Every finding on record at The Brook at High Falls Nursing Home and Rehabilit

Based on observations, interviews, and record review, the facility did not ensure it established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for seven (7) of nine (9) residents (Residents #1, #2, #12, #18, #21, #25, and #33) and one (1) of one (1) residential unit reviewed. Specifically, staff were observed performing wound care for Resident #1 and touching environmental surfaces without appropriate glove changes and hand hygiene. For Residents #2, #18, #21, #25, and #33 medications were prepared and handled by a licensed nurse with their bare hands. For Residents #2, #12, #18, #21, #25, and #33 a reusable blood pressure monitoring device was not cleaned and disinfected between residents; Resident #33 was on enhanced barrier precautions (an infection control strategy that uses gloves and gowns during high contact resident care to reduce the spread of infection). Additionally, there were multiple resident rooms observed without hand hygiene supplies readily available and soiled linen bin were observed uncovered on multiple occasions. The findings include: The facility policy Handwashing/Hand Hygiene dated August 2019 included hand hygiene products and supplies, including soap and alcohol-based hand rub, shall be readily accessible and convenient for staff use. Hand hygiene should be performed before and after direct contact with residents' blood or bodily fluids and after removal of gloves. Wearing artificial fingernails was strongly discouraged among staff members with direct resident-care responsibilities. The facility policy Administering and Storage of Medications dated 12/13/2025 included staff should follow facility infection control procedures, including handwashing, antiseptic techniques, and glove use. The facility policy Cleaning and Disinfection of Resident-Care Items and Equipment dated July 2014 included reusable resident care equipment would be decontaminated between residents. Issue #1:During an observation on 01/12/2026 at 9:26 AM, there was no soap dispenser located in the bathroom of room [ROOM NUMBER].here was no soap dispenser located in the bathroom of room [ROOM NUMBER]. During an observation on 01/13/2026 at 8:32 AM, there was no soap dispenser located in the bathroom of room [ROOM NUMBER]. During intermittent observations on 01/12/2026 and 01/13/2026 from 7:30 AM to 3:30 PM, there were no alcohol-based hand sanitizer dispensers available on the unit. During an interview on 01/14/2026 at 7:20 AM, Certified Nursing Assistant #3 stated they carry hand sanitizer in their pocket because hand sanitizer was not readily available, and not all rooms had soap dispensers. During an interview on 01/14/2026 at 7:22 AM, Certified Nursing Assistant #4 stated they carry hand sanitizer in their pocket, use the sanitizer on the medication cart, or use a bathroom with a soap dispenser to wash their hands. During an interview on 01/16/2026 at 8:42 AM, the Infection Preventionist stated staff should not keep hand sanitizer in their pockets due to the risk of cross contamination. Issue #2:During an observation on 01/14/2026 at 8:45 AM, Licensed Practical Nurse #1 prepared medications for Resident #25. Licensed Practical Nurse #1 opened a stock (medications used for more than one resident) bottle of Vitamin D, poured tablets into the palm of their bare hand, dropped two tablets into a medication cup, and poured the remaining tablets back into the bottle. Licensed Practical Nurse #1 then removed tablets from blister packs of oxybutynin, losartan, and fluoxetine by pushing the tablets through the packaging and pulling them out with their fingernails before placing them into the medication cup. Licensed Practical Nurse #1 placed a hand-held electronic blood pressure device in the resident's bed to obtain a blood pressure reading. The device was returned to the medication cart without cleaning. Licensed Practical Nurse #1 then handled the medications in the cup with their fingernails, removed the losartan, and administered the remaining medications. During an observation on 01/14/2026 at 9:01 AM, Licensed Practical Nurse #1 prepared medications for Resident #2 by pouring medications into their bare hand, returning unused tablets to stock bottles, removing blister-pack medications with fingernails, and using the same hand-held blood pressure device without cleaning it between residents or before returning it to the medication cart. During an observation on 01/14/2026 at 9:18 AM, Licensed Practical Nurse #1 used the same hand-held electronic blood pressure device to obtain vital signs for Resident #12 while the resident was in a wheelchair in the hallway. The device was returned to the medication cart without cleaning. During an observation on 01/14/2026 at 9:50 AM, Licensed Practical Nurse #1 prepared medications for Resident #33 using the same practices. The hand-held blood pressure device was placed in the resident's bed and returned to the medication cart without cleaning. Resident #33 was on enhanced barrier precautions. During an observation on 01/14/2026 at 10:19 AM, Licensed Practical Nurse #1 used the same hand-held electronic blood pressure device for Resident #18 and returned it to the medication cart without cleaning. During an interview and observation on 01/14/2026 at 10:28 AM, Licensed Practical Nurse #1 stated the facility did not have a mobile vital sign machine and they were using personal vital sign equipment. Licensed Practical Nurse #1 stated the blood pressure cuff and machine were not cleaned between residents. Licensed Practical Nurse #1 stated handling medications with their hands was how they usually prepared medications, and they sanitized their hands between residents. When observed at that time, Licensed Practical Nurse #1's fingernails were approximately two (2) inches in length with visible dark debris underneath. During an interview on 01/16/2026 at 8:42 AM the Infection Preventionist stated medications should be popped directly into a medication cup or poured from a bottle lid into the cup. The Infection Preventionist stated staff should not touch pills with bare hands or fingernails, returning pills from hands to stock bottles could contaminate the entire bottle, long fingernails can harbor germs, and vital sign equipment should be cleaned between each resident regardless of precautions. Issue #3:During an observation on 01/14/2026 at 8:20 AM, the Director of Nursing, while wearing gloves, sprayed wound cleanser onto adhered dressings on Resident #1's right heel and right ankle and removed both dressings using the same pair of gloves. The Director of Nursing removed gloves and exited the room to gather supplies. Upon return, the Director of Nursing wore gloves and cleansed both wounds using the same pair of gloves. The Director of Nursing changed gloves and applied betadine to the right heel, then applied Medi-honey (a wound care treatment) to a dressing base by touching the inside of the dressing with a gloved hand and applied dressings to both wounds. Without changing gloves or performing hand hygiene, the Director of Nursing pulled up the resident's blankets, touched items on the over-bed table, opened window blinds, touched the door handle when exiting the room, and placed resident-care supplies on the treatment cart. During an interview on 01/16/2026 at 8:42 AM the Infection Preventionist stated touching environmental surfaces with gloves used for wound care increases the risk of cross contamination. Issue #4:During observations on 01/12/2026 at 9:47 AM and 12:48 PM, 1/13/2026 at 11:48 AM, and 01/16/2026 at 8:01 AM and 9:47 AM, the dirty linen bins located in the hallway across from room [ROOM NUMBER] were uncovered and contained soiled linens. During an interview on 01/16/2026 at 8:42 AM, the Infection Preventionist stated dirty linen bin lids should remain closed to control odors and germs and stated they are constantly closing the lids. 10 NYCRR 415.19

