Every finding on record at Sunset Nursing and Rehabilitation Center, Inc

Based on record review, and interviews, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one of two residents (Resident #78) reviewed. Specifically, Resident #78 who had a history of elopement and wore a wander alarm device left the facility undetected on 07/25/2025. This resulted in Immediate Jeopardy and Substandard Quality of Care for Resident #78 and placed residents with risk for elopement at risk for serious harm, serious injury, serious impairment, or death. Findings include: The facility policy titled Missing Resident Elopement Dr. Walker, revised September 2023 documented if a resident left the premises without facility knowledge and supervision it was considered an elopement. If the resident was not located within a reasonable amount of time (as determined by the Administrator/ designee), the police and family were notified. Upon return of the resident to the facility, the supervising nurse examined the resident for injuries, contacted the attending physician, notified the resident's representative, completed an accident/incident form, made appropriate entries into the resident's medical record, and updated/ revised the care plan as indicated. The facility policy titled Elopement Security System Alarms/ Devices, revised July 2024 documented wander alarm devices were assessed at regular intervals to ensure proper functioning. They were monitored every shift on the Treatment Administration Record and location/placement of the devices was also identified and checked. Resident #78 had diagnoses including dementia, depression, and diabetes. The 06/03/2025 Minimum Data Set (a resident assessment tool) documented the resident's cognition was moderately impaired, was ambulatory utilizing a rolling walker with supervision and had a wander/elopement alarm in place. The 06/08/2025 Registered Nurse #38 progress note documented they were notified by staff the resident was seen outside walking down the sidewalk. The resident was assisted back inside, and a wander alarm device was applied.The Comprehensive Care Plan was updated on 06/09/2025 to include the resident was at risk for elopement related to dementia and wore a wander alarm device. The goal was to be without exit seeking behavior. There was no documented evidence of interventions for monitoring or responding to exit seeking behaviors. The 06/19/2025 Psychiatric Nurse Practitioner #39 progress note documented the resident was seen for concerns for agitation and hallucinations. The resident did not want to be at the facility and wanted to go home. The 06/25/2025 Licensed Practical Nurse #40 progress note documented the resident was exit seeking and had their bags packed. There was no documented evidence of interventions utilized to monitor and respond to the resident's increased exit seeking behavior. The 07/25/2025 facility investigation summary completed by the (former) Director of Nursing documented Resident #78 left the building at 6:00 PM to visit a family member who resided close to the facility. The resident had the capacity to make their own decisions and had a purposeful destination. The resident returned to the facility at 6:45 PM without injury. The resident was alert and oriented with a BIMs (Brief Interview for Mental Status) of 10 (moderate cognitive impairment). The resident explained they alerted staff and demonstrated how they put the code in the wander alarm and exited the building. The resident had capacity but there was concern now that cognition may vary and it would be appropriate to revoke any independent out on pass. The resident was educated regarding the sign out process. There was no documented evidence in the resident's medical record or a physician order related to the resident having the ability or privilege to leave the facility without supervision. The 07/25/2025 Police Incident Report documented they received a call at 7:00 PM by Licensed Practical Nurse Supervisor #6 who reported Resident #78 was missing from the facility. At 7:18 PM, the police department received a call from the resident's family member who stated they found the resident and were returning them to the facility. The 07/25/2025 at 9:38 PM Licensed Practical Nurse Supervisor #6 progress note documented the resident went to a nearby neighbor's house. Upon return, the resident was educated to alert staff for future outings. The 07/25/2025 24-hour nursing shift report documented during the 3:00 PM - 11:00 PM shift the resident was at the door several times, trying to get out. In the July 2025 Treatment Administration Record, the order to check the wander alarm device for the resident on 07/25/2026, during the 3:00 PM - 11:00 PM shift was blank. During a telephone interview on 08/05/2026 at 10:40 AM, the (former) Director of Nursing stated they recalled Resident #78 left the building without staff knowledge in July 2025. They had received a phone call from Licensed Practical Nurse Supervisor #6 who told them they could not find the resident, and they instructed them to call the police. They then came into the facility to help look for the resident. The resident had a wander alarm device at that time. They did not know how the resident was able to leave the building undetected. During an interview on 08/05/2026 at 10:53 AM, Certified Nurse Aide #7 stated approximately a year ago, the resident got out of the building. Their family member came to the facility to see if the resident was there and the family member told them they had received a phone call from a friend who said they saw the resident walking down the street. They looked for the resident and could not find them, so they told the supervisor who called the (former) Director of Nursing and they called the police. The resident had been missing for about an hour. Somehow, the resident got to a friend's house approximately a mile away. Someone must have let them out because they had a wander alarm device on. At that time, family members had passcodes to unlock the doors. After the resident returned to the facility, the supervisor checked the wander alarm device, and it was not working. During a telephone interview on 08/05/2026 at 1:41 PM, Licensed Practical Nurse Supervisor #6 stated on 07/25/2025, the resident's family member reported a friend told them they saw the resident walking down the street. Licensed Practical Nurse #6 immediately started looking for the resident and when they could not find them, they called the (former) Director of Nursing who told them to call the police. Then they started going door to door in the neighborhood asking if anyone had seen the resident. They found the resident in a private residence and brought them back to the facility. Resident #78 had a wander alert device and should not have been able to leave on their own. They knew the device was working because they checked it at 3:00 PM and again after the resident got back. The resident could not sign themselves out of the facility and needed a family member to sign them out. During a telephone interview on 08/05/2026 at 2:01 PM, the resident's family member stated on 07/25/2025, they received a call from a friend who told them they saw Resident #78 walking down the street. They alerted staff who searched for approximately one hour and eventually police were called. The resident was found inside another family member's house. The resident frequently sat by the doors and tried to convince people to let them out because they told them someone was coming to pick them up. The resident had dementia, hallucinated, and forgot things. They required 24-hour care for their cognition and medical problems and should not have been outside the facility alone. They were not provided an explanation as to why the resident was able to get out of the facility undetected with a wander alarm device. During an interview on 08/06/2026 at 11:45 AM, the Regional [NAME] President stated they were covering for the Administrator at the time of Resident #78's elopement. The incident scared them. The resident's wander alarm device was to prevent them from leaving the facility, but it did not, they were able to bypass the system. 10 New York Codes, Rules, and Regulations 415.12(h)(1)(2) Immediate Jeopardy was identified in F689 and was issued to the Administrator and the Regional [NAME] President on 08/07/2026 at 8:43 AM and signed by the Administrator at 8:50 AM. Immediate Jeopardy was removed on 08/07/2026 at 10:00 PM, prior to survey exit based on the following actions taken: As of 08/07/2026 at 4:38 PM, the facility's immediate plan was reviewed and accepted. The resident was moved to a secured unit.Door codes were changed and an additional wander device code was added for additional security. The vendor came in to evaluate door function. Wander alarm device placement is documented every shift for all residents utilizing a wander alarm. Wander device transmitter functionality is tested daily.Facility wide education was provided and supplemental education with a badge buddy instructing staff that residents could only leave the building with nursing supervisor permission. As of 08/07/2026 at 8:49 PM, 90% of all staff were educated on identifying residents at risk for elopement or unsafe wandering, understanding of out on pass/leave of absence process, recognizing the importance of assessing decision making capacity, knowledge of their responsibilities before, during, and after a resident leaves the facility, and the importance of monitoring residents and preventing elopement. Staff education was verified onsite during interviews conducted on 08/08/2026 and 08/09/2026. Multiple staff interviews were conducted including nursing, housekeeping, laundry, dietary, activities, maintenance, and some administrative personnel. Staff were able to report content of education, how they were provided the education, and when they received the education. Facility wide audits for residents at risk for elopement and residents approved for out on pass were completed on 08/07/2026 at 10:00 PM. Accuracy of the audits were verified onsite during record review on 08/10/2026 and no discrepancies were found.

Based on observations and interviews during the recertification survey, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional standards for two of three medication carts (Unit A cart and Unit B cart) and one of two medication rooms (Unit A) reviewed. Specifically, the Unit B medication cart contained a resident insulin pen that was expired, the Unit A medication room contained an unlocked and opened narcotic box and a medication refrigerator that contained food, and the Unit A medication cart was not secured when left unattended. Findings include: The facility policy, Medication/ Treatment Labeling and Storage, revised 7/2025, documented medications were stored under proper conditions of sanitation, temperature, light, moisture and ventilation. Multi-dose vials such as insulin were dated and initialed when opened. Only medications should be stored in the medication cart, medication cabinet, controlled substance cabinet, and medication refrigerator or treatment cart. Controlled substances were stored in double-locked cabinets in the locked medication room. The facility policy, Vials, effective 10/2024 documented multi-dose and single dose vials would be discarded when they were empty or when the manufacture's expiration date was reached, which ever came first, but not to exceed 28 days.During an observation and interview on 08/04/2026 at 1:04 PM, Licensed Practical Nurse #14 brought an insulin pen from the Unit B medication cart dated 07/02/2026 and stated they were going to administer it to Resident #13. When asked about the date on the insulin pen, they stated insulin pens were good for 30 days, therefore could be administered. After being asked the current date, they stated they were going to get a new pen because the current pen had expired. They stated every nurse that was assigned to the medication cart was responsible for making sure expired medications were discarded. They should have noticed the insulin pen was expired.During an observation on 08/06/2026 at 9:37 AM, the Unit A medication cart was unlocked and unattended.During an observation and interview on 08/06/202 at 9:39 AM, Licensed Practical Nurse Unit Manager #13 stated the medication cart should always be locked when unattended.During an interview on 08/06/2026 at 9:41 AM, Licensed Practical Nurse #12 stated they forgot to lock the cart and should have locked it.During an observation and interview on 08/06/2026 at 9:53 AM, the Unit A medication room refrigerator contained a sandwich and three puddings, both doors on the narcotic box were unlocked and opened and contained narcotics. Licensed Practical Nurse #12 stated the person who had the narcotic keys was responsible for making sure it was locked when not in use. Earlier that morning when they started their shift, they counted narcotics with Licensed Practical Nurse #21, and then locked the narcotic box. They returned the keys to Licensed Practical Nurse #21 because they needed to finish a few things before leaving for the day. Licensed Practical Nurse #21 must have forgotten to lock the narcotic box when they returned the keys to them before leaving for the day.During an interview on 08/06/2026 at 10:00 AM and 10:42 AM, Licensed Practical Nurse Unit Manager #13 stated at the change of shift the off going nurse verified and documented the narcotic count on the narcotic sheet. After the count was completed, the oncoming nurse locked both narcotic cabinet doors and kept the keys in their possession. Narcotic keys should not be passed back and forth. If the keys were transferred from one nurse to another, they would have to verify the narcotic count each time. There should never be any food in the medication refrigerator, including a sandwich or pudding. During an interview on 08/06/2026 at 11:09 AM, Licensed Practical Nurse #21 stated narcotics were counted every shift. The off going nurse documented the number on the narcotic sheets and the oncoming nurse counted the narcotics ensuring all narcotics were accounted for. Today they were the off going nurse and they did not handle the keys after counting off with Licensed Practical Nurse #12.10NYCRR 415.18(d)

Based on observations and interviews, the facility failed to ensure residents were provided food and drink that was palatable, flavorful, and at appetizing temperatures for two of two test trays (one lunch tray on 08/03/2026 and one breakfast tray on 08/04/2026). Specifically, the 08/03/2026 lunch tray included cold foods served above 41 degrees Fahrenheit that were not palatable, and the chicken served was hard to cut and chew, the 08/04/2026 breakfast tray included hot foods served below 130 degrees Fahrenheit and four anonymous residents stated the hot food was cold, flavorless, difficult to chew, and did not look good. Findings include: The facility policy Food Preparation, Service, and Distribution, revised 10/2022, documented the facility assured safe and sanitary food preparation, holding, transport, and distribution to prevent foodborne illness. The facility did not hold foods in the danger zones (cold foods would not be above 41 degrees Fahrenheit and hot foods would not be below 135 degrees Fahrenheit).During an anonymous meeting on 08/03/2026 at 1:57 PM, four residents stated their meals did not look or taste good, were served cold, and were difficult to chew at times.During an observation and interview on 08/03/2026 at 12:05 PM, Resident #5 stated their food was always served cold. When they asked for a replacement, it was always a cold sandwich, and they wanted something hot to eat. Resident #5's lunch meal was used as a test tray when delivered to the resident's room, and a replacement meal was ordered. Food temperatures were measured and verified by Certified Nurse Aide #15 as follows: barbeque chicken 121.3 degrees Fahrenheit, green beans 126.3 degrees Fahrenheit, pasta salad 69.1 degrees Fahrenheit. The chicken was difficult to cut and chew; the bottom of the corn bread was soggy and was sitting in the juice from the green beans, and the pasta salad tasted warm.During an observation and interview on 08/04/2026 at 8:22 AM, Resident #68's breakfast meal was used as a test tray when delivered to the resident's room, and a replacement meal was ordered. Food temperatures were measured and verified by Certified Nurse Aide #42 as follows: scrambled eggs 110.5 degrees Fahrenheit, coffee 118.4 degrees Fahrenheit, and toast 94.3 degrees Fahrenheit. The temperature of the bacon was not obtained because it was too thin. The bacon and eggs were cold and the toast was soggy. During an interview on 08/04/2026 at 12:26 PM, Certified Nurse Aide #34 stated residents complained the food was of poor quality, cold, there were not a lot of alternatives, it was too repetitive, and it was too tough. Yesterday they had a hard time cutting the chicken for residents and in the past had a hard time cutting the pork. When residents complained about the food, they offered an alternative.During an interview on 08/04/2026 2:55 PM, at Licensed Practical Nurse #14 stated residents often complained about the food saying it was not appealing, did not taste good, and was tough to cut. When residents complained about the food, they offered the residents an alternative.During an interview on 08/05/2026 at 2:33 PM, Food Service Worker #43 stated they were responsible for preparing the residents meal trays. They were not exactly sure what the temperatures should be when being served to the residents. They stated food should look and taste good and when residents complained about the food, they were offered a replacement. During an interview on 08/05/2026 at 2:49 PM, the Food Service Director stated they were ultimately responsible for making sure all items listed on meal tickets were on the resident trays and that food looked and tasted good when served to all residents. They used to have a supervisor to assist with those duties, however that position was currently vacant. At times they were notified that a resident did not like the food and it did not taste good and the resident was offered an alternative. They expected hot foods to reach the residents at 140 degrees Fahrenheit and cold foods served below 40 degrees Fahrenheit. They did not expect cornbread to sit in the juice of beans or chicken to be tough to chew. Chicken served at 121.3 degrees Fahrenheit and eggs served at 110.5 degrees Fahrenheit were not hot enough. Pasta salad was a cold item and should be served under 40 degrees Fahrenheit and pasta salad served at 69.1 degrees Fahrenheit was not preferred. They completed four test trays a month and were not sure why the food was not palatable. 10 New York Codes, Rules, and Regulations 415.14(d)(1)(2)

Based on observations, record review, and interviews (IQIES intake 2697120), the facility failed to ensure accommodation of resident food preferences for three of three (Resident #17, Resident #22, and Resident #105) reviewed. Specifically, Resident #17, Resident #22, and Resident #105 requested items on their meal tickets that were not received and ten anonymous residents that wanted a snack at bedtime were not offered a snack at bedtime. Findings include: The facility policy Food Preferences, revised 03/2010 documented the dietitian/diet technician interviewed each resident and/or their family member to obtain resident preferences. During an anonymous meeting on 08/03/2026 at 1:57 PM, ten residents stated they were not offered a snack at bedtime and wanted a snack. During an observation and interview on 08/04/2026 at 12:21 PM, Resident #22 was in their bed eating their lunch. Their meal ticket documented grilled cheese, tossed salad, ice cream, pudding, water, diet cola, coffee, and nutritional juice. The nutritional juice, coffee and ice cream were missing. The resident stated frequently items were missing off their tray they preferred and were listed on their meal ticket. They wanted the nutritional juice, however preferred chips to the ice cream and did not want the coffee. During an interview on 08/04/2026 at 12:26 PM, Certified Nurse Aide #34 stated meals were prepared and assembled in the kitchen by kitchen staff. All the items on the meal ticket should be on the tray, except coffee which was poured by the certified nurse aide that was passing the tray. Ice cream and nutritional drinks that were listed on the meal ticket should be on the tray that was prepared by the kitchen. Nutritional supplements were ordered because the residents required extra nutrition when they were not eating well. Many times, they noticed that items documented on the meal ticket were missing from the tray and they went to the kitchen for a replacement. Resident #17 and Resident #105 were often missing ice cream, including earlier today, and if Resident #17 relative was not in the facility when lunch was served, those residents, who shared a room, would not get their ice cream. Resident #22 was losing weight and their 08/04/2026 meal ticket documented nutritional juice, ice cream, and coffee. All were missing from their tray. The residents asked for their nutritional juice and Certified Nurse Aide #34 returned with it. Making several trips back and forth to the kitchen for items requested by residents and documented on resident meal tickets that were not on the tray was time consuming and interfered with resident care. During an observation on 08/04/2026 at 12:44 PM, Resident #22 had finished their nutritional juice drink. During an observation and interview on 08/04/2026 at 12:46 PM, Resident #17 and Resident #105 were eating ice cream in their shared room. Resident #17 and Resident #105 stated most days their ice cream was missing off their lunch tray. They ordered ice cream because they liked it, was sometimes better than the food, and when they did not eat items on their tray, they always finished the ice cream. Both meal tickets documented ice cream on them. They also stated they wanted a snack at bedtime and were never offered a snack. Resident #105 stated they used to bring a cart of snacks around just before bed and they stopped doing it and they were not sure why. They both stated they wanted a snack cart before bed so they could choose from a variety of snacks. Resident #17 relative stated they came to the facility most days before lunch and most days both residents were missing their ice cream. They walked to the kitchen and knocked on the door and were always given ice cream to bring back to the residents. During an interview on 08/04/2026 at 2:55 PM, Licensed Practical Nurse #14 stated the kitchen was responsible for assembling the tray and made sure all items listed on the ticket were on the tray. The staff passing the tray should make sure the tray was accurate. Many times, when they passed trays, residents complained about items they preferred were missing and had to get it from the kitchen. It was important for Resident #22 to get their ordered nutritional supplement because they had a poor appetite, had lost weight, was scheduled to get nutritional supplements with their lunch meal, and they liked the nutritional juice. Some days there were less items missing as it was dependent on what staff was working at that time. During an observation on 08/05/2026 at 8:30 AM, the snack bin behind the B wing nurses station contained 3 ginger ale sodas, 1 package of pretzels, 1 package of chips, 23 graham crackers (2 crackers in a pack), 4 saltines (2 crackers in a pack), and 3 packages of [NAME] doones. There were 39 residents on the B wing. During an interview on 08/05/2026 at 2:33 PM, Food Service Worker #43 stated there were two food service workers that put items on the resident's tray that corresponded with the meal ticket. One food service worker put the hot stuff on the tray, and one put the cold stuff on the tray. They were responsible for putting nutritional juice and ice cream on the trays and put ice cream on the meal trays just before leaving the kitchen to prevent the ice cream from melting. There were many times the unit called the kitchen because items the resident requested were not on their meal tray and they sent those items to the unit. They stated it was important for residents to get the items they chose because that was their preference. Snacks were located on each unit behind the nurse's station and residents could ask for a snack in the evening if they wanted a snack. The facility used to offer a snack from a cart in the evening but that stopped a while ago and they were not sure why. During an interview on 08/05/2026 at 2:49 PM, Food Service Director #32 stated they worked closely with the Registered Dietitian documenting resident preferences, which changed daily. At times the dietitian entered preferences and other times they entered preferences. The kitchen was opened at 5:30 AM and closed daily at 7:00 PM, however the supervisor has a key and could get into the kitchen if needed. They received calls from the unit when preferred items were not on a residents tray that were listed on their meal ticket and immediately sent the item to the unit. Ice cream was placed on the tray just before leaving the kitchen to prevent it from melting. When ice cream was missing from a tray, the food service worker must have forgotten to put it on the tray before the cart left for the unit. Certified nurse aides came to the kitchen at the beginning of their shift to fill a basket with snacks for the residents but do not go room to room offering snacks. There used to be a snack cart that went from room to room in the evening but that was discontinued before they were hired. During an observation interview on 08/06/2026 at 12:35 PM, Resident #22 was in bed eating lunch. Their meal ticket documented salami sandwich, roasted potatoes, vegetable blend, ice cream, cookies, diet cola, coffee, and nutritional juice. The resident stated frequently items they preferred were missing and the ice cream was missing. 10 New York Codes Rules Regulations 415.14(d)(3)(4)

