Every finding on record at Taconic Rehabilitation And Nursing At Hopewell

Based on observation and interview during a recertification survey from 2/05/2026 to 2/12/2026, the facility did not ensure that food was stored in accordance with professional standards for food service safety. Specifically, twelve (12) food items were not properly identified and dated in the kitchen refrigerators, freezers, and food storage areas.The findings include:The policy titled Food Receiving and Storage last revised December 2012, documented all opened items would be labeled, dated and discarded after three (3) days once opened. On 2/05/2025 at 9:31 AM, the initial inspection of the kitchen was conducted with the Food Service Manager, and the following were observed:One (1) gallon container of milk with no opened date and a one (1) quart container of half & half with no opened date in the night prep refrigerator.One (1) bag of chicken tenders with no identification label and one (1) bag of meatless chicken tenders with no identification label in the walk-in-refrigerator.One (1) bag of frozen pizza with no identification label and one (1) container of hot dogs with no identification label in the freezer. One (1) tray of Cheerio cereal in bowels with no identification label, one (1) bag of breadcrumbs with no opened date and no identification label, and one (1) bag of dry elbow macaroni with no opened date in the dry storage area.One (1) container of rice with no identification label, and one (1) container of flour with no identification label in the bulk storage area.One (1) quart container of almond milk with no opened date in the milk storage refrigerator. During an interview on 2/12/2025 at 9:27 AM, the Food Service Manager stated it was not acceptable for food not to be labeled with the date opened and identification on it. They stated they expected staff to follow the facility policy on food storage with proper labeling and dates. 10NYCRR 415.14(h)

Based on interview and record review the facility did not ensure that staff facilitated the inclusion of the resident or resident representative in all aspects of person-centered care planning that supports the resident's goals, choices, and preferences including potential for return to a community setting for one (1) of two (2) residents reviewed for Discharge. Specifically, Resident #22 was admitted on [DATE] for short term rehabilitation and there was no documented evidence that Resident #22 and/or their representative were invited to participate in the Comprehensive Care Plan meeting. Additionally, there was no documented evidence that evaluation of Resident #22's discharge needs and/or options was ongoing prior to notification of their Medicare coverage ending on 01/23/2026. The findings include:Resident #22 was admitted to the facility with diagnoses that included repeated falls, chronic kidney disease, and benign prostatic hyperplasia (noncancerous enlargement of the prostate).The 01/01/2026 Social Work progress note documented Resident #22 was alert and oriented times four, and able to make their needs known. The resident's overall goal was to discharge to the community. The 01/02/2026 five-day Minimum Data Set assessment documented Resident #22 had intact cognition, participated in assessment and goal setting, the goal was to discharge to the community, and active discharge planning was occurring. The 01/09/2026 care plan titled Discharge Planning documented Resident #22 would adjust to the subacute rehabilitation stay as evidenced by positive verbalizations/observations through the next review. Maintain customary routine/treatment and evaluate preferences and needs for possible transition to community.The Notice of Medicare Non-Coverage form was signed and dated by Resident #22 on 01/21/2026 and documented Medicare coverage would end as of 01/23/2026. The 02/05/2026 Medicare Non-Coverage appeal determination letter documented the appeal was denied. There was no documented evidence of an interdisciplinary care plan meeting to address discharge planning for Resident #22. During an interview on 02/05/2026 at 10:20AM, Resident #22 stated they did not recall if they had a care plan meeting yet. They stated they planned to go home.During an interview on 02/11/2026 at 2:12 PM, the Director of Social Work stated discharge plans started at the time of admission. They stated they were aware that Resident #22 would like to return home. They stated they usually scheduled care plan meetings within a couple of weeks of admission, but Resident #22 had not had a meeting since they arrived. They stated because the resident had COVID, the discharge process was held up. They stated they would meet with therapy to check on Resident #22's progress and then would schedule a meeting with the resident and their family.The 02/12/2026 Social Work progress note documented an interdisciplinary care plan meeting was conducted. Resident #22 is unsure if they want to remain in the facility as a long-term resident, pursue assisted living facilities, or return to their home in the community where they resided alone. Resident #22 does own a home in the community, however there is a mold issue in the basement and friends have informed the resident that it is unsafe. Resident #22 plans on speaking to a lawyer to assist with the financial piece. Resident #22 is also aware that they are currently paying privately here at the facility. Resident #22 will speak with the business office manager here at facility to discuss payment options. Resident #22 plans on speaking with family to determine what would be the best living situation for them. Resident's general medical condition has been stable since getting over Covid. However, they continue to require assistance with walking and activities of daily living. Care plan goals reviewed and remained ongoing at this time. During a follow up interview on 02/12/2026 at 2:01 PM, the Director of Social Work stated Resident #22 was admitted for short term rehabilitation and it was determined on 01/01/2026 that their plan was to discharge home. They stated there had been no further discharge planning until today. They stated Resident #22 did receive the Notification of Non-Medicare Coverage on 1/21/2026, which they appealed and lost, but there was no meeting at that time to discuss options or discharge planning. They stated the first day of private pay was 02/06/2026 which the business office discussed with the resident. They stated they did not have a follow-up discussion with Resident #22. They stated it was determined in the meeting today that Resident #22 was now uncertain whether they wanted to stay long term, go to assistive living, or receive assistance at home because of mold in their house and it may not be safe for them to return to their house. The Director of Social Work stated they should have planned a meeting sooner to plan the discharge for Resident #22 and could not say why they missed it.10 NYCRR 415.11(c)(2)(i-iii)

Based on observation, interview, and record review during the recertification survey and abbreviated survey (NY002683111) the facility did not ensure that grievances were resolved in a timely manner for (2) two of (4) four residents (Residents #24, and #162) reviewed for Personal Property. Specifically, 1) Resident #24 was missing a red flip phone as of 11/24/2025 and (2) Resident #162 was missing an iPhone case, and gold colored chain and cross as of 11/21/2025. Both residents were not provided with reimbursement as of 2/12/26. The findings include:The policy titled Management of Patient /Resident and Family Complaints Concerns/Grievances effective 01/01/2000 documented the facility would make prompt efforts to resolve complaints/concerns/grievances. The resident and/or designated representative will be instructed of both the facility and the Department of Health complaint procedures verbally and in writing. 1) Resident #24 was admitted to facility with diagnoses including Heart Failure and Depression.The 11/21/2025 quarterly Minimum Data Set (assessment tool) documented Resident #24 was cognitively intact. The 11/24/2025 Grievance Form documented a red flip phone was missing x 4 days. The family replaced the phone, and the facility would reimburse the cost of the phone, awaiting receipt from the family. The Grievance Form was signed as resolved on 12/01/2025.There was no documented evidence of the cost of reimbursement or that a check was provided to the family on 12/01/2025.During interview on 2/06/2026 at 11:58 AM Resident #24 stated their red flip phone went missing in November 2025. They further stated the nursing staff looked for it but never found it. They stated they were not provided with reimbursement of the phone.The 02/11/2026 note written by the Director of Social Work documented writer conducted a follow up call with the resident's family/daughter in law yesterday regarding a satisfactory resolution. Family informed the writer that they would return their call within a week. Writer will continue to follow up. 2) Resident #162 was admitted to facility diagnoses including Spinal Stenosis, End Stage Renal Disease and Diabetes.The 11/21/2025 Grievance Form documented Resident #162 reported a gold-colored chain with medal cross and an iPhone case was missing. Housekeeping and dietary staff were made aware, and room search was completed. The facility offered reimbursement and was awaiting an estimate from the family. The grievance form was signed as resolved on 12/01/2025.The 11/28/2025 quarterly Minimum Data Set assessment documented Resident #162 had moderately impaired cognition.There was no documented evidence of the cost of reimbursement or that a check was provided to the family on 12/01/2025.During an interview on 02/10/2026 at 1:36 PM and 1:46 PM, the Director of Social Work stated they made follow-up calls yesterday to the designated representatives for Resident #24 and Resident #162. They stated the designated representative for Resident #24 was supposed to come in on 02/09/2026 to provide information on the cost of the replacement phone and never showed up. The Director of Social Work stated the designated representative for Resident #162 was called and they were still waiting to receive the information on the value of the missing iPhone case and gold colored chain and cross. The Director of Social Work stated they liked to resolve grievances within 24 hours. They stated they had no explanation as to why reimbursement was not provided to the residents and/or designated representatives when the items were reported missing in November 2025. During an interview on 02/10/2026 3:04 PM, Administrator #2 stated Resident #24 had a red flip phone and when they asked Resident #24 about when it went missing, they stated the resident could not recall when it was lost. Administrator #2 stated the flip phone was on a plan and that the designated representative replaced it. They stated they felt the grievance was resolved when they offered reimbursement to the designated representatives for Resident #24 and Resident #162. They stated they never received information from the designated representatives of Resident #24 and Resident #162 and were waiting for them to call with the information. Administrator #2 stated they were unsure as to why there was no documentation of the follow up calls made to the resident representatives or attempts to finalize the reimbursement when the missing items were reported in November 2025.The 02/11/2026 note written by the Director of Social Work documented the writer conducted a follow up call yesterday with Resident #162's daughter to follow up with a satisfactory resolution. The family/daughter will call the writer back. The writer will continue to follow up.During an interview on 2/11/2026 at 3:08 PM, Administrator #1 stated although they were not aware of the specifics, they were aware of the facility reported incident for both Resident #24 and Resident #162. They stated that was the reason for the follow-up calls on 02/09/2026. Administrator #1 stated when the designated representatives of Resident #24 and Resident #162 were called, they were offered reimbursement. They stated the facility was still waiting for information on the value of the items. They stated the Director of Social Work called them again on 02/11/2026 to check on the status and were still waiting for a response from the designated representatives of Resident #24 and Resident #162. Administrator #1 stated they felt the resolution was completed by offering reimbursement and had no explanation as to why the reimbursement was still not provided to the family since the missing items were reported in November 2025.415.3(c)(1)(ii)

