Every finding on record at Susquehanna Nursing & Rehabilitation Center, L L C

Based on observations, interviews, and record review, the facility failed to ensure residents were free from abuse, neglect, misappropriation and exploitation for three of three residents (Residents #11, #63, and #90) reviewed. Specifically, on [DATE], the facility failed to remove Certified Nurse Aide #5 from direct resident care after Resident #90 filed a grievance against the aide. Subsequently, during a [DATE] facility Resident Council meeting with the Director of Social Services present, Residents #11 and #63 stated that Certified Nurse Aide #5 was rough with them while providing care. The facility's failure to remove Certified Nurse Aide #5 from resident contact after the [DATE] grievance was filed, resulted in psychosocial harm to Residents #11, #63 and #90 that is Immediate Jeopardy and Substandard Quality of Care and placed all 140 residents in the facility at risk for the likelihood of serious harm, serious impairment, serious injury, or death. Findings include:The facility policy Abuse Prohibition, last updated February 2023, documented residents had the right to be free from verbal, sexual, physical, mental abuse, mistreatment, neglect, and involuntary seclusion. The program included involving resident group council in developing, monitoring, and evaluating the facility's abuse prevention program. Inappropriate behaviors included rough handling of residents. The facility was to encourage all residents and personnel to report any signs or suspected incidents of abuse to facility management immediately.The facility policy Management of Patient/Resident and Family Complaints/Concerns/Grievances, last revised [DATE], documented the facility would make prompt efforts to resolve complaints/concerns/grievances and the resident had the right to voice grievances/concerns/complaints without fear of discrimination or reprisal. The facility was to take appropriate action in preventing any further potential violation of any resident during the grievance review and report certain violations as required by State law to the Administrator.The facility policy Facility Incident/Abuse Investigating and Reporting, last revised [DATE], documented residents had the right to be free from verbal, physical, sexual, mental abuse, neglect, and mistreatment. Personnel were required to report any resident incident or suspected incident immediately to the Supervisor/Administrator. Applicable incidents were to be reported to state agencies and all other required agencies within the specified time frames. All facility personnel were trained on abuse prevention and reporting requirements upon hire and at least annually. Any instances of alleged resident abuse were to be reported according to official federal and state rules and regulations. The facility would conduct an immediate and thorough investigation upon discovery of an incident. Allegations of mistreatment were to be reported within two hours, an incident (report) to be done, and an investigation to be conducted. Accused facility employees were to be suspended until the results of the investigation had been reviewed by the Administrator.1) Resident #11 had diagnoses including high blood pressure, anxiety, and need for assistance with personal care. The [DATE] quarterly Minimum Data Set (a resident assessment tool) documented the resident had full cognition, had impairment of one arm, used a walker or wheelchair, was dependent for toilet hygiene, was maximum assist with shower or bathing, was moderate assistance with upper body dressing, was dependent for lower body dressing, was supervision for personal hygiene, was maximum assistance for rolling in bed, was continent of bowel and bladder, and had frequent pain.The Comprehensive Care Plan dated [DATE] documented the resident had self-care deficits, was a fall risk, was at risk for impaired skin integrity, and was incontinent of bladder. Interventions included dependent of one for bathing/dressing/toileting, setup for personal hygiene, maximal assist for rolling side to side, remind to call for assistance, apply barrier cream after each incontinence, and incontinence care as needed.2) Resident #63 had diagnoses including high blood pressure and need for assistance with personal care. The [DATE] quarterly Minimum Data Set documented the resident had full cognition, used a walker and wheelchair, was set-up assistance for toilet hygiene/shower/bath/upper and lower body dressing/personal hygiene, was continent of bowel and bladder, had occasional pain, and had shortness of breath with exertion.The Comprehensive Care Plan dated [DATE] documented the resident had self-care deficits and was at risk for depression. Interventions included set-up assistance with bathing/dressing, independent with personal hygiene, respect and listening to expression of feelings, and provide emotional support.3) Resident #90 had diagnoses including stroke with left hemiplegia/hemiparesis (weakness or paralysis of one side of the body), high blood pressure, and depression. The [DATE] Minimum Data Set assessment documented the resident had full cognition, had impairments of one arm and leg, used a walker or wheelchair, and was dependent for toilet hygiene, and showering, Resident #90 was also dependent for dressing.The revised Comprehensive Care Plan dated [DATE] documented the resident had self-care deficits, had depression, and was on anticoagulant medications. Interventions included verbal cues and encouragement, reclining shower chair with foot portion elevated on shower days, shower on Thursday day shift, dependent of one for dressing, moderate assist with personal hygiene, maximum assist of two for stand and pivot transfers, non-ambulatory, offer choices, monitor for bruising, establish trust with resident, provide emotional support, psychotherapy referral as needed, respect and listen to expression of feelings, and was able to make needs known.The [DATE] facility Grievance Form documented Resident #90 complained of Certified Nurse Aide #5 being very rough with care. The resident did not inform the aide as the resident felt uncomfortable saying anything to the aide. The resident felt the aide did not care if they were being too rough. The resident stated they were not in fear of the aide but did not want the aide to provide further care for them. The aide was provided education on [DATE] and reviewed resident rights. The form was completed by the Director of Social Services and reviewed by the Director of Nursing and Administrator. The grievance form revealed the individuals interviewed were Resident #90, Certified Nurse Aide #5, and the Director of Social Services.Review of Certified Nurse Aide #5's timecard revealed they worked 20 days from [DATE] through [DATE].During a recertification survey Resident Council meeting on [DATE] at 1:38 PM, Resident #11 stated that during a facility run Resident Council meeting on [DATE], they stated that Certified Nurse Aide #5 was rough with them during routine care and they told the aide to stop hurting them. Additionally, Resident #63 stated Certified Nurse Aide #5 had sprayed their legs with cold water prior to a shower when the resident asked if the water was warm enough and then the aide laughed. Resident #63 stated they felt degraded. There were three other residents that stated they had similar experiences. Residents #11 and #63 stated the Director of Social Services was present during the [DATE] meeting and took notes. Residents #11 and #63 stated nothing was done about it. They stated, to their knowledge, the Director of Social Services was in charge of grievances.During an interview on [DATE] at 3:55 PM, Resident #63 stated that on the evening shift of [DATE], they were being given a shower by Certified Nurse Aide #5. Resident #63 stated the aide sprayed them with water prior to allowing the water to warm. The resident grabbed the hose and sprayed the aide with the water. Certified Nurse Aide #5 yelled out that the water was cold. The aide waited until the water warmed up and continued with the shower. Resident #63 stated they felt degraded and that Certified Nurse Aide #5 was mean.During an interview on [DATE] at 3:58 PM, Resident #11 stated Certified Nurse Aide #5 was rough when they came to do care. They would squeeze their bottom and hurt their genital area. They let it go because they thought it would stop when they told the aide not to come back. Certified Nurse Aide #5 smirked at them and acted like they were going to do what they had to do. They told them they did not want them to touch them that way. This happened this past month, and Certified Nurse Aide #5 stayed away for two weeks and then Certified Nurse Aide #5 came back and said they were going to change their bed. Resident #11 stated they had the aide's fingerprints on their leg immediately after being repositioned because Certified Nurse Aide #5 pushed so hard when turning them. They reported this to another aide but did not remember who. They stated they do not feel safe here and wish they had died when they were in the hospital.During an interview on [DATE] at 2:57 PM, Resident #32 stated there was a Resident Council meeting on [DATE]. The Director of Social Services attended the meeting. No other staff members from the facility attended the meeting that day. Resident #32 stated there were two residents that stated there was an aide that was rough when providing care.During a follow up interview on [DATE] at 3:53 PM, Resident #11 stated they told Certified Nurse Aide #5 in the late morning of [DATE], that they would like to get up and the aide told them that it was too late as it was almost 2:00 PM. Resident #11 also stated that Certified Nurse Aide #5 was very rough with them during care at times and that it hurt their perineal area. Resident #11 stated it happens every time Certified Nurse Aide #5 cares for them. They stated Certified Nurse Aide #5 told them that they were not being rough.During an interview with Social Worker #3 on [DATE] at 12:47 PM, with the Director of Social Services present, Social Worker #3 stated abuse training was done at least yearly for all staff. The Director of Social Services was the grievance officer. The facility had received a few grievances regarding staff. Social Worker #3 stated there was a certified nurse aide (unidentified), which residents had complained was too rough and that certified nurse aide received reeducation. Grievance forms were completed with two residents (unidentified), unidentified staff followed up, and the facility felt there was no abuse that occurred therefore it was not reported.During an interview with the Director of Social Services on [DATE] at 4:24 PM, with Social Worker #3 present, the Director of Social Services stated they were not sure when they last received abuse training, but it was mandated yearly. The Director of Social Services stated they were at the [DATE] Resident Council meeting and there were no abuse or inappropriate touching complaints reported. If that had happened, they would have notified the Administrator or Director of Nursing. The alleged staff member was to be removed from the unit pending completion of the investigation and the resident(s) made safe. They stated they were not a mandated reporter. The Director of Social Services stated they had a recent conversation with Resident #11, could not remember when other than it happened a while ago, about rough touching by staff in the genital area, took the complaint to administration, and did not feel it warranted a progress note. They stated the Director of Nursing did the investigation for this complaint. The Director of Social Services did not remember the employee's name. The Director of Social Services was not aware of an incident with Resident #63. It was determined through further interview, the Director of Social Services was referring to a complaint, involving a different certified nurse aide, from [DATE].During an interview on [DATE] at 11:37 AM, the Director of Nursing stated they were not aware of an allegation during a facility resident council meeting in which a resident stated a certified nurse aide was rough during their care or that a certified nurse aide sprayed a resident with cold water during a shower. They would expect staff to notify them if that occurred. All concerns during resident council meetings should be documented in the meeting minutes. The resident making the allegation was to be assessed, an investigation done, and a progress note made. The alleged staff member was to be suspended pending the investigation and residents and staff members of that unit were to be interviewed. The facility was to report such allegations to the New York State Department of Health within two hours. There should have been an incident report and investigation for the allegation of rough treatment with care and being sprayed with cold water in the shower.During an interview on [DATE] at 12:59 PM, Human Resources Manager #6 stated the facility was made aware in the beginning of [DATE] that Certified Nurse Aide #5 was accused of being rough during resident care. They did not think it was intentional and the aide was reeducated. Human Resources Manager #6 was not sure if the certified nurse aide was suspended. Human Resources Manager #6 was not aware of any shower incident. They stated they were present during part of the [DATE] Resident Council Meeting and could not recall any mention of roughness with care or a shower incident. If it was, a note should have been made and administration made aware. Certified Nurse Aide #5 was currently not suspended.During an interview on [DATE] at 4:08 PM, the Administrator stated all staff receive abuse training on hire and then yearly. Any abuse suspicion or allegations were to be reported to the supervisor, the Director of Nursing, and the Administrator. Prior to reporting the allegation, staff were expected to ensure the resident's safety, and the alleged staff member was to be removed from resident care and suspended pending investigation outcome. The facility would have to investigate any allegations of spraying cold water on a resident or inappropriate touching to determine if abuse occurred or not. If abuse was suspected, the facility had two hours to report that to the New York State Department of Health. The facility had their own reporting guidelines they were to follow. Any serious concerns brought up in a Resident Council Meeting were to be reported to the supervisor or Director of Nursing. The Administrator stated they were not aware of the allegations of a staff member being rough with a resident during care or of a staff member spraying a resident with cold water. If those concerns were brought up in resident council, they should have been documented in the meeting minutes. The staff member that was running resident council was responsible to maintain the meeting minutes. The Administrator stated they were aware of Resident #90's grievance of a staff member being rough during care, which occurred when the Administrator first began the job in early [DATE] and they did not know who Certified Nurse Aide #5 was. They stated they could not remember if the aide was suspended and did not recall the allegation.During an interview on [DATE] at 5:58 PM, the Director of Social Services stated they did not remember the roughness, and shower incident being brought up during the Resident Council Meeting, and stated they were made aware 15 minutes prior to this interview. The Director of Social Services stated that in the initial interview with surveyors, they were referring to an incident with another resident that occurred in [DATE] regarding sexual inappropriateness by another aide that was terminated. The Director of Social Services reiterated they were not aware of the allegation of roughness and the shower incident that involved Certified Nurse Aide #5 until [DATE]. If they had been made aware, they would have notified administration.During an interview on [DATE] at 9:00 AM, Certified Nurse Aide #5 stated they received abuse training within the last few months. They stated they had no disciplinary actions at the facility other than time attendance. They stated there was a complaint in [DATE] regarding them being too rough with care. The Director of Social Services talked to the aide about it, was given a verbal warning, and education was provided. The aide denied being aware of spraying a resident with cold water. The aide admitted that Resident #11 had told them to be more gentle with care.During a telephone interview on [DATE] at 12:14 PM, Physician #28 stated they had not been notified of recent staff-to-resident abuse. Physician #28 was aware of an incident that occurred a couple of months ago but did not have access to the record at the time of this interview. They stated they expected to be notified right away of any allegation of abuse or neglect. An investigation needed to be carried out, it should be reported to the New York State Department of Health, and it should be documented. The accused staff was to be suspended pending investigation for resident safety. Leaving an accused staff member to continue working could leave a negative impact. Physician #28 stated allowing a staff member to continue to perform care after a resident requested them not to posed emotional harm to that resident. Residents have rights and should be given a different care giver if requested.During an interview on [DATE] at 10:11 AM, the Director of Nursing stated the facility terminates staff members for rudeness to residents. Initially, they would send the accused home and educate them on customer services. The Director of Nursing stated they interview staff after receiving a submitted grievance. An investigation should occur for any staff-to-resident allegations and the staff member suspended during the investigation. The Director of Nursing was not aware of the allegations by Residents #11, #63, and #90 against Certified Nurse Aide #5, therefore Certified Nurse Aide #5 was not suspended and no other interviews conducted.During an interview on [DATE] at 1:13 PM, Registered Nurse Manager #14 stated they had been employed at the facility for three months. Registered Nurse Manager #14 stated resident specific care was documented in the care plan and on care instructions. They were aware of some staff being rough with resident care. Registered Nurse Manager #14 stated they were made aware, after assuming the manager position, of Certified Nurse Aide #5 being too rough with a resident during care and spraying another resident with cold water. Registered Nurse Manager #14 stated they had not had any issues with Certified Nurse Aide #5 since they assumed the manager role. Any inappropriateness, roughness, or abuse should be reported to the manager to prevent a reoccurrence to other residents. 10 New York Code Rules Regulation 415.4(b)(1)(i) Immediate jeopardy was identified, and the facility Administrator was notified on [DATE] at 5:10 PM. Immediate jeopardy was removed on [DATE] prior to survey exit based on the following corrective actions:- All residents were assessed and there were no further reports of staff inappropriateness or abuse.-The Immediacy and Removal Plan consisted of: Certified Nurse Aide #5 was removed from the schedule and placed on suspension in payroll. Final determination will be made at the conclusion of the investigation. Certified Nurse Aide #5 shall have no direct or indirect contact with any residents at Susquehanna Nursing and Rehabilitation Center. Residents #11 and #63 will have a comprehensive head-to-toe physical assessment by a registered nurse. Resident# 11's assessment will include a genital examination. They will be offered transfer to the hospital if they feel unsafe in Susquehanna Nursing and Rehabilitation Center. A psychosocial assessment will be completed and documented. Care plans for Residents #11 and #63 will be updated to reflect current needs, safety interventions, and psychosocial support. Social Services will follow up with resident #11 and #63 to assure psychological needs are met. Policy Review: The policy entitled Recognizing signs and symptoms of abuse or neglect, Facility Incident/Abuse Investigation and Reporting have been reviewed and found to be adequate. Immediate education and training of the entire facility has commenced regarding the policies noted above. Training includes identification of abuse as well as regulatory reporting per policies. All staff currently working (100%) in the facility have been educated and all additional staff will be educated prior to the start of their shift.-Staff education was completed [DATE]. There were no discrepancies identified in education provided and the response from the interviewed staff.

Based on observations, interviews, and record review, the facility failed to ensure allegations of abuse are reported immediately, but no later than two 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 of three incidents of alleged abuse involving Residents #11, #63, and #90. Specifically, on 07/08/2026, Resident #90 filed a grievance stating Certified Nurse Aide #5 was rough with care and on 07/22/2026, during a Resident Council meeting, Resident's #11 and #63 reported Certified Nurse Aide #5 was rough with care. There is no documented evidence these incidents were reported by the facility to the New York State Department of Health or local law enforcement and were not reported to the administrator of the facility. This resulted in psychosocial harm that is Immediate Jeopardy and Substandard Quality of Care for Residents #11, #63 and #90 placed all 140 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 Abuse Prohibition, last revised February 2023, documented residents had the right to be free from verbal, sexual, physical, mental abuse, mistreatment, neglect, and involuntary seclusion. The program included involving resident group council in developing, monitoring, and evaluating the facility's abuse prevention program. Inappropriate behaviors included rough handling of residents. The facility was to encourage all residents and personnel to report any signs or suspected incidents of abuse to facility management immediately. The facility policy Management of Patient/Resident and Family Complaints/Concerns/Grievances, last revised 05/15/2024, documented the facility would make prompt efforts to resolve complaints/concerns/grievances and the resident had the right to voice grievances/concerns/complaints without fear of discrimination or reprisal. The facility was to take appropriate action in preventing any further potential violation of any resident during the grievance review and report certain violations as required by State law to the Administrator. The facility policy Facility Incident/Abuse Investigating and Reporting, last revised September 2025, documented residents had the right to be free from verbal, physical, sexual, mental abuse, neglect, and mistreatment. Personnel were required to report any resident incident or suspected incident immediately to the Supervisor/Administrator. Applicable incidents were to be reported to state agencies and all other required agencies within the specified time frames. All facility personnel were trained on abuse preventions and reporting requirements upon hire and at least annually. Any instances of alleged resident abuse were to be reported according to official federal and state rules and regulations. The facility would conduct an immediate and thorough investigation upon discovery of an incident. Allegations of mistreatment were to be reported within two hours, an incident (report) to be done, and an investigation to be conducted. Accused facility employees were to be suspended until the results of the investigation had been reviewed by the Administrator. 1) Resident #11 had diagnoses including high blood pressure, anxiety, and need for assistance with personal care. The 05/22/2026 quarterly Minimum Data Set (a resident assessment tool) documented the resident had full cognition, had impairment of one arm, used a walker or wheelchair, was dependent for toilet hygiene, was maximum assist with shower or bathing, was moderate assistance with upper body dressing, was dependent for lower body dressing, was supervision for personal hygiene, was maximum assistance for rolling in bed, was continent of bowel and bladder, and had frequent pain. 2) Resident #63 had diagnoses including high blood pressure and need for assistance with personal care. The 06/12/2026 quarterly Minimum Data Set documented the resident had full cognition, used a walker and wheelchair, was set-up assistance for toilet hygiene/shower/bath/upper and lower body dressing/personal hygiene, was continent of bowel and bladder, had occasional pain, and had shortness of breath with exertion. 3) Resident #90 had diagnoses including stroke with left hemiplegia/hemiparesis (weakness or paralysis of one side of the body), high blood pressure, and depression. The 07/27/2026 quarterly Minimum Data Set documented the resident had intact cognition, had impairment of one arm and leg, used a wheelchair, was dependent for all hygiene and dressing, was dependent for shower/bath, was dependent for all transfers, and was continent of bowel and bladder. The 07/08/2026 facility Grievance Form documented Resident #90 complained of Certified Nurse Aide #5 being very rough with care. The resident did not inform the aide as the resident felt uncomfortable saying anything to the aide. The resident felt the aide did not care if they were being too rough. The resident stated they were not in fear of the aide but did not want the aide to provide further care for them. The aide was provided education on 07/16/2026 and reviewed resident rights. The form was completed by the Director of Social Services and reviewed by the Director of Nursing and Administrator. The grievance form revealed the individuals interviewed were Resident #90, Certified Nurse Aide #5, and the Director of Social Services. During a recertification survey Resident Council meeting on 08/03/2026 at 1:38 PM, Resident #11 stated that during a facility run Resident Council meeting on 07/22/2026, they stated that Certified Nurse Aide #5 was rough with them during routine care and they told the aide to stop hurting them. Additionally, Resident #63 stated Certified Nurse Aide #5 had sprayed their legs with cold water prior to a shower when the resident asked if the water was warm enough and then the aide laughed. Resident #63 stated they felt degraded. There were three other residents that stated they had similar experiences. Residents #11 and #63 stated the Director of Social Services was present during the 07/22/2026 meeting and took notes. Residents #11 and #63 stated nothing was done about it. They stated, to their knowledge, the Director of Social Services was in charge of grievances. Review of Certified Nurse Aide #5's timecard revealed they worked 20 days from 07/09/2026 through 08/05/2026. During an interview on 08/04/2026 at 3:53 PM, Resident #11 stated that Certified Nurse Aide #5 was very rough with them during care and that it hurt their perineal area. The resident stated it happens every time the aide cares for them. The resident stated the aide told them that they were not being rough. During an interview with Social Worker #3 on 08/05/2026 at 12:47 PM, with the Director of Social Services present, Social Worker #3 stated abuse training was done at least yearly for all staff. The Director of Social Services was the grievance officer. The facility had received a few grievances regarding staff. Social Worker #3 stated there was a certified nurse aide (unidentified), which residents had complained was too rough and that certified nurse aide received reeducation. Grievance forms were completed with two residents (unidentified), unidentified staff followed up, and the facility felt there was no abuse that occurred therefore it was not reported. There is no documented evidence of any facility reported events in the month of July related to Resident #90's grievance or complaints brought to the Director of Social Services by Resident #11 and #63. During an interview with the Director of Social Services on 08/05/2026 at 4:24 PM, with Social Worker #3 present, the Director of Social Services stated they were not sure when they last received abuse training, but it was mandated yearly. The Director of Social Services stated they were at the July 2026 Resident Council meeting and there were no abuse or inappropriate touching complaints reported. If that had happened, they would have notified the Administrator or Director of Nursing. The alleged staff member was to be removed from the unit pending completion of the investigation and the resident(s) made safe. They stated they were not a mandated reporter. The Director of Social Services stated they had a recent conversation with Resident #11, could not remember when other than it happened a while ago, about rough touching by staff in the genital area, took the complaint to administration, and did not feel it warranted a progress note. They stated the Director of Nursing did the investigation for this complaint. The Director of Social Services did not remember the employee's name. The Director of Social Services was not aware of an incident with Resident #63. It was determined through further interview, the Director of Social Services was referring to a complaint, involving a different certified nurse aide, from January 2026. During an interview on 08/06/2026 at 11:37 AM, the Director of Nursing stated they were not aware of an allegation during a facility resident council meeting in which a resident stated a certified nurse aide was rough during their care or that an aide sprayed them with cold water during a shower. They would expect staff to notify them if that occurred. All concerns during a resident council meeting should be documented in the meeting minutes. The resident making the allegation was to be assessed, and investigation done, and a progress note made. The alleged staff member was to be suspended pending the investigation and residents and staff members of that unit were to be interviewed. The facility was to report such allegations to the New York State Department of Health within two hours. There should have been an incident report and investigation for the allegation of rough treatment with care and being sprayed with cold water in the shower. During an interview on 08/06/2026 at 12:59 PM, Human Resources Manager #6 stated the facility was made aware in the beginning of July 2026 of Certified Nurse Aide #5 being rough during resident care. They did not think it was intentional and the aide was reeducated. Human Resources Manager #6 was not sure if the aide was suspended. Human Resources Manager #6 was not aware of any shower incident. Human Resources Manager #6 stated they were present during part of the July 2026 resident council meeting and could not recall any mention of the roughness with care or shower incident. If it was, a note should have been made and administration made aware. Certified Nurse Aide #5 was currently not suspended. During an interview on 08/06/2026 at 4:08 PM, the Administrator stated all staff receive abuse training on hire and then yearly. Any abuse suspicion or allegations were to be reported to the supervisor, the Director of Nursing, and the Administrator. Prior to reporting the allegation, staff were expected to ensure the resident's safety, and the alleged staff were removed from resident care and suspended pending investigation outcome. If abuse was suspected, the facility had two hours to report that to the New York State Department of Health. The facility had their own reporting guidelines they were to follow. Any serious concerns brought up in a resident council meeting were to be reported to the supervisor or Director of Nursing. The Administrator stated they were not aware of the allegations of a staff member being rough with a resident during care or of a staff member spraying a resident with cold water. If those concerns were brought up in resident council, they should have been documented in the meeting minutes. The Administrator stated they were aware of Resident #90's grievance of a staff member being rough during care, that occurred when the Administrator first began the job in early July 2026, and they did not know who Certified Nurse Aide #5 was. They stated they could not remember if the aide was suspended and did not recall the allegation. During an interview on 08/06/2026 at 5:34 PM, the Director of Social Services, Administrator, and the Director of Nursing all stated they were not aware of Resident #11's statements related to rough handling. During an interview on 08/06/2026 at 5:53 PM, the Director of Social Services, Administrator, and Director of Nursing all stated were not aware of the shower incident with Resident #63 until it was brought to their attention by surveyors. During an interview on 08/06/2026 at 5:58 PM, the Director of Social Services stated they did not remember the roughness, and shower incident being brought up during the resident council meeting, and the Director of Social Services was not aware of either until 15 minutes prior to this interview. The Director of Social Services stated that in the initial interview with surveyors, they were referring to an incident with another resident that occurred in January 2026 regarding sexual inappropriateness by another aide that was terminated. The Director of Social Services reiterated they were not aware of the allegation of roughness and the shower incident that involved Certified Nurse Aide #5 until 08/06/2026. If they had been made aware, they would have notified administration. During an interview on 08/07/2026 at 9:00 AM, Certified Nurse Aide #5 stated they received abuse training within the last few months. The aide stated they had no disciplinary actions at the facility other than time attendance. Certified Nurse Aide #5 stated there was a complaint in July 2026 regarding the aide being too rough with care. They stated the Director of Social Services talked to them about it, received a verbal warning, and education was provided. Certified Nurse Aide #5 denied being aware of spraying a resident with cold water. Certified Nurse Aide #5 admitted that Resident #11 had told them to be gentler with care. During an interview on 08/07/2026 at 2:57 PM, Resident #32 stated the resident council meeting was held on 07/22/2026. The Director of Social Services attended the meeting. No other staff members from the facility attended meeting that day. There were two residents that stated there was an aide that was rough when providing care. 10 New York Code Rules Regulation 415.4(b)(1)(i) Immediate Jeopardy was identified, and the facility Administrator was notified on 08/07/2026 at 5:10 PM. Immediate jeopardy was removed on 08/08/2026 prior to survey exit based on the following corrective actions:Plan to Remove Immediacy- To ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but not later than two hours after the allegation is made has the likelihood to cause serious injury, serious harm, serious impairment, or death. The following steps have been implemented: The facilities policy on Facility Incident/ Abuse Investigation and Reporting was reviewed and meets the needs of the facility. All staff members in the facility were educated on the policy and on their roles and responsibilities in the abuse reporting process. Specific portions of the policy addressing the components of abuse reporting have been highlighted. In addition, staff were given Badge buddies for quick reference about the abuse reporting process and required time frames to reinforce the policy.-Staff education was completed 08/08/2026. There were no discrepancies identified in education provided and the response from the interviewed staff.