Based on record review and interviews (iQIES intake 2681150), the facility failed to thoroughly investigate all alleged violations of abuse and neglect, for one of one resident (Resident #78) reviewed. Specifically, Resident #78 who had a history of elopement and wore a wander alert device, left the facility undetected on 07/25/2026 and the facility did not conduct a thorough investigation. The facility's investigation did not identify the resident eloped from the facility, why the resident was at risk for elopement, had a wander alert device on and also had privileges to leave the facility unsupervised, and the investigation inlcuded timeframes and events that were not consistent with the police report. Additionally, the facility did not report the incident to the New York State Department of Health as required. Findings include: The facility policy Accident/ Incident Investigation and Prevention, revised 06/2023, documented all accidents and incidents were recorded, investigated, and corrective measures were initiated. The policy did not include elopements. The facility policy Missing Resident Elopement Dr. Walker, revised 09/2023, did not document the elopement needed to be reported to New York State Department of Health. Resident #78 had diagnoses including dementia, depression, and diabetes. The 06/03/2025 Minimum Data Set (assessment tool) documented the resident's cognition was moderately impaired, was ambulatory utilizing a rolling walker with supervision and had a wander/elopement alarm in place. The Comprehensive Care Plan initiated 05/27/2025 and revised 06/09/2025, documented the resident was at risk for elopement related to dementia and wore a wander alarm device. The goal was to be without exit seeking behavior and there were no documented interventions for monitoring or responding to exit seeking behaviors. The 07/25/2025 facility investigation summary completed by the (former) Director of Nursing documented Resident #78 left the building at 6:00 PM to visit a family member who resided close to the facility. The resident had the capacity to make own decisions and had a purposeful destination. The resident returned to the facility at 6:45 PM without injury. The resident was alert and oriented with a BIMs (Brief Interview for Mental Status) of 10 (moderate cognitive impairment). The resident explained they alerted staff and demonstrated how they put the code in the wander alarm and exited the building. The resident had capacity but there was concern now that cognition may vary and it would be appropriate to revoke any independent out on pass. The resident was educated regarding the sign out process. There was no documented evidence in the resident's medical record or a physician order related to the resident having the ability or privilege to leave the facility without supervision. The 07/25/2025 Police Incident Report documented they received a call at 7:00 PM by Licensed Practical Nurse Supervisor #6 who reported Resident #78 was missing from the facility. At 7:18 PM, the police department received a call from the resident's family member who reported they found the resident and were returning them to the facility. There was no documented evidence of the following:-nursing progress notes indicating they were aware the resident left the building to visit family.-nursing progress notes the resident was assessed upon return. -how the facility determined the resident had capacity to leave the facility for family visits at 6:00 PM and after they returned at 6:43 PM they no longer had capacity. -why law enforcement was contacted if this was not considered an elopement. -how the resident had access to keypad code to exit the building when they had a wander alert device. -how the resident was at risk for elopement, but the facility provided out on pass privileges. -why the times reported by police were inconsistent with the facility investigation. On 08/04/2026 at 10:39 AM, the surveyor requested all investigations from June, July and August 2025 and the 07/25/2025 investigation related to Resident #78 was not provided. A second request was submitted on 08/04/2026 at 6:00 PM specifically requesting all investigations involving Resident #78 and the 07/25/2025 investigation was not provided. The investigation for the 07/25/2025 incident involving Resident #78 was not provided until 08/05/2026 when the surveyor directly asked the Administrator about the 07/25/2025 elopement involving Resident #78. There was no documented evidence Resident #78's 07/25/2025 elopement was reported to the New York State Department of Health as required. During a telephone interview on 08/05/2026 at 10:40 AM, the (former) Director of Nursing stated they recalled Resident #78 left the building without staff knowledge in July 2025. They had received a phone call from Licensed Practical Nurse Supervisor #6 and instructed them to call the police. The resident had a wander device at that time. They did not know how the resident was able to leave the building undetected. They did not recall if there was an investigation or if the incident was reported. During an interview on 08/05/2026 at 11:55 AM, the Administrator stated elopements required an investigation. They were on vacation at the time of the incident with Resident #78 but the (former) Director of Nursing completed the investigation and the Regional [NAME] President was covering the facility for them. During a telephone interview on 08/05/2026 at 1:41 PM, Licensed Practical Nurse Supervisor #6 stated they were involved in Resident #78's elopement. They had alerted the (former) Director of Nursing that they could not find the resident. They did end up finding the resident in a private residence after knocking door to door and they returned them to the facility. They did not provide any written statements. The (former) Director of Nursing would have done the investigation. During a telephone interview on 08/06/2026 at 9:34 AM, Certified Nurse Aide #9 stated they did not recall the details of Resident #78's elopement from a year ago but the resident was found down the street. They were on shift at the time. They were not asked to provide a statement. During an interview on 08/06/2026 at 11:07 AM, the (current) Director of Nursing stated a complete investigation included statements from all residents and staff involved and any witnesses. Investigations were completed for falls, suspected abuse, elopements, bruises of unknown origin, and others, but those were the top priority. They reviewed the 07/25/2025 investigation and stated this was not a complete investigation as there should have been statements from all staff on the shift, and anyone else that may have been on the unit. Elopements had to be reported to the Department of Health and could be done by the Director of Nursing or the Administrator. They would have no way of knowing if this was reported, they were not the Director of Nursing at that time. During an interview on 08/06/2026 at 11:45 AM, the Regional [NAME] President stated they were covering the facility at the time of Resident #78's elopement. They had gotten a phone call from the (former) Director of Nursing. They did not know the details of the investigation as they did not complete it. Ultimately, they decided the resident had capacity, so it did not need to be reported to the Department of Health. 10 New York Codes, Rules, and Regulations 415.4(b)

Based on record review and interviews, the facility failed to ensure the development and implementation of a comprehensive person-centered care plan to meet a resident's medical, nursing, mental, and psychosocial needs for one of two residents (Resident #6) reviewed. Specifically, Resident #6 did not have a care plan for the use of an anticoagulant (blood thinner). Findings include: The facility policy Anticoagulant Therapy and Administration, revised 07/2017, documented the resident was observed for signs of bleeding, shaved with an electric razor, and the care plan identified the increased risk of bleeding. Resident #6 had diagnoses including acute and chronic respiratory failure. The 07/13/2026 Minimum Data Set assessment documented the resident was cognitively intact and was taking an anticoagulant. The 07/07/2026 Physician orders documented Rivaroxaban 10 mg (blood thinner) once a day for anticoagulant. The Comprehensive Care Plan did not include the use of an anticoagulant. During an interview on 08/04/2026 at 2:51 PM, Certified Nurse Aide #34 stated they reviewed the individual care plan and Kardex (care instructions) every day to know the care residents required. During an interview on 08/04/2026 at 2:55 PM, Licensed Practical Nurse #14 stated care plans were completed by the interdisciplinary team of nursing, dietary, social work, and therapy. Once the care plan was completed it was posted in the resident's closet for certified nurse aides to use as a reference. When someone was on an anticoagulant, nursing documented that in the care plan as it alerted staff to monitor for bruising and bleeding. Resident #6 was on an anticoagulant and it should be documented in their care plan. During an interview on 08/05/2026 at 8:43 AM, Licensed Practical Nurse Unit Manager #35 stated that nursing, therapy, social work, and dietary worked together to create an individual care plan for each resident. They were responsible for completing the nursing section of the care plan and the nursing supervisor was responsible in their absence. Care plans were completed on admission, quarterly, annually, and when there was a significant change. When a resident was on an anticoagulant it should be included in the care plan so residents could be monitored for bruising and bleeding. Resident #6 was on an anticoagulant, it was not documented in their care plan, but should have been. It must have been overlooked. 10 New York Codes, Rules and Regulations 415.11(c)(1)

Based on observations, record review and interviews, the facility failed to identify and provide needed care and services that were resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that would meet each resident's physical, mental, and psychosocial needs for two of two residents (Resident #6 and #8) reviewed. Specifically, Resident #8 was not provided with the correct prescribed tube feeding formula and Resident #6's routine pulmonary inhaler was not available for administration for multiple days. There was no follow up with the pharmacy after the resident's inhaler was reordered on 07/27/2026 and when the pharmacy made a recommendation to change the type of inhaler being used it was not addressed.Findings include: The facility policy, Tube Feedings, revised 07/2020, documented a physician order would specify the formula, the amount, the calories, the rate and frequency of the tube feeding. The licensed nurse would check the physician order for the type of tube feeding formula. The facility policy, Medication/Treatment Administration: Documentation, revised 06/2024, documented medications or treatments that were not available for administration as ordered required the licensed nurse to inform the nursing supervisor immediately and notify the medical provider. 1) Resident #8 had diagnoses that included severe dysphagia (difficulty swallowing). The 05/15/2026 Minimum Data Set assessment documented the resident had moderate cognitive impairment, had weight loss, and had a feeding tube. The 06/11/2026 Comprehensive Care Plan documented the resident had a gastrostomy tube (a tube placed into the stomach to deliver medications, nutrition, and fluids) related to severe dysphagia. Interventions included tube feeding per physician order. The 07/27/2026 Registered Dietician #45 progress note documented the resident had a 10 pound weight loss in one month and was consistently having loose stools. They discussed the option of trying a different tube feeding formula and recommended, Diabetisource AC as it was lactose free. The 07/30/2026 physician order documented to change tube feeding from Glucerna 1.2 to Diabetisource AC and administer daily at 2:00 PM at 70 milliliters per hour. During an observation on 08/05/2026 at 2:06 PM, Resident #8's tube feeding was dated 08/05/2026, labeled Glucerna 1.2 and running at 70 millimeters per hour. During an observation and interview on 08/05/2026 at 2:08 PM, Licensed Practical Nurse #46 stated the process for administering a tube feeding was to review the physician order and check the type and rate of tube feeding formula. Licensed Practical Nurse #46 reviewed the physician order with the surveyor and stated the order was for Diabetisource AC, not Glucerna 1.2. Licensed Practical Nurse #46 walked into the resident's room and stated they administered Glucerna 1.2, they must have just glanced over the physician order and then they left the room to retrieve the correct tube feeding. During an interview on 08/05/2026 at 2:15 PM Licensed Practical Nurse Unit Manager #13 stated the process for administering a tube feedings was to verify the order. Resident #8 was previously on Glucerna 1.2 but was having loose stools so it was changed to Diabetisource AC to help decrease the loose stools and promote weight gain. The resident had been tolerating the new tube feeding well. They expected the nurse to verify the formula before administering it. During an interview on 08/05/2026 at 2:44 PM, Registered Dietician #45 stated Resident #8 had severe dysphagia and required a tube feeding to meet their nutritional needs. The resident was having loose stools and lost weight so the type of tube feeding was changed to Diabetisource AC. They would expect the ordered formula to be administered and notified if there was an issue. 2) Resident #6 had diagnoses that included chronic obstructive pulmonary disease and acute and chronic respiratory failure. The 07/13/2026 Minimum Data Set assessment documented the resident had intact cognition, was independent or required supervision for most activities of daily living and was on oxygen therapy. The 07/23/2026 Comprehensive Care Plan documented impaired pulmonary function related to chronic obstructive pulmonary disease. Interventions included provide medications as ordered. The 07/07/2026 medical provider order documented Brezti inhaler for two inhalations twice daily for chronic obstructive pulmonary disease. The July and August 2026 medication administration records documented the resident did not receive the Brezti inhaler from 07/27/2026-08/03/2026. There was no documented evidence that the medical provider was notified that Resident #6 did not receive their Brezti inhaler as ordered from 07/27/2026-08/03/2026. During an interview on 08/03/2026 at 10:34 AM, Resident #6 stated the facility had been out of their inhaler for a week. They were taking the Brezti inhaler and ever since they stopped getting it, they felt short of breath. During an interview on 08/04/2026 at 3:14 PM, Licensed Practical Nurse #11 stated when medication was not available, they called the pharmacy. They also checked the medication cabinet and if not, they would notify the supervisor who would then notify the medical provider. Medications reordered would typically arrive from the pharmacy within 24 hours. Resident #6 had been missing their Brezti inhaler for two to three days and they were not sure why. They should have documented that it was not available. During an interview on 08/05/2026 at 9:18 AM, Licensed Practical Nurse Unit Manager #35 stated after medication orders were placed, they were sent to the pharmacy to be filled. Medications would usually arrive at the facility the same day. If the medication was not available or was out of stock the pharmacy would call the nursing staff to let them know and may also instruct the nurse to check the electronic medication cabinet to see if there was any stock of the medication in there. If the medication was not available, they notified the supervisor and the physician to see if a replacement could be ordered. The supervisor would write a progress note. They had not been notified that the medication for Resident #6 was not available. The Licensed Practical Nurse check the resident's medical record and stated the Bretzi inhaler was reordered on 07/27/2026 and there was no documentation that the inhaler had been delivered by the pharmacy. During an interview on 08/05/2026 at 9:42 AM, Pharmacy Staff #47 stated the Brezti inhaler was first ordered on 07/07/2026 and sent to the facility on [DATE]. Another inhaler was requested and sent out on 07/15/2026. Another inhaler request was sent on 07/27/2026 but insurance would not cover it. They sent the facility a recommendation for Trelogy inhaler on 07/27/2026 and did not receive a response. Since there was no response to the 07/27/2026 fax, they did not send any inhaler. During an interview on 08/05/2026 at 11:33 AM, the Medical Director stated a resident would be prescribed a Brezti inhaler for chronic obstructive pulmonary disease, asthma, or lung issues. It was a relatively new medication that contained three types of medications in one inhaler. If the medication was not available for an extended period they would want to be notified as they would want to see how the resident was doing without it. During an interview on 08/06/2026 at 9:45 AM, Assistant Director of Nursing #48 stated the Brezti inhaler for Resident #8 would often come up missing and a fax would come in from the pharmacy saying it was too expensive and requesting a cheaper one be ordered. The nurse would have to call the pharmacy and tell them to please send the ordered Bretzi inhaler. There were times medications were missed because of how expensive they were. When pharmacy sends a fax over it would go to the supervisor's office and no one really checked the fax machine as it was not in a convenient spot. 10 New York Codes, Rules and Regulations 415.12

