Every finding on record at The Center for Nursing and Rehab at Hoosick Falls

Based on record review and interviews during survey, the facility failed to ensure that residents were free from abuse and or neglect for two (Resident #17 and #24) of five residents reviewed. Specifically, Residents #24 and #17 were involved in a resident-to-resident altercation. Specifically, on 07/18/2026 Resident #17 pushed Resident 24 after they had attempted to enter their room. Resident #24 was found on the floor with bruising on their bilateral forearms and an abrasion to their right elbow. This resulted in actual harm for Resident #24 that was not Immediate Jeopardy. Findings include:The facility's policy and procedure titled Abuse and Neglect Policy, reviewed 07/01/2026 documented the facility would assure residents were free from abuse and neglect, including involuntary seclusion. Furthermore, residents would not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, family members, legal guardians or outside members of the community. The facility investigation titled Resident-Resident Altercation Investigation Summary dated 07/18/2026 signed by Administrator #1 documented Residents #17 and #24 were involved in an altercation on 07/18/2026 at 3:30 PM. Resident #17 reported Resident #24 attempted to enter their room and they did not want them there, and when attempting to redirect Resident #24 out of their room, Resident #24 fell on the floor. Resident #24 was found on the floor with an abrasion to their right elbow. The local law enforcement was called to the facility and upon their initial investigation when responding to the facility and no further actions were warranted.Resident #17Resident #17 was admitted to the facility with diagnoses of schizoaffective disorder (chronic, potentially disabling psychotic disorder), bipolar (disorder a mental health condition that causes extreme shifts in mood), adjustment disorder with depressed mood (excessive reactions to stress that involve negative thoughts, strong emotions and changes in behavior). The Minimum Data Set (a resident assessment tool) dated 07/02/2026, documented the resident could be understood, could understand others, and was moderately cognitively impaired. The Comprehensive Care Plan initiated 09/11/2025 for Resident #17 titled Abuse/Aggressor documented as approaches created on 09/11/2025: ascertain and address cause of abuse, immediately separate residents, observe for further abusive behaviors, offer psychological services, psychiatric consult, review others' rights as needed, and review unacceptable behaviors towards others. There were no other approaches documented on this care plan between 09/12/2025 and 07/17/2026.Review of a progress note dated 07/13/2026 at 8:41 PM by Registered Nurse #1 documented Resident #17 had one behavioral outburst requiring law enforcement assistance. Resident became irate when another resident with dementia opened their door. Resident #17 was noted to be yelling at the resident threatening to take them out. Resident #17 continued to yell and threaten other residents near the nursing station and staff had to place themselves between Resident #17 and three other residents as the resident was approaching other residents and yelling in their faces. Review of a progress note dated 07/18/2026 at 3:30 PM by Registered Nurse #1 documented Resident #17 had an explosive outburst requiring law enforcement assistance. Resident #17 was noted to be standing above Resident #24 yelling in their face how do you like that pops?. Resident #17 stated they pushed Resident #24 to the floor after they opened the door to their room. Resident #24 had new bruises on their bilateral forearms and an abrasion on their elbow. Review of the Event Report dated 07/18/2026 at 3:30 PM by Assistant Director of Nursing #1 documented staff witness reported finding Resident #24 on the floor with Resident #17 in their wheelchair leaning over them. Upon their interview with Resident #17, Resident #17 stated Resident #24 opened their door, they told them to get out, they then wheeled into the hallway and pushed Resident #24 by the arms, and Resident #24 fell to the floor. Resident #24Resident #24 was admitted to the facility with diagnoses of unspecified dementia (condition that affects memory, thinking and the ability to perform daily activities), depression (persistent feeling of sadness and loss of interest), and type two diabetes (an endocrine dysfunction causing unregulated blood glucose levels). The Minimum Data Set, dated [DATE], documented the resident sometimes could be understood, sometimes understand others, and was significantly cognitively impaired. Review of Resident #24's Comprehensive Care Plan dated 06/29/2026 document resident was at risk for abuse due to medical status and resident would be free from abuse. Review of Resident #24's progress note dated 07/18/2026 at 9:48 PM by Registered Nurse #1 documented a post fall assessment was completed with a skin assessment. The resident had bruising to their bilateral forearms with mild swelling and an abrasion on their right elbow measuring three centimeters.During an interview on 08/19/2026 at 11:45 AM, Certified Nurse Aide #1 stated Resident #17 was verbally aggressive. Local law enforcement was called often to intervene with the resident. They were not in the facility at the time of the incident on 07/18/2026.During an interview on 08/21/2026 at 10:08 AM, Director of Nursing #1 stated they were not in the facility at the time of the incident between Resident #17 and Resident #24, and as far as they were aware, the investigation determined no abuse. They were aware Resident #24 was found on the floor with Resident #17 close by, Resident #24 had an abrasion to their right elbow and old bruises on their bilateral forearms. Resident #17 has a long history of behavioral outbursts and local law enforcement had been called many times to assist the facility with Resident #17's behaviors. Subsequently, on 08/24/2026 at 1:34 PM, Director of Nursing #1 stated the incident on 07/18/2026 between Resident #17 and #24 was unwitnessed. Resident #17 refuses medications and psychological referrals, their trigger moments are hard to identify. During an interview on 08/21/2026 at 11:08 AM, Assistant Director of Nursing #1 stated they were in the facility at the time of the incident between Resident #17 and #24. Resident #24 was found on the floor with Resident #17 standing over them. Per an interview with Resident #17, they had grabbed Resident #24 by the arms and pushed them down. During an interview on 08/24/2026 at 1:20 PM, Resident #17 stated I do not want to talk to anyone. During an interview on 08/24/2026 at 1:35 PM with Administrator #1 and Corporate Infection Preventionist #1, Administrator #1 stated because Resident #17 was redirecting the other resident out of the room, it was not an altercation. 10 New York Codes, Rules, and Regulations 415.4 (b)(1)(i)

Based on interview and record review conducted during a survey, the facility failed to report all alleged violations involving abuse, neglect, and injuries of unknown source immediately, but not later than two hours after the allegation was made, to officials (including to the State Agency) for three (Resident #s 17, 24, and 84) of three residents reviewed. Specifically, Resident # 17 and Resident #24 were involved in a resident-to-resident incident on 07/18/2026, local law enforcement was called by the facility at that time, the incident was not reported to the Department of Health. Resident # 84 had an altercation with another resident on 10/30/2025, local law enforcement was called by the facility at that time, the incident was not reported to the Department of Health.Findings Include: Cross reference F600 The facility's policy and procedure dated 07/01/2025 titled Abuse and Neglect-Section one Abuse Prevention and Reporting documented, all alleged or suspected incidents of abuse and/or neglect will be investigated. Injuries of unknown origin will be investigated to rule out abuse, neglect or mistreatment. The Administrator and Director of Nursing will be immediately informed of any alleged or suspected occurrence of abuse or neglect. The Administrator or designee will provide a two-hour notification to the New York State Department of Health for any alleged or suspected or confirmed case of abuse or neglect. Resident #17 Resident #17 was admitted to the facility with diagnoses of schizoaffective disorder (chronic, potentially disabling psychotic disorder), bipolar (disorder a mental health condition that causes extreme shifts in mood), adjustment disorder with depressed mood (excessive reactions to stress that involve negative thoughts, strong emotions and changes in behavior). The Minimum Data Set (an assessment tool) dated 07/02/2026, documented the resident could be understood, could understand others, and was moderately cognitively impaired. Review of event report for Resident #17 for event date 07/18/2026 at 3:30 PM by Assistant Director of Nursing #1documented, staff witness reported finding Resident #24 on the floor with Resident #17 in their wheelchair leaning over them. Upon their interview with Resident #17, Resident #17 stated Resident #24 opened their door, they told them to get out, they then wheeled into the hallway and pushed Resident #24 by the arms, and Resident #24 fell to the floor. Local law enforcement was contacted upon their initial investigation when responding to the facility, no further actions were warranted. Resident #24 Resident #24 was admitted to the facility with diagnoses of unspecified dementia (condition that affects memory, thinking and the ability to perform daily activities), depression (persistent feeling of sadness and loss of interest), and type two diabetes (an endocrine dysfunction causing unregulated blood glucose levels). The Minimum Data Set, dated [DATE], documented the resident sometimes could be understood, sometimes understand others, and was significantly cognitively impaired. Review of Resident #24's progress note dated 07/18/2026 at 9:48 PM by Registered Nurse #1 documented, a post fall assessment was completed with a skin assessment. They had bruising to their bilateral forearms with mild swelling and an abrasion on their right elbow. Resident #84 Resident #84 was admitted to the facility with diagnoses of unspecified psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), depression (persistent feeling of sadness and loss of interest), and personal history of traumatic brain injury (an outside force damages your brain and affects how it works). The Minimum Data Set, dated [DATE], documented the resident could be understood, could understand others, and was cognitively intact. The event report dated 10/30/2025 at 8:21 PM by Director of Nursing #2 documented, staff were alerted by another resident that Resident #84 had an altercation with a resident outside of the nurse's station that escalated and required that the resident be placed on one-to-one observation for safety. Local law enforcement was called to take a report from the victim. There was no documented evidence that the facility reported these events as required in the internet quality Improvement and Evaluation System (iQIES). Duriong an interview on 08/21/2026 at 10:08 AM, Director of Nursing #1 stated reporting for abuse including a resident-to-resident incident should be within two hours to the Department of Health. When local law enforcement was called to the facility for an incident with a resident, they discussed the incident with corporate. Corporate made the determination on what the next steps would be and if the incident is reportable. During an interview on 08/21/2026 at 11:08 AM, Assistant Director of Nursing #1 stated resident-to-resident incidents of abuse, should be called in to the Department of Health within two hours. They had been present for the incident with Resident #17 and Resident #24, administration and corporate were made aware of the incident at the time of incident and they made the decision if the incident was reportable. During an interview on 8/24/2026 at 1:25PM with Administrator #1 and Corporate Infection Preventionist #1, Administrator #1 stated the Director of Nursing and the Administrator were responsible for reporting incidents to the Department of Health. They reported per guidelines; suspected abuse/neglect, unknown injuries, emergency power outages, evacuations, etc. Resident to resident incidents would be reported if there was abuse. When local law enforcement was called to the facility it would depend on what they were called for if it was reportable. Law enforcement was called for a number of reasons; residents called them sometimes. The incident with Resident #17 and #24 was not reported because one resident was directing the other resident, it was not an altercation, they were only redirecting the resident into the room. They believed Resident #17 had contacted local law enforcement at the time of the incident, because they did that frequently. 10 New York Codes, Rules, and Regulations 415.4(b)(2)