Based on interview and record review, the facility did not ensure residents exercised their rights without interference, coercion, discrimination, or reprisal from the facility for one (1) of five (5) residents reviewed (Resident #4). Specifically, the facility did not ensure changes in Resident #4's Medicare health coverage were initiated by the resident or the resident's authorized representative, and did not ensure the resident and/or responsible party received required oral and written explanations regarding the impact of changing Medicare coverage.The findings include: The Centers for Medicare and Medicaid Services (CMS) undated publication Your Rights and Protections as a Nursing Home Resident requires nursing homes to inform residents of their rights and explain those rights orally and in writing in a language the resident understands. The Centers for Medicare and Medicaid Services Memo to Long Term Care Facilities on Medicare Health Plan Enrollment, dated October 2021, states only a Medicare beneficiary, the beneficiary's authorized or designated representative, or a party authorized to act on behalf of the beneficiary under state law may request enrollment in or voluntary disenrollment from a Medicare health or drug plan. Changes in Medicare health coverage generally must be initiated by the beneficiary or the beneficiary's representative. Facilities must explain orally and in writing the impact to the beneficiary if coverage is changed. At a minimum, explanations must include:-A clear explanation, where applicable, the beneficiary would no longer be a member of the Medicare health plan;-An explanation medical services would be billed to Original Medicare and/or Medicaid, including deductibles, co-payments, and coinsurance obligations, and the absence of supplemental coverage;-The name of the prescription drug plan covering medications, including deductibles and co-payments/coinsurance, particularly related to the resident's current drug therapy; and-Information regarding opportunities to change Medicare health plans and prescription drug coverage while residing in the facility and following discharge. The facility policy Resident Health Care Coverage Changes and Disenrollment from Health Maintenance Organizations (HMOs), reviewed 08/20/2025, states the facility shall not require, coerce, or improperly influence a resident to enroll in, disenroll from, or change any health care coverage plan. The policy requires coverage changes be resident-initiated or legally authorized, fully informed, documented, and compliant with federal and state regulations. The policy further states residents have the right to choose, retain, or change health care coverage without interference and must receive clear, unbiased information regarding available options. The policy specifies the facility may not initiate coverage changes unless the resident or legally authorized representative provides explicit written consent, and any facility assistance must be strictly administrative. The policy prohibits recommending disenrollment for facility convenience, misrepresenting coverage limitations, or applying pressure, and requires documentation of the resident or representative request, education provided regarding potential impacts, written consent when applicable, and actions taken by facility staff. Resident #4 had diagnoses including cerebral infarction (stroke) with hemiparesis (one sided muscle weakness), diabetes mellitus, and chronic kidney disease. The Minimum Date Set (a resident assessment tool), dated 11/24/2025, documented the resident had moderate cognitive impairment and did not have a Medicare-covered stay since the most recent entry. Addendum VII, Authorization for Legal Representantion (sic) for Medicare Part D, dated 11/13/2025, documented the sister facility Business Office Manager recorded verbal authorization over the phone from Resident #4's responsible party at 1:40 PM for the facility Administrator to act as a limited legal representative for Medicare Part D. The authorization applied only to Medicare Part D, was valid only during the resident's stay at the facility, and included enrollment and plan changes, insurance transactions, and claims and litigation. During a telephone interview on 01/15/2026 at 9:55 AM, Resident #4's responsible party stated they received a telephone call from facility staff on 11/13/2025 indicating it was important to allow the facility to change Resident #4's insurance coverage because more services would be covered. The responsible party stated they were not advised of deductibles, co-payments, or reenrollment rights and did not receive written information regarding the impact of the coverage change. During a telephone interview on 01/15/2026 at 10:16 AM, Business Office Manager #2 (from a sister facility) stated Resident #4 was initially admitted to their facility and later transferred. The Business Office Manager stated they contacted Resident #4's responsible party on 11/13/2025 to discuss changing insurance coverage to Original Medicare, stating Managed Medicare Plans typically cover skilled services for 10-14 days, while Original Medicare provides additional benefit days. The Business Office Manager stated the facility does not want the payor source to change to Medicaid because Medicaid is a lower reimbursement source. The Business Office Manager further stated residents admitted with Managed Medicare Plans are approached to explain the disenrollment process to allow residents to receive additional coverage days. During an interview on 01/15/2026 at 11:34 AM, Business Office Manager #1 stated the facility approaches all residents and/or responsible parties enrolled in Managed Medicare Plans to discuss disenrollment from their current health coverage. The Business Office Manager stated Original Medicare is explained as offering 100 benefit days without the constraints of Managed Medicare Plans. The Business Office Manager confirmed written information regarding the impact of coverage changes is not provided to residents or responsible parties. During an interview on 01/15/2026 at 12:02 PM, the Administrator stated when the facility becomes aware a resident may require a longer stay than their insurance will cover, the facility offers residents and/or responsible parties the option to disenroll from their current insurance coverage and enroll in Original Medicare. During a follow-up interview on 01/16/2026 at 12:07 PM, the Administrator stated the facility informs residents and/or responsible parties their current insurance coverage is ending and makes them aware of another option. 10 NYCRR 415.3(d)(1)(i)

Based on observation and interview, the facility did not ensure housekeeping and maintenance services were provided to maintain a sanitary, orderly, and comfortable interior for one (1) of one (1) resident use floor and one (1) of one (1) kitchen. Specifically, the facility did not ensure interior spaces were maintained free from unsanitary conditions and environmental hazards, as evidenced by damaged, jagged, or missing radiator covers; a dirty bathtub with a non-functioning lift chair; wall damage; a non-functional fan used for air drying dishes; cracked light lenses and missing end caps above the kitchen tray line; a damaged ice machine lid with exposed ice; and dirty floors and surfaces in resident rooms.The findings include: During observations in the main kitchen on 01/12/2026 from 8:50 AM to 9:05 AM, a wall-mounted fan in the dish room was not functional. Multiple racks of dishes recently cleaned in the dishwashing machine were stored nearby. During an immediate interview, the Head [NAME] stated they were not sure what happened, and the fan had not worked for approximately one month. Additionally, a large section of blue wallpaper behind the gas range was peeling, and multiple areas of brown splattered material were observed on the wall. During an observation on 01/12/2026 at 9:11 AM, the reach-in bin-style ice-making machine located in the employee break room did not have a cover, leaving an approximately two (2)-foot by one (1)-foot opening exposing ice within the bin. The broken cover was lying on top of the bin. The back interior of the ice machine near the drip tray had dark residue appearing to be mildew. During an observation on 01/12/2026 at 9:29 AM, the base of the radiator cover near the floor in the hallway outside Resident room [ROOM NUMBER] was jagged and sharp. During an observation on 01/12/2026 at 9:42 AM, a floor-level radiator was missing an approximately four (4)-foot-long section of cover, exposing metal radiator fins. During an observation on 01/12/2026 at 9:55 AM, the floor in Resident room [ROOM NUMBER] had multiple areas of dirty dried debris. The walls and light switch also had areas of brown dried debris. Observation on 01/12/2026 at 10:24 AM revealed the floor in Resident room [ROOM NUMBER] had multiple areas of dirty dried debris. During an observation on 01/12/2026 at 11:39 AM, the baseboard of the heater in Resident room [ROOM NUMBER]'s bathroom was separated from the wall, with the cover not fully in place. There was no garbage can present in the bathroom. During an observation on 01/12/2026 at 3:17 PM, the floor-level radiator behind the door-side bed in Resident room [ROOM NUMBER] was missing a cover, exposing multiple damaged metal radiator fins.During an observation on 01/13/2026 at 12:55 PM, 10 fluorescent tube light bulbs directly above the main tray line and throughout the kitchen had plastic sleeves that were partially cracked and missing end caps. During an observation on 01/14/2026 at 8:49 AM, there was dried debris, hair, and residue at the bottom of the bathtub in the shower room. The lift chair for the tub did not function when tested by the Director of Maintenance. The bathtub was one (1) of two (2) bathing fixtures available throughout the facility. During an immediate interview, the Director of Maintenance stated the tub should be usable, but they were not aware of any residents currently using it. 10 NYCRR: 415.29, 415.29(b), 415.29(i)(1), 415.29(j)(1),10 NYCRR: Subpart 14-1, 14-1.171, 14-1.188(c)

Based on observation, interview, and record review, the facility did not ensure the resident environment remained free of accident hazards for one (1) of one (1) resident use floor. Specifically, hot water exceeding 120 degrees Fahrenheit ( F) was accessible to residents at point of use, creating a risk for scalding.The findings include: The undated facility policy Water Temperatures, Safety of included tap water in the facility shall be maintained within a temperature range to prevent scalding of residents. The policy specified water heaters servicing resident rooms, bathrooms, common areas, and tub/shower areas shall be set to maintain temperatures between 90 and 120 degrees Fahrenheit. On 01/12/2026 at 9:20 AM, the surveyor's [NAME] brand thermocouple was checked for proper calibration in the main kitchen using the ice-point method and read 32.6 degrees Fahrenheit. During observation on 01/12/2026 from 9:35 AM to 9:56 AM, hot water temperatures from resident-accessible bathroom and shower room sinks exceeded 120 degrees Fahrenheit as follows: -room [ROOM NUMBER]: 124.0 degrees Fahrenheit-room [ROOM NUMBER]: 125.1 degrees Fahrenheit-room [ROOM NUMBER]: 122.8 degrees Fahrenheit-room [ROOM NUMBER]: 124.5 degrees Fahrenheit-Shower Room: 122.2 degrees Fahrenheit Record review on 01/13/2026 at 03:33 PM of the facility's hot water temperature logs revealed temperatures were documented approximately every three (3) to seven (7) days from 02/25/2025 through 12/18/2025. The next recorded temperature entry was dated 01/13/2026, indicating no documented monitoring between 12/18/2025 and 01/13/2026. During an immediate interview, the Director of Maintenance stated no hot water temperatures were taken during this period because maintenance staff were assigned to assist at an affiliated facility. 10 NYCRR: 415.12(h)(1), 415.29, 415.29(a), 415.29(f)(6)