Based on observations, record review, and interviews, the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection and prevent new ulcers from developing for two of three residents (Resident #12 and Resident #32) reviewed. Specifically, Resident #12 developed a wound on the right buttocks that was identified as an unstageable (full-thickness tissue loss where the true depth cannot be seen because the dead tissue block the wound base) pressure ulcer on 04/14/2025. Resident #32 developed a Stage 2 (partial-thickness skin loss that may appear reddened or as a ruptured blister) pressure ulcer on 04/08/2026 on the sacrum/coccyx (small, triangle-shaped bone at the very base of the spine). Subsequently, on 05/18/2026, the pressure ulcer progressed to a Stage 3 (full thickness tissue loss into the subcutaneous (fatty) tissue) and on 08/04/2026, a new Stage 1 (redness that does not fade when pressure is applied) pressure injury was identified on Resident #32's coccyx. The wound treatments for Resident #32 were not consistently documented as completed from 04/14/2026 through 07/27/2026. This resulted in actual harm to Resident #12 and Resident #32 that was not Immediate Jeopardy. Cross reference to F880Findings includeThe facility policy Documentation of Pressure Ulcer and Chronic Wounds revised June 2023 documented pressure ulcers and chronic wounds are monitored closely to monitor effectiveness of treatment and change in risk factors. Risk factors will be identified, monitored and documented on the Skin Risk Data Collection Tool; upon admission, then quarterly and whenever there is a change in condition. A skin inspection is completed weekly on shower day. An ongoing inspection and assessment of all pressure sores and chronic wounds will be conducted weekly and as needed. All pressure ulcers and chronic wound dressings will be inspected daily. The Assistant Director of Nursing will be the official baseline and subsequent reference point for all skin/wound assessment. The provider will be updated on new skin issues/or changes in conditions. The facility policy Risk for Skin Breakdown, revised January 2026, documented skin integrity assessments will be completed and documented upon admission and on an ongoing basis as indicated. For each qualifier category listed on the skin risk data collection tool the resident will receive one check mark. One related qualifier would be considered at risk for skin break down and are care planned accordingly. Qualifiers include history of skin breakdown, mobility deficits, moisture/aging skin, nutrition, refusal of treatment and comorbid conditions. Based on the qualifiers, preventative measures are developed by the Unit Coordinator, with input from the physical therapist, occupational therapist, dietitian and physician if indicated.1)Resident #12 had diagnoses including dementia, muscle weakness, and protein calorie malnutrition. The 04/02/2025 Minimum Data Set (a resident assessment tool) documented the resident had severely impaired cognition, was dependent on staff for toileting; substantial/maximal assistance for bathing; supervision for personal hygiene; was at risk for pressure ulcers, had a pressure reducing device for the bed and a chair, and did not have a pressure ulcer.The 01/26/2025 revised comprehensive care plan documented the resident was at risk for skin injury. Interventions included administer treatment per physician orders and evaluate skin weekly.The 03/10/2025 and 03/17/2025 Wound Consult notes documented the resident as at risk for pressure ulcers. Interventions included to continue the turning and positioning schedule, continue to provide incontinence care, use a chair cushion, use an alternating air loss mattress and ensure the settings were maintained, moisture barrier cream, and use wedges and pillows for positioning. The resident had a pressure ulcer on the bottom of the left foot. The foot wound was resolved, and the wound care provider was ending services on 03/18/2025.The 03/18/2025 Nursing Weekly Skin Status Documentation form, completed by, the Assistant Director of Nursing, documented a healed left plantar (bottom of the foot) Stage 3 pressure ulcer. There was no documented evidence of further Nursing Weekly Skin Status Documentation forms completed until 04/14/2025. The 04/09/2025 physician order documented a treatment to right buttocks: cleanse with Dakins 0.125% solution (topical antiseptic to clean skin wounds), apply nickel thick Santyl (used to clean and remove dead tissue) to peri area and secure with bordered foam, change twice a day and as needed for wound care. There was no other documented evidence of a right buttock wound from 03/18/2025 to 04/14/2025.The 04/14/2025 Wound Consultant Nurse Practitioner #17 note documented the resident was seen for a new wound to the right buttocks. There was a notable unstageable pressure injury to the right buttock. The resident was incontinent of bowel and bladder and had poor bed mobility. Nursing staff were unclear of the onset of the wound. The wound assessment was documented as a new unstageable pressure ulcer/injury to the right buttock. The wound measured 3.5 centimeters by 2.5 centimeters by 0.2 centimeters, and the calculated area was 8.75 square centimeters. The wound edges were unattached, with 100% slough (shedding of dead skin cells), and a moderate amount of serosanguinous (a thin, pale pink, or light red fluid) drainage noted. The resident was recommended for nutritional consult for reevaluation of current protein supplements. Education was provided to the staff regarding the resident wound, dressing care, and general treatment recommendations. Recommendations included moisture barrier cream for incontinence, ongoing pressure reduction, and turning and repositioning.The 04/16/2025 Nursing Weekly Skin Status form, completed by the Assistant Director of Nursing, documented a new, unstageable pressure area to the right buttock, measured 3.5 centimeters in length, 2.5 centimeters in width and 0.2 centimeters in depth, with a moderate amount of serosanguinous drainage. Treatment recommendations: cleanse with 0.25% Dakins solution, apply Santyl nickel thick layer to base of wound and secure with bordered foam, change daily and as needed. Continue offloading and recommend nutritional consultation to reevaluate the current supplementation. Increased protein intake was also recommended. The 04/18/2025 Registered Dietitian #21 progress note documented the resident had a new unstageable pressure ulcer to the sacrum. They received Ensure supplements at all meals, consuming 25-50% of their meals with some refusals. They also received a magic cup (dietary supplement) twice a day to further supplement nutritional status. The resident's meals and supplements exceed the estimated needs to support wound healing and weight gain. The 04/23/2025 physician order documented right buttocks to cleanse with Dakins 0.25%, apply skin prep to peri wound, apply Dakins moistened fluffed gauze to base of wound and secure with superabsorbent.The 04/28/2025 and 05/19/2025 Wound Consult notes documented to continue the turning and positioning schedule, continue to provide incontinence care, use a chair cushion, use an alternating air loss mattress and ensure the settings were maintained, moisture barrier cream, and use wedges and pillows for positioning. A new treatment was added to the right buttocks pressure ulcer to chemically remove the dead skin tissue layer. The wound was worsening. There were no further wound consult notes until 11/10/2025.The 7/11/2025 Comprehensive Care Plan documented the resident required assistance with activities of daily living. Interventions included positioning devices for bed such as pillow between the legs and a black positioning wedge and blue half bolster under the legs and knees for left side positioning.The 10/28/2025 physician order documented ensure every shift that the air mattress was functioning properly at current body weight.The October 2025 Treatment Administration Record documented to start on 10/28/2025 at 10:57 AM, (six months after the initial observation of the right buttock pressure) ensure air mattress was functioning properly at current body weight, every shift. Subsequent Treatment Administration Records documented the air mattress was functioning properly.The 11/13/2025 Comprehensive Care Plan documented the resident had osteoarthritis of the hip. Interventions included a pressure reducing cushion and Dycem (non-slip, gripping material) for out of bed.The 11/10/2025-12/29/2025 Wound Consult notes documented staff were to continue the turning and positioning schedule, continue to provide incontinence care, use a chair cushion, use an alternating air loss mattress and ensure the settings were maintained, moisture barrier cream, and use wedges and pillows for positioning. The wound had grown in size by 12/29/2025 and no new interventions were recommended. A recommendation to change the treatment was added to the 12/29/2025 note. There was no documented evidence pressure ulcer interventions, including turning and positioning, incontinence care, chair cushion, moisture barrier cream and the use of wedges and pillows for positioning were implemented by certified nurse aides as the facility did not document activities of daily living tasks other than bowel movements and meal and fluid intakes. The 08/03/2026 Wound Consultant Nurse Practitioner #17 documented the resident was seen for a Stage 3 pressure ulcer first noticed the week of 04/14/2025. On 10/04/2025, the wound was cultured (tested for infectious organisms) and no antibiotic therapy was noted to be initiated. On 11/03/2025, the x-ray of sacrum and coccyx showed tan-white fecal debris obscuring the view. There was poor visualization due to overlying artifact and significant fecal debris. The Stage 3 pressure ulcer/injury to the right buttock healing has stalled. The size of the wound measured 1.2 centimeters by 1.2 centimeters by 2.2 centimeters, and calculated area of 1.44 square centimeters with moderate amount of serosanguinous drainage. Recommend ongoing pressure reduction and turning and positioning precautions; ongoing intervention and protocol for incontinence management, and use of appropriate moisture barrier cream.During an observation and interview on 08/04/2026 at 8:47 AM, Resident #12 was sitting in bed upright eating their breakfast. They said their back was sore and they have a lot of pain. They mentioned the nurses' put bandages on their sore. The 08/2026 Treatment Administration Record documented treatment to right buttocks; cleanse with normal saline or wound cleanser; pack collagen with silver fiber sheet to base of wound; apply silver alginate over that; apply skin prep to surrounding tissue; secure with border gauze. During a wound treatment observation on 08/06/2026 at 12:12 PM, with Licensed Practical Nurse #19, the resident was incontinent of stool. Licensed Practical Nurse #19 did not perform toileting hygiene before cleansing and dressing the resident's right buttock wound. Licensed Practical Nurse #19 cleansed the wound cleanser moistened gauze; used the same gauze with multiple wound swipes; dried the wound with new gauze; packed the wound with collagen silver; applied Maxorb (absorbent dressing), and applied border gauze. During an interview on 08/05/2026 at 12:40 PM, Licensed Practical Nurse #19 stated the resident had a pressure ulcer/injury for a long time. The resident was always incontinent of urine and stool. The aides were supposed to notify nurses when the resident was soiled so they could change the dressing. They stated they used wound cleanser to clean the area because that is what they always used for this wound. During an interview on 08/06/2026 at 5:51 PM, Infection Preventionist/Registered Nurse #18 stated the resident had a pressure injury to their right buttocks since 04/2025. They stated staff should have performed incontinence care prior to the treatment to prevent cross contamination, staff should have changed gloves when soiled and maintained other infection control practices to prevent cross contamination of germs. Maintaining proper infection control was to prevent infection and encourage healing. During an interview on 08/07/2026 at 11:43 AM, the Assistant Director of Nursing stated they were the facility wound nurse. They stated to prevent pressure ulcers; they do weekly skin checks on all residents and encourage residents to be repositioned and up and out of their bed if possible. Nursing staff should be using the moisture barrier creams for residents with incontinence because they were at high risk for pressure ulcers. Wound rounds were completed weekly on Mondays with their wound consultant providers. Nursing staff were to monitor skin weekly during their weekly check, and these were completed on their designated shower day. A licensed practical nurse would observe the resident and make note of any concerns in the record and notify the Unit Manager. They stated Resident #12 has had an unhealed Stage 3 pressure ulcer/injury for a while. The resident could not turn and position themselves and had a lot of contractures. They stated they were not aware of the interventions in place prior to the pressure ulcer, but the resident was at high risk and would need interventions in place to prevent new or worsening pressure. During an interview on 08/11/2026 at 10:49 PM, Wound Consultant Nurse Practitioner #17 stated they were in the facility typically once a week on Mondays. They recalled Resident #12 had a right ischial (right lower hip) wound, either full thickness Stage 3 or 4, they could not remember. They could not recall if this was facility acquired. They stated fecal matter in or around a wound could put a resident at a higher risk for infection and slow the healing process. The resident had multiple comorbidities that have led to poor wound healing, such as poor mobility and decline in oral intake and the resident was incontinent. They stated it was very important for residents with these issues to have preventative measures in place to prevent wounds from starting or from getting worse. The staff should be assisting residents with offloading and repositioning every two hours and providing incontinence care management. 2) Resident #32 had diagnoses including polyneuropathy (the nerves throughout the body malfunction at the same time), and morbid obesity. The 03/27/2026 annual Minimum Data Set assessment documented the resident had full cognition, did not reject care, had impairments of both arms, required maximal assistance to dependent with most activities of daily living to include mobility and transfers, was occasionally incontinent of urine and frequently incontinent of bowels, had no unhealed pressure ulcers, and had a pressure reducing device for the bed. The Comprehensive Care Plan initiated 03/01/2022, revised on 11/05/2025, documented the resident was at risk for impaired skin integrity related to incontinence, impaired mobility, moisture/incontinence and poor nutrition. Interventions included pressure reduction device for bed and for out of bed, update medical with any skin changes as needed, and apply moisture barrier cream following incontinence care. The 04/08/2026 Nursing Weekly Skin Status form, completed by Licensed Practical Nurse #27, documented, Stage 2 pressure ulcer to the coccyx measured at 1.8 centimeters by 2.5 centimeters by 0 centimeters depth. The wound bed was red, and there was scant serosanguinous drainage noted. There was no documented evidence the Comprehensive Care plan was updated to reflect the resident had a pressure ulcer/injury or interventions to promote healing and prevent deterioration.The April 2026 Treatment Administration Record documented an order for wound care initiated on 04/08/2026 with the following instructions: Wash with normal saline/wound wash, pat dry, apply calmoseptine (moisture barrier ointment), cover with bordered gauze, change daily and as needed, measure weekly on Mondays, refer to wound care if not resolved in four weeks. The 04/12/2026 Physician General Progress note, Physician #28 documented the resident was sitting up in bed, had no new complaints; nursing had no notable concerns, and their skin had no rashes, no breakdown or suspicious lesion. The 04/17/2026 at 12:43 PM Licensed Practical Nurse #27 progress note documented wound care order to the coccyx: Wash with normal saline/wound wash, pat dry, apply calmoseptine, cover with bordered gauze, change daily and as needed, measure weekly on Mondays. The resident will be referred to wound care if not resolved in four weeks. The resident was out of bed and declined to go back to bed.There was no documented evidence the treatment was completed as ordered on 04/14/2026, 04/18/2026, and 04/24/2026.The 05/15/2026 Nursing Weekly Skin status, completed by Registered Nurse #29, documented a Stage 2 pressure ulcer to the right buttocks, measured at 3.2 centimeters by 2.0 centimeters by 0.2 centimeters, with serosanguinous drainage. The 05/18/2026 Wound Consultant Nurse Practitioner #17 note documented the resident was seen for an assessment of a new wound to the buttock presenting as a Stage 3 on 05/18/2026. The wound on the sacrum had odor, measured 4.5 centimeters by 6.5 centimeters by 0.1 centimeters, calculated area of 29.25 centimeters, with light amount of serosanguinous drainage. The resident had a history of pressure injury and was at high risk for pressure ulcer formation related to decreased mobility, impaired nutrition, comorbidities, incontinence of urine and stool, and history of previous pressure injury. The recommended interventions were listed: alternating air/low air loss mattress for pressure redistribution, ongoing pressure reduction to the heels and turning and position schedule per protocol, keep patient off bottom, use pillows/wedges for position, and offloading and chair cushion for pressure redistribution. There was no documented evidence Resident #32 was provided pillow/wedges, or chair cushion.The 06/17/2026 Diet Technician #30 nutrition consult/assessment documented the Stage 3 pressure wound was healing and there were no nutritional changes recommended. The 06/01/2026 nursing care instructions documented staff should apply moisture barrier cream following incontinence care; monitor skin for changes daily during care, pressure reduction device for bed. The 06/08/2026 Wound Consultant Nurse Practitioner #17 note documented the resident was seen for follow up to the stage 3 pressure ulcer to the sacrum noted on 05/18/2026. The wound is a Stage 3 pressure ulcer/injury improving without complications. The wound measures 3.5 centimeters by 5.5 centimeters by 0.1 centimeters, the calculated area is 19.25 centimeters. There is 60% epithelial (healthy skin cells), and 40% granulation (new healthy tissue). The wound edges were unattached, and there was light amount of serosanguinous drainage. All prevention measures were discussed with staff, and education was provided for staff and resident regarding pressure prevention.The 06/15/2026 Nursing Weekly Skin Status Form, completed by the Assistant Director of Nursing documented the resident had a Stage 3 pressure injury to the sacrum, measuring 3.5 centimeters by 5.5 centimeters by 0.1 centimeters. The wound was healing, with a light amount of serosanguinous drainage. The plan was to have weekly follow up with wound consultants until wound has been resolved. The 06/15/2026 Wound Consultant Nurse Practitioner #17 note documented the resident was seen for follow up on Stage 3 pressure to sacrum, noted on 05/18/2026. Prior treatment was honey dressing, barrier cream, alginate, dry dressing, offloading, incontinence care, offloading, chair cushion and air mattress. The wound is a Stage 3 pressure ulcer/injury measured at 3.5 centimeters by 5.5 centimeters by 0.1 centimeters with light amount of serosanguinous drainage. The resident has a full thickness wound that was healing with dermal/epithelia tissue exposed. The treatment recommendations were cleanse with wound cleanser; apply medical grade honey to base of wound, secure with bordered gauze, and change daily. Wound consultant to follow up weekly until wound resolution.The 07/01/2026 Nursing Care Instructions documented staff should apply moisture barrier following incontinence care; monitor skin for changes daily during care, pressure reduction device for bed. The 07/06/2026 Nursing Weekly Skin Status Form, completed by the Assistant Director of Nursing and signed on 07/16/2026, documented Stage 3 pressure ulcer to the sacrum that measures 2.5 centimeters by 2.2 centimeters by 0.1 centimeters. The current plan was to continue current treatment. The interventions include administer treatment per physician order, educate resident about weight shifts, evaluate the wound weekly and documenting outcome and treatment progress, medical provider to evaluate the skin as needed and Physical Therapy/Occupational Therapy evaluation for positioning. There was no documented evidence in the medical record of an order for an evaluation by physical therapy or occupational therapy per the 07/06/2026 recommendation. The July 2026 Treatment Administration Record documented an order for wound care to the right buttocks for Stage 2 pressure injury: Cleanse site with normal saline/wound wash, pat dry, apply Medi honey (this is a medical grade wound and burn dressing use to maintain a moist healing environment and clean up dead tissue) sheet to wound base, cover with border gauze, change daily and as needed for wound care. There was no documented evidence that the pressure ulcer treatment was completed daily as ordered for 11 days: 07/06/2026 through 07/09/2026, 07/13/2026, 07/14/2026, 07/17/2026, 07/21/2026, 07/23/2026, 07/24/2026, and 07/27/2026. The wound prevention interventions remain unchanged from previous documentation from April 2026. The 08/01/2026 Nursing Care Instructions remained unchanged from the previous month. The 08/04/2026 physician order documented wound care to the right buttock Stage 2 pressure injury: cleanse site with normal saline/wound wash, pat dry; Apply Medi honey sheet to the wound base; cover with bordered gauze and change daily as needed. The 08/04/2026 Nursing Weekly Skin Status Form, created and signed by Infection Preventionist/Registered Nurse #18 on 08/05/2026, documented sacrum Stage 3 pressure injury measured 2 centimeters by 1.5 centimeters by 0.1 centimeters with light amount of serosanguinous. The treatment recommendations were cleanse with wound cleanser, apply hydrocolloid (dressing to promote healing of wounds) dressing, secure with bordered gauze and change daily. Additionally, a new area noted on the coccyx area measured 11 centimeters by 8 centimeters no depth, was moisture-associated skin damage, and the treatment recommended was to use barrier cream, offloading, side to side, and turn and position. The interventions remain unchanged from previous documentation. There is no documented evidence that all implemented interventions were completed or verified as in place. The 08/04/2026 at 6:20 PM nursing progress note by Registered Nurse #31, documented Stage 1 blanchable erythemal/moisture associated skin damage to coccyx, measured 11 centimeters by 8 centimeters by 0.1 centimeters. The Stage 2 open area to left buttock measured 2 centimeters by 1.5 centimeters by 0.1 centimeters, small amount of serosanguinous drainage, surrounding tissue intact. The resident denies pain, other then when I lay on my backside too long. The new dressing was applied per treatment orders. Encouraged the certified nurse aide to turn and position every two hours, resident to shift weight, when possible, to avoid prolonged pressure to the area. There was no documented evidence new treatments and interventions for the Stage 1 pressure ulcer to the coccyx were implemented.During an interview and observation on 08/03/2026 at approximately 11:00 AM, Resident #32 stated they had a new sore area on their bottom for four to five weeks. The resident was observed lying in bed with a pressure mattress on the bed. During an interview and observation on 08/05/2026 at 8:56 AM, Resident #32 was in their wheelchair having their breakfast, they said they have an appointment today, and their wound care was completed the night before. At 4:29 PM, they were resting in bed and stated this was not their first pressure ulcer. The nurses do not catch them soon enough. The pressure ulcer has caused a lot of discomfort in the last few weeks. They mentioned the wound team wound round on Mondays, but they do not always look at the area and would delegate to another nurse to complete the dressing change if they are not in bed.During an interview on 08/07/2026 at 9:00 AM, Certified Nurse Aide #23 stated the resident was cooperative with care and if they needed to get back to bed for wound assessment they would. They were not known to refuse care.During a wound treatment observation and interview on 08/07/2026 at 9:09 AM, Licensed Practical Nurse #22 failed to follow infection prevention standards. During an interview on 08/07/2026 at 12:05 PM, the Assistant Director of Nursing stated there were preventative measures in place for Resident #32 and the resident liked to get out of bed early and did not like to go back to bed. The resident was able to reposition themselves in the wheelchair. There were two times when the resident was not seen by the wound team, because the resident had an appointment. Weekly skin checks happen on Tuesday during the day shift, in a shower chair. Then wound rounds were completed the following Mondays. The unit manager should notify the registered nurse to assess any skin areas of concern so that a provider will be able to determine the next steps for treatment. They stated it may be hard to observe the bottom skin area when a resident was seated on a shower chair. During an interview on 08/07/2026 at 3:07 PM, Resident #32 stated they would be in bed on Monday morning for wound rounds. They said the nurse that did the dressing change today did a good job, but not all the nurses do the treatment, or do a good job. They said they have never refused to have their pressure dressing changed. Sometimes the dressing may not be completed because the aides would not put them back to bed.During an interview on 08/10/2026 at 11:49 AM, Resident #32 was sitting up in their wheelchair and said they have been up since 9:30 AM. They stated the wound team did not come around today and their visit was postponed until tomorrow (08/11/2026). They mentioned their bottom was sore. During an interview on 08/07/2026 at 12:41 PM, Nurse Practitioner #16 stated they would see the residents they covered at least monthly. They stated if nursing staff suspected a pressure ulcer/injury, they would want to be notified so they could assess and ensure appropriate treatment and interventions were in place. They would need to document an observation of the areas of concerns. The facility policy is to have the wound consultants assess the resident. They confirmed Resident #12 and Resident #32 both had pressure ulcers. They stated Resident #32 was a medically complex person and if the pressure ulcer treatment was not done for several weeks, the register nurse would need to assess the wound and notify the Nurse Practitioner of any changes. They were not notified that Resident #32's pressure ulcer had gotten worse. They stated they would expect nursing staff to change their gloves after removing a soiled dressing and prior to cleaning a wound. Gloves should be changed frequently throughout the dressing change process. 10 New York Codes, Rules and Regulations 415.12(c)(1)