Based on observation, record review, and interviews conducted during the survey, the facility failed to ensure that written notification was sent to the representative of the Office of the State Long-Term Care Ombudsman of the resident's transfer or discharge and the reasons for the move for three (3) (Resident #'s 83, 84 and 87) of three (3) residents reviewed. Specifically, for Residents #83, #84 and #87 there was no documented evidence that the resident, representative, or Ombudsman received a transfer/discharge notice upon discharging from the facility. Findings Include: Resident #83 Resident #83 was admitted to the facility with diagnoses including primary osteoarthritis (joint disease caused by the natural breakdown of protective joint cartilage over time without a single known underlying cause), unsteadiness of feet, and need for assistance with personal care. The Minimum Data Set, dated [DATE], documented the resident could be understood, could understand others, and was cognitively intact. During an interview on 08/20/2026 at 9:55 AM, Social Worker #1 confirmed by checking their records that there was no documented evidence that a transfer/discharge notice was sent to the Ombudsman for Resident #83. Social Worker #1 stated Resident #83 left against medical advice and provided a form by Resident #83 signed and dated 07/10/2026 at 11:00 AM. Social Worker #1 stated they attempted to reach out to Resident #83's family but they were not very involved. In addition, a report was filed with Adult Medical Services. Social Worker #1 was uncertain whether the Ombudsman needed to be notified for residents that leave the facility against medical advice. Resident #84 Resident #84 was admitted to the facility with diagnoses including unspecified psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), depression (persistent feeling of sadness and loss of interest), and personal history of traumatic brain injury (an outside force damages the brain and affects how it works). The Minimum Data Set, dated [DATE], documented the resident could be understood, could understand others, and was cognitively intact. During an interview on 08/20/2026 at 9:45 AM, Social Worker #1 confirmed by checking their records that there was no documented evidence that a transfer/discharge notice was sent to the Ombudsman for Resident #84. Resident #87 Resident #87 was admitted to the facility diagnoses including other toxic encephalopathy (brain dysfunction or damage caused by exposure to poisonous or neurotoxic substances), depression (depression (persistent feeling of sadness and loss of interest) and dysphagia (difficulty or pain when swallowing food, liquids, or even saliva). The Minimum Data Set, dated [DATE], documented the resident could be understood, could understand others, and was cognitively intact. During an interview on 08/20/2026 at 9:50 AM, Social Worker #1 confirmed by checking their records that there was no documented evidence that a transfer/discharge notice was sent to the Ombudsman for Resident #87. During an interview on 08/20/2026 at 9:35 AM, Social Worker #1 stated they were responsible for resident discharges and explained that when a resident or family member requested a discharge after completing therapy, the Interdisciplinary Team (IDT) conducted a process to ensure clearance from therapy and medical provider, as well as to set up all necessary post-discharge services that may be needed. On the date of discharge, staff provided the resident with a discharge packet including their face sheet, provider records, a provider discharge summary, nursing notes, and a discharge observation note specifying who the resident is being discharged to and with, follow-up appointments, primary care provider (PCP) information, and medical equipment needs, after which the entire team signs off. Regarding Ombudsman notification, Social Worker #1 stated discharge notices were sent to the ombudsman once a month at the end of every month and admitted they had not been sending the notifications. Social Worker #1 stated Administrator #1 informed them a week ago that discharge notifications were required to be sent to the Ombudsman once a month at the end of every month. 10 New York Codes, Rules and Regulation 415.3 (h) (1)

Based on observation, record review, and interviews conducted during the survey, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen and two of two-unit kitchenettes. Specifically, (a) equipment and areas in the main kitchen and unit A kitchenette refrigerator required cleaning, (b) food and drinks on unit A and unit B kitchenette refrigerators had unlabeled, undated, and/or food items with use by dates past the date of inspection. Findings include: Facility policy titled, Foods Brought by Family/Visitors, revised 05/2025, documented that food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that is clearly distinguished. The nursing staff will discard perishable foods on or before the use by date. Facility policy titled, Food Brought in Policy- CNR Nutrition and Dining Services, dated 06/2025, documented that the purpose of the policy is to ensure food brought into the facility for residents will be handled safely and the priority is to ensure the wellness and safety of all residents. The policy documented that all food or beverage items must be in re-sealable containers and labeled with the residents name, food and beverage items without manufacturer expiration date will be dated upon arrival in the facility and thrown away six days after the marked date, and food and beverage items in the original containers marked with manufacture expiration dates and unopened do not have to be dated until opened. Facility policy titled, Sanitization, revised 11/2025, documented that all kitchens, kitchen areas, and dining areas are kept clean, free from garbage and debris. All utensils, counters, shelves and equipment are kept clean and maintained in good repair. During observations of the main kitchen on 08/17/2026 at 10:30 AM, the following equipment and areas required cleaning: non-handwashing sink, toaster, and floor under equipment in the preparation area. During observations on 08/17/2026 at 11:25 AM, unit A kitchenette refrigerator required cleaning. During inspection on unit A and unit B kitchenettes on 08/17/2026 the following items were found to be out of compliance with New York State food safety regulations: Leftover lasagna in plastic container, unlabeled and undated Salad dressing, creamer, grape and strawberry jelly squeeze bottles, and hot fudge topping, all open and unlabeled in the kitchenette refrigerators Two opened large bags of no calorie granulated sweeteners, best if used by date on 07/05/2026 Two packets of thickened coffee, use by dates on 03/13/2026 and 04/08/2026 Unopened strawberry preserves jar, best if used by 05/20/2026 Vanilla bean yogurt, dated 08/13/2026 and labeled with Certified Nursing Aide #3's name on the label Four apple sauce containers prepared by the kitchen, dated 08/13/2026 Caramel apple fudge dessert cup, unlabeled and undated During inspection of unit B kitchenette and interview on 08/17/2026 at 11:42 AM, Food Service Director #1 stated that the date on the apple sauce containers was the date they were prepared by the kitchen and should be discarded after three days. During an interview on 08/21/2026 at 1:22 PM, Certified Nursing Aide #3 stated that the expectations of food brought in by family/visitors is to have a label with the resident's name and the date. Certified Nursing Aide #3 stated that if there were any concerns about expired, undated, and unlabeled food or drink in the kitchenettes, they would throw it out. Certified Nursing Aide #3 stated that once food is opened and stored in the kitchenette refrigerators, they believed that they would discard it after a week, or by the expiration date. Certified Nursing Aide #3 stated that the kitchen staff should clean the kitchenette refrigerator and stated that had likely been a few months since they have been cleaned. During an interview on 08/21/2026 at 1:49 PM, Food Service Director #1 stated that there were concerns about foods brought in by residents or their family/visitors past their use by dates in the kitchenettes. After inspection of unit A and unit B kitchenette refrigerators, foods that were past their use by date were discarded. Food Service Director #1 stated that food and beverages brought into the facility by family/visitors should have names and dates labeled on them. Food Service Director #1 stated that the dietary department discards food, cleans the microwaves, refrigerators, freezers, and floors in the kitchenettes. Food Service Director #1 stated that the cleaning schedule included: sweeping and mopping the floors in between breakfast, lunch, and again at night. If there were concerns with the cleanliness of the kitchen, the morning cook would write it down, take pictures of the kitchen, and Food Service Director #1 would educate the dietary staff member on cleanliness. Food Service Director #1 stated that if there were multiple concerns about the cleanliness of the kitchen and a particular staff member, Food Service Director #1 would write that dietary staff member up. During an interview on 08/24/2026 at 9:10 AM, Administrator #1 stated the kitchen and unit kitchenettes are to have an organized and clean environment. Administrator #1 stated when the dietary staff leave for the day, they should sweep and mop the kitchen. Administrator #1 stated that Food Service Director #1 would educate the dietary staff if they were not keeping the kitchen and kitchenettes cleaned. Administrator #1 stated that food that is brought from the outside by residents and family/visitors would communicate to the staff. The food and drinks would be labeled with the date and name of the resident and after three to four days, they would toss the food item out. They would also throw out food if it was past the use by date. 10 New York Codes, Rules, and Regulations 415.14(h)

Based on observation, document review, and interviews conducted during the survey, the facility failed to ensure suitable, nourishing alternative meals and snacks were provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care. Specifically, the facility did not keep snacks readily available on the units or provide a variety beyond repetitive sandwiches for residents wanting food outside the scheduled mealtimes, despite facility policy documenting 24-hour snack availability. Findings include: The facility's policy titled Food and Nutrition Services dated 10/2025 documented Nourishing snacks are available to the residents 24 hours a day. The resident may request snacks as desired, or snacks may be scheduled between meals to accommodate the resident's typical eating patterns. During an interview on 08/17/2026 at 12:55 PM, Resident #59 stated they do not get enough food with meals. The servings are very small. When they ask for a second or larger portion they are denied. The only alternative available is a sandwich; they never get coffee. During a resident council meeting on 08/18/2026 at 10:40 AM, Residents #8, #68 and #61 stated they don't receive snacks as the facility does not normally have them readily available. Residents stated the facility used to have an activities aide who would go around the units with a snack cart, but they stopped doing it. The residents stated soda, cookies and chips are never available. In addition, they always get sandwiches for replacement meals and would like to have different options other than sandwiches. During an interview on 08/21/2026 at 1:22 PM, Certified Nurse Aide #3 stated they offer residents snacks when they have snacks on the unit. They stated 3 out of 10 times they have snacks available on the unit. They will not often call down to the kitchen for them. During an interview on 08/21/2026 at 1:49 PM, Food Service Director #1 stated snacks are in the units' kitchenettes every day, the morning cook goes up to the kitchenettes, they provide sandwiches for after dinner snacks. Food Service Director #1 provided a list for evening snacks which included approximately thirty sandwiches a night. During an interview on 08/24/2026 at 9:10 AM, Administrator #1 stated they put out snacks on the units as needed. Staff will call down to kitchen, and the kitchen will bring snacks to the units' kitchenettes. Certified Nurse Aides will get lists of residents who request snacks or sandwiches at the start of their shift. 10 New York Code of Rules and Regulations 415.14(f)(1)(2)(3)(4)

Based on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure the resident's right to a safe, clean, comfortable, and homelike environment. This was evident for two of three (Resident #'s 3 and 34) residents reviewed. Specifically, Resident #3 and #34 both had plywood placed in their windows to accommodate air-conditioning unit ventilation. Findings include: The facility's Policy and Procedures titled Quality of Life - Homelike Environment revised 07/2026 documented residents were provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. Comfortable and adequate lighting is provided in all areas of the facility to promote a safe, comfortable and homelike environment including maximum use of daylight. The facility's Policy Interpretation and Implementation of Resident Rights revised 2/2026, documented residents have the right to: Voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal; have the facility respond to his or her grievances. Resident #3 was admitted to the facility with diagnoses including osteomyelitis of right ankle (bone infection), end stage renal disease (the kidneys no longer work well, dialysis, or a transplant is needed) and orthopedic aftercare following surgical amputation (monitoring of the surgical site after limb removal). The Minimum Data Set (an assessment tool) dated 07/23/2026, documented the resident could be understood, could understand others, and was cognitively intact. Resident #34 was admitted to the facility with diagnoses including osteoarthritis of knee (the protective cartilage that cushions the ends of the bones wears down over time), essential (primary) hypertension (elevated blood pressure), and depression (persistent feeling of sadness and loss of interest). The Minimum Data Set (an assessment tool) dated 05/27/2026, documented the resident could be understood, could understand others, and was cognitively intact. During an observation of A Unit on 08/17/2026 at11:50 AM, a window in each of Resident #3 and Resident #34's rooms was noted to have plywood placed with a hole cut on the bottom allowing the in-room portable air conditioners vent to pass through. The plywood was noted to have rough edges. During an interview on 08/18/2026 at 10:29 AM, Resident #3 stated the portable air conditioner was put in their room because the room was not cooling enough. Administrator #1 has been telling them something on the roof needed to be fixed and the plywood would come down soon. They stated they would like to look out their window. During an interview on 08/17/2026 at 1:30 PM, Administrator #1 stated there was an issue with some rooms being cooled by the central air-conditioner. They had placed portable air conditioning units in the effected rooms. The windows had to be removed, and plywood was placed to accommodate the ventilation. The edges of the plywood were rough. Administrator #1 stated they would contact maintenance and have the plywood painted and secured around the edges to prevent injuries occurring. 10 New York Codes, Rules, and Regulations 415.5 (h) (1)(2)