Based on interview and record review the facility did not ensure that a copy of the notice of transfer or discharge was sent to the State Long Term Care Ombudsman for two (2) of three (3) residents (Resident #14, Resident #158) reviewed for Hospitalization. Specifically, 1) there was no documented evidence that a notice of transfer was sent to the New York State Ombudsman when Resident #14 was transferred to the hospital on [DATE], and 2) there was no documented evidence that a notice of transfer was sent to the New York State Ombudsman when Resident #158 was transferred to the hospital on [DATE], The findings include: The policy titled Discharge Notice last revised 06/2025, documented when a resident is temporarily transferred on an emergency basis to an acute care facility, notice of the transfer may be provided to the resident and resident representative as soon as practicable, according to 42 CFR 483.15(c)(4)(ii)(D). Copies of notices for emergency transfers must also still be sent to the ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis. A copy is kept in the resident record. 1) Resident #14's diagnoses included fracture of the right femur. The 11/16/2025 nursing progress note documented Resident #14 was admitted to the hospital with essential hypertension, dementia and a right hip fracture. The 11/16/2025 transfer/discharge notice had a documented resident representative signature, dated 11/17/2025. The 11/18/2025 bed hold policy form had a documented resident representative signature. There was no documented evidence that the New York State Ombudsman office was notified of Resident #14's 11/16/2025 transfer to the hospital. Resident #14 returned to the facility on [DATE]. 2) Resident #153's diagnoses included unspecified dementia and malignant neoplasm of the left breast The 11/13/2025 nursing progress note documented Resident #153 was sent to the hospital due to uncontrolled pain. The 11/15/2025 transfer/discharge notice documented the resident representative was verbally notified on 11/13/2025. There was no documented evidence that the New York State Ombudsman office was notified of Resident #153's 11/13/2025 transfer to the hospital. The 11/14/25 nursing progress note documented the emergency room nurse reported that the designated representative was at the bedside requesting the patient be transferred to hospice for end-of-life care. During an interview on 02/11/2026 at 9:38 AM, the Director of Social Work stated they kept a binder with a monthly transfer/discharge list, completed transfer/discharge forms and the bed hold forms. They stated the binder was available for the Ombudsman to review at their request. The Director of Social Work stated they had not sent/emailed copies of completed transfer and/or discharge notification forms or a monthly resident transfer/discharge list to the Ombudsman's office during the last six (6) months. During an interview on 02/12/2026 at 12:37 PM, the Ombudsman stated they had not received a copy of Resident #14 and Resident #153's transfer and/or discharge notification form. They stated they had not received a monthly list of residents that had been discharged /transferred from the facility since April 2025. 10 NYCRR 483.15 © (3)

Based on record review and interview the facility did not ensure accuracy of resident assessments for (1) one of (1) one resident (Resident #110) reviewed for Accidents, and (1) one of (1) one resident (Resident # 2) reviewed for Edema. Specifically, Resident #110 had documented falls on 08/09/2025 and 10/21/2025 that were not identified on their Minimum Dat Set assessments, and Resident #2 had a documented 12/04/2025 facility acquired stage three pressure ulcer that was coded on the Minimum Data Set assessment as having been present on admission to the facility. The findings include: The policy titled Minimum Data Set, last revised 02/2025, documented that the Minimum Data Set is expected to accurately reflect the resident status. 1)Resident #110 had diagnoses including orthopedic conditions, cancer, and osteoarthritis of the knee. The 8/09/2025 Accident /Incident Report documented Resident #110 was observed on the floor in front of their wheelchair. The 9/26/2025 quarterly Minimum Data Set assessment documented no falls anytime in the last month prior to admission, no falls in the last 2 to 6 months The 10/21/2025 Accident /Incident Report documented Resident #110 was observed on the floor of their room. The 12/12/2025 annual Minimum Data Set Assessment documented no falls since admission/entry or reentry or the prior assessment. On 02/11/2026 at 10:15 AM during an interview and record review, the Minimum Data Set Licensed Practical Nurse stated Resident #110's fall on 08/09/2025 was not documented on the 09/26/2025 quarterly Minimum Data Set assessment and Resident #110's fall on 10/21/2025 was not documented on the 12/12/2-25 annual Minimum Data Set assessment. They stated they completed the assessments and entered 'no falls' in error. They stated they overlooked the resident's falls. They stated they should have looked in the risk management tab in the electronic medical record to see a list of resident falls. They stated they were not aware of the correct process to note falls at the time of the assessments. They stated they recently learned the correct process for noting falls and would ask the regional Minimum Data Set nurse to submit corrections for both assessments. 2). Resident #2 had diagnoses that included cancer, hypertension, and anemia. The 12/04/2025 wound care note for Resident #2 documented initial evaluation of stage three to the left ischium. The 01/23/2026 quarterly Minimum Data Set documented Resident #2 had a stage three pressure ulcer that was present on admission. During an interview on 02/11/2026 at 10:28 AM, the Minimum Data Set Licensed Practical Nurse stated they entered the wound information on the Minimum Data Set assessments. They stated they obtained their information from evaluations, progress notes, and wound care notes that were in the resident's electronic medical record. They stated Resident #2 did not have a pressure ulcer on admission. They stated they should have coded the pressure ulcer was not present on admission when they completed the 01/23/2026 Minimum Data Set assessment. 10NYCRR 415.11(b)

Based on observation, interview, and record review the facility did not ensure comprehensive care plans were reviewed and revised with each assessment and as needed to reflect residents changing needs. This was evident for two (2) (Resident #4 and Resident #11) of five (5) residents reviewed for Unnecessary Medication. Specifically, 1) the cardiac care plan for Resident #4 did not address the diagnosis of atrial fibrillation and use of anticoagulants, and 2) the psychosocial care plan for Resident #11 did not address the use of antipsychotic medication. The findings include: The policy titled Interdisciplinary Care Planning last revised 09/25/2025 documented a comprehensive resident-centered care plan is developed by the Interdisciplinary Team upon admission and reviewed/updated on a regular basis throughout the resident's length of stay. 1) Resident #4 diagnoses included peripheral vascular disease, and atrial fibrillation. The 01/16/2026 quarterly Minimum Data Set (a resident assessment tool) documented Resident #4 had moderate cognitive impairment and received anticoagulants. The 02/03/2026 physician order documented Eliquis five (5) milligrams, give one (1) tablet by mouth twice a day. There was no documented evidence in the cardiac care plan to address the diagnosis of atrial fibrillation and the use of anticoagulants. During an interview on 02/11/2026 at 1:19 PM, the Director of Nursing stated they were unable to locate a care plan to address the use of anticoagulants for Resident #4. The Director of Nursing stated Resident #4 was taking an anticoagulant medication and should have interventions in place to monitor/report and signs/symptoms of bleeding/bruising. They stated the unit manager would have been responsible for updating Resident #4's care plan and the Assistant Director of Nursing, Director of Nursing and/or the Minimum Data Set Coordinator were responsible for overseeing that Unit Managers were updating care plans as needed. During an interview on 02/11/2026 at 1:40 PM, Licensed Practical Nurse Unit Manager #1 stated they were aware Resident #4 was prescribed an anticoagulant. They stated a Registered Nurse could add an anticoagulant use care plan with interventions. They stated updates to care plan interventions was a unit manager role. 2) Resident 11's diagnoses included dementia in other diseases classified elsewhere mild with anxiety, and unspecified pain. The 12/05/2025 quarterly Minimum Data Set documented Resident #11 had moderate cognitive impairment and received antipsychotic medication. The 11/03/2025 physician order documented olanzapine oral tablet five (5) milligrams. Give five (5) milligrams by mouth at bedtime for major depressive disorder. The 11/06/2025 care plan titled Psychosocial Well-Being documented administer non-psychotropic medication per physician order. During an interview on 02/10/2026 at 3:19 PM, Licensed Practical Nurse Unit Manager #2 stated Resident #11 received antipsychotic medication as per physician order. They stated they were unable to locate a care plan with interventions that addressed the use of antipsychotic medications. They stated they would discuss it with the Assistant Director of Nursing. They stated antipsychotic interventions could have been added under the psychosocial care plan. They stated the Social Work Department updated psychosocial care plans. During an interview on 02/11/2026 at 9:27 AM, the Director of Social Work stated antipsychotic medication use was to be documented under psychosocial care plans. The Social Worker stated they were unable to locate the use of antipsychotics on the resident care plan. They stated they were responsible for updating Resident #11's care plan to address the use of antipsychotic medication. The Director of Social Work stated the care plan should include interventions such as use of antipsychotic medication, psychology and psychiatry consults as needed, monitor for changes and report for changes in behavior (acting out, increase in lethargy, and report changes. 10 NYCRR 415.11(c)(2)(i-iii)

