchen would know to send it. During an interview on 06/09/2025 at 9:08 AM, the Director of Dining said two- handled cups should be on the meal ticket. Therapy makes the recommendation, writes on the care plan what (equipment) the resident should have, places the order for adaptive equipment, delivers the equipment to the kitchen, and the kitchen should know to include it on the meal ticket. The Director of Dining said if updates were made to the resident's care plan on a Friday, as the Key to Care indicated, it was likely the information was overlooked in the kitchen. 10 NYCRR 415.14(g)

Based on observations, interviews, and record reviews conducted during a Recertification Survey from 06/02/2025 to 06/09/2025, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) (Residents #112) of four (4) residents reviewed. Specifically, Resident #112 did not have Enhanced Barrier Precautions (EBP, techniques used to prevent transmission of infectious diseases utilizing gloves and gowns with all high contact care) signage outside their room and staff were observed providing hands on care without the appropriate personal protective equipment (gowns). Additionally, several infection prevention and control related policies, including the enhanced barrier precautions and Infection Control Surveillance plan were not reviewed annually per the regulation. The finding includes: The undated facility policy Enhanced Barrier Precautions (Currently Under Review) documented enhanced barrier precautions were used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms (MDROs) to staff hands and clothing. Residents/patients with the following conditions would be managed using Enhanced Barrier Precautions: (1) Infection or colonization with a Centers for Disease Control and Prevention (CDC)-targeted multidrug-resistant organisms (MDROs) when contact precautions do not otherwise apply, and (2) Presence of wound and/or indwelling medical devices regardless of their multidrug-resistant organisms (MDROs) status. Residents requiring enhanced barrier precautions are identified with a small sign. Enhanced barrier precautions may be discontinued upon resolutions of wounds or discontinuation of the indwelling medical device. The facility policy, Infection Control Surveillance, dated as last reviewed and revised December 2023. Resident #112 had diagnoses including Parkinson's (progressive brain disorder that slowly destroys memory and thinking skills), urinary retention (inability to fully or partially empty the bladder), benign prostatic hyperplasia (enlarged prostate) and pressure ulcers. The Minimum Data Set (a resident assessment tool) dated 05/09/2025, revealed Resident #112 had moderately impaired cognition, had an indwelling urinary catheter, and several pressure ulcers. Review of the current Comprehensive Care Plan on 06/05/2025 included Resident #112 had the potential for pressure ulcer development and had an indwelling catheter. The Comprehensive Care Plan and Key to Care (care plan used by Certified Nursing Assistants for daily care) did not include Resident #112 was on enhanced barrier precautions. Review of current Physician orders as of 06/06/2025 included several orders for care of a urinary catheter, and treatment orders for multiple pressure ulcers. There were no current orders for enhanced barrier precautions. During an observation and interview on 06/03/2025 at 10:09 AM, Resident #112 was in bed with an indwelling urinary catheter. Resident #112 stated they may have a pressure ulcer. There was no signage outside the resident's room for enhanced barrier precautions, nor personal protective equipment (PPE). During an observation and interview on 06/05/2025 at 4:27 PM, Resident #112 was in bed. There was no signage indicating enhanced barrier precautions were required. At 4:35 PM, Certified Nursing Assistant #10 emtered Resident #112's room and stated they were going to check (the resident for incontinence) and change the resident (if needed). At 4:38 PM, Licensed Practical Nurse #11 and Certified Nursing Assistant #10 were wearing gloves but no gowns provided incontinence and wound care to Resident #112. During an interview on 06/06/2025 at 11:07 AM, Licensed Practical Nurse #8 said residents on enhanced barrier precautions should have a cart outside of their room with the needed supplies and a sign on their door with what would be needed (personal protective equipment) to go into the room. During an interview on 06/06/2025 at 2:47 PM, with the Infection Prevention Nurse and the Director of Nursing, the Infection Prevention Nurse said residents with chronic wounds and catheters should be placed on enhanced barrier precautions. The Infection Prevention Nurse stated they or the nurse managers could put residents on enhanced barrier precautions, and it would be discussed during morning report. The Infection Prevention Nurse said when they started in the role in December 2024, they noticed the enhanced barrier precautions practice was not fully in place (by previous leadership) and a policy was put together, which was currently under review. The Infection Prevention Nurse stated education on enhanced barrier precautions was provided to the nurse managers, who then educated the nursing staff. The Director of Nursing said there had been a huge turnover in facility leadership, the Infection Prevention Nurse had to implement an entire infection control program during the midst of outbreaks and inspections, and the previous facility leadership left outdated or no policies. The Director of Nursing stated currently enhanced barrier precautions did not require an order, but the process was under review. The Infection Prevention Nurse stated Resident #112 should have been on enhanced barrier precautions since they had a foley catheter and several wounds, and they were not sure why the resident was not. The Infection Prevention Nurse said staff should wear gloves and a gown (during care) for a resident requiring enhanced barrier precautions. The Director of Nursing said the facility had several nurse manager and clinical coordinator vacancies which were intricate roles that assisted with tracking (residents needing precautions), and Assistant Director of Nursing #3 was overseeing three units. During an interview on 06/09/2025 at 11:16 AM, Assistant Director of Nursing #3 said residents with chronic wounds and urinary catheters should be on enhanced barrier precautions. Assistant Director of Nursing #3 said staff would know if a resident were on enhanced barrier precaution because there should be a sign outside their room door and (personal protective equipment) setup. Assistant Director of Nursing #3 said Resident #112 was not on enhanced barrier precautions but should have been. They said staff should have worn gowns while providing care to Resident #112. 10 NYCRR 415.19(a) (1-3)(b)(4)