The facility policy Resident Rights and Responsibilities, dated 01/13/2025, documented the facility services provided to the resident demonstrated the belief in dignity and worth of every individual. The facility provided the resident with optimal nursing and psychosocial care. Every effort is made by the staff to meet the resident's individual needs and requirements. The facility policy Facility Incident/Abuse Investigation and Reporting, dated 09/2025, documented personnel must report any resident incident or suspected incident immediately to the Supervisor/Administrator. The facility would investigate instances of alleged resident abuse to ensure the physical and mental well-being of the resident. The facility would conduct an immediate and thorough investigation, upon discovery of sexual abuse. Sexual abuse was defined as non-consensual sexual contact of any type with a resident. Conduction of an investigation included rendering aid to protect the residents, removing them from harm; and ensuring an appropriate individualized care plan. 1) Resident #4 had diagnoses including depression, anxiety, and Alzheimer's disease. The 09/03/2025 Minimum Data Set assessment (a resident assessment tool) documented the resident had severely impaired cognition; did not exhibit wandering behaviors; was independent with ambulation; and did not require a walker or wheelchair. The 10/05/2025 at 8:22 PM Licensed Practical Nurse #7 progress note documented on 10/05/2025 at 6:45 PM, staff notified them another resident's family member found Resident #4 with Resident #1 on top of them in bed and both residents did not have on pants or under garments. Staff immediately intervened and removed the residents from the room. The writer made the supervisor (unnamed) aware immediately. Both residents were educated on appropriate behaviors. Resident #4 complained of stomach pain following the incident. There was no bruising or vaginal bleeding (to Resident #4) noted at the time. The supervisor was made aware, and an incident report was filled out and given to the supervisor. There was no documented evidence of a registered nurse assessment of Resident #4 following the inappropriate sexual contact and complaint of stomach pain on 10/05/2025, and no documented evidence of notification to the resident's family regarding the incident. The 10/06/2025 at 7:11 AM Licensed Practical Nurse #8 progress note documented they followed up from the previous incident, 15-minute checks continued (for Resident #4) and there was no interaction with the other resident throughout the night. Resident #4's Comprehensive Care Plan, initiated 09/11/2024 and revised 09/23/2025, documented the resident had the potential to wander into other residents' rooms and sit/lie down on the beds. Interventions included redirect as able. There was no documented evidence the care plan was revised to include potential/actual abuse. The 10/08/2025 at 10:41 PM Nurse Practitioner #13 progress note documented Resident #4 was seen at the request of nursing staff for a 30-day review. There was no documentation regarding the 10/05/2025 incident. The 10/24/2025 at 4:23 AM Licensed Practical Nurse #8 progress noted documented at 11:00 PM (on 10/23/2025) while doing rounds, Resident #4 was not in their bed. Resident #4 was found in Resident #1's bed with their shirt raised and their breast exposed. They immediately assisted Resident #4 out of the bed and out of the room. Resident #1 stated they played with the resident's breast when Resident #4 got in their bed. The supervisor (unnamed) was made aware. Resident #4 had no complaints and no signs of fear. The 10/24/2025 at 4:23 AM Licensed Practical Nurse Supervisor #9 progress note documented on 10/23/2025 at 11:10 PM, Resident #4 was found in Resident #1's bed by Licensed Practical Nurse #8. Resident #4 was escorted of out the room and put on 15-minute checks. The Director of Nursing was notified. There was no documented evidence of a registered nurse assessment of Resident #4 following the 10/23/2025 incident, and no documented notification of the resident's family regarding the incident. The Comprehensive Care Plan for potential to wander into other residents' rooms and sit/lie down on the bed was updated on 10/23/2025 to include an intervention to maintain 15-minute visual checks. There was no documented evidence the care plan was revised to include potential/actual abuse or potential for victimization. There was no documented evidence of social worker progress notes from 10/1/2025 -10/31/2025 that included psychosocial assessments of Resident #4 after the incidents on 10/05/2025 and 10/23/2025.The 10/27/2025 at 10:30 AM Registered Nurse #4 progress note documented Resident #4 continued to wander during the night. This was discussed with the provider and a new order was obtained to increase Trazadone (antidepressant with sedative effects) to 50 milligrams daily. There was no documentation the medical provider was notified about the 10/23/2025 incident. The 10/29/2025 at 7:09 PM Nurse Practitioner #13 progress noted documented the resident was seen for insomnia. The plan was to increase Trazadone to 50 milligrams nightly, monitor the resident's sleep, and update the provider as needed. There was no documentation or assessment related to the 10/23/2025 incident. 2) Resident #3 had diagnoses including dementia. The 10/05/2025 Minimum Data Set assessment documented the resident had severely impaired cognition; was independent with ambulation; and did not require a walker or wheelchair.The 10/09/2025 at 12:07 AM Licensed Practical Nurse #8 progress noted documented they and the supervisor (unnamed) found Resident #3 lying in Resident #1's bed with their shirt pulled up and their breasts exposed. Resident #1 was not in the bed at the time. They assisted Resident #3 back to their bed and placed Resident #3 on 15-minute checks to monitor per the supervisor. There was no documented evidence Resident #3 was assessed following the incident, or their care plan was reviewed for effective interventions; and no documented notification of the resident's family regarding the incident. The Comprehensive Care Plan, initiated 10/15/2024 and revised 10/30/2025, documented the resident had a high incidence of wandering due to cognitive impairment. An intervention added on 10/09/2025 documented 15-minute visual checks and was resolved on 10/14/2025. There was no documented evidence of social worker progress notes from 10/01/2025 -10/31/2025 that included psychosocial assessments of Resident #3 after the incident on 10/09/02025.The 10/09/2025 at 12:40 PM Medical Director progress note documented Resident #3 was being seen for their federally mandated visit. There was no documented evidence of an assessment after the 10/09/2025 incident. 3) Resident #1 had diagnoses including stroke, cognitive communication deficit, and depression. The 09/24/2025 Minimum Data Set assessment documented the resident had severely impaired cognition; no verbal or physical behavioral symptoms or other behavioral symptoms directed towards others; and ambulated independently. On 4/24/2025, Resident was #1 was transferred to the dementia unit.Resident #1's Comprehensive Care Plan initiated 12/27/2024 documented the resident demonstrated alteration in mood and behavior related to episodes of verbal aggression, stroke; the potential to become physically aggressive toward care givers when helped with care; and the potential to hold hands with residents on the memory care unit. On 05/21/2025, an intervention was added to maintain visual checks and was documented as resolved on 07/09/2025. On 09/26/2025 an intervention of an alarming floor mat for the doorway of the resident room with the potential for the resident to take down and misplace was added. The 10/05/2025 at 8:24 PM, Licensed Practical Nurse #7 progress note documented on 10/05/2025 at 6:45 PM, another resident's family member found Resident #1 on top of Resident #4 in bed and both residents did not have pants or undergarments on. Staff immediately intervened and removed the residents from the room. Licensed Practical Nurse #7 made the supervisor (unnamed) aware immediately. Both residents were educated on appropriate behaviors, an incident report was filled out and given to the supervisor. The 10/05/2025 Investigation Summary report completed by the Director of Nursing documented Resident #5's (the roommate of Resident #1) family member observed Resident #1 and Resident #4 lying down in Resident #1's bed sleeping. When nursing staff arrived at the room, there was no physical contact noted, and Resident #1 was in the corner of the room with their incontinent brief intact, and not near Resident #4. Staff intervened and Resident #4 was redirected from the room. The documented immediate response was to separate the residents, a registered nurse (no name indicated) skin assessment was performed on Resident #4 and there was no injury, fear, pain or mental anguish noted. Resident #4 was evaluated by a medical provider (no name indicated) and Trazadone (antidepressant with sedative effects) was implemented to improve Resident #4's wandering into other residents' rooms. Resident #1 had an alarming floor mat, and an alarming stop sign. The incident was not witnessed by staff and was reported by a family member. The incident was not reported to the New York State Department of Health because there was no pain, injury or mental anguish noted at the time of the incident with Resident #1 and Resident #4. The 10/09/2025 at 12:07 AM, Licensed Practical Nurse #8 progress note documented they and the supervisor (unnamed) found Resident #3 lying in Resident #1's bed with their shirt pulled up and their breasts exposed. Resident #1 was not in their bed at the time. They assisted Resident #3 back to their bed and placed Resident #3 on 15-minute checks per the supervisor.There was no documented evidence an incident report was completed by the facility for the 10/09/2025 incident. The 10/17/2025 at 9:53 PM Nurse Practitioner #13 progress noted documented Resident #1 was seen for their annual wellness exam. There was no documentation regarding the 10/05/2025 and 10/09/2025 incidents with Resident #3 and Resident #4.The 10/23/2025 Investigation Summary report completed by the Director of Nursing documented Resident #4 was found by staff lying down in Resident #1's bed. Resident #4 had their shirt slightly pulled up and staff intervened. Resident #4 was redirected back to their room and both residents were placed on 15-minute checks. The 10/23/2025 at 11:15 PM incident report initiated by Licensed Practical Nurse Supervisor #9, documented an inappropriate behavior incident with no injury. Licensed Practical Nurse #8 witnessed Resident #4 in Resident #1's bed while Resident #4 had their shirt pulled up and their breast exposed. Resident #4 was moved to the opposite hallway (a room change) and both residents were placed on 15-minute checks. The Administrator signed an undated and typed statement that Resident #1 was interviewed after the incident and reported that Resident #4 wandered in their room and laid in their bed to sleep. Resident #1 denied any physical contact and reported being irritated with residents wandering in their room, and a room change was made. There was no documented evidence Resident #1's care plan was updated timely, and no documented evidence Resident #1 was assessed timely. There was no documented evidence the residents' families were notified. The 10/24/2025 at 4:18 AM, Licensed Practical Nurse Supervisor #9 progress note documented at 11:10 PM, they were made aware that Resident #1 was found in bed with Resident #4 in Resident #1's bed. The residents were separated and placed on 15-minute checks. The Director of Nursing was notified by Licensed Practical Nurse Supervisor #9. The Comprehensive Care Plan was updated on 10/24/2025 with the intervention to maintain visual checks (15-minute room checks). There was no documented evidence of social worker progress notes from 10/01/2025 -10/31/2025 that included psychosocial assessments of Resident #1 after the incidents on 10/05/2025, 10/09/2025, and 10/23/2025.The 10/24/2025 at 10:26 AM, Medical Director progress note documented Resident #1 was seen for their federally mandated visit. There was no documented evidence of assessments after the 10/5/2025, 10/9/2025 or 10/23/2025 incidents. During a telephone interview on 10/30/2025 at 12:45 PM, former Certified Nurse Aide #40 stated Resident #1 seemed to be aware of what they were doing and would go into female resident rooms. One night Resident #1 was undressing a resident (unable to identify) and taking their top off and staring at the resident. They immediately went to get Certified Nurse Aide #39 and Licensed Practical Nurse Supervisor #8. They did not write a statement and thought Licensed Practical Nurse Supervisor #8 documented on the incident. Certified Nurse Aide #40 stated there was a similar incident and was told by a supervisor (unnamed) they could not make assumptions, so it was not reported. They said they only saw Resident #1 do this one (1) time but heard of inappropriate touching by Resident #1 happening at least four (4) other times. During a telephone interview on 10/30/2025 at 10:55 AM, Certified Nurse Aide #5 stated on 10/05/2025 Certified Nurse Aide #6 asked for their assistance and told them Resident #5's wife saw Resident #1 on top of Resident #4 in Resident #5's bed. When they approached the room, Resident #1 was walking away from the bed and pulling their pants up. Resident #4's pants and incontinence brief were between their knees and ankles, Resident #4 was rocking and shaking and complained of stomach pain. Resident #4 was confused and appeared scared. Resident #1's behaviors started when they were on the dementia unit. Resident #1 was touchy and would follow residents into their rooms. Resident #4 was known to walk into a room and get into the bed but could not take their own clothes off. Certified Nurse Aide #5 stated when they entered the room on 10/05/2025, Resident #1's buttocks and back of their thighs were exposed. They stated they took Resident #4 to the dining room and the resident appeared scared and was trembling. Registered Nurse Supervisor #10 reported to Registered Nurse Unit Manager #4 at that time. An alarm mat was placed in front of Resident #1's doorway but this did not prevent the resident from exiting their room. Resident #1 would hop over it, kick it out the way, remove or shut it off. Resident #1 was also put on 15-minute checks.During a telephone interview on 10/30/2025 at 1:01 PM, Certified Nurse Aide #6 stated they recalled inappropriate encounters with Resident #1 and other residents. They thought it was during the first week of October. They stated Resident #5's family member walked into Resident #5's room, Resident #1 had their pants down to their knees, was on top of Resident #4, and Resident #4 was without pants and was visibly uncomfortable. They redressed Resident #4 and brought them to the dining room. Resident #4 complained of stomach pain, and they reported this to Licensed Practical Nurse #7. They stated they wrote a statement and turned it into Licensed Practical Nurse #7. They were called into the Director of Nursing's office, and they reported Resident #1 had their pants down. There was another incident when Resident #3 was with Resident #1 and Resident #3's shirt was up with their breast exposed. The nurse reported it to the supervisor, but they were not sure what happened after that. They stated it felt repetitive and like no one was doing anything. There were many other similar instances that were not reported. Resident #1 was only on 15-minute checks for a week and a half. They could not recall the exact time when the checks started. Resident #1 appeared to know what they were doing. When they opened the door, Resident #1 started fixing their pants and went into the corner of their room. During a telephone interview on 10/30/2025 at 11:27 AM, Licensed Practical Nurse #7 stated they there was an incident on 10/05/2025 when Resident #1 and Resident #4 were in Resident #5's bed. Resident #5's family member walked in on the incident and immediately informed staff. Certified Nurse Aide #6 told Resident #1 to get up and removed Resident #4 from the room. Resident #4 stated they were scared. They thought Resident #1 was oriented, but Resident #4 was not oriented. They stated they filled out an incident report and completed a handwritten statement they provided to Registered Nurse Supervisor #10. They were unsure if anyone else was notified. They thought Registered Nurse Supervisor #10 assessed Resident #4. The Director of Nursing asked them to strike out their progress note and write a different note, stating they could not document a family member found the residents. Licensed Practical Nurse #7 stated they refused to remove the note. They asked Registered Nurse Supervisor #10 for help with documentation of the incident, and they would not help. During a telephone interview on 10/30/2025 at 12:20 PM, Licensed Practical Nurse #8 stated there were several incidents of inappropriate encounters with Resident #1 when the resident was transferred to the dementia care unit. Resident #1 was found in bed with Resident #4 and they both had their pants off. They did not witness that incident but knew about it. There were similar incidents, and they put a sensor bar at Resident #1's door, but Resident #1 constantly took it down or turned it off. The first incident with Resident #4 was about six (6) months ago. They stated they documented on another incident when Resident #3 was found with Resident #1 with their shirt up and breasts exposed. Resident #1 was observed sitting in the chair next to Resident #3. They reported this to the supervisor and called the Director of Nursing and was told they could not assume anything, and they put Resident #3 on 15-minute checks. The most recent incident was when they arrived at the facility on 10/23/20205 at 11:30 PM and when doing their rounds they discovered Resident #4 was not in their bed. They looked in Resident #1's room and the residents were in bed together. Resident #4's shirt was pulled up and Resident #1 was lying next to Resident #4's breasts. When Licensed Practical Nurse Supervisor #9 asked Resident #1 about the incident, Resident #1 stated, If they wander into my bed, I am going to play with their boobies. The Director of Nursing was called at home and there was no response, so they moved Resident #4 to another room for the night. There was no registered nurse in the building that night, and neither resident was assessed. They stated if there was an incident of suspected abuse, they should report to their supervisor and the priority was to get residents to safety. Sensitive subjects such as resident to resident sexual encounters were passed on to Administration, Unit Managers, and the Director of Nursing. During a telephone interview on 11/03/2025 at 10:13 AM, the former Director of Social Work stated if they were notified of an issue with sexual behaviors, they visited with the resident one to one and then monitored the resident's mood and cognition and ensured there were no changes. They documented a statement and wrote a progress note. They recalled Resident #1 was on the memory care unit and the resident's cognition score was very low. They recalled there was a resident they care planned Resident #1 to hold hands with. They did not recall any other incidents. During an interview on 11/03/2025 at 12:45 PM, the Administrator stated they were aware of incidents when Resident #3 and Resident #4 wandered into Resident #1's room and were in Resident #1's bed. They were not sure of the dates. All the residents involved were deemed to not have capacity to consent to sexual behaviors. The Director of Nursing was responsible for completing suspected abuse investigations. They or the Director of Nursing were responsible to report abuse. They stated they could not confirm any intimate contact between the residents and did not feel the incidents were reportable. The first incident (10/05/2025) staff reported to the Director of Nursing the residents were clothed. The registered nurse assessment did not indicate any contact. They had all the residents on 15-minute checks, and Resident #1 had an alarming floor mat and stop sign at the door. They eventually moved Resident #1 off the dementia unit to another unit. They thought the family was notified by the supervisor or the Director of Nursing the next day. They determined there was no sexual contact because the family who witnessed the incident did not see any sexual behaviors.During an additional interview on 11/07/2025 at 11:48 AM, the Administrator stated:-on 10/05/2025 they were notified by the Director of Nursing regarding the 10/05/2025 incident between Residents #1 and #4. -They were not notified of the 10/09/2025 incident with Residents #1 and #3 until they moved Resident #1 off the unit on 10/24/2025. -They were notified by the Director of Nursing of the 10/23/2025 incident on 10/24/2024 at the same time they were notified of the 10/09/2024 incident when Resident #1 was moved to a different unit. -The Director of Nursing typically notified them verbally or in person of any incidents. They stated a thorough investigation included interviewing all staff, assessing the resident, following proper reporting guidelines, and implementing interventions depending on the investigation or situation determines. The Director of Nursing was responsible for investigations.During an interview on 11/03/2025 at 12:46 PM, the Director of Nursing stated Registered Nurse Supervisor #10 made them aware of the 10/05/2025 incident when Certified Nurse Aide #6 found Residents #1 and #4 without pants on. This was reported to the Director of Nursing by Registered Nurse Supervisor #10 during or after the 3:00 PM-11:00 PM evening shift report. The incident on 10/09/2025, when Resident #1 was seated in a chair and Resident #3 had their breasts exposed, was not reported to them. They reviewed the 24-hour report and discovered the 10/09/2025 incident. Nursing staff should notify the Director of Nursing of these types of incidents even during off hours. The incident on 10/23/2025 when Resident #4 was in bed with Resident #1 and Resident #4's breasts were exposed, was brought to their attention on 10/24/2025 early in the morning by Licensed Practical Nurse Supervisor #9. They ruled out abuse on the 10/05/2025 incident because Resident #5's family member stated there was no physical contact and the residents were fully clothed. They ruled out abuse on 10/09/2025 because they thought it was just Resident #3 wandering into Resident #1's bed and Resident #1 was not near Resident #3. They ruled out abuse on 10/23/2025 because Licensed Practical Nurse #8 stated there was no contact made, and no one witnessed physical contact and there were no changes in the resident's behavior or demeanor. For all three (3) incidents, the facility determined there was no sexual contact based on staff interviews and family member witnessed accounts, and therefore there was no abuse. They stated none of the residents involved were able to consent to sexual contact. They confirmed there was no registered nurse assessment on 10/05/2025 and 10/09/2025. On 10/24/2025, Registered Nurse Unit Manager #4 completed an assessment on Resident #1 and Resident #4. They were not sure if the Administrator, who was a social worker, was able to complete the mental health assessments. They stated they did not report this incident because they did not think abuse happened. During a telephone interview on 11/03/2025 at 1:44 PM, Nurse Practitioner #13 stated they were aware of Resident #1 being found in a room with another resident but was not aware of anything sexual. Resident #1 and Resident #4 were both in bed together. It was reported the residents were sleeping together. Resident #4 had wandered into Resident #1's room. They stated if the residents were found without their pants on, they would want to know so that they could complete a physical exam. The exam would determine any further action. They were not aware of any incidents with Resident #1 with another resident and exposed breasts. They stated the residents were not able to consent to sexual behaviors. If they were made aware of the Resident #4 having pain, they would have documented that in their notes. During a telephone interview on 11/03/2025 at 10:48 AM, the Medical Director stated they were not told about the sexual incidents between Resident #1, Resident #3 and Resident #4. They stated if they were alerted, if that were part of the facility process, which would include an appropriate investigation and appropriate reporting, communication with family would be completed. The results of the investigation would determine the next steps. If Resident #4 reported abdominal pain after one (1) incident, they expected a registered nurse to assess the resident. To prevent reoccurrence, they needed to look at the specific situation and come up with specific interventions/actions for safety and update the care plan. Nursing interventions would depend on the exact situation. 10 NYCRR 415.4(b)(1)(i) _________________________________________________________________Immediate Jeopardy was identified, and the facility Administrator and Corporate Administrator were notified on 11/04/2025 at 5:26 PM. Immediate Jeopardy was removed on 11/05/2025 at 10:21 PM prior to survey exit based on the following corrective actions:- Facility hall monitors were instated for all three (3) shifts to ensure residents stayed out of other resident rooms- All residents in the facility were assessed for aggression risk.- Resident #1 was placed on continuous 1:1.- As of 11/06/2025, 100% of all staff currently working in the facility were educated on abuse, responding to abuse, signs of abuse, steps to take to protect residents, and reporting abuse.- Staff education was completed online, and multiple department facility staff working were interviewed on 11/06/2025 and were able to demonstrate understanding of the education. There were no discrepancies identified in the education provided and the responses from the interviewed staff.

