Every finding on record at Sunrise Manor Center for Nursing and Rehabilitatio

Based on observations, record review, and interviews during survey, the facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was identified during the kitchen task observation. Specifically, the walk-in freezer was observed at 25 degrees Fahrenheit (normal temperature is zero degrees Fahrenheit) and a two-door refrigerator was at 50 degrees Fahrenheit (normal temperature is 41 degrees Fahrenheit or below). Multiple foods were observed in the walk-in freezer and the two-door reach-in refrigerator that were not labeled or dated.The findings include: A facility policy and procedure titled Food Receiving and Storage, last reviewed 12/16/2024 documented that food and nutrition products are inspected upon receipt and stored under proper conditions of sanitation, temperature, light, moisture, ventilation and security. Foods will be maintained at or below 41 degrees Fahrenheit unless otherwise specified. Refrigerator temperatures will be taken/monitored daily and at routine intervals during operation when needed. All opened items will be labeled and dated and discarded after three days once they are opened. Freezer storage temperatures will be maintained at or below zero degrees Fahrenheit. Freezer temperatures will be taken/monitored daily and at routine intervals during operation when needed. All opened items will be labeled and dated and discarded after three days, once they are opened. A facility policy and procedure titled Safe Food Storage, documented acceptable temperature ranges are 34 to 41 degrees Fahrenheit for refrigerators and less than zero for freezers. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures, and action taken. The last column will be completed only if temperatures are not acceptable. Food service supervisors or designated employees will check and record refrigerator and freezer temperatures. The supervisor will take immediate action if temperatures are out of range. Actions necessary to correct the temperatures will be recorded on the tracking sheet, including the repair personnel and/or department contacted. During the initial tour of the kitchen with the Food Service Director and [NAME] #1 present on 06/24/2026 at 9:20 A, the walk-in freezer temperature measured 25 degrees Fahrenheit. There was also a package of waffles, and a bag of unidentifiable patties which were soft to touch and pliable (identified by the Food Service Director as eggplant patties) not labeled and dated, out of their original packaging. A two-door reach-in refrigerator temperature measured 50 degrees Fahrenheit. There were two American cheese sandwiches, one ham sandwich, two bologna sandwiches; two shopping bags with bagels (identified by [NAME] #1) that were not labeled or dated. [NAME] #1 was interviewed and stated that the refrigerator temperature should be kept below 41 degrees Fahrenheit. During an interview on 06/24/2026 at 9:40 AM, the Food Service Director stated that the freezer temperature should be at zero degrees Fahrenheit or below. They did not know why the temperature was so high. The Food Service Director stated they had noticed that the freezer temperature had been slowly increasing but they did not call for service. A review of the refrigerator and freezer temperature log for the month of June 2026 revealed that the walk-in freezer temperature was recorded at 10 degrees Fahrenheit on 06/22/2026 and 06/23/2026 at the closing of the kitchen. During a follow-up tour of the kitchen with the Food Service Director on 06/30/2026 at 10:10 AM, the walk-in freezer temperature was measured at 15 degrees Fahrenheit. During an interview on 06/30/2026 at 10:23 AM, the Administrator stated they were notified on 06/24/2026 that the walk-in freezer was not maintaining temperature and has been repaired since. The Administrator stated they were not aware that the freezer temperature was still out of normal range. 10 New York Code of Rules and Regulations 415.14(h)

Based on observations, record review, and interviews during survey, the facility failed to ensure that drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles. This was identified for two (Unit 1 and Unit 2) of two units reviewed during the medication storage task. Specifically, the first-floor medication room refrigerator was observed with a dark colored dried substance on the bottom of the refrigerator and the door. The second-floor medication storage room was observed with multiple expired medications.The findings include:The facility policy titled Medication Storage and Labeling last reviewed on 04/2026 documented the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. The nursing staff will ensure that medication is rotated based on the date and stored as per the recommended manufacturer guidelines. All expired medications should be removed and discarded as per medication waste management policy, and new inventory ordered if needed.During an observation, in the presence of Licensed Practical Nurse #4, on 06/29/2026 at 7:10 AM, the first-floor medication room refrigerator was observed with a dark colored dried substance on the bottom of the refrigerator and the door.During an interview on 06/29/2026 at 07:12 AM, Licensed Practical Nurse #4 stated they did not see the dark colored dried substance and the housekeepers were supposed to clean the refrigerator. During an observation, in the presence Registered Nurse Supervisor #1, on 06/29/2026 at 07:33 AM, the second-floor medication storage room was observed with the following:-16 bottles containing 30 tablets each of famotidine 10 milligrams (heartburn relief) with an expiration date of January 2026. -one bottle of children's pain and fever oral suspension acetaminophen 160 Milligram per 5 Milliliter 4 ounce with an expiration date of February 2026.-one box of acetaminophen suppository 325 milligram containing 6 rectal suppositories with an expiration date of March 2026.During an interview on 06/29/2026 at 07:33 AM, Registered Nurse Supervisor #1 stated they were responsible for making sure there were no expired medications in the medication storage cabinets. Registered Nurse Supervisor #1 stated it was their mistake for not discarding the expired medications.During an interview on 06/29/2026 at 11:22 AM, the Director of Nursing Services stated all Nursing Supervisors were responsible for making sure that there were no expired medications in the medication storage. The Director of Nursing Services stated the nurses were responsible for making sure the medication refrigerators were kept clean to maintain infection control. The Director of Nursing Services stated they were not aware that non-medicine items were not to be stored on the same drawing as medications.New York Code Rules and Regulations 415.18(e) (1-4)

Based on observation, record review and interviews during the survey, the facility failed to ensure that it established and maintained 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. This was identified for the laundry room observation conducted during the Infection Control Task. Specifically, there were uncovered clean resident clothing hanging on a rack in close proximity to a dirty laundry bin that was filled with bags of dirty laundry. There were 15 wire and plastic hangers observed on top of the dirty laundry bags. There was an uncleaned dirty laundry bin stored between the washers and the dryers, directly in the path of transferring clean clothing from the washers to the dryers.The findings include:The facility policy title Safe handling and storage of laundry and linen last revised 01/10/2026, documented the facility may utilize its in house laundry equipment for laundering resident personal clothing, emergency needs, or during interruptions in contracted laundry services, as determined by the Administrator or the Director of Housekeeping. All in house laundering will be performed in accordance with current infection prevention and control standards and manufacture recommended laundering procedures. Clean and soiled laundry will remain physically separated throughout the collection, washing, drying, folding, storage, and distribution processes to prevent cross contamination. Clean laundry will be stored only in designated clean storage areas or covered carts, protected from dust, moisture, and other sources of contamination, and will never be placed on the floor.During an interview on 06/25/2026 at 1:20 PM, The Director of Environmental Services stated resident laundry is done in house, and linen is sent out.During an observation and interview on 06/25/2026 at 1:26 PM, Laundry Aid #1 was sitting on a chair in front of the washing machines, folding the clean laundry from a bin that was full of clean laundry. There were uncovered clean resident clothing that was hanging on a rack in close proximity of a dirty laundry bin that was filled with dirty laundry bags. There were at least 15 wire and plastic hangers stored on top of the dirty laundry bags. Laundry Aid #1 stated the hangers were to be used for the clean laundry. There was an uncleaned dirty laundry bin stored between the washers and the dryers, directly in the path of transferring clean clothing from the washers to the dryers.During an interview on 06/26/2026 at 11:07 AM, the Director of Environmental Services stated the hangers should not be stored on top of the dirty laundry bags and that the clean laundry should not be stored next to the dirty laundry bin due to the possibility of cross contamination.During an interview on 06/29/2026 at 9:00 AM, the Infection Preventionist stated Laundry Aids must keep clean and dirty laundry separated to prevent cross contamination. The dirty laundry bins should not be stored in the path of the washers to the dryers to prevent cross contamination.During an interview on 06/30/2026 at 10:11 AM, the Director of Nursing Services stated the laundry aides are responsible to handle the resident laundry and they are expected to follow facility policy related to infection control. To prevent cross contamination, the dirty laundry bins should not have been stored near the clean laundry or in the area where clean clothing was being handled.10 New York Code Rules and Regulations 415.19(a)(1-3)