Based on interviews and record review conducted during the Recertification Survey from 06/02/2024 to 06/09/2025, the facility did not ensure that a representative of the Office of the State Long-Term Care Ombudsman (an official patient advocate not hired by the facility) was notified of resident transfers or discharges including the reasons for the move in writing and in a language and manner they understand for three (3) (Residents #112, #217, and #314) of four (4) residents reviewed for discharges. Specifically, the facility did not notify the Office of the State Long-Term Care Ombudsman of Residents #112 and #117's transfers/discharges to the hospital and Resident #314's discharge to the community. The findings are: The facility policy Admissions: Referral Evaluation, admission Process, Bed Holds and Re-Admissions, dated 03/19/2025, documented a Notice of Transfer/Discharge, Bed Hold Letter & Discharge Rights are all completed by Social Work and sent to the resident's financial representative, and a copy is placed in the resident chart. The policy did not include any notification of residents' discharges or transfers to the Office of the State Long-Term Care Ombudsman. 1. Resident #112 had diagnoses that included Parkinson's disease (tremors and rigidity of movement), pneumonia, and acute deep vein thrombosis (blood clot) of the right lower extremity. The Minimum Data Set Discharge Assessments, dated 01/10/2025 and 03/07/2025, documented the resident was discharged from the facility to an acute care hospital. There was no documented evidence that the Office of the State Long-Term Care Ombudsman had been notified of Resident #112's 01/10/2025 or 03/07/2025 transfers/discharges to the hospital. 2. Resident #217 had diagnoses that included Parkinson's disease, chronic kidney disease, and retention of urine. The Minimum Data Set Discharge Assessment, dated 02/21/2025, documented the resident was discharged from the facility to an acute care hospital. There was no documented evidence that the Office of the State Long-Term Care Ombudsman had been notified of Resident #217's transfer/discharge to the hospital. 3. Resident #314 had diagnoses that included Parkinson's disease, cerebral infarction (stroke), and unspecified fracture of second lumbar vertebrae (back bone). The Minimum Data Set Discharge Assessment, dated 03/10/2025, documented the resident was discharged from the facility to home/community. There was no documented evidence that Office of the State Long-Term Care Ombudsman had been notified of Resident #314's discharge to the community. During an interview on 06/06/2025 at 3:31 PM, the Director of Social Work stated the social work department was responsible to contact the resident and/or responsible party for bed hold and discharge rights. The ombudsman should receive all discharge and transfer notifications within a week, but they were unable to provide documented evidence of this as the facility had not been notifying the ombudsman since January 2025. During an interview on 06/09/2025 at 9:32 AM, the Director of Nursing stated the resident and/or responsible party should receive transfer notices as well as the ombudsman. There have been multiple staffing changes within the facility and the system for notifying the ombudsman of transfers/discharges fell through the cracks. 10 NYCRR 415.3(i)(1)(iii)(a-c)

Based on observations, interviews and record review conducted during the Recertification Survey and complaint investigation (#NY00300345) from 12/6/23 to 12/13/23, for three (Residents #90, #108 and #183,) of six residents reviewed for pressure ulcers, the facility failed to ensure the residents received the necessary care, treatment, and services, consistent with professional standards of practice, to promote healing, prevent new pressure ulcers from developing, and/or prevent existing pressure ulcers from worsening. Specifically, the facility did not consistently provide Residents #90, #108 and #183 with physician-ordered treatments for skin impairments and/or care plan interventions. This resulted in actual harm to Resident #90 that is not Immediate Jeopardy. This is evidenced by the following: The facility policy Wounds: Pressure Ulcer Care, dated August 2023, documented that all residents admitted without a pressure ulcer will receive preventative care according to their documented Braden Scale (an assessment that indicates level of risk for skin breakdown). Residents with a pressure injury/ulcer will receive necessary treatment and services to promote healing, prevent infection, and prevent new pressure ulcers from developing. Incontinence care should be provided at least every 4 hours, repositioning should be completed every 2 hours, and treatments should be documented in the Electronic Medical Record with each completion. The facility policy Care: Standards of Care, dated 10/18/18, documented that a significant position change should be done every 2-4 hours, and toileting should be completed according to the Care Plan and Key to Care of Our Elders (care plan used by the Certified Nursing Assistant (CNA) for daily care). 1. Resident #90 had diagnoses of Parkinson's Disease (a progressive disease of the nervous system marked by tremors and muscular rigidity), stroke, and muscle weakness. The Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #90 was cognitively intact, had hemiplegia (paralysis on one side of the body), was occasionally incontinent of bladder, required extensive assist from staff for toileting, and had multiple pressure ulcers at the time of the assessment. Review of the current Comprehensive Care Plan documented that Resident #90 had a pressure ulcer to the natal cleft (where the upper butt cheeks meet) and was incontinent of urine. The Comprehensive Care Plan interventions included to follow the Key to Care of our Elders. Review of the current Key to the Care of our Elders revealed that Resident #90 was to be toileted, checked for incontinence, and turned and positioned every two to three hours. During an observation of incontinence care on 12/08/23 at 3:45 PM, and again on 12/11/23 at 10:02 AM, Resident #90 had no dressing to the natal cleft unstageable pressure ulcer. The wound was macerated (skin was white and fragile from being in contact with moisture for an extended period of time) and covered with yellow slough (non-viable tissue leading to necrotic tissue-dead tissue black or brown in color). Resident #90 was wearing an incontinence brief that was saturated through with urine on both observations. During an interview on 12/8/23 at 3:45 PM, Resident #90 stated they had not received toileting assistance, incontinence care, or re-positioning since 10:00 AM. Review of Resident #90's Interdisciplinary Progress Notes revealed Resident #90 was being followed by the facility's wound care team, comprised of two Registered Nurses. In a wound care team Interdisciplinary Progress Note dated 11/7/23, Registered Nurse #2 documented that Resident #90 had Moisture Associated Skin Damage (MASD-skin damage caused by prolonged exposure to moisture such as urine) to the natal cleft, and a new Physician's order included triamcinolone acetonide paste (a medicated lotion to help promote wound healing) to be applied twice daily. In a wound care team Interdisciplinary Progress Note, dated 11/21/23, Registered Nurse #2 documented the Moisture Associated Skin Damage had worsened to a Stage 3 (full thickness tissue loss involving damage to or necrosis (dead tissue) of subcutaneous tissue) pressure ulcer. Review of Resident #90's medical orders revealed no new orders to address the new pressure ulcer documented on 11/21/23. In a wound care team Interdisciplinary Progress Note dated 12/5/23, RN #2 documented that Resident #90's Stage 3 pressure ulcer was now an unstageable pressure ulcer (wound base is unable to be seen because it is covered by necrotic tissue). The note documented that the wound was macerated, and that there was a new Physician order for the triamcinolone acetonide paste with the application of a border gauze (a dressing with an adhesive border) to be completed twice daily. Review of the Treatment Administration Records, dated 11/7/23 through 12/13/23, revealed 31 of 66 