Based on observation, record review, and interviews during the survey, the facility failed to ensure garbage and refuse were disposed properly. Specifically, the garbage dumpster had garbage littered around the outside dumpster area. Findings include: Facility policy titled, Food-Related Garbage and Refuse Disposal, revised 10/2025, documented that the outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. During an observation on 08/17/2026 at 11:02 AM, the outside garbage dumpster had garbage littered in the area. During an interview and observation on 08/19/2026 at 9:02 AM, Food Service Director #1 stated that the garbage littered near the outside dumpster was cleaned. During the observation, the garbage was observed to be cleaned up. New York Codes, Rules, and Regulations Title 10 S415.14(h)

Based on observation, record review, and interviews conducted during the survey, the facility failed to ensure that residents were provided food and drink that was palatable and at an appetizing temperature. Specifically, (a) Residents #28 and #27 had coffee listed on their lunch meal tickets and did not receive coffee on 08/17/2026 and 08/20/2026; (b) for Residents #27, #18, and #58, foods and drinks were not served at an appetizing temperature during a lunch meal on 08/20/2026; (c) three of three residents requested double portions on their lunch meal tickets on 08/20/2026, and did not receive double portions on their lunch meal trays; (d) five of five residents stated that coffee was requested on the meal ticket but they did not receive it on 08/18/2026. Findings include: Facility policy titled, Food and Nutrition Services, revised 10/2025, documented that each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. Document titled, Quality Assurance Performance Improvement, Quality Assurance Audit Tool, dated 06/15/2026 and completed by Food Service Director #1, documented the concerns/problems were tray temperatures and that they were warm. The findings included that some trays were an appropriate temperature, and some were warm. The corrective actions were to check temperatures when leaving the kitchen, in the dining room, and room audits. During an observation on 08/17/2026 at 12:35 PM, Resident #28's lunch meal ticket had coffee listed on the ticket and was not on their lunch meal tray. During an observation on 08/20/2026 at 12:06 PM, Resident #27's lunch meal ticket had coffee listed on the ticket and was not on their lunch meal tray. During an observation and interview on 08/19/2026 at 11:42 AM, Certified Nursing Aide #3 stated that coffee never came up on residents' meal trays. Coffee station was observed in the dining room at time of interview. Certified Nursing Aide #3 stated they ask residents in the dining room and on the units if they wanted coffee. During an interview on 08/17/2026 at 12:26 PM, Certified Nursing Aide #5 stated that meal tickets listed coffee, but residents do not get the coffee on their meal trays. Certified Nursing Aide #5 stated that they only get coffee for breakfast. During an interview on 08/20/2026 at 12:30 PM, Resident #27 stated that they do not get coffee even though it is on their ticket. Resident #27 stated no one came around asking them if they wanted coffee. During an observation on 08/20/2026 at 12:06 PM, Resident #27's lunch meal was delivered and contained the following items with temperatures measured as follows: Stuffed shells were 116.7 degrees Fahrenheit, green beans were 113 degrees Fahrenheit, pudding was 60 degrees Fahrenheit, and diet ginger ale was 60 degrees Fahrenheit. After tasting the food and drinks, the temperatures of the stuffed shells and green beans were lukewarm. During an interview on 08/20/2026 at 12:35 PM, Resident #58 stated that the meal carts came to the units and they sit a bit before the aides started passing trays and then the meals were cold when they get them. Resident #58 stated their lunch meal tasted lukewarm, and the green beans tasted cold. During an interview on 08/21/2026 at 1:12 PM, Resident #27 stated that dinner meal the night before on 08/20/2026, Salisbury steak and mashed potatoes, were ice cold. During an observation on 08/20/2026 at 12:10 PM, Resident #18's lunch meal was delivered and contained the following items with temperatures measured as follows: Whole milk was 67.3 degrees Fahrenheit, butterscotch pudding was 64.6 degrees Fahrenheit, stuffed shells were 127.3 degrees Fahrenheit, and green beans were 120.7 degrees Fahrenheit. There was no coffee on Resident #18's lunch meal tray and Resident #18 was in the common area asking for coffee. The whole milk tasted warm. During an observation on 08/20/2026 at 12:10 PM, Residents #18, #59, and #35 meal tickets documented that they requested double portions. Residents #18, #59, and #35 were served only one dinner portion. During an interview on 08/20/2026 at 12:20 PM, Certified Nursing Aide #5 stated that double portions for today's lunch meal should have included four stuffed shells. Certified Nursing Aide #5 stated that every resident that was on a regular diet, single or double portions, received two stuffed shells. During an interview on 08/20/2026 at 12:32 PM, Food Service Director #1 stated that double portions today should have included four stuffed shells. Food Service Director #1 stated they were unsure why residents who were ordered double portions were only served two stuffed shells. During an interview on 08/20/2026 at 2:40 PM, Registered Dietitian #1 stated that double portions for today's lunch meal would have been four stuffed shells and one cup of green beans. Registered Dietitian #1 stated that Food Service Director #1 would be responsible for making sure portions and meals were served as per the meal ticket. During a surveyor led resident council meeting on 08/18/2026 at 10:30 AM, five of five residents stated that coffee is on the meal tickets but do not get it. The residents stated they have to ask for coffee and sometimes do not get it. They stated that if the coffee pot is empty, they do not refill it. During an interview on 08/21/2026 at 1:22 PM, Certified Nursing Aide #3 stated that residents were not too fond of the food in the facility. They stated they think the quality of the food was not good and variety of foods was a concern brought up by residents. Certified Nursing Aide #3 stated that sometimes the food does came up cold for all meals. They stated if there were two aides on the floor to pass out meal trays, it took around 20 to 30 minutes to pass out meal trays. During an interview on 08/21/2026 at 1:49 PM, Food Service Director #1 stated the kitchen has been trying to make a lot of different foods for the residents and discussed trying new foods in the food committee meetings. Food Service Director #1 stated they have completed tray accuracy audits for the last Quality Assurance Performance Improvement meeting as well. During an interview on 08/24/2026 at 9:10 AM, Administrator #1 stated they have food committee meetings where residents speak about their food preferences. They discussed what they liked or what they did not like, and the dietary department would adjustments the menu based on that. They stated that occasionally, something on a meal tray would be cold. Administrator #1 stated that if something is cold on the meal tray, staff would reheat the meal in the unit kitchenettes' microwave. During an interview on 08/24/2026 at 1:25 PM, Administrator #1 and Infection Preventionist #1 stated that if residents wanted double portions, that would be added to their meal ticket. Administrator #1 stated that the coffee comes up separate from the meal and was served during the meal. They were not aware residents were not receiving coffee. They stated that the activities department usually passes a coffee tray mid-morning, but Activities Director #1 has been out, and it was not always being done. 10 New York Code of Rules and Regulations 415.14(d)(1)(2)

Based on observation, record review, and interviews conducted during the survey, the facility failed to implement a system to consistently and accurately reconcile controlled medications in accordance with professional standards of practice. Specifically, the narcotic count record signature sheet for one (B unit) of two units were incomplete. Findings include: The facility's policy titled Medication Administration reviewed 07/2026 documented: The licensed nurse receiving and checking in a medication listed in Schedule II is to prepare a controlled medication audit for that medication. Thereafter, two persons who are authorized to administer the medication, in accordance with the procedures for medication administration, will make a physical inventory of that medication at the change of each shift. Usually, that will be the medication nurse going off duty and the medication nurse coming on duty. Immediately after a dose is administered, the licensed nurse administering the medication is to enter all of the following information on the wing's proof-of-use record: date and time of administration, resident's name, dose administered, and signature of the nurse administering the dose. A review of narcotic count record book for Unit B documented: On 08/19/2026 at 11:30 AM Licensed Practical Nurse #1 had not signed the Narcotic Count Record for the oncoming nurse at 6:00 AM On 08/19/2026 Resident #63 Narcotic Record for Tramadol 100 milligram, give two tabs twice a day indicated there were 34 blisters containing two tabs. The blister packs containing medication for the Resident contained 32 blisters with two tabs. On 08/19/2026 Resident #44 Narcotic Record for Butalbital/Tylenol/Caffeine tabs, indicated there were 30 tabs. The blister packs containing the medication for the Resident contained 29 tabs. On 08/19/2026 Resident #60 Narcotic Record for Oxycodone 5 milligram, indicated there were 10 blisters including one and a half tabs. The blister packs containing the medication for the Resident contained nine blisters with one and a half tabs in each. During an interview on 8/19/2026 at 11:30 AM, Licensed Practical Nurse #1 stated they had a system for narcotic record keeping. They would sign the Narcotic Record book at the end of their shift, when they started their shift, and for all narcotics administered during their shift. They had a personal notebook they documented every narcotic they had administered through their shift; they would then transfer that information to the official records for narcotic administration record. The facility's narcotic record books were large and heavy; they did not carry them around with them on the medication cart. During an interview on 08/19/2026 at 1:00 PM, Assistant Director of Nursing #1 stated the narcotic count book should be signed by each nurse at change of shift when confirming narcotic counts and at the time any narcotic was administered. During an interview on 08/21/2026 at 10:08 AM, Director of Nursing #1 stated the narcotic count books should be signed by both nurses every shift and when the narcotic medication was administered. Nurses should not be keeping a personal record of narcotics administered and completing narcotic reconciliation at the end of the shift, they were unaware anyone in the building was doing so. 10 New York Codes Rules and Regulations 415.22(a)(1-4)

Based on observation, record review, and interviews conducted during the survey, the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one (Resident #67) of four residents reviewed. Specifically, Resident #67 remained in wet clothing for over two hours after ringing their call light for assistance with personal hygiene. Findings Include: The facility policy titled, Activities of Daily Living (ADLs), Supporting last revised 03/2026 documented Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Hygiene (bathing, dressing, grooming, and oral care); Mobility (transfer and ambulation, including walking); Elimination (toileting). Resident #67 was admitted to the facility with diagnoses including the need for assistance with personal care, muscle weakness, and urinary tract infection (an infection that affects any part of the urinary system including the kidneys, ureter, bladder, or urethra). The Minimum Data Set (an assessment tool) dated 05/27/2026, documented the resident could be understood, could understand others, and was moderately cognitively impaired. During an interview on 08/19/2026 at 10:39 AM, Resident #67 stated they pressed their call bell at 9:20 AM and had been waiting for staff to change their wet clothing. Resident #67 stated call bells were answered either quickly or slowly depending on which staff members were working during the shift. Resident #67 further stated that when Certified Nurse Aide #7 is assigned to them, they would wait a long time for help. During observations on 08/19/2026 at 10:39 AM, Resident #67 had a clock mounted on the wall above their television and a cell phone on their bedside stand to keep track of time. At 10:43 AM, Certified Nurse Aide #2 answered Resident #67's call bell and informed them that their assigned aide, Certified Nurse Aide #7 would be in to change them. During an interview on 08/19/2026 11:42 AM, Resident #67 stated they had a family member call the facility to notify staff that they needed to be changed, after which an aide finally changed them. During an interview 08/19/2026 at 10:45 AM, Certified Nurse Aide #2 stated the facility was short staffed. Resident #67 wass often soaking wet through their bed sheets when they staredt their shift at 6:00 AM. Residents should be checked and changed if needed every two hours. During an interview on 08/19/2026 at 10:55 AM, Certified Nurse Aide #3 stated they frequently came into the facility to start their shift at 6:00 AM, and residents were soaked with urine through the bed sheets. During an interview on 08/19/2026 at 11:45 AM, Certified Nurse Aide #1stated proper activities of daily living care, such as two-hour checks, were not getting done as they should be because there was not enough staff. They stated they often come on to their shift at 6:00 AM and residents were in the same clothing as when they left the previous night at 10 PM and soaked with urine through their bed sheets. During an interview on 08/19/2026 at 1:00 PM, Assistant Director of Nursing #1 stated they had been aware that when the day shift starts at 6:00 AM residents are soaked with urine. They stated there were a lot of agency staff overnight, they would not have the agency staff members who were not working up to expectations return to the facility. During an interview on 08/21/2026 at 10:08 AM, Director of Nursing #1 stated staff not doing two-hour checks on residents for incontinence care puts the residents at risk for multiple things. 10 New York Codes, Rules and Regulation 415.12 (a)(3)