Based on observations, record review, and interviews, the facility failed to ensure that a comprehensive person-centered care plan was developed and implemented for each resident that included measurable objectives and timeframes to meet each resident's medical, psychosocial, and nursing needs. This was identified for one (Resident #2) of four residents reviewed for accidents and one (Resident #1) of three residents reviewed for activities of daily living. Specifically, 1) Resident #2 did not have an out on pass physician's order or a care plan developed for community visits. 2) Resident #1 was observed without the use of the Geri sleeves (protective arm and leg sleeves designed to safeguard fragile skin) as per the physician's orders. Additionally, there was no care plan developed for the use of Geri-sleeves. The findings include: The facility policy titled Out On Pass last reviewed 11/2025, documented to identify and give authorization to the residents who are deemed appropriate by the interdisciplinary team to leave the facility, escorted or unescorted. The ultimate determination of the resident's ability to leave the facility is made by the attending physician. The physician will evaluate the resident and obtain psychological and or psychiatric evaluation if deemed necessary. Nursing will be informed by the physician of their decision, and an order will be placed in the chart. The facility policy titled Comprehensive Care Plan last reviewed 02/2026, documented a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents' physical, psychosocial and functional needs are developed and implemented for each resident. 1) Resident #2 was admitted with diagnoses that included schizoaffective disorder (chronic mental health condition characterized by a combination of schizophrenia symptoms), post laminectomy syndrome (chronic pain that persists or develops after spinal surgery), and obstructive and reflux uropathy (blockage in the urinary tract that prevents urine from flowing naturally). The admission Minimum Data Set assessment dated [DATE], documented a Brief Interview for Mental Status score of 15, indicating Resident #2 was cognitively intact. The Minimum Data Set assessment further documented Resident #2 required partial to moderate assistance with sit to stand (position) and walking 10 feet. The resident utilized a manual wheelchair and a rolling walker with supervision for mobility. A review of the comprehensive care plan revealed there was no documented evidence that a care plan for Resident #2 to go out on pass was initiated. A review of Resident #2's physician orders from 04/07/2026 to 06/24/2026 indicated no order for out on pass. A social work progress note dated 06/12/2026 documented Resident #2 requested the Director of Social Work to help them obtain an ambulette to go home for the day. A social work progress note dated 06/15/2026 documented the Director of Social Services assisted Resident #2 in obtaining an ambulette transportation to go home for the day to see their significant other. The unit manager was made aware. A nursing progress note dated 06/24/2026 documented Resident #2 went out on pass unescorted at 10:00 AM. During an observation and interview on 06/26/2026 at 10:23 AM, Resident #2 was in their room sitting in a chair eating a snack, they stated they went home a few days ago to see their significant other, and the Social Worker helped them arrange for transport. During an Interview on 06/26/2026 at 12:48 PM, The Director of Social Work stated they thought there was a physician's order in place for Resident #2 to go out on pass. The interdisciplinary team met on 06/12/2026, including Social Worker #2, the Administrator, nursing staff, and physical therapy staff were present during the meeting. The Director of Social Work stated they should have checked the electronic medical record to confirm the physician's order for out on pass. The Social Worker stated they should have also initiated a care plan regarding the resident's wishes to go out on pass. During an interview on 06/26/2026 at 02:08 PM, The Director of Nursing Services stated there should have been a physician's order and care plan in place for Resident #2 after the interdisciplinary team decided that it was acceptable for the resident to go out on pass. During an interview on 06/30/2026 at 3:30 PM, Physician #1 stated that the staff should have obtained the out on pass order for Resident #2 prior to the resident going out on pass. 2) Resident #1 was admitted with diagnoses of seizures disorder and type 2 diabetes mellitus. A significant change Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 9, indicating moderate cognitive impairment. The assessment indicated the resident was at risk for skin breakdown. A comprehensive care plan titled Risk for Skin Breakdown, last revised on 06/15/2026, documented the resident had fragile skin. The interventions included observing skin integrity daily. Report signs and symptoms of skin breakdown and report significant changes to the Doctor and administer medications as ordered. There was no documented evidence that the comprehensive care plan included the use of Geri sleeves. A physician's order dated 03/07/2026 documented to put on Geri sleeves and perform skin check twice a day (day and evening shift). Resident #1 was observed on 06/24/2026 at 12:49 PM without the use of the Geri sleeves. Resident #1 was observed 06/26/2026 at 12:31 PM without the use of the Geri sleeves. Resident #1 was observed on 06/29/2026 at 9:11 AM without the Geri sleeves in place. Resident #1 stated the staff do not place any sleeves on their arms. A review of the June 2026 Medication Administration Record and Treatment Administration Record revealed no evidence of skin checks twice daily or the use of the Geri sleeves. During an interview on 06/29/2026 9:30 AM, Licensed Practical Nurse #3 stated that skin checks should be documented either on the Medication Administration Record or the Treatment Administration Record and confirmed that the physician's order for Geri sleeves and skin checks for Resident #1 were not documented on either of the administration records or in the care plan. During an interview on 06/29/2026 at 9:40 AM, Registered Nurse Supervisor #1 stated that nurses should place and remove the Geri sleeves and perform the skin check simultaneously. The physician's order for the Geri sleeves and skin checks should appear on the Medication or the Treatment Administration Record. Registered Nurse Supervisor #1 confirmed that the use of Geri sleeves was not noted on either of the Administration Records or included in any care plan for Resident #1. During an interview on 06/29/2026 at 9:49 AM, the Director of Nursing Services stated that the use of Geri sleeves should have been added to Resident #1's comprehensive care plan and documented on the Treatment Administration Record. 10 New York Code of Rules and Regulations 415.11(c)(1)

Based on observation, record review, and interviews, the facility failed to ensure that nurse staffing data was posted on a daily basis at the beginning of each shift in a prominent place that is readily accessible to residents and visitors. This was identified during the sufficient and competent nurse staffing task. Specifically, during the initial tour on 06/24/2026, the daily staffing data was not posted in a prominent place that was readily accessible to residents and visitors. Additionally, the daily staffing data that was posted on 06/29/2026 was dated 06/26/2026 and did not include the actual number of licensed and unlicensed staff for all shifts. The findings include: The facility policy and procedure titled Census and Nursing Staffing last reviewed in December 2025, indicated the facility will post nurse staffing information daily at the beginning of each shift. The posting is to include the resident census and the total number and actual hours worked by licensed and unlicensed nursing personnel. The policy indicated that the Nursing Supervisor or Clinical Care Coordinator was responsible for completing the staffing information sheet at the beginning of each shift in a clear and readable format. Upon completion of the form, reflecting the actual number of staff on duty, absences, tardiness, and the projected/scheduled staff for the following shift, the form is to be posted in a prominent designated location. The policy further indicated the Staffing Coordinator will review the census/staffing sheet daily to ensure its accuracy and make any necessary corrections. During an initial tour on 06/24/2026 at 9:15 AM, nurse staffing data was not posted in a prominent place that was accessible to residents and visitors. During an observation on 06/29/2026 at 6:10 AM, the nursing staffing data dated 06/26/2026 was posted near the elevator in the ground floor lobby that did not include the 11:00 PM to 7:00 AM shift staffing information was not complete. During an interview on 06/30/2026 at 02:17 PM, the Staffing Coordinator stated that they were responsible for posting the daily staffing data on weekdays. The Registered Nurse Supervisor was responsible for posting the nurse staffing data for the 11:00 PM to 7:00 AM shift and on the weekends. The Staffing Coordinator confirmed that the nurse staffing data posting for 6/24/2026 was posted late because they were late to work that day. The Staffing Coordinator acknowledged that the nurse staffing data posting on 06/29/2026 was from 06/26/2026 and was not completed with the 11:00 PM to 07:00 AM shift staffing information. The Staffing Coordinator stated complete and accurate nurse staffing information should be posted daily as required. During an interview on 06/30/2026 at 2:31 PM, the Director of Nursing Services confirmed the staffing information should have been completed and posted daily. 10 New York Code of Rules and Regulations 415.13

Based on observation, record review, and staff interviews, the facility failed to ensure that medications were administered in accordance with physician orders and in accordance with the facility's medication administration policy for one (1) of three (3) residents reviewed for a medication error (Resident #1). Specifically, the facility administered Vimpat (lacosamide), a controlled anti-seizure medication, at a dose of 200 milligram by mouth for four (4) doses when the medication administration record reflected an order for 50 mg by mouth twice daily.Findings Include:Resident #1 was admitted on [DATE] with diagnosis that include Cerebellar stroke syndrome, Conversion disorder with seizures or convulsions, and depression. On 12/23/2025 a Minimum Data Set Brief Interview of Mental Status was completed for Resident #1 and documented a score of 00 indicating severe cognitive impairment.Review of the facility policy titled Administering Medications dated 12/2025 required staff to: Verify there is a physician's medication order; Check the medication label against the Medication Administration Record; Confirm the medication name and dose prior to administration.Hospital Discharge Medication Orders for Resident #1 dated 10/27/2025 documented Resident #1 was ordered Vimpat (Lacosamide) 50 milligram twice a day by oral route. Medical Doctor Orders for Resident #1 dated 11/01/2025 documented an order for Vimpat (Lacosamide) tablet 50 milligram twice a day. The E-Script order dated 11/03/2025 documented an order for Vimpat (Lacosamide) 200 Milligrams 1 tablet by mouth twice daily. The pharmacy delivery receipt dated 11/03/2025 documented Vimpat (Lacosamide) 200 milligrams was delivered to the facility and signed. Medication Administration Record for Resident #1 documented Vimpat 50mg was ordered and signed for by Licensed Practical Nurse #1 on 11/03/2025, Vimpat 50 milligrams was ordered and signed for by Licensed Practical Nurse #2 on 11/04/2025, Vimpat 50 milligrams was ordered and signed for by Licensed Practical Nurse #3 on 11/04/2025, and Vimpat 50 milligrams was ordered and signed for by Licensed Practical Nurse #4 on 11/05/2025A review of the medication card for Vimpat 200 milligrams reflected 4 missing tablets. A Review of the Narcotic Count Sheet dated 11/03/2025 reflected 4 signatures indicating Vimpat 200 milligrams was administered. Review of a Facility Reported Incident dated 11/07/2025 documented that Resident #1 received Vimpat (Lacosamide) 200 mg by mouth for four (4) doses despite an active electronic medication administration record order for Vimpat 50 mg by mouth twice daily. The report documented no identified adverse physical or psychological outcomes. Neurological status and vital signs remained within baseline. The medication was discontinued upon discovery of the error. Review of the facility's five-day investigative report dated 11/13/2025 documented that four licensed practical nurses administered the incorrect dose. The report further documented counseling, retraining, and competency validation of involved staff and re-education of licensed nursing staff on medication administration procedures.The Medication Error report dated 11/5/20205 document resident received 200mg on 11/03/2025 during the 3-11PM shift, 11/04/2025 twice 7-3AM & 3-11PM and on 11/5/2025 the7AM-3PM shift During an interview on 02/10/2026 at 11:31AM, the Director of Nursing stated that Medical Doctor #1 entered an incorrect dose of Vimpat 200 milligram twice daily into the electronic prescribing system. The pharmacy processed the order and delivered 200 milligram tablets to the unit. Four nurses administered the 200-milligram dose despite the electronic medication administration record reflecting 50 milligram.During a subsequent interview on 03/03/2026 the Director of Nursing stated the current electronic medical record is not linked to the pharmacy for narcotics. When ordering narcotics the physician must go into another system called e-script to enter the order for narcotics, which then goes to the pharmacy for delivery. The pharmacy stated they filled the e-script order because the prescription is coming from the doctor and does not reconcile with the physician order in the resident's chart. There is no process in place to reconcile the narcotic order with the physician order in the chart. During telephonic interview on 02/10/2026 at 01:55 PM, Medical Doctor #1 confirmed the incorrect prescribing of Vimpat 200 milligrams instead of 50 milligrams. The physician stated no adverse effects occurred and the resident required no hospitalization.415.12(m)(2)

Based on observations, record review, and interviews during the Recertification and Abbreviated (NY 00363437) Survey initiated on 3/26/2025 and completed on 4/1/2025, the facility did not develop a comprehensive person-centered care plan for each resident that includes measurable objective and time frames to meet a residents medical, nursing, mental and psychosocial need that are identified in the comprehensive assessment. This was identified for one (Resident #50) of three residents reviewed for Skin Conditions. Specifically, Resident #50 was incontinent of bowel and bladder and there was no care plan developed to address the resident's incontinence care. The finding is: The Policy and Procedure for Urinary/Bowel Continence and Incontinence Assessment and Management, revised on 1/2025, documented that if a resident is incontinent, an incontinent care plan will be initiated, reviewed, and revised as needed. The Policy and Procedure for Comprehensive Care Plan reviewed on 10/2024, documented that the Comprehensive Person-Centered Care Plan includes measurable objectives and time frames. The care plan describes services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Resident #50 was admitted with diagnoses that include Secondary Malignant Neoplasm of Cerebral Meninges, Paraplegia ( inability to voluntarily move the lower parts of the body), and Retention of Urine. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 15, indicating the resident had intact cognition. The Minimum Data Set documented the resident was always incontinent of bowel and bladder and was dependent on the staff for toileting. The Physician's orders dated 2/28/2025 documented to administer 1 capsule of Flomax (tamsulosin) 0.4 milligrams by oral route once a day at 10:00 PM for Urinary Retention. A review of the medical record revealed there was no documented evidence of a care plan addressing incontinence care. During an observation on 3/26/2025 at 11:00 AM, Resident #50 was in their bed watching television. Resident #50 stated sometimes they have to wait hours for their incontinence briefs to be changed. During an interview on 3/28/2025 at 1:46 PM, Certified Nurse Assistant #5, the regularly assigned 7:00 AM-3:00 PM shift Certified Nursing Assistant for Resident #50, stated the resident was frequently incontinent of bowel and bladder. Certified Nurse Assistant #5 stated they check Resident #50 every two hours to make sure Resident #50 was not soiled. Certified Nurse Assistant #5 stated they documented the incontinence care in the electronic medical record every shift. During an interview on 4/01/2025 at 11:14 AM, Registered Nurse Supervisor #1 stated Resident #50 was incontinent of bowel and bladder due to Paraplegia. Registered Nurse Supervisor #1 stated they were responsible for initiating the care plan for bowel and bladder incontinence but they forgot to initiate the care plan. During an interview on 4/01/2025 at 12:18 PM, the Director of Nursing Services stated that residents who are incontinent of bowel and bladder, require a care plan for incontinence care. The care plan should be initiated upon admission and reviewed each quarter. The Director of Nursing Services stated the Registered Nurses were responsible for initiating the care plan. 10 NYCRR 415.11(c)(1)