opportunities for treatments to the natal cleft wound were blank. There was no documented evidence between 11/7/23 and 12/12/23 that a medical provider had assessed Resident #90's worsening pressure ulcer. During an interview on 12/11/23 at 9:27 AM, Certified Nursing Assistant #2 (assigned to Resident #90) stated they provided toileting and incontinence care twice a shift, usually in the morning and after lunch. During an interview on 12/11/23 at 10:41 AM Licensed Practical Nurse (LPN) #4/ Clinical Coordinator stated that a blank in the Treatment Administration Record meant that the treatment had not been done. During an interview on 12/11/23 at 2:10 PM Nurse Practitioner #1 stated they do not participate in wound rounds but would go see a wound if needed. Nurse Practitioner #1 stated if medical treatments were not completed it would be considered an error and an incident report filed, which we (medical) would then see and assess. Nurse Practitioner #1 stated they have identified that wound treatments were not being completed as ordered and that staffing has been a struggle. Nurse Practitioner #1 stated that not providing incontinence care, turning, and positioning and/or wound treatments could cause a wound to worsen. During an interview on 12/12/23 at 11:20 AM, with the wound care team nurses Registered Nurse #1 and Registered Nurse #2, both stated that residents with wounds should receive toileting or incontinence care (per their care plan), and that the treatments should be completed as ordered. They both stated a wound could worsen if care plan interventions were not being completed, and Registered Nurse #2 stated a resident with a wound should be turned and positioned at least several times a shift (8 hours). Registered Nurse #1 stated that any wound over a stage 3 should be reported to medical. During an interview on 12/12/23 at 12:15 PM, Resident #90 stated they had not been toileted, had incontinence care, or been re-positioned since getting out of bed at 6:00 AM. During an interview on 12/12/23 at 2:32 PM, the Director of Nursing stated that toileting, incontinence care, and turning and positioning should be completed per the Comprehensive Care Plan and the Key to the Care of Our Elders. 2. Resident #183 had diagnoses that included Alzheimer's disease, muscle weakness, and pressure ulcers. The Minimum Data Set assessment dated [DATE] revealed Resident #183 was severely impaired cognitively and had multiple pressure ulcers requiring the application of dressings and pressure ulcer care. Resident #183's current Comprehensive Care Plan and their Key to Care of Elders included they had a pressure ulcer to the right heel, right hip and coccyx (tailbone), with interventions that included but were not limited to providing treatments as ordered, and a specialized boot (soft boot to offload pressure for the heel) to the right foot at all times. During an observation on 12/12/23 at 2:04 PM, Resident #183 was observed sitting in their wheelchair in a common area. There was no specialized boot on their right foot, which was resting on the floor. Review of Physician orders dated 9/6/23 revealed collagenase (a medicated ointment to promote wound healing by removing dead tissue) and border gauze once daily and as needed to the unstageable pressure ulcer of the upper coccyx. Physician orders dated 10/27/23 included to clean the right heel ulcer with normal saline, pat dry, and apply skin prep twice daily. Review of November 2023 Treatment Administration Records revealed that the wound care to the coccyx was not documented as administered on 11 of 30 opportunities. Wound care to the right heel pressure injury was not documented as administered on 27 of 60 opportunities. Review of December 2023 Treatment Administration Records from 12/1/23 through 12/12/23 revealed that wound care to the coccyx had not been documented as administered on 4 of 12 opportunities. Wound care for the right heel had not been documented as administered on 7 of 24 opportunities. 3. Resident #108 has diagnoses that included paraplegia (paralysis of the lower extremity), osteomyelitis (infection of the bone), and pressure injury. The Minimum Data Set assessment dated [DATE], revealed that Resident #108 was cognitively intact, was always incontinent of bladder and bowel, and had multiple unhealed pressure ulcers. Review of Resident #108's Comprehensive Care Plan included pressure ulcers to the left ischium (upper buttocks) and interventions included, treatments as ordered, and weekly wound assessments by the skin team. Resident #108's current medical orders included the following: a. Stage 4 (full thickness tissue loss with extensive destruction to the tissue that could involve bone and muscle) pressure ulcer of upper left ischium: clean wound with soap and water, pat dry, apply skin-prep to periwound then pack with alginate (absorbs wound drainage) and cover with foam dressing daily and as needed. b. Pressure ulcer to the left distal ischium: apply skin prep twice daily. c. Stage 3 pressure ulcer distal to existing Stage 3 ulcer: apply triamcinolone ointment once daily. During an interview on 12/7/23 at 10:27 AM, Resident #108 stated that they have had their sore forever, and some staff do not change the dressings. Review of the November 2023 Treatment Administration Records revealed that the wound care to the left ischium was not documented as administered as ordered on 6 of 30 days. Review of the December 2023 Treatment Administration Records revealed wound care to the left ischium was not documented as administered as ordered on 4 of 11 days. During an interview on 12/13/23 at 9:46 AM, Licensed Practical Nurse #6/Clinical Coordinator stated there were wound nurses (who do dressing changes when on duty), but if they were not on then the unit nurses are responsible for doing the treatments. Licensed Practical Nurse #6/Clinical Coordinator stated that a blank box on the Treatment Administration Record meant the treatment was not done or that the nurse forgot to document it; if unable to complete the treatment, the nurse should let the next shift or nursing supervisor know. Licensed Practical Nurse #6/Clinical Coordinator said on some weekends, there is only one nurse (on the unit) and the treatments do not always get done. After reviewing Resident #183 and Resident #108's Treatment Administration Records (observing blank boxes for ordered treatments), Licensed Practical Nurse #6/Clinical Coordinator said they were not notified by staff that the wound treatments were not done as ordered. Licensed Practical Nurse #6/Clinical Coordinator said the wound nurses do audits (of ordered treatments) and did mention to them Resident #183 missing treatments. Licensed Practical Nurse #6 stated that Resident #183 had the right heel pressure injury for a while, and it was likely from positioning (lack of). They said that after they had been made aware that Resident #183 had not been wearing their special boot the day before, that it may have been because float aides (aides from other departments) had been assigned to Resident #183 that day. During an interview on 12/13/23 at 10:42 AM, the Director of Nursing (DON) stated wound care treatments should be signed off on the Treatment Administration Record when they are completed, and if not done, an error report should have been generated. The Director of Nursing stated they have recently hired treatment nurses to assist with the dressing changes. During an interview on 12/13/23 at 1:29 PM, the Administrator stated that they had addressed this issue in their Quality Assessment meetings, resulting in hiring a treatment nurse to improve the issue. 10 NYCRR 415.12 (c)(1)