Based on observations, record review, and interviews, the facility failed to ensure sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for eight of eight anonymous residents who expressed concerns regarding the lack of sufficient staffing, and one of one resident (Resident #137) who experienced prolonged wait time for care. Specifically, during a resident council meeting on 08/03/2026 with the survey team, eight anonymous residents stated the facility was frequently short-staffed, they missed activities because there were not enough staff to get them up in time to attend, and call bell wait times were often over an hour; and Resident #137 did not receive incontinence care for one hour after their request for having a bowel movement.Findings include: The Facility Assessment, last reviewed 05/15/2026, documented the facility was licensed for a total of 160 beds (60 beds on the second and third floors and 40 beds on the fourth floor), with 136 long term care beds and 24 subacute beds. The average daily census of long-term care residents was 128 and subacute beds was 20. The staffing plan documented there would be 5-7 licensed nurses providing direct care during day shifts; 8-18 nurse aides during day shifts. The facility policy Toileting-Continence, revised 01/01/2000, documented residents with total incontinence of bowels would be considered total assistance and incontinence products would be changed as needed.During an interview on 08/03/2026 at 10:58 AM, Resident #137 stated they often waited one to two hours for a response to their call bell. The facility was usually short staffed, especially on the night shift.During an interview on 08/03/2026 at 11:05 AM, Resident #6 stated it seemed like it took forever for staff to answer call bells and they are often rushed through their care. Staff were impatient with them because they were backed up. The staffing levels were too low to care for them in a dignified way.During an interview on 08/03/2026 at 12:04 PM, Resident #9 stated staff often took hours to answer their call bell, and nursing did not provide ostomy care on the night shift, even when they put their call bell on, which caused their ostomy to leak. They felt there were not enough staff to take care of the residents, especially on the night shift.During a resident council meeting with the survey team on 08/03/2026 at 1:38 PM, eight of eight anonymous residents stated the facility was frequently short-staffed and call bell wait times were often over an hour. They often missed activities they wanted to attend because there was not enough staff to get them out of bed, groomed, and dressed. During a continuous observation on 08/05/2026 from 9:00 AM through 11:45 AM, Resident #137 was lying in bed waiting for care. The resident turned their call bell on at 10:28 AM. At 11:26 AM, Certified Nursing Aide #25 entered the resident room and closed the door to provide incontinence care. At 11:40 AM, Certified Nursing Aide #25 came out of the resident's room with an incontinence brief that was heavily saturated with a brown, odorous substance.During an interview on 08/05/2026 at 11:42 AM, Certified Nursing Aide #25 stated all dependent residents required toileting or incontinence care every two hours or as needed. Incontinence care included wearing protective gear if needed, removing the dirty incontinence brief, washing the resident, then applying a clean incontinence brief. They knew a resident needed help because they would put their call bell on or yell out. An acceptable time to wait for requested incontinence care was approximately five minutes. An hour was an unacceptable time to wait for staff assistance in a soiled incontinence brief. The resident had to wait that long because three other residents were ahead of them waiting for care and they were behind. Resident #23 approached Certified Nursing Aide #25 during the interview and requested to be toileted before going to the main dining room for lunch. Certified Nursing Aide #25 stated the next resident was waiting for over an hour for a bed bath but would need to wait longer now. They did not have enough staff to provide incontinence care as often as required and they were frustrated by that.During an interview on 08/05/2026 at 12:03 PM, Registered Nurse Unit Manager #14 stated residents received toileting or incontinence care every two hours and as needed, depending on their level of function. They knew if a resident needed care by walking rounds on the unit and by resident call bells. There was no acceptable time for a resident to wait in a soiled incontinence brief, and they needed to be changed as soon as possible, and an hour was too long for a resident to wait. The resident waited that long because of staffing issues and the number of nurse aides was low. They needed a minimum of six and usually only had three or four. They did not have enough staff to toilet residents as often as they needed to.During an interview on 08/11/2026 at 10:11 AM, Director of Nursing #1 stated staffing had been a rotating door at times for all nursing positions. Average staffing was four certified nursing aides and two licensed nurses on the second and third floor and three certified nursing aides and one licensed nurse on the fourth floor. Staffing should be:Second floor days and evenings: six certified nursing aides, two licensed nurses; Third floor days and evenings: six to seven certified nursing aides, two licensed nurses;Fourth Floor days and evenings: three to four certified nursing aides, one licensed nurse;Night shifts on all units: three certified nursing aides, one licensed nurseDuring an interview on 08/11/2026 at 12:16 PM, Certified Nursing Aide #26 stated residents receive care based on resident specific care on the Kardex (a document of resident specific care instructions). The residents should be up, dressed, and groomed by 9:00 AM. Not all activities of daily living care tasks were documented in the electronic medical record. There were only three certified nursing aides today, so they were behind in care. Residents were to be toileted at least every two hours but there were times when that did not happen due to staffing levels.During an interview on 08/11/2026 at 1:13 PM, Registered Nurse Unit Manager #14 (for Unit 3) stated when fully staffed they had six certified nursing aides and two licensed nurses on days and evenings and three certified nursing aides and one licensed nurse on nights. They often had three certified aides for the day shift and sometimes residents and linens were urine soaked because the previous shift was short staffed. Registered Nurse Unit Manager #14 stated some residents were not dressed and still in hospital gowns during the interview because they only had three nursing aides that day for 60 residents.During an interview on 08/12/2026 at 8:56 AM, Certified Nursing Aide #33 stated the facility usually scheduled four or five certified nursing aides, but because of daily staff call ins, they usually worked with three. All residents should be dressed, groomed and out of bed by 10:30 AM unless they refused, but that did not happen because of staffing. They tried to get the residents all up by noon. Residents needed to be checked and changed every two hours, but that did not happen due to staffing, they could only do those tasks before and after lunch. There were times they came in, and residents were soaked in urine.During an interview on 08/12/2026 9:17 AM, Certified Nursing Aide #34 stated they were supposed to have six certified nursing aides but usually only had three or four. All residents were to be dressed, groomed and out of bed by 11:30 AM but that did not always happen due to staffing. Yesterday they had 20 residents on their list, and the third floor is a hard floor for resident care. The resident care did get done but they could not always get all showers done. The reason so many residents were still in hospital gowns was staff did not get to provide the needed care yet or the resident did not have enough clothing. There were times when resident linens and briefs were soaked in urine because they were not toileted as planned.During an interview on 8/12/2026 at 9:30 AM, Staffing Coordinator #35 stated minimum staffing on day shift was three certified aides and two licensed nurses on the second and third floor, and two certified aides and one licensed nurse on the fourth floor. Minimum staffing on the night shift was two certified aides and one licensed nurse on the second and third floor, and one certified aide and one licensed nurse on the fourth floor. The facility was short-staffed for the past few years. The last month was low on staffing, staff did not show up to work, quit without notice, or called in sick. They were working on increased certified nursing aide pay rates, attended job fairs and posted jobs on social media. During an interview on 08/12/2026 at 10:22 AM, Staffing Coordinator #35 stated they determined staffing based on census and unit resident acuity and they did not have specific certified nursing aide to resident ratios. They tried to maintain staffing by giving staff rides to and from work if needed and offered them snacks. The third floor had the highest acuity, so they had higher staffing numbers on that floor.During an interview on 08/12/2026 at 9:44 AM, Director of Nursing #1 stated the facility had open interviews, referral bonuses, and advertised on social media and job recruiter websites. They had a lot of call ins but were not sure why, possibly poor work ethic. They started a new certified nursing aide training class this week. They picked staff up at home if they had no way to drive in. They had frequent staff call ins, but resident care was still expected to get completed and residents should have been up and dressed before lunch, toileted prior to breakfast, and incontinence care completed. 10 New York Codes, Rules and Regulations 415.(a)(1)(i-iii)

Based on observations, record reviews and interviews during survey, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to prevent the development of transmission of communicable diseases and infections for two of seven residents (Resident #12 and Resident #32) reviewed. Specifically, Resident #12 and Resident #32 were both on Enhanced Barrier Precautions (staff wear gown and gloves for resident contact care) related to active pressure wounds. During an observation on 08/06/2026, Licensed Practical Nurse #19 failed to assist Resident #12 with incontinence care prior to removing their pressure ulcer dressing, then applied a new dressing while the resident remained soiled from feces, and they did not cleanse the wound according to professional standards to prevent infection. During an observation on 08/07/2026, Licensed Practical Nurse #22 failed to change their gloves and perform hand hygiene as often as required during Resident #32's wound care dressing treatment and they failed to cleanse the wound according to professional infection prevention standards. Findings include: The facility policy titled Infection Prevention and Control - General Statement revised November /2024, documented the facility's infection prevention and control program is to establish guidelines to provide a safe, sanitary and comfortable environment and to help prevent the develop and transmission of communicable diseases and infections. Written standards, policies, and procedures for the program include standard and transmission-based precautions to be followed to prevent the spread of infection. The hand hygiene procedures to be followed by staff involved in direct resident contact. The Infection Prevention Control Program is responsible for training and competency of staff regarding proper hand-washing techniques, donning/doffing and proper use of Personal protective equipment. The facility's Treatment Audit revised 08/2014 documented the following: -the staff should prepare for treatment by verifying the treatment ordered in the record, -explain the procedure to the resident, gather sufficient supplies prior to procedure,- gloves worn to remove old dressing, and discarded in receptacle with soiled dressing, -wounds cleanse utilizing the correct techniques, -soiled dressing place in proper disposable bag, -hand washing at the appropriate times, -and dressing should be initialed and dated. 1) Resident #12 had diagnoses including dementia, muscle weakness, and protein calorie malnutrition. The 06/05/2026 Minimum Data Set(a resident assessment tool) documented the resident had severely impaired cognition, did not reject care; was dependent on staff for most of their activity of daily living; was at risk for developing pressure ulcers and had one stage three (full thickness tissue loss, subcutaneous fat may be visible but bone and tendon is not exposed) pressure ulcer that was not present upon admission or reentry. The Comprehensive Care Plan initiated 12/09/2022, revised on 05/22/2026 documented the resident was at risk for skin injury related to advanced age, frail skin, anticoagulant use, incontinence, impaired mobility and Alzheimer's Disease. Interventions included monitor skin for changes daily during care, medical provider evaluation of skin/wound as needed, and follow recommended infection control practices. The 04/15/2026 physician order documented Enhanced Barrier Precautions due to skin impairment. The 08/05/2026 physician order documented treatment to right buttocks: cleanse with normal saline, pack with collagen with silver fiber sheet to base of wound, apply silver alginate over that and skin prep to surrounding tissue or peri wound, secure with bordered gauze, change daily and as needed everyday during the day shift, for wound care. During observation on 08/05/2026 at 12:12 PM, Licensed Practical Nurse #19 prepared their supplies for Resident #12's wound care treatment to the right buttocks. They washed their hands and then donned their personal protective equipment, a gown and gloves. The resident was in bed lying on their back, they were dressed, there was a wedge pillow under their left back side, they were laying toward their right side. Licensed Practical Nurse #19 mentioned they had forgotten their scissors. They removed their gown and gloves and went to the treatment cart to get scissors. They reentered the room, washed their hands and then started to set up their dressing supplies. They stopped and mentioned they needed to put on a gown and gloves. They put on a gown and gloves. Licensed Practica Nurse #19 removed the resident's pants and unfastened the incontinence brief. The resident was visibly soiled with feces. The current dressing was dated 08/05. Licensed Practical Nurse removed the dressing and placed it in the incontinence brief. The resident remained soiled with feces. Licensed Practical Nurse #19 removed the soiled incontinence brief by rolling the old dressing into the brief and pulling it up and out from under the residents and then tossed into the trash can next to the bedside. They completed hand hygiene with hand sanitizer and applied new gloves and began the wound care treatment. They sprayed wound cleanser on several pieces of gauze bunched in their hand. Then they began to rub toward the wound and away from the wound several times with the same bunch of wet gauze. They grabbed a dry gauze with the same gloved hand used to clean around the wound and wiped the wound with a dry gauze. They removed gloves using hand sanitizer and applied new gloves. They opened a skin prep and rubbed the skin prep all around the outer part of the wound, four times with the same skin prep. The nurse failed to change gloves and opened a sterile applicator and packed the wound with a small piece of Maxorb (silver alginate - an absorbent dressing with fibers used to absorb heavy drainage) they had cut to size. They paused the packing and explained the Maxorb was not supposed to be packed in the wound and removed the dressing. They used the same dirty sterile applicator and packed the wound with the collagen alginate (a wound care dressing that manages drainage and supports tissue growth to speed up healing). Next, they applied the Maxorb over the wound, applied the bordered gauze, removed their gloves, then began to provide incontinence care, and cleaned and redressed the resident. During an interview on 08/05/2026 at 12:40 PM, Licensed Practical Nurse #19 stated the resident had a pressure ulcer/injury for a long time. The resident was always incontinent with urine and stool. The aides were supposed to notify nurses when the resident was soiled so they could change the dressing. They stated they used wound cleanser to clean the area because that is what they always used for this wound. During an additional observation and interview on 08/05/2026 at 12:45 PM, Licensed Practical Nurse #19 pulled up the treatment order in the electronic medical record and the order documented treatment to right buttocks, cleanse with normal saline, pack collagen with silver fiber sheet to base of wound apply silver alginate (Maxorb) over the wound and skin prep to surrounding tissue or peri wound, secure with bordered gauze, change daily and as needed every day shift for wound care. Licensed Practical Nurse #19 stated they should not have used the wound cleanser; the order was normal saline. They should not have used the same sterile applicator twice; they should have not rubbed the wound vigorously and wiped back and forth over the wound with the same gauze. They should clean the wound from dirty to clean with a new gauze for each wipe. At the time of the dressing change, they were unsure what the order was and did not know why they packed the wound with Maxorb. The resident was incontinent of feces and should have been cleaned up prior to the application of a new dressing to decrease infection of the wound. During an interview on 08/06/2026 at 5:51 PM, Infection Preventionist/Registered Nurse #18 stated the resident had a pressure injury to their right buttocks since April 2025. They stated if a resident was incontinent prior to a wound dressing change, the nurse should clean the resident first. Then they should wash their hands with soap and water and put on new gloves. A sterile applicator should not be used twice, if it was placed in the wound, it would then be dirty and not sterile, thus creating potential infections. The Maxorb dressing should not be cut because the dressing fibers may not be effective after it was cut. Skin and soft tissue infections were the biggest infection issues in the facility. Wounds should always be cleaned in a circular motion, from clean to dirty (from inside the wound to outward), discard the gauze and do this process until the wound is clean. They stated that without good infection control practices, it would take a wound longer to heal, can lead to bone infection, decline in resident quality of life, and pain. During an interview on 08/11/2026 at 10:49 PM, Wound Consultant Nurse Practitioner #17 stated they were in the facility typically once a week on Mondays. They recalled Resident #12 had a right ischial (lower and back part of the hip bone) wound, either full thickness Stage 3 or 4 (through the skin layers into the fat and muscle), they could not remember. They could not recall if this was facility acquired. They stated fecal matter in or around a wound could put a resident at a higher risk for infection and slow the healing process. 2) Resident #32 had diagnoses including polyneuropathy (the nerves throughout the body malfunction at the same time), and morbid obesity. The 06/19/2026 Minimum Data Set documented the resident had intact cognition, did not reject care; required substantial/maximal assistance or was dependent on staff for most of their activities of daily living and mobility; was at risk for pressure ulcers and had a Stage 3 pressure ulcer that was not present on admission and four pressure ulcer. The 06/22/206 physician order documented Enhanced Barrier Precautions related to wounds. The 08/04/2026 physician order documented wound care to the right buttock Stage 2 (open area with some skin loss) pressure injury: cleanse site with normal saline/wound wash, pat dry; apply Medihoney (this is a medical grade wound and burn dressing use to maintain a moist healing environment and clean up dead tissue) sheet to the wound base; cover with bordered gauze and change daily and as needed for wound care. During an observation and interview on 08/07/2026 at 9:09 AM, Licensed Practical Nurse #22 removed the bandage from sacral area and there was a large amount of serosanguinous discharge covering the entire bandage. Licensed Practical Nurse #22 indicated this was a great deal more drainage than the last wound care dressing completed, and the wound looked worse from the last time. They stated the resident was last evaluated by a provider on Monday, 08/03/2026, and the resident had a Stage 2 pressure ulcer. During the treatment observation, the wound appeared to be between the size of half dollar coin and a baseball. The area was dark in color, dark pink to red with small areas around the edges white/yellow in color. The nurse did not measure the wound pressure/area that appeared to be open. Licensed Practical Nurse #22 began cleansing the wound with a wound spray and dabbing the area with four gauze pads. They did not change gloves between each cleansing pads. They used the same gloves for each pad. They did not have a dirty and a clean hand. The nurse verbalized they would use two Medihoney sheets instead of one as ordered because the wound was larger in size and they would alert the provider. They changed their gloves after applying the Medihoney. The right upper area on the buttocks was not covered by the Medihoney but covered by gauze. The pressure area appeared to be deep purple/red in color. During an additional interview after the dressing change was completed, Licensed Practical Nurse #22 stated if they changed their gloves every time, they would have changed their gloves a dozen times. They did not change gloves between each cleaning or between application of Medihoney. They were not sure why they did not change their gloves. They did not label their dressing change because they did not have a marker at the time of the dressing change. The dressing should be labeled with a date and time. During an interview on 08/07/2026 at 12:41 PM, Nurse Practitioner #16 stated they would see the residents they covered at least monthly. They confirmed Resident #12 and Resident #32 both had pressure ulcers. They stated they would expect nursing staff to change their gloves after removing a soiled dressing and prior to cleaning a wound. Gloves should be changed frequently throughout the dressing change process. 10 New York Codes, Rules and Regulations 415.19(a)(b)

Based on observations, record review, and interviews, the facility failed to ensure residents who required dialysis services (filtration of blood when the kidneys do not work) received such services consistent with professional standards of practice for one of one resident (Resident #15) reviewed. Specifically, Resident #15 received hemodialysis treatments at a community-based dialysis center and there was no documented evidence they were assessed post treatments at the facility from 04/012026 through 08/06/2026. Findings include:The facility policy titled Off-Site Dialysis and Arteriovenous (A/V) Fistula Graft Care, reviewed 01/28/2022, documented the resident would be assessed post dialysis, which included vital signs. Resident #15 had a diagnosis of end-stage kidney disease (kidneys function at less than 15%). The 05/12/2026 Minimum Data Set (a resident assessment tool) documented the resident required hemodialysis treatments. The Comprehensive Care Plan, initiated 12/05/2024 and revised 05/22/2026, documented the resident had renal failure and required dialysis. Interventions included dialysis as ordered, monitor shunt for bleeding, infection, bruit and thrill, medications as ordered, and follow up with nephrology. The 05/28/2026 physician orders documented the dialysis communication book was to be reviewed when the resident returned from dialysis. Dialysis appointments were on Tuesday, Thursday, and Saturday. The dialysis access site was to be monitored at dialysis. There was no documented evidence of a pick-up time or length of treatment for Resident #15's dialysis in the electronic medical record. There was no documented evidence that the dialysis center notes were reviewed post treatment for Resident #15 upon return to the facility on [DATE], 04/25/2026, 04/28/2026, 04/30/2026, 05/02/2026, 05/05/2026, 05/07/2026, 05/09/2026, 05/16/2026, 05/19/2026, 05/27/2026, 05/28/2026, 07/11/2026, 07/16/2026, 07/21/2026, 07/25/2026, 07/28/2026, 07/30/2026, and 08/01/2026. There was no documented evidence that Resident #15 was assessed by facility nursing post dialysis treatment on 04/23/2026, 04/25/2026, 04/28/2026, 04/30/2026, 05/02/2026, 05/05/2026, 05/07/2026, 05/09/2026, 05/14/2026, 05/16/2026, 05/19/2026, 05/26/2026, 05/27/2026, 05/28/2026, 05/30/2026, 06/02/2026, 06/04/2026, 06/06/2026, 06/11/2026, 06/13/2026, 06/16/2026, 06/17/2026, 06/20/2026, 06/23/2026, 06/25/2026, 06/27/2026, 07/02/2026, 07/04/2026, 07/07/2026, 07/09/2026, 07/11/2026, 07/16/2026, 07/21/2026, 07/25/2026, 07/28/2026, 07/30/2026, 08/01/2026, 08/04/2026, and 08/06/2026. During an interview on 08/06/2026 at 2:48 PM, Licensed Practical Nurse #12 stated the dialysis communication book went with the resident to the dialysis center from the facility. They made sure vital signs were recorded in the book before they left for dialysis then checked the book when they returned from treatment and signed off on the form. A licensed practical nurse was responsible for ensuring that the communication book was filled out prior to dialysis and went to dialysis with the resident. They monitored vital signs before going to dialysis and as needed. Vital signs were not completed when they returned from dialysis. When the resident returned to the facility a licensed practical nurse should review the communication book and notify a registered nurse if there were any issues. During an interview on 08/07/2026 at 11:43 AM, Licensed Practical Nurse #13 stated they reviewed the dialysis communication book sheets when the resident came back from treatment, but they did not obtain vital signs or evaluate the resident. During an interview on 08/07/2026 at 12:08 PM, Registered Nurse Unit Manager #14 stated any licensed staff could review the dialysis paperwork when the resident returned from treatment. It should be done as soon as they return. They were not assessed when they returned to the facility. During an interview on 08/11/2026 at 10:01 AM, Director of Nursing #1 stated Resident #15 had a dialysis communication book they took with them to treatment. The dialysis center recorded pre and post treatment vital signs and weights and documented if anything needed to be addressed at the facility. Vital signs were only recorded upon return to facility if there was an issue. They did not complete a pre or post dialysis assessment at the facility. 10 New York Codes, Rules and Regulations 415.12(k)