Based on record review and interviews during the abbreviated (#2639795) survey, the facility failed to ensure allegations of abuse, are reported immediately, but not later than two (2) hours after the allegation is made, to the Administrator of the facility and the New York State Department of Health in accordance with State law for three (3) of three (3) incidents of alleged abuse (10/05/2025, 10/09/2025 and 10/23/2025) involving Resident #1. Specifically, Resident #1 was witnessed engaging in sexually inappropriate behavior with Residents #3 and #4 who did not have capacity to consent on 10/05/2025, 10/09/2025, and 10/23/2025 and the incidents were not reported by the facility to the New York State Department of Health or local law enforcement. Additionally, the incident on 10/09/2025 was not reported to the Administrator until 10/24/2025. The facility's failure to report abuse to Administration, law enforcement, and the State Agency resulted in harm that is Immediate Jeopardy and Substandard Quality of Care for Residents #3 and #4 and placed all 111 residents in the facility at risk for the likelihood of serious harm, serious impairment, serious injury, or death. Refer to F 600 Free from Abuse and Neglect and F 610 Investigate/Prevent/Correct Alleged Violations. Findings include:The facility policy Facility Incident/Abuse Investigation and Reporting, revised 09/2025, documented staff were to report any resident incident or suspected incident immediately to Supervisor/Administrator. All applicable incidents were to be reported to the state agency, adult protective services and to all other required agencies including law enforcement within specified timeframes. For allegations of abuse, the Director of Nursing was to notify the Department of Health and other appropriate Law Enforcement Agencies immediately and not to exceed two (2) hours.10/05/2025 Incident The 10/05/2025 at 8:24 PM, Licensed Practical Nurse #7 progress note documented on 10/05/2025 at 6:45 PM, another resident's family member found Resident #1 on top of Resident #4 in bed and neither resident had pants or undergarments on. Staff immediately intervened and removed the residents from the room. Licensed Practical Nurse #7 made the supervisor (unnamed) aware immediately. Both residents were educated on appropriate behaviors, an incident report was filled out and given to the supervisor. The 10/05/2025 Investigation Summary report completed by the Director of Nursing documented Resident #5's family member observed Resident #1 and Resident #4 lying down in Resident #1's bed sleeping. When nursing staff arrived at the room, there was no physical contact noted, and Resident #1 was in the corner of the room with their incontinent brief intact, and not near Resident #4. Staff intervened and Resident #4 was redirected from the room. The documented immediate response was to separate the residents, a Registered Nurse (no name indicated) skin assessment was performed on Resident #4 and there was no injury, fear, pain or mental anguish noted. Resident #4 was evaluated by a medical provider (no name indicated) and Trazadone (antidepressant with sedative effects) was implemented to improve Resident #4's wandering into other residents' rooms. Resident #1 had an alarming floor mat, and an alarming stop sign. The incident was not witnessed by staff and was reported by a family member. The incident was not reported to the New York State Department of Health because there was no pain, injury or mental anguish noted at the time of the incident with Residents #1 and #4. There was no documented evidence of notification to the New York State Department of Health or local law enforcement regarding the incident. 10/09/2025 Incident A 10/09/2025 at 12:07 AM Licensed Practical Nurse #8 progress note (in Resident #3's medical record) documented they and the supervisor (unidentified) found Resident #3 in another resident's bed (unidentified) with their shirt pulled up and their breasts exposed. The other resident was not in bed at the time. Resident #3 was placed on 15-minute checks per the supervisor. The 10/09/2025 Investigation Summary completed by the Director of Nursing documented:- Staff were performing 15-minute checks on Resident #1 on 10/09/2025, Resident #3 was found lying in Resident #1's bed with their shirt slightly pulled up and Resident #1 was not in the room. - Investigative findings were that Resident #3 had a history of wandering and was independent with ambulation. - Resident #3 was placed on 15-minute checks for wandering and started on 50 milligrams of Trazodone for sleep. - The incident was not reported to the New York State Department of Health due to there being no pain, injury, or mental anguish noted at the time of the incident with Resident #3. There was no documented evidence of notification to the New York State Department of Health or local law enforcement regarding the incident.10/23/2025 Incident The 10/23/2025 at 11:15 PM incident report initiated by Licensed Practical Nurse Supervisor #9 documented an inappropriate behavior incident with no injury. Licensed Practical Nurse #8 witnessed Resident #4 in Resident #1's bed while Resident #4 had their shirt pulled up and their breasts exposed. Resident #4 was moved to the opposite hallway (a room change) and both residents were placed on 15-minute checks. The Administrator signed an undated and typed statement that Resident #1 was interviewed after the incident and reported that Resident #4 wandered in their room and laid in their bed to sleep. Resident #1 denied any physical contact and reported being irritated with residents wandering in their room, and a room change was made. The 10/23/2025 Investigation Summary report completed by the Director of Nursing documented Resident #4 was found by staff lying down in Resident #1's bed. Resident #4 had their shirt slightly pulled up and staff intervened. Resident #4 was redirected back to their room and both residents were placed on 15-minute checks. It was determined there was no touching of intimate body parts. There was no pain, injury, or mental anguish noted with Residents #1 or #4 at the time of the incident. The 10/24/2025 Licensed Practical Nurse #8 progress note documented at 11:00 PM (the previous night) they were doing rounds and noted Resident #4 was not in their bed. The resident was in Resident #1's bed with their shirt pulled up and breasts exposed. They immediately assisted Resident #4 out of Resident #1's bed and brought them to their room. They informed the nursing supervisor of what was found. Licensed Practical Nurse Supervisor #9 and Licensed Practical Nurse #8 spoke with Resident #1 about the incident. Resident #1 stated they were playing with Resident #4's breasts once they got in bed with them. Resident #1 was placed on 15-minute checks. Resident #1 became upset when Licensed Practical Nurse #8 performed the check at 12:00 AM. Resident #1 stated it was not their problem the residents wander into their room. There was no documented evidence of notification to the New York State Department of Health or local law enforcement regarding the incident. During a phone interview on 10/30/2025 at 1:40 PM, Licensed Practical Nurse Supervisor #9 stated they were the supervisor on 10/23/2025. Resident #4 was found in Resident #1's bed with their shirt up and breasts exposed. Resident #1's alarming floor mat was pushed away from the door, and Resident #1 was mad. Resident #1 stated the other resident was in their bed, so they were going to play with their breasts. Licensed Practical Nurse Supervisor #9 stated they documented it in a note and an incident report. They had gotten handwritten statements from everyone on the shift. They called the Director of Nursing who did not answer so they sent a text message regarding what happened. During an interview on 11/03/2025 at 12:45 PM, the Administrator stated they were aware of incidents when Resident #3 and Resident #4 wandered into Resident #1's room and were in Resident #1's bed. They were not sure of the dates. All the residents involved were deemed to not have capacity to consent to sexual behaviors. The Director of Nursing was responsible for completing suspected abuse investigations. They or the Director of Nursing were responsible to report abuse. They stated they could not confirm any intimate contact between the residents and did not feel the incidents were reportable. The first incident (10/05/2025) staff reported to the Director of Nursing the residents were clothed. The registered nurse assessment did not indicate any contact. They had all the residents on 15-minute checks, and Resident #1 had an alarming floor mat and stop sign at the door. They eventually moved Resident #1 off the dementia unit to another unit. They thought the family was notified by the supervisor or the Director of Nursing the next day. They determined there was no sexual contact because the family who witnessed the incident did not see any sexual behaviors.During an additional interview on 11/07/2025 at 11:48 AM, the Administrator stated:-on 10/05/2025 they were notified by the Director of Nursing regarding the 10/05/2025 incident between Residents #1 and #4. -They were not notified of the 10/09/2025 incident with Residents #1 and #3 until they moved Resident #1 off the unit on 10/24/2025. -They were notified by the Director of Nursing of the 10/23/2025 incident on 10/24/2024 at the same time they were notified of the 10/09/2024 incident when Resident #1 was moved to a different unit. -The Director of Nursing typically notified them verbally or in person of any incidents. They stated a thorough investigation included interviewing all staff, assessing the resident, following proper reporting guidelines, and implementing interventions depending on the investigation or situation determines. The Director of Nursing was responsible for investigations.During an interview on 11/03/2025 at 12:46 PM, the Director of Nursing stated they were notified on 10/05/2025 Resident #1 and Resident #4 were found in Resident #1's roommate's bed without pants on. They were informed by Registered Nurse Supervisor #10. They were not made aware of the 10/09/2025 incident until they read it on the 24-hour report on 10/10/2025. Resident #3 was found in Resident #1's bed with their breasts exposed and Resident #1 was seated in their chair observing. They were informed on the morning of 10/24/2025 of the 10/23/2025 incident between Residents #1 and #4 when Resident #4 was found in Resident #1's bed with their breasts exposed. They based their investigation outcome on both staff interviews and the family member witness that there was no sexual contact for any of the instances. If there was abuse, they would report the incidents. They stated they could not speculate abuse occurred.10NYCRR 415.4 (b)(2)(3)_______________________________________________________________________________________________________________________Immediate Jeopardy was identified, and the facility Administrator and Corporate Administrator were notified on 11/04/2025 at 5:26 PM. Immediate Jeopardy was removed on 11/05/2025 at 10:21 PM prior to survey exit based on the following corrective actions:- Facility hall monitors were instated for all three (3) shifts to ensure residents stayed out of other resident rooms- All residents in the facility were assessed for aggression risk.- Resident #1 was placed on a 1:1 at all times. - As of 11/06/2025, 100% of all staff currently working in the facility were educated on abuse, responding to abuse, signs of abuse, steps to take to protect residents, and reporting abuse.- Staff education was completed online, and multiple department facility staff working were interviewed on 11/06/2025 and were able to demonstrate understanding of the education. There were no discrepancies identified in the education provided and the responses from the interviewed staff.

Based on record review and interviews during the abbreviated (#2639795) survey, the facility failed to ensure all alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated for three (3) of eight (8) residents reviewed (Residents #1, #3, and #4). Specifically, on 10/05/2025, 10/09/2025, and 10/23/2025, Resident #1 was witnessed by visitors and/or staff engaging in sexually inappropriate behavior with Residents #3 and #4, who did not have capacity to consent. There was no documented evidence the incidents were thoroughly investigated to determine abuse and to protect residents from further abuse during the investigation. The facility's failure to investigate abuse thoroughly resulted in harm that is Immediate Jeopardy and Substandard Quality of Care for Residents #3 and #4 and placed all 111 residents in the facility at risk for the likelihood of serious harm, serious impairment, serious injury, or death.Refer to F 600 Free from Abuse and Neglect. Findings include: The facility policy Facility Incident/Abuse Investigation and Reporting, revised 09/2025, documented staff were to report any resident incident or suspected incident immediately to Supervisor/Administrator. The facility would conduct an immediate and thorough investigation, upon discovery of an incident including abuse. Should there be an allegation or suspected abuse, the employee was to notify the nursing supervisor who would assess the resident. The nursing supervisor would initiate an Accident/Injury report in the electronic program and notify the Director of Nursing immediately. The Director of Nursing would initiate the investigation which included witness statements and notify the Administrator. For residents who were cognitively impaired who may be unable to self-report abuse, the staff observed for verbal and non-verbal indications of changes in behavior, body language that may indicate physical discomfort or distress, unusual bruising, unexplained outbursts, and sudden negative responses to staff, family, visitor, or other residents.On 10/29/2025, Accident and Incident reports from 09/01/2025 to 10/29/2025 were requested. There was no documented evidence of a completed accident and investigation form for a 10/09/2025 incident between Resident #1 and Resident #3. The investigations provided for 10/05/2025 and 10/23/2025 only included the investigative summary and unsigned witness statements. The Administrator provided a copy of the 10/09/2025 investigation on 10/31/2025.10/05/2025 and 10/23/2025 Incidents: Resident #1 had diagnoses including stroke, unspecified dementia without behavioral disturbance, and depression. The 09/24/2025 Minimum Data Set documented the resident had severe cognitive impairment, no behavioral symptoms, and was independent with mobility and transfers.Resident #4 had diagnoses including Alzheimer's disease, cognitive communication deficit, and insomnia. The 09/03/2025 Minimum Data Set documented the resident had severely impaired cognition, had no behaviors, and was independent with mobility and transfers. The 10/05/2025 Licensed Practical Nurse #7 progress note for Resident #4 documented another resident's family member found Resident #4 with Resident #1 on top of them with no pants or undergarments. Staff intervened immediately and removed the residents from the room. The supervisor (unidentified) was made aware, and both residents were educated on appropriate behaviors. Resident #4 complained of stomach pain following the incident. There was no bruising or vaginal bleeding at the time. An incident report was filled out and given to the supervisor. The 10/05/2025 investigation summary completed by Director of Nursing #3 documented: - A visiting family member reported Resident #4 was lying down in Resident #1's bed asleep. No physical contact was noted by the staff (unidentified) when they arrived at the room. Resident #1 was noted to be in the corner of the room with their brief intact. Resident #4 was redirected from the room.- There was no fear, pain, or distress noted from Resident #1 or Resident #4. - Resident #4 complained about residents entering their room. Resident #1 had an alarming floor mat and alarming stop sign.- Both Resident #1 and Resident #4 were noted to only like to sleep in a brief on their lower half at night. - A Registered Nurse skin assessment was performed on Resident #4 with no findings. - Resident #4 was evaluated by the provider and Trazodone was started to help improve wandering into other resident rooms.- The incident was not reported to the New York State Department of Health as there was no pain, injury, or mental anguish noted at the time of the incident. - A witness statement by Licensed Practical Nurse #7 documented on 10/05/2025 at 6:45 PM, they were counting narcotics in the C Wing medication room when Certified Nurse Aide's #5 and #6 came to tell them a resident's family member found Resident #1 and Resident #4 in bed with no pants or briefs on. Resident #1 was lying on top of Resident #4. The two (2) residents were moved away from each other and placed on 15-minute checks.- A witness statement by Certified Nurse Aide #5 documented they were informed by Certified Nurse Aide #6 that Resident #1 and Resident #4 were lying in bed together. When they entered the room, Resident #1 was standing in the corner of the room with their brief intact with Resident #4 still lying on the bed. It was typed and not signed. The facility's immediate response to prevent recurrence included Resident #4 was evaluated by the medical provider to help improve wandering into other residents' rooms. Resident #1 had an alarming floor mat and alarming stop sign. The incident was not witnessed by staff and was reported by a family member. There was no documented evidence the family who witnessed the event was questioned regarding the incident between Residents #1 and #4. There was no documented determination how abuse was ruled out and what measures were put in place to protect other residents during the investigative process. During an interview on 10/30/2025 at 10:55 AM, Certified Nurse Aide #5 stated an incident occurred between Resident's #1 and #4 but they were unsure of the specific date. A certified nurse aide in training came to get them because a spouse of another resident saw Resident #1 on top of Resident #4. They stated when they approached the room, Resident #1 was walking away from their bed while picking their pants back up. Resident #4 had their pants and depends mid-shin between their knees and ankles and was rocking, shaking, and complaining of stomach pain. Resident #4 was not cognitively intact and was known to walk into another resident's bed but not take their clothes off. Registered Nurse Supervisor #10 came to the unit. They stated they were not asked to provide a statement of what they witnessed. They were told the Director of Nursing did not want a statement. During a phone interview on 10/30/2025 at 1:01 PM, Certified Nurse Aide #6 stated an incident occurred between Resident #1 and Resident #4 at the end of the first week of October. Another resident's family member came to get them to go to Resident #1's room. They stated when they arrived at the room Resident #1 had their pants down to their knees and was on top of Resident #4 who was without their pants or a brief. Resident #4 was visibly uncomfortable. They got Certified Nurse Aide #5, redressed Resident #4 and took the resident to the dining room. Between the short time they opened the door and got Certified Nurse Aide #5, Resident #1 had started fixing their pants and went to the corner of the room. They informed Licensed Practical Nurse #7. They had written a statement on a piece of lined paper because they were not given a statement form. They turned their statement into Licensed Practical Nurse #7. During a phone interview on 10/30/2025 at 11:27 AM, Licensed Practical Nurse #7 stated Resident #1 was found in their roommate's bed with Resident #4. Resident #4 was removed from the room. They did not ask either resident what happened and just kept them separated. They reported it to Registered Nurse Supervisor #10 who called the Director of Nursing. They were unaware if anyone else was notified. They filled out an incident report and completed a handwritten statement which were given to Registered Nurse Supervisor #10. They asked Registered Nurse Supervisor #10 for assistance with writing the progress note and they declined to assist. They were asked by the Director of Nursing to strike out their note in the electronic medical record and write another note, but they declined. During a phone interview on 10/30/2025 at 11:53 AM, Registered Nurse Supervisor #10 stated they did not recall the exact date of the incident between Resident #1 and Resident #4, but a nurse and three (3) certified nurse aides came in and told them another resident's spouse stated Resident #1 and Resident #4 were in bed together. They notified the Director of Nursing who told them to do an incident report and separate the residents. They did the incident report on paper but was told not to put a note in about the incident. They did not obtain statements from the staff. The 10/23/2025 Incident Report completed by Licensed Practical Nurse Supervisor #9 documented:- The incident was inappropriate behavior that occurred 10/23/2025 at 11:15 PM.- Resident #1 was physically impaired.- Resident #1 had no apparent injuries. - They were called to the unit as Resident #1 was found in their bed with Resident #4 and Resident #4's shirt was pulled up exposing their breasts.- When asked what happened, Resident #1 stated they were playing with Resident #4's breasts while the resident was in their bed. Resident #1 became upset during the conversation. - Resident #4 was moved to the opposite hallway and both residents were placed on 15-minute checks. The 10/23/2025 Investigation Summary completed by the Administrator documented: - Resident #4 was found in Resident #1's bed by staff (unidentified). Resident #4's shirt was slightly pulled up. Resident #4 was redirected to their room. - Resident #1 and Resident #4 were placed on 15-minute checks. - Resident #4 had a history of wandering into other resident rooms and did not remember why they went into Resident #1's room. Resident #4 preferred to only sleep in their brief. - Resident #1 became agitated when interviewed about the incident. They stated other residents wandered into their room and they were becoming irritated. Resident #1 reported a resident wandered in their bed and laid down to sleep. The resident denied any physical contact. - Resident #4's room was moved to another room on a different wing which the resident was agreeable with. - There were no histories of sexual tendencies with either Resident #1 or Resident #4. There was no documented evidence of how it was determined abuse was ruled out and what measures were put in place to protect other residents during the investigative process. There were no staff witness statements included in the report. There was no documentation of the previous incident with alleged sexual contact between Residents #1 and #4 on 10/05/2025. The 10/24/2025 at 4:23 AM progress note by Licensed Practical Nurse #8 documented at 11:00 PM (on 10/23/2025), they were doing rounds and noted Resident #4 was not in their bed. The resident was in Resident #1's bed with their shirt pulled up and breasts exposed. They immediately assisted Resident #4 out of Resident #1's bed and brought them to their room. They informed the nursing supervisor of what was found. Licensed Practical Nurse Supervisor #9 and Licensed Practical Nurse #8 spoke with Resident #1 about the incident. Resident #1 stated they were playing with Resident #4's breast once they got in bed with them. Resident #1 was placed on 15-minute checks. Resident #1 became upset when Licensed Practical Nurse #8 performed the check at 12:00 AM. Resident #1 stated it was not their problem the residents wander into their room. The 10/24/2025 at 4:23 AM progress note by Licensed Practical Nurse Supervisor #9 documented they were made aware Resident #1 was found with Resident #4 in their bed. The residents were separated and placed on 15-minute checks. They notified the Director of Nursing. During a phone interview on 10/30/2025 at 11:50 AM, Licensed Practical Nurse #8 stated on 10/23/2025, they found Resident #4 in Resident #1's bed with Resident #1. Resident #4 had their shirt pulled up and Resident #1 was lying next to Resident #4's breasts. They pulled Resident #4's shirt down and assisted them out of the room. They informed Licensed Practical Nurse Supervisor #9 and when Licensed Practical #9 asked Resident #1 what happened, they stated if the residents wander into their bed, they were going to play with the resident's breasts. Licensed Practical Nurse Supervisor #9 called the Director of Nursing at home with no response. They wrote a note in the electronic system and a handwritten statement. During a phone interview on 10/30/2025 at 1:40 PM, Licensed Practical Nurse Supervisor #9 stated they were the nurse and supervisor on C wing (the dementia unit) when Resident #4 was found in bed with Resident #1. They did not recall the details of the incident. The other incident they were present for as the supervisor was on 10/23/2025. Resident #4 was found in Resident #1's bed with their shirt up and breasts exposed. Resident #1's alarming floor mat was pushed away from the door, and the resident was mad. Resident #1 stated the other resident was in their bed, so they were going to play with their breasts. They documented it in a note and an incident report. They received handwritten statements from everyone on the shift. They called the Director of Nursing who did not answer so they sent a text message regarding what happened. 10/09/2025 Incident:Resident #3 had diagnoses including dementia with agitation, unspecified psychosis, and insomnia. The 10/05/2025 Minimum Data Set (a resident assessment tool) documented the resident had severely impaired cognition, was continuously inattentive, had fluctuating disorganized thinking, had no behaviors, and was independent with mobility and transfers. A 10/09/2025 at 12:07 AM Licensed Practical Nurse #8 progress note (in Resident #3's medical record) documented they and the supervisor (unidentified) found Resident #3 in another resident's bed (unidentified) with their shirt pulled up and their breasts exposed. The other resident was not in the bed at the time. The resident was placed on 15-minute checks per the supervisor. The 10/09/2025 Investigation Summary completed by Director of Nursing #3 documented:- Staff were performing 15-minute checks on Resident #1 on 10/09/2025, Resident #3 was found lying in Resident #1's bed with their shirt slightly pulled up and Resident #1 was not in the room. - Investigative findings were that Resident #3 had a history of wandering and was independent with ambulation. - Resident #3 was placed on 15-minute checks for wandering and started on 50 milligrams of Trazodone for sleep. - The incident was not reported to the New York State Department of Health due to there being no pain, injury, or mental anguish noted at the time of the incident. There was no documented evidence of how it was determined abuse was ruled out and what measures were put in place to protect other residents during the investigative process. There were no staff witness statements included in the report to determine when the last time Residents #1 and #3 were observed. There was no documentation of the previous incident with alleged sexual contact between Residents #1 and #4 on 10/05/2025. During a phone interview on 10/30/2025 at 11:50 AM, Licensed Practical Nurse #8 stated they found Resident #3 in Resident #1's bed with their shirt up and breasts exposed. Resident #1 was sitting in the chair next to the bed. They notified Licensed Practical Nurse #14 who was the supervisor who then notified the Director of Nursing at home. They were told they could not assume anything happened and Resident #3 was put on 15-minute checks. During an interview on 11/03/2025 at 12:45 PM, the Administrator stated they were aware of incidents when Resident #3 and Resident #4 wandered into Resident #1's room and were in Resident #1's bed. They were not sure of the dates. All the residents involved were deemed to not have capacity to consent to sexual behaviors. The Director of Nursing was responsible for completing suspected abuse investigations. They or the Director of Nursing were responsible to report abuse. They stated they could not confirm any intimate contact between the residents and did not feel the incidents were reportable. The first incident (10/05/2025) staff reported to the Director of Nursing the residents were clothed. The registered nurse assessment did not indicate any contact. They had all the residents on 15-minute checks, and Resident #1 had an alarming floor mat and stop sign at the door. They eventually moved Resident #1 off the dementia unit to another unit. They thought the family was notified by the supervisor or the Director of Nursing the next day. They determined there was no sexual contact because the family who witnessed the incident did not see any sexual behaviors.During an additional interview on 11/07/2025 at 11:48 AM, the Administrator stated:-on 10/05/2025 they were notified by the Director of Nursing regarding the 10/05/2025 incident between Residents #1 and #4. -They were not notified of the 10/09/2025 incident with Residents #1 and #3 until they moved Resident #1 off the unit on 10/24/2025. -They were notified by the Director of Nursing of the 10/23/2025 incident on 10/24/2024 at the same time they were notified of the 10/09/2024 incident when Resident #1 was moved to a different unit. -The Director of Nursing typically notified them verbally or in person of any incidents. They stated a thorough investigation included interviewing all staff, assessing the resident, following proper reporting guidelines, and implementing interventions depending on the investigation or situation determines. The Director of Nursing was responsible for investigations.During an interview on 11/03/2025 at 12:46 PM, the Director of Nursing stated they were notified on 10/05/2025 Resident #1 and Resident #4 were found in Resident #1's roommate's bed without pants on. They were informed by Registered Nurse Supervisor #10. They were not made aware of the 10/09/2025 incident until they read it on the 24-hour report on 10/10/2025. Resident #3 was found in Resident #1's bed with their breasts exposed and Resident #1 was seated in their chair observing. They were informed on the morning of 10/24/2025 of the 10/23/2025 incident between Resident #1 and Resident #4 when Resident #4 was found in Resident #1's bed with the resident with their breasts exposed. They based their investigation outcome on both staff interviews and the family member witness. There was no sexual contact for any of the instances. They stated they could not speculate. A thorough investigation had proper witness statements, the Director of Nursing being notified timely, and multiple interviews. The care plans and interventions should also be reviewed to ensure they were appropriate and working. For the 10/05/2025 incident, they reviewed the records for the residents, looked at the Accident and Incident reports, the interventions currently in place and made sure the supervisor put in some new interventions. The 10/09/2025 incident they were not made aware of, so the investigation was quick since Resident #1 was not in bed with Resident #3. The 10/23/2025 incident they reviewed the interventions in place, they did not think Resident #1 should be on that unit, so they moved the resident. The staff made it sound like Resident #1 was after people, but the resident was confused and did not know what they were doing. The Director of Nursing looked through the three (3) folders containing the investigations and stated there was not much in the folders and they were unaware of where the staff statements were. The Director of Nursing stated they did not know if family was called for the 10/05/2025 incident. The 10/09/2025 investigation was incomplete as there were missing witness statements and they were unsure if family was notified of this incident for Resident #1. The 10/23/2025 incident investigation was not complete as they needed to tidy up the witness statements from the staff. They could not locate any assessments for any of the incidents except for one (1) assessment done on 10/24/2025 the day after the 10/23/2025 incident. They based their investigation outcome on both staff interviews and the family member witness that there was no sexual contact for any of the instances. 10NYCRR 415.4(b)(1)(i) Immediate Jeopardy was identified, and the facility Administrator and Corporate Administrator were notified on 11/04/2025 at 5:26 PM. Immediate Jeopardy was removed on 11/05/2025 at 10:21 PM prior to survey exit based on the following corrective actions:- Facility hall monitors were instated for all three (3) shifts to ensure residents stayed out of other resident rooms- All residents in the facility were assessed for aggression risk. - Resident #1 was placed on a 1:1 - As of 11/06/2025, 100% of all staff currently working in the facility were educated on abuse, responding to abuse, signs of abuse, steps to take to protect residents, and reporting abuse.- Staff education was completed online, and multiple department facility staff working were interviewed on 11/06/2025 and were able to demonstrate understanding of the education. There were no discrepancies identified in the education provided and the responses from the interviewed staff.