Based on observations, interviews, and record review, the facility did not ensure medications were stored securely and accessible only to authorized personnel, in accordance with professional standards of practice and State and Federal regulations, for one (1) of one (1) residential unit reviewed. Specifically, the facility stored medications in an unsecured and frequently opened soiled linen room being used as a temporary medication room during renovations. Medications stored in this area were accessible to residents, visitors, and non-authorized staff. Additionally, there were unidentified, loose pills found in a medication cart and missing signatures identified on narcotic count sheets for various shifts with no additional evidence of accurate narcotic counts and/or accountability for controlled substances.The findings include: The facility policy Administering and Storage of Medications revised [DATE], included, but was not limited to, medications should be checked monthly in the medication cart and in the overflow room of stock medications for expiration dates. If expired, medications need to be sent back to pharmacy and replaced immediately. During an observation and interview on [DATE] at 11:46 AM, a medication cart (located near the lower room numbers) was found to contain two (2) loose pills lying unsecured in the bottom of the second drawer. The pills were not labeled and were not contained in individual packaging, preventing verification of medication integrity, dose, or intended recipient. When interviewed at that time, Licensed Practical Nurse #1 stated medication carts were checked by nursing staff during their shift and loose pills found in carts would be discarded in a sharps container (specialized, puncture-resistant, and leak-proof containers designed for the safe disposal of needles, syringes, and other medical sharps). During an observation and interview on [DATE] at 12:02 PM, there were multiple medications stored on the top shelf of a three (3)-tiered cart in the temporary medication room (labeled soiled linen room). The room door was unsecured and unlocked. Review of medications included an unopened bottle of Vitamin B with an expiration date of February 2024. When interviewed at that time, Licensed Practical Nurse #1 stated the Nurse Manager usually checks the medication room, the medication must be taken to the Director of Nursing for the discard process and acknowledged it may have been missed during prior checks. During an observation on [DATE] at 12:17 PM, 14 missing signatures were identified on narcotic count sheets during shift changes for various shifts between [DATE] and [DATE]. The facility was unable to provide verification of accurate narcotic counts and accountability for controlled substances on those shifts. When interviewed at that time, Licensed Practical Nurse #1 stated they were not aware why the signatures were missing and suggested staff working double shifts may forget to re-sign. Staffing schedules and time punches were reviewed for this timeframe and did not support double shifts as the cause of the missing signatures. During an interview on [DATE] at 10:35 AM, the Director of Nursing stated nurses on shift were primarily responsible for the medication carts they worked on, and the Director of Nursing checked carts weekly as part of auditing. The Director of Nursing stated the facility was undergoing renovations and awaiting approval from the Drug Enforcement Administration to relocate the medication cabinet. The Director of Nursing stated they were responsible for maintaining medication storage and securing medications in the storage room. The Director of Nursing stated loose pills were discarded in a sharps containers and expired or discontinued medications were returned to the pharmacy. The Director of Nursing stated medications should be locked and medication room doors should remain closed and locked. During an observation on [DATE] from 9:40 AM to 10:00 AM, the medication room door was open and unlocked while staff passed by performing routine tasks without securing the room. 10 NYCRR 415.18(e)(1-4)

Based on observations and interviews conducted during a Recertification Survey completed 11/07/2024 to 11/14/2024, the facility did not provide maintenance services necessary to maintain a sanitary, orderly, and comfortable homelike environment. Specifically, kitchen lighting was not protected or operable, a residential kitchen freezer and a staff bathroom were inoperable, bathrooms exhaust ventilation was not installed or was inoperable, there was no soap in resident bathrooms, a call bell was not installed in a resident bathroom, and a corridor exit sign was not affixed to the ceiling. The findings are: Observations on 11/07/24 from 9:05 AM to 11:08 AM included the following: 1. A Frigidaire residential stand-up freezer by the back kitchen entrance was empty and not operational. During an interview at this time, the cook stated that it did not work and had been out of order for a while. 2. Two glass fluorescent light fixtures above the cook line in the main kitchen were uncovered and unprotected from shattering. Another similar light fixture near the back kitchen door had no bulbs or cover. During an interview at this time, the Kitchen Manager stated the fixture did not work. 3. A staff bathroom outside the Director of Nursing office was inoperable with the water shut off. During an interview at this time, the Director of Maintenance stated they did not have time to fix it; the residents come first. 4. The Dirty Utility room hand wash sink had a sign across the basin marked: Do not use. During an interview at this time, the Director of Maintenance stated someone hit the drainpipe with the mop bucket so it leaks, and that they had not had time to fix it. 5. The exhaust ventilation in the housekeeping closet next to the kitchen was not pulling any air when tested with a paper towel. 6. There was a foul odor in the staff restroom across from the kitchen door and the ceiling exhaust grate was not pulling any air when tested with a paper towel. During an interview on 11/07/2024 at 12:27 PM, Anonymous Staff Member #1 stated they needed soap dispensers in all the resident rooms and when they finish care, they cannot wash their hands after taking off their gloves. Observations on 11/07/2024 beginning at 1:05 PM included a bathroom in resident room [ROOM NUMBER] with no exhaust ventilation. The exhaust vent was closed in the bathroom of resident room [ROOM NUMBER], and the exhaust vents in the bathrooms in resident rooms #9 and #22 were inoperable when tested with a piece of paper. Observations on 11/07/2024 beginning at 1:29 PM included resident rooms #1, 3, 5, 6, 7, 8, 9, 10, 11, 12, 21, 22 and 23 lacked soap or hand sanitizer for residents and staff to wash their hands in the rooms or bathrooms. During an interview on 11/08/2024 at 10:28 AM, the Administrator stated they were aware (of the missing ventilation in resident room [ROOM NUMBER]) and that the construction workers were not done. Observations on 11/12/2024 from 8:42 AM to 8:45 AM included the bathrooms in rooms #9, 15, and 16 did not have soap or hand sanitizer for residents and staff to wash their hands. Observations on 11/12/2024 beginning at 8:53 AM included a bathroom in resident room [ROOM NUMBER] had no exhaust ventilation. Observations on 11/12/2024 at 8:57 AM included there was no nurse call button in resident room [ROOM NUMBER]. During an interview on 11/12/2024 at 12:57 PM, Certified Nursing Assistant #2 stated there was no soap or hand sanitizer in the resident rooms and they must go to a staff bathroom or shower room to wash their hands. During an interview on 11/12/2024 at 2:20 PM, the Director of Maintenance stated a service vendor was in the building fixing the air handler, and a belt had come off, causing the vents to not work earlier in the day. During an interview on 11/13/2024 at 9:22 AM, the Director of Maintenance stated they checked the ventilation in the rooms that had newly constructed bathrooms and noticed resident room [ROOM NUMBER] did not have a vent installed. The Director of Maintenance stated a senior maintenance person had showed them what to look for with the ventilation back in August, but they do not check the ventilation on a regular basis. During an interview on 11/13/2024 at 9:43 AM, the Administrator stated the renovations will be hopefully be done by the end of the year. Observations on 11/13/2024 at 12:09 PM included an exit sign in the corridor between rooms #11 and #12 that was not affixed to the ceiling and was hanging by the electrical cord. During an interview on 11/14/2024 at 10:18 AM, the Kitchen Manager stated the inoperable freezer needs to be replaced and they had tried to get it fixed, but by the next morning it was not working again. During an interview on 11/14/2024 at 10:33 AM, Director of Nursing #2 stated they were aware of the resident bathrooms not having soap dispensers and were concerned about the limited amount of hand sanitization areas and the staff's ability to wash their hands in the resident's room. 10 NYCRR: 415.29, 415.29(b), 415.29(d), 415.29(h)(1), 415.29(j)(1), 415.14(h), 10 NYCRR: Subpart 14-1.88(c), 14-1.174