Based on observations, interviews, and record review, the facility failed to investigate alleged reports of abuse, neglect or mistreatment for three of three residents (Residents #11, #63, and #90). Specifically, the facility failed to perform a thorough investigation to determine other resident involvement when Certified Nurse Aide #5 was allegedly rough with care.Findings include:The facility policy Abuse Prohibition, last revised February 2023, documented residents had the right to be free from verbal, sexual, physical, mental abuse, mistreatment, neglect, and involuntary seclusion. The program included involving resident group council in developing, monitoring, and evaluating the facility's abuse prevention program. Inappropriate behaviors included rough handling of residents. The facility was to encourage all residents and personnel to report any signs or suspected incidents of abuse to facility management immediately.The facility policy Management of Patient/Resident and Family Complaints/Concerns/Grievances, last revised 05/15/2024, documented the facility would make prompt efforts to resolve complaints/concerns/grievances and the resident had the right to voice grievances/concerns/complaints without fear of discrimination or reprisal. The facility was to take appropriate action in preventing any further potential violation of any resident during the grievance review and report certain violations as required by State law to the Administrator.The facility policy Facility Incident/Abuse Investigating and Reporting, last revised 09/2025 documented residents had the right to be free from verbal, physical, sexual, mental abuse, neglect, and mistreatment. Personnel were required to report any resident incident or suspected incident immediately to the Supervisor/Administrator. The facility would conduct an immediate and thorough investigation upon discovery of an incident. The nursing supervisor/designee initiated an Accident/Injury Report. Witness statements were to be obtained, to include pertinent staff interviews preceding the incident, and to interview other residents in which the employee provided care.1) Resident #11 had diagnoses including high blood pressure, anxiety, and need for assistance with personal care. The 05/22/2026 quarterly Minimum Data Set (a resident assessment tool) documented the resident had full cognition, had impairment of one arm, used a walker or wheelchair, was dependent for toilet hygiene, was maximum assist with shower or bathing, was moderate assistance with upper body dressing, was dependent for lower body dressing, was supervision for personal hygiene, was maximum assistance for rolling in bed, was continent of bowel and bladder, and had frequent pain.2) Resident #63 had diagnoses including high blood pressure and need for assistance with personal care. The 06/12/2026 quarterly Minimum Data Set documented the resident had full cognition, used a walker and wheelchair, was set-up assistance for toilet hygiene/shower/bath/upper and lower body dressing/personal hygiene, was continent of bowel and bladder, had occasional pain, and had shortness of breath with exertion.3) Resident #90 had diagnoses including stroke with left hemiplegia/hemiparesis (weakness or paralysis of one side of the body), high blood pressure, and depression. The 04/24/2026 Minimum Data Set assessment documented the resident had full cognition, had impairments of one arm and leg, used a walker or wheelchair, and was dependent for toilet hygiene, and showering, Resident #90 was also dependent for dressing.The 07/08/2026 facility Grievance Form documented Resident #90 complained of Certified Nurse Aide #5 being very rough with care. The resident did not inform the aide as the resident felt uncomfortable saying anything to the aide. The resident felt the aide did not care if they were being too rough. The resident stated they were not in fear of the aide but did not want the aide to provide further care for them. The aide was provided education on 07/16/2026 and reviewed resident rights. The form was completed by the Director of Social Services and reviewed by the Director of Nursing and Administrator. The grievance form revealed the individuals interviewed were the Resident #90, Certified Nurse Aide #5, and the Director of Social Services.During the recertification survey Resident Council meeting on 08/03/2026 at 1:38 PM, Resident #11 stated during a facility Resident Council meeting on 07/22/2026, they reported Certified Nurse Aide #5 was rough with them during routine care and they told the aide to stop hurting them. During the meeting Resident #63 stated Certified Nurse Aide #5 sprayed their legs with cold water prior to a shower when the resident asked if the water was warm enough and then the aide laughed. Resident #63 stated they felt degraded. There were three other residents who stated they had similar experiences. Residents #11 and #63 stated the Director of Social Services was present during the 07/22/2026 meeting and took notes. Residents #11 and #63 stated nothing was done about it and to their knowledge, the Director of Social Services was in charge of grievances.During an interview on 08/05/2026 at 12:47 PM, Social Worker #3 stated the facility had had a few grievances regarding staff. There was an aide of which residents had complained was too rough. The aide received re-education. Grievance forms were completed with two residents, the facility followed up, and the facility felt there was no abuse that occurred.There was no documented evidence additional resident or staff interviews were conducted.During an interview on 08/05/2026 at 4:24 PM, the Director of Social Services, with Social Worker #3 present, stated they were at the July 2026 Resident Council meeting and there were no abuse or inappropriate touching complaints reported. If that had happened, the director would have notified the Administrator or Director of Nursing. The alleged staff member was to be removed from the unit pending investigation completion and the resident made safe. The Director of Social Services stated they had a recent conversation with Resident #11, could not remember when other than it happened a while ago, about rough touching by staff in the genital area, took the complaint to administration, and did not feel it warranted a progress note. They stated the Director of Nursing did the investigation for this complaint. The Director of Social Services did not remember the employee's name. The Director of Social Services was not aware of an incident with Resident #63. It was determined through further interview, the Director of Social Services was referring to a complaint, involving a different certified nurse aide, from January 2026.During an interview on 08/06/2026 at 11:37 AM, the Director of Nursing stated they were not aware of an allegation during a facility resident council meeting in which a resident stated a certified nurse aide was rough during their care or that an aide sprayed them with cold water during a shower. They would expect staff to notify them if that occurred. All concerns during a resident council meeting should be documented in the meeting minutes. The resident making the allegation was to be assessed, and investigation done, and a progress note made. The alleged staff member was to be suspended pending the investigation and residents and staff members of that unit were to be interviewed. There should have been an incident report and investigation for the allegation of rough treatment with care and being sprayed with cold water in the shower.During an interview on 08/06/2026 at 4:08 PM, the Administrator stated any abuse suspicion, or allegations were to be reported to the supervisor, the Director of Nursing, and the Administrator. The facility would have to investigate any allegations of spraying cold water on a resident or inappropriate touching to determine if abuse occurred or not. Any serious concerns brought up in a resident council meeting were to be reported to the supervisor or Director of Nursing. The Administrator stated they were not aware of the allegations of a staff member being rough with a resident during care or of a staff member spraying a resident with cold water. If those concerns were brought up in resident council, they should have been documented in the meeting minutes. The Administrator stated they were aware of Resident #90's grievance of a staff member being rough during care, that occurred when the Administrator first began the job in early July 2026. 10 New York State Codes, Rules and Regulations 415.4(b)(1)(ii)

Based on observations, record review, and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one of nine residents (Resident #137) reviewed. Specifically, Resident #137 did not receive incontinence care on 08/05/2026 for one hour after their request for having a bowel movement. Findings include:The facility policy Toileting- Continence, revised 01/01/2000, documented residents with total incontinence of bowels would be considered total assistance and incontinence products would be changed as needed. Resident #137 had diagnoses including cerebral infarct (blood vessel in the brain was blocked) and unspecified general weakness. The 05/08/2026 Minimum Data Set (a resident assessment tool) documented Resident #137 was cognitively intact, had a cerebrovascular accident (blood and oxygen was blocked from part of the brain) with generalized weakness, required dependent care for toileting hygiene, and was always incontinent of bowels. The Comprehensive Care Plan initiated 03/13/2025 and revised 01/28/2026, documented Resident #137 was dependent on staff for toileting related to cerebral vascular accident and muscle weakness. The Kardex (resident care instructions) for Resident #137 as of 08/04/2026 documented dependent care for toileting tasks. There was no documented evidence in the electronic medical record of staff documentation of toileting assistance/care for Resident #137 for all of 2026, and per interviews with staff, staff only record food and fluid intake and bowel movements. During a continuous observation on 08/05/2026 from 9:00 AM through 11:45 AM, Resident #137 was lying in bed. At 10:08 AM, Licensed Practical Nurse #12 entered the room for a few seconds and left. No care was provided. At 10:28 PM, Licensed Practical Nurse #12 returned with ginger ale for the resident. The resident turned their call bell on as soon as the nurse left the room, and at 10:33 AM Registered Nurse Unit Manager #14 entered the room and the resident asked to get cleaned up. At 11:17 AM, Certified Nursing Aide #25 entered the room to provide care but exited the room without care being provided. At 11:26 AM, Certified Nursing Aide #25 returned to the resident's room and closed the door to provide incontinence care. At 11:40 AM Certified Nursing Aide #25 came out of the resident's room with an incontinence brief that was heavily saturated with a brown, odorous substance. During an interview on 08/05/2026 at 11:42 AM, Certified Nursing Aide #25 stated all dependent residents required toileting or incontinence care every two hours or as needed. Incontinence care included wearing protective gear if needed, removing the dirty incontinence brief, washing the resident, then applying a clean incontinence brief. They knew a resident needed help because they would put their call bell on or yell out. An acceptable time to wait for requested incontinence care was approximately five minutes. An hour was an unacceptable time to wait for staff assistance in a dirty incontinence brief. The resident had to wait that long because three other residents were ahead of them waiting for care already and they were behind. Resident #23 approached Certified Nursing Aide #25 during the interview and requested to be toileted before going to the main dining room for lunch. Certified Nursing Aide #25 stated the next resident was waiting for over an hour for a bed bath but would need to wait longer now. They did not have enough staff to provide incontinence care as often as required and were frustrated by that. During an interview on 08/05/2026 at 12:03 PM, Registered Nurse Unit Manager #14 stated residents received toileting or incontinence care every two hours and as needed, depending on their level of function. They knew if a resident needed care by walking rounds on the unit and by resident call bells. There was no acceptable time for a resident to wait in a dirty incontinence brief, and they needed to be changed as soon as possible, and an hour was too long for a resident to wait. The resident waited that long because of staffing issues and the number of nurse aides was low. They needed a minimum of six and usually only had three or four. They did not have enough staff to toilet residents as often as they needed to. During an interview on 08/11/2026 at 10:11 AM, Director of Nursing #1 stated all staff were to follow the care plan for all required activities of daily living. Staff did not have to record activity of daily living tasks; we did audits to ensure the care was done and the unit managers rounded. Only food and fluid intake, bowel movements, and supplement intake were recorded. It was hard to determine who provided care or when the last care was provided. During an interview on 08/11/2026 at 12:16 PM, Certified Nursing Aide #26 stated residents received care based on resident specific care on the Kardex. The residents should be up, dressed, and groomed by 9:00 AM. Not all activities of daily living care tasks were documented in the electronic medical record. Residents were to be toileted at least every two hours but there were times when that did not happen due to staffing levels. During a follow up interview on 08/11/2026 at 1:13 PM, Registered Nurse Unit Manager #14 stated not all activities of daily living tasks are documented, only meal intakes and bowel elimination are recorded in the electronic medical record. 10 New York Codes, Rules and Regulations 415.12(a)(3)

Based on observations, record review and interviews, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional standards and principles for two of two medication carts (Unit 2 and Unit 3). Specifically, during observations on 08/05/2026 and 08/06/2026, the Unit 2 short hallway medication cart contained medications for two discharged residents; the Unit 3 short hallway medication cart had one vial of expired influenzas vaccine, medications for a discharged resident, and one expired long-acting insulin pen not initialed when opened and had two opened dates, 05/17/2026 and 06/24/2026. Findings included:The facility policy Medication/ Treatment Labeling and Storage, revised July 2025, documented multi-dose insulin would be dated and initialed when they were opened. There was no documentation on how long insulin was stored for, who checked for expired medications and vaccines, or when expired medications and discharged resident medications were removed from the unit. During an observation and interview with Licensed Practical Nurse #36 on 08/05/2026 at 8:55 AM, the Unit 3 short hall medication cart had medication for a discharged resident, an expired vial of influenzas vaccine dated 06/30/2026, and Resident #51 had an opened basaglar (long-acting) insulin pen that was not initialed and had two opened dates, 05/17/2026 and 06/24/2026, both expired. Resident #51 was ordered to receive the insulin at bedtime. Licensed Practical Nurse #36 stated they were not sure why the pen had different open dates and insulin expired 28 days after opened. They stated It was the responsibility of the person who first opened the pen to initial and date it; t was the responsibility of every nurse to make sure medications were initialed and dated when opened. The night nurses checked the medications when they cleaned the carts, and the insulin pen should have been pulled. The flu vaccine came from the pharmacy and should have been pulled because it was expired. Expired medications or discharged resident medications were removed from the floor weekly. During an observation on 08/06/2026 at 3:15 PM, the Unit 2 short hall medication cart contained medications for two discharged residents. 10 New York Codes, Rules and Regulations 415.18(d)

Based on observations and interviews the facility failed to ensure a safe, clean, comfortable, and homelike environment for one of three units (Unit 2) reviewed. Specifically, Unit 2 had dirty floors, dirty walls, a missing baseboard and a damaged corner board. Findings include:The facility policy titled General Daily Cleaning, last reviewed March 2026, documented the facility provides an environment that fosters a positive self-image for the resident and preserves human dignity. The entire facility will always be clean; this includes daily cleaning of resident rooms, lounges, and hallways. The following observations were made of Unit 2:-On 08/04/2026 at 8:44 AM, outside of room [ROOM NUMBER] under the resident name plate, there was a red/brown colored splattered type stain.- On 08/11/2026 at 1:57 PM, outside of room [ROOM NUMBER], the same red/brown stain remained under the resident name plate. At 1:58 PM, observed the walls under the television across from the nurse's station to have brown and black splatters on the wall. At 1:59 PM, across from the medication room, where the sit to stand machine was stored, there was a piece of missing baseboard approximately 12 inches long, and across from that missing baseboard was a corner that appeared to have sheet rock separating from the floor and the plastic corner board was not intact. At 2:02 PM, the lower portion of the wall between room [ROOM NUMBER] and 230 had multiple dirty black sticky substance splatters on the wall. At 2:04 PM, outside of room [ROOM NUMBER], the baseboard molding was noted to be peeling up off the floor and was dirty. At 2:05 PM, the floors near the wall next to the crash cart were very dirty with brown and sticky black substances noted near the edge of the baseboards. During an interview on 08/11/2026 at 2:07 PM, Housekeeper #8 stated they were assigned to Unit 2 daily. They were responsible for cleaning the residents' rooms, taking out dirty linen and trash, and cleaning the employee bathrooms. They stated the floors do not get routinely mopped. There was a housekeeper assigned to clean the floors with the floor machine, but that machine does not clean the baseboards. They said if they noticed the walls were dirty, they should wipe them down. They were not aware of the specific areas that were observed. They said this must have been an oversite. They stated it was important to ensure the residents' rooms and living space were clean to make a good impression on residents' families and visitors. During an interview on 08/11/2026 at 2:38 PM, Certified Nurse Aide #9 stated they had concerns about the cleanliness on Unit 2. They mentioned they were an agency staff member and explained that the walls and floor were always dirty. All the staff should have the moral integrity to pick up trash and clean up messes as they see them. They stated the housekeepers do not clean the rooms, but just talk with the residents, and the nursing staff would just walk past trash that should be picked up. During an interview on 08/12/2026 at 8:26 AM, the Housekeeping Supervisor stated the housekeepers were responsible for cleaning the resident rooms. They were not responsible for cleaning the hallways. Nursing and Housekeeping staff can clean the hallways. They had a staff person that would use the floor machine to clean the floors, but that does not clean the baseboards. Housekeeping staff would have to scrape or mop those areas. The area on the wall near room [ROOM NUMBER] was a stain and will not come off. They stated if staff noticed something was dirty, they should just clean it up. They do not do audits on the hallways. During an interview on 08/12/2026 at 9:44 AM, the Maintenance Supervisor stated the wallpaper on Unit 2 was porous and absorbs everything. They were in the process of remodeling Unit 3 and Unit 2 would be next, and this would include removal of all the wallpaper. They were not aware of the missing, peeling baseboards and loose corner board. This was an easy fix, and they would make sure it was addressed. 10 New York Codes, Rules, and Regulations 415.29(i)(1)

Based on record review, observation, and interview the facility failed to ensure a safe, clean, comfortable, and homelike environment for one (1) resident unit. Specifically, the temperature of the facility's hot water was not maintained.Findings include:An undated resident bathing training form documented:- if the resident refused to take a shower or bath because the water was too cold, the supervisor was required to be notified immediately; and- anytime a supervisor was notified of cooler than normal water temperatures the Director of Nursing and the Administrator must be notified immediately. An undated creating maintenance requests training form documented how staff can enter work orders. An 09/09/2025 loss of hot water policy documented the following:- Notify the maintenance department of the loss of hot water by either entering a work order, or directly contacting the maintenance department;- Take water temperatures at identified locations of water loss, if the water temperatures were outside of the allowable range maintenance was tocontinue taking temperatures in other locations on that floor and expand the temperature monitoring to alternate floors, and maintenance had to verify the temperature leaving from and returning to the mixing valve in the boiler room;- Notify residents and families of the service loss with an expected time frame for service recovery, residents are notified in person/ in writing, and families/emergency contacts could be notified via ROBO-call; and- Notify staff of loss of service and provide education on interim measures to be taken during service loss;- Administration/ designee to determine if reporting criteria have been met to notify DOH. An undated work order log documented:- On 01/13/2026 at 11:14 AM, the second-floor short hall shower hot water was working;- On 01/16/2026 at 7:38 AM, there was a follow up on an after-hours call at 2:40 AM that there was no hot water and that the mixing valve in the boiler room was hung up;- On 01/17/2026 at 11:09 AM, there was no hot water on the third floor;- On 01/18/2026 at 10:38 AM, there was no hot water in the facility;- On 01/19/2026 at 9:46 AM, residents complained about not having hot water for showers; - On 01/21/2026 at 5:20 AM, an electronic mix valve was reset for the domestic hot water;- On 01/25/2026 at 7:27 AM, there was no hot water in the building; and- On 01/29/2026 at 5:51 PM, there was no hot water on the fourth floor. The January 2026 Domestic Hot Water Temperature form documented that room water temperatures were required to have a top limit of 110 degrees Fahrenheit and bottom readings over 90 degrees Fahrenheit. A work order, dated 01/20/2026, documented that the fourth-floor shower room had no warm water. The comment section documented if hot water was used before the hot water tank was up to temperature it would result in no hot water. The facility did not provide work orders for resetting the electronic mix valve for domestic hot water from 01/22/2026 to 01/29/2026. A 01/05/2026 a vendor call summary report documented that a new mixing valve was installed on 01/30/2026 at 4:00 AM, and the proper water temperature was being sent to the building. During an interview on 01/30/2026 at 12:06 PM, the Regional Director of Facilities stated water temperatures were not taken on the weekends as the maintenance staff was onsite Monday through Friday, and on call for the weekends. They stated there was no documentation to verify that the water in any shower had been temperature checked.During an observation and interview on 01/30/2026 at 12:50 PM, with the Regional Director of Facilities present, the water in resident room [ROOM NUMBER] sink had a temperature of 85.6 degrees Fahrenheit. The Regional Director of Facilities stated that hot water temperatures had to be 90 degrees Fahrenheit or higher, and this water temperature was not acceptable.During an interview on 01/30/2026 at 2:04 PM, the Assistant Administrator stated they were made aware of a facility hot water issue on either 01/23/2026 or 01/24/2026. They stated that the maintenance department had reset the boiler valve over the weekend but there was never a loss of hot water emergency issue. The Assistant Administrator stated the facility had been utilizing the emergency plan for loss of hot water. They stated the acceptable hot water temperature range was between 90 degrees Fahrenheit and 110 degrees Fahrenheit. The Assistant Administrator stated that throughout the day the water would intermittently get cold and maintenance staff would reset the boiler valve to get the water hot again. During an interview on 01/30/2026 at 3:19 PM, Maintenance Technician #5 verified there was a work order on 01/20/2026 that the fourth-floor shower had no warm water, and they had not checked the temperature of the water in this room before closing out this work order. They stated that water temperatures were required to be between 90 degrees Fahrenheit and 110 degrees Fahrenheit. They stated that they had reset the boiler electronic mixing valve multiple times between 01/20/2026 and 01/28/2026, that other maintenance technicians had also reset this valve at different times, and that there was no documentation to verify this. They stated water temps were not retaken after resetting the mixing valve and cannot recall any water temperatures under 90 degrees Fahrenheit. Maintenance Technician #5 stated they had not been told that the facility's loss of water policy was in effect. During an interview on 01/30/2026 at 3:59 PM, Resident #1 stated they last took a shower last Thursday (01/22/2026), that the shower was lukewarm and not comfortable, and there had previously been lukewarm showers. They stated they were told on 01/29/2026 that they could not get a shower due to the cold water.During an interview on 01/30/2026 at 4:04 PM, Resident #2 stated they have not had a shower in the last five weeks as the water was cold. They stated the facility was always repairing the water system. During an interview on 01/30/2026 at 4:31 PM, Certified Nurse Aide #6 stated there were times when water would be hot for fifteen minutes and then get cold again. They stated water had been cold for approximately 4 weeks and had told their nurse manager about this. Certified Nurse Aide #6 had not told the maintenance staff about the loss of hot water issue as most maintenance staff had left for the day by the time they arrived at work Certified Nurse Aide #6 stated that after the maintenance staff would reset the boiler switch the hot water would last approximately fifteen minutes and enough time for one shower, and then water would get cold again. They stated that once maintenance staff would leave for the day the water would stay cold until the next day. During an interview on 01/30/2026 at 4:46 PM, Certified Nurse Aide #7 stated that hot water had been brought from the kitchen within the last week to the third floor for a resident bed bath. They stated that the shower water for the residents had been cold for the last ten or eleven days. Certified Nurse Aide #7 stated residents were showered weekly and some of the residents had not got showered within the last week. They stated when the water was too cold and when a resident would refuse a shower, they would tell their supervisor. Certified Nurse Aide #7 stated it was not acceptable that residents had not been showered in ten or eleven days and would not like it if that had happened to them.During an interview on 01/30/2026 at 5:01 PM, Registered Nurse #8 stated that for the last few weeks the hot water would intermittently go from hot to cold. They stated that when maintenance department was called the boiler would be reset and after 45 minutes the water was hot again. Registered Nurse #8 stated that once the boiler had been reset the loss of hot water issue went away and staff would get their work done. They stated a work order would be created if there was a loss of hot water and they would contact on-call maintenance staff to correct it. During an interview on 02/26/2026 at 11:58 AM, the Administrator stated the loss of hot water issue had been fixed and the residents were getting warm showers. They stated on 01/30/2025 the facility was in process of fixing the loss of hot water issue and that additional repairs were made the following day. The Administrator stated they had heard there was a loss of hot water on 01/19/2026 and they were not aware of any loss of hot water issues prior to that date. They stated there were no resident complaints of lack of hot water prior to 01/19/2026, and that a loss of hot water issue should be made into a work order so that the maintenance department could check on it. The Administrator stated they had been told by staff that hot water had been brought up from the kitchen to the third floor on one of the days between 01/19/2026 and 01/29/2026. They stated they had not requested that hot water was to be brought to the third floor during the day shift. The Administrator stated the certified nurse aides on the third floor decided to get hot water from kitchen themselves with no direction from facility management staff, and there was no documentation that the temperature of the water brought up to the third floor had ever been checked.During an interview on 02/26/2026 at 2:32 PM, the Administrator stated on 01/19/2026 they had been told by maintenance staff that there were intermittent times in which there was a loss of hot water, that the vendor was going to be onsite the next day to investigate, and the Administrator had left for vacation on 01/21/2026. They stated replacement boiler parts were ordered, was told that it would take a few days for these parts to be delivered. The Administrator stated that bringing hot water from kitchen to the third floor was part of the emergency management plan, this was not allowed without approval from management, and it was not acceptable for the third-floor certified aides to have brought hot water from the kitchen. They stated online training was sent to all staff regarding how to follow facility emergency procedures, that bringing hot water up from the kitchen without approval was not acceptable, and how to put in a work order. The Administrator stated it was not acceptable for the facility to go ten days without hot water or with intermittent hot water. and had not been contacted by the Assistant Administrator regarding any loss of hot water issues. They stated they would not want to take a cold shower, and if a resident refused a shower, they would get a bed bath. The Administrator stated they were told by maintenance staff that the sink water was warm enough, there was a shower water temperature that was cold and verified the temperatures documented daily water temperature logs. They stated there was one water temperature complaint since 01/29/2026, that a work order had been created and closed out, and the water temperature was not rechecked after the maintenance department had closed out the ticket. During an interview on 02/26/2026 at 4:07 PM, the Assistant Administrator stated they were in charge on 01/22/2026 and stated that on 01/19/2026 a water valve had been reset. They were not aware that boiler parts were on order and stated it was important to know when the hot water was going to get fixed so they would have implemented actions to address the potential loss of hot water. The Assistant Administrator stated they were not made aware of any other water issues by staff prior to 1/19/2026. They were not aware that third-floor certified nurse aides had gone down to the kitchen and had brought hot water to the third floor for a bed bath and stated this would not be appropriate as this water may not be within the acceptable temperature range if the water had not been checked. The Assistant Administrator stated the facility has a loss of hot water policy, and this policy was not activated by them. They stated it would not be acceptable for there to be no hot water in the facility for ten days and would not want to take a cold shower. The Assistant Administrator stated there was one resident complaint on 01/22/2026, was not sure who that resident was, that the boiler water valve was reset, and that they were told the facility's hot water was restored. They stated that there was hot water in the sinks, and no staff had stated the sinks were cold. The Assistant Administrator verified that they had completed the emergency procedures for staff training and was not sure of the specific date.The facility did not provide any staff training documentation regarding the loss of hot water.During an interview on 02/27/2026 at 10:08 AM, the Administrator stated the Assistant Administrator was not made aware of the loss of hot water issues prior to their vacation and could not recall any specific conversations with the Assistant Administrator regarding boiler parts on order for the repair of the hot water system. They stated at the time they went on vacation they felt the loss of hot water issue had been addressed with the hot water reset, and that the intermittent hot water issue was not a significant impact concern for the residents. The Administrator stated there was an urgency when the loss of hot water started as a vendor was called immediately and control not the time to get the parts delivered for the vendor to make the required boiler repairs. The Administrator stated they would have expected the maintenance department to tell the Assistant Administrator if there were any hot water concerns, which would include replacement boiler parts being delayed in fixing the intermittent hot water system. They stated even if there was a hot water issue, staff could wash hands in cold water for twenty seconds and the hand sanitizer alternative if needed. The Administrator stated that washing bodily fluids and other soiled contaminants with cold water was as effective as washing with warm water, although using warm water is recommended. They stated if hands were visibly soiled then staff would be required to use soap and water. During an interview on 02/27/2026 at 10:46 AM, the Assistant Administrator stated they knew about the loss of hot water issue on 01/19/2026 and had thought it had been repaired before the Administrator had gone on vacation on 01/21/2026. They stated it was acceptable to use cold water to wash hands to rinse soiled hands and that the term comfortable water was referenced in the handwashing policy. They stated if a staff's hands were soiled, they would be required to wash with soap and water.During an interview on 02/27/2026 at 11:26 AM, the Director of Facilities and Maintenance stated on 01/19/2026 that it had reset the mixing valve and was under the assumption that the facility's hot water was still working. They stated they had told the Assistant Administrator at that time that hot water was functioning. The Director of Facilities and Maintenance stated that once the vendor had notified them that the boiler parts had arrived, they did tell the Assistant Administrator. They stated that there was a hot water system with two boiler loops, and they did not know what was creating the loss of hot water until being told by the vendor. The Director of Facilities and Maintenance stated the left boiler controlled the heat only and the circulation pump on this boiler had seized up, which led to the center boiler getting signals for both hot water and heat at same time, and this would force the hot water zone valve to turn off. They stated that the hot water for the showers and the sinks utilized the same central boiler. NYCRR 415.29(j)(1)