Based on observations, record review, and interviews during the Recertification Survey initiated on 3/26/2025 and completed on 4/01/2025, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents. This was identified for one (Resident #3) of three residents reviewed for Accidents. Specifically, Resident #3 was assessed to require a mechanical lift with two staff members for transfer from one surface to another. On 3/26/2025, Certified Nursing Assistant #4 was observed transferring Resident #3 with a mechanical lift by themselves. The finding is: The facility's policy titled Mechanical Lifts, last reviewed on 10/2024, documented at least two nursing assistants are needed to safely move a resident with a mechanical lift. Resident #3 was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease Stage 3, and Type 1 Diabetes Mellitus. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 9, indicating the resident had moderate cognitive impairment. The Minimum Data Set indicated the resident was dependent on the assistance of two or more caregivers for transfers from a bed to a chair. A Comprehensive Care Plan titled Activities of Daily Living, last revised on 11/26/2024, documented interventions that included transferring the resident with a standing lift with the assistance of two staff members. During an observation on 3/26/2025 at 10:50 AM, Resident #3 was observed awake in bed while Certified Nursing Assistant #4 provided a bed bath and morning care. A mechanical lift (the standing lift) was observed in the room near the bed. During a second observation on 3/26/2025 at 11:04 AM, Certified Nursing Assistant #4 was observed in the resident's room transferring Resident #3 from their bed to their wheelchair utilizing the mechanical lift by themselves. During an interview on 3/26/2025 at 11:16 AM, Certified Nursing Assistant #4 stated they provided morning care before using the standing lift to transfer Resident #3 out of bed to the wheelchair. Certified Nursing Assistant #4 stated they regularly provide care to Resident #3 and do not need a second caregiver's assistance to transfer the resident from the bed to the wheelchair. Certified Nursing Assistant #4 stated they are comfortable using the lift to get the resident out of bed without a second person. During an interview on 3/28/2025 at 10:17 AM, Registered Nurse Supervisor #1 stated there should always be, at a minimum, two staff members when a standing lift is being used. Certified Nursing Assistant #4 should have called for assistance when they used the standing lift. During an interview on 3/31/2025 at 11:17 AM, the Director of Nursing Services stated that Certified Nursing Assistants should not be transferring a resident with a standing lift without the assistance of two staff members to prevent accidents. 10 NYCRR 415.12(h)(2)

Based on record review and staff interviews during the Recertification Survey initiated on 3/26/2025 and completed on 4/01/2025, the facility did not ensure the Physician documented in the resident's medical record that the irregularity identified by the Pharmacist had been reviewed and what action had been taken to address the recommendations. This was identified for one (Resident #64) of five residents reviewed for Unnecessary Medications. Specifically, the Physician disagreed with a recommendation provided by the Consultant Pharmacist on the Medication Regimen Review form for Resident #64 and did not document the rationale for the disagreement. The finding is: The facility's policy, titled Medication Regimen Review, last reviewed on 10/2024, documented the facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. The medical director will review all medication regimen recommendations and will address and document if indicated. Resident #64 had diagnoses including Left Leg Below Knee Amputation, Type 2 Diabetes Mellitus, and Hypertension. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 6, which indicated the resident had severe cognitive impairment. A Comprehensive Care Plan titled Cardiovascular dated 12/03/2024, documented interventions that included administering medications as ordered. Monitor for effectiveness and adverse effects. The Physician's Order dated 12/3/2024 documented Metoprolol Tartrate (beta-blocker medication that affects the heart and circulation) 50 milligrams, 1 tablet, twice a day by oral route for Hypertension. The Drug Regimen Review dated 1/14/2025 documented that the resident was currently receiving Metoprolol Tartrate 50 milligrams twice daily. The Consultant Pharmacist recommended to consider switching to Metoprolol Succinate, which offers once daily dosing and reduces administration time requirements. Consider 100 milligrams once daily as a starting dose, follow up blood pressure daily for three days then weekly thereafter, and adjust dosing as necessary. The Physician checked the Disagree box and the reason for the disagreement was not documented. The Medication Regimen Review form was signed by the physician on 1/20/2025. During an interview on 3/31/2025 at 2:27 PM, the Medical Director, who was also the resident's Primary Physician, stated the resident had stable blood pressure and therefore disagreed with the Pharmacist's recommendation of changing the resident's current medication. The Medical Director stated there was no documentation in the resident's medical record or on the Drug Regimen Review form with a rationale as to why they disagreed with the Pharmacist's recommendation made on 1/14/2025 and there should have been. 10 NYCRR 415.18(c)(2)

Based on observation, record review, and interviews during the Recertification Survey initiated on 3/26/2025 and completed on 4/01/2025, the facility did not ensure food was stored in accordance with professional standards for food service safety. This was identified during the Kitchen Task. Specifically, the ham sandwich temperatures were not maintained at a safe temperature of 41 degrees Fahrenheit (F) or below. The finding is: The facility policy titled Food Preparation, Service and Distribution, revised on 10/2024 documented that the facility will ensure safe and sanitary food preparation, holding, transport, and distribution to prevent food-borne illness. The facility will avoid the following potential risks to reduce food-borne illness: will not hold foods in the danger zone (temperatures above 41 degrees and less than 135 degrees Fahrenheit). During an observation of the Kitchen tray line service on 3/28/2025 at 12:13 PM, multiple ham sandwiches were stored in a hotel pan. The Food Service Director conducted random temperature checks of ham sandwiches and the temperature measured at 68 degrees Fahrenheit. During an interview on 3/28/2025 at 12:15 PM, the Food Service Director stated that cold food items should be held at a temperature of 40 degrees Fahrenheit or below. The Food Service Director further stated there is a potential for foodborne illness when food is served outside of the appropriate temperature zone. During an interview on 3/28/2025 at 1:17 PM, the Administrator stated cold food should be kept at a temperature of 41 degrees Fahrenheit or below to prevent food-borne illness. 10 NYCRR 415.14(h)

Based on observations, record review, and interviews during the Recertification Survey initiated on 3/26/2025 and completed on 4/01/2025, the facility did not ensure call systems were accessible to each resident while residents were in their rooms. This was identified for one (Resident #274) of one resident reviewed for call systems. Specifically, Resident #274 was observed in bed on 3/26/2025 at 9:36 AM and again on 3/26/2025 at 11:20 AM with no call bell within reach. The finding is: The facility's policy and procedure titled Call Bells, reviewed in 9/2024, documented to ensure accessibility and timely response to the activated call bells. Call bells are to be attached near the resident's bed appropriately and be within reach at all times. Resident #274 was admitted with diagnoses including Cardiac Arrest, Gout, and Major Depressive Disorder. The Minimum Data Set was not completed as the resident was recently admitted to the facility. The Brief Interview for Mental Status completed upon admitted d 3/26/2025 documented a score of 15, indicating the resident was cognitively intact. A Physical Therapy Evaluation dated 3/26/2025 documented that Resident #274 was totally dependent on two staff members for bed mobility and transfers. A Baseline Care Plan titled Potential for Falls dated 3/25/2025 documented interventions that included keeping the call bell within reach or accessible while (the resident) was in the room. During an observation on 3/26/2025 at 9:36 AM, Resident #274 was alone in their room, in bed. There was no call bell observed within reach of the resident. During an interview on 3/26/2025 at 9:36 AM, Resident #274 stated they did not have a call bell and did not know why they were never given a call bell. During an observation on 3/26/2025 at 11:20 AM, Resident #274 was awake in bed, alone in their room, with no call bell. During an interview on 3/26/2025 at 11:35 AM, the assigned Certified Nursing Assistant #1 stated Resident #274's call bell was placed by their roommate's bed in error. Certified Nursing Assistant #1 then pulled back the privacy curtain of the resident's roommate area and located two call bells attached to the roommate's bedding. Certified Nursing Assistant #1 stated they should have checked that Resident #274 had their call bell within reach. During an interview on 3/28/2025 at 10:13 AM, Registered Nurse Supervisor #1 stated a call bell should be within reach of the resident while in their room. All staff members on the unit are responsible for making sure each resident's call bell is within reach. During an interview on 3/31/2025 at 11:26 AM, the Director of Nursing Services stated the call bell should be placed within reach and accessible to the residents while they are in their rooms. 10 NYCRR 415.29