Based on observations, interviews, and record reviews conducted during the Recertification Survey completed 12/6/23 to 12/13/23, it was determined that for one of one main kitchen, and five (Reservoir fifth and sixth floors, [NAME] first and second floors, and South third floor) of twenty resident use floors, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, potentially hazardous foods were not cold held at or below 45 degrees Fahrenheit ( F), potentially hazardous foods were not properly cooled, there were undated and unlabeled food items, and a freezer had a significant buildup of ice. The findings are: The undated facility policy titled 'Resource: Food Safety for Your Loved One' included the following: If you plan to bring food into the facility for your loved one, please be sure that the food is handled safely. Food or beverages should be labeled and dated to monitor for food safety. Food or beverage items without a manufacturer's expiration date should be dated upon arrival in the facility and thrown away three days after the date marked. Foods in unmarked or unlabeled containers should be marked with the current date the food item was stored. Observations during the initial tour of the main kitchen on 12/6/23 at 9:25 AM included three large six-inch-deep stainless-steel pans of cooked elbow pasta covered in plastic wrap and dated 12/6, located in the prep walk-in refrigerator. When measured by the surveyor using a digital Thermapen, the pans of cooked elbow pasta were 45 F, 47 F, and 48 F. In an interview at that time, the Director of Dining Services (DDS) stated that the elbow pasta was prepared yesterday afternoon and that they have a cooling log. Record review of the cooling log provided by the DDS included no documentation of how the elbow pasta was cooled. The DDS then voluntarily discarded the three pans of elbow pasta. Observations on 12/6/23 at 9:45 AM included a significant amount of solid ice built up at the top of a 'Kelvinator' brand upright freezer located in the central dining room across from resident room [ROOM NUMBER] (Reservoir sixth floor). The ice was observed to completely cover the internal temperature gauge and had dripped down all over and inside a box of popsicles. Additionally at this location was an upright refrigerator that contained a black plastic container of an unlabeled and undated food item. Observations on 12/6/23 at 10:12 AM included an undated and unlabeled glass jar of an unknown semi-liquid substance located in the Reservoir fifth floor dining room refrigerator. The jar was only marked with the word 'BONDI'. When interviewed at this time, a food service worker stated that they were not sure what was in the jar. Observations on 12/7/23 at 10:23 AM included a container of three hard boiled eggs, one of which was cracked, stored on the counter near the kitchenette in the South third floor dining room. When interviewed at this time a food service worker stated that the eggs were brought up from the kitchen at breakfast. The eggs were then voluntarily discarded. Observations on 12/7/23 at 10:28 AM included a refrigerator in the South third floor Snack Center across from room [ROOM NUMBER] contained four plates of unlabeled and undated food items that appeared to be meat, broccoli, and mashed potatoes, and five cups that appeared to be gravy. Additionally, there were three covered containers of food items that were only labeled as 'Milton' and 'Drees'. During an interview at this time, the clinical coordinator stated that the plates were from a recent party and saved for night staff, and the three containers of food were for residents and will be discarded. Observations on 12/7/23 at 1:18 PM included two covered plates of eggs, sausage, and bacon were stored on the counter in the [NAME] second floor kitchenette, and temperatures of each item were between 73 F and 77 F. When interviewed at this time a food service worker stated that the plates were from breakfast and should be thrown out. Observations on 12/7/23 at 1:44 PM included a cardboard box containing plastic containers of sliced meats and meat salads dated 12/10/23 were stored on the counter in the [NAME] first floor kitchenette. When measured by the surveyor using a digital ThermaTech thermometer the temperatures were as follows: Roast beef - 61 F, Egg salad - 57 F, chicken salad - 59 F. When interviewed at this time a food service worker stated they think the temperature should be about 50 and the food items came up from the kitchen with the lunch meal. The food service worker also stated that they had not received any training regarding safe food temperatures. A review of the posted meal times included that lunch is served starting at 11:30AM. Additionally, there was a bowl of fried eggs in the oven which was off, and the temperature of the eggs was 69 F. The food service worker stated that they had no idea about the eggs and then voluntarily discarded them. Record review at this time included the temperature log from the lunch meal was dated 12/7/23 and included: Hot foods: soup-76, blended soup - 74, entree 1 - 71, entree 2 - 95 and veg. 1 - 81. At 2:10 PM the surveyor asked the food service worker to discard the plastic containers of salads and sliced meats. 10NYCRR: 415.14(h); 10NYCRR: Subparts 14-1.10(b)(2), 14-1.31, 14-1.40, 14-1.43(e), 14-1.95

Based on observations, interviews, and record reviews conducted during the Recertification Survey from 12/6/23 to 12/13/23, it was determined that for eight of nine medication carts reviewed for medication storage, the facility did not ensure that all drugs and biologicals were properly stored in accordance with State and Federal Laws. Specifically, multiple loose unlabeled pills were observed in the drawers of several medication carts ([NAME] 1, [NAME] 2, [NAME] 3 and Reservoir 6 cart 1) and medications were observed unlabeled and/or expired ([NAME] 1, Reservoir 4, Reservoir 5 and Reservoir 6 cart 2). The evidence included but not limited to the following: The facility Policy Medication Administration, dated reviewed 6/1/23, documented that the medication pouches will include the name and description of each medication included in that pouch, along with the full directions for use and the expiration date, do not use medication from an unmarked or poorly labeled bottle or container, the nurse is to check the expiration date of the medication before administering, and all medication carts are to be cleaned monthly. During an observation of medication storage on 12/11/23 at 11:06 AM on [NAME] 1 resident care unit, there were approximately 50, loose unlabeled pills (medications) of varying colors, size and shapes, an unlabeled bottle of medicated cream and an uncapped inhaler labeled with a first name only in a drawer of one of the medication carts. During an observation on 12/11/23 at 11:20 AM on [NAME] 3 resident care unit, there were approximately 30, loose unlabeled pills of varying colors, size and shapes were in a drawer of one of the medication carts. During an observation on 12/12/23 at 9:07 AM on Reservoir 4 resident care unit there was a bottle of docusate sodium (stool softener) with had an expiration date of May 2023 in one of the medication carts. During an observation on 12/12/23 at 9:18 AM on Reservoir 5 resident care unit there was a bottle of opened nitroglycerin tablets (used for acute chest pain) without any resident information or instructions for use in one of the medication carts. During an observation on 12/12/23 at 10:01 AM on Reservoir 6 resident care unit there were 7 loose unlabeled pills of varying colors, size and shapes in cart 1 and an uncovered bottle of calcium containing approximately 50 pills and an open bottle of medicated cream that was not labeled with any resident information in cart 2. In an interview on 12/11/23 at 11:06 AM LPN #4/Clinical Coordinator stated medication bottles in the medication carts should be labeled and have expiration dates, and the carts should be organized and not have any free-floating pills in the drawers. During an interview on 12/12/23 at 2:32 PM Director of Nursing (DON) stated the medication carts should have no loose pills. Resident specific meds should be labeled and there should never be expired medications in the carts, but the nurses should check expiration dates before administering medications. The clinical coordinators should help monitor the carts, but the nurse who is working the cart should be looking for all these things. 10 NYCRR 415.18(d)