Based on record review and interviews during the abbreviated survey (NY00371419), the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care person-centered care plan, and the resident's choices for 2 of 3 residents (Resident #1 and 7) reviewed. Specifically: -Resident #1 had a feeding tube (a device that delivered liquid nutrition into the stomach or intestine through a surgically created opening in the abdomen) and had physician orders to verify placement and check residuals. There was no documented evidence that placement and residuals were checked for 4 months. The resident developed new onset diarrhea and nausea, and there was no documented evidence the resident was assessed to determine if the resident's tube feeding should have been held. Approximately 8 hours later, the resident was found deceased with vomit on their face. -Resident #7 had an order for lorazepam 0.5 milligrams (a controlled substance medication for anxiety) by mouth every day at bedtime and the resident did not receive the medication for 7 days. Findings include: The facility policy, Change in a Resident's Condition or Status, revised ,d+[DATE], documented if a significant change in the resident's condition occurred (new, change worsening), a comprehensive evaluation/assessment of the resident's condition was conducted and documented. The facility policy, Tube Feedings, revised ,d+[DATE], documented gastric (stomach) tubes were used to supply nutrition and hydration to residents unable to take liquid or food by normal means. Tube placement was verified every shift and prior to administration of each feeding. Tube placement was checked using at least two of the following techniques: monitor and evaluate for bloating, nausea, or abdominal pain; check residual (excessive amount of fluid/food remaining in the stomach after feeding through a tube) before feeding was started; and if concerns arose regarding placement or dislodgement, notify physician and obtain x-ray confirmation. When checking for gastric contents, if over 100 milliliters (or an amount specified by the physician), hold feed for 2 hours and notify physician. Feed, flushes and tube placement checks were recorded on the Medication or Treatment Administration Record. Record any unusual symptoms or response to tube feed and report as needed to supervisor. The revised ,d+[DATE] policy, Reordering Medications, documented the purpose was to prevent any missed medication doses due to failure of reordering when necessary. The Unit Coordinator was responsible for overseeing that procedure and assignment of the medication reordering process. The nurse designated for that duty would check the medication in the cart by taking a visual inventory of all resident supplies and reordering when there was a 7-day or less supply remaining. The revised [DATE] policy, Automated Drug Dispensing System, documented the purpose of the automated medication system would be to securely store emergency supplies of controlled substances and other medication needed for use by nursing home residents in the event the immediate administration of the medication was necessary, and that no alternative treatment was available. The Automated Drug Dispensing System was a locked, automated medication storage cabinet with programmable-metered drawers with controlled and limited access. Features included, but not limited to, computerized inventory tracking, controlled password mediated access and recorded drug utilization. The procedure for the Automated Drug Dispensing System included: -the Automated Drug Dispensing System would be monitored continuously using the pharmacy interface. Any action involving the Automated Drug Dispensing System would be logged by the pharmacy and upon request generated in a detailed, comprehensive report. -Class 3A pharmacy licensed facilities should be responsible for maintaining a separate record of the administration of controlled substances from the Automated Drug Dispensing System. -Initially, authorized facility staff would be provided with a personal sign-on code and a default password to allow sign-in. -All staff nurses would have station privileges that included the ability to remove, waste and witness medications from the Automated Drug Dispensing System. -All controlled substances would be stored in an individual compartment allowing the nurse access to only that medication per transaction. -The pharmacy would work closely with the Director of Nursing to resolve all stock-related problems. The revised ,d+[DATE] policy, Medication/Treatment Administration: Documentation, documented medications and treatments were checked against the prescription order before they were administered and would be administered per physician orders. If medications or treatments were not available, nursing was to inform the nursing supervisor immediately, the emergency medication kit was used, and the medical provider was notified, and immediate medication delivery was requested. 1) Resident #1 had diagnoses including dysphagia (difficulty swallowing), malnutrition and other artificial openings of the gastrointestinal tract. The [DATE] Minimum Data Set assessment documented the resident's cognition was intact, they were independent with rolling left and right and they had a feeding tube. The [DATE] physician #18's note documented the resident was recently readmitted after hospitalization on [DATE] with mental status changes, hypotension (low blood pressure) and septic shock (life threatening condition where blood pressure drops dangerously low from infection). The resident developed dysphagia that required a feeding tube placement on [DATE]. The tube was working well and Jevity (liquid nutrition for long term tube feeding) should be continued. The [DATE] physician order documented to verify placement of feeding tube before each feeding, medication administration or flush, and record the amount of residual. The [DATE] comprehensive care plan documented the resident had a feeding tube and would remain without complications such as gastrointestinal distress, nausea/vomiting/diarrhea, abdominal distention and increased residuals through next review. Interventions included Jevity at 60 cubic centimeters per hour continuously for a total of 1440 cubic centimeters per day. Medications were to be flushed with 60 cubic centimeters of water before, during and after each administration, and residuals and signs and symptoms of intolerance checked every shift and as needed. The [DATE] at 8:24 PM Licensed Practical Nurse #7 note documented the resident had large amounts of loose stools multiple times and they complained of not feeling well. The note documented the resident's family was updated. There was no documented evidence the resident was assessed by a qualified professional. The [DATE] at 5:33 AM Licensed Practical Nurse Supervisor #8 note documented the resident was found expired, the provider was notified and orders obtained to release the body. The [DATE] through [DATE] Medication Administration Record did not contain any documentation related to checking and recording the resident's residuals before each feeding, before medication administration or before flushes per physician order. The resident's [DATE] death certificate documented the resident's immediate cause of death was acute cardiopulmonary arrest due to multiorgan failure as a consequence of Diabetes Mellitus. During a telephone interview on [DATE] at 11:34 AM, Certified Nurse Aide #9 stated they worked the night shift and was notified by the outgoing shift the resident was sick and they had an emesis basin. Most residents on the floor had a gastrointestinal illness with loose stools at that time. They checked on the resident at midnight and 2 AM and they were asleep. Around 4 AM, Registered Nurse #10 went in the resident's room to change out the tube feeding equipment and found the resident had expired. Registered Nurse #10 brought Certified Nurse Aide #9 to the resident's room, and they observed the resident's head hanging near the side of the bed with arms stretched towards the waste basket on the floor. The emesis basin was on the floor, and they observed a large amount of vomit. Registered Nurse #10 notified Licensed Practical Nurse Supervisor #8 who came to the unit. During an interview on [DATE] at 10:40 AM, Licensed Practical Nurse #7 stated when a resident had a change in condition, it was documented on the 24-hour report, the supervisor was notified, and the supervisor evaluated the resident. On [DATE], the resident was not feeling well and had not been feeling well since they returned from the hospital. The only change for them was the loose stools. The resident did not give any specifics about how they felt. They believed there was a gastrointestinal illness affecting other residents on the unit at the same time. They stated they did not recall if the resident was nauseous and did not recall if aides reported the resident was nauseous. They believed they reported loose stools to the supervisor or the other nurse on the unit and did not recall who they were. They did not recall if the resident was evaluated. They stated they did not notify the provider. They did not check a residual for the resident as it was not on the Medication Administration Record. They did not give the resident a basin and nobody reported to them the resident was given a basin. Vomiting would have been a change in condition and if they were made aware, the resident's tube feed would have been held and the provider made aware immediately. During a telephone interview on [DATE] at 11:35 AM, Certified Nurse Aide #11 stated they provided care to the resident on the evening shift on [DATE]. On [DATE], the resident was not acting themselves. They were in bed all day and that was not their normal. The resident said they did not feel well. The resident required one assist with incontinence care and could roll on their own when prompted. However, on [DATE], when they prompted the resident to roll, they instead sat up and was not following directions. A second aide had to assist them with the resident's incontinence care that night. They stated they reported to Licensed Practical Nurse #7 the resident was not acting themselves and that they also had diarrhea. They saw Licensed Practical Nurse #7 go into the resident's room sometime around 6 PM. The resident complained of nausea but did not vomit and could not recall if they reported to the nurse. They could not recall if they gave the resident an emesis basin. When they left the shift, the resident was sleeping. They did not report to the oncoming aide because they left early that night around 10:30 PM. During a telephone interview on [DATE] at 2:09 PM, Licensed Practical Nurse Supervisor #8 stated they were the supervisor on [DATE] at 7 PM through the night shift on [DATE]. On [DATE] at around 4:50 AM, they received a call from Registered Nurse #10 to come to the unit as the resident had expired. They observed the resident lying in bed, head of bed elevated, and laying on their left side. When they rolled the resident to their back, vomit was covering their face. They notified the resident's family member and that was when they first heard the resident had been nauseous that night. Nobody reported to them the resident was nauseous while they were supervisor. If they had known, they would have rounded more frequently on the resident. Because the resident had a tube feeding, the provider should have been notified when nausea started to determine if the tube feed should have been held. On [DATE] at 10:38 AM, Registered Nurse #10 was not reached in an interview. During a telephone interview on [DATE] at 11:11 AM, Assistant Director of Nursing #29 stated once a physician order was obtained, the nurse entered the order into the electronic record by entering the medication, the amount, the frequency and who the ordering physician was. To determine if the order would be placed on the Medication Administration Record or the Treatment Administration Record, the nurse needed to select the Order Type, and the physician order would show up on one of those documents depending on what was chosen. They looked in the electronic record at the resident's [DATE] physician order for verifying placement of feeding tube before each feeding, medication administration or flush, and record the amount of residual. They stated Registered Dietitian #20 entered the order on [DATE] and chose Advance Directives as the Order Type. Choosing Advance Directives as the Order Type would not transfer the order to the Medication or Treatment Administration Record and was the reason the resident's feeding tube for placement or residuals was not checked. Licensed Practical Nurse #21 revised and confirmed the order on [DATE] and they should have caught the error. Checking residuals on residents with feeding tubes was important to determine if the resident was digesting the feed. If too much feed was present in the stomach when checking residual, staff needed to determine if the feed should be stopped. If a resident with a feeding tube had nausea, an assessment was needed to see if there was excessive residual. When Resident #1 had nausea on [DATE], they expected a registered nurse to be notified, and an assessment done. They were not aware the resident was not assessed. During a telephone interview on [DATE] at 12:37 PM, Registered Dietitian #20 stated the purpose of checking residuals was to see how a resident was tolerating a tube feed. If a resident had nausea, they expected a nurse to assess the resident because they would not want to continue feeding someone that was not feeling well. They were trained to enter tube feed orders into the electronic record. A nurse signed off on the order after they enter it. On [DATE], they were not aware they selected Advance Directives for the Order Type when they entered the order for verifying placement and checking residual. During a telephone interview on [DATE] at 12:46 PM, Licensed Practical Nurse #21 stated they were trained on entering physician orders into the electronic record. The purpose of confirming the order was to ensure the order was entered correctly. On [DATE], they recalled changing the Order Type from Advance Directive to the Medication Administration Record and was not sure why the changes were not saved. 2) Resident #7 had diagnoses including malignant neoplasm of the prostate and secondary malignant neoplasm of the bone. The [DATE] Minimum Data Set assessment documented the resident was cognitively intact, had no impairment to upper and lower extremities, used a walker, was independent with most activities of daily living and used an antianxiety medication. The comprehensive care plan revised [DATE] documented: Psychosocial well-being, total severity score 2, absence of mood and behavior problems. Interventions were monitor for mood and behavior change, encourage activities, encourage hobbies of interest, encourage to express emotions in a safe environment, report changes in behavior or psychosocial functioning. There was no documentation regarding the resident's lorazepam for anxiety. Physician orders documented: - on [DATE], lorazepam 0.5 milligrams one tab by mouth at bedtime for anxiety; end date [DATE] (the end date was more than 30 days). -verbal order on [DATE], lorazepam 0.5 milligrams by mouth one time only for anxiety for one day, may pull from Automated Drug Dispensing System, approved by on-call provider. -on [DATE], lorazepam 0.5 milligrams give one tab by mouth one time a day for anxiety. -verbal order on [DATE], lorazepam 0.5 milligrams one tab by mouth one time a day for anxiety for two days. -on [DATE], lorazepam 0.5 milligrams one tab by mouth at bedtime for anxiety, start date of [DATE]. The facility Controlled Substance Medication Record for Resident #7's lorazepam 0.5 milligrams, prescription number 2700180, documented the medication was sent to the facility [DATE] with a quantity of 30 pills. The record documented the last dose of lorazepam 0.5 milligrams was administered on [DATE] by Licensed Practical Nurse #12. The vendor pharmacy Patient Usage Report for Resident #7 documented lorazepam 0.5 milligrams was dispensed from the Automated Drug Dispensing System: -on [DATE] by Licensed Practical Nurse #12. -on [DATE] by Licensed Practical Nurse #7. -on [DATE] by Licensed Practical Nurse #12. The facility Pharmacy Narcotic Access Code form documented on [DATE] lorazepam 0.5 milligrams was dispensed from the Automated Drug Dispensing System for Resident #7 by Licensed Practical Nurse #12. It also documented to attach the form to a copy of the printed narcotic order from the facility electronic health system and return to the Director of Nursing's mailbox; must be done, or it was a narcotic error. There was no documented evidence a pharmacy access code was obtained on [DATE] and [DATE] when nurses removed lorazepam 0.5 milligrams from the Automated Drug Dispensing System. The resident's February 2025 Medication Administration Record for lorazepam 0.5 milligrams, give one tablet by mouth at bedtime for anxiety for [DATE] - [DATE], documented: -on [DATE] lorazepam 0.5 milligrams administered by Licensed Practical Nurse #12 from the Automated Drug Dispensing System; no access code obtained from pharmacy prior to removal from system. -on [DATE] code 9 meaning other/see progress notes, by Licensed Practical Nurse #12, awaiting new order (medication not administered). -on [DATE] code 9, by Licensed Practical Nurse #12, awaiting pharmacy (medication not administered). -on [DATE] code 9, by Licensed Practical Nurse #13, med unavailable, reordered (medication not administered). -on [DATE] signature block blank, staff working was Licensed Practical Nurse #12 (medication not administered). -on [DATE] lorazepam 0.5 milligrams marked as administered by Licensed Practical Nurse #17, but medication was not available, and it was not administered. -on [DATE] lorazepam 0.5 milligrams marked as administered by Licensed Practical Nurse #17, but medication was not available, and it was not administered. -on [DATE] lorazepam 0.5 milligrams marked as administered by Registered Nurse #10, but medication was not available, and it was not administered. -on [DATE] code 9, by Licensed Practical Nurse #7 from the Automated Drug Dispensing System; the nurse called the on-call provider who approved a one time lorazepam 0.5 milligrams dose for [DATE] at 7:00PM and [DATE]; the resident's primary provider to be notified to obtain a refill of the order. -on [DATE] lorazepam 0.5 milligrams administered by Licensed Practical Nurse #12 from the Automated Drug Dispensing System; protocol was followed, and an access code was obtained for the medication prior to removal from the Automated Drug Dispensing System. - Between [DATE] and [DATE], the resident received their routine lorazepam 0.5 milligrams at bedtime [DATE], [DATE] and [DATE], with an access code to obtain from the Automated Drug Dispensing System only on [DATE]. The resident did not receive their routine lorazepam 0.5 milligrams at bedtime for 7 straight days, [DATE] - [DATE]. During an interview on [DATE] at 9:00 AM Licensed Practical Nurse #3 stated they had a lot of medications during the morning medication pass that were not available because nurses did not reorder them timely. They usually reordered medications when they got down to two pills in the blister pack. If there was a medication unavailable during the medication pass, they would first check the Automated Drug Dispensing System which was in the utility room on Unit 2. If the medication was not in the Automated Drug Dispensing System, they would call pharmacy to order it. They would then sign off in the electronic medication administration record that the medication was on order, as that is what the facility had told them to do. During an interview on [DATE] at 9:29 AM Licensed Practical Nurse Unit Manager #4 stated if a medication was unavailable on the medication cart, they would first check the Automated Drug Dispensing System. If the medication was not in the Automated Drug Dispensing System they would call pharmacy to order it. During an interview on [DATE] at 12:30 PM Resident #7 stated they recalled not getting their lorazepam 0.5 milligrams at bedtime for several days recently. Nurses told them they needed a refill for the lorazepam, and they were getting locked out with the code when they tried to reorder it. The medical provider never spoke to them about the lorazepam not being available. They had done okay without the lorazepam as they also took melatonin (a supplement that helped indirectly with anxiety by improving sleep). During a phone interview on [DATE] at 9:18 AM Registered Pharmacist #5 from the facility's vendor pharmacy stated Resident #7's lorazepam 0.5 milligrams was last filled by them on [DATE] and the order was good for 30 days. There was a one-time order filled by them on [DATE] by Licensed Practical Nurse #12, who dispensed it from the Automated Drug Dispensing System. When nurses removed a controlled substance from the Automated Drug Dispensing System the protocol was for them to call the pharmacy for an access code first, before removing it from the Automated Drug Dispensing System. Then they would log into the Automated Drug Dispensing System with their login credentials to remove the medication. Nurses could still remove a controlled substance from the Automated Drug Dispensing System without an access code, but that would be considered a medication error. They stated the pharmacy's Client Access Manager told facility staff many times the procedure to follow. During a phone interview on [DATE] at 9:33 AM Registered Pharmacist Director of Operations from the facility's vendor pharmacy stated nurses needed to call the pharmacy first for an access code in order to remove a controlled substance from the Automated Drug Dispensing System. They would look up the dates between [DATE] and [DATE] for Resident #7 to verify when nurses had called for an access code for removing lorazepam 0.5 milligrams and call back. During a follow-up phone interview on [DATE] at 9:46 AM Registered Pharmacist Director of Operations stated they ran a report for Resident #7's lorazepam 0.5 milligrams for the dates [DATE] - [DATE]. On [DATE] and [DATE] lorazepam 0.5 milligrams was removed from the Automated Drug Dispensing System, but nurses did not call the pharmacy for an access code first. They sent a discrepancy code form to the facility for those two dates which were supposed to be returned to them within 24 hours, and they never heard back from the facility. They used to send the discrepancy code forms to the Director of Nursing, who was no longer at the facility as of [DATE]. They did have an access code for the lorazepam 0.5 milligrams removed from the Automated Drug Dispensing System on [DATE]. During a phone interview on [DATE] at 10:40 AM Licensed Practical Nurse #12 stated they worked at the facility the last two years as an agency nurse. They usually passed medications but were sometimes the supervising nurse. They were thrown into the nurse supervisor role without any training. If a resident did not have a controlled substance medication available on the medication cart, they would call the pharmacy for an access code to the Automated Drug Dispensing System. Controlled substances were not indefinite orders; they were only good for 30 days. If controlled substance medications were past 30 days pharmacy would not provide an access code number. When on-call medical providers were called regarding a controlled substance medication order they would not return the call quickly unless it was an urgent situation, such as a resident fall. They knew about Resident #7's lorazepam 0.5 milligrams not being available. They had called the on-call medical provider, but the provider never got back to them. If an on-call medical provider was not familiar with a resident they did not feel comfortable ordering a one-time medication. The pharmacy would not give them an access code for Resident #7's lorazepam 0.5 milligrams on [DATE] because the resident's order was past 30 days. They still dispensed the lorazepam 0.5 milligrams from the Automated Drug Dispensing System and administered it to the resident. They could not remember if they wrote a nursing progress note about notifying the on-call medical provider about Resident #7's lorazepam 0.5 milligrams being unavailable. They received a medication error from the facility on [DATE] for not administering Resident #7 their lorazepam 0.5 milligrams on [DATE], [DATE] and [DATE]. They were told by the facility they should have notified the supervisor about the unavailable medication, but they stated they were the supervisor on those dates. They were aware Licensed Practical Nurse #7 put in a two-day order for lorazepam 0.5 milligrams on [DATE] (for administration on [DATE] and [DATE]). They were never initially trained on the protocol to follow for removing a controlled substance from the Automated Drug Dispensing System. Recently, Licensed Practical Nurse Unit Manager #4 went over the process of removing a controlled substance from the Automated Drug Dispensing System with them. They and other nurses recently received a random education on removing medications from the Automated Drug Dispensing System because none of them knew the process. They had spoken with Resident #7 and Resident #7's family member about the lorazepam 0.5 milligrams being unavailable and how their hands were tied in attempting to get it without success. Resident #7 had shown no outward appearances of having any adverse effects such as agitation, anxiety or complaining from not receiving their lorazepam 0.5 milligrams. On [DATE] at 12:45 PM, Registered Nurse #10 was not reached in an interview. During a phone interview on [DATE] at 12:50 PM Licensed Practical Nurse #13 stated they were an agency nurse and had only worked two shifts at the facility. If they did not have a controlled substance medication for a resident when they were passing medications, they would normally get a supervisor. They were told they had no access to the Automated Drug Dispensing System because they were an agency nurse. They were familiar with Resident #7 and recalled trying to get their lorazepam 0.5 milligrams on [DATE]. They called the Registered Nurse Supervisor (name unknown) and the floor licensed practical nurse (name unknown) but they did not do anything about it. They (the Registered Nurse Supervisor and floor licensed practical nurse) had brushed it off and had commented that they knew the lorazepam 0.5 milligrams had been unavailable. Licensed Practical Nurse #13 spoke with who they thought was the Director of Nursing the next morning about Resident #7's lorazepam 0.5 milligrams, but they did not do anything about it and told them most nurses did not have a log-in for the Automated Drug Dispensing System. They had never been educated on the process for getting a medication from the Automated Drug Dispensing System. For the two shifts they worked at the facility, many residents had medications unavailable because they were not re-ordered. They no longer worked at the facility. During a phone interview on [DATE] at 2:37 PM Nurse Practitioner #14 stated for a controlled substance medication to be reordered the licensed practical nurse or registered nurse would need to send an electronic order to refill, and they would double-check to see if it was a routine order. The order notification would show up on their phone. If they were not notified a resident's medication needed to be reordered, they could not refill it. Routine medication orders were good for 30 days, and with 14-day or as needed medication orders they would re-assess to see if the resident still needed that medication. The nurses had to put the refill order under the primary provider's name for it to be refilled. Resident #7 was their patient, and they were not aware they had not received their routine lorazepam 0.5 milligrams at bedtime for seven days ([DATE] - [DATE]). They re-ordered Resident #7's lorazepam 0.5 milligrams on [DATE]. The on-call medical providers were available from 5:00 PM - 8:00 AM. If they had a day off, they would let the covering medical provider know so that the correct provider's name would be on an order. Medication orders were frequently not reordered timely at the facility. During a phone interview on [DATE] at 9:40 AM Licensed Practical Nurse #17 stated if a medication was unavailable on the medication cart, they would notify the supervisor. They worked many double shifts, and it was very busy. They remembered Resident #7 talking to them about their lorazepam 0.5 milligrams not being available because the nurses did not have an access code to the Automated Drug Dispensing System. They had never been educated on using the Automated Drug Dispensing System and there was no handbook available that Administration told them to refer to. They had no access to the Automated Drug Dispensing System. They could not remember if they had administered lorazepam 0.5 milligrams to Resident #7 on [DATE] and [DATE]; it was possible they signed for it when they never really gave it due to its unavailability. They could not remember notifying a supervisor on [DATE] and [DATE]. They remembered giving that medication to the resident in the past when they worked evening shifts. They recently received a medication error from the facility for not administering lorazepam 0.5 milligrams to Resident #7 as ordered. Resident #7 showed no signs of distress or anxiety on [DATE] and [DATE]. Resident #7's family member frequently took them out on pass. During a phone interview on [DATE] at 10:21 AM Licensed Practical Nurse #7 stated they were passing medications on [DATE] when they noticed Resident #7 did not have their lorazepam 0.5 milligrams. The resident needed an order for the lorazepam 0.5 milligrams as it had not been refilled. They called the on-call medical provider and did not get a call-back right away. They passed the information on to Licensed Practical Nurse Supervisor #8. They eventually got a call-back from the on-call provider and were able to get an order for the lorazepam 0.5 milligrams for [DATE] and [DATE]. The resident received their lorazepam 0.5 milligrams before they left their shift on [DATE]. Resident #7 had been asking about their lorazepam 0.5 milligrams earlier in the shift and if it had come in yet. They were pleasant about the situation and did not appear to be having any withdrawal symptoms from not having had the lorazepam 0.5 milligrams for several days. The resident was thankful after they received their lorazepam 0.5 milligrams on [DATE]. They had not had a training on removing a controlled substance from the Automated Drug Dispensing System and were not aware they needed an access code. 10NYCRR 415.12 37516