Based on observation, record review, and interview during the recertification and abbreviated survey (623104/NY00345976), the facility did not ensure each resident received care, consistent with professional standards of practice, to treat and/or prevent pressure ulcers for two (2) of seven (7) (Residents #13 and Resident #143) reviewed for Pressure Ulcers. Specifically, 1) Resident #13 who was assessed as at risk for pressure ulcers was not provided heel offload/float as per the comprehensive care plan, 2) Resident #143 who was assessed as at risk for pressure ulcers was not provided heel offload/float as per physician order and comprehensive care plan and a pressure reducing device was not provided as per comprehensive care plan.The findings include:1)Resident #13's diagnoses included bipolar disorder, unspecified dementia without behavior disturbance, and dysphagia.The current care plan titled Skin Integrity documented Resident #13 was at risk for impaired skin integrity related to impaired mobility. Float heels when in bed. The 12/26/2025 quarterly Minimum Data Set (a resident assessment tool) documented Resident #13 had severe cognitive impairment, was dependent on staff with bed mobility, was at risk for pressure ulcers and had one stage IV pressure ulcer present on admission/reentry.The 02/12/2026 certified nurse aide Kardex (resident task sheet) documented skin integrity: float heels when in bed, reposition every two (2) to four (4) hours and as needed. Pressure relief mattress.During observation on 02/05/2026 at 9:47 AM and 02/06/2026 at 9:19 AM, Resident #13's bilateral heels were resting on the mattress. The heels were not offloaded/floated.During observation and interview on 02/09/2026 at 12:49 PM, Certified Nurse Aide #8 stated Resident #13's bilateral heels rested on the mattress and were not offloaded/floated They stated the heels should be offloaded/floated. They stated Resident #13 was hand-fed lunch a short time earlier and their heels should have been checked to ensure they were offloaded/floated.During interview and observation on 02/09/2026 at 12:56 PM, Licensed Practical Nurse #7 stated Resident #13's bilateral heels were not offloaded/floated. They stated Resident #13 had a care plan intervention for their heels to be offloaded when in bed. They stated the resident's heels should be offloaded because they were bedbound. They stated all nursing staff including certified nurse aides were responsible for ensuring the resident's heels were offloaded/floated. They stated nurses were responsible for ensuring that certified nurse aide tasks were completed. During interviews on 02/10/2026 at 10:18 AM and 02/12/2026 at 4:26 PM, Licensed Practical Nurse Unit Manager #2 stated Resident #13 had a care plan intervention for heels to be offloaded/floated when they were in bed. They stated staff should have used pillows or a wedge type device to offload/float the heels. They stated nurses were responsible for ensuring certified nurse aides offloaded the resident heels. 2) Resident #143 diagnoses included unspecified epilepsy non-intractable with status epilepticus, history of transient ischemic attack and cerebral infarction without residual deficits and bipolar disorder. The 05/05/2025 physician order documented offload heels on pillow in bed as tolerated every shift for skin integrity. The 05/08/2025 care plan titled Skin Integrity documented Resident #143 was at risk for impaired skin integrity related to diabetes mellitus type one (1) and impaired mobility. Offload heels while in bed on a pillow as tolerated, turn and reposition every two (2) to four (4) hours while in bed as needed, float heels while in bed, and pressure reduction device for out of bed. The 06/06/2025 occupational therapy progress note documented Resident #143 was provided with a reclining high back wheelchair with elevating leg rests. Resident currently with aqua cell cushion in the wheelchair. The 10/22/2025 care plan titled Transfer documented Resident #143 had a self-performance deficit related to muscle weakness. Pressure reduction device for out of bed. The 01/16/2026 quarterly Minimum Data Set documented Resident #143 had moderate cognitive impairment, required substantial/maximal assistance for bed mobility, was at risk for pressure ulcers and did not have a pressure ulcer. The current Kardex documented under the skin integrity section, off load heels on a pillow while in bed.During observation on 02/05/2026 at 11:46 AM, 02/06/2026 at 11:22 AM and 02/09/2026 at 9:46 AM, Resident #143 was in bed with their bilateral heels on the mattress. The heels were not offloaded. During observation on 02/09/2026 at 11:46 AM and 02/10/2026 at 11:41 AM, Resident #143 was sitting in their wheelchair, without the use of a pressure relieving device/cushion.During interview and observation on 02/10/2026 at 11:42 AM, Certified Nurse Aide #9 stated Resident #143's wheelchair did not have a pressure relieving device/cushion in place. They stated the last time they observed Resident #143's cushion was in late December 2025 when Resident #143 was using a Geri chair. They stated Resident #143 was transitioned to a high back wheelchair at the beginning of 2026 and they did not observe the cushion since that time. They stated they did not report that Resident #143 did not have a cushion to nurses and rehabilitation staff. They stated they should have reported the missing cushion. During observation and interview on 02/10/2026 at 1:53 PM, Resident #143 was in bed resting on their back with their bilateral heels on the mattress. The heels were not offloaded/floated. Certified Nurse Aide #9 stated they were not aware that Resident #143 had a physician order and care plan intervention to offload/float the heels while in bed. They stated the task was not documented on the Kardex (certified nurse aide task document).During an interview on 02/11/2026 at 11:33 AM, Licensed Practical Nurse Unit Manager #1 stated Resident #143 had a care plan intervention and physician order to offload/float bilateral heels when in bed and they were not aware why the task was not completed. Licensed Practical Nurse Unit Manager #1 stated certified nurse aides should complete the task as documented on the certified nurse aide Kardex. They stated Resident #143 should have a pressure reducing device/cushion on the wheelchair. They stated no staff reported the device/ cushion missing. They stated the last time they observed a cushion on Resident #143's wheelchair was over three weeks ago. During an interview on 02/11/2026 at 1:55 PM, the acting Director of Rehabilitation stated Resident #143 was at risk for pressure ulcers. They stated use of a pressure reduction device/cushion for the wheelchair was added to the care plan on10/22/2025. They stated the resident had the cushion at that time. They stated when unit staff noticed a missing cushion, they were supposed to report to rehabilitation staff during morning meeting, or they could complete a referral form at the nursing station. They stated they were not aware of unit staff requesting a replacement pressure reduction device/cushion. 10NYCRR 415.12(c)(1)

Based on observation, interview, and record review the facility did not ensure care consistent with professional standards of practice, and the comprehensive person-centered care plan was provided for one (1) of three (3) residents (Resident #13) reviewed for Respiratory Care. Specifically, Resident #13 was administered oxygen at a liter flow greater than the current physician's order. Additionally, Certified Nurse Aide #8 did not adhere to enhanced barrier precautions when they had contact with and handled Resident #13's nasal cannula. The findings include:The policy titled Oxygen Therapy, last revised 09/2023, documented oxygen administered by licensed staff. Oxygen administration requires physician order.Resident #13's diagnoses included bipolar disorder, unspecified dementia without behavior disturbance, and dysphagia.The 06/07/2023 care plan titled Impaired Pulmonary Function documented administer oxygen per physician order.The 10/28/2025 physician order documented enhanced barrier precautions stage 4 wound sacrum. The 06/14/2025 physician order documented continuous oxygen via nasal cannula at two (2) liters per minute.The 12/26/2025 quarterly Minimum Data Set (a resident assessment tool) documented Resident #13 had severe cognitive impairment and received oxygen therapy. During observation on 02/05/2026 at 9:47 AM and 02/06/2026 at 9:26 AM Resident #13 received oxygen via nasal cannula at three (3) liters/minute. During observation and interview on 02/09/2026 at 12:43 PM and 12:49 PM Resident #13's nasal cannula was resting in Resident #13's hair/scalp on the top of their head. Certified Nurse Aide #8 removed the nasal cannula from Resident #13's hair/scalp without performing hand hygiene, donning gloves, or wearing a gown and inserted the cannula prongs into Resident #13's nostrils. Certified Nurse Aide #13 stated they should have applied appropriate personal protective equipment and performed hand hygiene before they handled and placed the nasal cannula in Resident #13's nostrils.During interview and observation on 02/09/2026 at 12:56 PM, Licensed Practical Nurse #7 stated they checked the oxygen flow rate for Resident #13 earlier in the shift between 8:00 AM and 9:00 AM. Licensed Practical Nurse #7 stated Resident #13's oxygen concentrator was running at three (3) liters/minute and stated they were not aware of the exact physician order for oxygen administration. After review, Licensed Practical Nurse #7 stated the physician order was for oxygen to be administered at two (2) liters/minute. They stated they should have double checked the order during medication administration and adjusted the oxygen flow rate to two (2) liters as per physician order. During interview on 02/10/2026 at 10:18 AM and 02/12/2026 at 4:26 PM, Licensed Practical Nurse Unit Manager #2 stated nursing staff were required to check oxygen flow rates during medication administration and during each shift to ensure the flow rate matched the physician order. Licensed Practical Nurse Unit Manager #2 further stated staff should mask, glove and gown when they provided cares for residents on enhanced barrier precautions. They stated nurses were responsible for supervision of certified nurse aides to ensure personal protective equipment was applied when necessary. 10NYCRR 415.12 (k)(6)