Based on observations, interviews, and record review during an abbreviated (NY00360500) survey conducted on 12/04/2024 through 12/09/2024, the facility failed to protect each resident's right to be free from sexual abuse. This was identified for one (Resident #1) of four residents reviewed for sexual abuse. Specifically, Resident #1, with a diagnosis of Dementia and severely impaired cognition, was observed in Resident #2's room by Licensed Practical Nurse #1 performing oral sex. Resident #2 was cognitively intact. Resident #1's family member was interviewed and stated that if Resident #1 was cognitively intact, they would have been upset, embarrassed, and humiliated. This resulted in actual psychosocial harm to Resident #1 and the potential for harm to 9 of 72 cognitively impaired residents reviewed for sexual abuse, which was Immediate Jeopardy and Substandard Quality of Care. The Findings Are: The facility policy titled, Abuse Prohibition and Prevention Policy, revised on 9/11/2024 documented, Definition of Criminal Sexual Abuse as including the resident lacks the ability to understand the nature of the sexual act. Resident #1, [AGE] years old admitted on [DATE] with diagnoses including vascular dementia and depression with a Minimum Data Set assessment dated [DATE], documented a Brief Interview for Mental Status score of 7, which indicates severely impaired cognition. (The Brief Interview for Mental Status assessment uses a points system: 0 to 7 points suggests severe cognitive impairment, 8 to 12 points suggests moderate cognitive impairment, and 13 to 15 points suggests that cognition is intact.) Resident #2, [AGE] year-old admitted on [DATE] with diagnoses including right leg above knee amputee, coronary artery bypass graft and hypertension, had intact cognition with a Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental status score of 15. Nursing progress notes dated 11/13/2024 at 5:43 PM signed by the Director of Nursing documented they were informed on 11/13/2024 by Licensed Practical Nurse #1 that they witnessed an incident involving Resident #1 and Resident #2 engaging in a sexual activity. Resident #1 was assessed and was confused but alert. No bruising, pain or redness. Medical Doctor made aware and ordered Psychiatric consult. The note further documented that Resident #1 was transferred to a different unit for safety. Nursing progress notes dated 11/13/2024 at 6:19 PM signed by the Director of Nursing documented they were informed on 11/13/2024 by Licensed Practical Nurse #1 that they witnessed an incident involving Resident #1 and Resident #2 engaging in a sexual activity. Resident #2's arms and legs were assessed no bruising redness or marks. Resident #2 refused assessment of their genitalia and abdomen. Medical Doctor made aware and ordered Psychiatric consult. Nursing Progress notes dated 11/13/2024 at 10:49 PM signed by Licensed Practical Nurse #1 documented they observed Resident #1 engaging in oral sex with Resident #2. Licensed Practical Nurse #1 removed Resident #1 from Resident #2's room and paged the Director of Nursing. \A Comprehensive Care Plan dated 11/13/2024 for Resident #2 documented risk for abuse with a long goal for no lasting effects from the event for 90 days. The Accident and Incident report dated 11/14/2024 documented Resident #1 as the alleged perpetrator, They (Resident #1) were having fun with a smile on their face. The incident was witnessed by a facility staff member (Licensed Practical Nurse #1). The incident report documented Resident #2 as the victim. Resident #2 stated it was consensual. The facility concluded no abuse, neglect or mistreatment occurred. A Comprehensive Care Plan dated 11/14/2024 for Resident #1 lacked documented interventions to prevent victimization. The comprehensive care plan did not address the witnessed sexual contact with Resident #2. A telehealth Psychiatric consult note dated 11/25/2024 at 3:48 PM documented Resident #1 could not recall the incident of the witnessed sexual activity. The note did not include any further psychiatric follow up or interventions. A Psychiatrist noted 11/25/2024 at 4:04 PM documented Resident #2 refused to be evaluated. During an observation on 12/04/2024 at 10:15 AM Resident #1 was observed in their wheelchair outside of the nurse's station. Resident #1 was unable to be interviewed due to their severely impaired cognition. Resident #2 was observed on their unit sitting in their wheelchair and refused to be interviewed. During an interview with Certified Nursing Assistant #1 on 12/04/2024 at 3:28 PM, they were assigned to Resident #1 on the day of the incident. They stated Resident #1 would circle the unit in their wheelchair but does not wander off the unit or into other resident's rooms. During a telephone Interview with the former Social Worker #1 on 12/06/2024 at 12:58 PM and 3:47 PM they stated they did the Brief Interview of Mental Status assessment for Resident #1 on 09/16/2024. They recall Resident #1 was confused at the time of the assessment. Social Worker #1 stated Resident #1 wandered around the unit but does not wander into other resident's room. Social Worker #1 further stated that based on their mental status assessment, Resident #1 does not have the capacity to give consent due to their severely impaired cognitive status. During an interview with Licensed Practical Nurse #1 on 12/4/2024 at 3:02 PM, they stated during a medication pass they went into Resident #2's room and witnessed Resident #2 sitting in their wheelchair by the window side of their bed wearing shorts. The shorts were pulled up along their right leg with the amputation. Resident #2 was holding their genitals in their hand. Resident #1 was in their wheelchair and was performing oral sex on Resident #2. Licensed Practical Nurse #1 stated they immediately separated the residents and notified the Nurse Supervisor. During an interview with the Director of Nursing on 12/5/2024 at 1:38 PM they stated at the time of the incident on 11/13/2024 Resident #1 knew what they were doing because when they interviewed Resident #1, Resident #1 smiled and stated they were having fun. Resident #2 had the capacity to notify the nurse, but stated it was consensual. The Director of Nursing did not respond whether Resident #1 had the capacity to give consent. During an interview with the Administrator on 12/5/2024 at 4:37 PM, they stated they were aware of the incident involving Resident #1 and Resident #2. The Administrator further stated they believe the sexual act between the residents was consensual because Resident #1 stated they were having fun and was smiling. The Administrator stated they notified Local Law Enforcement as a method of precaution. During an interview with the Psychiatrist on 12/6/2024 at 7:11 PM they stated they saw Resident #1 about 2-3 times since their admission to the facility. They assessed Resident #1 a couple of days after the incident via Tele-Health, and Resident #1 was unable to recall the incident. The Psychiatrist stated staff should be monitoring Resident #1 for any negative effects. The Psychiatrist stated the incident should never have occurred, and all efforts should be made to prevent reoccurrence. During an interview on 12/6/2024 at 3:45 PM with Resident #1's family member (Health Care Proxy), they stated the facility called them and informed them on 11/13/2024, does not recall the time. The facility informed them that Resident #1 was observed in the room of a male resident and as a result, they would be changing Resident #1's room. The family member began crying and stated, This makes me want to vomit to recount this. The family member stated they went to the facility later that day and heard from a staff member on the unit that Resident #1 was witnessed to have male genitals in their mouth. Family member further stated that should not have occurred, and it saddened them deeply. The family member stated if Resident #1 had been cognitively intact they would have been very upset, humiliated, and embarrassed. 415.4(b)(1)(i)

Based on observations, record review and interviews during the abbreviated Survey initiated on 8/4/2024 and completed on 8/09/2024 (NY00360500) the facility did not ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was identified for one (1) (Resident #1) of four (4) residents with the potential to affect 9 of 72 cognitively impaired residents reviewed for sexual abuse. Specifically, Resident #1 who had severely impaired cognition and was found in Resident #2's room by Licensed Practical Nurse #1 performing oral sex on Resident #2 (with intact cognition.). Additionally, the Administrator did not monitor and enhance the quality of care and services for Resident #1 after the abuse occurred or the potential for abuse for all (72) residents in the facility from 11/13/2020. This resulted in actual psychosocial harm to Resident #1. Refer to F600 Freedom from Abuse, Neglect, and Exploitation: Scope and Severity of J. The finding is: There was no documented evidence in the medical record that the facility evaluated Resident #1 for physical, mental, and psychosocial well-being or initiated interventions to protect Resident #1 and all other cognitively impaired residents in the facility. The Accident and Incident report dated 11/14/2024 documented Resident #1 as the alleged perpetrator, They (Resident #1) were having fun with a smile on their face. The incident was witnessed by a facility staff member (Licensed Practical Nurse #1). The incident report documented Resident #2 as the victim. Resident #2 stated it was consensual. The facility concluded no abuse, neglect or mistreatment occurred. Resident #1, [AGE] years old female, admitted with diagnoses including vascular dementia and depression with a Brief Interview for Mental status score of 7/15 indicating severely impaired cognition. Resident #2 [AGE] year-old male admitted with diagnoses including right leg above knee amputee, coronary artery bypass graft and hypertension, with a Brief Interview for Mental status score of 15/15 indicating complete intact cognition. During an interview with Licensed Practical Nurse #1 on 12/4/24 at 3:02 PM, they stated during a medication pass they went into Resident #2's room and witnessed Resident #2 sitting in their wheelchair by the window side of the bed wearing shorts and the shorts were pulled up along their right leg with the amputation. Resident #2 was holding their genitals and Resident #1 was in their wheelchair and was performing oral sex on Resident #2. Licensed Practical Nurse #1 stated they immediately separated the residents and notified the Nurse Supervisor. During an interview with the Administrator on 12/5/2024 at 4:37 PM, they stated they are aware of the incident involving Resident #1 and Resident #2. The Administrator further stated that they believe the sexual act between the residents were consenting because Resident #1 stated they were having fun and was smiling. The Administrator stated they notified Local Law Enforcement as a method of precaution. During an interview with the Psychiatrist on 12/6/24 at 7:11 PM they stated they saw Resident #1 about 2-3 times since their admission to the facility. They assessed Resident #1 a couple of days after the incident via Tele-Health, and the resident was unable to recall the incident. The Psychiatrist stated staff should be monitoring the resident for any negative effects. The Psychiatrist stated that the incident should never have occurred, and all efforts should be made to prevent reoccurrence. 10 NYCRR 415.26