Based on record review and interview during the abbreviated survey (NY00371419), the facility was not 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 for 1 of 3 residents (Resident #2). Specifically, facility Administration, including the Director of Nursing, did not ensure a complete and accurate investigation was completed following an allegtion of abuse. Additionally, the staff statements provided to the Department of Health (as part of the abuse investigation) were falsified. The staff that provided statements stated they did not author the statements or provide a verbal statement to anyone at the facility, they did not sign the statements, and the signatures on the documents were not theirs. Findings include: The facility policy, Facility Incident/Abuse Investigation and Reporting revised 6/7/2023, documented should a resident be observed with unexplained injuries or suspected/alleged abuse, neglect or mistreatment, the employee notified the supervisor who conducted an assessment. The supervisor/designee initiated an Accident/Injury Report in the electronic record and recorded information in the record. The supervisor notified the Director of Nursing immediately. The Director of Nursing initiated the investigation. In the event the Director of Nursing was not on-site, the supervisor might begin the investigation as directed by the Director of Nursing. The Director of Nursing/designee notified the Administrator immediately. For allegations of abuse, neglect, mistreatment, misappropriate or once suspicion of abuse had been formed, the Director of Nursing Services must notify the Department of Health. Facility employees that have been accused of resident abuse would be suspended or reassigned to non-resident care duties until the results of the investigation had been reviewed by the Administrator. The 11/30/2024 untimed and unsigned Investigative Summary (no Incident Report was provided) documented the resident stated a night shift nurse was rough with them and the resident could not provide details on what rough meant. Staff present did not witness any rough actions by the nurse. Staff reported the resident was unusually confused. At baseline, the resident was alert and oriented to person, place, time, and event. Staff reported the resident was combative and hit the nurse. The resident had some swelling but no bruising to their right wrist and the x-ray was negative. The resident stated they were not afraid. There was no care plan violation, and no abuse found as a result of the investigation. The investigation did not document who the accused nurse was or what action was taken with them (statements identified Licensed Practical Nurse #15). Typed statements dated 11/30/2024, with the employee signatures documented: - From Licensed Practical Nurse Supervisor #8, during the night shift of 11/29-11/30/2024, the resident was very combative and insisted they needed to find their car and pick their family members up. The resident was pacing the unit at 4:00 AM, was redirected to their room, and became combative. Licensed Practical Nurse #15 helped the resident into a wheelchair and got them to their room. The resident was very upset, did not want to return to their room, and attempted to hit Licensed Practical Nurse #15 multiple times. - From Licensed Practical Nurse #17, the resident was wandering the unit throughout the night and was attempting to leave to go to their car. Initially the resident was redirectable. Around 4:00 AM, Licensed Practical Nurse #15 helped the resident into a wheelchair and transported them back to their room. The resident was very confused and combative towards the nurse. The resident attempted to hit staff who were redirecting them. Licensed Practical Nurse #15 was firm in their speech with the resident in attempt to redirect them. - From Registered Nurse #16, they spoke with the resident following their claims the night shift staff were rough with them. The resident could not recall specific details besides providing a basic description of the nurse who was rough with them. Staff members reported the resident was disoriented and combative on the night shift. An assessment was completed and the resident had no complaints of pain or discomfort. During a telephone interview on 2/25/2025 at 2:09 PM, Licensed Practical Nurse Supervisor #8 stated on 11/30/2024 during the night shift: - The resident was up and wandering on their shift. - Licensed Practical Nurse #15 was the unit floor nurse and Licensed Practical Nurse #15 expected all residents to be in their rooms on the night shift. Licensed Practical Nurse Supervisor #8 had counseled the nurse in the past that residents had a right to be up as the facility was their home. -They heard Licensed Practical Nurse #15 say to the resident it was time to go to bed and Licensed Practical Nurse #15 sounded annoyed. They did not witness Licensed Practical Nurse #15 place the resident in the wheelchair. - The resident did not allege abuse or complain of wrist pain on their shift. - During their shift the next day, they heard the resident alleged abuse against a night shift staff and the incident was under investigation. They stated they were surprised that nobody had spoken to them because they were present when the incident occurred. If someone had spoken to them, they would have reported Licensed Practical Nurse #15's inappropriate tone when telling the resident they needed to go to bed. - A copy of the 11/30/2024 statement included in the Investigative Summary, with Licensed Practical Nurse Supervisor #8's name and signature was provided to them. The nurse stated they did not author the statement, or provide a verbal statement to anyone at the facility, did not sign the statement, and the signature on the document was not theirs. During a telephone interview on 2/27/2025 at 11:35 AM, Registered Nurse #16 stated: - On 11/30/2024, they were the supervisor on the day shift. They were asked by the former Director of Nursing to do an assessment on the resident and was not told why the assessment was needed. They were not aware the resident alleged abuse and did not know any details. - A copy of the 11/30/2024 statement included in the Investigative Summary with Registered Nurse #16's name and signature was provided for Registered Nurse #16 to review. Registered Nurse #16 stated they did not author the statement, or provide a verbal statement to anyone at the facility, did not sign the statement, and the signature on the document was not theirs. During a telephone interview on 3/3/2025 at 7:31 AM, former Director of Nursing #2 stated incidents should be reported the supervisor, the Administrator or themselves so a thorough investigation could be completed. The staff that was accused of abuse should be suspended to keep residents safe. All staff on duty when the alleged abuse occurred should provide statements and statements were obtained by the supervisor, the Administrator, or themselves. The Administrator was responsible for completion of the Investigative Summary though they had completed them in the past. The Administrator was responsible to determine if abuse or neglect occurred and the Administrator or themselves reported abuse to the New York State Department of Health. On 11/30/2024, they reported the incident to the Administrator. They were not sure why only 3 nurses provided statements and no certified nurse aides were interviewed. They stated the certified nurse aides should have provided statements. They could not recall if they wrote the Investigative Summary for the incident. The Investigative Summary should have been signed and dated. They were not aware Licensed Practical Nurse #15 worked on 12/1/24 and depending on if the investigation was completed and abuse ruled out, they should not have worked. They could not recall if they obtained statements from Licensed Practical Nurse Supervisor #8 or Registered Nurse #16 and was not aware the statements or the signatures were not from those nurses. They did not think the facility could rule out abuse and neglect if the statements were false. They were not sure why the incident was not reported the New York State Department of Health. During a telephone interview on 3/3/2025 at 10:49 AM, the Administrator stated staff statements were obtained by the supervisor or the Director of Nursing. The Director of Nursing was responsible to complete the Investigative Summary. The Administrator reviewed all the incident documentation once completed and they, the Director of Nursing and corporate ruled out abuse and neglect. They or the Director of Nursing reported abuse to the New York State Department of Health. They stated on 11/30/2024, the Director of Nursing investigated the allegation of abuse and determined from staff statements that abuse had not occurred. Staff stated the resident was not at their baseline and was confused. Staff were concerned the resident would fall. The resident alleged they were pushed in to the wheelchair and staff statements did not support this. They stated they did not write the Investigative Summary for this incident and assumed former Director of Nursing #2 did. Former Director of Nursing #2 should have signed and dated the summary. They believed abuse and neglect was ruled out the same day and why Licensed Practical Nurse #15 returned to work on 12/1/2024. They were not aware staff alleged their statements were forged and stated they had no reason to not believe the staff. They stated abuse and neglect could not have been ruled out if staff statements were incorrect. The facility would need to reopen the case to investigate. The incident was not reported to the New York State Department of Health because the facility initially ruled out abuse and neglect. During a telephone interview on 3/4/2025 at 12:52 PM, Licensed Practical Nurse #17 stated they were not on duty on the night shift on 11/30/2024. They were provided a copy of the statement from the Investigation Summary with Licensed Practical Nurse #17's name and signature for their review. Licensed Practical Nurse #17 stated they did not author the statement, or provide a verbal statement to anyone at the facility, did not sign the statement, and the signature on the document was not theirs. 10NYCRR 415.26(a)

Based on record review and interviews during the recertification and abbreviated (NY00350839) surveys conducted 9/9/2024-9/16/2024, the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection and prevent new ulcers from developing for 2 of 6 residents (Residents #88 and #195) reviewed. Specifically, Resident #88's wound treatments were not consistently documented as completed; and Resident #195 developed impaired skin integrity on the sacrum (the triangular bone at the base of the spine) that was not assessed by a qualified professional to determine interventions and routine monitoring, and treatments were not consistently applied as ordered. Subsequently, the area progressed to a Stage 4 (full thickness skin loss exposing muscle, bone, or tendon) pressure ulcer and the resident developed sepsis requiring hospitalization . This resulted in actual harm to Resident #195 that was not immediate jeopardy. Findings include: The facility policy, Documentation of Pressure Ulcer and Chronic Wounds, revised 6/2023 documented pressure ulcers and chronic wounds were monitored closely to monitor effectiveness of treatment and change in risk factors. An ongoing inspection and assessment of all pressure sores and chronic wounds would be conducted weekly and as needed. The Assistant Director of Nursing was responsible for initiating weekly skin status evaluations when a pressure ulcer, stasis wound, or chronic wound was identified. The provider would be updated on new skin issues and/or change in condition. The Assistant Director of Nursing or designee were responsible for weekly evaluations which included, type, site, stage, size, description/characteristics, treatment, debridement (removal of dead tissue), exudate (drainage), pain management, and progress toward healing. The facility policy, Dressing-Clean Technique, revised 12/2007, documented the treatment was performed by a licensed nurse following a physician order or house treatment. The treatment would be completed, and the nurse was to initial the treatment sheet and document changes as needed. 1) Resident #195 had diagnoses including a hip fracture and chronic kidney disease. The 4/27/2022 Admission Minimum Data Set assessment (a health screening tool) documented the resident had moderately impaired cognition, required extensive assistance with bed mobility and transfers, was at risk of developing pressure ulcers, had no unhealed pressure ulcers, and had moisture associated skin damage (skin impairment caused by excessive moisture). The 4/21/2022 physician order documented Calmoseptine (protective barrier cream) to buttocks twice daily with incontinence care; licensed nurse weekly skin checks and report any new skin issues to the registered nurse for assessment. The 5/6/2022 at 1:39 PM Licensed Practical Nurse #1 progress note documented the resident had an open area to their buttock and Assistant Director of Nursing #11 was made aware. A new order was obtained to cleanse the buttock with normal saline, apply Medihoney (medicinal honey used as a wound treatment), cover with a dry dressing, and change every other day. The 5/6/2022 physician order documented to cleanse open area to buttocks, apply Medihoney, and cover with dry dressing every other day until healed. There was no documented evidence the wound was assessed by a qualified professional. There was no corresponding progress note by former Assistant Director of Nursing #11. The 5/11/2022 at 10:37 PM Licensed Practical Nurse #2 progress note documented the resident was noted with an open area and they reported their findings to the Registered Nurse Supervisor. The 5/12/2022 at 1:22 AM Registered Nurse Supervisor #3 progress note documented the resident had 2 right buttocks wounds that measured 3.8 centimeters x 1.5 centimeters, and 1.9 centimeters x 1.7 centimeters; and a left buttock wound that measured 1.8 centimeters x 1.5 centimeters (no depth recorded for any of the areas). The areas had bloody drainage, they were cleansed, and a protective dressing was applied. Nursing was to update the primary care provider in the morning. There was no documented evidence the medical provider was notified of the buttock wounds. There were no documented wound assessments in the nursing progress notes from 5/13/2022-6/15/2022. The 6/2022 Treatment Administration Record documented: - cleanse open area to buttock with normal saline, apply Medihoney, cover with dry dressing, change every other day, and as needed until healed one time a day every other day with a start date of 5/6/2022 and a discontinue date of 6/10/2022. There was no documentation the treatment was completed on 6/2/2022 and 6/6/2022. - cleanse open areas to buttock with normal saline, apply Medihoney, cover with a dry dressing, change every day as needed until healed one time a day every other day with a start date of 6/10/2022 and a discontinue date of 6/17/2022 (same as previous order). There was no documented evidence the treatment was completed on 6/12/2022 and 6/14/2022. The 6/16/2022 at 2:19 PM Physical Therapist #5 progress note documented the resident's family expressed concern about a wound on the resident's buttock and requested a wound care appointment at the hospital. Therapy provided the resident with a wedge cushion for offloading the wound. The resident had no ROHO (specialized air-filled wheelchair cushion to reduce pressure injury and provide skin protection) at the present time for pressure reduction. The Comprehensive Care Plan was updated to reflect a wedge cushion. The 6/16/2022 at 4:44 PM Registered Nurse Unit Manager #6 progress note documented the resident had an unstageable (a pressure ulcer where the wound bed was obscured by non-viable tissue) pressure ulcer on their coccyx (tailbone) that was 6 centimeters x 3 centimeters x 1.5 centimeters with 0.3 centimeters of undermining (wound edges separate from surrounding healthy tissue creating a pocket). Slough (tan/grey non-viable tissue) was noted with moderate serosanguinous (combination of blood and serum, the clear part of blood) and odor (possible indication of infection). The resident stated they had frequent pain in the area. The area was cleansed and dressed, and a wound care consult was ordered. The Comprehensive Care Plan initiated 6/16/2022 documented the resident had a skin related injury of an unstageable wound to the coccyx. Interventions included monitor skin for changes daily during care, and treatment per physician order. The 6/16/2022 Nurse Practitioner #7 progress note documented nursing staff had concerns of a sacral wound which was not present during the last routine examination (5/19/2022). The resident reported pain at the wound site and required oral narcotics for pain. The wound was assessed as a large unstageable sacral ulcer with odor and sloughing eschar (brown/black non-viable tissue). Wound care orders were in place. The plan was an immediate referral to outpatient wound care, and nursing staff were to continue twice a day wound dressing changes. There was no documented evidence of twice a day wound dressing changes for the resident. The last physician orders were from 5/6/2022 and documented to cleanse open areas to buttock, apply Medihoney, and cover with dry dressing every other day until healed. Physician orders documented : - on 6/16/2022, to buttock open area cleanse with normal saline, sterile wet to dry inside wound, Aquacel (absorbent dressing) to excoriated areas, cover with Opticell two times a day for wound care. - on 6/17/2022, clean open areas to buttock with normal saline, apply Medihoney, cover with dry dressing and change every other day and as needed until healed. There was no physician order discontinuing the 6/16/2022 treatment or documentation as to why the treatment was changed back to every other day from twice daily. The 6/2022 Treatment Administration Record documented: - cleanse open area to buttock with normal saline. Apply Medihoney, cover with dry dressing, change every other day, and as needed until healed, one time a day every other day with a start date of 6/17/2022. - to buttock open area cleanse with normal saline, sterile wet to dry inside wound, Aquacel to excoriated areas, cover with Opticell two times a day for wound care with a start date of 6/16/2022 and a discontinue date of 6/17/2022. The 6/17/2022 at 7:34 AM Physical Therapist #5 note documented the resident was provided an alternating air mattress (a specialty mattress for pressure reduction) on 6/16/2022. The 6/23/2022 Wound Care Consultant Nurse Practitioner #9 documented the resident's family member was visiting when the resident complained of buttock pain and upon further examination, the family member realized the resident had a large opening in the sacral area. The family notified nursing who was not aware of the wound. Today, the Stage 4 pressure ulcer had moderate serosanguinous drainage without odor. There was a rash like excoriation (scraped) surrounding the wound with a small opening on the left buttock. The wound was 8 centimeters x 8 centimeters x 1.8 centimeters with undermining between 8 to10 o'clock that was 0.9 centimeters. The wound was mostly covered in eschar and slough which was debrided (removal of dead tissue using a scalpel). Recommendations included Medihoney to wound bed and cover with foam border dressing daily. Cover left buttock excoriation with Xeroform (petroleum-based treatment) and foam dressing daily. Follow up in 1 week. The 6/24/2022 physician order documented cleanse coccyx wound with soap and water, Medihoney to wound base, Xeroform to left buttock and cover with foam bordered dressing daily. The 6/2022 Treatment Administration Record documented to wound on coccyx cleanse with soap and water, Medihoney to sacral base, Xeroform to left buttock, cover with foam border, skin prep to peri-wound (skin surrounding wound), Calmoseptine to red areas after foam applied with a start date of 6/23/2022 and a discontinue date of 7/3/2022. On 6/29/2022 and 6/30/2022 Licensed Practical Nurse #12 documented 9 other/see progress note. There were no associated progress notes by Licensed Practical Nurse #12. The 7/1/2022 Wound Care Consultant Nurse Practitioner #9 documented the resident's Stage 4 pressure ulcer was 8 centimeters x 7.8 centimeters x 1.8 centimeters and the wound continued to make minimal progress. The note documented to switch from Medihoney to Hydofera Blue (antibacterial wound treatment) and cover the larger excoriation on the right buttocks with Xeroform and foam border and finish with Calmoseptine (protective treatment) to exposed red areas. Advised little to no wheelchair time and spend most time in bed with turning and positioning. The 7/7/2022 at 5:26 PM Registered Nurse #10 progress note documented the resident was sent to the hospital from their wound care appointment. There was no documented evidence of a wound care appointment for 7/7/2024 in the resident's record. The 7/8/2022 at 5:31 AM Registered Nurse #13 progress note documented the resident was admitted to the hospital for sacral osteomyelitis (infection of the bone), a surgical consult was to be obtained, and the Wound Clinic was unable to debride the wound without going to the bone. The 7/13/2022 hospital discharge summary documented a discharge diagnosis of sepsis secondary to an infected sacral ulcer. The resident was treated by an outside wound consultant and at their 7/7/2022 wound appointment, the resident's wound was noted with odor and drainage and the resident was sent to the hospital. At the hospital, the resident was found with a large infected sacral ulcer with foul odor, exposed bone and surrounding necrotic (dead) tissue. Debridement was done by surgery and the resident had a wound vacuum assisted closure device applied (a treatment that uses suction to help heal wounds). During a telephone interview on 8/22/2024 at 11:41 AM, Licensed Practical Nurse #1 stated when a resident was found with a new wound, they were supposed to let the charge nurse and wound nurse know and have a registered nurse assess the area. On 5/6/2022, they recalled the resident's wound was superficial with some missing skin and they notified the former Assistant Director of Nursing #11 for assessment. They believed Assistant Director of Nursing #11 assessed the resident's wound that day though was not sure why a note was not written. On 8/22/2024 at 11:41 AM and 8/23/2024 at 10:17 AM, former Assistant Director of Nursing #11 was unable to be reached for an interview. On 8/22/2024 at 12:17 PM and 8/23/2024 at 10:18 AM, Registered Nurse #6 was unable to be reached for an interview. During an interview on 9/4/2024 at 8:20 AM and on 9/9/2024 at 8:07 AM, the Director of Nursing stated a registered nurse needed to assess skin after staff found an impairment. They expected an assessment to be completed within a couple of hours so the physician could be notified, and a treatment ordered. They expected the care plan to be reviewed at that time. Pressure ulcers, skin with moisture issues, and skin tears were tracked weekly because they could see changes to skin from week to week and keep dietary and therapy involved with changes. They expected treatments to be signed for when completed. On 5/6/2022, they expected a registered nurse assessment. In 2022, assessments were done on paper, and they were not able to find documentation if an assessment was done. They stated the resident's care plan should have been reviewed on 5/6/2022 and the resident's wound should have been tracked weekly. They expected the physician would have been notified on 5/16/2022 of the resident's new skin impairments and expected the care plan to have been reviewed. On 6/2/2022, 6/6/2022, 6/12/2022, and 6/14/2022, when treatments were not signed on the Treatment Administration Record, that meant either the treatment was not completed, or staff forgot to sign they completed the treatment. During a telephone interview on 9/4/2024 at 10:16 AM and on 9/9/2024 at 8:28 AM, the facility's current Medical Director stated when a resident was found with impaired skin integrity, the wound nurse and wound provider should be notified. The Medical Director stated they wanted to be notified the same day if a wound was worsening or had become infected. They expected resident wounds to be monitored at the time of the dressing change and if changes were noted, the wound nurse or registered nurse should be notified for assessment. They expected treatments to be completed as ordered. 2) Resident #88 had diagnoses including Alzheimer's disease, depression, and age-related physical debility. The 7/24/2024 Minimum Data Set assessment (a health screen tool) documented the resident had severely impaired cognition, did not reject care, had both upper and lower extremity impairments, required substantial/maximal assistance with rolling left and right, had 1 Stage 3 pressure ulcer (full thickness tissue loss) that was not present on admission. The 2/15/2024 physician orders documented to apply Prevalon boots (a cushioned pressure relief device placed on the foot) to bilateral feet or skin protection every shift. The revised 5/10/2024 Comprehensive Care Plan documented the resident had a pressure ulcer on the left plantar (bottom) foot. Interventions included administer treatments as ordered. The 8/20/2024 physician orders documented to cleanse the left plantar foot with 1/4 strength Dakins (antimicrobial solution), paint the outside of the wound with betadine (antiseptic), pack wound base with betadine soaked gauze, and cover with a dry dressing twice daily and as needed when soiled. The 9/2024 Treatment Administration Record documented to cleanse the left plantar foot with 1/4 strength Dakins, paint the outside of the wound with betadine, pack wound base with betadine soaked gauze, and cover with a dry dressing twice daily and as needed when soiled with a start date of 8/20/204. There was no documented evidence the treatment was completed as ordered on the 9/7/2024 7:00 AM - 3:00 PM shift, and on 9/8/2024 for both the 7:00 AM - 3:00 PM and 3:00 PM -11:00 PM shifts. The 9/2024 Treatment Administration Record documented Licensed Practical Nurse #31 applied Prevalon boots to the resident on 9/7/2024 during the 7:00 AM - 3:00 PM shift, and on 9/8/2024 during the 7:00 AM - 3:00 PM and 3:00 PM - 11:00 PM shifts. During an interview on 9/12/2024 at 1:25 PM Licensed Practical Nurse #32 stated if a resident had a treatment order the nurse should document the treatment was completed as ordered. If they were unable to complete the treatment, they should document in a progress note and let the Nursing Supervisor know. If staff did not document the treatment was completed it was assumed the treatment was not completed. If they observed a resident without their ordered treatment completed, they would document their findings and let the Nursing Supervisor know. Treatments should be completed as ordered to aid with wound healing. During an interview on 9/12/2024 at 2:52 PM, Licensed Practical Nurse #31 stated they worked both the 7:00 AM - 3:00 PM and 3:00- 11:00 PM shifts on 9/7/2024 and 9/8/2024 on the 4th floor. A treatment order should be listed on the Treatment Administration Record. When they completed the treatment, they should sign that it was done. If the resident refused or they were unable to complete the treatment as ordered, they should document a progress note and let the Nursing Supervisor know. If the treatment was not signed as completed it was assumed the treatment was not done. It was important to complete the wound treatments as ordered to aid with wound healing. They stated Resident #88 could be combative with care, but they would reapproach the resident when they were. They stated they did not recall not being able to complete the resident's dressing changes on 9/7/2024 and 9/8/2024. If they were unable to do so they would have let the Nursing Supervisor know and write a note. During an interview on 9/16/24 at 12:17 PM the Assistant Director of Nursing stated treatments should be completed as ordered and signed for in the medical record. If a nurse was unable to complete the treatment due to a resident refusal or other issues, they should notify the Nursing Supervisor and document in a progress note. It was important to complete treatments to aid with wound healing. If a nurse did not document the treatment was completed it meant the treatment was not done. 10 NYCRR 415.12(c)(2)