Based on observation, record review, and interviews conducted during a survey, the facility failed to ensure each resident's drug regimen was free from unnecessary psychotropic medications for one (Resident #1) of five residents reviewed. Specifically, Resident #1's medical record did not document consent for prescribed antipsychotic medication, mental health assessments, or evaluations. Findings include: The facility policy titled Psychotropic Medications revised 6/2025 documented, residents who are admitted from the community or transferred from a hospital and who are already receiving psychotropic medications will be evaluated for appropriateness and indications for use. Re-evaluate the use of the medication at the time of admission and/or within two weeks (at the initial MDS assessment) to consider whether the medication can be reduced, tapered, or discontinued. The Attending Physician will determine the justification to continue the medication based on assessment, previous history vs current symptoms, and overall situation. The order will be placed with an appropriate name, dose, route, and diagnosis. A follow-up psychiatry re-evaluation in two weeks to assess the effectiveness and appropriateness of medication should also be considered. The primary contact /next of kin will be contacted and given an update on the behavior, and consent will be signed by the resident/family. Telephone consent can be obtained, provided the form is signed on the next visit. Consent is required when initiating or increasing psychotropic medication. Resident #1 Resident #1 was admitted to the facility on [DATE] with diagnoses including insomnia (difficulty in initiating or maintaining a restorative sleep), restlessness and agitation (severe restlessness or inner tension), and Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). The Minimum Data Set (an assessment tool) dated 07/06/2026, documented the resident could be understood, could understand others, and was significantly cognitively impaired. Review of resident's consults, provider visits, and progress notes revealed no documented evidence of behavioral health provider visits or a provider medication monitoring visit. Review of consents obtained for the resident revealed no documented evidence of a consent for quetiapine (antipsychotic medication). Provider orders dated 06/29/2026 documented resident was to receive quetiapine tablet 25 milligrams, one tab by mouth every morning and quetiapine tablet 50 milligrams, one tab by mouth every evening for restlessness with agitation. During an interview on 08/21/2026 at 10:08 AM, Director of Nursing #1 stated they would expect consent for quetiapine, a completed provider assessment, and a mental health diagnosis for Resident #1. 10 New York Codes Rules and Regulations 415.4(a)(1)

Based on observation, record review, and interviews conducted during the survey, the facility failed to ensure that one of three residents reviewed (Resident # 27) was treated with dignity and respect. Specifically, (a) Infection Preventionist #1 entered Resident #27's room unannounced and did not respond to the resident questioning who entered. Also, Resident #27's foley catheter bag (a collection pouch attached to a thin, flexible tube that drains urine from the bladder) was observed to be uncovered. Findings include: Facility policy titled, Quality of Life- Dignity, revised 08/2026, documented that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Residents' private space and property shall always be respected. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by helping the resident to keep urinary catheter bags covered. Resident #27 Resident #27 was admitted to the facility with diagnoses of urinary tract infection (an infection in any part of your urinary system, which includes the kidneys, ureters, bladder, and urethra), anxiety disorder (a mental health condition marked by excessive, ongoing, and hard-to-control fear, dread, or worry that disrupts a person's daily life), and depression (mood disorder characterized by persistent sadness and loss of interest, significantly impacting daily functioning). The Minimum Data Set (an assessment tool) dated 05/25/2026, documented the resident understood others, was able to be understood, and was cognitively intact. During an observation and interview on 08/18/2026 at 10:30 AM, Infection Preventionist #1 entered Resident #27's room and did not announce themselves to either the resident or the surveyor. Resident #27 stated, Who even is that?. Infection Preventionist #1 did not respond to the resident's question. Infection Preventionist #1 only made themselves known to the surveyor once the surveyor and preventionist stepped outside of Resident #27's room. During an observation on 08/19/2026 at 12:05 PM, Resident #27 was viewed in the main hallway going into the therapy gym. Resident #27's foley catheter was hung on the side of their wheelchair uncovered. During an observation on 08/24/2026 at 1:26 PM, Resident #27 was viewed in unit B hallway. Their foley catheter was hung on their wheelchair uncovered During an interview on 08/21/2026 at 1:12 PM, Resident #27 stated they do not like it when people do not knock on their door and do not announce themselves. They stated they feel like their privacy is being invaded. During an interview on 08/21/2026 at 1:22 PM, Certified Nursing Aide #3 stated that foley bags should be covered when residents are outside of their room for privacy reasons. Certified Nursing Aide #3 stated that staff should knock on residents' doors, announce themselves, speak calmy, and behave as if they are entering their family's home. During an interview on 08/21/2026 at 12:51 PM, Social Worker #1 stated they expect staff to knock first on resident rooms, wait for an answer, and announce themselves. During an interview on 08/21/2026 at 2:38 PM, Director of Nursing #1 stated that residents with a foley catheter should have a dignity bag so that it would be covered. They stated that the dignity bag should always cover the foley catheter bag, even in the hallway. Director of Nursing #1 stated that they expected staff to knock on residents' room doors, introduce themselves, and indicate why they were coming into the residents' rooms. Director of Nursing #1 stated that it was not respectful or dignified to not introduce themselves or knock on the residents' doors. During an interview on 08/24/2026 at 9:10 AM, Administrator #1 stated that they expect staff to knock on residents' door and introduce themselves because it was the residents' home. Administrator #1 stated that it was a dignity issue. 10 New York Code of Rules and Regulations 415.5(a)

Based on observation, record review, and interviews conducted during a survey, the facility failed to ensure residents were able to exercise the right to self-determination, including making choices regarding daily routines and preferences, for three (Resident #3, #59 and #67) of three residents reviewed for choices. Specifically, (a.) Resident #59's bed was removed from their room leaving only the recliner to sleep in; (b.) Resident #'s 3 and 67 were not permitted to have a shower as regularly as they preferred.Findings include: The Facility's Policy and Procedure titled Bath, Shower/Tub revised 02/2026 documented, the purpose was to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Staff were to document the date and time the shower/tub bath was performed including the name and title of the individual(s) who assisted the resident with the shower/tub bath. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. The Facility's Resident Rights Policy Interpretation and Implementation revised 02/2026 documented Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: (a.) a dignified existence; (e.) self-determination. Resident #59 was admitted to the facility with diagnoses including acute on congestive heart failure (the heart does not pump blood well; fluid backs up into the lungs or body tissues); lymphedema (swelling that happens when fluid builds up in body tissue); and cirrhosis of liver (permanent scarring that damages the liver and interferes with its functioning). The Minimum Data Set (an assessment tool) dated 07/21/2026, documented the resident could be understood, could understand others, and was cognitively intact. During an interview on 08/17/2026 at 1:12 PM, Resident #59 stated one day staff came into their room and removed their bed. The staff stated they were taking the bed for another resident who needs it because Resident #59 slept in the recliner. Resident #59 stated they alternated between the bed and recliner for comfort but were no longer able to do so since their bed was taken. They stated they had slept in the recliner for over three weeks. During an interview on 08/17/2026 at 1:45 PM, Administrator #1 stated each resident has a bed unless they ask to have the bed removed to create more space in their rooms. Some residents prefer to sleep in recliners instead of bed. Administrator #1 stated they vaguely recalled removing the bed from resident #59's room. Resident #59 can have a bed, and they will arrange to have one placed in their room immediately. Resident #3 Resident #3 was admitted to the facility with diagnoses including osteomyelitis of right ankle (bone infection), end stage renal disease (the kidneys no longer work well necessitating dialysis, or transplant) and orthopedic aftercare following surgical amputation (monitoring of the surgical site after limb removal). The Minimum Data Set (an assessment tool) dated 07/23/2026, documented the resident could be understood, could understand others, and was cognitively intact. Review of document provided labeled Shower list dated 06/21/2026-07/09/2026 and 08/02/2026-08/08/21/2026, Shower lists for 07/10/2026-08/2026 were not provided, documented: Resident #3 had been bathed on 06/23/2026, 06/29/2026, 07/05/2026 (was not recorded), 08/03/2026, 08/10/2026, and 08/17/2026 with no documentation of whether a bed bath or shower was given. During an observation on 08/18/2026 at 10:29 AM, Resident #3 was in bed speaking with certified nurse aide #2. Resident #3 asked, what would be the possibility of getting a shower today? The aide responded, slim, we do not have the time. During an interview on 08/18/2026 at 10:29 AM, Resident #3 stated they only had two showers since they arrived at the facility in June. The resident stated they commonly had bed baths. They had asked for showers often and had been told by staff they did not have time. Resident #67 Resident #67 was admitted to the facility with diagnoses including chronic respiratory failure (a condition where there was not enough oxygen or too much carbon dioxide in the body), muscle weakness, and urinary tract infection (an infection that affects any part of the urinary system including the kidneys, ureter, bladder, and urethra). The Minimum Data Set (an assessment tool) dated 05/27/2026, documented the resident could be understood, could understand others, and was moderately cognitively impaired. Review of document provided labeled Shower list dated 06/21/2026-07/09/2026 and 08/02/2026-08/08/21/2026, Shower lists for 07/10/2026-08/2026 were not provided, documented: Resident #67 had been bathed on 06/22/2026, 06/28/2026, 08/06/2026, and 08/29/2026 with no documentation of whether a bed bath or shower was given. On 07/06/2026 and 08/03/2026 a bed bath was documented. During an interview on 08/17/2026 at 11:03 AM, Resident #67 stated they did not get showered often enough. They did get bed baths but did not feel clean afterwards. The staff generally told them they were too busy to give them a shower. During an interview 08/19/2026 at 10:45 AM, Certified Nurse Aide #2 stated the facility was short staffed and showers cannot be done. They stated evening staff were not completing the showers, which was leading to residents requesting showers on day shifts and they do not have time for additional showers. They stated Resident #67 received bed baths mostly because they had to use a shower chair that was not comfortable for them and did not allow them to lie back. During an interview on 8/19/2025 at 2:40 PM, Administrator #1 reviewed the shower list with surveyor, they stated they would not be able to identify if a resident had a shower or a bed bath by documentation. During an interview on 08/21/2026 at 11:40 AM Certified Nurse Aide #2 looked at the shower book. They stated they would not be able to determine if a resident had a shower or a bed bath, just that they had been bathed. They also stated the resident shower list should be signed and have documentation if the resident was given a shower or bed bath. 10 New York Codes, Rules, and Regulations: 415.3(b)(1)