Based on observations, record review, and interviews during the Recertification Survey initiated on 11/08/2023 and completed on 11/14/2023, the facility did not ensure that a Comprehensive person-centered care plan was developed and implemented for each resident. This was identified for two (Resident #18, and Resident # 69) of two residents reviewed for Respiratory care. Specifically, 1) Resident #18 had Physician's order to receive 2 liters (L) of Oxygen (O2) per minute (min). On 11/08/2023 and 11/10/2023, Resident # 18 was observed receiving Oxygen at a flow rate of 6 liters/per minute; and 2) Resident # 69 had Physician's orders to receive Oxygen at a flow rate of 3 L/min. On 11/08/2023 and 11/10/2023, Resident # 69 was observed receiving Oxygen at a flow rate of 6L/min. The findings are: : The facility's oxygen policy and procedure, last revised 6/2023, documented: 8. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute. 9. Place appropriate oxygen device on the resident (i.e., mask, nasal cannula and/or nasal catheter). 10. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. The policy did not include guidance for staff to follow the physician orders related to oxygen administration. 1) Resident #18 was admitted with diagnoses that include Chronic Obstructive Pulmonary Disease (COPD), Presence of cardiac pacemaker, and Congestive Heart Failure. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #18 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderately impaired cognition. Resident #18 did not have any behavior concerns. Resident #18 required total assistance of two persons for both transfers and bed mobility; and was non-ambulatory. The MDS indicated Resident #18 was on Oxygen therapy and did not have any Dyspnea (difficult or labored breathing). The monthly physician's orders, originally dated 3/14/2023 and last dated 11/1/2023, documented to administer Oxygen continuously at 2 liters per minute via a Nasal Cannula (tubing used to provide external oxygen through the nose) to maintain an Oxygen saturation rate greater than (>) 92 percent (%). The Comprehensive Care Plan (CCP) for Oxygen therapy, dated 4/26/2023 documented interventions including but not limited to: provide supplemental oxygen per Physicians (MD) order; monitor skin integrity for signs of breakdown related to use of oxygen tubing or mask; monitor for signs and symptoms of respiratory distress; and report to the Registered Nurse (RN) or the MD. Resident #18 was observed on 11/08/2023 at 11:26 AM in bed in their room receiving Oxygen via a concentrator and a Nasal Cannula (N/C) at 6 L/min. Resident #18 was observed on 11/10/2023 at 10:45 AM in bed in their room receiving Oxygen via a concentrator and a Nasal Cannula (N/C) at 6 L/min. The observation on 11/10/2023 at 10:45 AM was immediately brought to Licensed Practical Nurse (LPN) # 1's attention. LPN #1 stated Oxygen should not be given at this rate and further stated they were not aware the resident was being given Oxygen at 6L/min. LPN # 1 adjusted Resident # 18's Oxygen flow rate to 2L/min. Certified Nurse Assistant (CNA) #1, who was assigned to Resident # 18 during the day shift (7 AM - 3PM) was interviewed on 11/14/2023 at 12:11 PM. CNA #1 stated they do not adjust the residents Oxygen. 2) Resident #69 was admitted with diagnoses that include Acute and Chronic Respiratory Failure with Hypoxia, Atherosclerotic Heart Disease and Unspecified Asthma. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #69 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #69 did not have any behavior concerns. Resident # 69 required total assistance of two persons for bed mobility and was non-ambulatory. The MDS indicated Resident #69 was on Oxygen therapy and did not have any Dyspnea (difficult or labored breathing). The monthly physician orders dated 10-13-2023 to 11-13-2023 documented to administer Oxygen continuously at 3 LPM via nasal cannula. The Comprehensive Care Plan (CCP) for at risk for Respiratory distress related to Acute Respiratory failure with Hypoxia, and Chronic Obstructive Pulmonary Disease (COPD), dated 9/15/2023 included interventions to provide supplemental oxygen per MD order. Resident #69 was observed on 11/08/2023 at 11:26 AM in bed in their room receiving Oxygen via a concentrator and a Nasal Cannula (N/C) at 6 L/min. Resident #69 was observed on 11/10/2023 at 10:30 AM in bed in their room with Oxygen being administered at 6 L/min via a concentrator and a N/C. The observation on 11/10/2023 at 10:30 AM was immediately brought to Licensed Practical Nurse (LPN) # 1's attention. LPN #1 stated Oxygen should not be given at this rate and further stated they were not aware the resident was being given Oxygen at 6L/min. LPN #1 adjusted Resident # 69's Oxygen flow rate to 2L/min. Certified Nursing Assistant (CNA) #2, who was assigned to Resident # 69, was interviewed on 11/14/2023 at 12:11 PM and stated they do not adjust the residents Oxygen. The Director of Nursing Services (DNS) was interviewed on 11/10/2023 at 11 AM regarding the observations made for Resident # 18 and Resident # 69. The DNS stated the residents should be given the prescribed Oxygen levels and should not be given anything above the prescribed Oxygen level without a physician order. The Medical Director was interviewed on 11/14/2023 at 1:00 PM and stated they (the Medical Director) were not aware that the residents were not receiving oxygen as per their physician's order. The Medical Director further stated the residents should receive the prescribed oxygen as ordered. NYCRR 415.11(c)(1)

Based on observation, record review and staff interviews conducted during the Recertification Survey initiated on 11/08/2023 and completed on 11/14/2023, the facility did not ensure that each resident's medical record was maintained in accordance with accepted professional standards and practices. The facility did not maintain medical records for each resident that were complete and accurately documented. This was identified for one (Resident #51) of five residents reviewed for unnecessary medications. Specifically, during an observation of Resident #51 on 11/09/2023 at 4:17 PM, Resident #51 was observed with redness to the inner corner of their left eye. During a second observation on 11/10/2023 at 3:15 PM Resident #51's left eye inner corner remained red. During a third observation of Resident #51 on 11/13/2023 at 1:52 PM the left eye was completely reddened. There was no documented evidence in the resident's medical record indicating the resident's left eye status. The finding is: The facility's policy titled, Electronic Medical Records dated 11/2017 and last revised on 6/2023 documented, the official medical record includes but is not limited to daily shift report, therapy screens, consults, comprehensive care plans, lab results, labs/radiology, progress notes, and MD [Physician] orders. Resident #51 was admitted with diagnoses including Type 2 Diabetes Mellitus, Heart Failure, and Chronic Kidney Disease. The annual Minimum Data Set (MDS) assessment dated [DATE] documented the resident was unable to complete a Brief Interview for Mental Status (BIMS) because the resident was rarely/never understood. The MDS documented Resident #51 had short and long-term memory problems. The MDS documented Resident #51 had moderately impaired cognitive skills for daily decision making. Resident #51 was observed sitting in their wheelchair in their room on 11/09/2023 at 4:17 PM. Resident #51 was observed with a red discoloration to the inner portion of their left sclera (white portion of the eye). Resident #51 reported no pain or discomfort to the eye. Resident #51 reported that they dried their face with a towel and the corner of the towel went into their eye. On 11/10/2023 at 3:15 PM Resident #51 was observed sitting in their wheelchair in the hallway outside of their room and the discoloration was present in the same area of their left sclera. Resident #51 reported no pain or discomfort. On 11/13/2023 at 1:52 PM Resident #51 was observed sitting in their wheelchair opposite the nurse's station. The sclera of Resident #51's left eye was completely reddened. Resident #51 reported no pain or discomfort and stated someone took care of it this morning. Resident #51's progress notes dated 11/08/2023 through 2:00 PM on 11/13/2023 were reviewed and there was no documentation pertaining to the redness in Resident #51's left eye. Licensed Practical Nurse (LPN) #2, medication nurse, was interviewed on 11/13/2023 at 2:05 PM. LPN #2 stated they observed the redness to Resident #51's left eye on 11/09/2023 sometime in the afternoon. LPN #2 stated Resident #51 reported they rubbed their eye. LPN #2 stated they observed the increased redness to Resident #51's left eye on 11/13/2023 in the morning. LPN #2 stated Resident #51 did not complain of pain, and they (LPN #2) planned to call Resident #51's physician. LPN #2 stated they would not document the occurrence because Resident #51 was able to report why their (Resident #51's) eye was red. The Medical Director was interviewed on 11/13/2023 at 3:16 PM and stated they were in the facility on 11/10/2023 between the hours of 8:30 AM and 11:30 AM. The Medical Director stated they came in to check on all of the residents. The Medical Director stated they observed the reddened area to Resident #51's left eye. The Medical Director stated they did not document the discoloration in Resident #51's medical record and should have written a progress note in the electronic medical record LPN #3 was interviewed on 11/13/2023 at 3:27 PM. LPN #3 stated they observed Resident #51 with a reddened left eye on the 3 PM-11 PM shift on 11/09/2023 and documented their (LPN #3) observation on the daily report. LPN #3 stated they do not have time to complete resident medications, resident treatments, and documentation so they document concerns on the daily report. LPN #3 stated they provide the daily report to the Registered Nurse Supervisor on the shift. The Director of Nursing Services (DNS) was interviewed on 11/14/2023 at 9:18 AM and stated the concern regarding Resident #51's reddened left eye was documented in the 3 PM-11 PM shift report on 11/09/2023. The DNS stated the expectation is that concerns will be documented in the progress note section of the resident's electronic medical record. 10 NYCRR 415.22(a)(1-4)

Based on record review and staff interviews during the Abbreviated Survey initiated on 3/7/2023 and completed on 7/18/2023 the facility did not ensure for influenza vaccine that each resident's medical record indicated either the resident received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. This was identified for two (Resident #1 and Resident #4) of four residents reviewed for influenza vaccine. The findings are: The facility's policy titled Influenza Vaccination: Residents revised May 2022 documented to obtain written order from attending physician; to obtain informed consent from resident or their responsible party and provide educational literature; this should be included on admission and annually. Consent may be obtained in writing or verbally and to document vaccination in the Medication Administration Record and in nurse notes. 1) Resident #1 was admitted to the facility on [DATE] with diagnoses including Essential Hypertension (HTN), Alzheimer's Disease and 2019-CoV Acute Respiratory Disease. The Quarterly Minimum Data Set (MDS-an assessment tool) dated 1/9/2023 documented the resident with Brief Interview for Mental Status score of 4 indicating severely impaired cognition. The MDS Assessment documented that the resident had received the influenza vaccine in the facility for this year's (2022-2023) vaccination season with date of influenza vaccine received on 11/1/2021. The Immunization Comprehensive Care Plan (CCP) dated 7/22/2020 documented the resident is at increased risk for contracting influenza infection during flu season secondary to residing in a skilled nursing facility (SNF). Interventions included administer Influenza vaccine per policy, document vaccination per policy in resident record and educate resident/family regarding the benefits and side effects of taking the flu vaccine. The New York State Department of Health Bureau of Immunization form titled Influenza/Pneumococcal Immunization Consent Form was reviewed and the form documented Resident #1's personal information. Ten screening questions were completed with all responses checked off as No. Under the Influenza Consent section, it was documented that the resident was not able to sign and the NOK's name and phone number were written. The form was undated. There was no documented evidence that NOK consented or declined the influenza vaccine. The Physician's orders (PO) were reviewed from 9/1/2022 to 3/7/2023 and there was no documented evidence to administer the influenza vaccine. Resident #1's Preventive Health Care Report was reviewed. There was no documented evidence that the resident received any vaccine including an Influenza vaccine since November 2021. Resident #1 was observed on 3/7/2023 at 12:25 PM. Resident #1 was, unable to answer questions related to their (resident #1) vaccination status. The Director of Nursing Services (DNS)/ Infection Preventionist (IP) was interviewed on 3/9/2023 at 12:53 PM stated that they (DNS) have been working in the facility for less than one month. The DNS/IP was unaware of how and what the influenza and COVID-19 vaccine programs and protocols were in the fall of 2022. The DNS/IP stated that the current facility policy on Influenza vaccination does not indicate who is responsible to obtain informed consent each year from resident/representative regarding Influenza vaccine. The DNS/IP reviewed the residents medical record and stated that resident #1 did not have a contraindication to receive the influenza vaccine and that the resident's consent form on file was incomplete. The DNS/IP stated that there was no written documentation whether the resident/representative were educated, accepted, or refused the Influenza vaccine in 2022. The DNS/IP stated that there was no documented evidence that the Influenza vaccine was administered. The Former Assistant Director of Nursing Service (ADNS)/ Infection Preventionist (IP) was interviewed on 4/5/2023 at 11:23 AM. The ADNS stated that they were certified as infection Preventionist but were not responsible for the roll out and tracking of influenza/COVID vaccine program in the fall of 2022 and they left in October 2022. The ADNS stated that the Administrator and corporal personnel have been responsible to keep track and monitor for the influenza/covid vaccine campaign. The ADNS stated that every resident should be offered the flu vaccine in the fall, and consent should be obtained, documented, and kept on file. The ADNS stated that the tracking was done by Administration. The Administrator was interviewed on 7/18/2023 at 12:37 PM. The Administrator stated that they (the Administrator) have been working in the facility 6 months ago and was not involved in the flu/pneumococcal campaign in the fall of 2022. The Administrator stated that they were not aware of how the annual flu campaign was run before they started. The Administrator stated that constant effort must be provided and documented to ensure all residents were offered opportunities to be vaccinated for flu during the flu season. 2.) Resident #4 was admitted to the facility on [DATE] with diagnoses including 2019-nCoV Acute Respiratory Disease, Sepsis and Urinary Tract Infection. The Quarterly Minimum Data Set (MDS-an assessment tool) dated 12/7/2022 documented the resident with Brief Interview for Mental Status score of 10 indicating moderately impaired cognition. The MDS assessment documented that the resident was offered and declined the influenza vaccine in the facility for this year's (2022-2023) vaccination season. Resident #4's Face Sheet documented a family member of the resident as emergency contact and Healthcare Agent. The Immunization Comprehensive Care Plan (CCP) dated 10/31/2021 documented the resident is at increased risk for contracting influenza infection during flu season secondary to residing in a skilled nursing facility (SNF). Interventions included administer Influenza vaccine per policy, document vaccination per policy in resident record and educate resident/family regarding the benefits and side effects of taking the influenza vaccine. The New York State Department of Health Bureau of Immunization form titled Influenza/Pneumococcal Immunization Consent Form was reviewed, and the form documented resident #4's personal information. Ten screening questions were completed with all responses checked off as No. Under the Influenza Consent section, it was documented that the resident was not able to sign and the Healthcare Agent's name and phone number were written. The form was undated. There is no documented evidence that resident #4's Healthcare Agent consented or declined the influenza vaccine. The Physician's orders (PO) were reviewed from 9/1/2022 to 3/7/2023 and no order for influenza vaccine was found. Resident #4's Preventive Health Care Report was reviewed. There was no documented evidence that the resident received an influenza vaccine since November 2021. The Director of Nursing Services (DNS)/ Infection Preventionist (IP) was interviewed on 3/9/2023 at 12:53 PM stated that Resident #4 was not contraindicated to receive the influenza vaccine. The DNS stated that the resident's consent form on file was incomplete and not valid. The DNS stated that there was no written documentation whether the resident/representative were educated, accepted, or refused the flu vaccine in 2022. The DNS stated that there was no documentation that the flu vaccine was administered. The DNS stated that an informed consent can be obtained now, and the flu vaccine can still be administered to the resident. The Former Assistant Director of Nursing Service (ADNS)/ Infection Preventionist (IP) was interviewed on 4/5/2023 at 11:23 AM. The ADNS stated that they were certified as infection Preventionist but were not responsible for the roll out and tracking of influenza/COVID vaccine program in the fall of 2022 and they left the facility in October 2022. The ADNS stated that the Administrator and corporal personnel have been responsible to keep track and monitor for the influenza/covid vaccine campaign. The ADNS stated that every resident should be offered the Influenza vaccine in the fall, and consent should be obtained, documented, and kept on file. The ADNS stated that the tracking was done by Administration. The Administrator was interviewed on 7/18/2023 at 12:37 PM. The Administrator stated that they (the Administrator) were not involved in the flu/pneumococcal campaign in the fall of 2022. The Administrator stated that they were not aware of how the annual flu campaign was run before they started. The Administrator stated that constant effort must be provided and documented to ensure all residents were offered opportunities to be vaccinated for flu during the flu season. 10 NYCRR 415.19(a)(3)