Based on record review and staff interviews, the facility did not provide evidence that care plan interventions were consistently carried out for the resident reviewed for pressure injuries. Specifically, Resident #1 who was admitted with a deep tissue injury, had an intervention to turn and position every two hours which wasn't consistently documented indicating this intervention was not properly performed. Review of the policy titled Documentation of Pressure Ulcer and Chronic Wounds last revised 6/2023 documented that Pressure ulcers and chronic wounds are monitored closely to monitor effectiveness of treatment and change in risk factors. Review of the policy titled Activities of Daily living last reviewed 9/2025 documents that each resident will receive, and the facility will provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. This policy further documented that Certified Nurse Assistants will follow the resident Kardex/ Care Plan interventions (i.e. transfer status, turning and positioning, assistive devices, ADLs, etc.).Resident #1 was admitted to the facility with diagnoses that included unspecified fracture of right femur, hypotension, encounter for palliative care.In review of all notes provided by facility from date range of when Resident #1 was in the facility, from 04/05/2024 until 05/03/2024, there were only 14 notes that indicate Resident #1 may have been moved from one position to another and possibly off their back. Of those 14 notes only five (5) indicate that Resident #1 was actually turned and positioned. Most notes just indicate that Resident #1 may have been moved, they do not specifically document that they had been turned and positioned either when the note was written or every two hours as per the care plan. Review of note dated 05/02/2024 at 10:46pm by Registered Nurse #7 documented Resident #1 resting comfortable in bed with eyes closed. Took all post meridiem (PM / evening) and [NAME] somni (HS / at bedtime or hour of sleep) medications without adverse reaction. Turned and positioned every two hours, heels off loaded. Skin beneath immobilizers is dry and intact, positive pedal pulses. No complaints of pain or discomfort. Review of note dated 05/02/2024 at 1:59pm by Registered Nurse #7 as prior message documented continue to offload heels and turn and position resident everyone (1) to two (2) hours or as per facility protocol.Review of note dated 04/30/2024 at 3:21pm by Social Worker #8, documented that Resident #1 was having a room change, so while it does not explicitly state that the resident was turned or positioned it is probable that they were moved around and possibly off their back.Review of progress note dated 04/30/2024 at 10:52am by Nurse Practitioner #1 documented that Resident #1 was being examined for skin impairment involving multiple areas. It further documents that to improve the patient's comfort and healing an air mattress will be added to reduce pressure on the affected areas with turning and positioning as they tolerate.Review of progress note dated 04/29/2024 at 6:55pm by Registered Nurse #6 documented that the Assistant Director of Nursing is in the process of getting an air mattress from the maintenance department. It further documented that Resident #1 was repositioned on their right side with both heels off loaded with pillows. Review of progress note dated 04/28/2024 at 12:07pm by Registered Nurse #7 documented that Resident #1 turned and positioned every two hours, and treatment to buttocks completed.Review of progress note dated 04/27/2024 at 1:53pm by Registered Nurse #7 documented that Resident #1 turned and positioned every two hours, and treatment to buttocks completed. Review of progress note dated 04/25/2024 at 12:06pm by Licensed Practical Nurse #9 documented that the patient (Resident #1) was examined on wound rounds and that they remain to be turned and positioned every 2 hours and as necessary.Review of progress note dated 04/22/2024 at 2:54pm by Registered Nurse #7 documented that Resident #1 went out to an orthopedic appointment.Review of progress note dated 04/06/2024 at 2:06pm by Licensed Practical Nurse #10 documented that ADL care was provided. Review of care plans found that Resident #1 had a care plan initiated 04/06/2024 with a focus of Bed Mobility documented that resident had a self-performance deficit related to fracture of bilateral femur, limited mobility, limited range of motion. The intervention date initiated 04/06/2024 will continue to be positioned safely through next review intervention dependent x2 rolling side to side.Review of care plans found that Resident #1 had a care plan initiated 04/05/2024 with a focus of Skin Integrity at risk: at risk for impaired skin integrity related to fracture of bilateral femur, limited mobility, limited range of motion, surgery left intramedullary nailing, incontinence, deep tissue injury sacrum, and redness to inner heel. The goal was that Resident #1 would be free from further skin breakdown through next review. One of the interventions dated 04/05/2024 documented Turn and Position every 2 hours and as needed. In an interview on 08/27/2025 at 8:41am with a Certified Nurse Aide #3, they stated that they just started and that they were never told to document turn and position, that they tell their nurse but does not know if the nurse documents it.In an interview on 08/27/2025 at 9:12am with Certified Nurse Aide #2 they stated there is one resident that needs to be turned and positioned every 2 hours, and we have a paper we mark which is on the cabinet in the residents' rooms. Certified Nurse Aide #2 then said It is all done in the computer and tried to show how nutrition information for breakfast and lunch is put into the tablet, but they were unable to log into the tablet. Certified Nurse Aide #2 stated that they give report to each other at change of shift. Certified Nurse Aide #2 stated we don't know the hours, or how long ago, or exactly when the last time was that someone was turned or positioned.In an interview on 8/27/2025 at 9:25am with Licensed Practical Nurse #4 they stated they do not know when someone was last turned and positioned, it is not documented. Licensed Practical Nurse #4 stated they were sure that if they asked a Certified Nurse Aide that they would know, but that the Certified Nurse Aides do not let them know unless there is a wound then they would come and get the nurse to do a dressing change. In speaking of a current resident on their unit that they knew were care planned to be turned and positioned every two hours, Licensed Practical Nurse #4 stated that it was 9:30am and they were sure that the resident was still in bed and had probably not been changed from the overnight shift, they stated they could not tell if turning and positioning was done every two hours, since they do not document that it gets done every 2 hours. Licensed Practical Nurse #4 also confirmed that there is no tracking sheet (paper) on the wall in the resident's rooms.In an interview on 08/27/2025 at 9:21am with the Assistant Director of Nursing they were not sure how a Certified Nurse Aide documented turning and positioning, but they were sure it was not being documented in the computer.In an interview on 08/27/2025 at 10:18am with Licensed Practical Nurse #5 they stated that there is no documentation for turning and positioning. Licensed Practical Nurse #5 stated that back in the day it was paper and pen - now it is not in the computer - staff do not know if residents were turned. Licensed Practical Nurse #5 stated that they have seen wounds get worse here - no one really writes notes.10 NYCRR 415.12

Based on record review and interviews during an abbreviated survey (NY00341591), the facility did not have a comprehensive patient centered care plan developed or implemented for 1 (Resident #1) out of three residents reviewed for care planning. Specifically, Resident #1 was admitted to the facility from a local hospital on [DATE] and when they came into the facility, they already had Hospice care in place from the hospital. Review of Resident #1's care plan revealed they did not have a Hospice care plan in place.The facility's policy titled Hospice Services with a revision date of 07/2025 documents that the resident and family participate in developing the care plan where appropriate and that nursing coordinates the plan of care and ongoing collaboration and communication closely with Hospice, the resident and family, and other disciplines. The facility policy titled Interdisciplinary Care Planning last revised 04/15/2024 documented that a comprehensive resident-centered Care Plan is developed by the Interdisciplinary Team upon admission and reviewed/updated on a regular basis throughout the resident's length of stay.Review of the electronic medical record for Resident #1 shows there were no orders for Hospice, there were no progress notes from any medical provider indicating that they were collaborating with the Hospice facility, and there were no care plans that indicate that the facility had a comprehensive resident-centered care plan developed regarding Hospice for Resident #1. Review of a progress note dated 04/29/2024 at 7:19pm by Registered Nurse #6 indicated that after providing wound care to Resident #1 the nurse called family to notify them of the change in skin condition, the Nurse documented in their note that the family replied to the nurse that the Hospice nurse had notified them of the change in skin condition already.Review of a note dated 04/24/2024 written by a Registered Nurse #7 documented Resident #1 is on Hospice. Review of the discharge paperwork from the hospital dated 04/4/2024 documented Resident #1's disposition as: Patient is medically optimized for discharge back to subacute rehab, Hospice case management working on placement, anticipate discharge tomorrow. Review of all the care plans for Resident #1, revealed that there are no care plans for or related to Hospice. In an interview on 08/22/2025 at 2:35pm with Registered Nurse #1 when asking about the process for Hospice and how the exchange of information occurs. Registered Nurse #1 stated that there is a Hospice doctor, nurse, and aide, but they only see them once a week for a short period of time. Registered Nurse #1 stated the Hospice provider writes a note in their own book, and they must let the nurse manager on the unit know who they saw and if there is anything new. Registered Nurse #1 stated they did not think there is a Hospice note in the system. Registered Nurse #1 stated they described the system of communication as such: Hospice sees the resident and tells the nurse floor manager for that day, who then writes a note and contacts the facility doctor if there are any new orders or changes to orders. In an interview on 09/02/2025 at 10:11am with the Nursing Home Coordinator for the Hospice provider, they confirmed that Resident #1 was receiving Hospice services at the facility and that the beginning date was 04/05/2024. The Nursing Home Coordinator stated that while Resident #1 was at the facility, they had 3 nursing visits from the assigned Hospice Case Manager on 04/09/2024, 04/18/2024, and 04/29/2024. The Nursing Home Coordinator stated Resident #1 had Certified Nurse Aide visits, with different Aides, on 04/11/2024, 04/15/2024, 04/20/2024, 04/25/2024, 04/2720/24, and 04/29/2024. The Nursing Home Coordinator stated Resident #1 also had a Hospice social worker that visited on 04/08/2024 and 04/25/2024, and they had a Nurse Practitioner face-to-face visit to recertify on 04/25/2024.In an interview on 09/08/2025 at 3:43pm with the Director of Social Work, they stated that they update the care plan and share with team that the resident is on Hospice. The Director of Social Work stated they are available to talk to the Hospice nurse and to maintain contact with family to provide support. The Director of Social Work stated they cannot have this type of a conversation or do anything with a care plan if they are not aware a resident is on Hospice.In an interview on 09/09/2025 at 10:28am with the Nurse Liaison they went through all their information from 2024 and stated that the admissions alert email that they would have sent doesn't say anything about Hospice, usually that is where it would be- somewhere the ball got dropped- usually there is an email with the information. The Nurse Liaison stated they did not see where this information was relayed to the staff. the Nurse Liaison stated they cannot find anything that says this, they did not put it in the email to the admissions person at the facility. The Nurse Liaison stated that they obviously dropped the ball. 10NYCRR 415.11(c)(1)