Based on observation, record review, and interviews conducted during a Recertification Survey, the facility did not ensure individual resident financial records were made available to resident and resident representatives through quarterly statements. Specifically, quarterly statements were not provided in writing to residents and/or resident representatives within 30 days after the end of the quarter. This was evident in 3 (Residents #8, #61, and #62) of 3 residents reviewed for Personal Funds. Findings include: The facility's Policy Interpretation and Implementation of Resident Rights revised 2/2026, documented residents have the right to: manage his or her personal funds, or have the facility manage his or her funds (if he or she wishes). Regulation 483.10(f) (10) (iii) Accounting and Records. A. The facility must establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf. C. The individual financial record must be available to the resident through quarterly statements and upon request. Resident #8 was admitted to the facility with diagnoses including long QT syndrome (a heart rhythm disorder that causes fast, chaotic heartbeats), bilateral corneal ulcers (sores on the clear, dome-shaped covering at the front of the eye), and low back pain. The Minimum Data Set (an assessment tool) dated 08/04/2026, documented the resident could be understood, could understand others, and was cognitively intact. Resident #61 was admitted to the facility with diagnoses including perforated intestine (a serious hole or tear in the wall of the small or large intestine), colostomy (a surgical procedure that creates an opening in the belly to redirect a portion of the large intestine, allowing waste to exit the body into an external collection bag), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Minimum Data Set (an assessment tool) dated 07/23/2026, documented the resident could be understood, could understand others, and was cognitively intact.Resident #62 was admitted to the facility with diagnoses including atherosclerosis (a disease where sticky plaque builds up inside arteries, making them narrow and hard); diabetes mellitus type 2 (a condition where the body cannot properly control the amount of sugar in the blood); and generalized muscle weakness. The Minimum Data Set (an assessment tool) dated 05/20/2026, documented the resident could be understood, could understand others, and was cognitively intact. During an interview on 08/21/2026 at 2:52 PM, Resident #'s 8, 61 and 62 stated they had not received any statements from the Business Office. They were unaware that they could ask for cash while in the facility. During an interview on 8/21/2026 at 11:00 AM, Ombudsman #1, stated residents had complained of not receiving quarterly statements and were unable to access funds. During an interview on 08/21/2026 at 11:49 AM, Business Office Manager #1 stated they were unfamiliar with how to send out statements; they had only been in the position for a short time. During an interview on 08/21/2026 at 11:55 AM, Administrator #1 stated the corporate office had been assisting while the new Business Manager was fully trained. They demonstrated where quarterly statements were generated on a system application. They stated statements were mailed to a family representative and delivered to residents with intact cognition. Administrator #1 provided the following three residents who have their statements handed to them, i.e.: Resident # 8, #61 and #62. In addition, residents had access to cash by asking a staff member who would contact the business office for cash. 10 New York Codes, Rules, and Regulations 415.26(h)(5)(iii)

Based on record review and interviews during an abbreviated survey (Case # 2590765), the facility did not ensure that a resident with an indwelling catheter (a tube inserted into the bladder to drain urine) received appropriate care and services to prevent urinary tract infections for one (1) (Resident #1) of three (3) residents reviewed. Specifically, for Resident #1, the facility did not ensure daily catheter care for the resident's indwelling Foley catheter in May, June, July, and August 2025. There was no documented physician order for daily catheter care until 8/20/2025.This is evidenced by:Resident #1: Resident #1 was admitted to the facility with diagnoses of spina bifida (a condition that occurs when the spine and spinal cord do not form properly), constipation, and retention of urine with obstructive and reflux uropathy (retention due to a blockage that makes it difficult or impossible to pass urine). The Minimum Data Set (an assessment tool) dated 6/26/2025, documented the resident had sever cognitive impairment. The resident usually made themselves understood (difficulty communicating some words or finishing thoughts but was able if prompted or given time) and usually understand others (missed some pertinent of message but comprehended most conversation). Policy and Procedure titled, Catheter Care - Urinary, revised 9/2024, documented the purpose of the procedure was to prevent catheter-associated urinary tract infections. The Documentation section documented, the following information would be recorded in the resident's medical record: date/time catheter was given; name/title of individual giving the catheter care, all assessment data obtained when giving catheter care; characteristics of the urine; any problems noted during care; how the resident tolerated the procedure; if the resident refused the procedure, the reason(s) why and the intervention taken.Care Plan for Foley Catheter related to urinary retention, initiated 8/10/2024 and revised 7/09/2025. Approaches (interventions) included provide catheter care per facility policy. Review of Physician Order Reports documented:- Report dated 5/01/2025 to 5/30/2025, documented an order dated 10/08/2024 for Resident had a Foley Catheter related to urinary retention. There was no documented evidence of order for daily catheter care.- Report dated 5/30/2025 to 6/29/2025, documented an order dated 10/08/2024 for Resident had a Foley Catheter related to urinary retention. There was no documented evidence of order for daily catheter care.- Report dated 7/01/2025 to 8/29/2025, documented an order dated 10/08/2024 for Resident had a Foley Catheter related to urinary retention. An order dated 8/20/2025, documented provide Foley Catheter Care every shift: days, evening, nights.Review of Nursing Progress dated 5/01/2025 to 8/21/2025, did not have documented evidence for Foley catheter care was provided.During an interview on 8/20/2025 at 11:20 AM, Licensed Practical Nurse #1 stated the Certified Nurse Aide would ask them to come to the resident's room and do the Foley catheter care, since it was usually done with peri care. They stated there would be an order on the Medication Administration Record for the Foley catheter care and they would document on the record once it was completed. They stated they monitored the urine output, and the characteristics for signs and symptoms of infection. They stated if there was no order for Foley catheter care, they would not be prompted in the computer that it needed to be done.During an interview on 8/20/2025 at 11:41 AM, Director of Nursing #1 stated a general order was entered for Foley catheter care at the time of admission along with the admission orders. They stated there would also be orders for tubing changes and urinary drainage bag changes. They stated every resident with a Foley catheter had an order for catheter care to prevent urinary tract infections.During an interview on 8/22/2025 at 11:20 AM, Licensed Practical Nurse #2 stated they checked every resident and knew which residents had a Foley catheter and needed catheter care. There was an order for catheter care in the computer and they would document once the care was provided. If no order in the computer, they stated they would still do the care and document care was done in a progress notes. They stated there should be an order for daily catheter care for each resident who had a Foley catheter.During an interview on 8/22/2025 at 11:59 AM, Licensed Practical Nurse #3 stated residents with a Foley a catheter had orders in the computer for catheter care and flushing. If there were no catheter orders they would tell the supervisor, and the supervisor would call the physician to obtain an order. 10 New York Code of Rules and Regulations 415.12(d)(1)

Based on record review and interviews during an abbreviated survey (Case # 2590765), the facility did not ensure residents received treatment and care in accordance with professional standards of practice that would meet each resident's physical, mental, and psychosocial needs for one (1) (Resident #1) of three (3) residents reviewed. Specifically, the facility did not ensure a physician order for treatment of a new wound on Resident #1's back, identified on 8/04/2025 during a wound care consult. This is evidenced by: Resident #1:Resident #1 was admitted to the facility with diagnoses of spina bifida (a condition that occurs when the spine and spinal cord do not form properly), constipation, and retention of urine with obstructive and reflux uropathy (retention due to a blockage that makes it difficult or impossible to pass urine). The Minimum Data Set (an assessment tool) dated 6/26/2025, documented the resident had severe cognitive impairment. The resident usually made themselves understood (difficulty communicating some words or finishing thoughts but was able if prompted or given time) and usually understand others (missed some part/intent of message but comprehended most conversation).Policy and Procedure titled, Consultants, revised 12/2024, documented the facility may use outside resources to furnish specific services to residents and to the facility. Such personnel were employed on a consultant basis. Consultant services included wound care. Consultants would provide the Administrator with written, dated, and signed reports of each consultation visit. Consultation reports contained recommendations; plans for implementation of their recommendations; findings; and plans for continued assessments. The facility retains the professional and administrative responsibility for all services provided by consultants.The Hospital wound care consult note for Resident #1 dated 8/04/2025, documented a new wound #6 located on the resident's back. Wound Treatment documented instructions for wound care of the back wound and included Triad 2.5 ounces, apply as directed three (3) times per week for fifteen (15) days; Alginate AG 4 x 4 inches, apply to wound bed three (3) times per week for fifteen (15) days. Diagnosis coding included spina bifida. There was no documented evidence of a physician order for treatment of the wound on the resident's back.Physician Order Report dated 7/01/2025 to 8/29/2025, documented an open-ended order dated 7/14/2025 for Wound Care Consult.The hospital wound care consult dated 7/28/2025, documented the resident had five (5) wounds as follows:o Wound #1 lower leg, right;o Wound #2 calcaneus (heel), righto Wound #3 coccyx (tail bone)o Wound #4 gluteus (buttock muscle), lefto Wound #5 upper leg, leftThe Hospital wound care consult note for Resident #1 dated 8/04/2025, documented wounds #1 through #5 and a new wound #6 located on the resident's back. Wound Treatment for the back wound included clean wound with saline, Triad 2.5 ounces (wound ointment), apply as directed three (3) times per week for fifteen (15) days; Alginate AG 4 x 4 inches (highly absorbent wound dressing), apply to wound bed three (3) times per week for fifteen (15) days. Diagnosis coding included spina bifida.There was no documented evidence of a physician order for treatment of the wound on the resident's back: Physician Order Report dated 7/01/2025 to 8/29/2025, did not document a treatment order for the wound on the resident's back. Treatment Administration Record dated 8/01/2025 to 8/20/2025, did not document an order for the wound on the resident's back. Review of the Medication Administration Record dated 8/01/2025 to 8/21/2025, did not document any wound treatment orders. Review of Nursing Progress Notes dated 8/04/2025 to 8/21/2025, did not document any notes about the new wound on the resident's back identified on 8/04/2025.Care Plan for Pressure Ulcer/Injury, revised 8/21/2025, documented the resident had actual skin impairment as evidenced by pressure ulcer to right heel and lateral foot, venous ulcers to right lower extremity, coccyx, and back. Approaches (interventions) included report any skin changes to provider as necessary; wound care treatment(s) as ordered.During an interview on 8/20/2025 at 1:53 PM, Assistant Director of Nursing #1 stated the facility's in-house wound care provider saw Resident #1 on 7/16/2025, and less than a week later, the resident's son wanted the resident to go to the hospital wound care center. Resident #1 usually returned with documentation from the hospital wound care center that was either given to them or Director of Nursing #1. Assistant Director of Nursing #1 reviewed the hospital wound care consult notes dated 8/04/2025, and stated there were six (6) wounds with treatments and there should be corresponding orders for all treatments in the computer system. They further stated, orders from the consult were entered in the computer system by them or Director of Nursing #1. The consult notes were then given to the Medical Records staff person to scan into the system. They stated the treatment orders would be documented on the Medication Administration Record, as they did not have a separate Treatment Administration Record.During an interview on 8/21/2025 at 2:05 PM, Director of Nursing #1 stated Resident #1's wounds were being treated and monitored by the facility's wound care provider and then ultimately was sent out to the hospital for wound care because the resident was refusing wound care. The resident had spina bifida and had a wound on their spine that closed last month (July 2025) and then reopened. Director of Nursing #1 reviewed the hospital wound care note dated 8/04/2025 and physician orders and stated, wound #6 was not identified by the facility and there was no order for the treatment. They stated typically the consultant would send the documentation with the treatment orders with the resident. There was a day when the resident came back from the wound consult and did not have paperwork. Sometimes the consult note was not dictated right away, and the facility would not receive the report until three (3) or four (4) days later. They reviewed the consult dated 8/04/2025, and stated it looked like it was faxed to the facility on 8/19/2025. When consult notes were faxed, they were scanned into the computer system by the Medical Records staff person and then they would notify them that it was scanned. Director of Nursing #1 would then contact the physician and enter the order into the computer system. They stated best practice would be for the facility to call the wound care clinic when the resident returned without documentation. They stated Resident #1 was the only resident in the facility who was sent out for wound care.During an interview on 8/21/2025 at 3:06 PM, Administrator #1 stated there was a delay in getting consult notes from the wound clinic and stated the wound clinic would not call the facility when they identified a new wound.During an interview on 8/22/2025 at 11:20 AM, Licensed Practical Nurse #2 stated wound care orders were documented in the computer system. When a resident returned from an outside wound consult, they would have paperwork that was given to the Assistant Director of Nursing #1 or Director of Nursing #1.During an interview on 8/22/2025 at 11:59 AM, Licensed Practical Nurse #3 stated they worked for an Agency, and it was their second time in the building. They stated if a resident had a wound and was ordered to have a treatment, it would be documented in the computer system. If the resident went out of the facility for a wound consult, they would return with paperwork and they would inform Director of Nursing #1 or the Assistant Director of Nursing #1. 10 New Code of Rules and Regulations 415.12