Based on observations, interviews, and record review, during an abbreviated survey (Complaint # NY00307797) the facility failed to develop and implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act. This was evident for one (Resident #1) of 7 residents reviewed for sexual abuse. Specifically, on 12/10/2022 Resident #1 reported to their family that Licensed Practical Nurse (LPN) #1 on 12/9/2022 asked them to perform oral sex and then proceeded to touch their breast and vaginal area. The resident's family reported the incident to the Administrator on 12/10/2022. LPN #1 continued to work in the facility and had access to the resident on 12/11/2022. As of 1/6/2023 the facility did not report the allegation to the Department of Health and the law enforcement. This resulted in potential harm to Resident #1 and all other residents in the facility, that is Immediate Jeopardy and Substandard Quality of Care. The finding is: The facility's policy titled Abuse revised 5/2022 documented it is the policy of the facility that each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion and misappropriation of funds. Any complaint of, observation of, or suspicion of resident abuse, mistreatment or neglect is to be thoroughly investigated and reported. When any allegations of abuse, mistreatment, neglect, misappropriation of resident property is observed, reported or suspected by any employee ensure the resident is no longer being provided care and does not have any contact with the accused employee. The Administrator, Director of Nursing or their designee assumes responsibility for notification of the incident. The policy revealed no documented evidence that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the event that caused the allegation involve abuse or result in serious bodily injury, to the administrator and to other officials, other officials including to the State Survey Agency and Law enforcement. Resident #1 was admitted with diagnoses including Traumatic Brain Injury, Encephalopathy (disease of the brain), Mental and behavioral disorders and Opioid Abuse. The Minimum Data Set (MDS assessment tool) dated 10/19/2022 documented the resident with Brief Interview for Mental Status score of 9 indicating moderately impaired cognition. Review of the progress notes dated 12/10/2022 to 1/6/2023 revealed no documented evidence of a resident assessment or investigation related to the 12/9/2022 or 12/10/2022 sexual abuse allegation. Review of the care plans revealed no documented evidence that the resident was care planned for abuse as victim. The care plan was updated on 12/18/2022 and included risk for abuse. The care plan notes revealed no documented evidence it was updated related to 12/9/2022 or 12/10/2022 sexual abuse allegation. A review of staffing sheets dated 12/8/2022 and 12/10/2022 documented LPN #1 was scheduled during 7:00 AM-3:00 PM shift as Unit Manager for the 1st and 2nd floor. LPN #1 was not scheduled to work on 12/9/2022. During an interview with Resident #1 on 1/4/2023 at 12:38 PM they stated they were touched by a staff member identified as LPN #1. Resident #1 stated they could not recall the date, but it was dark, and it happened in their room. Resident #1 stated, LPN #1 went under my clothes and touched my breast and tried to make me suck their dick. Resident #1 further stated they told LPN #1 they were going to call the Police and LPN #1 stopped and left the room. Resident #1 stated they told their family member #1 the next day. Resident #1 was unsure of the date and time of the incident. During a telephone interview on 1/4/2023 at 2:23 PM with Resident #1's family member #1 they stated that Resident #1 reported to them on 12/10/2022 during a home visit that on 12/9/2022 LPN #1 touched their breast and vaginal area and asked them to perform oral sex. Family member #1 stated they reported the incident to the Administrator on 12/10/2022 at approximately 9-10 PM. They stated that the Administrator stated they will conduct an investigation and LPN #1 will be suspended. The family member #1 stated that the Administrator stated they will not report the incident to the Department of Health (DOH) because there was no proof. The family member #1 stated they saw LPN #1 on 12/11/2022 working in the facility The family member stated they brought Resident #1 to the Police station on 12/19/2022 to report the incident. The facility did not report the incident to the police because there was no police report. The family member stated that a care plan meeting was held on 12/29/2022 with the facility and Ombudsman #1 regarding the incident and the Administrator did not report the allegation citing there was no proof. During an interview with the Administrator on 1/4/2023 at 3:39 PM they stated that on 12/10/2022 they received a call at approximately 8:00 PM from the family of Resident #1. The family reported an allegation that an unnamed staff inappropriately touched Resident #1. The family identified the staff as LPN #1 because they wheeled Resident #1 down to the lobby to go out on pass on 12/10/2022. The Administrator stated they contacted the Director of Nursing (DON) on 12/10/2022 and informed them of the allegation. The Administrator stated they reviewed the video surveillance on their cellphone on 12/10/2022 and based on video there was no sexual contact, or any inappropriate touching or physical contact. The Administrator stated the allegation was not reported to DOH or the police because they had no finding that abuse occurred. The Administrator stated they report incidents if there is an allegation of abuse and if abuse occurred. During an interview with the DON on 1/4/2023 at 4:21 PM they stated they were not aware of any allegation of abuse involving Resident #1 and LPN #1 on 12/9/2022 or 12/10/2022. The DON stated they received a call from the administrator on 12/10/2022 and was instructed to move to Resident#1 to the 1st floor because of infection control concerns. The DON stated they first learned about the allegation during a meeting with Ombudsman #1 on 12/29/2022. The DON stated they did not do an investigation or report the allegation to the police. The DON was not aware of the facility's policy on abuse reporting and stated they have to read the policy. During an interview with the Director of SW (DSW) on 1/6/2023 at 10:08 AM they stated that the Police came to the facility on [DATE] and informed them that Resident #1's family filed a report regarding inappropriate sexual contact with a staff member. The DSW was told by the Administrator that the allegation was unfounded. During an interview with the Ombudsman #1 on 1/5/2023 at 11:33 AM they stated they were made aware of the allegation of inappropriate sexual contact between LPN #1 and Resident#1 on 12/22/2022 by the family member who called their program. The Ombudsman #1 stated they went to the facility on [DATE] and spoke with the Administrator about the allegation on 12/9/2022 and they stated that they did not report it to the DOH because the resident could not tell them what happened, and they had no proof. The Administrator stated they checked the video and did not find any proof. The Ombudsman #1 spoke to the resident on 12/22/2022 and resident reported that LPN #1, mentioning them by their name, touched them in their breast and over their vaginal area with their finger in a thrusting manner. Resident #1 did not say they were penetrated but was pointing to their vaginal area. During a subsequent interview with the DON on 1/5/2023 at 12:27 PM they stated that LPN #1 was scheduled to be off on 12/9/22 and did not come to the facility for any other reasons on that date. They stated LPN #1 last worked on 12/11/2022 on the 7-3 shift. On 12/12/2022 LPN #1 filed a leave of absence and is out sick. During a telephone interview with LPN #1 on 1/6/2023 at 11:07 AM they stated they worked on 12/11/22 on the 2nd floor. LPN #1 stated they are on leave of absence. LPN #1 stated they were not aware of any sexual allegation involving them. LPN #1 stated they have not been interviewed or asked to write a statement. LPN #1 stated they did not touch Resident #1 on their breast or vaginal area. LPN #1 stated they did not show Resident #1 their private area and did not ask Resident #1 to perform oral sex. LPN #1 was not aware of any allegation against them and was not restricted to go to the first floor. LPN #1 stated they last worked on 12/11/22 and they were off on 12/9/22. 10 NYCRR 415.4 b (2)