Based on record review, and interviews conducted during the abbreviated Survey (NY00341591), the facility did not provide services in accordance with professional standards of care. Specifically, for one (Resident #1) of three residents reviewed for Hospice, Resident #1 was receiving Hospice care from an outside agency; however, the resident record contained no documentation, orders, progress notes, medical provider notes, or care plans addressing the Hospice care. The facility policy titled Hospice Services last revised 07/2025 documented that nursing coordinates the plan of care and ongoing collaboration and communication closely with Hospice, the resident and family, and other disciplines. The facility policy titled Interdisciplinary Care Planning last revised 04/15/2024 documented that a comprehensive resident-centered Care Plan is developed by the Interdisciplinary Team upon admission and reviewed/updated on a regular basis throughout the resident's length of stay.Resident #1 was admitted to the facility with diagnoses that included unspecified fracture of right femur, hypotension, encounter for palliative care.Review of the electronic medical record for Resident #1 shows there were no orders for Hospice, there were no progress notes from any medical provider indicating that they were collaborating with the Hospice facility, and there were no care plans that indicate that the facility had a comprehensive resident-centered care plan developed. Review of a progress note dated 04/29/2024 at 7:19pm by a Registered Nurse #6 indicated that after providing wound care to Resident #1 the nurse called family to notify them of the change in skin condition, the Nurse documented in their note that the family replied to the nurse that the Hospice nurse had notified them of the change in skin condition already.In an interview on 08/22/2025 at 2:35pm with Registered Nurse #1 when asked about how the Hospice care is documented and how Hospice care is provided, they stated there is a Hospice doctor, nurse, and aide. The Registered Nurse #1 stated the Hospice staff only see the resident once a week for a short period of time and the Hospice provider writes a note in their own book, and they must let the nurse manager on the unit know who they saw and if there is anything new. Registered Nurse #1 stated they do not think there is a Hospice note in the system. They stated they think the way it goes is Hospice sees the resident and tells the unit manager which residents were seen and then writes a note and contacts the facility doctor if there are any new orders or changes to orders. In an interview on 09/02/2025 at 10:11am with the Nursing Home Coordinator for the Hospice provider, they confirmed that Resident #1 was receiving services at the facility and that the beginning date was 04/05/2024. The Nursing Home Coordinator stated that when Resident #1 was at this facility, they had 3 nursing visits from the assigned Hospice Case Manager on 04/09/2024, 04/18/2024, and 04/29/2024. The Nursing Home Coordinator stated Resident #1 had Certified Nurse Aide visits, with different Aides on 04/11/2024, 04/15/2024, 04/20/2024, 04/25/2024, 04/2720/24, and 04/29/2024. The Nursing Home Coordinator stated Resident #1 also had a Hospice social worker that visited on 04/08/2024 and 04/25/2024, and they had a Nurse Practitioner face-to-face visit to recertify on 04/25/2024. The Nursing Home Coordinator for Hospice stated that they reviewed the process and that they have worked with this facility often. The Nursing Home Coordinator stated when a staff member goes into the facility, they must check in with the manager on the unit and let them know who they intend to visit with and check if there are any changes, and after the visit they return to the manager and let them know if there are any recommendations. They explained that every unit should have a binder and that is where the staff write any notes about the resident they are visiting. In an interview on 09/05/2025 at 10:10am with the Medical Director, they stated they always write an order if the resident is on Hospice. The Medical Director stated that they reviewed the process for residents on Hospice at the facility. The Medical Director stated that there are residents that get Hospice, and it is all from the same Hospice facility. The Medical Director stated that they haven't seen any notes written about Hospice for this resident, The Medical Director stated they were not aware of any binder on the units regarding Hospice. The Medical Director reiterated that they must have an order for Hospice, and that this is the first time they were hearing about this issue. The Medical Director added that the problem is no one noticed. In an interview on 9/9/25 at 10:28am with the Nurse Liaison they went through all their information from 2024 and stated that the admissions alert email doesn't say anything about Hospice, usually that is where it would be - somewhere the ball got dropped - usually there is an email with the information. The Nurse Liaison stated they did not see where this information was relayed to the staff. The Nurse Liaison stated they cannot find anything that says this, they did not put it in the email to the admissions person at the facility. 10 NYCRR 415.11(c)(3)(ii)

Based on record review and interviews during an abbreviated survey (NY00341591), the facility did not have a resident's total program of care created, specifically orders for Hospice were never entered by the medical provider for one (Resident #1) of three residents reviewed for Hospice. Specifically, Resident #1 was admitted on [DATE] and was on Hospice care from their prior facility and the Physician has no progress note addressing this and there are no orders to continue Hospice care for Resident #1 who was being seen regularly by the outside Hospice provider.The facility policy titled Hospice Services with a revision date of 07/2025 document that there is a collaborative effort between Hospice and the facility for residents with life-limiting illnesses. The Facility will maintain a written agreement with Hospice. Resident #1 was admitted on [DATE] and in review of the entire chart, there are no orders, no physician notes documenting physician was aware resident was on Hospice. Review of all notes and orders provided by facility from date range of when Resident #1 was in the facility, from 04/05/2024 until 05/03/2024, there were no orders for Hospice care, and there were no notes written to indicate that the Medical Director was aware that Resident #1 was on Hospice care.In an interview on 09/05/2025 at 10:10am with the Medical Director, they stated they always write an order if the resident is on Hospice. The Medical Director stated that they reviewed the process for residents on Hospice at the facility. The Medical Director stated that there are residents that get Hospice, and it is all from the same Hospice provider. The Medical Director stated that they haven't seen any notes written about Hospice for Resident #1. The Medical Director stated they were not aware of any binder on the units regarding Hospice. The Medical Director reiterated that they must have an order for Hospice, and that this is the first time they were hearing about this issue. The Medical Director stated that this was my mistake and that they did not know how this happened without an order. The Medical Director added that the problem is no one noticed. 10 NYCRR 415.15 (b)(2)(iii)