Based on observations, interviews, and record review conducted during a Recertification Survey from 11/07/2024 to 11/14/2024, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of infection. Specifically, for one of one dining room reviewed during a meal, a staff member was observed making direct contact with a resident's food without applying gloves and did not perform hand hygiene after touching used meal trays and utensils prior to touching unused meal trays and meal set-up for multiple residents. For one of one laundry room, a laundry staff was observed handling soiled potentially contaminated linen without wearing appropriate personal protective equipment that included gowns. Additionally, the facility did not ensure the Infection Prevention and Control Program policies and procedures were reviewed at least annually as required. This is evidenced by the following: 1. The facility's Handwashing and Hand Hygiene policy, revised August 2019, documented that hand hygiene was considered the primary means to prevent the spread of infection. Use of an alcohol-based hand rub containing at least 62% alcohol or soap and water should be used before and after eating and handling food, and before and after assisting a resident with meals. During an observation on 11/12/2024 at 1:11 PM, Certified Nursing Assistant #2 picked up a resident's bread and applied butter with their bare hands. Certified Nursing Assistant #2 then touched used meal trays and equipment and, without performing hand hygiene, passed unused trays to other residents touching equipment. During an interview at this time, Certified Nursing Assistant #2 stated they should wear gloves when directly touching the resident's food, but did not have gloves readily available in their pocket. During an interview on 11/12/2024 at 1:31 PM, Director of Nursing #2 stated staff should never directly touch food with their bare hands. The Director of Nursing also stated staff should wear gloves to help meal set-up, and handwashing or hand sanitizing should be done in between helping residents. 2. The facility policy titled Infection Prevention and Control Program, last revised in August 2016, did not include the requirements for laundry staff when handling, storing, processing, and transporting linens and laundry, including soiled linens. During an observation on 11/12/2024 at 11:28 AM, Laundry Attendant #1 placed soiled linen in the washer wearing gloves but no gown. Laundry Attendant #1 stated they did not use gowns and were not sure where gowns were kept. Laundry Attendant #1 also stated if linen was in a red biohazard bag, which were used to collect contaminated laundry, they would wash the items separately, but only wore gloves to handle the laundry. During an interview on 11/14/2024 at 9:49 AM, Laundry Attendant #1 stated they had not been educated by the facility to wear a gown. During an interview on 11/14/2024 at 10:10 AM, the Infection Preventionist stated they did not know the process at the facility for washing soiled clothing and linens, but laundry staff should be wearing protective gowns when handling soiled linens. The Infection Preventionist also stated they did not know the laundry room did not have gowns to use. During an interview on 11/14/2024 at 10:15 AM, Director of Nursing #2 stated they would expect laundry staff to wear protective gowns when handling soiled linen and did not know laundry staff did not have access to gowns. 3. Review of 15 various Infection Prevention and Control Program facility policies revealed all policies were last reviewed and/or revised in 2008, 2016, and 2022. The policy titled Infection Prevention and Control Program was last revised August 2016 and the Enhanced Barrier Precautions policy was undated. During an interview on 11/14/2024 at 12:44 PM, the Director of Nursing stated they did not know how often the infection control policies were reviewed or updated, but they did not consider polices revised in 2008, 2016, and 2022 as annually (per the regulations). During an interview on 11/14/2024 at 1:39 PM, the Regional Director of Nursing stated the Infection Prevention and Control Polices provided were the most current, revised, and up-to-date polices they had. 10 NYCRR 415.19(b)(4) & 415.19(c)

Based on interviews and record review conducted during a Recertification Survey from 11/07/2024 to 11/14/2024, for one (Resident #3) of twelve residents reviewed for care planning, the facility did not ensure a comprehensive person-centered care plan meeting was held at least quarterly and that the resident and/or their representative had been invited to attend. Specifically, Resident #3 had been in the facility for approximately 22 months, and there was no evidence that the resident and/or their representative had been invited to any care plan meetings. This is evidenced by the following: The facility policy Care Plans-Comprehensive, revised December 2010, documented the facility's interdisciplinary team in coordination with the resident and their representative develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain, and the interdisciplinary team is responsible for the review and updating of care plans at least quarterly. The policy did not include if the resident and/or their representative would be invited to attend the care plan meetings. Resident #3 had diagnoses that included unintentional poisoning by unspecified drugs, diabetes, and chronic pain. The Minimum Data Set Resident Assessment, dated 09/01/2024, documented the resident was cognitively intact. During an interview on 11/08/2024 at 10:23 AM, Resident #3 stated since their admission (approximately 22 months ago), they had never been invited to a care plan meeting and they did have questions pertaining to their care. The resident stated they had requested a meeting with a member of the interdisciplinary team (specific name or department unknown) previously, but had not heard anything back. The resident stated they felt a meeting would be important. Review of all nursing and social services interdisciplinary team progress notes since admission revealed no documentation that a care plan meeting had been held or if Resident #3 and/or their representative had been invited to any care plan meeting to review their care and get their input. During an interview on 11/13/2024 at 9:35 AM, the Director of Social Work stated care plan meetings should be held quarterly and they invited Resident #3 and their family to a meeting in April, but the family did not return their call and they did not follow up. The Director of Social Work stated the family was involved in the resident's care, and although the family had not returned their call, no additional care plan meeting invitations had been extended. Additioanlly, the Director of Social Work stated they started at the facility in February 2024, and during that time, the resident should have had a care plan meeting. The facility had been trying to develop a schedule for care plan meetings but there was no system currently in place. During an interview on 11/13/2024 at 1:41 PM, Resident #3 stated their family visited often and would want to be included in any care plan meetings. They also stated even if their family could not attend, they would still want to have a care plan meeting to discuss their money, pain management, and the food. During an interview on 11/13/2024 at 2:05 PM, Director of Nursing #2 stated they were new to the facility and were unaware that care plan meetings were not being held for all residents. They also stated care plan meetings should be held quarterly and with any significant changes, and families should be invited, with a progress note be entered after each meeting. 10 NYCRR 415.11(c)(2) (i-iii)

Based on observations, interviews, and record review conducted during the Recertification Survey from 11/07/2024 to 11/14/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for one (Resident #9) of one resident reviewed for activities of daily living. Specifically, Resident #9 was observed over several days with debris underneath their fingernails, including while eating with their hands. This is evidenced by the following: The undated facility policy Activities of Daily Living, Supporting Policy Statement documented residents will be provided with care, treatments, and services appropriate to maintain or improve their ability to carry out activities of daily living, including that refusals of care and treatments would be documented in the resident's clinical record. Resident #9 had diagnoses including chronic obstructive pulmonary disease (lung disease), arthritis, and dementia. The Minimum Data Set Resident Assessment, dated 08/15/2024, documented that Resident #9 was severely impaired of cognitive function, required substantial/maximal assistance with personal hygiene, had no behaviors, and no rejection of care at the time of the assessment. Review of the current Comprehensive Care Plan, revised 06/06/2024, and the current Kardex (care plan used by Certified Nursing Assistants for daily care) documented Resident #9 had an activities of daily living self-care performance deficit related to activity intolerance and fatigue. Interventions included, but not limited to, supervision and set-up assistance with personal hygiene, to check nail length, and trim and clean nails on bath days and as necessary. The care plans included that Resident #9 could be resistive to care and for staff to reassure, leave, and return in 5 to 10 minutes to try again. Physician's orders, dated 05/15/2024, included for the Licensed Nurse to perform a head to toe skin check with shower every Wednesday evening, to check finger/toenails for cleanliness and length, and to summarize findings in a progress note. Review of nursing progress notes from 10/16/2024 to 11/06/2024 revealed no documentation that Resident #9's fingernails had been checked for cleanliness and length, had been cleaned and trimmed, or that the resident had refused to have their nails cleaned or trimmed for the prior three weeks. During an observation on 11/07/2024 at 8:59 AM, Resident #9 had completed their breakfast. The resident had multiple dirty fingernails on both hands with a dark brown substance underneath. During an observation on 11/12/2024 at 8:28 AM, Resident #9 continued to have multiple dirty fingernails on both hands with a dark brown substance underneath. The resident was eating toast with their hands at the time. There was no soap dispenser or hand sanitizer available in the resident's room. During an observation on 11/13/2024 at 9:31 AM, Resident #9 continued to have multiple dirty fingernails on both hands with a dark brown substance underneath. During an interview on 11/14/2024 at 10:22 PM, Director of Nursing #2 stated the Certified Nursing Assistants should be cleaning their nails as needed with morning and evening care if they are dirty. During an interview on 11/14/2024 at 10:45 AM, Certified Nursing Assistant #1 stated that Resident #9's fingernails were cleaned on their shower day (Wednesday evenings) and in between during regular care. Certified Nursing Assistant #1 said the resident can be mean at times and give the staff a hard time, and that the resident is known to put their hands in their bowel movement and spread it around, and that would be the brown debris underneath their nails. During an interview on 11/14/2024 at 10:50 AM, Licensed Practical Nurse Manager #1 stated the Certified Nursing Assistants were responsible for cleaning residents' nails. During a record review at this time with the surveyor, Licensed Practical Nurse Manager #1 was unable to show any documentation in the electronic health record for the summary of findings for fingernail cleanliness and length. Review of Resident #9's electronic medical record for the prior 2 weeks did not include any documented evidence that the resident had refused nail care. 10 NYCRR 415.12(a)(3)