Based on observation, record review, and interview during the recertification and abbreviated surveys (NY00314894 and NY99331169) conducted 09/9/2024-9/16/2024, the facility did not provide a safe, clean, comfortable, and homelike environment for 4 of 4 resident areas (Main Lobby, Second floor resident room [ROOM NUMBER]A, Third floor nursing station, and Third floor day room area) reviewed; and for 2 of 2 oxygen storage rooms (Third and Fourth floor oxygen storage rooms) reviewed. Specifically, there were multiple walls with peeling wallpaper and unclean floors with dust and food debris. Additionally, Resident #36's right wheelchair brake was broken and not repaired timely. Findings include: The facility policy, Daily Cleaning, dated 6/1/2000, documented the facility was cleaned daily and would be always kept clean; VCT (vinyl composition tile) flooring was dust mopped and then wet mopped with the specified cleaner; walls and doors were spot washed with a disinfectant cleaner when soiled; and all repair work must be logged in the maintenance logbook. The facility policy, Maintenance Electronic Work Order System, revised 12/2008, documented the facility would use an electronic work order system to better facilitate maintenance repairs/requests and to further communicate the needs of the residents with the maintenance staff. Designated facility staff would enter requests into the electronic system and maintenance would view them; maintenance would only sign off on requests when they had been addressed. The facility policy, Medical Equipment Management Plan, revised 7/2017 documented the goal of the facilities medical equipment management plan was to minimize the clinical and physical risks of equipment through inspection, testing, and regular maintenance and to provide education to personnel and the procedures to follow when reporting equipment problems, failures, and user errors; and the skills and/or information to perform maintenance activities. UNCLEAN, UNHOMELIKE ENVIRONMENT The following observations were made on 9/9/2024: - at 9:15 AM, the Main Lobby/receptionist area had peeling wallpaper. - at 10:36 AM, the housekeeping closet across from resident room [ROOM NUMBER] had an 8-inch x 3-inch hole in the wall. - at 11:03AM, the Fourth floor oxygen storage room had a thick layer of dust and dried debris on the floor. - at 11:25 AM, the Third floor day room had peeling and curling wallpaper that was falling off the walls. - at 11:27 AM, the floors in resident room [ROOM NUMBER]A were unclean. There were yogurt containers, chocolate candy rolls, and food crumbs under the bed. - at 11:29 AM, the Third floor oxygen storage room had significant dust on the floor. - at 11:46 AM the Second floor nursing station floors were unclean and stained. - at 11:54 AM, the Second floor storage room next to resident room [ROOM NUMBER] had unclean and stained floors. During an interview on 9/12/2024 at 11:37 AM, Certified Nurse Aide #25 stated they thought housekeeping was responsible for cleaning the floors around the nursing station and resident rooms. During an interview on 9/12/2024 at 11:42 AM, Housekeeping Aide #39 stated they were responsible for cleaning half of the unit which included the solarium and the nursing station. Their duties included emptying trash and mopping floors. They stated maintenance was responsible for cleaning the oxygen storage closets and if floors were heavily stained Housekeeping Supervisor #47 would take care of them. During an interview on 9/12/2024 at 11:50 PM, Unit Secretary #50 stated the floors under the Second floor nursing station were not clean but had been mopped. They were unsure how long the floor had been unclean. During an interview on 9/13/2024 at 1:23 PM, Certified Nurse Aide #34 stated when areas or objects on the unit were damaged or broken, they asked Unit Secretary #50 to place a work order. They did not put work orders in themselves. They stated the resident rooms should be clean and home-like. During an interview on 9/13/2024 at 1:25 PM, Certified Nurse Aide #46 stated the wallpaper in the Third floor dayroom had been peeling for a while. It was not a clean and home-like environment, and they would not want their house to be in the same condition. During an interview on 9/16/2024 at 2:23 PM, Housekeeping Supervisor #47 stated floors were cleaned twice daily. They had problems with removing the black stains from the nursing station floors and agreed they were unclean. They had been stripping and waxing floors but fell behind in schedule. If an area or object needed repairs, staff would notify them, and they would put a work order in. They were unsure who was responsible for cleaning the oxygen storage room closets due to limited staff having keys. They had a key, but housekeeping staff did not. UNSAFE BROKEN RESIDENT EQUIPMENT Resident #36 had diagnoses including Alzheimer's disease. The 8/9/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, had upper extremity impairment on one side, used a wheelchair, and required supervision/touching assistance with transfers. During an observation and interview on 9/9/2024 at 2:15 PM and 9/11/24 at 11:43 AM, Resident #36 was in their room with their wheelchair on the right side of their bed. They attempted to lock the right wheel on their wheelchair, but it would not lock. They stated their right wheelchair brake had been broken for a few weeks. They had notified staff multiple times and were still waiting for maintenance to fix it. During an interview on 9/13/2024 at 9:30 AM, Certified Nurse Aide #25 stated Resident #36's right wheelchair brake was broken. They thought it had not worked for a few weeks. They did not notify the nurse or maintenance because they thought they were already aware it did not work. During an interview on 9/13/2024 at 9:50 AM, Licensed Practical Nurse #26 stated Resident #36 was alert and oriented, able to make their needs known and they used their wheelchair to get around the unit. They stated they were not aware their wheelchair did not lock, or they would have notified maintenance. During an interview on 9/13/2024 at 10:39 AM, Registered Nurse Supervisor #27 stated they were not aware of Resident #36's right wheelchair brake not locking. They expected staff to notify them so they could have provided the resident with another wheelchair until it was fixed. During interviews on 9/13/2024 at 1:20 PM and at 3:26 PM, Plant Operations Manager #29 stated housekeeping and certified nurse aides were responsible for cleaning the utility rooms. They thought housekeeping cleaned the oxygen storage room, Housekeeping Supervisor #47 had a key, but the housekeepers did not. They were not aware of Resident #36's broken wheelchair brake until they received a work order on 9/11/2024 at 2:47 PM. 10 NYCRR 415.29(j)(1)

Based on record review and interview during the recertification and abbreviated (NY00350839 and NY00331169) surveys conducted 9/9/2024-9/16/2024, the facility did not ensure maintenance of acceptable parameters of nutritional status for 3 of 4 residents (Residents #2, #88, and #195) reviewed. Specifically, Residents #2, #88, and #195 developed pressure ulcers and their nutritional needs were not reassessed timely to accommodate increased requirements for wound healing. Findings include: The facility policy, Nutritional Screen/Assessment, revised 5/2017, documented the dietetic technician and registered dietitian were responsible for nutritional screening, assessment, setting of measurable goals and implementing the nutritional plan of care to obtain the resident's optimal nutritional status. The screening included but was not limited to skin intervention as indicated. The resident would be continually assessed, and findings were documented in the dietary progress notes and nutritional care plan. Estimated needs were documented as 30 - 35 calories/ kilograms of body weight for pressure sore healing, 1.2 grams - 1.5 grams of protein for pressure ulcers and 25 milliliters to 30 milliliters of fluid for the elderly. 1) Resident #195 had diagnoses including a hip fracture and chronic kidney disease. The 4/27/2022 Admission Minimum Data Set assessment documented the resident had moderately impaired cognition, required supervision with set up help for eating, was at risk of developing pressure ulcers, weighed 168 pounds, had no unhealed pressure ulcers, and had moisture associated skin damage (skin impairment caused by excessive moisture). The 4/22/2022 physician order documented a regular diet, mechanical soft (easy to chew) texture, and regular liquid consistency. The 4/26/2022 Registered Dietitian #4 Dietary/Nutritional Screen documented the resident required 1300 calories and 52 grams of protein (0.8 grams of protein per kilogram of body weight) per day. The resident had intact skin with a surgical incision, received a regular consistency diet, and had variable intakes consuming 50-75% of meals, with some 25-75%. The plan was to encourage intake and follow up as needed. The 5/6/2022 at 1:39 PM Licensed Practical Nurse #1 progress note documented the resident had an open area to their buttock and the Assistant Director of Nursing was made aware. The 5/12/2022 at 1:22 AM Registered Nurse Supervisor #3 progress note documented the resident had right buttocks wounds that measured 3.8 centimeters x 1.5 centimeters, and 1.9 centimeters x 1.7 centimeters; and a left buttock wound that measured 1.8 centimeters x 1.5 centimeters (no depth recorded for any of the areas). The areas had bloody drainage, they were cleansed, and a protective dressing was applied. Nursing was to update the primary care provider in the morning. There was no documented evidence the resident's provider was notified of the skin impairments. The 5/16/2022 at 1:25 PM Registered Dietitian #4 progress note documented they were made aware of a wound on the resident's buttocks. The resident was consuming 75-100% meals and intakes were adequate to improve wound status and maintain weight. The plan was to trial Ensure Clear (dietary supplement) at breakfast. There was no documented evidence the resident's nutritional status was reassessed timely when the resident developed multiple wounds 10 days prior, or that the resident's protein and calorie needs were reassessed to accommodate increased needs for wound healing. The Comprehensive Care Plan initiated 4/21/2022 documented the resident was at risk for alterations in nutrition related to impaired skin integrity. Interventions included a regular diet, mechanical soft consistency. On 5/16/2022 supplements on meal trays; Ensure Clear at breakfast was added as an intervention. The 6/7/2022 at 4:27 PM Registered Dietitian #4 progress note documented the resident had no reported skin breakdown and Ensure Clear would be discontinued. There was no documentation in the resident's medical record their skin impairment was healed. The 6/16/2022 at 4:44 PM Registered Nurse Unit Manager #6 progress note documented the resident had an unstageable (type of pressure ulcer where wound bed was obscured by non-viable tissue) pressure ulcer on their coccyx (tailbone) that was 6 centimeters x 3 centimeters x 1.5 centimeters with 0.3 centimeters of undermining (wound edges separate from surrounding healthy tissue creating a pocket). Slough (tan/grey non-viable tissue) was noted with moderate serosanguinous (combination of blood and serum, the clear part of blood) and odor (possible indication of infection). A wound care consult was ordered. The 6/16/2022 Nurse Practitioner #7 progress note documented nursing staff had concerns of a sacral wound which was not present during the last routine examination. The resident reported pain at the wound site requiring oral narcotics. The wound was assessed as a large unstageable sacral ulcer with odor and sloughing eschar (brown/black non-viable tissue). Wound care orders were in place and an immediate referral to outpatient wound care was recommended. The 6/23/2022 outside Wound Care Nurse Practitioner #9 progress note documented the resident had a Stage 4 pressure ulcer with moderate serosanguinous drainage measuring 8 centimeters x 8 centimeters x 1.8 centimeters with undermining between 8 to10 o'clock that was 0.9 centimeters. The wound was mostly covered in eschar and slough which was debrided (removal of dead tissue using a scalpel). The 6/24/2022 at 11:23 AM Registered Dietitian #4 progress note documented they were made aware the resident had impaired skin and their intakes were fair at 25-75%. Promod (high protein supplement) was recommended twice daily to promote wound healing. There was no documented evidence the resident's protein and calorie needs were reassessed to accommodate increased needs for wound healing and to ensure the resident's provided food and fluids met their nutritional needs. The 7/1/2022 outside Wound Care Nurse Practitioner #9 progress note documented the resident's Stage 4 pressure ulcer was 8 centimeters x 7.8 centimeters x 1.8 centimeters and the wound continued to make minimal progress. The 7/6/2024 at 10:24 PM Registered Dietitian #4 progress note documented the Interdisciplinary Team met to discuss the resident. The resident received a regular consistency diet, consumed 50% of meals, and received a protein supplement. There was no documented evidence the resident's protein and calorie needs were reassessed to accommodate increased needs for wound healing. The 7/7/2022 at 5:26 PM Registered Nurse #10 note documented the resident was sent to the hospital from their wound care appointment. The 7/13/22 hospital discharge summary documented the resident was treated by an outside wound consultant and at their 7/7/2022 wound appointment, the resident's wound was noted with odor and drainage and sent to the hospital. At the hospital, the resident was found with a large infected sacral ulcer with foul odor, exposed bone and surrounding necrotic (dead) tissue. Debridement was done by surgery and a wound vacuum assisted closure device was applied. During an interview on 8/23/2024 at 10:22 AM and on 9/6/2024 at 10:09 AM, Registered Dietitian #4 stated they were notified of resident skin issues during morning report however, they could not recall if this was the process when Resident #1 was admitted . When a resident's wound healed, they were also notified in morning report. They stated they should assess nutritional needs within 5 days after a skin impairment was found. A resident's nutritional needs changed when they had a wound and protein needs needed to be increased because protein helped with wound healing. When the resident initially developed a skin impairment, their nutritional needs would have changed from their initial assessment on 4/26/2022. On 6/7/2022, they did not recall how they became aware the resident's wound had healed when they discontinued Ensure and was not aware the wound treatment continued. When the resident developed a Stage 4 pressure ulcer, their needs would have changed again, and they would have increased nutritional needs. The resident should have been reassessed when the wound worsened. The resident was consuming 25-100% of meal and that could be inadequate calories and protein to promote wound healing. During an interview on 9/4/2024 at 8:20 AM, the Director of Nursing stated pressure ulcers, skin with moisture issues, and skin tears were tracked weekly because they could see changes to skin from week to week and keep dietary and therapy involved with changes. The registered dietitian should be involved with wounds and either the Nurse Manager or Wound Nurse was responsible for notifying them. They expected the registered dietitian to be notified within 24 hours during the week. If the registered dietitian made a recommendation, the physician determined if it would be implemented, and it required an order. Once the order was obtained, it should be implemented as soon as nursing confirmed the order. During a telephone interview on 9/9/2024 at 8:28 AM, the facility's current Medical Director stated it was important for the registered dietitian to be involved with wounds and residents were typically put on some sort of liquid protein to assist with wound healing. They expected the registered dietitian to reassess resident nutritional needs when a wound was found or worsened. If a resident did not receive adequate nutritional intake, it could potentially contribute to wounds worsening. 2) Resident #88 had diagnoses including Alzheimer's disease, depression, and age-related physical debility. The 7/24/2024 Minimum Data Set assessment (a health screen tool) documented the resident had severely impaired cognition, weighed 120 pound, had no significant weight changes, received a mechanically altered diet, and had 1 Stage 3 pressure ulcer (full thickness tissue loss) that was not present on admission. The Comprehensive Care Plan initiated 12/9/2022 documented the resident was at risk for skin injury related to advanced age, frail skin. The revised 5/10/2024 care plan documented a pressure ulcer on left plantar 9bottom) foot. Interventions included administer treatments as ordered. The Comprehensive Care Plan initiated 12/9/2022 documented the resident was at risk for alteration in nutrition related to depression, hypertension, and difficulty swallowing. Interventions included set up for meals with intermittent verbal cues. On 4/17/2024 interventions were updated to include Ensure Plus (a nutritional supplement) at all meals and fortified pudding at dinner. The 7/22/24 Quarterly Nutrition Review completed by Registered Dietitian #3 documented the resident received a ground consistency house diet, received Ensure Plus three times daily, an extra sandwich at lunch, and fortified pudding once daily at dinner. The resident weighed 119.3 pounds (54 kilograms), their body mass index was 23.3 (healthy), and had not had significant weight changes in the past six months. The resident had a Stage 3 pressure ulcer on their left foot. Their estimated daily nutritional needs were 1200 calories (22 calories/ kilogram of body weight), 69 grams protein (1.3 grams of protein per kilogram of body weight), and 1330 milliliters (25 milliliters per kilogram of body weight). The 8/13/2024 Wound Care Nurse Practitioner #42 progress note documented the resident was seen for follow up for their Stage 3 left foot pressure ulcer. The resident had poor oral intakes. The wound was worsening, it measured 1 centimeter x 0.9 centimeters x 0.6 centimeters, had undermining (erosion under the wound edges) from 1 o'clock to 1 o'clock, and the wound had heavy amounts of serosanguineous (a mix of blood and serum) exudate (drainage). Recommendations included a nutritional consult for the presence of the wound, with moderate to high risk for complications and to re-evaluate current supplementations. There was no documented evidence a nutrition consult was completed for the resident. The 8/21/2024 physician order documented the resident was to receive 100 milligrams of Doxycycline (antibiotic) twice daily for day 10 days for a wound infection. The 8/27/2024 Registered Dietitian #3 progress note documented the resident continued with a Stage 3 pressure ulcer to their left foot. They had recently started on antibiotics and fluids were to be encouraged. The resident weighed 114 pounds, had no significant weight changes, and their oral intakes were variable. Their estimated fluids needs were 1785 milliliters of fluids (35 milliliters of fluid per kilogram). The resident continued to receive whole milk at all meals, an additional sandwich at lunch, fortified pudding, and Ensure Plus at all meals. A Magic Cup (nutrition supplement) would be added at lunch and fortified pudding would be provided at the dinner meal instead of the lunch meal. During an interview on 9/13/2024 at 8:17 AM, Wound Care Nurse Practitioner #42 stated wound rounds were done weekly with the Assistant Director of Nursing and the registered dietitian did not round with them. The facility let them know which residents needed to be seen. They communicated their recommendations to the Assistant Director of Nursing who passed the recommendations on to the Interdisciplinary Team. They stated nutrition played a role in wound healing. Resident #88 has a Stage 3 pressure ulcer on their left foot. They had recommended a nutritional consult as the resident's wound had worsened and they were at high risk. They expected the registered dietitian to make them aware of any nutritional recommendations to follow up on. They were unaware a nutrition consult was not done. During an interview on 9/16/2024 at 11:39 AM Registered Dietitian #3 stated they used to go on wound rounds but did not go anymore. The Assistant Director of Nursing sent out a weekly wound sheet that documented the residents who had wounds, the stage of the wounds, and any recommendations the wound care physician had. They had 2 weeks to follow up with recommendations. Nutrition played an important role in wound healing. Residents who had wounds had increased nutrient needs, which included calories and protein. They stated Resident #88 had a Stage 3 pressure ulcer on their left foot. They had last assessed the resident's nutritional needs on 7/22/2024 at the lower end of their needs for protein and calories. They were unsure if they were made aware of the recommendation for a nutrition consult on 8/13/2024. They reassessed the resident's fluid needs on 8/27/2024 and added a magic cup when they were receiving antibiotic for an infected wound. They stated they did not follow up timely. During an interview on 9/16/2024 at 12:17 PM, the Assistant Director of Nursing stated wound rounds were completed weekly at the facility. The Wound Care Nurse Practitioner and the Director of Therapy attended wound rounds and the registered dietitian sometimes did. They documented the wound care physician's recommendations and sent them out to the interdisciplinary team. The registered dietitian should be reviewing the wound notes and following up on recommendations as nutrition played a role in wound healing. They stated Resident #88 had a Stage 3 pressure ulcer on their left foot and received antibiotics due to the wound becoming infected. They were unsure what the nutrition protocols were for wound healing. 3) Resident #2 had diagnoses including diabetes, Alzheimer's disease, and obesity. The 6/12/2024 Minimum Data Set assessment (health screening tool) documented the resident had severely impaired cognition, did not reject care, weighed 179 pounds, had no significant weight loss, and was at risk for pressure ulcers. The comprehensive care plan initiated 3/1/2022 and revised 3/22/2024 documented the resident was at risk for alteration in nutritional status related to diabetes and weight loss. Interventions included a sugar free diet, 4-ounce Health Shake (oral nutrition supplement) at all meals, and Magic Cup (nutrition supplement) at lunch and dinner. The 6/10/2024 Quarterly Nutrition Review by Registered Dietitian #4 documented the resident received a sugar restricted diet, 4-ounce Health Shake at all meals, weighed 179 pounds, had no known significant weight changes, and their skin was intact. Their estimated daily nutritional needs were based on 146 pounds (66 kilograms). Estimated calories were 1730 calories (26 calories per kilograms of body weight), 68 grams of protein (1 gram of protein per kilograms of body weight), and 1700 milliliters of fluids (25 milliliters per kilograms of body weight). A 7/30/2024 Licensed Practical Nurse #37 progress note documented a certified nurse aide made them aware the resident had an open area on their right buttocks. They notified the Wound Nurse, and the resident was seen by the Wound Care physician. New orders were obtained for treatment and the family was notified. New orders included to cleanse areas with wound wash, apply Medihoney (medicinal honey used for wound treatment) to wound base and cover with boarder dressing, change daily and as needed. A 7/30/2024 Wound Care Nurse Practitioner #42 progress note documented the resident was seen for a new skin and wound consult. The resident had a Stage 3 (full thickness tissue loss) wound measuring 1.2 centimeters x 1.5 centimeters x 0.2 centimeters. The treatment plan included cleanse area with wound cleanser, apply medical grade honey to the base of the wound, secure with border foam and change daily, and increase protein intake. There was no documented evidence the resident's protein needs were reassessed prior to the wound resolving on 8/13/2024. During an interview on 9/13/2024 at 8:17 AM Wound Care Nurse Practitioner #42 stated wound rounds were done weekly with the Assistant Director of Nursing and the registered dietitian did not round with them. The facility let them know which residents needed to be seen. They communicated their recommendations to the Assistant Director of Nursing who passed the recommendations on to the Interdisciplinary Team. They stated nutrition played a role in wound healing and they expected the registered dietitian to be made aware of any nutritional recommendations and to follow up. During an interview on 9/16/2024 at 11:39 AM Registered Dietitian #3 stated they used to go on wound rounds but did not go anymore. The Assistant Director of Nursing sent out a wound sheet weekly that documented the residents who had wounds, the stage of the wounds, and any recommendations the wound care physician had. They had 2 weeks to follow up with recommendations. Nutrition played an important role in wound healing. Residents who had wounds had increased nutrient needs, which included calories and protein. They stated Resident #2 had a Stage 3 pressure ulcer on their sacrum that was identified on 7/30/2024. They did not reassess the resident's needs when the wound was identified and did not follow up on the wound care physician's recommendations as it was an oversight. They did not see the resident again until 8/19/2024. During an interview on 9/16/2024 at 12:17 PM the Assistant Director of Nursing stated wound rounds were completed weekly at the facility. The Wound Care Nurse Practitioner and the Director of Therapy attended wound rounds and the registered dietitian sometimes did. They documented the Wound Care physician's recommendations and sent them out to the Interdisciplinary Team. The registered dietitian should review the wound notes and following up on recommendations as nutrition played a role in wound healing. 10 NYCRR 415.12(c)(2)