Based on record review and interviews conducted during an abbreviated Survey (NY00380249/623119, NY00382698/623133 ), the facility did not ensure that Certified Nurse Aides had the appropriate competencies and skills sets necessary to care for residents' needs, and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments, and described in the plan of care. Specifically, 1) Certified Nurse Aide #1 was involved in an allegation of abuse on 05/07/2025. Review of their employee file revealed Certified Nurse Aide #1's required abuse training was last completed on 06/19/2025. Prior to that, the last abuse training was completed on 03/14/2024. 2)Certified Nurse Aide # 2 who was involved in an allegation of abuse on 5/3/2025 had their required training for abuse prevention and compliance on 05/20/2025. Prior to this, their last abuse training was completed on 02/16/2024.3) Certified Nurse Aide # 3 had their required training for abuse prevention and compliance on 05/22/2025. Prior to this date the last abuse training was completed on 04/17/2024.The findings included: The facility policy titled Abuse Prohibition last revised on 2/2023 documented that the facility's abuse prevention/intervention program includes but is not necessarily limited to regularly scheduling in-service training programs designed to teach staff how to better understand the resident's abusive actions. The policy did not include the frequency of or indicate that trainings are to be done annually. During an interview on 7/31/25 at 2:19 PM, the Staffing Educator stated that mandatory educations for staff are located on the SNF clinic (a training program and resources for nurses and caregivers in skilled nursing facilities). Staff is required to complete these trainings via computer. The Staffing Educator stated Certified Nurse Aides #1, #2, and #3 were overdue and out of compliance with completing their required training for abuse prevention and compliance and that they along with facility staff should have received several messages to complete the in-services when they were due. Notifications are also sent out through the system if their trainings are due or overdue. The Staffing Educator stated that Certified Nurse Aide #1 was assigned Abuse training on 02/01/2025 and did not. until 06/19/2025 and prior to that their last abuse training was completed on 03/14/2024. Certified Nurse Aide #2 was assigned Abuse training on 02/01/2025 and did not complete it until 05/20/2025 and prior to that, their last Abuse training was completed on 02/16/2024 and Certified Nurse Aide #3 was assigned Abuse training on 02/01/2025 and did not complete it until 05/22/2025 and prior to that, Certified nurse Aide #3's last Abuse training was completed on 4/17/2024. All three Certified Nurse Aides were out of compliance as per the requirements to complete their annual abuse trainings. The Staffing Educator stated an email is sent to the administrative team to notify them of who was out of compliance. In addition, notices are created and posted by the time clock reminding staff to complete the required annual trainings. During an interview on 07/31/2025 at 2:51 PM, the Regional Director of Nursing stated that the Staff Educator notified them earlier in the week that there are multiple staff who's required Inservice trainings have not been completed, and that it would be discussed with the team the best way to get staff to complete the required trainings. During an interview on 07/31/2025 at 3:17 PM, the Interim Administrator stated that they are aware that staff are not completing their required Inservice trainings when they are due. They plan to hold a meeting with staff and ask them to do the in-services/trainings or remove them from the schedule. During an interview on 07/31/2025 at 3:36 PM, the Director of Nursing stated that they are trying to address the staff's noncompliance of trainings/in-services with the administrative team. The Staff Educator puts out notices and does their best to reach staff to complete in-services, and they do that alone. The Director of Nursing. stated that they have decided that for the actions to be effective, they need to get involved and assist with getting in-services completed. The Director of Nursing stated that in 2 weeks the Staff Educator will no longer conduct the Certified Nurse Aide Class and will only focus on staff in services. All staff removed from duty due to an incident must be retrained. During an interview on 07/31/2025 at 12:56 PM, Certified Nurse Aide #1 stated that they do not remember the last time that they had abuse training and that trainings are done on the computer, and they have never received any disciplinary actions for not completing their trainings when they are due. Attempted to reach Certified Nurse Aide #3 on 08/01/2025 at 03:07 PM and was unsuccessful. Voice message was left. 10 NYCRR 415.26(c)(1)(iv)

Based on observations, record review, and interviews conducted during an abbreviated survey (NY00359790/623106), the facility did not ensure that the residents had a right to a safe, clean, comfortable, and homelike environment, including housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 5 (Resident #5, #6, #7, #8 and #9) of 9 residents rooms observed for environmental concerns. Specifically, 1) In room [ROOM NUMBER]B of the Roosevelt unit, occupied by Resident #5, a new admit, the window was observed to have gray duct tape covering the entire bottom width of the windowsill. The window screen contained multiple ripped holes of varying sizes, several spackle paste were noted on the wall behind the Resident's bed, and the dresser drawer was broken and unable to close; 2) In room [ROOM NUMBER] B on the Roosevelt unit, occupied by Resident #6, the window was entirely covered with plastic and white patches of spackle were observed on the wall behind the Resident's bed; 3) In room [ROOM NUMBER] A on the Roosevelt unit, occupied by Resident #7, a new admission, multiple white patches of spackling compound were observed on the wall behind the Resident's bed and the lower portion of the walls around the bed was scratched and had scuff; 4) In room [ROOM NUMBER]A on the Roosevelt unit, occupied by Resident #8, multiple white patches of spackle were observed on the wall behind the Resident's bed; 5) In room [ROOM NUMBER]B on the Roosevelt unit, occupied by Resident #9, multiple white patches of spackle were observed on the wall behind the Resident's bed. The findings include:The facility policy titled Maintenance revised on 10/2024 documented that the facility provides an environment that fosters a positive self-image for the Resident and preserves his or her human dignity. The entire facility including, but not limited to, the floors, walls, doors, windows, ceilings, lighting, furnishings and equipment shall be maintained in good repair. Windows are checked by Maintenance. Windows that are broken or separated from the frame or otherwise not functioning as designed will be repaired or replaced. Maintenance is responsible for maintaining all the wall coverings. Supplies of the various paints, wallpapers and supplies are kept in stock.During an observation on 08/14/2025 at 11:39 am, room [ROOM NUMBER] B of the Roosevelt unit, occupied by Resident #5, the following were noted: The window had gray duct tape along the entire bottom of the windowsill, the window screen contained multiple holes of varying sizes, several spackled patches were visible on the wall behind the Resident's bed, and the dresser drawer was broken and would not close. During an interview on 08/14/2025 at 11:40 AM, Resident #5 stated that they were recently admitted a few days prior to the day of the onsite visit and was placed in the room in the current condition. The resident and family requested that the window be repaired, the patches of spackle removed, and the dresser fixed so that they could store their clothing without them being visible. Resident #5 stated that they preferred a different room, noting that the current room appeared damaged and that they would have raised concerns prior to admission had they known the condition of the room.During an observation on 08/14/2025 at 11:54 AM, room [ROOM NUMBER] B of the Roosevelt unit, occupied by Resident #6, the following were noted: plastic covered the entire window and patches of spackle were noted behind the resident's bed. During an interview 08/14/2025 at 11:55 AM, Resident #6 stated that they've been in the current room for over two months. When they first got into the room, they complained that there was a draft coming in and the room was very cold. Resident #6 stated that Maintenance initially put up duct tape, but the duct tape wasn't working, and then they came and placed a plastic covering, which has now been up for over a month. Resident #6 stated that even with the plastic covering, they could still feel the draft. When it rains, water gets trapped behind the plastic and water starts coming in through the window. Resident #6 stated that the patches of spackle behind their bed has been that way since they removed white boxes that was on the wall, and they never came back to sand or paint. During an observation on 08/14/2025 at 12:00 PM, room [ROOM NUMBER] A, occupied by Resident #7, a new admission to the facility, the following was noted: spackled patches on the wall behind the bed and the lower portions of the walls surrounding the bed and their side of the room, was dirty with scuff.During an interview on 08/14/2025 at 12:01 PM, Resident #7 stated they were admitted to the facility the day prior to the onsite visit. They were placed in the room in the current condition. Resident #7 stated that when spackle is applied to the wall and not painted promptly, the outer layer begins to flake and fall, creating dust. Resident #7 expressed concern that the spackle dust could spread throughout the room causing a safety hazard. Resident #7 stated that they would like their room cleaned, noting that the lower portions of the walls were very dirty.During an observation on 08/14/2025 at 12:07 PM, room [ROOM NUMBER] A, occupied by Resident #8, was noted to have patches of spackle on the wall behind the bed.During an observation on 08/14/2025 at 12:08 PM, room [ROOM NUMBER] B, occupied by Resident #9, a new admit to the facility, patches of spackle were noted on the wall behind the bed.During an interview on 08/14/2025 at 12:09 PM, Resident #9 stated they arrived at the facility a few days ago and that they received the room in the current condition. During an interview on 08/14/2025 at 12:57 PM, the Maintenance Director stated that maintenance staff conduct weekly rounds, covering different areas of the building, but sometimes issues needing repair or replacement are missed. The Maintenance Director stated that there is no formal system in place for work orders. Regarding the patches of spackle observed in multiple resident rooms, the Maintenance Director stated that these areas need to be sanded and painted. The Maintenance Director stated that monitors were removed from the walls in the resident room approximately two months ago and the walls should have been repainted at that time. Due to the workload, the sanding and painting have not been completed. They plan to address this immediately. The Maintenance Director stated that the Roosevelt Unit has not been painted in several years, although the goal is to repaint every two years. A full repaint of the unit is now due. The Maintenance Director stated that the windows are as old as the building, approximately 30 years, and they need to be replaced; approval from a contractor is being sought. When residents report drafts from windows, temporary fixes such as duct tape are sometimes applied, though these are not fully effective. Some windows leak when it rains. Regarding dressers, the Maintenance Director stated that replacements of drawers are made regularly, and that staff are expected to notify maintenance when a dresser needs repair. The Maintenance Director stated that the plastic covering on the window in room [ROOM NUMBER] B should have been removed and should not have remained in place for two months.During an interview on 08/14/2025 at 1:23 PM, the Administrator stated that they conducted initial rounds and observed rooms in need of repair. the Administrator stated that beginning Tuesday, environmental concern will be discussed with the Directors of Maintenance and Housekeeping and will focus on addressing the issues. The administrator stated that areas that have been spackled should have been painted. Plastic coverings should not remain on the windows in resident rooms. 10NYCRR 415.5(i)(2)