Based on observations, interviews, and record review conducted during the Recertification Survey from 11/07/2024 to 11/14/2024, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (Resident #178) of three residents reviewed for nutrition/hydration and one (Resident #178) of one resident for pressure injury. Specifically, the facility did not ensure the resident received the highest practical, physical, mental and psychosocial wellbeing, including maintaining adequate hydration status and ensuring interventions to promote pressure ulcer injury healing. This is evidenced by the following: Resident #178 was recently admitted with diagnoses that included a stroke and hemiparesis (weakness or the inability to move on one side of the body), a history of falls, and a compression fracture of the lower back. The Minimum Data Set Resident Assessment, dated 11/01/2024, documented the resident had moderately impaired cognition, clear speech, and was able to communicate their needs. The facility policy Pressure Injury Risk Assessment. revised March 2020, included that a resident's risk factors that increase a resident's susceptibility to pressure injury included, but were not limited to malnutrition, hydration deficits, impaired/decreased mobility, and the presence of existing pressure injury. In a document titled Calvado Care, dated 11/05/2024, Nurse Practitioner #1 documented that Resident #178 was at risk for malnutrition based on the resident's medical record and dietary assessment. Review of Resident #178's current Comprehensive Care Plan revealed the following: -Initiated on 11/02/2024, the resident required extensive assist of staff for bed mobility and, initiated on 11/04/2024, the resident required limited assist of staff for eating. -Initiated on 11/04/2026 and 11/06/2024, the resident was at risk for fluid deficit and malnutrition with a goal to be free of dehydration and to maintain weight. Interventions included to monitor intake and record every meal. -Initiated 11/01/2024 and 11/05/2024, the resident had a stage 3 (full thickness tissue loss) pressure injury to the coccyx (buttock) region related to immobility. Interventions included to turn and position every 2 hours while in bed, and to off-load from surface with use of pillows (relieve pressure from the coccyx pressure injury). Review of the Kardex (a care plan used by Certified Nursing Assistants to provide daily care) included that the resident needed 1 to 2 person assist with turning in bed, to turn and position every 2 hours while in bed, and to off load from surface with use of pillows. Additionally, if resident resists with activities of daily living, reassure resident, leave, and return 5 to 10 minutes later to try again. Review of Resident #178's Physician orders, dated 11/01/2024, revealed to turn and position every 2 hours while in bed, every 1 hour when in chair, and use pillows to off-load weight. On 11/04/2024, Glucerna (nutritional supplement) 237 millimeters with meals was ordered. During observations on 11/12/2024, Resident #178 was eating breakfast in bed and stated they had difficulty swallowing. The resident took a few bites of yogurt and a few sips of ginger ale and Glucerna. At 1:36 PM, the resident was eating lunch and stated the food was making them nauseated and they could not eat. During observations on 11/13/2024 at 8:52 AM, Resident #178 was eating breakfast in bed and only a few bites of food had been consumed. At 9:27 AM, the resident's tray with only a few bits consumed was removed. Review of the fluids consumed task documentation in the resident electronic medical record, dated 11/03/2024 to 11/13/2024, revealed out of 32 meal opportunities, 18 meals had no fluid intakes documented, including five days with no fluid intake recorded for the entire day. Review of the 'nourishment' (Glucerna) consumed for the same time period included 18 of 32 meal opportunities were not documented as having received any of the supplement. During an interview on 11/13/2024 at 8:54 AM, the Registered Dietician stated the documentation (resident's intakes) was sparce. In a progress note, dated 11/06/2024, the Wound Physician documented all wounds (including the pressure injury on the coccyx area) showed signs of healing. In a progress note, dated 11/11/2024 ,Director of Nursing #2 documented the stage 3 pressure injury on the resident's coccyx had changed appearance and had a black wound bed (signs of dead tissue). During observations on 11/12/2024 at 8:52 AM, 1:09 PM, and 3:04 PM, Resident #178 remained in bed on their back with no off-loading of the coccyx wound. During observations on 11/13/2024 at 8:52 AM, 9:46 AM, and 1:29 PM, Resident #178 remained in bed on their back with no off-loading of the coccyx wound. During an interview on 11/13/2024 at 9:46 AM, Resident #178 stated it had been a long time since anyone had turned (repositioned) them. In Resident #178's Treatment Administration Record, dated 11/01/2024 to 11/14/2024, several Licensed Practical Nurses had documented that Resident #178 was turned and repositioned every two hours while in bed during their shift (including 11/12/24 day shift). On 11/13/2024, the day shift was left blank. No refusals were documented. During an interview on 11/13/2024 at 3:25 PM, Certified Nursing Assistant #2 stated Resident #178 did not like to be on their side, or to be off-loaded (pillow placed under hips). Certified Nursing Assistant #2 said that the resident refused breakfast that morning and only had a few bites of lunch. Certified Nursing Assistant #2 stated they usually let the nurse know when Resident #178 refused any care and would then document this in the electronic medical record under tasks. During an interview on 11/13/2024 at 3:37 PM, Licensed Practical Nurse #1 stated Resident #178's coccyx wound looked worse possibly from not eating enough and not moving. During an interview on 11/13/2024 at 4:14 PM, License Practical Nurse Manager #1 stated Resident #178 was not eating and refused care, and the nurses and Certified Nursing Assistants should document all refusals. During an interview on 11/13/2024 at 10:18 AM, Director of Nursing #2 stated Resident #178's coccyx wound looks worse and now has eschar (dead tissue) that was not present last week. Director of Nursing #2 stated intakes should be documented after every meal, including refusals, and the nurses should be made aware of refusals. Additionally, they stated turning and positioning should be done and documented every 2 hours as ordered, and refusals brought to the nurse for further follow-up. 10 NYCRR 415.12

Based on observations, interviews, and record review conducted during the Recertification Survey from 11/07/2024 to 11/14/2024, for one (Resident #13) of four residents reviewed, the facility did not ensure that the resident's menus items containing dietary recommendations were followed. Specifically, Resident #13 did not receive multiple food items as listed on their tray ticket during mealtime and refused 100% of their meal without staff intervention to assist and encourage them. This is evidenced by the following: Resident #13 had diagnoses that included vascular dementia, depression, and anxiety. The Minimum Data Set Resident Assessment, dated 08/03/2024, documented the resident was severely impaired cognitively, did not exhibit behaviors or rejection of care at the time, and required supervision or touching assistance with eating. The current Comprehensive Care Plan, revised on 07/11/2024, and the current Kardex (care plan used by the Certified Nursing Assistants for daily care) documented Resident #13 had a potential nutritional problem and was at risk for malnutrition related to adult failure to thrive, depression, dementia, and a history of weight loss. The goal for the resident was to consume more than or equal to 51% of meals. Staff interventions included set-up help for eating, providing the resident's diet as ordered, providing fortified pudding three times daily, encouraging resident to drink fluids of choice, and encouraging the resident to eat in the dining room with their peers as accepted. During an observation on 11/12/2024 at 8:17 AM, Resident #13 was observed sitting in a chair in their room with breakfast in front of them. Their meal was untouched and their tray card (description of therapeutic diet items the resident should receive and/or their preferences) indicated the resident should have received four ounces of fortified pudding and two (approximately four ounces) mighty shakes (nutritional supplements). There was no fortified pudding on their tray and there was only one mighty shake. Resident #13 reached for the one mighty shake to drink more but the container was empty. During an observation and interview on 11/12/2024 at 8:35 AM, Certified Nurse Assistant #3 collected Resident #13's meal tray. The resident had had not eaten any of their meal other than the one mighty shake and had not been encouraged or offered assist by staff to eat. During an interview at this time, Certified Nurse Assistant #3 stated that if a resident's tray card had two mighty shake drinks indicated and fortified pudding, the resident should have what was ordered. Certified Nurse Assistant #3 stated they had not offered the resident the missing items. During an interview on 11/12/2024 at 8:41 AM, with the Registered Dietician and the Food Service Director, the Registered Dietician stated they had recently spoken with Resident #13 about their weight loss and asked if they could accommodate them with items of their preference, but the resident had not been interactive and offered no feedback. The Registered Dietician also stated they had not contacted the resident's family, and it was likely they were unaware the resident had experienced weight loss. Additionally, the resident's therapeutic diets (fortified foods and nutritional shakes) were their responsibility. The Food Service Director stated the kitchen staff were aware they had overlooked some of the residents who should have received fortified pudding, but they did not know which residents were missed. The Food Service Director also stated the kitchen staff were moving fast, and did not realize Resident #13 only received one mighty shake. During an interview on 11/12/2024 at 9:03 AM, Certified Nurse Assistant #3 stated they should have encouraged Resident #13 to eat when they saw they had not touched their meal, but the resident had wandered. During an interview on 11/12/2024 at 9:10 AM, Director of Nursing #2 stated if a resident was ordered to have fortified foods, they should receive what was ordered and if the resident had declined their entire meal tray, staff should encourage them. They also stated Certified Nursing Assistants should notify the nurse (if a resident did not eat everything). 415.14(c) (1-3)