Based on observation, record review, and interview during the recertification survey conducted 9/9/2024-9/16/2024, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles and include the expiration date when applicable for 3 of 3 medication carts (Second floor short hall, Second floor long hall, and Third floor long hall) reviewed. Specifically, - the Second floor short hall medication cart contained 49 loose, unidentified pills; eye drops for Resident #446 without an opened or expired/discard date; inhalers for Residents #127, #118 and #47 without an opened or expired/discard date; and an inhaler without any resident identifiers. - the third-floor long hall medication cart had one loose pill; 2 opened medicated pain patches and a vial of nitroglycerin (treats chest pain) tablets without resident identifiers; an insulin (treats blood sugar) pen for Resident #14, eye drops for Resident #33, and inhalers for Residents #63, #18, and #16 that did not have opened or expired/discard dates. Findings include: The facility policy, Vials, effective 10/2004 documented multi-dose vials were dated and initialed when they were opened. The vials were discarded when they were empty or when the manufacturer's expiration date was reached, but not to exceed 28 days. All drugs were checked prior to use and ensured outdated drugs were not used. Multi-dose vials that were not dated when opened were disposed of 28 days after the date dispensed by the pharmacy. This was a quality control fail safe. The facility policy, Inhalers, revised 3/2011 documented inhalers were stored (labeled) in the medication cart and discarded when empty or expired. The expiration date was checked prior to administration. The facility policy, Medication/ Treatment Labeling and Storage, revised 7/2013 documented the facility maintained proper labels for medications and proper storing instructions. Medications without labels were returned to the pharmacy for destruction, all medications were stored in their original containers. Medication carts were kept clean, organized, restocked, and fully equipped. SECOND FLOOR SHORT HALL MEDICATION CART: During an observation of the Second floor short hall medication cart with Registered Nurse #36 on 9/10/2024 at 3:14 PM there were Lumigan (treats eye pressure) 0.01% eye drops without and opened or expiration/ discard date for Resident #446; a Budesonide-Formoterol 80-4.5 microgram/ actuation inhaler, an albuterol sulfate (treats difficulty breathing) 90 microgram/ actuation inhaler with a pharmacy dispensed date of 7/22/2024 without an opened or expired/ discard dates for Resident #127; an albuterol sulfate 90 microgram/ actuation inhaler with a pharmacy dispensed date of 7/29/2024 without an opened or expired/ discard dates for Resident #118; and an albuterol sulfate 90 microgram/ actuation inhaler with a pharmacy dispensed date of 7/22/2024 without an opened or expired/discard dates for Resident #47. There were 49 loose, unidentified pills scattered in the medication drawer, and a Dulera (treats asthma) inhaler that did not have a resident identifier. Registered Nurse #36 stated any multi-dose medication should be dated as opened. If there was a medication that was not dated it should be discarded because it may not be good. It was important to know if medications were expired. Expired medications may not be as effective or overly effective. If Resident #446 was receiving expired eye drops their glaucoma (eye disease causing eye pressure and blindness) could progress. They were not sure of the policy on dating inhalers as opened but thought inhalers should be labeled as opened for the same reasons as the eye drops. During an interview on 9/10/2024 at 4:14 PM Licensed Practical Nurse #37 stated if a medication was not dated, they would not use it. An opened date on medications was important to know if the medication was expired. There could be a reaction if expired medications were given. THIRD FLOOR LONG HALL MEDICATION CART: During an observation of the Third floor long hall medication cart on 9/10/2024 at 4:00 PM with Licensed Practical Nurse #31, there was an opened vial of nitroglycerin tablets, an opened box 1% lidocaine (treats pain) patches, an opened box of 5% menthol patches (treats pain) with no resident identifiers; an opened multi-dose Lantus (long-acting) insulin pen for Resident #14 with a pharmacy dispensed date of 7/4/2024 without an opened or expired/ discard date; refresh liquid eye gel and eye drops for Resident #33 without an opened or expired/discard date; one loose round white pill labeled with AZ 011 in the third drawer of the medication cart; an opened fluticasone-vilanterol (treats breathing problems) 100-25 microgram/ actuation inhaler dispensed from the hospital with a due date of 4/1/2024 for Resident #63; a budesonide-formoterol (treats breathing problems) 160-4.5 microgram/ actuation inhaler with no opened or expired/ discard date for Resident #18; and an opened Combivent (treats breathing problems) 20-100 microgram/ actuation inhaler with no opened or expired/ discard date for Resident #16. Licensed Practical Nurse #31 stated without an opened date they would not know if the medication was expired, and all medications should have resident identifiers to ensure they were administered to the correct resident. If the resident's received expired medications, they may not be as effective or there could be negative effects. The opened/ expired date should be checked on all medications prior to administration. If they had medications that were not dated as opened, they should discard them, and a replacement would be ordered. Insulin was good for 30 days and they were not sure about eye drops or inhalers but went by the 30-day rule for expiration of medications. During an interview on 9/11/2024 at 1:28 PM Licensed Practical Nurse #24 stated expired medications might not be as effective or work as intended. They had administered the medications yesterday without opened or expired/ discard dates. They should have looked for the expiration dates and should have thrown away the undated medications and ordered new ones. During an interview on 9/16/2024 at 1:37 PM, the Assistant Director of Nursing stated medications should be dated when opened. The opened date was used to determine the expiration date. Without an opened date, it would not be known if the medication was still good. Residents should not receive expired medications. Staff should check the opened and/or expired date prior to administering a medication. If a medication was expired, it should be thrown away and the pharmacy should be called for a replacement. The pharmacy delivered twice daily during the week and once daily on the weekends. 10NYCRR 415.18(d)

Based on observation and interview during the recertification and abbreviated (NY00336546) surveys conducted 9/9/2024-9/16/2024, the facility did not ensure each resident received food and drink that was palatable, flavorful, and at an appetizing temperature for 1 of 2 meals (the 9/10/2024 dinner meal) reviewed and for 4 of 4 residents (Residents #15, #93, and #112). Specifically, food was not served at palatable and appetizing temperatures during the dinner meal on 9/10/2024. Additionally, Residents #15, #93, and #112 stated the food was served cold, and Resident #36 stated the food was not palatable and was served cold. Findings include: The facility policy, Food Preparation, Service and Distribution, revised 10/2022, documented: - Holding foods in the tray line or alternate meal preparation and service areas may include steam tables, where hot foods were held and served, and chilled areas where cold foods were held and served, would not hold foods in the danger zone (temperatures above 41 degrees Fahrenheit and less than 135 degrees Fahrenheit). - Dining locations included any area where one or more residents ate their meals. These included dining rooms or mobile food carts that maintained food in proper temperature and out of the danger zone. - Hot foods should be served hot and cold foods should be cold in accordance with resident preference. During an interview on 9/9/2024 at 11:27 AM, Resident #93 stated they usually ate their meals in their room and by the time it was served, the food was usually cold. During an interview on 9/9/2024 at 1:58 PM, Resident #15 stated meals were served cold and there was no microwave to reheat the food on the unit. During an interview on 9/9/2024 at 2:14 PM, Resident #36 stated the food did not taste good, did not look appealing, and was served cold. During an interview on 9/10/2024 at 9:19 AM, Resident #112 stated meals were often late and served cold. During a dinner meal observation on 9/10/2024 at 6:17 PM, Resident #71 was served their dinner meal tray. A replacement tray was ordered, and Resident #71's original tray was tested . The hamburger was measured at 118.4 degrees Fahrenheit, the noodles were 116.8 degrees Fahrenheit, the peanut butter and jelly sandwich was 46.2 degrees Fahrenheit, the applesauce was 67.5 degrees Fahrenheit, the coffee was 133.9 degrees Fahrenheit, and the water was 52.2 degrees Fahrenheit. During an interview on 9/10/2024 at 6:19 PM, Certified Nurse Aide #30 stated if meals were not served at appropriate temperatures the food could grow bacteria and if ingested by the residents, they could get sick. They took a food safety course, and the hot food was supposed to be over 140 degrees Fahrenheit, and the cold food was supposed to be under 45 degrees Fahrenheit. They stated all the food/drink items on Resident #71's meal tray were not at appropriate temperatures. During an interview on 9/11/2024 at 1:05 PM, Food Service Director #40 stated they completed test trays two or three times a week along with the registered dietitian. They would send an extra tray to the unit, take the food temperatures, and taste the food to ensure quality. They stated they wanted hot food items over 135 degrees Fahrenheit, cold food items less than 55 degrees Fahrenheit, and milk less than 45 degrees Fahrenheit. Hot food items that measured between 116 degrees Fahrenheit and 118 degrees Fahrenheit was not appropriate, and applesauce should have been served cold and measured less than 67 degrees Fahrenheit. During an interview on 9/16/2024 at 11:16 AM, Registered Dietitian #4 stated they completed test trays once or twice a week throughout the facility. They tested the food temperature after it was cooked and would test it again when it was on the unit. They stated breakfast was hard because of the scrambled eggs and most of the residents' complaints were that breakfast was served cold. They would offer alternates if they received complaints. They stated it was important for food to be palatable and served at appropriate temperatures or the residents might not eat as much. They stated there was danger for food borne illness if temperatures were not in range, but they were unsure of specific temperatures. Their expectation was for all residents to have palatable foods. 10NYCRR 415.14(d)(1)(2) 49448

Based on observation, record review, and interviews during the recertification survey conducted 9/9/2024- 9/16/2024, the facility did not ensure food was prepared, distributed, and served in accordance with professional standards for food service in the facility's main kitchen and Third floor kitchenette. Specifically, in the main kitchen, there was debris on the floors and counters, unclean areas, a drain back up, gloves were not used properly, and food was not cooled properly. The Third floor kitchenette was unclean. Findings included: The facility policy, Grease Traps, revised 12/2006, documented the facilities safety elements of the environment were maintained, tested , inspected, and included checking the grease traps monthly. Staff should maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. The facility policy, General Kitchen Cleaning, revised 6/1/2023, documented staff shall maintain sanitation of the kitchen through compliance with a written comprehensive cleaning schedule. The facility policy, Food Cooling Temperature Log, effective 7/2008, documented staff would ensure the proper temperatures for chilling of foods to eliminate food borne illness. All potentially hazardous foods were cooled from 135 degrees Fahrenheit to 41 degrees Fahrenheit within six hours or less. The following observations were made in the main kitchen on 9/9/2024: - at 9:42 AM, the dry storage area had debris on the floor and under the shelving. - at 9:46 AM, there was food debris under and around the cookline equipment. - at 9:48 AM, the 2 bay sink at the end of the cookline was leaking from the right-side faucet, there was grime build up on the plumbing, and a bus pan was full of moldy stagnant liquid beneath the sink plumbing. There were numerous ant bait stations, glue traps, and steel box traps for pests throughout the kitchen. - at 9:57 AM, the cooler was labeled out of order and handwritten next to the out of order sign was for two years and counting. The cooler had food spills and debris inside. - at 10:00 AM, the walk-in freezer had food debris on the floors and under the shelving, there was ice piling up beside the door. - at 10:01 AM, there was a yellow dried puddle under shelving of the walk-in cooler. - at 10:07 AM, there was a significant amount of food debris on the floor under the ice machine and around the floor drain. There was debris where water had backed up from the floor drain by the back door. The following observations were made in Third floor kitchenette on 9/9/24: - at 9:37 AM, there were sugar packets scattered on the floor. - at 9:39 AM, the right side of the warmer was not clean. - at 9:41 AM, a dirty black plastic bin under the sink was full of water with a white/grey film on the surface of the water. - at 9:45 AM, the faucet of the large sink basin was leaking behind the cold water handle. - at 9:49 AM, the stainless-steel shelving in the middle island had dried food debris on the bottom shelf. - at 9:56 AM, the walk-in freezer had food debris on the floor and ice buildup on the door. - at 10:00 AM, there was food debris behind the ice machine - at 10:02 AM, the eye wash station was unclean with food debris. - at 10:04 AM, the paper towel dispenser had a dried white/gray substance covering it. The following observations were made in the main kitchen on 9/10/24: - at 10:10 AM, there was debris and grease staining under and around the cook line equipment and tables. - at 10:10 AM, there was a dirty bus pan. - at 10:11 AM, there was debris and drain back up by the back door, ice machine, and around the mop sink area. Dish racks were stacked and stored on the floor by the ice machine. - at 10:27 AM, the out of order cooler had debris and food spills. - at 10:28 AM, the kitchen floors were unclean and had a tacky/sticky built up layer of grease and grime. - at 10:39 AM, the walk-in freezer had several cases of food stored directly on the floor. There was food debris and excessive icing on the floor. During an observation on 9/10/2024 at 10:09 AM and 10:19 AM, the third-floor kitchenette area ice machine was dirty, and the floors were sticky. During an observation in the main kitchen on 9/11/2024 at 12:11 PM, there was food debris under the refrigerator at the end of the cook line, and at 12:12 PM the floor around the ice machine and back door had a significant amount of food debris and drain backup strewn around the ice machine and leading to the back door. During an observation in the main kitchen on 9/11/24 at 1:18 PM, there was a six-inch square pan wrapped in plastic wrap labeled grilled cheese PR (pureed) 9/11 just inside the walk-in cooler door on a middle shelf. The pureed grilled cheese temperature was measured at 104 degrees Fahrenheit. At 1:43 PM, the pan and contents measured at 98 degrees Fahrenheit. At 1:47 PM, Food Service Director #40 placed the pureed grilled cheese in the walk-in freezer and uncovered the product. During an interview on 9/11/24 at 1:51 PM, [NAME] #55 stated when they made food items like pureed grilled cheese, they put it in the freezer. They had also made a cold three bean salad and put that in the walk-in cooler by accident. They stated the pureed grilled cheese was made about an hour or two prior to the observation. They normally documented only when they checked the temperatures for food items like turkey. They stated the cooling requirement when meat was put in the oven to be used the next day, it must be cooled down within 2 hours, or 4 hours after that. [NAME] #55 referred to the cooling log sheet for guidance and stated the temperature was required to be around 70 (degrees Fahrenheit) and below after two hours, and 40 (degrees Fahrenheit) and below after another 4 hours. The grilled cheese would not meet the cooling requirement if it was left in the walk-in cooler. They would have to discard the food and start over because it would not meet the cooling requirements. During an interview on 9/12/2024 at 11:42 AM, Housekeeping Aide #39 stated they took out the trash in the Third floor kitchenette, wiped down the tables, and mopped after lunch. They stated they were not trained to wipe down the refrigerator. During an interview on 9/13/2024 at 1:34 PM, the Food Service Director stated they were not sure who cleaned the kitchenettes. They stated the shelf was stained from spilled cranberry juice. The faucet in the main kitchen was leaking for one month. They stated over the weekend they noticed the grease in the bus pan, and they discarded it. The floors in the kitchen were cleaned daily and the floors in the walk-in coolers were cleaned weekly. There was a problem with the floor drain earlier in the week when it got clogged. They were not sure when the water backed up by the ice machine. Food and debris should not be on the floors, under equipment, or in the coolers. It was important to keep the kitchen and kitchenette clean and to cool foods properly for the safety of the residents. 10NYCRR 415.14(h)

Based on observation, interview, and record review during the recertification survey conducted 9/9/2024-9/16/2024, the facility did not ensure each resident had the right to a dignified existence for 2 of 6 residents (Residents #37 and #137) reviewed. Specifically, Resident #37 was not provided with a requested shower prior to attending a significant family event, and Resident #137's urinary collection bag was visible in plain sight. Findings include: The facility policy, Activities of Daily Living, revised 10/2023, documented the facility would provide each resident the necessary care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being consistent with the resident's comprehensive assessment and plan of care. The facility policy, Resident Rights and Responsibilities, revised 4/2/2024, documented the facility functioned on the premise that the service it rendered would demonstrate its belief in the dignity and worth of every individual, and the objective of the facility was to provide the resident with optimal nursing and psychosocial care. 1) Resident #37 had a diagnosis of osteoarthritis, muscle weakness, and right above the knee amputation. The 5/24/2024 Minimum Data Set documented it was very important to the resident to choose between a tub bath, shower, bed bath, or sponge bath. The 8/22/2024 Minimum Data Set documented resident was cognitively intact, was frequently incontinent of bowel and bladder, and required substantial assistance with bathing. The Comprehensive Care Plan last reviewed 8/31/2024 documented a self-care performance deficit related to limited mobility, limited range of motion, and above the knee amputation; and a psychosocial well-being problem due to alteration in mood and behavior. Interventions included dependence for bathing and offer choices related to care routine. The 8/30/2024 Social Worker #33 progress note documented the resident was preparing to attend their child's wedding that weekend. During interviews on 9/11/2024 at 9:42 AM and 9/13/2024 at 3:28 PM, Resident #37 stated they asked to receive a shower prior to attending their child's wedding on 8/31/2024. They told staff they were willing to give up their normally scheduled shower on 8/27/2024 in exchange for a shower on 8/31/2024. The resident stated they were told their shower was on Tuesday and if they passed up that shower, they would have to wait until the following Tuesday to receive a shower. They received a bed bath on 8/31/2024 but felt that was not the same as a shower especially since the bed bath was given in the morning and the wedding was not until 3:00 PM. During the interview the resident was tearful and said it was hard to talk about how not having a shower affected their experience at the wedding because they did not feel clean. They stated they had clean clothes on, but their body did not feel clean. The resident did not tell their family because they would be upset, especially their parent. They said in the future they would not ask the staff for a favor when it came to their shower ever again. Every time they received a shower, they thought about the situation and how bad it made them feel. The 8/31/2024 facility staffing form documented four certified nurse aides and two licensed practical nurses were scheduled to work on the second floor (the resident's unit) on 8/31/2024 at 6:45 AM. During an interview on 9/16/2024 at 12:21 PM, Certified Nurse Aide #34 stated each resident had a weekly shower in accordance with the schedule located at the front desk. If the unit had less than four aides working on the day or evening shift, they did not give showers and would instead give a bed bath. An attempt would be made to squeeze that missed shower in prior to their next shower day. They were not working on 8/31/2024, but the plan was the resident would be showered the day before the wedding and that did not happen. It would not feel good to go to a wedding and not feel clean. It was a dignity issue that could cause feelings of sadness and depression. During an interview on 9/16/2024 at 2:12 PM, Licensed Practical Nurse Unit Manager #1 stated showers were given once a week. Staff should try to accommodate resident's preferences by doing such things as switching shower days with another resident. If someone missed their shower an attempt was made to do it on the following shift or day. The number of staff working did not determine if someone received a shower or not. They were not aware of Resident #37 asking for a shower on 8/31/2024, but felt they had the right to have a shower in preparation for the wedding. That was important as the resident probably saw family they had not seen in a while. If they felt unclean it was undignified and could lead to depression. 2) Resident #137 had a diagnosis of benign prostatic hypertrophy (enlarged prostate). The 7/29/2024 Minimum Data Set documented the resident had intact cognition, had a urinary drainage device, and had no refusals of care. The Comprehensive Care Plan last reviewed 8/9/2024, documented the resident had a urinary drainage device related to benign prostatic hypertrophy and a sacral (lower back) wound. Interventions included urinary catheter care every shift and leg bag (a small collection bag attached underneath clothing) to be worn during daytime hours. The 8/12/2024 physician order documented an order to change urinary drainage device once a month and as needed and catheter care every shift. The following observations of Resident #137 were made: - On 9/9/2024 at 10:14 AM, walking in their room carrying their uncovered urine collection bag. The bag was visible from the hallway. - On 9/9/2024 at 12:51 PM, standing in the doorway of their room with their urinary catheter tubing threaded through their left pant leg and the uncovered collection bag hooked on their right pants pocket. The collection bag was visible from the hallway. - On 9/10/2024 at 8:33 AM, the resident had their uncovered urine collection bag hanging on their bed visible from the hallway. During an interview on 9/16/2024 at 12:01 PM, Certified Nurse Aide #34 stated nurse aides provided catheter care and that included changing from a leg bag to large collection bag. Blue dignity bags were used when a resident was out of bed. If someone refused a dignity bag, they reported that to the nurse as the refusals may need to be care planned. They had observed Resident #137 walking around with the collection bag hanging from their pants pocket without a dignity bag. Dignity bags were important to prevent a resident from feeling self-conscious and from feeling as though others would be judgmental towards them. During an interview on 9/16/2024 at 1:24 PM, Licensed Practical Nurse Unit Manager #1 stated they expected urine collection bags to be placed in a dignity bag and any refusals were reported so education and care planning would be done. Resident #137 had a catheter and they had observed the resident walking around the unit without a dignity bag. Dignity bags were important because it could cause the resident to feel bad or embarrassed. 10NYCRR 415.5(a)