Based on observations, interviews, and record review, during an abbreviated survey (Complaint # NY00307797) the facility failed to ensure that all allegations of abuse, neglect and mistreatment were thoroughly investigated. In addition, the facility failed to ensure the residents were free from further potential abuse. This was evident for one (Resident #1) of 7 residents reviewed for Sexual Abuse. Specifically, on 12/10/2022 Resident #1 reported to their family that Licensed Practical Nurse (LPN)#I on 12/9/2022 asked them to perform oral sex and then proceeded to touch their breast and vaginal area. The resident's family reported the incident to the Administrator on 12/10/2022. LPN #I continued to work in the facility and had access to the resident on 12/11/2022. As of 1/6/2023 the facility did not initiate an investigation. This resulted in potential abuse and harm to Resident #1 other residents that is Immediate Jeopardy and Substandard Quality of Care. The finding is: The facility's policy titled Abuse revised 5/2022 documented it is the policy of the facility that each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion and misappropriation of funds. Any complaint of, observation of, or suspicion of resident abuse, mistreatment or neglect is to be thoroughly investigated and reported. When any allegations of abuse, mistreatment, neglect, misappropriation of resident property is observed, reported or suspected by any employee ensure the resident is no longer being provided care and does not have any contact with the accused employee. Notify administrative staff or nursing supervisor on duty. Suspend or reassign the employee pending investigation. Resident #1 was admitted to the facility with diagnoses including Traumatic Brain Injury, Encephalopathy (disease of the brain), Mental and behavioral disorders and Opioid Abuse. The admission Minimum Data Set (MDS-an assessment tool) dated 10/19/2022 documented the resident with Brief Interview for Mental Status score of 9 indicating moderately impaired cognition. The Comprehensive Care Plan dated 10/13/2022 documented the resident has potential for impaired cognition. Interventions included monitor for cognitive changes or regression and report to the nurse and reorient as needed. The notes dated 10/13/022 documented the resident is able to make basic needs known. Review of Accident/Incident (A/I) reports and Grievances for December 2022 revealed no documented evidence of an investigation related to allegation on 12/9/2022 or 12/10/2022. Review of the progress notes dated 12/10/2022 to 1/6/2023 revealed no documented evidence of a resident assessment or investigation related to the 12/9/2022 or 12/10/2022 sexual abuse allegation. A review of staffing sheets dated 12/8/2022 and 12/10/2022 documented LPN #1 was scheduled during 7:00 AM-3:00 PM shift as Unit Manager for the 1st and 2nd floor. LPN #1 was not scheduled to work on 12/9/2022. Review of the progress notes dated 12/11/2022 at 2:44 AM documented the resident was transferred to 1st floor. A review of staffing sheets revealed LPN #1 was scheduled to work on 12/11/2022 during 7:00 AM-3:00 PM shift for the 1st and 2nd floor. Review of the care plans revealed no documented evidence that the resident was care planned for abuse as victim. The care plan was updated on 12/18/2022 and included risk for abuse. The care plan notes revealed no documented evidence it was updated related to 12/9/2022 or 12/10/2022 sexual abuse allegation. During an interview with Resident #1 on 1/4/2023 at 12:38 PM they stated they were touched by a staff member identified as LPN #1. Resident #1 stated they could not recall the date, but it was dark, and it happened in their room. Resident #1 stated, LPN #1 went under my clothes and touched my breast and tried to make me suck their dick. Resident #1 further stated they told LPN #1 they were going to call the Police and LPN #1 stopped and left the room. Resident #1 stated they told their family member #1 the next day. Resident #1 was unsure of the date and time of the incident. Resident #1 stated they did not want this to happen again and stated they don't feel safe. During a telephone interview on 1/4/2023 at 2:23 PM with Resident #1's family member #1 they stated that Resident #1 reported to them on 12/10/2022 during a home visit that on 12/9/2022 LPN #1 touched their breast and vaginal area and asked them to perform oral sex. Family member #1 stated they reported the incident to the Administrator on 12/10/2022 at approximately 9:00 PM-10:00 PM. They stated that the Administrator stated they will conduct an investigation and LPN #1 will be suspended. The family member #1 stated that the Administrator stated they will not report the incident to the Department of Health (DOH) because there was no proof. The family member #1 stated they saw LPN #1 on 12/11/2022 working in the facility They stated they brought Resident #1 to the Police station on 12/19/2022 to report the incident. The facility did not report the incident to the police because there was no police report. The family member #1 stated that a care plan meeting was held on 12/29/2022 with the facility and Ombudsman #1 regarding the incident and the Administrator did not report the allegation citing there was no proof. During an interview with the Administrator on 1/4/23 at 3:39 they stated that on 12/10/2022 they received a call at approximately 8:00 PM from the family of Resident#1. The family reported an allegation that an unnamed staff inappropriately touched Resident #1. The family identified the staff as LPN #1 because they wheeled Resident#1 down to the lobby to go out on pass on 12/10/2022. The Administrator stated they contacted the Director of Nursing (DON) on 12/10/2022 and informed them of the allegation. The Administrator stated they reviewed the video surveillance on their cellphone on 12/10/2022 and based on video there was no sexual, or any inappropriate touching or physical contact. The Administrator stated the allegation was not reported to DOH or the police because they had no finding that abuse occurred. The Administrator stated they report incidents if there is an allegation of abuse and if abuse occurred. During an interview with the DON on 1/4/2023 at 4:21 PM they stated they were not aware of any allegation of abuse involving Resident #1 and LPN #1 on 12/9/2022 or 12/10/2022. The DON stated they received a call from the administrator on 12/10/2022 and was instructed to move to Resident#1 to the 1st floor because of infection control concerns. The DON stated they first learned about the allegation during a meeting with Ombudsman #1 on 12/29/2022. The DON stated they did not do an investigation or report the allegation to the police. The DON was not aware of the facility's policy on abuse reporting and stated they have to read the policy. During an interview with the Director of SW (DSW) on 1/6/2023 at 10:08 AM they stated that Police came to the facility on [DATE] and informed them that Resident #1's family filed a report regarding inappropriate sexual contact with a staff member. The DSW stated they immediately informed the administrator and they spoke to the Police. DSW stated they spoke to Resident #1 and the resident did not say much regarding the allegation. DSW did not document their interview with the resident or the Police inquiring about an allegation. DSW was told by the Administrator that the allegation was unfounded. During an interview with the Ombudsman #1 on 1/5/2023 at 11:33 AM they stated they were made aware of the allegation of inappropriate sexual contact between LPN #1 and Resident#1 on 12/22/2022 by the family member who called their program. The Ombudsman #1 stated they went to the facility on [DATE] and spoke with the Administrator about the allegation on 12/9/2022 and they stated that they did not report it to the DOH because the resident could not tell them what happened, and they had no proof. The Administrator stated they checked the video and did not find any proof. The Ombudsman #1 spoke to the resident on 12/22/2022 and resident reported that LPN #1, mentioning them by their name, touched them in their breast and over their vaginal area with their finger in a thrusting manner. Resident #1 did not say they were penetrated but was pointing to their vaginal area. The video surveillance was reviewed on 1/5/2023 at 12:55 PM and on 1/6/2022 at 10:45 AM with the Administrator and the Staffing Coordinator. Review of 1st floor video on 12/11/2022 at 12:38 PM revealed Resident #1 was taken out of the room by RNS #1. On 12/11/2022 hallway camera revealed LPN #1 punched in at 7:00:14 AM and took the elevator and was observed sitting at the 2nd floor nursing station. The LPN #1 was then observed going in and out of residents' rooms. During an interview with the Administrator on 1/5/2023 at 1:58 PM they stated there is no investigation being conducted at this time. The Administrator stated they had no findings that the allegation actually happened to support suspending LPN #1. They moved Resident #1 from the 2nd floor to the 1st floor because of the allegation. The Administrator denied speaking to the police on 12/21/2022 and was not informed that there was an allegation involving LPN #1. During interviews conducted between 1/5/2023 at 2:30 PM to 1/6/2023 at 5:16 PM with LPN #2, LPN #3, Certified CNA #1, RNS #1, CNA #2, RNS #2, CNA #4 and LPN #4, who all worked between 12/8/2022 to 12/11/2022 on various shift, stated that they were not aware of the allegation involving Resident #1 and LPN #1 and they were not questioned by the facility or asked to write a statement. During an interview with the DON on 1/5/2023 at 2:59 PM they stated that there is no investigation conducted related to the allegation involving LPN #1 and Resident#1. The DON stated they initiated the investigation on 1/4/2022 and wrote down in the paper the interview conducted with Resident #1. Resident #1 stated a white, male staff, identifying LPN #1 by their name, pulled out their private area and asked Resident #1 perform oral sex. Resident #1 did not state a date, Resident #1 said it was light outside not dark when LPN #1 went in the room. The DON stated the resident denied any physical contact. The DON stated no other staff were interviewed at this time. The DON stated they were not aware that Police came to the facility and reported a family member filed a report of the allegation against LPN #1. During a subsequent interview conducted with the Administrator on 1/6/2023 at 10:00 AM they stated that they did not interview other staff because based on video there was no evidence of inappropriate sexual contact. The administrator stated they were not aware of the facility's policy on abuse reporting and investigation. During a telephone interview with LPN #1 on 1/6/2023 at 11:07 AM stated they worked on 12/11/22 on the 2nd floor and were assigned to Resident #1. LPN #1 stated they last worked on 12/11/2022 and they were off on 12/9/22. LPN #1 stated they brought Resident #1 sandwiches like anyone else and encouraged resident to use their left hand more. LPN #1 stated they are on leave of absence. LPN #1 stated they are not aware of any sexual allegation involving them. LPN #1 stated they have not been interviewed or asked to write a statement. LPN #1 stated they did not touch Resident #1 on their breast or vaginal area. LPN #1 stated they did not show Resident #1 their private area and did not ask Resident #1 to perform oral sex. LPN #1 was not aware of any allegation against them and was not restricted from going to the first floor. During an interview with ADON on 1/10/2023 at 2:41 PM they stated that all allegations of abuse are handled by DON. ADON stated the DON informed them sometime in mid-December that Resident #1 was touched inappropriately by a staff, but DON did not know which staff. ADON stated they assumed the DON and Administrator was handling the investigation. ADON stated the allegation was not discussed in the morning report. 10 NYCRR 415.4 b (3)

Based on record review and staff interviews during the Focus Infection Control Survey on 12/20/2022, the facility did not ensure that it designated one or more individual(s) as the Infection Preventionist(s) (IP)(s) who are responsible for the facility's Infection Prevention Control Program (IPCP); and the IP must have completed specialized training in infection prevention and control. Specifically, the facility's designated IP did not have documented evidence of specialized training in infection prevention and control. Finding is: The facility's Infection Prevention and Control policy for the position of Infection Control Officer/Preventionist dated 1/2022 documented the Infection Prevention and Control Program (IPCP) is coordinated and overseen by an Infection Prevention Specialist (Infection Preventionist). The policy did not document specialized infection control training requirements for the IP. The Director of Nursing Services (DNS) was interviewed on 12/20/2022 at 2:30 PM and stated that they (DNS) were assigned to the DNS and the IP position on 11/16/2022. The DNS stated they started taking the infection prevention and control courses in the second week of December 2022, and they still have to complete a lot of classes to receive the IP certification. The DNS stated that the facility's corporate nurse comes to the facility two times a week to help with infection control concerns. The Administrator was interviewed on 12/20/2022 at 2:58 pm and stated that the facility does not have a full-time qualified IP in the building since November 16, 2022, when the previous IP left the facility. The Administrator stated until the DNS completes their (DNS) infection prevention control courses, the corporate IP will come to the facility twice a week to assist with the infection control concerns. Licensed Practical Nurse (LPN) #3, who was the corporate nurse, was interviewed on 12/20/202 at 3:12 PM and stated they (LPN #3) visit the Facility twice a week to guide the new DNS; however, they (LPN #3) did not complete the infection prevention control course and were not officially qualified infection preventionist. 415.19 (a)