Based on observations, interviews, and record review conducted during the Recertification Survey from 11/07/2024 to 11/14/2024, the facility did not ensure all resident rooms were equipped with privacy curtains which extended around the bed to provide total visual privacy in combination with adjacent walls and curtains for two (Residents #9 and #15) of two residents reviewed. Specifically, privacy curtains were not present in two semi-private rooms both occupied with two residents. This is evidenced by the following: 1. Resident #15 had diagnoses including congestive heart failure, depression, and diabetes. The Minimum Data Set Resident Assessment, dated 09/20/2024, documented the resident was moderately impaired of cognitive function. During observations on 11/08/2024 at 1:12 PM, 11/12/2024 at 8:27 AM, 11/13/2024 at 9:22 AM, and 11/14/2024 at 10:05 AM, Resident #15's, double occupancy room did not have a privacy curtain in place. During an interview on 11/08/2024 at 1:19 PM, Resident #15 stated there had not been a curtain since they had been in that room, they like their privacy, and having the curtain hung would help them to receive privacy as they do not want their roommate or others seeing them getting care or without their clothes on. During an interview on 11/13/2024 at 9:22 AM, Resident #15's (whose door was open) stated they really do not like their door open because everyone can see in and it was nobody's business (what they were doing). Resident #15 also stated they would prefer to have their door closed for privacy since the curtain has been down for a few weeks and were told it was being washed. 2. Resident #9 had diagnoses including depression, schizophrenia, and anxiety. The Minimum Data Set Resident Assessment, dated 08/15/2024, documented the resident was severely impaired of cognitive function. During observations on 11/08/2024 at 11:42 AM, 11/12/2024 at 8:28 AM, and 11/13/2024 at 9:31 AM, Resident #9's double occupancy room did not have privacy curtains in place while the resident was in their bed with their door open and the room visible from the hallway. During an interview on 11/12/2024 at 12:47 PM, Resident #9 stated the curtain was taken down to get washed, but they liked their privacy and would like the curtain back up. During an interview on 11/13/2024 at 9:34 AM, Certified Nursing Assistant #1 stated that privacy curtains were not hung in some bedrooms because the bedrooms were being refurbished. They also stated when they asked housekeeping to put the privacy curtains back up, housekeeping said they did not know where the curtain hooks were. Certified Nursing Assistant #1 pointed to a black garbage bag in an alcove by equipment and stated the curtains were right there. During an interview on 11/13/2024 at 9:50 AM, Licensed Practical Nurse Manager #1 stated that the privacy curtains were taken down to be washed about a week and a half ago and were unaware that they were sitting in the alcove. During an interview on 11/13/2024 at 1:58 PM, Director of Nursing #2 stated they had taken all privacy curtains down to have them all washed due to a family member complaining of a soiled one, they had asked maintenance to put the curtains back up, and had reached out to the Administrator and reminded them that no one had put the privacy curtains back up. 10 NYCRR 415.29

Based on observations, interviews, and record review conducted during the Recertification Survey from 11/07/2024 to 11/14/2024, the facility did ensure the nurse staffing information was posted on a daily basis. Specifically, the nurse staffing information was not posted at the beginning of each shift and was not posted on weekends per the regulations. This is evidenced by the following: During observations on 11/08/2024 at 9:02 AM, 9:58 AM, 11:38 AM, and 1:12 PM, the nurse staffing information sheet was dated 11/07/2024. During an interview on 11/08/2024 at 1:26 PM and on 11/14/2024 at 9:52 AM, Receptionist #1 stated they were responsible for completing and posting the nurse staffing sheets including the resident census and had been since 2022. Receptionist #1 stated they complete the staffing sheets for the weekend (Saturday and Sunday) on the following Monday morning by looking back to see who worked Saturday and Sunday. Receptionist #1 stated the nurse staffing sheet was posted late on 11/08/2024 because the facility was supposed to get a new admission that day and they wanted to wait to change the census, but the resident did not come into the facility. Receptionist #1 stated they were trained by the previous Receptionist (who was a Certified Nursing Assistant), not by nursing leadership or administration, and they were not aware of the process for the weekend staffing posting, and no one has checked to see if they were doing it correctly. During an interview on 11/14/2024 at 10:28 AM, Director of Nursing #2 stated they were not aware of the process for positing the nurse staffing information on the weekends as it was taken care of by the Receptionist. Director of Nursing #2 stated the nurse staffing should be posted at the beginning of the shift and updated with any changes throughout the day including Saturday and Sunday. 10 NYCRR 415.13

Based on observations and interview conducted during a Recertification Survey completed from 11/07/2024 to 11/14/2024, the facility did not safeguard resident medical record information against loss, destruction, or unauthorized use. Specifically, resident medical records were stored in damaged boxes and in a room that was unlocked. The findings are: Observations on 11/07/2024 at 11:50 AM included pallets of damaged boxes of records stored in the unlocked basement electrical room. Observations on 11/13/2024 at 10:55 AM included pallets of multiple damaged boxes of records (including, but not limited to, resident medical, billing, and discharge records) were stored in the basement electrical room. Additionally, the boxes were observed to be stacked two high and were falling over with many of the boxes in the pile badly damaged with files protruding. Some of the boxes were observed to have water damage and there was a pile of loose resident files stacked on other boxes. The door to this room was not locked. During an interview on 11/13/2024 at 11:08 AM, the Regional Director of Nursing was shown the area and the records, then verified that these were resident records and they should not be stored there. 10 NYCRR: 415.29, 415.22, 415.22(c)

Based on observations, interviews, and record review conducted during an Abbreviated Survey (complaint #s NY00333143, NY00316809, and NY00330622) for one of one resident floor and two of two basements, the facility did not maintain an effective pest control program. Specifically, there was evidence of rodent activity and pest harborage areas within the facility. The findings are: In an interview on 2/14/24 at 9:04 AM the Facilities Director stated that they have a mouse problem that has been going on for a long time, and the pest vendor comes once a month. The Administrator stated that they had a plan to renovate which included fixing doors to take care of the mouse problem. In an interview on 2/14/24 at 9:45 AM Resident #5 stated, you are probably looking for [NAME]. Resident #5 stated that [NAME] is what they named the mouse that comes to visit periodically and sometimes come out from under the sink. Observations at this time included numerous small brown mouse droppings inside a cabinet under the sink in resident room [ROOM NUMBER]. Additionally, there was an approximately one half-inch unsealed annular space around the sink drainpipe extending through the floor. Observations in the kitchen on 2/14/24 at 10:00 AM included three small brown mouse droppings in the back corner of the pantry by the right-side shelves. Additionally, there was an unsealed opening underneath the kitchen exit door which could serve as an entrance point for mice and other pests, and light from the outside was visible. In an interview on 2/14/24 at 11:18 AM the Administrator stated they did not have a pest sighting log but that they do have a maintenance log where that information could be entered. Record review on 2/14/24 at 11:20 AM included several pest vendor service reports from 8/24/23 through 1/25/24. A report dated 9/28/23 included a statement that the back door in the kitchen was repaired but still is not rodent proof, and the basement door is not rodent proof. A report dated 10/26/23 included a statement that the back kitchen door and the basement door were not rodent proof. A report dated 11/10/23 included that several snap traps were set in the office basement where three mice were spotted. A report dated 1/25/24 included statements that the basement door is not rodent proof and propped open doors are easy access for rodents. Observations in the kitchen dish room on 2/14/24 at 12:05 PM included a pipe from the mechanical dishwasher extending through the wall towards the kitchen/pantry area. There was an unsealed opening in the wall approximately two-inches long and one-inch wide on each side of the pipe allowing for harborage and movement of rodents and other pests. In an interview on 2/14/24 at 12:10 PM Resident #5 stated that they saw a mouse about 5:30 AM today and it ran under their bed, and they have seen it at least three times. Resident #5 stated that a family member had come to visit, and a mouse ran down the hall. In an interview on 2/14/24 at 1:40 PM Resident #13 stated that they had seen mice in their room and on the bed, and the last one they saw was about a month ago. Observations at this time included small brown mouse droppings on the floor in the corner below the head of the bed in resident room [ROOM NUMBER]. Observations on 2/14/24 at 2:00 PM included small brown mouse droppings under a metal shelf in the basement kitchen supply room by the wall near the door to the room. Additionally, the back exit door in the basement had a metal strip across the bottom. In an interview at this time the Director of Environmental Services stated that the door would not close properly. 10N YCRR: 415.29(j)(5)