Based on record review and interviews during the abbreviated survey (#2639795) the facility did not ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, administration failed to ensure residents were free from abuse, neglect and exploitation; and failed to ensure policies and procedures were properly identified, communicated, and consistently implemented. This failure resulted in Immediate Jeopardy in the areas of F600 Free from Abuse and Neglect, F609 Reporting of Alleged Violations, and F610 Investigation/Prevent/Correct Alleged Violation.Findings include: The undated Administrator job description documented they would set an example for all staff members, consultants and others affiliated with the facility which recognized the facility existed to serve the interest and the needs of the residents. They emphasized the importance of a resident's right to independence regarding all aspects of facility life and encouraged residents to participate together with staff in resolving conflict and problems which may arise. The Administrator notified the New York State Department of Health Office of Health Systems Management as required (including but not limited to); any changes in personnel as required by code; disaster/disruption of service events; facility alteration and all other issues required by code.The facility Quality Assurance Performance Improvement (QAPI) Plan, dated 10/2025, documented the purposed of quality assurance performance improvement was to take a proactive approach to continually improve the way the facility cared for and engaged with residents, caregivers, staff and other partners, to realize the vision to improve the lives of nursing home residents. The facility provided a means whereby negative outcomes related to resident care and safety could be identified and resolved through an interdisciplinary approach and positive outcomes could be reinforced and expanded to improve care. Resident's Free from Abuse and Neglect, Refer to the citation text under F600.The facility failed to ensure residents were free from abuse and failed to protect residents from further abuse for two (2) of four (4) residents reviewed.Reporting of Alleged Violations, Refer to the citation text under F609.The facility failed to ensure an incident of resident-to-resident abuse was reported to the State Agency, law enforcement, and the Administrator for three (3) of eight (8) residents reviewed. Investigate/Prevent/Correct Alleged Violation, Refer to the citation text under F610.The facility failed to ensure all alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated for three (3) of eight (8) residents reviewed. During an interview on 10/29/2025 at 12:49 PM, the Administrator stated the abuse incident files were with the Director of Nursing. At 12:55 PM, they provided a file for a 10/05/2025 incident and stated the Director of Nursing was wrapping up another investigation. At 2:12 PM, an incident report for 10/23/2025 was provided but they stated it was not complete.During an interview on 11/03/2025 at 12:45 PM, the Administrator stated they were informed of incidents of residents wandering into Resident #1's room and lying in Resident #1's bed. As far as they knew the residents were clothed. Resident #3's and #4's shirts were only slightly lifted. All three residents were deemed to not have decision making capacity for consent. Either they or the Director of Nursing reported incidents to New York State. Reporting depended on the investigation and witness statements to determine if the situation met reporting guidelines. They could not confirm any intimate contact between the residents for any of the incidents, so they did not feel it was reportable. During an interview on 11/06/2025 at 3:24 PM, the Administrator stated they did not previously have abuse on their list for quality performance improvement. They stated if a resident had inappropriate behaviors this was brought up in the staff morning meetings and they would evaluate if the interventions in place were working. They recently lost their social worker, but the unit managers should be assisting with interventions with the support of the certified nurse aides with managing residents with inappropriate behaviors.During a follow up interview on 11/07/2025 at 11:48 AM, the Administrator stated they were made aware of the 10/5/2025 the next day on 10/6/2025 but were not aware of the 10/09/2025 incident until 10/24/2025 after they were informed of the 10/23/2025 incident when the resident was moved off the unit. They were informed of all the incidents by the Director of Nursing. A thorough investigation included interviewing all staff, assessing the resident, following proper reporting guidelines, and implementing interventions depending on the investigation or situation. The Director of Nursing was responsible for investigations and verbally updated them on their investigative findings. 10 NYCRR 483.70(i)