Based on observations, interviews, and record review conducted during the Recertification Survey completed 12/6/23 to 12/13/23, it was determined that the facility did not ensure compliance with all applicable State codes. Specifically, the facility was not in compliance with Section 915 of the 2015 Edition of the International Fire Code as adopted by New York State, which requires the use of carbon monoxide (CO) detection in a building that has fuel-burning appliances. The findings are: Record review on 12/8/23 at 11:35 AM revealed a list of facility carbon monoxide detectors within the facility was provided to the surveyor by the Director of Facilities (DF). The list of the locations of the carbon monoxide detectors were as follows: 1) [NAME] basement hallway by laundry, 2) [NAME] basement hallway between parts room doors, 3) Reservoir basement between two boiler room doors, 4) Reservoir first floor cafeteria by emergency exit, 5) East end hallway of second floor Reservoir building, 6) Ground floor South hallway near pay phone/vending. Two additional hard-wired carbon monoxide detectors were listed as passing a functional test on the fire alarm system testing report dated 2/27/23. During an interview at this time, the Director of Facilities stated that only the two hard wired carbon monoxide detectors are being tested but not the battery-operated ones. Observations on 12/12/23 at 10:50 AM included two hard-wired ceiling mounted carbon monoxide detectors located on the ceiling of the [NAME] building ground floor gas fireplace lounge. The 2015 Edition of the International Fire Code requires that carbon monoxide alarms shall be maintained in accordance with NFPA 720. The 2012 Edition of NFPA 720, Standard for the Installation of Carbon Monoxide Detection and Warning Equipment, requires that single-station carbon monoxide alarms shall be inspected and tested in accordance with the manufacturer's published instructions at least monthly. 10NYCRR: 415.29(a)(2), 711.2(a)(1), 42 CFR: 483.70(b), 2015 IFC: Section 915, 915.6 2012 NFPA 720: 8.7.1

Based on observations, interviews, and record reviews conducted during the Recertification Survey 12/6/23 to 12/13/23, it was determined that for 4 (South 3, South 4, Reservoir 4, Reservoir 6) of 11 resident care units reviewed, the facility did not provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, and homelike environment. Specifically, multiple resident wheelchairs, sit-to-stand lifts (assistive standing device), a shower mat, a resident reclining chair, and a dining room floor were observed soiled. This is evidenced by the following: During multiple observations on South 4 day shift on 12/6/23, 12/7/23, 12/8/23, 12/11/23 and 12/12/23 four wheelchairs, all occupied by residents had multiple dried food debris visible on them over three and four days. During observations on 12/6/23 at 9:40 AM on Reservoir 6, a shower mat on top of a wheeled stretcher located in the shower room near resident room [ROOM NUMBER] was soiled. The underside of the mat had a brown smear that appeared to be feces and the mesh on the stretcher below the mat had an accumulation of hair and white and brown debris. During observations on 12/6/23 at 9:58 AM on Reservoir 6 two sit-to-stand lifts located in the corridor across from resident room [ROOM NUMBER] had a significant accumulation of crumbs and debris in the foot tray. During observations on 12/6/23 at 10:56 AM-11:15 AM on Reservoir 4 two sit-to-stand lifts located in the corridor across from resident rooms #421 and #434, had a significant accumulation of crumbs and debris in the foot tray. During an interview at this time, the Director of Facilities (DOF) stated that maintenance only does the safety checks, not cleaning of the lifts. During observations on 12/7/23 at 9:11 AM on Reservoir 6 a blue recliner chair for resident use in the dining room had a foul-smelling brown substance on the seat of the chair. During observations on 12/7/23 at 10:14 AM on South 3, briefs, lift slings, and blankets were stored directly on the floor in a storage room next to resident room [ROOM NUMBER]. During an interview at this time, the DOF stated that the nurse manager needed to see this. During observations on 12/11/23 at 11:53 AM, on 12/12/23 at 2:10 PM and again on 12/13/23 at 9:43 AM, on Reservoir 6, a whitish-gray dried substance (liquid) measuring approximately seven inches by seven inches round, was on the dining room floor. During an interview on 12/11/23 at 11:18 AM, Licensed Practical Nurse (LPN) #7 stated that maintenance fixes the wheelchairs, and that nursing is responsible for cleaning the wheelchairs, and the wheelchairs are cleaned when the nursing staff have the time. During an interview on 12/12/23 at 2:22 PM, LPN #5 said the dining room assistant is responsible for cleaning the dining room and if there is not a dining room assistant, nursing staff should clean it. During an observation and interview on 12/13/23 at 8:59 AM, LPN #7 stated that the two soiled wheelchairs (identified on South 4) definitely needed to be cleaned. During an interview on 12/13/23 at 9:46 AM, LPN #6 (Reservoir 6) said if something spilled on the floor, staff should clean it up. If a resident was incontinent while sitting in a recliner, LPN #6 said staff should let them know and they would notify Environmental Services (EVS). At 10:30 AM, LPN #6 observed the dried whitish-gray substance on the dining room floor, as well as a substance on the blue resident recliner chair and stated they would call EVS to have them cleaned. During an interview on 12/13/23 at 10:42 AM, the Director of Nursing (DON) said nursing staff can clean equipment (tables, chairs, etc.) if something needed to be wiped down. Additionally, the DON said that the dining room assistants are responsible for cleaning the dining rooms. 10 NYCRR 415.5(h)(2)