Based on observation, record review, and interview conducted during a recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice. Specifically, opened insulin had no open and/or expiration dates written on them. This was evident for 1 (Unit B medication cart) of 2 medication carts reviewed for medication storage. This is evidenced by: The facility's Policy and Procedure, titled Medication Administration and last revised ,d+[DATE] did not address labeling multi-use medications with expiration dates. During a medication cart review on Unit B with Licensed Practical Nurse #1 on [DATE] 9:16 AM, the following was observed: Resident #15's Basaglar KwikPen (insulin) was opened, and had no date opened or date of expiration. Resident #37's Basaglar KwikPen (insulin) was opened, and had no date opened or date of expiration. Resident #165's Humalog KwikPen (insulin) was opened, and had no date opened or date of expiration. Resident #166's Humalog KwikPen (insulin) was opened, and had no date opened or date of expiration. Resident #215 had 2 opened vials of insulin lispro solution with no dates when opened or expiration. Resident #216's Novolog FlexPen (insulin) was opened, and had no date opened or date of expiration. During an interview on [DATE] at 9:16 AM, Licensed Practical Nurse #1 stated both the date opened, and date expired - of 28 days after opening - should have been put on the sticker when a new pen or vial was opened. Licensed Practical Nurse #1 stated they had administered the undated medications to Residents #15, 165, and 166 this morning ([DATE]) and should not have because there was no way to know when the medications were opened or if they were expired, and all the insulins that were not dated would have to be discarded. During an interview on [DATE] at 9:46 AM, Licensed Practical Nurse #3 stated all multi-use insulin pens and vials needed to be labeled with the date they were opened, and that opened insulin pens and via were to be discarded 28 days after that date. hey were to be discarded 28 days after that date. During an interview on [DATE] 11:17 AM, Director of Nursing #1 stated nurses should have been writing on the labels when the insulins was opened and when they expired, which was 28 days after opening. Director of Nursing #1 stated they were new to the facility and not familiar with the policy related to labeling of multi-use medications. 10 New York Codes, Rules, and Regulations 415.18(d)

Based on record review and interview conducted during the recertification survey, the facility did not ensure the development and implementation of comprehensive person-centered care plans that included measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychosocial needs, that were identified in the comprehensive assessment, for 8 (Resident #s 7, 20, 21, 25, 30, 44, 55, and 215) of 19 residents reviewed for comprehensive care plans. Specifically, for (a.) Resident #7 comprehensive care plan was not implemented to provide the resident with a means of communication; (b.) for Resident #20, a comprehensive care plan was not developed for lymphedema, which the resident was receiving treatment for; And (c.) Residents #30 and #215 comprehensive care plan was not developed to be resident centered as to address the specific needs of the residents. This is evidenced by: 43805 The Policy and Procedure titled, CNR Care Planning - IDT, revised 9/2013 stated the care planning/interdisciplinary team was responsible for the development of an individualized comprehensive care plan for each resident. Resident #7 was admitted to the facility with the diagnoses of Alzheimer's disease, cognitive communication deficit, and unspecified dementia. The Minimum Data Set (an assessment tool) dated 7/06/2024 stated the resident was rarely/never understood, could rarely/never understand others and was severely cognitively impaired. The face sheet demographics documented the resident's preferred language was Japanese. The Comprehensive Care Plan titled, Resident is at risk for altered communication, included the interventions to utilize a translator if needed and utilize communication boards. During an observation on 10/03/2024 at 10:00 AM, no communication boards were observed in the resident's room. During an interview on 10/03/2024 at 12:40 PM, Certified Nurse Aide #4 stated they were not aware of a language line or translation services. They stated there were no communication boards used for the resident. They stated that at times some Certified Nurse Aides would use translation apps on their cellular phones to assist in communication. During an interview on 10/07/2024 at 12:01 PM, Licensed Practical Nurse #3 stated they were aware of a language line for translation, but they hadn't been taught how to use it. They stated they had not seen any translation devices or communication boards to use with the resident. Resident #20 was admitted to the facility with the diagnoses of atrial fibrillation, obstructive sleep apnea, and lymphedema. The Minimum Data Set, dated dated dated [DATE] documented the resident was able to be understood, could understand others, and was cognitively intact. Record review of the resident's comprehensive care plans showed no comprehensive care plan in place for the diagnosis of lymphedema. During an interview on 10/07/2024 at 2:15 PM, Director of Nursing #1 stated all conditions being treated should have a resident specific care plan. Resident #25 was admitted to the facility with the diagnoses of traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head), severe dementia with agitation, and delusional disorder. The Minimum Data Set, dated dated dated [DATE] documented the resident was rarely/never understood, could rarely/never understand others and was severely cognitively impaired. The Comprehensive Care Plan dated 8/18/2024 and titled, The resident exhibits behaviors as evidenced by, contained a list of potential symptoms. None of the symptoms were checked. The only approach documented in the Care Plan was not resident specific and not applicable to this resident who was rarely/never understood or able to understand-- It documented to: 'Approach the resident in a calm, consistent manner. Make eye contact. Use the resident's name and explain the purpose upon approach. Psychiatric/psychological consult and follow-up as necessary. Provide resident with the opportunity to express feelings through 1:1 and group visits. Encourage resident to participate in facility routine. Monitor for any changes in mood state. Provide reassurance and emotional support during episodes. Other.' The Comprehensive Care Plan dated 8/18/2024 and titled, Resident has a diagnosis of dementia severe with agitation, insomnia, traumatic brain injury, hallucinations, delusional disorder, restlessness, psychosis and is at risk for impaired decision making. The only approach documented in the Care Plan was not resident specific and not applicable to this resident who is rarely/never understood or able to understand-- It documented to: 'Administer medications as ordered. Encourage family/conservator/Power of Attorney to attend care planning and call with any changes. Encourage resident to attend preferred recreational activities. Assist resident in engaging tasks of historical interests, past profession, or hobbies as able. Observe for decline and provide rehabilitation services as needed. Speak slowly and clearly allowing time for resident to respond. Use resident's name when speaking to.' During an interview on 10/08/24 at 12:01 PM, Director of Nursing #1 stated care plans should be resident specific, that if there was a checklist then what applied to the resident should be checked off and then specific information that might help the resident should be added. Director of Nursing #1 stated they had just started in this facility last week and was already aware of the issues with the care plans, and would be making corrections as soon as possible. 10 New York Codes, Rules, and Regulations 415.11 (c)(1)

Based on observation, interviews, and record review conducted during the recertification survey, the facility did not provide effective housekeeping and maintenance services on 2 (Unit A and Unit B) of 2 resident units. Specifically, the carpeting throughout Unit A, Unit B, and the lobby was heavily soiled with dirt. This is evidenced by: During an observation from 10/03/2024 through 10/08/2024, the carpeting in the corridors on Unit A, Unit B, and the lobby area was heavily soiled with ground-in dirt. During an interview on 10/04/2024 at 1:35 PM, Environmental Manager #1 stated the carpeting cleaning machine has recently been repaired and that the facility had begun working on cleaning the carpeting. During an interview on 10/04/2024 at 1:41 PM, Administrator #1 stated the facility ownership was planning to replace the carpeting. 10 New York Codes, Rules, and Regulations 415.5(h)(4)

Based on medical record review and interview during the recertification survey, the facility did not ensure that residents and/or their designated representative were fully informed of their right to an expedited review of a service termination for 1 (Resident #54) of 3 residents reviewed. Specifically, a Notice to Medicare Provider Non-coverage, form CMS-10123 was not issued to Resident #54 prior to the Medicare Part A Service Termination. This is evidenced by: There was no documented evidence that a Notice to Medicare Provider Non-coverage, form CMS-10123 was issued to Resident #54 prior to the Medicare Part A Service Termination. During an interview on 10/08/2024 at 10:21 AM, Social Worker #1 stated they could not find the Notice to Medicare Provider Non-coverage, form CMS-10123 for Resident #54 and issuing this notice could have been overlooked. 10 New York Codes, Rules, and Regulations 415.3 (g)

Based on record review and interviews during an abbreviated survey (Case #NY 395) completed on 10/5/2021, the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with the resident rights for 1 resident (Resident #3) of 3 residents reviewed. Specifically, Resident #3, who was care planned for two-person assistance, was transferred from the bed to the chair by a Certified Nursing Assistant without additional assistance. Subsequently, Resident #3's legs buckled causing the resident to fall, and was diagnosed with fractures of the two bones in the lower leg (the tibia and fibula). This resulted in actual harm that is not immediate jeopardy to the resident's health and safety. This was evidenced by: Resident #3 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- an assessment tool) dated 5/29/2020 documented the resident had severe cognitive impairment, could be understood, and could understand others. An undated Investigative Summary documented that on 8/16/2020, Resident #3 was transferred from the bed to wheelchair by Certified Nurse Aide (CNA) #1. The care plan interventions required extensive assistance of 2 staff to move the resident between surfaces using a wheeled walker or a railing when available. The Comprehensive Care Plan (CCP) for Activities of Daily Living (ADLs) revised on 8/16/2020, documented the resident required extensive assistance of 2 staff and a total mechanical lift for toileting. The CNA Kardex (used by staff to know what care the resident required) that was in effect on 8/16/2020 was not available at the time of the abbreviated survey. A Fall Note dated 8/16/2020 at 7:30 AM, documented Registered Nurse (RN) #1 assessed Resident #3, who was laying on the floor in their room. CNA #1 was transferring the resident when the resident's knees buckled and the resident fell on to CNA #1, with both landing on the floor. The resident complained of pain in their left leg, and there was left knee swelling and the left leg was shorter than the right with the resident lying on their back. The resident requested to go to the hospital. A Nurse's Note dated 8/16/2020 at 3:22 PM, written by Licensed Practical Nurse (LPN) #1 documented the emergency room (ER) reported the resident had a distal left tibia/fibula fracture. The resident returned to the facility approximately 1:30 PM and was wearing a splint from knee to toe. An untimed X-ray report dated 8/16/2020 documented diffuse osteopenia and a distal tibial and fibular fracture on the left leg. During an interview on 5/19/2021 at 11:15 AM CNA #1 stated that on 8/16/2020 they were doing a stand-pivot transfer from the resident's bed to the wheelchair that was next to the bed. During the transfer, the resident's knees buckled causing CNA #1 to fall flat on their back and the resident fell on top of them. CNA #1 was able to get up from the floor and get the nurse by yelling for help. The nurse came into the room and checked the resident. The ambulance arrived at the facility and took the resident to the hospital. CNA #1 stated they misread the Kardex thinking it said the resident was a one-person stand pivot from the bed to the chair, but the Kardex documented the resident was a two-person transfer. CNA #1 stated they did not know how they misread the care card. During an interview on 4/12/2021 at 1:25 PM, the Director of Nursing (DON) stated that, at the time of the incident on 8/16/2020, the resident's CNA Kardex documented the resident was a one assist for toileting because the resident had the grab bar in the bathroom to hold while being transferred and required two assists for transfers to and from the bed and chair. The DON stated they felt CNA #1 glanced at the Kardex and saw the one assist for toileting and missed the care plan for two assists for transfers in and out of bed, so transferred the resident as a one assist. During an interview on 9/23/2021 at 11:16 AM, the Medical Director (MD) stated the resident may have been at an increased risk for a fracture based on age and immobility. The MD also stated the resident's care plan was not followed and the fracture may have been avoided if the care plan was followed and the resident was transferred by two staff rather than just the 1 CNA. NYCRR 415.11(c)(1)