Based on observations, record review, and interviews during the abbreviated (2639795) survey, the facility did not ensure a resident who displayed or was diagnosed with dementia received the appropriate treatment and services to attain and or maintain their highest practicable physical, mental, and psychosocial well-being for three (3) of seven (7) residents (Residents #1, #8, and #9) reviewed. Specifically, Residents #1, #8, and #9 had behavioral symptoms related to diagnoses of dementia and were not cared for in a dementia-informed manner with a personalized plan of care and interventions. Refer to F 600 Findings include:The facility policy Behavior Monitoring, revised 2/2025, documented behavior monitoring was utilized to identify specific behaviors, the frequency of behaviors, non-pharmacological interventions, and outcomes of prescribed psychological medications. The facility policy Social Worker-Services and Responsibilities, revised 8/2024, documented the facility provided a social service program that met the psychosocial needs of individual residents and provided services, based upon a comprehensive assessment, which assured the maximum attainable quality of life for the residents, the residents' emotional and physical well-being, self-determination, self-respect and dignity. Social Services was responsible for interpreting residents' needs and behaviors and extending professional intervention to all levels of staff suggesting positive approaches, such as alternatives to the use of restraints and psychotropic medications, and for assisting in providing corrective action for the residents' needs by developing and maintaining individualized social care plan.The facility did not provide a policy regarding dementia or their dementia care unit when requested.The dementia education for dealing with Dementia with Difficult behaviors provided by the facility included:- what dementia was and understand why difficult behaviors occur.- New Approaches for Dealing with Difficult Dementia documented someone dealing with dementia was not being deliberately difficult and being aware could keep the staff member safe. Strategies included to validate the person's feelings, avoid topics you think will upset them, not to argue, maintain a sense of calm, be accepting instead of contradicting, introduce pleasant stimuli into the situation, use familiar music, scents, and other items, try to engage the resident in their favorite hobby or interest, and use a cooling off period if needed.- Strategies on how to help a resident with dementia with difficulty behaviors were by knowing what causes the agitation, worry or frustration for the resident, speak in a calming soothing voice, and to step away if it was safe to do so.1) Resident #1 had diagnoses including stroke, unspecified dementia without behavioral disturbance, and depression. The 9/24/2025 Minimum Data Set documented the resident had severely impaired cognition with continuously present inattention, had no behavioral symptoms, was independent with mobility and transfers, and did not receive psychotropic medication. Resident 31's Comprehensive documented the following;-initiated 12/24/2024 and revised 1/7/2025, the resident had potential for alteration in socialization/leisure time activities related to preferring privacy and in room/unit activities. The resident was registered to vote and was a veteran. Interventions included provide an activity calendar, inform and invite to scheduled activities, provide verbal direction to leisure time activities, facilitate participation as desired, and promote program participation and praise efforts. Blank template interventions for resident's family history, life history, special interests, and room visits were on the care plan but were not updated with the resident's information.-initiated 12/27/2024 the resident had a problem related to neurological/memory deficits. The resident was alert and oriented to person and had memory loss/deficit related to a stroke. Interventions included to monitor for cognitive changes daily with care and their cognitive status necessitated frequent reminders.-Initiated 12/27/2024 and revised 10/30/2025, the resident had no alteration in their psychosocial well-being but had an alteration in mood and behavior pattern related to episodes of verbal aggression and a stroke. They had the potential to refuse care, hold hands with a resident on the memory care unit, to become physically aggressive toward caregivers when offered assistance with care. Interventions included an alarming floor mat for the resident's room door, encourage activities, encourage hobbies of interest, they preferred to wear only a brief on their bottom half to bed, provide a quiet environment and redirect from crowded areas, offer choices when assisting with personal care, monitor for sleep pattern and changes in mood/behavior and respond to behaviors by reapproaching during episodes of refusals. Nursing progress notes for Resident #1 documented:- on 10/5/2025 by Licensed Practical Nurse #7 it was reported a family member of another resident found Resident #1 on top of Resident #4 with no pants or undergarments. Staff immediately intervened and removed the residents from the room. They informed the supervisor immediately and both residents were educated on appropriate behaviors.- on 10/24/2025 by Licensed Practical Nurse #8 they were doing rounds and Resident #4 was in Resident #1's bed with their shirt pulled up and their breasts exposed. They immediately assisted Resident #4 out of Resident #1's bed and brought them to their room. Licensed Practical Nurse Supervisor #9 and Licensed Practical Nurse #8 spoke with Resident #1 about the incident, and they stated of course they were playing with Resident #4's breasts once they got in bed with them. Resident #1 was placed on 15-minute checks. Resident #1 became upset when Licensed Practical Nurse #8 performed the check at 12:00 AM. Resident #1 stated it was not their problem residents wandered into their room. Resident #1 picked up their alarm mat from in front of their door and threw it and stated, go [expletive] yourself. When the nurse went in to check the resident's wander alert device, they told the nurse they could not check it. Resident #1 told the nurse they would report them for touching them inappropriately if they tried to check their wander alert device. There was no documented evidence of follow up from behavioral health or social services regarding the behaviors documented in the referenced nursing notes. There were no documented care plan updates regarding the resident's behaviors or interventions regarding the resident's memory impairment except for the resident had the potential to take down or misplace their alarming floor mat in front of their door. During a phone interview on 10/30/2025 at 10:55 AM, Certified Nurse Aide #5 stated they were alerted by another certified nurse aide Resident #1 was on top of another resident in their roommate's bed. Resident #1 was walking away from the bed picking their pants back up while the other resident had their pants and brief mid-shin. They stated this was not the first time Resident #1 had behaved this way. The resident would give a smirk and say they were having fun. They stated the resident was touchy and would follow female residents on the dementia unit as well as lure them into their room. They also found the resident kissing other residents in the hallway. They would correct the resident and separate them. The resident had memory issues but was more alert than others on the dementia unit and could have a conversation. The alarm mat in the resident's doorway did nothing as the resident hopped over it, would kick it out of the way or shut it off themself. During a phone interview on 10/30/2025 at 11:50 AM, Licensed Practical Nurse #8 stated Resident #1 had several occurrences of inappropriate encounters with other residents after being moved to the dementia unit. The resident had a couple of different rooms on the unit due to their behaviors. The facility put a sensor bar on their door, but the resident constantly took down the sensor or turned it off. The resident stood in their doorway and attempted to lure female residents into their room. They stated when they asked Resident #1 about the resident in their bed with their shirt up, Resident #1 told them if another resident wandered into their bed they were going to play with their breasts. During a phone interview on 10/30/2025 at 12:45 PM, former Certified Nurse Aide #40 stated Resident #1 went into other resident rooms and appeared to know what they were doing. They witnessed Resident #1 going into a female resident room they undressed the resident by taking their top off and stared at the resident. They could not remember the other resident's name. During a phone interview on 10/30/2025 at 1:40 PM, Licensed Practical Nurse Supervisor #9 stated Resident #1 had behaviors for a while. After Resident #1 was found in bed with another resident with the other resident's breasts exposed, Resident #1 stated they would play with the resident's breasts if they were in their bed. The resident's alarm floor mat was pushed aside. Resident #1 was upset they had removed the other resident from their room and was getting physically aggressive with the staff and stated they hated all you women. They stated Resident #1 could remove the batteries from their alarm, turn it off and move it themselves. During a phone interview on 10/31/2025 at 4:06 PM, Former Director of Social Worker stated they had been the only social worker in the building. If a resident had sexual behaviors and they were notified of the issue they visited with the resident one on one, then monitor their moods and cognition to ensure there were no changes. If there were changes the resident would be referred to the Psychiatric Nurse Practitioner. The facility did not have a licensed psychologist or therapist. They documented the visit in a one-to-one visit note in the electronic medical record. Resident #1 was on the memory care unit, and they were asked to meet with the resident because a female resident was observed in their room. Resident #1 scored low on the Brief Interview for Mental Status (determines cognitive status), so they were demented. The resident was care planned for holding hands with a different female resident. They did not recall any other behaviors. Interventions on a resident's care plan were reviewed in the morning meeting if a resident had behaviors. Interventions should be reassessed, and different interventions would be tried if the current interventions were not working.2) Resident #8 had diagnoses including early onset Alzheimer's disease, dementia with agitation, and psychotic disorder not due to a known substance or physiological condition. The 8/2/2025 Minimum Data Set documented the resident had severely impaired cognition, continuous inattention, disorganized thinking that fluctuated, felt down depressed or hopeless for seven to eleven days, had physical and verbal behaviors directed towards others one to three days, and wandered one to three days. Resident #8's Comprehensive Care Plan documented:-initiated 11/4/2024 and revised 5/5/2025 the resident had a potential alteration in socialization and leisure time activities. Interventions included the resident was not able to vote, was a truck driver, enjoyed reading, bike riding, and being outdoors, was to be provided an activity calendar and verbal direction to the activities, and to promote and praise activity participation.-11/7/2024 and revised 10/30/2025, the resident was alert and orientated to person and their family. The resident had memory loss/deficit related to Alzheimer's dementia and disorder of the brain. Interventions included to monitor for cognitive changes daily with care and their cognitive status necessitated frequent reminders.-11/7/2024 and updated 11/5/2025, the resident had no alteration in psychosocial well-being and had an alteration in mood and behavior pattern related to a history of physical aggression, sexually orientated comments, and had the potential to disrobe and remove their Kardex (resident care instructions) from their closet. They were at risk for victimization related to their verbal outbursts, combativeness, Alzheimer's disease, dementia, anxiety, and wandering. Interventions included to call the resident's sibling when they had increased behaviors, encourage activities, encourage to express themself in a safe environment, establish trust with the resident, offer books and movies during periods of agitation, monitor for sexually inappropriate behavior, redirect and remind of appropriate behavior, and report changes in behavior, psychosocial functioning, and changes in expression of feelings. On 9/26/2025 the intervention to have two caregivers during care was added. On 11/4/2025 the resident had a history of non-targeted verbal outbursts and to redirect from other residents if they displayed any signs or symptoms of agitation. On 11/5/2025 the interventions to encourage hobbies of interest such as long walks and listening to music and to encourage to verbalize any forms of abuse or concerns regarding interactions with others. Prior to the update on 9/26/2025 the resident's care plan or interventions had not been updated since 6/26/2025. -11/3/2025 the resident had an alteration in behavior patterns related to physical and verbal aggression. The interventions included to monitor and report changes in behavior, monitor the anxiety level, report altercations to the Nurse Manager or social worker, and separate others from others when agitated. Nursing progress notes documented:-on 8/19/2025 the resident slept most of the shift but was awake and slightly agitated at lunch. The resident became mean quickly but was easily redirected.-on 8/23/2025 the resident was monitored for behaviors and was exit seeking one time during the shift and was banging on the door.-on 9/8/2025 the resident was wandering into other resident rooms and yelling at them. When redirected, the resident was yelling and swearing at staff.-on 9/8/2025 the resident had increased behaviors, continued to wander the halls and enter other resident rooms. They were verbally aggressive with redirection. They were aggressively shaking the back door, shoving walkers at staff, and slamming objects on tables. They continued to remove their non-skid socks. A one-time order of 0.5 milligrams of Ativan (anti-anxiety medication) was obtained and given to the resident.-on 10/10/2025 another resident complained the resident walked into their room, slammed the door, and started to go through their stuff. The other resident was able to get them out of their room. The other resident stated it was not the first time this happened.-on 10/20/2025 the resident was going into other resident rooms and pacing the halls. They became agitated and aggressive with staff when they were tried to enter other resident rooms. They were provided with food, fluids, and emotional support with some good effect.-on 10/24/2025 the resident was wandering inside the unit, invading the privacy of other resident's rooms, was difficult to redirect, and was verbally and physically abusive with residents and staff.-on 11/1/2025 the resident had a verbal altercation with another resident when they told the resident I'm going to stab you and then walked away.-on 11/2/2025 the resident was agitated, pacing the hallways, going into other resident rooms, and trying to get outside. Staff followed the resident, and the resident was given an as needed Ativan due to yelling and screaming at staff and other residents.-on 11/3/2025 at 7:59 AM, the resident reached for another resident's water and when the other resident told Resident #8 it was theirs, Resident #8 turned to walk away while saying they would stab the other resident with a knife.-on 11/3/2025 at 2:12 PM, the resident was slightly agitated at times and defecated in the activity room but was easily redirected.-on 11/3/2025 at 4:50 PM, staff heard yelling and responded to a resident room. Resident #8 was in another resident's room and the other resident struck Resident #8 with their reacher.- on 11/4/2025 a certified nurse aide was trying to toilet the resident when they became agitated and lunged at the certified nurse aide. They chased the certified nurse aide out of the bathroom where a different certified nurse aide intervened and assisted the resident to a different bathroom. The resident was mumbling to themself as they were assisted to the bathroom and was given an as needed Ativan for agitation.-on 11/6/2025 at 3:30 AM, the resident was walking down the hallway and opening the doors to other resident rooms. The certified nurse aide attempted to distract the resident from entering the room. The resident walked down the hallway to the lobby area and back. They were offered a snack and refused. The resident went into the dining room to the greenhouse exit and attempted to open the door. The alarm sounded and the resident left the area. They entered another resident's room and sat on their bed. When a certified nurse aide and the supervisor attempted to redirect out of the room, the resident stated, I am entering this room and one of you will die here and they threw a pair of pants at the supervisor. The resident was redirected out of the room and given an as needed dose of their Ativan with crackers and juice.-on 11/7/2025 the resident was wandering the halls, attempted to strike staff multiple times, threw multiple objects towards staff, and attempted to enter other resident rooms. Nurse Practitioner #13 was notified and provided a new order to transfer the resident to the hospital.The 10/9/2025 Psychiatric Nurse Practitioner #41 progress note documented the resident had a history of dementia, depression, impulsivity/inappropriate sexual behaviors. They were a poor historian and stated their mood was good during the visit but offered no other information. There were no acute concerns identified. A review of medications indicated the primary provider increased the resident's morning Trazodone (an anti-depressant) dose and combined the resident's Depakote (a mood stabilizer) doses into one dose. The resident was also on cimetidine (an antihistamine) for their inappropriate sexual behaviors with some effectiveness. Ativan was also added. The recommendation was to continue current medications, monitor for changes in behavior, reinforce coping skills, and non-pharmacological interventions, and monitor for medication side effects. There was no documentation indicating what the coping skills were or what non-pharmacological interventions were recommended.There was no documented social work follow up or reassessment following the resident's behaviors. There were no social work progress notes for the resident after 7/28/2025. During an interview on 11/6/2025 at 3:36 PM, Certified Nurse Aide #6 stated they knew what care a resident needed by their care plan. The care plan listed the interventions for behaviors, and they also received information on behavioral interventions in report and if a resident had a stop sign. Resident #8 became really agitated and irritated quickly and would get mean. The resident also liked to throw their drink cup. The staff did not do anything with Resident #8 alone. If the resident had behaviors, they reported it to the nurse and dealt with it as they had to give the resident care. The resident has also had behaviors directed toward other residents which included screaming matches with other residents and wandering into other resident rooms. They did not document behaviors as the certified nurse aide, they just reported to the nurse. There were no interventions that worked best for the resident they were aware of, they just got medications. If the resident received their medications consistently, they were redirectable. If they were in an altercation with another resident, sometimes offering them a ginger ale and saying to them Let's go drink the bubbly water would work to redirect them out of the area. During an interview on 11/7/2025 at 11:08 AM, Licensed Practical Nurse Unit Manager #32 stated they were responsible for the care plans on the B wing. If there were any changes needed to be made on an off shift, the supervisor on that shift would make them. Care plans were reviewed quarterly. They and the social worker were responsible for a resident's behavior care plan which included updating interventions. Interventions should be personalized. A resident with dementia did not have a specific dementia care plan, it was under their psychosocial well-being care plan. The intervention of activities or hobbies of choice should be made specific to the resident and their preferred hobbies. During an interview on 11/7/2025 at 11:33 AM, Licensed Practical Nurse #43 stated they know how to care for a resident through report, the Medication Administration Record and updates from the Unit Manager. Residents with behaviors were discussed in report. For a resident with dementia, it was likely the progression of their dementia, so they provided one-to-one support, supervised the resident, or removed them from the situation. They documented behaviors in a progress note, to the oncoming nurse, and on the 24-hour report. They also let the Unit Manager or supervisor know. Resident #8 had behaviors where they could become aggressive with staff and other residents. They intervened and redirected the resident elsewhere. The resident's medications that were prescribed to them seemed to work well with managing the resident's behavior. 3) Resident #9 had diagnoses including dementia with agitation and depression. The 8/13/2025 Minimum Data Set documented the resident had severely impaired cognition, had no behavioral symptoms, and was dependent or required moderate assistance for all activities of daily living.Resident #9's Comprehensive Care Plan documented:-8/20/2024 and revised 6/12/2025, the resident had an alteration in psychosocial well-being related to depression and a potential for alteration in mood and behavior pattern related to their dementia, history of verbal aggression, physical aggression and depression. The resident was at risk for victimization related to other resident's behaviors and their dementia. They declined to wear their identification bracelet. Interventions included encourage activities, hobbies of interest, reminiscing, expression of emotions in a safe environment, establish trust, separate from other residents when agitated, respond to behaviors with following diversions/approaches: re-approach during episodes of agitation and have two caregivers for activities of daily living when restless and behavior and monitor anxiety level, sleep pattern and mood and behavior change.-8/20/2024 and revised 7/24/2025, the resident had problems related to their neurological/memory. The resident was alert and orientated to person and family, had memory loss/dementia and a disorder of the brain related to dementia.-8/22/2024 and revised 6/12/2025, the resident had potential for alteration in socialization/leisure time activities related to preferring their room/unit, agitation/restlessness, and interruption of normal activity pursuits. Interventions included they chose not to vote, their daughter visited often, they worked as a police officer, was an Army veteran, provide an activity calendar, invite and transport to activities, and facilitate participation as desired. The intervention template for Special Interests was activated but resident information was not added, and it was not personalized for the resident.The 9/2/2025 Care Conference progress note by the Former Director of Social Services documented the resident declined attending group activities but did well with one-to-one visits and had no recent behaviors.The resident's behavior monitoring for September 2025 documented the resident had behaviors of yelling out multiple times during the morning shift of 9/26/2025 and the evening and night shift of 9/27/2025. There were several shifts without documentation. Nursing notes documented:-on 10/28/2025 the resident was yelling out at the beginning of the shift and was able to be redirected.-on 11/1/2025 the resident was in a fair mood during the shift but did try hitting staff when they were caring for the resident. The resident was redirected on behavior and informed staff was trying to help.-on 11/2/2025 the resident was yelling out for help and was fine when staff went into the room to address why the resident was yelling out.-on 11/6/2025 the resident was occasionally yelling out; one-on-one was done with some effect.-on 11/7/2025 the resident was calling out throughout the shift. They were medicated for generalized discomfort with positive effect and was easily calmed with conversation.There was no social work follow up regarding the resident's behaviors of yelling out or reassessment of needs or care plan interventions.During an interview on 11/7/2025 at 10:30 AM, Certified Nurse Aide #42 stated they knew how to care for a resident by the care plan in the resident's closet. They knew what behavioral interventions to use by knowing the resident and how the resident was talked to and approached. On the dementia wing, they usually took the resident by the hand and took them for a walk. If a resident had behaviors, they should talk to them, calm them down and talk to the Unit Manager about the behavior. They documented behaviors on paper on the dementia unit and if an incident happened or a resident had behaviors, they reported it to the nurse. Resident #8 sometimes had behaviors and wandered a lot around 3:00 AM. They would feed Resident #8, so they stayed happy. Resident #9 yelled out and sometimes got agitated. When Resident #9 yelled out, it helped to remind them where they were and remind them the staff were there to help take care of them. Resident #9's biggest issue was they forget where they were, and they could not get up and take care of themself anymore. Reassuring the resident where they were and that they were okay puts the resident in a better place.During an interview on 11/7/2025 at 11:05 AM, Registered Nurse Unit Manager #25 stated they were responsible for the nursing components of a resident's care plan. The social worker was responsible for a resident's psychosocial issues as well as the dementia care plan. Sometimes nursing did update the care plan if there was a behavioral component. Care plans were updated at least quarterly or sooner if there was a significant change. If a resident had behaviors, it would be on the care plan and the certified nurse aides would see them on the Kardex as it was tied to the care plan. Any sexual, physical, or verbal behavior would be on the care plan. Care plans should be personalized for the resident. They stated the social worker was no longer at the facility, so they worked with the Administrator on care plans.During an interview on 11/7/2025 at 11:16 AM, Registered Nurse Unit Manager #4 stated supervisors on the off shifts, managers, and all registered nurses were responsible for the care plans. The care plans were reviewed whenever there was a change for the resident and quarterly. The behavior care plan was an interdisciplinary team approach for interventions. All the behavior interventions were supposed to be listed on the care plan. Interventions should be personalized to the resident. A resident with dementia did not have a specific dementia care plan, it was listed under the psychosocial care plan and a memory care plan. The interventions for behaviors related to dementia should be listed on the psychosocial care plan. An intervention that included only activities or hobbies of choice was a personalized intervention.During an interview on 11/7/2025 at 11:48 AM, the Administrator stated they currently performed the social work duties for the facility. They did some care plans, but nursing staff had taken that over. Care plans were reviewed at least quarterly unless there was an incident or change. Care plan interventions should be personalized. An intervention that included hobbies or activities of interest should have a specific activity listed. A resident with a diagnosis of dementia should have their needs met under the care plans for activities, cognition, and psychosocial well-being. There was no social work follow up or psychosocial assessment conducted for Resident #1 after their three incidents with other residents. Resident #8 did not have any social work interventions or assessments for their recent behaviors as they had only been looking at pain for the resident. An activities aide came up with a great activity for the resident, collaging, which was effective for them. The resident also liked bicycles and had a book of pictures of old bikes they would let people look at with them. They also liked to talk about Europe. All those interests should be on the resident's care plan, so staff knew what to do for the resident. Resident #9 had behaviors of calling out but was unpredictable on how they were going to react to staff attempting to do one-to-one with them. Sometimes it agitated them more and they would say to get out of their room.During a phone interview on 11/12/2025 at 11:42 AM, the former Director of Social Services stated they met with Resident #1 following an incident when another resident went into their room. They were unsure of the context of the resident going into Resident #1's room but thought the resident was lying in bed with Resident #1. They could not recall if Resident #1 had behaviors. When a resident had behaviors, such as yelling at another resident or arguing, they talked with both residents. If the behavior was significant enough for the resident to be seen by the psychiatric nurse practitioner, they made that referral. The facility did not have a one-to-one therapeutic person. They stated they were also responsible for care planning that behavior in the psychosocial section. They documented any interaction they had with residents regarding their behaviors, in the electronic medical record. Resident #8 had behaviors. They met with the resident, but their cognitive status did not allow them to process any conversation about their behaviors. They would mainly meet with the resident to see if they could help the situation when allowed by the resident. They did not document every visit with Resident #8. Resident #8 liked to listen to music, was very cultured and liked to travel. They also met with Resident #9 a few times. Resident #9 did not have behaviors, but the resident could not have a roommate.10 NYCRR 415.12

Based on record review and interviews during the abbreviated survey (#2639795) the facility's governing body did not establish and implement policies regarding the management and operation of the facility. Specifically, there was not consistent communication between the governing body and the facility Administrator to ensure regulatory compliance. Deficiencies identified during the abbreviated survey included three Immediate Jeopardies in Free from Abuse and Neglect (F600), Reporting of Alleged Violations (F609), and Investigate/Prevent/Correct Alleged Violations (F610). Findings include:The 10/2025 facility policy Quality Assurance Performance Improvement (QAPI) Plan, documented:-The facility maintains a planned, systematic, organization-wide approach to design process that will measure, assess and improve the organization's performance and focus on indicators of quality.-The purpose of quality assurance performance improvement in the organization is to take a proactive approach to continually improve the way they care for and engage with residents, care givers, staff and other partners, to realize their vision to improve the lives of the nursing home residents. -The facility will provide a means whereby negative outcomes related to resident care and safety can be identified and resolved through an interdisciplinary approach and positive outcome can be reinforced and expanded to improve care. Refer to F 600 Free from Abuse and NeglectRefer to F 609 Reporting of Alleged ViolationsRefer to F 610 Investigate/Prevent/Correct Alleged ViolationsDuring an interview on 11/3/2025 at 12:46 PM, the Director of Nursing stated the 10/5/2025, 10/9/2025, and 10/23/2025 incidents were investigated by interviewing staff and reviewing the care plans for proper interventions. They ruled out abuse for the 10/5/2025 incident based on the interview of Resident #5's family member who stated there was no physical contact between Resident #1 and Resident #4. The 10/9/2025 incident they thought it was just Resident #3 wandering into Resident #1's bed and lying down in the bed. The 10/23/2025 incident, abuse was ruled out because Licensed Practical Nurse #8 stated there was no physical contact made, and no one witnessed any physical contact. For all three incidents, they ruled out abuse based on witness statements. They did not report the potential abuse to the New York Stated Department of Health because they did not think abuse happened. During an interview on 11/6/2025 at 3:24 PM, the Administrator stated they did a performance improvement plan for abuse prevention and detection. They stated they recently had been filling in as the social worker while being the Administrator. They did not assess the involved resident's mental health on 10/5/2025, because that would have been the prior social workers responsibility. They did not assess the resident's mental health on 10/9/2025 and 10/23/2025 because they were the Administrator.During an additional interview on 11/7/2025 at 11:48 AM, the Administrator stated they were made aware of the 10/5/2025 incident between Resident #1 and Resident #4 the day after the incident, when the Director of Nursing called them. They were not notified about the 10/9/2025 incident until 10/24/2025 when they moved Resident #1 to another unit after the 10/23/2025 incident. They stated they previously did not sign off on incident investigations, but the Director of Nursing notified them verbally about incidents. 10NYCRR 415.26(b)(3)(1)