Based on observations, record review, and interviews conducted during an Abbreviated Survey (NY00316809, NY00322695, NY00327824, NY00328450, NY00326411, and NY00330622) for one of one resident-use floor the facility did not provide an environment designed, constructed, equipped, and maintained to provide a safe, healthy, functional, sanitary, and comfortable home like environment. Specifically a railing on an exit ramp was deteriorated and unsafe, a door threshold transition strip was missing, walls were damaged, there were broken floor tiles in a resident room, resident room windows could not be opened due to missing handles, and there was a hole in the carpet in a resident room. The findings are: Observations on 2/14/24 at 8:41 AM included a concrete ramp on the northeast side of the building with a metal handrail, a support rail running down the ramp, and seven metal support posts. Of the seven support posts only two were observed to be attached to the ramp. The other five support posts were heavily corroded at the bottom and had gaps of up to an inch between the base of the rusted support posts and the ramp surface. The entire handrail was observed to wobble from side to side when contacted. The designated exit from the corridor nearest resident rooms #22 and #23 was observed to lead to this ramp and exit discharge pathway. In an interview on 2/14/24 at 12:37 PM the Nurse Manager stated that there are nine residents that are able to ambulate independently. In an interview on 2/14/24 at 9:03 AM the Director of Environmental Services stated that they had brought the ramp handrail problem up in their safety meetings. In an interview on 2/14/24 at 9:05 AM the Facilities Director stated that they plan on replacing the whole ramp, and a vendor told them that the entire ramp had to be destroyed and rebuilt. The Facilities Director stated that they cannot do that in the winter. In an interview on 2/14/24 at 9:08 AM the Administrator stated that they plan to remodel in about a month, including redesigning the therapy gym, fixing windows, and the ramp. The Administrator also stated that they have an architect and are still in the planning stage and have not entered their information into the New York State Electronic Certificate of Need website. When asked for a copy of the renovation plan, the Administrator stated that they do not have the plans yet, but the architect came on 2/6/24 for the blueprints and a designer will be in next week. Observations on 2/14/24 at 12:02 PM included a door threshold transition strip was missing from between the corridor floor tiles and the carpet at the entrance to resident room [ROOM NUMBER]. Additionally in room [ROOM NUMBER] there was a large missing section of horizontal wall protective material near the head of the two beds. Observations on 2/14/24 at 1:33 PM included broken floor tiles in resident room [ROOM NUMBER] by the bed. The damaged sections of the tiles were approximately an inch wide, another had approximately half of the tile missing, and another had a circular gouge approximately three inches across. Observations on 2/14/24 at 1:40 PM included the windows in resident rooms #21, #20, #8, #7, #5, #4, and #1 were not equipped with a handle or other mechanism to allow them to open. During an interview at this time the Director of Environmental Services stated that they did not know why the handles were missing. Observations on 2/14/24 at 1:47 PM included two sections of wall damage behind the bed closest to the door in resident room [ROOM NUMBER] that measured approximately 6 inches by 4 inches. Additionally in this room was an approximately one inch by two-inch hole in the carpet near the bottom of the bed. 10NYCRR: 415.29, 415.29(a), 415.29(c), 415.29(i)(1), 415.29(j)(1), 10NYCRR: 713-2.5(b)(3)

Based on observations, interview, and record review conducted during the Standard Recertification Survey completed from 5/4/23 to 5/10/23, it was determined that for one of one kitchen the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, food was not thawed properly, foods were held at improper temperatures in a refrigerator, a three-bay sink and milk cooler were inoperable, and a hand-wash sink was not properly maintained. The findings are: Observations and interview during the initial tour of the kitchen from 8:46 a.m. to 10:00 a.m. included the following: 1. When attempting to wash hands at the designated hand-wash sink the surveyor observed that only the hot water handle was operable; the cold handle would not dispense cold water. In an interview at this time the cook/tray aide stated that it was turned off because it came out so forcefully and splashed all over. 2. There was a large stainless-steel bowl of water in the food prep sink with a five-pound tube of ground beef submerged in non-running water. In an interview at this time the cook-aide stated that they forgot to take the ground beef out of the freezer last night and was taken out this morning. 3. There was a sign by the three-bay sink that included not to use the sinks. There were two pads on the floor in front of the sink and a sanitizer bucket under the left side of the sink. In an interview the cook/aide it stated that it leaks. The Food Service Director stated that the whole waste line needs to be replaced. The Mobile Maintenance worker stated that the grease trap was rusted and backs up, and the whole waste pipe underneath the sinks needs to be replaced. 4. A Kenmore refrigerator/freezer had a gasket attached to the door with masking tape. Within this refrigerator were the following food items not held at an acceptable temperature: a bag of sausage links that were 51degrees Fahrenheit ( F), a five-pound bag of sliced potatoes in a pot were 67 F, and a five-pound turkey breast was 49 F. In an interview at this time the Food Service Director stated that those foods were in the refrigerator all night. All foods were voluntarily discarded and the Food Service Director stated that they would replace the refrigerator. 5. A dairy cooler was located in an alcove in the kitchen and the bottom panel was open, and the cooler was empty. In an interview at this time the Food Service Director stated that the dairy cooler broke down in March, and all dairy items are now located in the two-door 'True cooler because they are waiting for a part. 10NYCRR: 415.14(h), 10NYCRR: Subpart 14-1.40(a), 14.1.44, 14-1.86(b), 14-1.95, 14-1.111, 14-140, 14-1.143(b)

Based on interviews and record review conducted during a Recertification Survey 5/04/23 to 5/10/23, the facility did not maintain a quality assessment and assurance committee consisting at a minimum of the director of nursing services, the Medical Director or his/her designee, at least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role, and the infection preventionist. Specifically, the facility could not provide documented evidence that the Medical Director or their designee attended the quality assurance meetings for the past 10 months (available documentation). This is evidenced by: Review of the facility's Quality Assurance and Performance Improvement (QAPI) and QA (Quality Assurance) meeting attendance sheets dated June 2022, July 2022, August 2022, and 4/6/2023 (with heading QAPI Feb-March) did not include the Medical Director or a designee that represented medical. When interviewed on 5/10/23 at 1:39 p.m., the Administrator stated that QAPI meetings are held every three months and the Quality Assurance Committee meets monthly and the sign in sheets are same for both committees. The Administrator stated that the Medical Director (MD) has not been attending any of the meetings that they were aware of despite reaching out. The Administrator stated that they started at the facility approximately four months ago and the MD had not been to a meeting including the last meeting on 4/6/23. The Administrator stated that we do not have a corporate MD and the facility owners are drawing up another contract with a new MD at this time. 10NYCRR: 415.27(a-c)

Based on record review and interviews conducted during a Recertification Survey and complaint investigations (#NY00311675, #NY00302654) from 5/4/23 to 5/10/23, it was determined that the facility did not use the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days per week per the regulations. Specifically, the facility was unable to provide documented evidence that a RN had worked any hours on 26 days during the four months reviewed. This is evidenced by the following: Review of the nurse staffing reports (report posted to inform residents and visitors of the number and hours of nursing staff working) that are posted adjacent to the front entrance, revealed the facility had no RN coverage for all three shifts for the following: a. On 4 of 30 days in the month of April 2023. b. On 8 of 31 days in the month of March 2023. c. On 2 of 28 days in the month of February 2023 d. On 8 of 31 days in the month of December 2022. During an interview on 05/08/23 at 1:23 p.m., the Receptionist in charge of posting the nurse staffing numbers and hours stated that there had been no RN coverage for some time on the weekends, prior to the current Director of Nursing and the weekend RN recently becoming employed at the facility. During an interview on 05/09/23 at 12:16 p.m. the Licensed Practical Nurse/Nurse Manager stated that the facility had been operating for some time without a weekend RN. During an interview on 5/10/23 at 1:39 a.m., the Administrator stated they were aware that the facility did not have a RN for the weekends prior to their hire and had recently hired one. 10NYCRR 415.13(b)(1)