Based on observation, record review and interview the facility failed to ensure that the Quality Assessment and Assurance program (QA) identified issues and activities necessary to develop a system to ensure that residents were appropriately assessed/reassessed and protected from accidents, including potential entrapment related to the use of mobility rails and devices during the extended recertification survey. This resulted in no actual harm with the potential for than minimal harm for residents # 18, 33, 37, 45, 47, and 67. and the potential for serious harm for 42 residents that were identified to have mobility rails and devices on their beds, which was determined to be Immediate Jeopardy and Substandard Quality of Care to residents ' health and safety. This was evidenced by the following information: See F 323 scope and severity - K The facility failed to ensure that residents were appropriately assessed for safety and protected from accidents (including entrapment) related to the use of mobility rails and devices (commonly referred to as "bed buddies" by the facility). The facility failed to have a policy that included an assessment and ongoing evaluation for the need and safe use of the mobility rails and devices. The facility failed to have a system in place to ensure proper application and monitoring of the application of the mobility rails and devices. Specifically, on 03/21/2011 resident #47 was found sitting on the floor next to the standard bed with her head entrapped between the mobility rail (side rail) and the mattress. The facility failed to identify the incident as an entrapment and failed to educate staff regarding the safe use of mobility rails and devices and the risks of entrapment following the incident. During an interview on 8/17/11 at 11:45am the Director of Nurses (DON), who oversees the QA program, stated that the QA committee meets quarterly. She stated that different departments bring the results of audits they do. She stated that Maintenance brings audits on doors, wanderguards, door alarms and they look at beds to check the wiring and mechanics of the bed. She stated that Maintenance was in charge of environmental audits, looking at call lights, if doors are shut, bed alarms. She stated that neither QA or nursing had completed audits for beds and/or mobility rails and devices at this time. During an interview on 8/10/11 at 8:10am the Maintenance Director stated that he does complete weekly audits. He stated that he does weekly audits for the use of the mobility rails and devices but, the audits do not include checking the functionality, mechanical placement or tightness of the rails, only that they are still in place on the bed. 10 NYCRR 415.27(a-c)