Based on record review and interviews during the abbreviated survey (#2639795), the facility did not comply with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standard and principles that apply to professionals providing services in such a facility. Specifically, the facility did not provide requested accident and incident reports including abuse incident documentation when requested by the New York State Department of Health surveyor in a timely manner.Findings include:Refer to F609 - Reporting of Alleged ViolationsRefer to F610 - Investigate/Prevent/Correct Alleged ViolationsOn 10/29/2025 at 8:45 AM, the surveyor provided the Administrator a request for documents including their accident and incident reports for September 2025 and October 2025.On 10/29/205 at 9:45 AM, the Administrator provided copies of accident and incident reports for September 2025 and October 2025.On 10/29/205 at 10:45 AM, after review of the files provided, the surveyor clarified with Administrator the accident and incidents should include all abuse or injuries of unknown origin. The Administrator stated those were separate files and they would provide them for September 2025 and October 2025. On 10/29/2025 at 11:55 AM, the surveyor requested from the Administrator a second time the abuse incidents and files for September 2025 and October 2025.On 10/29/205 at 12:49 PM, the surveyor requested from the Administrator a third time the abuse incidents and files from September 2025 and October 2025. The Administrator stated the Director of Nursing had the files and they would bring them to the conference room.On 10/29/2025 at 12:55 PM, the Administrator brought in one file dated 10/5/2025 and stated the Director of Nursing had one more report they were finishing. The surveyor requested to review the unfinished file as it was.On 10/29/2025 at 2:12 PM, the Director of Nursing provided an incident report for an incident dated 10/23/2025 and stated the report was not completed. On 10/29/2025 at 4:18 PM, the surveyor requested additional accident and incident reports from April 2025 to date. On 10/31/2025 at 8:53 AM, the Administrator had not provided the requested accident and incident reports from April 2025 to date. On 10/31/2025 at 9:50 AM, the surveyor notified the Director of Nursing the 10/30/2025 at 4:18 PM requested accident and incident reports were not received.On 10/31/2025 at 9:53 AM, the Administrator provided hard copies of accidents and incidents since April 2025.10NYCRR 400.2

Based on observations and interviews during the recertification survey conducted 6/23/2025-6/27/2025, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for one (1) of three (3) medication carts (Unit A cart) and two (2) of two (2) medication rooms (Units A and B) reviewed. Specifically, the Unit A medication cart had one opened and undated insulin pen, one opened and undated multidose eye drop, and one opened and expired multidose eye drop; and the medication refrigerator temperatures on Units A and B were not consistently monitored. Findings include: The facility policy, Medication/ Treatment Labeling and Storage, revised 7/2013, documented medications were stored under proper temperature. The policy did not include instructions for labeling multidose vials or discarding expired medications. During an observation of the Unit B medication room on 6/25/2025 at 8:31 AM, the June 2025 medication refrigerator log was missing documentation of temperature readings on 6/14/2025, 6/18/22025, 6/19/2025, and 6/20/2025. During an observation of the Unit A medication cart and medication room on 6/25/2025 at 8:48 AM, the medication cart contained one opened and undated Lantus (long-acting) insulin (regulates blood sugar) pen, one opened and undated Latanoprost (reduces eye pressure) eye drops, and one opened and expired brinzolamide (reduces eye pressure) eye drops dated 4/13. The June 2025 medication refrigerator log was missing documentation of temperature readings on 6/1/2025, 6/6/2025, and 6/15/2025. During an interview on 6/25/2025 at 8:48 AM, Licensed Practical Nurse #4 stated the Lantus insulin pen was only good for 28 days after it was opened, and it did not have an opened date. Without being labeled there was no way of knowing when it was opened. The Latanoprost eye drops also did not have an opened date but should have. Eye drops were good for 30 days, so the brinzolamide eye drops with an opened date of 4/13 were expired. They stated the nurse who opened the medication was responsible to label them with an opened date. It was important the medication refrigerator temperatures were checked to ensure the stability of medications. During an interview on 6/27/2025 at 9:42 AM, Registered Nurse Unit Manager #3 stated medications should be dated when opened and discarded when expired. Insulin and eye drops required an opened date and expired 28 days later to ensure stability and safety. The day shift nurses were responsible for checking and documenting the medication refrigerator temperatures. If the temperatures were not documented, there was no way to ensure they were in the proper range for medication stability. During an interview on 6/27/2025 at 9:50 AM, the Director of Nursing stated medication carts should not have expired medications. Medications such as insulin, nasal sprays, eye drops, and inhalers should be labeled when opened and expired in 28 days after opening. The medication refrigerator temperatures should be monitored daily by the day shift nurse to ensure the medications inside were safe to administer. If the temperatures were missed by the day shift nurse the evening or night nurse should document the temperatures. 10NYCRR 415.18(d)

Based on observations, record review, and interviews during the recertification survey conducted 6/23/2025-6/27/2025, the facility did not ensure residents had the right to a dignified existence in a manner and an environment that promoted the maintenance or enhancement of quality of life for one (1) of one (1) resident (Resident #99) reviewed. Specifically, Resident #99 was independent with activities of daily living and was not allowed to shave independently. Findings include: The facility policy Resident Rights and Responsibilities, revised 1/13/2025, documented the facility rendered services that demonstrated belief in the dignity and worth of each individual. It was the objective of the facility the patient/representative was provided with optimal nursing and psychosocial care. Every effort was made by the staff to meet the patient/representative individual needs and requirements. The facility policy Activities of Daily Living, revised 10/2023, documented each resident received and the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care consistent with the residents needs and choices. Resident #99 had diagnoses including dementia, hypertension (high blood pressure), and chronic kidney disease. The 4/15/2025 Minimum Data Set assessment documented the resident had moderate cognitive impairment was independent with personal hygiene including combing hair, shaving, and washing/drying face and hands. The Comprehensive Care Plan initiated 1/13/2025 documented Resident #99 had a self-care deficit related to delirium with no performance deficit. Interventions included the resident was independent with hygiene needs until a revision on 1/24/2025 when the resident required set up assistance (helper sets up and resident completes activity, helper assists only prior to or following the activity). The undated care instructions documented the resident required set up assistance with hygiene. Observations and interviews with Resident #99 included: - on 6/23/2025 at 12:43 PM, they had stubble on their face. The resident stated they asked an unidentified staff earlier that day for a razor to shave as they had been shaving independently since admission several months ago. They were told by the staff they had to shave in front of them. The resident stated they gave the razor back to the staff and was upset because they shaved themself since they were [AGE] years old. - on 6/24/2025 at 8:52 AM, in the dining room with stubble on their face. - on 6/25/2025 at 9:52 AM, in the hall with stubble on their face. During an interview on 6/25/2025 at 11:30 AM, Certified Nurse Aide #11 stated they were responsible for assisting residents with their hygiene needs. Individual hygiene requirements were documented on the care plan which generated the residents care instructions. Resident #99 was independent with all their hygiene needs. They gave the resident a towel, hygiene supplies, and a razor and the resident completed all tasks including shaving and dressing. They were assigned to Resident #99 on several occasions and never watched them shave and the resident was always clean shaven. They observed the resident in the hallway and stated the resident needed a shave. They were not sure why staff did not allow the resident to shave independently and stated it was a dignity issue for the resident. During an interview on 6/25/2025 at 1:53 PM, Registered Nurse Unit Manager #13 stated certified nurse aides were responsible for assisting with activities of daily living care for all residents which included shaving. Care was completed according to the care plan and if a resident required set up only, they should be set up and not supervised. 10 NYCRR 415.5(d)(1)(i)

Based on observations and interviews during the recertification survey conducted 6/23/2025 -6/27/2025, the facility did not ensure a safe, clean, comfortable, and homelike environment for one (1) of three (3) units (A Unit) reviewed. Specifically, the ice/water dispenser in the A Unit dining room had standing fluids backed up in the drip tray and a public drinking fountain located at the A Unit nurses' station had standing fluids in the drink well. Findings include: During an observation on 6/23/2025 at 11:40 AM, the A Unit ice/water dispenser had a buildup of white scaley debris behind the dispenser chute. There was clear fluid built up to the very top of the drip tray. When water was dispensed it caused the water to overflow over the sides of the drip tray. During an observation on 6/23/2025 at 11:53 AM, Licensed Practical Nurse #4 filled two water pitchers with ice and water from the ice/water dispenser by placing the bottom of the pitcher over the drip pan that was filled to the top with fluid. The pitcher was in direct contact with the stagnant water. During observations on 6/23/2025 at 12:33 PM and 6/24/2025 at 8:52 AM, the water fountain near the nurses' station area had a sign that said, do not pour anything down it but water. There was standing brownish/pink fluid accumulated at the bottom of the drinking well. During an observation on 6/25/2025 at 12:20 PM, the ice/water dispenser drip tray was empty. The drip pan grate was rusty. When water was dispensed the drip tray filled quickly to the top and slowly began to drain. During an interview on 6/26/2025 at 10:51 AM, Licensed Practical Nurse #4 stated they practically had to smash the ice/water dispenser to get it to work and often had to go to dietary to get ice. The ice machine was like that for a month or two and they thought a new machine was ordered. It backed up in the past and had to be cleaned out in order to get it to drain. They did not recall the drain being full to the top on 6/23/2025 when they filled the ice pitchers. The drinking fountain did back up sometimes, and they thought it was because thickened liquids were poured down it. It was important the ice machine and the drinking fountain drained because there could be debris floating in the water/fluids which could be unhealthy. During an interview on 6/26/2025 at 11:02 AM, Registered Nurse Unit Manager #3 stated they did not notice the ice/water dispenser drip tray backed up and there were no work orders submitted they were aware of. The drinking fountain should be unplugged and was out of use for sanitary reasons. 10 NYCRR 415.29(b)(j)(1)

Based on observations, record review, and interviews during the recertification survey conducted 6/23/2025-6/27/2025, the facility did not ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for two (2) of two (2) meals reviewed (Lunch meals on 6/24/2025 and 6/25/2025). Specifically, food was not served at palatable and appetizing temperatures during the lunch meals on 6/24/2025 and 6/25/2025. Additionally, nine (9) of fifteen (15) anonymous residents during a resident council meeting and one (1) resident (Resident #12) interviewed stated the food did not taste good and was cold. Findings include: The facility policy Food Preparation, Service and Distribution, initiated 7/1/2008 and revised 10/2/2022, documented the facility would serve hot foods hot and cold foods cold in accordance with resident preference. During an interview on 6/23/2025 at 1:02 PM, Resident #12 stated the food was not good, they did not like the way food was prepared, and the food was never hot. During a resident council meeting on 6/23/2025 at 2:00 PM, nine anonymous residents stated the food was not good. During an observation on 6/24/2025 at 11:53 AM, Resident #77's meal was tested in the presence of Certified Nurse Aide #5, and a replacement tray was ordered. Food temperatures were measured as follows: sausage 113.4 degrees Fahrenheit, milk 60.4 degrees Fahrenheit, pudding 79.3 degrees Fahrenheit, and chocolate milk 59.5 degrees Fahrenheit. The lettuce in the lettuce and tomato salad was brown, wilted, and watery. Certified Nurse Aide #5 stated the lettuce was brown and did not look appetizing, the pudding was warm, and the sausage was cold. During a meal observation on 6/25/2025 at 1:03 PM, Resident #25's meal tray was tested in the presence of Nurse Educator #6, and a replacement tray was requested. Food temperatures were measured as follows: pasta 131.9 degrees Fahrenheit, milk 49.3 degrees Fahrenheit, beans 119.7 degrees Fahrenheit, mandarin oranges 71.2 degrees Fahrenheit, and tea 135.3 degrees Fahrenheit. The resident stated the food was not good and was cold. During an interview on 6/27/2025 at 9:07 AM, Dietary Aide/Cook #7 stated they did test trays once a month, which included temperatures. Hot temperatures should be over 145 degrees Fahrenheit and cold food should be below 40 degrees Fahrenheit. Pudding and mandarin oranges were considered cold and should be below 40 degrees Fahrenheit; sausage should be hotter than 113 degrees Fahrenheit; the milk was too warm at 60.4 degrees Fahrenheit; and the chocolate milk was too warm at 59.5 degrees Fahrenheit. They used shredded lettuce, and it should not have been wilted, brown, or watery. Food should be hot and palatable. During an interview on 6/27/2025 at 9:22 AM, the Food Service Director stated they did four test trays a month at different mealtimes to test temperature and palatability. They heard residents complained about the food. Hot food should be 140 degrees Fahrenheit and cold food should be below 40 degrees Fahrenheit. Sausage at 113.4 degrees Fahrenheit and was not hot enough; milk at 60.4 and 49 degrees Fahrenheit was not cold; chocolate milk at 59.5 degrees Fahrenheit was too hot; mandarin oranges at 71.2 degrees Fahrenheit was not palatable; and brown, wilted, and watery salad was not palatable. 10NYCRR 415.14(d)(1)(2)

Based on observations, record review, and interviews during the recertification survey conducted 6/23/2025-6/27/2025, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of one (1) resident (Resident #75) reviewed. Specifically, Resident #75 was on transmission-based precautions (contact precautions) and Housekeeper #9 cleaned Resident #75's room without wearing all required personal protective equipment, did not remove gloves or perform appropriate hand hygiene upon leaving the room, and cleaned another resident's room while wearing the same gloves; and Certified Nurse Aide #10 provided toileting care to Resident #75 without wearing appropriate personal protective equipment or washing their hands prior to leaving the resident's room. Findings include: The facility policy Policy Transmission Precautions, revised 7/2009, documented when it was determined that a resident needed isolation or special infection precautions to prevent the spread of infection, the appropriate precautions were utilized. Isolation and special infection precautions were carried out in accordance with Centers for Disease Control and Prevention guidelines and were designed to protect residents, employees, and visitors. The facility policy Infection Prevention and Control-General Statement, revised 11/2024, documented staff were trained regarding proper hand washing and proper use of personal protective equipment. The appropriate signage and personal protective equipment stations were present and stocked. The facility's Contact Precaution signage posted near resident room doors documented everyone must clean their hands, before entering and when leaving the room; providers and staff must put on gloves and gown before room entry and discard gloves and gown before room exit; do not wear the same gown and gloves for the care of more than one person; use dedicated or disposable equipment and clean and disinfect the reusable equipment before use on another person. Resident #75 had diagnoses including chronic kidney disease and adult failure to thrive (decline in overall health). The 4/25/2025 Minimum Data Set assessment documented the resident was cognitively intact and required partial/ moderate assistance with most activities of daily living. The Comprehensive Care Plan initiated 1/27/2025, and revised 6/26/2025, documented the resident had methicillin-resistant staphylococcus aureus (an antibiotic resistant bacteria) in a wound and vancomycin-resistant enterococci (an antibiotic resistant bacteria) in their urine. Interventions included transmission-based precautions per policy. The 6/17/2025 physician order documented contact precautions for methicillin-resistant staphylococcus aureus. During an observation on 6/24/2025 at 12:50 PM, the door to Resident #75's room had a contact precaution sign with the letter A on it. Housekeeper #9 knocked on Resident #75's door, put on gloves, grabbed a mop, and entered the room without putting on a gown. Housekeeper #9 mopped the floor in the room, exited the room with the mop, placed a wet floor sign, picked up a pen and made a notation on a piece of paper on their housekeeping cart, moved their housekeeping cart down the hallway, entered another resident room with the same mop, and touched the privacy curtain with their gloved hand. They did not change their gloves or perform hand hygiene between the two resident rooms. Housekeeper #9 exited the second room wearing the same gloves, placed the mop in the bucket, and removed their gloves. They did not perform hand hygiene. Housekeeper #9 took a roll of toilet paper and a clean trash bag from their housekeeping cart and re-entered the second room with those items. During an observation on 6/24/2025 at 1:02 PM, Certified Nurse Aide #10 entered Resident #75's room without performing hand hygiene or putting on a gown or gloves. They turned off the resident's call light and went behind the privacy curtain. When they exited the room they used an alcohol-based hand rub and proceeded down the hall. During an interview on 6/24/2025 at 1:08 PM, Certified Nurse Aide #10 stated there was a sign that told them what to put on before they entered a precaution room. The sign pertained to all staff and there was never a time the sign should not be followed. It was important precautions were followed because they prevented the spread of germs. After looking at the door, they stated Resident #75 was on precautions. They put Resident #75 on the bedpan, and did not wear a gown or wash their hands before they exited the room. They stated they should have done those things but was not paying attention. During an interview on 6/24/2025 at 1:15 PM, Housekeeper #9 stated they wore gloves when they cleaned resident rooms, and the gloves should be changed before entering another resident's room. They did not think they needed to wash their hands between glove changes. They were not sure if Resident #75 was on precautions, but they just cleaned their room. They saw the sign on the door and the bin outside the door, but did not think it applied to them as a housekeeper because it was for direct care staff only. They should have changed their gloves in between cleaning different resident rooms because they could transfer germs and chemicals from one room to the other. During an interview on 6/26/2025 at 11:02 AM, Registered Nurse Unit Manager #3 stated if a resident was on contact precautions hand hygiene was performed and a gown and gloves were put on before the room was entered. Before leaving the room, the gown and gloves should be removed and hand hygiene performed. Contact precautions applied to all staff who entered the room. Resident #75 was on contact precautions. They finished their antibiotic on 6/24/2025 and that was why the precaution order was discontinued 6/24/2025 at 11:59 PM. Housekeeper #9 should have followed the sign and should not have left the room with gloves, walked down the hall, and cleaned another resident's room wearing the same gloves. Certified Nurse Aide #10 should not have placed the resident on the bedpan only wearing gloves and should not have left the room without washing their hands. It was important contact precautions were followed to prevent the spread of infection and to protect residents, families, and staff. During an interview on 6/26/2025 at 12:53 PM, the Director of Nurses stated every staff member in the building was required to follow the directives on the signs to protect themselves and the residents from the spread of infection. Infection control training was an annual mandatory training for all employees. Staff should wear a gown while placing a resident who was on contact precautions on a bedpan. If their hands were not visibly soiled, then hand sanitizer was sufficient. Staff should never leave a contact room wearing the same gloves and proceed to touch their pen, cleaning cart, mops, or go into other resident rooms as that could spread infection. 10NYCRR 415.19(a)(b)