Based on observations, interviews, and record review conducted during a Recertification and complaint investigation (#NY00305787) completed 12/6/23 to 12/13/23, it was determined that for two (Residents #62 and #235) of five residents reviewed for dignity, the facility did not ensure that the residents were treated in a respectful and dignified manner. Specifically, Resident #62 was observed walking on the unit completely naked from the waist down with several other residents and multiple staff members in the vicinity and Resident #235 was observed to have multiple different pureed foods mixed together for their meal and fed to them by staff. This is evidenced by the following: 1.Resident #62 had diagnoses including dementia with behavioral disturbances a history of falls, anxiety, and depression. The Minimum Data Set (MDS) Assessment, dated 11/7/23, documented the resident had severe impairment of cognitive skills and required partial assistance with dressing. Review of the current Comprehensive Care Plan (CCP) documented that Resident #62 had a history of resting in bed unclothed and at times would forget to put on clothing before leaving their room. Staff interventions included maintaining the resident's choices and dignity and using signage by the resident's door reminding them not to leave their room without wearing clothes. During an observation and interview on 12/07/23 at 11:01 AM, Resident #62 walked approximately 106 feet from one end of the hall to the opposite end of the hall where their room was located, completely naked from the waist down with dried stool visible on their buttocks. Certified Nurse Assistant (CNA) #3 walked with the resident for more than half the distance of the hallway without redirecting, requesting assist and/or covering the resident up as soon as possible. Seated at and across from the nurse's station where the resident was walking were three staff members and nine other residents all within sight of Resident #62. CNA #4 said at the time that Resident #62 had been redressed several times that day. During an interview on 12/07/23 at 12:03 PM, with CNA #3 and CNA #4, CNA #4 stated that Resident #62, who becomes undressed several times a day is redirectable at times but not always because they do not like to be touched. When asked if they could have called for help to avoid the resident walking in the hall unclothed, CNA #3 said they could have. During an interview on 12/11/23 at 11:13 AM, Licensed Practical Nurse (LPN) #1/ Clinical Coordinator said that at times Resident #62 comes out of their room not fully dressed and required staff redirection. LPN #1/Clinical Coordinator said they try to cover the resident up as soon as possible. During an interview on 12/12/23 at 11:06 AM and at 12:18 PM, the Director of Nursing (DON) said that if a resident was walking around unclothed, they would expect staff to intervene immediately to redirect the resident and by calling out for another staff person to help. The DON said even if the other residents on the unit were cognitively impaired, it was unacceptable for any resident to walk around on the unit unclothed without staff stepping in immediately. 2.Resident #235 had diagnoses including Alzheimer's disease, muscle weakness, and dysphagia (difficulty swallowing). The MDS assessment dated [DATE] documented the resident was severely impaired cognitively, had trouble swallowing requiring a mechanically altered diet, and needed extensive assistance from staff with eating. Review of the medical orders for Resident #235 revealed a pureed diet. Review of the CCP dated 12/8/23 revealed Resident #235 required feeding assistance from staff and was on a mechanically altered diet. The CCP did not include that Resident #235, or their representative had requested their meals to be all mixed together. During an observation on 12/6/23 at 1:09 PM, Resident #235 was being fed in the dining room by CNA #1. The meal that was served was all mixed together in one bowl. When asked if it was Resident #235's preference, CNA #1 stated the meal should not have been mixed all together and the foods should have been served separately. During an observation on 12/8/23 at 10:04 AM, Resident #235 was being fed in the dining room. Their meal had been put on a plate and mixed together. During an interview on 12/11/23 at 10:41 AM, LPN#1/ Clinical Coordinator said that residents on a pureed diet should have their meals served in a divided plate or in bowls and not all mixed together. 10 NYCRR 415.5(a)

Based on observations, staff interviews, and record reviews conducted during the Recertification Survey and complaint investigation (#NY 541), it was determined that for two of two residents reviewed for quality of care, the facility did not ensure that necessary care and services were provided to maintain the residents' highest practicable physical well-being. THIS IS A REPEAT DEFICIENCY FROM THE ABBREVIATED SURVEY OF 4/13/12. The issue involved a resident that developed an avoidable pressure sore after admission. Specifically, Resident #257 was not seen for a follow-up orthopedic appointment in a timely manner. As a result, the resident wore a splint for approximately two months, and when seen in the ortho clinic, the resident was found to have a Stage IV pressure ulcer of the heel. In addition, Resident #81 had recommendations for a pacemaker check to be completed three months after surgery and this was not done. This resulted in actual harm that is not immediate jeopardy for Resident #257, and no actual harm with potential for more than minimal harm that is not immediate jeopardy for Resident #81. This and is evidenced by the following: 1. Resident #257 has [DIAGNOSES REDACTED]. Review of an Incident and Accident Report, dated 5/31/12, revealed that the resident was found on the floor at 4:25 a.m. The Physician Assistant (PA) was notified and x-rays were ordered. X-ray results showed an impacted [MEDICAL CONDITION] right tibia and fibula. The resident was sent to the Emergency Department at 11:15 a.m. and readmitted back to the facility on [DATE]. Physician orders, dated 6/1/12, included "NWBRLE" (nonweight bearing right lower extremity). There were no physician orders that day for care of the splint on the right lower extremity. Review of records dated 6/1/12 include the following: a. The Hospital Physician Discharge Summary revealed that the resident was hospitalized for [REDACTED]. No interventions were pursued because the advance directives were for comfort measures only. b. The Hospital After Visit Summary instructions included to follow-up with Orthopedic (Ortho) physician in one to two weeks, follow-up with facility physician in three to five days, non-weight bearing to the right lower extremity, and to keep the wound clean and dry. c. The Hospital Nursing Summary includes a soft cast to the right lower leg. d. The Physician Readmission History and Physical documented a plan for care of the lower leg fracture, to continue with current pain management, non-weight bearing status, and have Ortho follow-up as scheduled. e. Physician orders included non-weight bearing to right lower extremity. There were no orders for a follow-up Ortho visit. On 6/7/12, the PA documented that the resident's right lower extremity was in a splint. This splint covered from the distal part of the foot to above the resident's knee. The resident was able to move her toes. The PA also noted that the resident is non-weight bearing and will need to follow-up with Ortho. In a 7/6/12 progress note, the attending physician noted to continue non-weight bearing status. A follow-up visit with Ortho was not seen in the record. A nursing note, dated 7/27/12, revealed the Medical Director and the Assistant Director of Nursing were notified at 8:00 p.m. regarding an Outside Visit report from Ortho. The 7/27/12 Outside Visit Communication report from Ortho revealed that after removal of the splint, the resident was found to have a Stage IV pressure ulcer on her right heel. The report included that this was the resident's first follow-up visit since her fracture on 5/31/12. A 7/27/12, 8:00 p.m. nursing note included a