Based on record review, and interviews conducted during an abbreviated survey (NY00348484/623066), the facility did not ensure residents received quality of care in accordance with professional standards of practice for 1 (Resident #4) of 4 residents reviewed. Specifically, Resident #4 had an unwitnessed fall on 03/24/2024 which resulted in a pelvic and iliac crest fracture. The hospital discharge instructions documented for Resident #4 to be non-weight bearing to the right lower extremity and to follow up with the orthopedic surgeon in 2-4 weeks. The facility was unable to provide documented evidence that Resident #4's follow-up appointment with the orthopedic surgeon as per the hospital physician's discharge instructions was done.The findings include:The facility policy titled Process for Scheduling Outside Appointments revised on 11/2024 documented that the facility will assist the resident in gaining access to specialty providers per their preference and per provider recommendation when needed for the resident's health and wellbeing. Resident #4 had diagnoses including but not limited to dementia, multiple fractures, nontraumatic intracerebral hemorrhage, and repeated falls.The 05/24/2024 Quarterly Minimum Data Set documented that Resident #4 had severely impaired cognition. The Resident required maximal assistance with bed mobility and toilet transfers and was dependent with chair and bed transfers. The 03/24/2024 Accident and Incident Report documented Resident #4 was found in the bathroom doorway laying on their right side. Resident had pain in their groin and was sent to the hospital for head trauma and pelvic and groin pain.The 03/24/2024 at 8:50 PM Nursing Progress note documented that Resident #4 was sent to the hospital status post fall and was admitted with diagnosis of pelvic and iliac crest fractures.The 03/27/2024 Hospital Discharge Summary documented that Resident #4 is to be non-weight bearing status to the right lower extremities and to follow up with the orthopedic surgeon in 2-4 weeks.During an interview on 08/14/2025 at 4:04 PM, the complainant stated that approximately one month after Resident #4's readmittance back to the facility status post pelvic and iliac crest fracture, they requested that Resident #4 be seen by the orthopedic surgeon as per their discharge instructions to follow up with the surgeon in 2-4 weeks, so that they could be cleared from to weight bear and be discharged home. They were informed that the family had to provide their own transportation for the follow up appointment to the orthopedic surgeon.During an interview on 08/14/2025 at 4:36 PM, the Director of Social Services stated that during a Care Plan meeting it was discussed that Resident #4 needed an appointment with the orthopedic surgeon and that the complainant did not want to pay for their own transportation. The Director of Social Services was unable to provide documented evidence of the discussion held during the care plan meeting concerning the transportation for the follow up appointment to the orthopedic surgeon. There was no evidence of any follow up communication with the complainant.During an interview on 08/15/2025 at 4:37 PM, the Director of Therapy stated that Resident #4 sustained a fracture and was non weight bearing on the right lower extremity, and that they asked the family what they want the facility to do, the family did not want Resident #4 to go to Westchester because of the cost of the ambulette. The Director of Therapy stated that they told the family that they would do them a favor and contact an orthopedic surgeon that they know of but was unable to provide a date or time of when they contacted orthopedic surgeon from Mid-[NAME] Regional and arranged a telehealth consultation. When documentation was requested, the Director of Therapy stated they did not write a progress note because they are a man of their word and thought they were doing the right thing by assisting nursing in getting Resident #4 an orthopedic surgeon appointment. The Director of Therapy stated that when residents return from the hospital, the unit manager and and/or unit secretary are responsible to make all follow up appointments. There was no documentation of the telehealth consultation. The Facility did not provide documentation for the date of the follow up orthopedic appointment as per the discharge instructions. During an interview on 08/14/2025 at 5:09 PM, the Director of Nursing stated that the unit manager is supposed to review all discharge paperwork when Residents are admitted and communicate follow up appointments with the unit clerk, and that the unit clerk that was responsible for making appointments. The unit clerk was no longer working in the facility. The Director of Nursing was unable to provide Orthopedic consults, orthopedic appointment progress notes, or any for follow up orthopedic appointment correspondences, when requested. 10NYCRR415.12

Based on observations, interviews, and record review conducted during the recertification survey from 5/1/2023 to 5/8/2023, the facility failed to store drugs and biologicals in accordance with currently accepted professional principles. Specifically, 1) Expired drugs and biologicals were found in 2 of 3 medication storage rooms (Boscobel and Roosevelt units) and 4 of 6 medication carts (2 medication carts on the Boscobel unit and 1 medication cart on the Roosevelt unit) reviewed for medication storage and labeling; and 2) Medications were stored improperly and left out on a resident's bedside table (Resident #94). The findings include: 1. Multiple observations were conducted of the facility's medication carts and medication storage rooms on 5/4/2023 between 12:00 PM and 4:00 PM and revealed the following: -Boxes of Juven (a therapeutic nutrition powder) with expiration dates ranging from 2/2023-4/2023 were discovered in the medication rooms of the Boscobel and Roosevelt units, as well as the facility's central supply room. -Individual packets of Juven with expiration dates ranging from 2/2023-4/2023 were discovered in 2 medication carts on the Boscobel Unit, 1 medication cart on the [NAME] Grove unit, and 1 medication cart on the Roosevelt Unit. -A pre-mixed saline enema with an expiration date of 12/2022 and a bottle of Sodium Chloride tablets with an expiration date of 4/2023 was discovered on a medication cart of the Roosevelt Unit. -1 box of Aspirin with and expiration date of 6/2022 and 1 Normal Saline IV flush with an expiration date of 6/30/2022 was discovered in the medication room of the Roosevelt unit. During an interview on 5/4/2023 at 12:45 PM, Licensed Practical Nurse (LPN) #3 stated nurses were responsible for stocking medication carts from the unit's medication room and checking the expiration dates before giving the medication to the residents. LPN #1 stated that it was not acceptable for any expired medications to be on the medication carts and anything that was expired should be disposed immediately. During an interview on 5/4/2023 at 12:55 PM, Registered Nurse Unit Manager (RNUM) #1 stated nurses were responsible for checking all expiration dates on medications on the medication carts. RNUM #1 stated central supply was responsible for stocking Juven and over-the-counter medications to units each week and was responsible for checking expiration dates on all items. During an interview on 5/4/2023 at 1:15 PM the facility's staffing coordinator stated they were responsible for the central supply department. The staffing coordinator stated a Certified Nursing Assistant (CNA) was responsible for stocking the facility's units weekly with supplies and over-the-counter medications. While stocking the units, the CNA should have been rotating stock and checking for expired medications and supplies. The staffing coordinator stated all medications and supplies on nursing units should have been checked weekly and recently this had not been happening. The staffing coordinator stated it was not acceptable to have any expired supplies or medications in the building. During an interview on 5/5/2023 at 8:13 AM, CNA #1 stated they were responsible for stocking units weekly with medications and supplies, and checking units for expired medications and supplies while stocking. CNA #1 stated it was not acceptable to have expired medications or supplies on nursing units. CNA #1 stated that working in central supply was not their primary job, and they may have been very busy and missed some expired items. During an interview on 5/4/2023 at 3:52 PM, the Director of Nursing (DON) stated supplies and medications should have been checked weekly when the units were stocked. The DON stated there were some recent changes to the stocking process and that the current process needed to be tightened up to ensure there were no expired medications or supplies on nursing units. 2. Resident # 94 was admitted with Dementia, Cerebral Amyloidal Angiopathy and Type II Diabetes Mellitus. The 2/21/2023 physician order documented Hemorrhoid Relief Cream 5% apply to the rectum topically every 24 hours as needed. The 2/27/2023 physician order documented Zinc Ointment to the left buttock wound every day. There were no orders in place for the administration of Anti-Fungal Powder. During observations on 5/2/2023 at 09:57 AM and 5/3/23 at 9:20 AM, Hemorrhoid Cream, Zinc Ointment and Anti-Fungal Powder were left out on the resident's bedside table. During an interview on 5/2/2023 at 9:57 AM Resident # 94 stated the staff used the creams and powder to put on his wound. During an interview on 5/3/2023 at 2:03 PM, Registered Nurse (RN) #7 stated storing medications and creams at the resident's bedside table was not allowed and all medications were to be stored in the medication carts. RN#7 stated they did not know why the creams were left out and stated they could get into the wrong hands. S483.45(h)(1) 41666

Based on observations, interviews, and record review conducted during the recertification survey from 5/01/2023 to 5/08/2023, the facility did not ensure they provided a safe, clean, comfortable, and homelike environment on 3 of 3 units. Specifically, gray markings were noted on a resident room ceiling, an air vent was dusty/dirty/chipped/scratched, and peeling paint, peeling wallpaper, and broken bathroom floor tiles were observed. The findings are: The facility Policy and Procedure titled Facility Policy-Maintenance effective 6/1/2020 and last revised 9/2021 documented the facility provided an environment that fostered a positive self-image for the residents and preserved their dignity. The entire facility including but not limited to the floors, walls, and ceilings would be maintained in good repair. During observation tours of [NAME] Grove, Boscobel, and Roosevelt Units on 5/01/2023 and 5/03/2023, the following were observed: - gray markings on the ceiling near the resident room air vent and the air vent was dusty/dirty, paint chipped off the wall behind the A bed, bathroom wallpaper falling off, and discolored [NAME] on the bathroom air vent in room [ROOM NUMBER] on the [NAME] Grove Unit, - chipped paint in resident rooms 101,102, 103, 104, 106, 106, 107, 108, 109, 112, 114, 115, 116, 117, and 118 on the Boscobel Unit, - peeling wallpaper in the hallway outside of rooms 102-104, 105, and between rooms 109-111 on the Boscobel Unit, - scratched paint on the wall near the A bed in room [ROOM NUMBER] and peeling paint under the window in room [ROOM NUMBER] on the Roosevelt Unit. A review of the Maintenance Repair Logs for March, April, and May 2023 did not list need of repairs to scratched, chipped, or peeling paint, peeling wallpaper, cracks on bathroom floors, dark [NAME] on vents or on ceilings. On 5/05/2023 at 08:35 AM, an interview was conducted with the Director of Maintenance in resident room [ROOM NUMBER] and was shown the gray markings on the ceiling directly in front of the air vent. The Director of Maintenance stated they saw the same thing as this writer. When asked how often they clean the air vents, the Director of Maintenance stated they were not sure. When asked about the bathroom in room [ROOM NUMBER], the Director of Maintenance stated they observed the rusted air vent and the peeling wallpaper and chipped floor. The Director of Maintenance stated they had not done environmental rounds since they took the position at the facility two months ago. On 5/05/2023 at 09:37 AM, an interview was conducted with Licensed Practical Nurse (LPN) #7 on the Boscobel Unit. They stated there were many areas of chipped paint and peeling wallpaper in the hallways. They stated the company which took over in July said they were going to do renovations, but they have not seen any renovations yet. On 5/05/2023 at 10:45 AM, a follow-up interview was conducted with the Director of Maintenance in the first floor lobby. The Director of Maintenance stated they were aware of chipped and peeling paint and wallpaper but have not had the time to address these issues. The Director of Maintenance stated it was not appropriate to have chipped or peeling paint and peeling wallpaper in resident areas. 415.5(h)(2) 43478 45478