Based on observations and interviews during the recertification survey conducted 6/23/2025-6/27/2025, the facility did not maintain an effective pest control program so that the facility was free of pests in the main kitchen. Specifically, mouse droppings were observed in the kitchen dry storage room. Findings include: The facility policy Pest Control, revised 12/2006, documented a competent authority addressed issues of pest control on a monthly and as needed basis. Rodents were kept away by keeping dumpsters away from the facility, garbage from the kitchen was taken directly to the dumpster, and general garbage was taken out four times daily. Observations of mouse droppings under shelving in the dry storage room were made on: - 6/24/2025 at 12:25 PM - 6/25/2025 at 2:04 PM - 6/26/2025 at 12:04 PM During an interview on 6/26/2025 at 12:04 PM, Food Service Director #8 stated that kitchen floors were cleaned twice daily, and the walls were cleaned as needed. The dry storage room was swept and mopped nightly. Mice were occasionally found in the facility, and someone came routinely to check for pests. Mouse droppings should not be on the floor in dry storage. 10 NYCRR: 415.29(j)(5)

Based on observation, record review and interview during the recertification and extended surveys conducted from 7/13/21- 7/21/21, the facility failed to ensure the environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 2 of 2 residents (Residents #28 and #22) reviewed. Specifically, Resident #28 was observed in their room with a peanut can that contained 8 cigarette butts with ashes. Resident #28 reported that after smoking the resident would routinely bring the peanut can with cigarette butts and ashes into the facility and empty the contents into a plastic trash can in the unit kitchenette across from their room. The housekeeper reported the plastic trash can routinely contained smoked cigarette butts and ashes and that they had not reported this finding to anyone. The facility's failure to provide an approved metal disposal container with a self-closing lid in the smoking area and the resident's improper disposal of smoking materials in an unapproved container inside the facility puts all 97 residents and others in the building at immediate risk for injury as those materials could cause a fire. This resulted in Immediate Jeopardy and Substandard Quality of Care with the likelihood for serious harm to Resident #28 and the facilities other 97 resident's health and safety. -Resident #22 was observed smoking unsupervised and had smoking materials, including cigarettes and a lighter, unsecured in their room. Findings include: The facility's Smoking Policy documented there were two residents grandfathered into a smoke free facility. Regularly designated smoking session will take place at the southwest corner of the Garden Courtyard, which is more than 50 feet from the building entrance. Residents must turn in all smoking supplies (cigarettes, cigars, tobacco, pipes, lighters, and matches) to the nurse's station where they will be properly labeled with the resident's name. All smoking supplies will be stored in a container at the nurse's station to be distributed to the residents by a designated employee at the designated smoking time. Facility personnel shall report the finding of any smoking article found on the resident that had not been turned into the nursing station. 1) Resident #28 had diagnoses including [CONDITION(S)] (paralysis), [CONDITION(S)] (COPD) and major depressive disorder. The 4/19/21 Minimum Data Set (MDS) assessment documented the resident had intact cognition, required extensive assistance from 2 persons for most activities of daily living (ADL), supervision of one person for locomotion off the unit, did not ambulate, required a wheelchair. The residents current daily care guide (care instructions) last updated 2/12/18 documented the resident required assistance with dressing, grooming, and hygiene; was non-ambulatory; used a high back wheelchair; must be supervised at all times while smoking; and must wear a smoking apron at all times while smoking. The comprehensive care plan (CCP) initiated 1/21/20 and revised 5/7/21 documented the resident had self-care performance deficits related to [CONDITION(S)] and limited range of motion (ROM). Interventions included extensive assistance of 1. The CCP included smoking, resident used tobacco with the goal the resident would smoke in a safe environment through next review. The smoking CCP did not document an initiated date. Interventions included: provide resident with smoking policy, resident was a responsible smoker, smoking data collection tool was completed per policy, smoking safety equipment/apron provided during smoking times and the resident refused a smoking apron. The 1/22/21 comprehensive nurse practitioner (NP) exam documented Resident #28 was stable and continued to smoke daily. The 5/6/21 Smoking Data Collection tool completed by social worker (SW) #5 documented the resident would smoke in the designated smoking area. The resident did not need assistance to smoke, was a safe smoker, and had never had any unsafe smoking incidents. The resident was able to get to the smoking area, knew how to obtain cigarettes/lighter, could hold a cigarette securely, disposed of ashes in the ashtray, could extinguish the cigarette, returned cigarettes and lighter to appropriate designated area/staff and was able to call for emergency assistance if needed. Recommendation included the resident could smoke safely and did not require supervision or assistance. The 6/2/21 physician progress note documented the resident was evaluated for a routine visit, the resident complained of pain on and off in the lower extremities. However, the resident was up in their chair for long periods of time outside smoking cigarettes. The 6/25/2019 physician order documented use smoking apron while outside unattended. There were no additional orders related to resident smoking. During an interview on 7/13/21 at 1:00 PM, the Assistant Administrator/Director of Maintenance and Administrator both stated there were two residents at the facility who smoked, and both were grandfathered in to be allowed to smoke. Resident #28 could hold their cigarette in their hand and used a peanut to extinguish cigarettes. The resident was supposed to empty their ashes and cigarettes into the metal self-closing unit attached to the exterior wall adjacent to the courtyard exit door (approximately 10 feet from the door), before entering the facility. The 7/14/21 electronic Kardex (care instructions for the nursing assistant) documented under the safety category the resident was unable to ambulate, was a responsible smoker, and refused the smoking apron. During an interview on 7/14/21 at 9:31 AM, Resident #28 had a peanut can with cardboard sides, a metal bottom, and a plastic lid, that contained 8 cigarette butts and ashes was observed in the resident's room. The can was located on the table just inside room by the door. The resident stated that they dumped the cigarette butts in a receptacle outside in the smoking area. Resident #28 stated that propped the can beside their legs when they were in their wheelchair when going to smoke. The resident stated they had a full box of self-rolled cigarettes. The resident said that their lighter was in the soft bag that was currently on the floor in their room. Resident #28 stated that they were very careful when they extinguished a cigarette and made sure they put out all the embers before it went in the peanut can. During an observation on 7/14/21 at 1:54 PM, Resident #28 was outside in the courtyard behind the tent. The resident was lighting a cigarette and was not wearing a smoking apron. The resident was interviewed and said they kept their smoking supplies safe, and there were no residents that wandered into their room. The resident demonstrated scraping the tobacco off the end of the cigarette when they put the cigarette out. The peanut can was observed to have no lid. The resident stated that they did not usually keep the cigarette butts in the can but would get rid of them by throwing them away in the garbage in the staff break room/kitchenette located across the hall from their room. When observed on 7/14/21 at 2:30 PM, Resident #28 was coming back in from the main courtyard area and could not open the door. The resident was knocking on the door and the Assistant Administrator opened the door for the resident to come in. The resident was in a wheelchair and had a box of cigarettes, a peanut can, and a plastic bag on their lap. When observed on 7/14/21 at 3:56 PM, there were 3 cigarette butts and ashes in the B Unit staff breakroom plastic trash can just inside the doorway to the room. The cigarette butts and ashes were lying on top of a paper towel in the trash can. During an interview on 07/14/21 at 4:34 PM, temporary nurse aide (TNA) #1 stated that they were assigned to Resident #28 that evening. The resident went to their room and unloaded the bag off their lap and the peanut can was set on a table by their door. Staff did not empty the peanut can and that was usually already done by the resident. TNA #1 stated they were not sure where the resident disposed of the contents of the can. The TNA stated the resident usually stayed outside until 8-8:30 PM and the doors to the courtyard locked at 8:00 PM. When Resident #28 wanted to come inside, the resident would knock on the window and the supervisor would either hear the resident, or the resident would use a cell phone and call the main number. The resident was observed on 7/14/21 at 4:40 PM smoking unsupervised outside in the courtyard. During an interview on 07/15/21 at 11:28 AM, B Wing housekeeper #11 stated Resident #28 did not want anyone to touch their things. The resident kept lighter and cigarettes in a bag. Housekeeper #11 stated that Resident #28 had an empty peanut can they put the cigarette butts in outside and when the resident came inside, the resident dumped the can in the staff break room trash. Housekeeper #11 stated that they observed the resident doing this every day while in the breakroom. The housekeeper stated that they were not sure how the resident extinguished their cigarettes. Housekeeper #11 stated the trash can in the breakroom was plastic with a plastic bag liner and had a swing top and was used to dispose of cups, papers, paper plates, napkins, and plastic silverware. During an interview on 07/15/21 at 11:33 AM, licensed practical nurse (LPN) #2 stated the smoking area was out the back door where the solarium was located. LPN #2 stated there was another resident besides Resident #28 that went out there to smoke. LPN #2 stated they were not sure if there was a receptacle for the residents to put cigarette butts in. The LPN stated aides usually let Resident #28 out there and would bring the resident back in. LNP #2 stated the resident's lighter was kept in the top drawer of the medication cart. There was a lighter observed in the top drawer when the LPN opened the medication cart. The LPN stated that they were not sure if the resident had more than one lighter. LPN #2 stated they did not know where Resident #28 currently was located, and the resident had not asked for their lighter. The LPN stated there were no cigarettes kept in the medication cart and the resident kept their cigarettes in the bottom drawer of the dresser in their room. LPN #2 stated that they were not aware of the peanut can in the resident's room. During an observation on 07/15/21 at 11:51 AM, Resident #28 was outside in the far courtyard area, accompanied by physical therapy, doing upper body exercises. The resident had the peanut can at their side and there was one cigarette butt in the can. There was no smoking receptacle in the immediate area where the resident was sitting. During an interview on 07/15/21 at 11:51 AM, housekeeper #29 stated there were 2 residents that smoke outside by the gazebo area and thought there was a container outside for the cigarette butts which was emptied by maintenance. During an interview on 07/15/21 at 11:59 AM, certified nurse aide (CNA) #3 stated Resident #28 would go outside to smoke by themselves. The CNA stated the resident did not turn in their cigarettes or lighter when they came in from smoking and they did not know what the resident did with them. CAN #3 stated the peanut can was for the resident to put the cigarette butts in so the resident would not drop them. The CNA said that they thought the resident usually emptied the can outside but was not sure where. The CNA stated that they do not do anything with the peanut can as the resident took care of those things. During an interview on 07/15/21 at 1:25 PM, the DON stated the facility had two residents that smoked, Resident #28, and Resident #22. The DON stated there was a smoking assessment for each resident in the computer. The SW had been completing the assessments and then nursing reviewed them during the care plan meeting. Both residents were determined to be safe smokers and did not require supervision. The residents had smoking aprons to wear, and Resident #28 would wear the apron if staff would insist. The DON stated there were no scheduled smoking times. Resident #28 goes out before lunch and then again in the evening. The nursing staff were supposed to have the lighters at the nurse's station, in the medication cart. The residents had been keeping their cigarettes in their rooms but did not have access to light them in their rooms. The DON stated the smoking area was just off the entrance to the garden or courtyard, and there was a receptacle there connected to the building. That was where the residents sit to smoke. The DON stated Resident #28 went out to the gazebo at times to smoke, but usually sat by the area where the receptacle was. The DON was not aware of Resident #28 was using a peanut can for cigarette butts or that the resident was emptying the can in the trash can in the kitchenette. The DON stated the facility Administrator had asked residents to put the cigarette butts in the proper receptacle. The DON stated staff were supposed to go get the lighter from the resident when the resident came inside. The facility smoking policy specified the resident should be 50 feet away from the building and that staff should be getting the lighter from the resident or that the resident should be giving it back to the staff. The DON stated when Resident #22 goes to [CONDITION(S)] their lighter was kept at the nursing station, and their cigarettes stayed in their room. The DON stated that they assumed resident #22's lighter was in the medication cart. 2) Resident #22 had diagnoses including [CONDITION(S)] (COPD) and [CONDITION(S)] accident (CVA) with generalized muscle weakness and left side [CONDITION(S)] (partial paralysis). The 5/8/21 Minimum Data set (MDS) assessment documented the resident was cognitively intact and required extensive assistance of one person for activities of daily living (ADL), extensive assistance of one person for locomotion off the unit and utilized a wheelchair. Nursing progress notes dated 4/1/21 through 7/14/21 did not include documentation the resident was a smoker, went outside to smoke and/or where their cigarettes and lighters were kept. The Smoking Data Collection Tool completed by social worker #5 on 5/6/21 documented the resident designated smoking area was outside in the designated area. The resident did not need assistance while smoking, was a safe smoker and was able to state where the designated smoking area was and where smoking was not permitted. The resident was able to identify appropriate clothing for outdoor smoking. The resident had no physical limitations and used oxygen but was able to remove the oxygen prior to smoking times. The resident knew how to obtain cigarette/lighter, could light a cigarette, hold the cigarette safely, dispose of ashes in an ashtray, extinguish cigarette and return cigarettes and lighter to the appropriate designated area/staff. It was recommended the resident could smoke safely and did not require supervision or assistance. Staff would assist the resident with transport to and from the designated smoking area. The comprehensive care plan (CCP) initiated on 5/19/20 documented the resident smoked tobacco products. The resident was educated on safe smoking procedures by the Director of Nursing (DON) and the social worker. The resident declined to use the smoking apron. On 5/28/21 the resident continued to smoke and refused the apron. The goal documented was the resident would smoke in a safe environment through the next review and would utilize the proper smoking receptacle for disposal of cigarette butts. The resident was a responsible smoker and was to be supervised by staff when smoking. The resident would surrender their lighter to the staff so it may be locked in the medication cart during times when the resident was not smoking. The 6/8/21 Resident Daily Care Guide (care instructions) documented the resident required extensive assistance of 2 staff to assist the resident to the wheelchair. The resident required a smoking apron on when smoking and required supervision with smoking. The Kardex (care instructions) active on 7/14/21 documented under safety-smoker- responsible; smoking materials to be kept at nursing station; and supervise resident during smoking. During an interview on 7/13/21 at 11:33 AM, Resident #22 stated they smoked in the courtyard three times a day and staff would take them and leave them outside for about 15 minutes. The resident stated that they were able to remove their oxygen independently prior to smoking. On 7/13/21 at 12:38 PM, Resident #22 was observed alone on the courtyard patio smoking. The resident was wearing a smoking apron. During an interview on 7/13/21 at 1:56 PM, Resident #22 stated they keep their cigarettes and lighter in their nightstand drawer. During observation on 7/14/21 at 9:00 AM, Resident #22 was not in their room, their room door was wide open, and there was a lighter visible inside an empty tissue box in a basket on the rolling bed side tray table. During an interview on 07/14/21 at 2:11 PM, Resident #22 stated that they have always kept their cigarettes and lighter in the dresser/nightstand drawer. The lighter was observed in the basket on the bedside table. During an interview on 07/14/21 at 2:16 PM, CNA #6 stated Resident #22 went outside with a smoking apron on, and that the resident always sat on the pavement (patio) and was near the ash tray. The CNA stated that the resident kept their cigarettes and lighter in the top drawer of the nightstand. CNA #6 stated, as soon as the resident got up for the day, the resident put the lighter inside their top undergarment. The CNA stated the resident was safe to be left alone to smoke and the CNA set a timer on their phone to know when to go get the resident. The CNA stated that the resident had always kept their smoking supplies in their room. The resident's family would bring cigarettes and lighters to the resident. The CNA stated that they have never seen the lighter in plain sight when the resident was not there, and the resident's room door was usually closed. During an observation on 07/15/21 at 11:40 AM, Resident #22 had a lighter in their undergarment and cigarettes in their pant pocket. The smoking apron was folded and tucked next to their leg. Resident #22 stated that they only had one lighter, and the nursing staff trusted them. The resident stated, I am a safe smoker. During an interview on 7/15/21 at 1:22 PM, the Administrator stated the Quality Assurance committee wrote and reviewed the smoking policy and it was approved for two residents (Residents#22 and #28). The Administrator stated the facility was a non-smoking facility but Residents #22 and #28 had been grandfathered in. The social worker completed a smoking assessment which included checking the residents' cognitive ability with regards to safety. Physical therapy and occupational therapy would assess the residents to ensure their dexterity was acceptable. The Administrator stated Resident #28 goes further into the courtyard than Resident #22 to smoke. The two Residents could be outside alone because they were deemed independent. The Administrator stated the designated smoking area was right outside the door near the ashtray. There had been no accident or incidents with [CONDITION(S)] to clothes and/or personal materials. The Administrator stated that Resident #28 refused to wear the smoking apron and Resident #22 would wear the smoking apron. Resident #22 disposed of their cigarette butts in the ashtray on the wall ashtray near the courtyard door. Resident #28 used a can and emptied the ashes or butts in the ashtray on the wall on the way back in the building. The Administrator stated residents should not bring ashes or butts inside the building and they needed to be disposed of in the ashtray outside and not inside the building. The Administrator stated that the residents should keep their smoking supplies at the nurse's station and there was no documented log-in for smoking supplies. The Administrator was not aware that the residents were keeping their smoking supplies in their rooms or that Resident #28 was disposing of their cigarette butts in the trash can inside the building. The Administrator stated the facility social worker provided the smoking policy information to the residents. Nursing staff would be able to look at a resident's care plan and Kardex to know who smoked and what the supervision requirements were. During an interview on 07/15/21 at 1:33 PM, social worker (SW) #5 stated that they had 2 resident who smoked, Residents #22 and #28. The social worker stated that they completed a quarterly smoking evaluation for the two residents. SW #5 stated that the smoking assessment tool assessed for the resident's ability to properly extinguish, ability to light and dispose of butts properly. SW #5 stated during the smoking evaluation the social worker would have the resident explain the process of smoking and where the resident was supposed to extinguish and dispose of their butts. The SW stated the residents should keep their smoking supplies locked at the nursing station and not in their rooms. SW #5 stated Resident #22 used the ash tray outside of the building for cigarette butt disposal and Resident #28 had their own personal can and would empty it outside. Cigarette butts should not be disposed of in a trash can inside the building because it was fire hazard. During an interview on 07/19/21 at 3:01 PM, the Medical Director stated they were not aware the two residents and facility staff were not following the facility smoking policy. The Medical Director was familiar with Residents #28 and #22 and they were the only two smokers in the building. The Medical Director stated there should be smoking posts or pots for the garden area where Resident #28 preferred to smoke. ------------------------------------------------------------------------------------------------------------ Immediate Jeopardy was identified, and the facility Administrator was notified on 7/15/21 at 6:01 PM. The Immediate Jeopardy was removed on 7/17/21 based upon the following corrective actions taken: - Resident #28 and #22 were instructed that the only approved disposal receptacle was located on the patio attached to the building. The facility indicated they would have additional approved receptacles available for use within 7 days. - The facility educated and provided a test with pictures of the appropriate smoking area and receptacle to a total of 74 of 124 employees. Education was provided by the shift supervisors. Staff who had not received education would be educated by the Director of Nursing. 10 NYCRR 415.12(h)(1)(2)