wound assessment of the right heel wound, with measurements of 5.5 centimeters (cm) x 5 cm x .1 cm, thin yellow slough tissue noted at base of wound, and thick yellow slough noted at 6 o'clock. The wound had a foul odor with serosanguinous drainage. On 7/30/12 at 10:25 a.m. the Registered Nurse (RN)/Wound Care documented that upon removal of the old dressing (right heel) a foul smelling odor was detected. The area of the wound measured 4.5 cm x 4.5 cm x .25 cm deep, was 25 percent necrotic tissue, and was draining thick yellow slough. A recommendation was made to use Santyl ointment to debride necrotic area and thick slough. Interviews on 7/31/12 include the following: a. At 8:56 a.m., the Unit Secretary said that she did not recall being told that this resident needed a follow-up appointment until 7/26/12 (eight weeks later) when a Post-it note was left on her desk. b. At 9:15 a.m., the Medical Director stated that the follow-up visit was not made, nor was it written on the physician readmission orders [REDACTED] c. At 10:00 a.m., the Nurse Practitioner (NP) said she recalled seeing the resident on 6/7/12, and at that time, according to her note, the resident had a splint on her right leg which went from the distal part of the foot to above the knee. The resident was able to move her toes, the NP did not identify any issues, and she did not see the resident again after that. d. At 10:30 a.m., the attending physician said that he had seen the resident on 6/1/12 and had reviewed the hospital discharge orders. He was aware that the resident needed to be followed up with Ortho in one to two weeks and confirmed that he did not write the follow-up appointment on the readmission orders [REDACTED]. He saw the resident again on 7/6/12 and was under the assumption that the resident had already been followed up by Ortho. e. At 11:05 a.m., the RN/NM said that she remembers the day the resident was readmitted to the facility. She recalls looking at the hospital discharge information and was just focusing on the cardiac piece of the paperwork because the resident had a [MEDICAL CONDITION]. She reported that she usually looks at the entire discharge orders to confirm that the physician orders are correct, but for some reason, she did not for this resident. 2. Resident #81 had [DIAGNOSES REDACTED]. The Comprehensive Care Plan, dated 7/6/12, includes the use of pacemaker. There is no documentation related to pacemaker checks. The physician orders, dated July 2012, do not include pacemaker checks. The resident had a follow-up appointment with the cardiologist on 2/14/12 regarding her upcoming surgery in March 2012. A pacemaker check was done at the visit, and a letter with recommendations was sent to the surgeon. The cardiologist indicated that the resident will be followed up in six months for a pacemaker check. However, she is to have three months remote check in the interim. (check by telephone in the facility). A 1-800 telephone number was written to call after the resident has her surgery to set up the remote check. When interviewed on 7/25/12 at 4:10 p.m., the RN/NM said that she could not find documentation that the resident had a pacemaker check done by telephone in June 2012. In an interview on 7/26/12 at 1:30 p.m., the RN/NM said that she had spoken to the attending physician, and he said that it was the responsibility of the Cardiology office to schedule the pacemaker check. During an interview on 7/31/12 at 2:40 p.m., the RN/NM said that the cardiology consultation of 2/14/12 was reviewed by the attending physician. She said that the Licensed Practical Nurse (LPN) called the cardiologist regarding the pacemaker check not being completed in June 2012, which was three months after the resident's surgery. They told the LPN that the resident already has a follow-up appointment for a pacemaker check on 8/14/12, there was no need to do one sooner, and that the expectation is that the resident is to have pacemaker checks every six months in the cardiologist's office and every three months after the six month visit by phone at the facility. The NM also said that pacemaker checks are never written on the physician orders. She said the unit secretary is responsible for scheduling the phone pacemaker checks. The secretary has a calendar, which she uses to keep track of the date the checks are due. Once the check is completed, it is recorded on the Pacemaker Check Form by the staff, which is kept in the medical record. When interviewed on 7/31/12 at 3:20 p.m., the Assistant Director of Nursing stated that the facility does not have a policy regarding pacemaker checks. (10 NYCRR 415.12)

Based on interviews and record reviews conducted during an Abbreviated Survey (complaint #NY 644) completed on 9/27/10, it was determined that for one of two residents reviewed for quality of care services, the facility did not ensure necessary care and services were provided to maintain their highest practical physical well being. The issues included lack of specific physician orders for management of a surgical wound, lack of timely Registered Nurse assessment, lack of dressing changes, lack of recognition that axillary temperatures vary from oral temperature, and lack of timely communication of the status of a surgical wound to the physician. This affected Resident #1, who had a surgical right knee wound that became infected, which required hospitalization , and subsequently, resulted in a right hip disarticulation (amputation at the hip joint). This resulted in actual harm that is not immediate jeopardy, and is evidenced by the following: Resident #1 was admitted to the facility for pain management and physical rehabilitation on 8/6/10 with [DIAGNOSES REDACTED]. The electronically signed hospital discharge instructions, dated 8/6/10, included to keep a dry sterile dressing over the incision, remove staples at follow-up in 10-14 days, and to notify the physician if the incision was warm, red, swollen, bleeding, or draining, or if the resident had a temperature greater than 101 degrees (?) Fahrenheit (F) for more than 24 hours or if the resident had unrelenting pain. The facility's admission physician orders requested that nursing check with orthopedics for instructions regarding staple removal, use of the leg immobilizer, and a follow-up appointment. The Comprehensive Care Plan, dated 8/6/10, included to assess skin every shift for any signs of skin breakdown. The facility's "Monthly Treatment Sheet," dated August 2010, revealed that there were no treatments from 8/6/10 until 8/12/10. Review of the medical record revealed that Registered Nurse Assessment of the wound was documented on 8/6/10 in the progress notes, on 8/12/10 on the non-pressure condition documentation (NPCD), and on 8/21/10 in progress notes when the resident was sent to the hospital. Additionally, there were no physician orders written on the 8/6/10 admitted for surgical wound care. These were not received until 8/12/10, when a telephone order for a dry sterile dressing was taken. The nursing/medical communication sheets (residents to be evaluated by a physician) for 8/6/10 to 8/21/10 do not include Resident #1. The 24-hour reports from 8/6/10 to 8/21/10 revealed that the resident was on report 8/6/10 for an elevated temperature (101?F), lethargy, and right arm [MEDICAL CONDITION]. The resident was sent to the hospital for evaluation and returned that day. The resident also was on this report on 8/7 and 8/8/10 related to routine admission documentation and on 8/21/10, when he was sent to the