Based on observations, record review and interview during the Recertification Survey and Complaint Survey NY 499, the facility did not ensure that all residents had a clean and homelike environment. This was identified from the Resident Council meeting conducted on 10/05/2021 and observations made in 15 of 40 rooms in the facility (#101, #102, #103, #109, #113, #119, #120, #203, #204, #205, #206, #212, #216, #217, and #218). Specifically, 1) residents from the resident council voiced concerns about dirty shower drains during four resident council meetings (5/19/2021, 7/6/2021, 8/3/2021, and 9/14/2021) and observations revealed that the shower drains continued to be clogged with hair and dirt; and 2) observations revealed debris including wrappers, straws, and surgical masks, dust, and food residue in 15 of 40 rooms. Additionally, food stains were identified on the floors in the hallway of Unit 2. The findings include but are not limited to: The facility was requested to provide a Policy and Procedure for Housekeeping and Environmental Services. The facility Director of Housekeeping stated there currently are no Policies and Procedures developed for Housekeeping and Environmental Services. The facility Housekeeper job description dated 9/2018 documented that the housekeeper is responsible to maintain cleanliness throughout the facility. General responsibilities include cleaning and dusting within the facility such as in the bedrooms, bathrooms, windows, offices, dining rooms, corridors, lobby elevators, nursing stations, multipurpose rooms and service areas. The housekeeper is responsible to maintain the facility in an orderly, healthy and attractive condition. The housekeeper also stocks rooms with paper towels, toilet tissue and soap. 1) Review of the Resident Council meeting minutes revealed Resident Council members complained of the shower rooms needing to be cleaned and complained of clogged drains on 5/19/2021, 7/6/2021, 8/3/2021 and 9/14/2021. The resident council meeting was held on 10/5/2021 at 9:30 AM with ten Resident Council members present. Three of ten residents (Resident #59, #40, #26) stated that the floors are dirty, and housekeeping does not clean the rooms well. They also complained of the dirty showers and clogged drains. On 10/05/2021 at 9:45 AM, Resident #59 stated that the facility is dirty, and the resident council brought concerns about cleanliness to the resident council meetings. The Resident #59 stated that the floors are usually dirty, and items are left on the ground. Resident #49 stated that nothing has been done to address the problem. On 10/05/2021 9:47 AM, Resident #40 stated that the floors still look dirty after being mopped. Resident #40 stated it appears as though the dirt is just being pushed around and it does not smell like they are using any cleaning agents in the water or changing the water. Resident #40 stated that the nurses just throw their gloves on the floor in the room and Resident #40 has to put it in the trash after they leave or else it will just stay there. On 10/05/2021 at 9:49 AM, Resident #26 stated the floor is also dirty their room and Resident #26 uses a Reacher to pick up discarded items left behind on the floor if no one cleans the floor. On 10/8/2021 at 9:15 AM, the shower room on the 1st floor was observed with the Charge Nurse present. The bathroom drains were covered in hair and dust. The Charge Nurse stated that they did not notice the drains before and none of the staff members or residents reported it. A tour of the 1st and 2nd floor units was completed with the Director of Housekeeping on 10/8/2021 at 9:28 AM. At 9:32 AM, the Director of Housekeeping kneeled down and pulled up one of shower drain covers in the 1st floor shower room. The Director of Housekeeping stated the drain was covered in hair and dirt. The Director of Housekeeping proceeded to clean the drain cover and then removed the second shower drain cover. The Director of Housekeeping stated that the second shower drain also had hair and dirt. The Director of Housekeeping stated that Housekeeping staff are responsible for cleaning the shower rooms including the drains. At 9:48 AM an observation was made at the 2nd floor shower room. The Director of Housekeeping looked at the shower drains in the 2nd floor shower room and stated that they are also full of hair and dirt. The Housekeeping Director stated they (the Housekeeping Director) were not aware of the multiple complaints about the shower drains being clogged and dirty. The Housekeeping Director stated that they did not notice the buildup of hair and dirt on the shower drains until today, 10/8/2021. The Recreation Aide was interviewed on 10/8/21 at 1:20 PM and stated that they (the Recreation Aide) were responsible to record the minutes from the resident council meetings. The Recreation Aide stated that they did witness complaints on 5/19/2021, 7/6/2021, 8/3/2021, and 9/14/2021 about the shower drains being clogged and the bathrooms not being cleaned. The Recreation Aide stated that they assumed that the Director of Recreation relayed the message to the Director of Housekeeping but was not sure if the resident's concerns were followed up. The Recreation Aide further stated the Director of Recreation that was present during the Resident council meetings held on 5/19/2021, 7/6/2021, 8/3/2021, and 9/14/2021 is no longer employed at the facility. The Assistant Administrator was interviewed on 10/08/2021 at 1:54 PM. The Assistant Administrator stated that they (the Assistant Administrator) were present for the Resident Council meetings and did recall the resident council members voicing concern about the showers not being cleaned. The Assistant Administrator stated they went to the showers to check on the condition of the showers but could not recall when. The Assistant Administrator stated that the facility only adjusted the shower head. The Assistant Administrator further stated that they did not recall the shower drain complaints specifically or what measures were taken to correct the problem. 2a) Resident #29 was admitted to the facility with the diagnosis of [CONDITION(S)], Hypertension and [CONDITION(S)]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #29 had a Brief Interview for Mental Status (BIMS) assessment score of 9, indicating moderately impaired cognition. Resident #29 was observed sitting in a wheelchair in room 204 on 10/04/2021 at 10:27 AM. The floor was visibly soiled with food debris (wrappers and crumbs) and was white but appeared grey in color due to residue buildup. Resident #29 was not able to state when the floors were last mopped. Resident #29 stated that the housekeeping staff are very busy, they work fast, and they sometimes leave trash behind. Resident #29 stated that a family member purchased a broom for Resident #29 and pointed to the broom resting against the wall. Resident #29 stated that Resident #29 sweeps up when the housekeeping staff does not get to everything. 2b) Resident #320 was admitted to the facility with the diagnosis of Arthritis, Hypertension and Anxiety Disorder. The Admission Minimum Data Set (MDS) dated [DATE] documented that Resident #320 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Resident #320 was observed lying in bed in room 203 on 10/04/2021 at 10:41 AM. Resident #320 stated they (Resident #320) were a new admission since 9/29/2021. Resident #320 stated the housekeeping staff have not mopped their room since Resident #320 arrived. The floors were white with grey colored residue, dirt and wrappers observed on the floor. Housekeeper #1 was interviewed on 10/7/2021 at 10:48 AM. Housekeeper #1 stated that they (Housekeeper #1) work on the 6 AM-2 PM shift on the 2nd floor during the week. Housekeeper #1 stated that Housekeeper #1 makes separate rounds for sweeping the floor, emptying the garbage and mopping. Housekeeper #1 stated the residents and staff often make requests to clean and it is difficult to get to it all. Housekeeper #1 stated that the facility used to have a maid to do spot cleaning in addition to the housekeeper. Housekeeper #1 stated that Housekeeper #1 has had meetings with the Director of Housekeeping regarding getting additional help. The last meeting was approximately one month ago and there have not been any changes. Housekeeper #2 was interviewed on 10/07/2021 at 2:25 PM. Housekeeper #2 stated that they (Housekeeper #2) work on the 11:30 AM-7 PM shift. Housekeeper #2 stated that they are usually assigned to the ground floor but has been providing coverage for the whole building for the past month due to lack of coverage. Housekeeper #2 stated that there is usually 1 housekeeper per floor and currently there is a housekeeper on the 1st and 2nd floor from 11:30 AM to 2:00PM and then just Housekeeper #2 from 2:00 PM to 7:00 PM. Housekeeper #2 stated they try to get to everything, and it is difficult with just one person. A tour of the 1st and 2nd floor units was conducted with the Director of Housekeeping on 10/8/2021 at 9:28 AM. The Director of Housekeeping acknowledged observations of debris (including wrappers, straws, and a surgical mask), dust, food residue and stains on the floors in the hallway of the 2nd floor, 7 of 20 rooms on the 1st floor (#101, #102, #103, #109, #113, #119, and #120) and 8 of 20 rooms on the 2nd floor (#203, #204, #205, #206, #212, #216, #217, and #218). During the tour, the Director of Housekeeping stated that the facility does not have enough housekeeping staff to keep up with the work required. The facility currently only has 2 full time housekeeping staff members and the facility requires 3 full time housekeeping staff members to handle all of the responsibilities. There is one housekeeper from 6:00 AM to 2:00 PM and another from 11:30 AM to 7:00 PM. The 11:30 AM to 7:00 PM housekeeper also handles supplies and linens which makes it difficult to stay on top of keeping the facility clean. The Director of Housekeeping stated that the facility needs another employee to be dedicated to just handling supplies and linens to handle the workload. The Director of Housekeeping stated that they assist with cleaning, but they are also responsible for maintenance tasks such as maintaining oxygen tank supplies and doing some repairs. The Director of Housekeeping stated that they discussed concerns with the Assistant Administrator last month but was informed that they will only hire a per-diem employee. The Housekeeping Director stated that it has been difficult to recruit and retain a per-diem housekeeper. The Housekeeping Director stated that they attended one resident council meeting in September in which a resident complained about the cleanliness of the facility and the Director of Housekeeping was aware of problem. The Assistant Administrator was interviewed on 10/08/2021 at 1:54 PM. The Assistant Administrator stated when they (the Assistant Administrator) became employed at the facility in June 2021, they observed that the facility was not clean and does not meet expectations in cleanliness. The Assistant Administrator stated that they observed the floors appearing dirty with debris and dust build up. The Assistant Administrator stated that a Housekeeper was let go on 9/14/21 and the facility has had trouble with employing another person. The Assistant Administrator stated that the facility needs 3 full time housekeepers and there are currently only 2 full time housekeepers with overlapping schedules. Housekeeper #2 is also responsible for supplies and linen distribution. The Assistant Administrator stated that they expect that Housekeeper #2 to do the supplies and linens when the employee arrives at 11:30 AM because they expect Housekeeper #1 to have most of cleaning done by that time. The Assistant Administrator further stated that he was not aware that there was no standard housekeeping policy and procedure. The Assistant Administrator expected that the facility would have one. 415.5(h)(2)