Based on observation, interview, and record review conducted during a recertification survey, the facility did not ensure that the resident and/or their representative were provided a written summary of the Baseline Care Plan of the initial plan for delivery of care and services by receiving a written summary of the Baseline Care Plan within 48 hours of admission. This was evident for 1 of 26 sampled residents. Specifically, Resident #78 or their representative did not receive a written copy of their Baseline Care Plan within 48 hours. The findings are: A review of the facility policy and procedure signed and dated 2/10/23 titled, Interdisciplinary Care Planning documented that the facility would develop a Baseline Care Plan within 48 hours of resident admission. The facility would provide the resident and/or representative with a summary of the Baseline Care Plan. The electronic Baseline Care Plan acknowledgement was completed by an interdisciplinary team member which would identify who received the Baseline Care Plan and date and time of receipt. Resident #78 was admitted to the facility on [DATE] with diagnoses including compression fracture of T11-T12 vertebra, fracture of the first lumbar vertebra, and dementia. The Entry Minimum Data Set (MDS a resident assessment tool) dated 4/27/23 documented entry, start date of acute Medicare stay 4/27/23, admission to the facility from the hospital. On 05/01/23 at 10:19 AM, during an interview with the resident's spouse, they stated the resident was admitted on [DATE] and they did not receive a Baseline Care Plan. A review of the undated Baseline Care Plan documented in the Resident Dashboard documented Physician's Orders, Activities of Daily Living, Rehab, Skin, Pain Management, Urinary Incontinence, and Urinary Tract Infection. A Baseline Care Plan Acknowledgment form dated 5/01/23 signed by the Director of Social Work documented that a copy of the Baseline Care Plan was given to the resident's spouse/daughter on 5/01/23 at 11:00 AM, and Social Work reviewed the Baseline Care Plan and goals. On 5/03/23 at 9:00 AM, during an interview with the Director of Social Work (DSW), they stated the resident's spouse and daughter received the resident's Baseline Care Plan on Monday, 5/01/23. The DSW stated they realize the resident's family should have received the resident's Baseline Care Plan within 48 hours of admission, on 4/29/23, but since that was a Saturday, it was not provided to the resident's representative until the following Monday. On 5/04/23 at 8:40 AM, during an interview with the Director of Nursing (DON), they stated that residents who were admitted on Thursdays did not receive Baseline Care Plans until the following Monday. They stated staff was not trained or allocated to give residents or their representatives their Baseline Care Plan on the weekends. They stated that even though Baseline Care Plans were generated by Point Click Care (electronic medical software program) from the Nursing Evaluations and Physician's Orders which were completed during the admissions process, Baseline Care Plans were not given to residents or their representatives on the weekends. On 5/8/23 at 12;50 PM, during an interview with the Administrator, they stated that it was their goal to provide residents and/or their representatives with a Baseline Care Plan within 48 hours of admission. They stated the Medical Director came in every weekend, and the Nursing Supervisor could provide Baseline Care Plans to residents and/or family members. 415.11 (c)

Based on observations, interviews, and record review conducted during the recertification survey from 5/1/2023 to 5/8/2023, the facility failed to ensure each resident's right to personal privacy for 1 of 4 residents (Resident #70) reviewed for dignity, and 1 of 3 nursing units ([NAME] Grove) reviewed for confidentiality of resident records. Specifically, 1) Resident #70 was not provided privacy during an ultrasound procedure and, 2)A unit roster with confidential medical record information for multiple residents was discovered visible and unattended in a public area on the [NAME] Grove unit. The findings are: 1. Resident #70 was admitted to the facility with diagnoses including dementia, chronic kidney disease, and hypertension. A review of Resident #70's 2/14/2023 Quarterly Minimum Data Set (MDS, a resident assessment tool) documented the resident had severe cognitive impairment, required extensive assistance of two or more staff for bed mobility, and was totally dependent on one person for performing their personal hygiene. During an observation on 5/1/2023 at 12:24PM, Resident #70 was having an ultrasound procedure in their bed. This was viewed from the public hallway outside of their room and no privacy was provided during the procedure. During an interview on 5/1/2023 at 12:44 PM, the ultrasound technician stated they forgot to pull the curtain because the room felt warm and they should have provided Resident #70 privacy during their procedure. During an interview on 5/5/2023 at 9:38 AM, Registered Nurse Unit Manager (RNUM) #1 stated all facility staff and all contract/agency staff were responsible for providing residents with privacy during patient care and during medical procedures. RNUM #1 stated the ultrasound technician should have pulled the curtain for the procedure. During an interview on 5/5/2023 at 12:31 PM, the Administrator stated it was not acceptable for Resident #70 to have an ultrasound without being provided privacy for the procedure. 2. During an observation on 5/3/2023 at 9:38 AM, a roster containing confidential medical record information was on top of a medication cart in a public hallway in front of the [NAME] Grove nurses station, unattended by any staff. The roster contained the full name, room number, and confidential medical record information including vital signs and medication administration information of 20 residents on the [NAME] Grove unit. During an interview on 05/03/2023 at 09:35 AM, Registered Nurse Unit Manager (RNUM) #2 stated staff should not have left the roster, containing residents' confidential information, on the medication cart in the hallway unprotected. During an interview on 05/05/2023 at 12:31 PM, the Administrator stated that leaving protected resident health information in a public place was not acceptable. S483.10(h)

Based on observations, record reviews and interviews during a Recertification Survey conducted from 5/1/2023-5/08/2023, the facility did not ensure 9 of 9 residents were treated in a dignified manner while dining (Residents #51, #106, #46, #20, #5, #79, #63, #37 and #72). Specifically, a Licensed Practical Nurse (LPN) was observed standing over Resident #51 while feeding the resident; four staff members (Certified Nurse Aides (CNA) #5, #3, #6 and Activity Aide #1) were observed pointing to Residents #46 and #106 and referred to them as feeders; Resident #37 was served a meal 8 minutes after their tablemate was served; and staff spoke to Resident #72 in an undignified manner during a meal. Findings include: 1) During an observation on 5/8/2023 at 8:53 AM, LPN #5 was observed standing over Resident #51 in the community dining room while feeding the resident oatmeal. During an interview on 5/8/2023 at 8:53 AM, LPN #5 stated they did not know staff were not supposed to stand up while feeding residents. 2) During an observation on 5/3/2023 at 11:45 AM, Activity Aide #1 verbalized to CNA #6 that the feeders needed to be at a particular table and pointed to Residents #46 and #106. CNAs #3, #5, and #6 were observed having a conversation in the dining area and used the word feeders to describe Residents #46 and #106. During an interview on 5/3/2023 at 12:06 PM, Activity Aide #1 stated they were not aware they could not use the word feeder to describe residents. During an interview on 5/3/2023 at 12:06 PM, CNA #6 stated they did not know it was not proper to use the word feeder. During a combined interview on 5/3/2023 at 2:47 PM, CNAs #5 and #3 stated they received instructions to call residents by their name using Mr. and Mrs. were unaware that they could not refer to residents as feeders. During an interview on 05/08/2023 at 02:59 PM, the Director of Nursing (DON) stated resident rights were reviewed constantly. The DON stated the nurse in the dining area was expected to know not to stand while feeding a resident. The DON also stated during orientation, staff were instructed to address residents by their proper name and knew not to use the term feeder. 3) During an observation on 5/3/2023 at 11:46 AM, Residents #63 and #37 were seated together for the noon meal. Resident #63 was eating at 11:46 AM while Resident #37 waited until 11:54 AM to be served. During an interview on 5/5/2023 at 8:55 AM, the Food Service Director (FSD) stated the current system had trays arranged for all the residents as eating in their rooms. The FSD stated it was confusing for the staff when residents ate in the dining room and did not sit at the same table every day. During an interview on 5/8/2023 at 11:21 AM, the Director of Nursing (DON) stated they were aware of the meal service issues and were working on a way to streamline meal service. 4) During an observation on 5/01/2023 at 12:36 PM, LPN #8 stated to Resident #72 we aren't going to spend 2 hours eating. During an interview on 5/8/2023 at 9:30 AM, LPN #8 stated Resident #72 often took too long to eat. 483.10 45478