hospital for evaluation. On the NPCD form and in the patient progress notes, dated 8/6/10, Licensed Practical Nurse (LPN) #1 documented the first observation of the resident's surgical wound, where she described the right upper leg (thigh to knee) as having a small amount of bloody drainage, no odor, no redness, no [MEDICAL CONDITION], and 42 intact staples. The initial treatment section of the form included dry sterile dressing (DSD) changed. Axillary (under the arm) temperatures daily from 8/7 to 8/14/10. On 8/10 and 8/11 these axillary temperatures measured 100.6?F and 100.3?F, respectively. Telephone orders received on 8/13/10 from the physician included to leave two staples at the knee intact, remove the next three staples at the skin tear site, then remove every other staple. Also, on 8/16/10, remove remaining staples. On the NPCD sheet and inpatient progress notes, dated 8/15/10, LPN #5 documented that the dressing was changed on the right leg. The staples were intact and skin was sloughing in a 4 x 9 centimeter area by the knee and had brown drainage. LPN #5 documented on the NPCD to continue treatment as recommended. No evidence was found in the record to show that this was communicated to a physician or Registered Nurse. On 8/16/10, LPN #2 documented in the progress notes that the wound was draining a small amount of serosanguineous drainage when the dressing was changed. The note did not refer to staple removal. In the 8/18/10 patient progress notes, LPN #2 (at 10:10 p.m.) documented that the dressing on the right leg was dry and intact but did not describe the condition of the wound. There were no nursing notes on 8/17, 8/19, or 8/20/10 that addressed the condition of the wound. On the 8/21/10 NPCD form, LPN #5 noted that the wound was red and inflamed in a 6.5 x 12 centimeter area, was draining a bloody brown substance, and had no odor. The staples had been removed, and steri strips had been placed on the wound. LPN #5 documented on the NPCD that the current treatment would be continued. In a patient progress note, dated 8/21/10 at 12:45 p.m., the Nursing Supervisor documented that she was called by the LPN to check the resident related to an axillary temperature of 103.4?F. The Nursing Supervisor removed the dressings to check the leg wound and found the right knee red, five steri strips in place. The wound had no odor and was open. Two steri strips fell off when the dressing was removed. The wound measured 14 x 4.5 cm at the widest point (distal). The distal area was centrally dark and dried over. There was yellow slough around edges and suture line. The smaller circular area at center of distal wound also had yellow slough. Some purulent (pus) and brownish bloody discharge was present. The reddened area was 12 x 6.5 cm. in size. The lower thigh was somewhat swollen. The on-call physician was notified, and an order was received to transfer the resident to the hospital for emergency care on 8/21/10 at 1:00 p.m. A physician's note, dated 8/25/10, revealed that the resident was sent to the emergency roiagnom on [DATE] with a fever and possible wound infection that required a hospital admission. The hospital discharge summary, dated 8/29/10, revealed that due to presumed necrotizing fascitis (infection in the soft tissues under the skin with localized death of tissue) of the right leg, the resident underwent [REDACTED]. During interviews on 9/8/10 from 10:35 a.m. through 3:15 p.m., the following information was gathered: 1. LPN #8 (11:05 a.m.) had documented that the dressing was dry and intact. When asked what that meant, she said that when she looked at the dressing, it was securely in place and had no drainage. She added that she changed the dressing if it had visible drainage. This was not documented. LPN #8 said that the first major change that she noticed with the surgical site was on 8/12/10 and that the Nurse Manager (NM) and physician (MD #1) looked at the surgical wound that day because it was swollen and the staples were pulling. LPN #8 said that she removed half of the staples on 8/13/10 and the rest on 8/16/10. She said that there was drainage near the skin tear by the knees at the surgical site, and after the staples were removed, an abdominal pad was used to cover the incision. LPN #8 said that if something is not documented, it is presumed that it has not been done. 2. MD #1 (12:10 p.m) stated that she would expect staff to follow the orthopedic orders upon admission. She stated that it is a professional standard to use a dry sterile dressing on a surgical wound and that this dressing should be changed daily. When the dressing is changed the wound should be assessed for color and drainage. MD #1 said she did assess the wound on 8/13/10 and at that time found no evidence of drainage or infection. This was an informal visit and was not documented. She did not see the resident's wound after this because she was not contacted. 3. MD #2 (12:10 p.m.) was on call on 8/21/10 when the resident had an axillary temperature of 103?F and required hospitalization . She described axillary temperatures as "not the standard, not good enough, and that an oral temperature would be the same or higher." She also said that for a temperature of greater than 100?F, the physician should be notified. 4. LPN #1 (10:35 a.m.) said that dressing change orders should be written by the physician on admission and put on the Monthly Treatment Sheet. She added that the skin sheets should be documented on every time the dressing is changed, and if there is a problem, it should be reported to the NM or supervisor. Interviews conducted on 9/23/10 from 9:10 a.m. to 2:45 p.m. revealed the following: 1. LPN #1 (9:10 a.m.) and LPN #8 (9:30 a.m.) both said that concerns are written in the NM's communication book. The NM then uses her judgement and documents the issue on the nursing/medical communication sheet. LPN #1 said that a fever over 100?F would be written on the 24-hour report. 2. The NM (9:40 a.m., 11:00 a.m.) reported that she reviews concerns written in a communication book and determines if they need to be included on the nursing/medical communication sheet. She confirmed that the secretary's initials are next to the admitting orders and marked, "Done," signifying that the secretary had called the orthopedic surgeon to get the information. 3. In a telephone interview (10:15 a.m.), the secretary said she does schedule follow-up orthopedic appointments but is not allowed to clarify orders on the telephone. 4. The DON (1:00 p.m.) said that if staff is unable to read orders then she would expect that staff call MD to clarify. She said that secretaries can clarify orders if a doctor is present, but that they do not call the doctors on the phone. 5. LPN #1 (1:20 p.m.) said that she checks orders for accuracy and then she signs them off. When reviewing the admission orders done," so she assumed it was done. The facility's instruction sheet for the 24-hour report revealed that each nursing unit will prepare a written report at the end of shift to communicate significant resident related information. This would include condition changes and temperatures with symptoms of greater than 100?F. The transcribing orders policy, dated 10/7/05, revealed that physician orders transcribed by the unit secretary are verified and co-signed by a nurse on that shift. Orders are clarified if needed by the NM or delegate. If the transcriber has any questions about an order he/she will go to the NM, charge nurse, or supervisor to review the order. (10 NYCRR 415.12)