Based on observations, interviews, and record reviews conducted during a Recertification Survey 5/04/23 to 5/10/23, for two (Resident #5, Resident #329) of 14 residents reviewed the facility did not provide services, as outlined by the resident's person-centered comprehensive care plan (CCP), that meet professional standards of quality. Specifically, for Resident #5 the facility did not provide the resident with adult briefs that had been prescribed by the physician. For Resident #329, there was no documented evidence that medications were consistently administered per the current physician orders. This is evidenced by: 1. Resident #5 had diagnoses including multiple sclerosis, quadriplegia, and pemphigoid (a rare auto-immune disorder that results in skin rashes and blistering on the legs, arms, and abdomen). The Minimum Data Set (MDS) Assessment, dated 4/10/23, documented the resident was cognitively intact. Resident #5's CCP initiated on 05/26/22 and revised on 5/2/23, documented the resident had allergies to components in some adult briefs requiring special order of briefs that the resident could tolerate. Review of current physician orders revealed an order, dated 6/8/22, for Covidien XL wings plus quilted adult briefs and noted the resident had an allergy to all other briefs. Review of a facility Record of Concern, grievance form dated 3/23/23, included that Resident #5 complained of irritation to their peri-area (private areas of the resident) due to the lack of a special brief. It was documented that the Director of Nursing (DON) and Social Worker contacted the Medical Director to assess the resident and the facility purchaser was instructed to order the special briefs to use going forward. The conclusion of the facility investigation included that the special briefs were on routine order for the resident and recommended staff to monitor supply levels to ensure there was a supply on hand. During an observation of incontinence care on 5/5/23 at 11:56 a.m., the resident was observed to have several open blisters to her inner right thigh and to the back of her right thigh. After providing incontinence care, CNA #3 retrieved an adult brief from a package that read Cardinal Health Quilted Adult Briefs Wings Plus Heavy Absorbency X-Large. During an interview on 5/8/23 at 2:07 p.m., when asked what brand of briefs the Resident has been using, CNA #3 retrieved a package of the Cardinal Health adult briefs from the closet and stated these are the briefs we use. During an interview on 5/8/23 at 2:21 p.m., the Licensed Practical Nurse (LPN)/ Nurse Manager (NM) stated that they were not sure that the briefs in the resident's closet were the right ones, but that the resident did tell them that those were not the right ones. The LPN/NM stated that they were made aware that there were some of the ordered briefs in the basement and would go down to check. When interviewed at this time, the resident stated on the day they had reported not having the right briefs the doctor was present and contacted someone at the corporate office and told them they needed the Covidien briefs. The corporate office was going to purchase the briefs. Resident #5 stated they had not received the Covidien briefs since the last administrator was at the facility (some months prior). During an interview on 5/9/23 at 1:40 p.m., the DON stated that they had emailed the person who does supplies, and they ordered the Covidien or Cardinal briefs who then informed the DON that the briefs were at the facility and that the DON had found yesterday in the basement. The DON stated they had been told the briefs had been there, but they did not know the actual delivery date. During an interview on 5/9/23 at 1:52 p.m., Resident #5 stated Covidien is the brand of briefs they need, not the Cardinal brand they are using because they cause irritation to their waist, hips, back, and belly button. The edges caused a rash a while ago which was gone but the other areas itch and are irritated. The resident stated that it made their spasm worse which made them twitch. Resident #5 said the facility could get them from [NAME] (a local medical supply store), so they did not know why it was an issue. During an interview on 5/9/23 at 9:43 a.m., the LPN/NM stated that CNA #3 was the resident's regular aide and said the briefs are the same ones. The LPN/NM said that resident continues to say they are not the right ones but the blisters the resident has are in other areas besides the edges of the briefs. The LPN/NM stated that it was possible the Covidien brand may be less irritating to the resident's skin. 2. Resident #329 had diagnosis including end stage renal disease requiring hemodialysis three days a week and orthostatic hypotension (low blood pressure with position changes). The MDS Assessment, dated 4/17/23, documented the resident was cognitively intact. The resident's CCP, dated 4/20/23, documented the resident had altered cardiovascular status, low blood pressure and heart failure and interventions included for staff to administer medications as ordered. Review of current physician orders revealed an order dated 4/7/23 for Midodrine 15 milligrams (mg) three times a day for low blood pressure. Review of the Medication Administration Records (MAR) dated 4/8/23 to 4/30/23 revealed no documented evidence that the medication was administered on three occasions and the MAR dated 5/1/23 through 5/7/23 was not documented as administered on two occasions in the seven days. Additionally, there were multiple other medications not signed off as administered on the same days and shift as above. During an interview on 5/8/23 at 1:42 a.m., the dialysis Registered Nurse (RN) stated that they were having difficulty keeping the resident's blood pressure up and removing the necessary fluids during dialysis which was why the resident was on the Midodrine. Upon review of the missed doses, the dialysis RN stated that it could explain some of the issues they had been experiencing with the resident's blood pressure the previous week. During an interview on 5/8/23 at 11:56 a.m., the LPN/NM stated that the resident was not approved to go out on pass and had no explanation for the missed doses which were all on the evening shift when the resident was not at dialysis. The LPN/NM stated that all nurses should check the record at the end of their shift to ensure all medications were signed off if given but that the facility had no formal process regarding this. 10NYCRR: 415.11(c)(3)(i)

Based on observations, resident and staff interviews, and record reviews, conducted during an Abbreviated Survey (complaint #NY 314) completed on 4/10/12, it was determined that for one of four residents identified at risk for and reviewed for unsafe wandering, the facility failed to ensure that residents identified for unsafe wandering are supervised and have interventions in place to prevent elopement, failed to re-assess residents who have a history of elopement for interventions to prevent the possibility of future elopement, and failed to thoroughly investigate the event to determine a root cause and prevent further instances of unsafe wandering. Specifically, the facility failed to have a system in place to provide supervision for Resident #1, who was assessed as at risk for unsafe wandering and who had attempted to elope on 3/25/12. On 4/5/12, the resident exited the building a second time without staff knowledge and returned on her own at 9:45 p.m. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to Resident Health and Safety and Substandard Quality of Care for four of four residents at risk for unsafe wandering. The facility implemented appropriate measures to remove the Immediate Jeopardy and correct the deficient practice on 4/10/12. This is evidenced by the following: Resident #1 is a [AGE] year-old female, who was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. An Interdisciplinary Care Plan, dated 1/18/12, revealed that the resident was at risk for wandering, was on facility wandering protocol with a motion detector at her door and had visual checks at night. An Elopement Risk Assessment and a Wandering Risk Scale, both originally dated 1/21/11 and most recently reviewed 4/4/12, revealed that the resident is at risk of both elopement and wandering. Review of an Incident Report, dated 3/25/12, shows that a kitchen staff member alerted facility staff at 7:30 p.m. that evening that the resident was entering the building from outside through the ramp doors. Licensed Practical Nurse #1 (LPN) who initiated the report interviewed the resident who stated that she thought she saw another resident outside sitting in his wheelchair by the door, and then she did not see him and was worried that he had rolled down the ramp and got hurt. The resident stated that she knew she should not have gone out the door. LPN #1 documented that measures in place prior to the incident included a motion detector by the resident's room and safety checks at night. Measures to prevent reoccurrence were to consider a room change when a more appropriate room becomes available. An undated addendum to the Incident Report of 3/25/12 documented that the resident has significant short-term memory loss and often thinks that she is a staff member. The Incident Report lacked information to show when and where the resident was last seen to determine how long she may have been outside. An Incident Report and Nursing Progress Report, dated 4/5/12, both documented that when LPN #2 went to the resident's room at 9:30 p.m. to administer medications, the resident was not in her room. In an immediate building search the resident was not found. At 9:45 p.m., LPN #2 discovered the resident outside walking up the driveway from the street. The resident stated that she had been looking for her daughter. Per the Incident Report, facility staff immediately began safety checks every 15 minutes, applied a Watch Mate bracelet, activated the door alarm and motion sensor, made a plan to move the resident to a room closer to the nurses' station, and to continue every half-hour visual checks after the room change was made. The facility's investigation included a written statement, dated 4/6/12, where the Certified Nursing Assistant (CNA) noted that she last saw the resident in the bathroom at 8:30 p.m. and that the resident had been fully clothed at that time. Additionally, when facility staff contacted the Registered Nurse Supervisor who had been on duty on 4/5/12 by telephone, she reported that she had called the Rochester Transit System on 4/5/12 at approximately 10:00 p.m. and learned that an elderly woman fitting the description of Resident #1 was on a city bus that transported her back to the facility, that she was able to identify. Interviews conducted on 4/6/12 are as follows: a. At 3:50 p.m., the Director of Nursing (DON) said that the daughter had been at the facility visiting on 4/5/12 and had left the building at 8:00 p.m. The DON reported that when she spoke with the daughter, she stated that her mother seemed confused and had been telling her she wanted to go home more often in the past two weeks. When the daughter left, the resident was resting in bed. b. At 4:45 p.m., Resident #1 said that she was trying to go home. She reported that she rode the bus downtown and that she has been riding the bus for years. c. At 6:00 p.m., LPN #2 said that at 9:30 p.m. he could not find the resident when he went to her room to administer her medications. She was not in her room, bathroom, or kitchen. The CNAs were also looking for the resident and could not find her. He went outside and found her walking up the driveway. He said that he asked her where she was coming from, and she told him that she had been looking for her daughter and that she had taken the bus. LPN #2 stated that this had been verified with the bus company. The facility has taken the necessary steps to remove the immediacy of risk to resident health and safety by 4/10/12. 1. Immediate interventions on 4/6/12 for Resident #1 included a Watch Mate bracelet that will be checked each shift for placement and tested weekly per manufacturer's recommendations. Resident #1 was moved to a room opposite the nurses' station for closer supervision. The resident continued to wear an orange identification bracelet and had an orange name tag on her room door. 2. On 4/7/12, the facility reviewed elopement assessments, care plans and policy for all residents Residents identified as at risk are wearing orange identification bracelets, orange name tags are in place on resident's doors, visual checks of residents at risk to be documented on 24-hour safety log. The Watch Mate bracelet system will be checked for functioning by walking residents through the building, and placement and proper fit of Watch Mate bracelet to be checked. 3. On 4/9/12, all staff, including agency and per diem staff on all shifts, were inserviced regarding elopement policy and how to identify residents at risk for elopement/wandering. (10 NYCRR 415.12(h)(1)(2))