Based on observation, record review and interview during the extended recertification Quality Indicator Survey, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible; and that each resident received adequate supervision and assistance devices to prevent accidents for 6 (#'s: 18, 33, 37, 45, 47, 67) of 6 residents reviewed for environmental accident hazards. The facility failed to ensure that residents were appropriately assessed for safety and protected from accidents (including entrapment) related to the use of mobility rails and devices (commonly referred to as "bed buddies" by the facility). The facility failed to have a policy that included an assessment and ongoing evaluation for the need and safe use of the mobility rails and devices. The facility failed to have a system in place to ensure proper application and monitoring of the application of the mobility rails and devices. Specifically, on 03/21/2011 resident #47 was found sitting on the floor next to the standard bed with her head entrapped between the mobility rail (side rail) and the mattress. The facility failed to identify the incident as an entrapment and failed to educate staff regarding the safe use of mobility rails and devices and the risks of entrapment following the incident. This resulted in no actual harm with the potential for than minimal harm for residents # 18, 33, 37, 45, 47, and 67 and the potential for serious harm for 42 residents that were identified to have mobility rails and devices on their beds, which was determined to be Immediate Jeopardy and Substandard Quality of Care to residents' health and safety. The Immediate Jeopardy was removed prior to the end of the survey when the facility completed audits and assessments for the 42 residents with mobility rails and devices, removed the unsafe devices, developed policies and procedures for the use of mobility rails and devices, and educated staff regarding safety of mobility rails and devices. This was evidenced by: On 8/8/2011 at 1:11 pm, resident #47 was observed to have a low to floor bed with bilateral mobility rails/devices. The rail/device that was on the right side of the bed was observed to be approximately four inches from the side of the mattress, leaving a four inch gap between rail/device and the mattress. There was no gap on the left side of the bed at the time of this observation. The resident was not in bed at this time. On 8/8/2011 at 3:00 pm, three survey team members returned to the resident #47 ' s room to observe and measure the mobility rail/device that was in place on the low to the floor bed. The right mobility rail/device was observed to be in an upright position and to have a gap between it and the mattress. The gap was measured with a measuring tape and found to be four inches wide. There was no significant gap observed on the left side of the bed. A surveyor was able to easily move and lift the entire concave mattress from the frame of the bed by using the mobility rail/device. The entire mattress easily shifted side to side between the right and left mobility rail/devices, which created varying measurements of the space or gap between the mattress and the mobility rail/device. The mobility rails/devices were not attached to the bed frame but, were observed to be attached to each other while under a hard plastic mattress support that was lying on the bed frame. During Stage I observations completed at various times on 08/08 and 08/09/2011, three different types of mobility rails and devices were identified to be in use for the reviewed residents. The Survey team then completed a comprehensive observation of all of the resident rooms on both the A and B nursing units on 08/10/2011, to determine the use of mobility rails and devices facility wide. A total of 42 residents were identified to have one of the three different mobility rails or devices on their beds. The manufacturer's recommendations for the mobility rails and devices and the beds the facility used were requested from the Director of Nursing (DON) and the Director of Maintenance (DOM) upon the completion of the tour on 08/10/2011. The three different mobility rails or devices were identified as the following: 1. The AbleRise Bed Assist device (referred to as bed buddies by the facility). These were observed to be used as one sided for one resident and two sided for two residents. The manufacturer's directions for assembly included direction to be sure the handles (rails) butt (position next to) against the mattress. Resident #47 was observed to have two sided AbleRise Bed Assist device in place on her bed on 08/08/2011 and 08/10/2011. During the observation on 08/10/2011 at approximately 11 am, the handle (rail) did not butt against the mattress as directed. Resident #67 was observed to have a one sided AbleRise Bed Assist on the bed. During observation on 8/10/11 at approximately 11:00am the handle (rail) did not butt against the mattress. 2. Traditional beds were observed with the manufacturers included upper one and two sided rails in use. Residents #33 and #37 were observed to have two sided upper side rails in use. Residents #45 and #18 were observed to have one sided upper side rails in use. 3. M-Rail devices (also called bed buddies by the facility staff) were observed in use for 36 residents at the facility. The manufacturer ' s recommendation for this device stated the mattress must be tight against the assistive hand rail, with no gaps at all times. This should be checked frequently, at least daily. The manufacturer further recommended for added safety installing two M-Rails, one on each side of the bed, to assist with keeping the mattress in place, with no gaps. The facility provided a list of M-Rails in use by residents on each unit. Based on observation and the facility provided list: The A nursing unit had 11 residents with the M-Rail on one side of the bed The B nursing unit had 1 resident with the M-Rail on one side of the bed During an interview with the Maintenance Director on 8/10/11 at 8:10am, regarding the mobility rails and devices, he stated that the traditional beds come with standard side rails. He went on to say that about 3 months ago the facility started to replace the standard side rails with M-Rails (bed buddies) for those residents who needed them. He stated that he does weekly audits for the use of the mobility rails and devices but, the audits do not include checking the functionality, mechanical placement or tightness of the rails, only that they are still in place on the bed. On 8/10/11 at approximately 8:45am policies and procedures for the use of mobility rails and devices were requested from the Director of Nursing (DON). There was not a policy or procedure for mobility rails and devices provided. The facility policy titled "Side Rails " was submitted by the DON. The policy included that as part of the admission assessment, a side rail and resident assessment would be completed by the nurse. This policy documented the interdisciplinary team would meet quarterly to provide education regarding the risks and benefits and alternatives to side rails. The policy did not include the evaluation or reassessment for use of side rails. The policy also included that a comprehensive care plan would be developed. Resident # 47: The facility failed to ensure that residents were appropriately assessed for safety and protected from accidents (including entrapment) related to the use of mobility rails and devices (commonly referred to as "bed buddies" by the facility). The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident was understood and usually able to understand. It assessed her with intact cognition. She was assessed as requiring limited assistance of one person with bed mobility and had a fall in the last two to six months prior to admission. This MDS did not indicate the use of side rails. The Care Area Assessment (CAA) Summary noted that the care area of "Falls" triggered for the resident and that it had been addressed in the care plan. The MDS dated [DATE] assessed the resident had moderately impaired cognitive status, required extensive assistance of one staff person for bed mobility, and did not indicate the use of side rails. The MDS dated [DATE] assessed the resident with short and long term memory impairment with moderately impaired cognitive skills for daily decision making. The resident was noted as requiring extensive assistance of one person for bed mobility, and had two falls since the prior assessment with no injury. This MDS did not indicate the use of side rails. The Nursing History and assessment dated [DATE] documented the resident had side rails. A nurses note dated 9/24/10 documented the resident had requested the side rails up as enablers (to assist with mobility) and was aware of the risks. There was no documented evidence of an initial side rail/bed mobility device assessment done in the medical record. There was no documented evidence of an admission Falls Risk Assessment having been completed in the medical record. The resident's "Nurse Care Plan", a form referenced by the Certified Nursing Assistants (CNAs) to provide care to the resident's, was dated 9/24/2010. It included that the resident moved to and from a lying position, turned side to side, and positioned her body while in bed by herself with assistance as needed. It was noted that the resident had two upper side rails as enabler's that were discontinued on 3/21/11 and changed to bed buddies (Able Rise bed mobility device) as enabler's on a low to floor bed. A Comprehensive Care Plan (CCP) titled "At Risk for Falls due to history of falls and increased weakness" initiated on 9/24/10 documented that on the dates of 1/10/11, 2/6/11, 3/12/11, 3/21/11, and 5/2/11 the resident had falls out of bed. The outcome evaluation dated 3/21/11 noted that the resident had fallen from bed, that a reddened area to the neck had resolved, and that her side rails were discontinued with a low to floor bed and bed buddies to be used as enabler's provided. The CCP titled "Use of Side rails" initiated on 9/27/10 documented the resident had two top side rails up while in bed. The quarterly evaluation on 12/23/10 documented that the care plan was reviewed; enabler's were used for bed mobility, and to continue the action and approaches. The quarterly evaluation did not include an assessment of the resident's continued need and safe use of the side rails. On 3/21/11, this care plan was discontinued, at which time the resident's side rails were discontinued and the resident was provided with bed buddies and a low to floor bed. A CCP for "Self Care Deficit" initiated on 9/24/10 documented that the resident required one to two person assist for bed mobility. It documented that the resident had two upper side rails discontinued on 3/21/11 and that the resident was using bed buddies. It did not include documentation of an assessment of the resident's continued need and safe use of the side rails. On 3/21/11, the resident's side rails were discontinued, a low to floor bed and bed buddies were provided after the fall the resident had out of bed. A Nurse's Note dated 1/10/11 at 12:45 pm documented that the resident's bed alarm sounded, that a CNA went to the room, and found the resident sliding out of bed to her knees to the floor with her torso and head still on the bed. It noted that the resident stated she rolled over and started to slide out of bed. At 6:00 am, it was documented that the resident had a noted abrasion with light bruising on her right upper chest. An Incident Report dated 1/10/11 noted that at 12:45 AM the resident's bed alarm sounded, a CNA went to the room and found the resident sliding out of bed with her knees to the floor and her torso and top of body still on the bed. It was documented that the resident stated she rolled over and started to sIide out of bed. It noted only her knees were on floor, that top side rails were present and that the bed was in down position. The report was signed by the Administrator, the DON, and the Medical Director. A Nurse's Note dated 2/6/11 at 1:45 am documented that the resident was found sitting on the floor at the edge of the bed and that she had stated "I was getting out of bed to go to the bathroom". No incident report was located for the fall on 2/6/11. A Fall Risk Assessment for the fall on 2/6/11 was dated 2/7/11. The assessment did not include documentation for the continued need or safe use of the side rails. The plan of action documented the resident was on an active Physical Therapy (PT) program, but overall declined steadily in balance and in independence. A Nurse's Note dated 3/12/11 at 4:00am documented that the resident was found on her knees at the side of her bed, tangled in a blanket and sheets. It noted that the alarms sounded and that the resident was holding onto the side rail with her left hand. An Incident Report dated 3/12/11 at 4:00am documented that resident stated she got too close to the edge of the bed and slid out. It noted that she was tangled in a sheet and a blanket, and stated she did not hit her head, but landed on her knees. It was noted that the fall was not witnessed, that the side rails were up, and that the bed was in the down position. It documented the possible use of a low to floor bed with a mat under steps taken to prevent recurrence. It was signed by the DON and the Medical Director. A Nurse's Note dated 3/21/11 at 8:00 am documented that the patient was found on the floor by an aide sitting on the mat at the side of the bed. It noted that the patients head was found between the mattress and the side rail. It noted that the patient was assessed with [REDACTED]. It was noted that she continued with ecchymosis to the upper right arm and upper aspect of the right chest near her arm and that this was old from a previous fall. At 9:30 am, it was noted that the fall was discussed with the care team and that the side rails were being discontinued and that a low to floor bed with bed buddies as enabler's was being provided. An Incident Report dated 3/21/11 at 6:15 am documented that the resident was found on the floor by an aide, sitting on the mat at the side of the bed. It included documentation that resident #47 ' s head was found between the mattress and side rail and that she had redness on the right side of the neck. A CNA was witness to the fall and it was documented that the side rails were present and the bed was in the down position. The incident report was signed by the DON and the Medical Director. An attached investigation written by the DON on 3/21/11, documented that the resident was told the side rails were being discontinued and that the facility was going to get a low to floor bed for her. The investigation also stated that the facility would look into a bed buddy for her. On 3/22/11 it was documented that the resident liked her new bed and the bed buddies. The investigative summary included that the incident had been discussed with the Administrator. A Fall Risk assessment dated [DATE] was signed by a Registered Nurse (RN) on 3/21/11 and the Rehabilitation Director on 3/22/11. It documented that at 6:15 am, the resident was found sitting on the floor on the mat at the side of her bed with her head between the mattress and side rail and that she had five previous falls during the past quarter. The plan of action documented to discontinue the side rails and to provide a low to floor bed with bed buddies to be used as enabler's. This assessment did not include documentation of an evaluation of the resident's safe use of the bed buddies as enabler's. A Nurse's Note dated 4/23/11 at 5:20 am, documented that the resident was found sitting on the mat at the side of her bed and that it was not witnessed. An Incident Report dated 4/23/11 documented the resident fell at 4:50 am and noted that the resident stated she was going to the bathroom and sat on the mat. It was noted that side rails were not present and that the bed was in the down position. The report was signed by the DON and the Medical Director. A Nurse's Note dated 5/2/11 at 2:00 am, documented that the patient was in bed and slid out of bed. The note included that the slide from bed was witnessed. It was noted the resident stated she turned over. It was noted that she slid onto her knees on the right side of the bed. An Incident Report incorrectly dated 5/1/11 at 11:50 pm was completed for the resident's fall and documented that the resident stated she turned over and slid out of bed. It noted that it was witnessed by a CNA and that she slid onto her knees on the right side of the bed with no apparent injuries. It noted that side rails were not present and that the bed was in the down position. The report was signed by the DON and the Medical Director. A Fall Risk assessment dated [DATE] documented the resident slid out of bed onto her knees at the right bedside and that she had right and left bed buddies in place on a low to floor bed. The Plan of Action documented the resident recently completed Physical Therapy treatment and that safety measures were in place by the bed. It then noted that, unfortunately, the resident did attempt out of bed on occasion despite the need for one assist. On 8/8/2011 at 1:11 pm, resident #47 was observed to have a low to floor bed with bilateral mobility rails/devices. The rail/device that was on the right side of the bed was observed to be approximately four inches from the side of the mattress, leaving a four inch gap between rail/device and the mattress. There was not a gap on the left side of the bed at the time of this observation. The resident was not in bed at this time. On 8/8/2011 at 3:00 pm, three survey team members returned to the resident #47 ' s room to observe and measure the mobility rail/device that was in place on the low to the floor bed. The right mobility rail/device was observed to be in an upright position and to have a gap between it and the mattress. The gap was measured with a measuring tape and found to be four inches wide. There was not a significant gap observed on the left side of the bed. A surveyor was able to easily move and lift the entire concave mattress from the frame of the bed by using the mobility rail/device. The entire mattress easily shifted side to side between the right and left mobility rail/devices, which created varying measurements of the space or gap between the mattress and the mobility rail/device. The mobility rails/devices were not attached to the bed frame but, were observed to be attached to each other while under a hard plastic mattress support that was lying on the bed frame. On 8/10/11 at 6:58 am, the surveyor returned to measure the distance between the mattress and bed buddies while the resident was in bed sleeping. The measurement on the right side of the bed from the mattress to the bed buddy was again measured as four inches on 8/10/11 at 6:58 am and at this time, with two inches from the mattress to the bed buddy on the left side. These measurements were taken when the resident was in bed sleeping with the concave mattress depressed by her body weight. During an interview on 8/10/11 at 7:45 am, Licensed Practical Nurse # 1 stated if she noticed a gap between a mattress and a bed mobility device, then she would first look at the mattress to see if it shifted or if it was the right mattress for the frame and would then discuss it with the Registered Nurse Unit Manager (RNUM) if she thought the mattress needed to be fixed or changed to a different one. She stated they would then have someone from Maintenance address it. She stated she had never noticed any gaps between the mattresses and bed mobility devices. During an interview on 8/10/11 at approximately 8:15 am, the Staff Development Coordinator (SDC) stated she was not aware of the 3/21/11 incident with this resident. She stated she had not completed any training after the incident. She stated the mobility rails and devices were discussed in her restraint education program and touched upon in the facility's resident rights and abuse annual in-service. She further stated that the side rails were discussed in the Nurse Aide Trainee Program for restraints. She stated she was not aware of annual in-service or other education related specifically to mobility rails and devices or side rails having been done. She later stated at 8:45 am, that a restraint in-service completed last year talked about entrapment and rail use, but nothing had been done since then. During an interview on 8/10/11 at 8:40 am the DON stated the facility did not have a formal in-service regarding side rails or mobility rails and devices following the incident with resident #47 that occurred in March. During interview on 8/10/11 at 9:50 am, the Rehabilitation Director stated that if a resident/family requested the use of a side rail, then this was discussed with her in morning report. She stated that if through discussion, she agreed that side rails or bed mobility rails and devices were appropriate, the maintenance staff applied them to the bed. She stated that they then discussed the side rails and bed mobility devices at their quarterly team meetings for the residents. She stated the therapy staff did not do assessments and evaluations on side rails and bed mobility devices to see if they were appropriately applied or to see if the residents were still using the devices safely. She stated that therapy staff primarily reevaluated resident range of motion and balance quarterly, and did not reevaluate side rails and bed mobility devices at quarterly assessments. During an interview on 8/10/11 at 11:00 am, the Registered Nurse (RN), who worked the night shift at the time of the 3/21/11 incident with the resident, stated that there were some residents with bed buddies in place. When she was asked what these were, she stated the residents used them to move about in bed or to get up. She stated that she assesses resident position in bed, making sure they are in the center of the bed, and checks to make sure that the resident's extremities were not entangled in the side rails or bed mobility devices. She stated she did check the up and down position of the side rails, but did not check the space between mattresses and side rails. When asked if she remembered anything particular with this resident having fallen, she stated she did recall a morning earlier in the year when the resident was found sitting on the floor next to her bed with her head near the mattress and the side rail. She stated a lab tech had been in to draw blood from the resident at 6:00 am and about fifteen minutes later, a CNA found the resident sitting on the floor next to her bed with her head between the mattress and the side rail as the resident was sitting on the floor. She stated the resident had not removed her head from that position before she arrived. She stated that on assessment, she believed the resident had a red mark on her neck. She reported that the back of the resident's head, from ear to ear, was the area of the head that was between the mattress and the side rail. During an interview on 8/10/11 at 2:00pm, Certified Nursing Assistant (CNA) # 1 stated that the resident did fall one morning in March 2011 when she came into work at 6:00 am. She stated that she and the night CNA responded to an alarm sounding in the resident's room. She stated they found the resident sitting on the floor mat next to her bed. She first stated the resident head was near the mattress and the side rail, and then when asked to explain, she stated the resident's back of her head was between the mattress and the side rail. She stated the resident was in a regular bed with regular side rails then, and now was in a low bed with a concave mattress and fixed rails with pockets (AbleRise bed assist mobility device). On 8/10/11 at 2:00pm, the DON was interviewed about the incident of 3/21/11 with the resident. She stated the resident had been sleeping, and had her blood drawn at approximately 6:30am. After the blood was drawn, the CNAs went in to do care and they found her falling out of bed. She stated that at the time of this fall, the resident had a standard hospital bed with standard side rails. She stated that she was informed of the fall when she came in to the facility at 8 am on 3/21/11. She stated she immediately wanted the side rails removed from the bed and a low to floor bed implemented for the resident. She stated she talked with the resident about the removal of the side rails, but the resident then stated that she still wanted something to help her move in bed and the team decided on the implementation of bed buddies. She stated from what staff had told her that morning, the residents knees were down on the floor with her head on the mattress and the head against a closed side rail (there were no staff statements provided to verify this information). She stated she had not heard that the resident's head was between the mattress and the rail. On observation of the resident's mattress and the bed buddy with the DON at 2:15 pm, she stated that she could then see how there concern with how the bed buddies was had been applied to the bed. She stated that she would prefer the mattress to be closer to the rail and that the gap was not acceptable considering the resident's history of falls out of bed. She stated she would have these removed and replaced by the " M-Rail" mobility devices right away. She stated she thought therapy staff typically evaluated side rails and bed mobility devices prior to placement. She stated she would say that the CNAs, the Nurse Managers, and the therapists should be looking to see if the rails and the mattresses were appropriate for the resident based on their use. She next stated that at this time, the facility had no system in place to monitor safe application of bed mobility devices. She stated that review of side rails should be documented in the RN's admission assessment and nurse ' s note and at quarterly comprehensive care plan meetings. She stated that residents with side rails all know the risk and benefits of them prior to use. She stated that maintenance has been looking into new beds for the facility and that they had found other side rails may not be compatible with the current beds in use. She stated they started using the "M-Rail" mobility devices in February or March of 2011. She stated when resident and/or families insist on having side rails, then they don't remove these, but are sure to provide education to them on the risks and benefits and this should be documented on admission and quarterly evaluations. She stated she thought therapy staff had been assessing and evaluating resident use of side rails and bed mobility devices. During an interview on 08/10/2011 at 3:00 pm, the Director of Maintenance stated this resident had been in a standard bed with side rails in March 2010 and that she was changed to an older style of a low to floor bed after she fell in March or so. He stated that the "M-rail" bed mobility devices did not fit on that low to floor bed so the bed buddies were used instead. He stated they were attached to a mattress support on top of the bed frame and that they were not directly attached to the bed frame. He stated that maintenance does not have records of work orders for when changes to beds were made. During an interview on 8/16/11 at 1:45 pm the facility's Medical Director stated he reviews and signs off on all the incident reports at the facility and deals with them based on nursing assessments and historical information. He stated he did not remember the specific incident with this resident that occurred on 3/21/11 where it was indicated that she slid out of bed with her head between the mattress and the side rail. He stated that if there had been no injury at that time, or if she had not been sent out to the hospital, then he probably would not have recommended anything. He stated he reviewed so many incident reports each week and he just couldn't recall. During an interview on 8/16/11 at 2:45 pm the Assistant Director of Nursing stated she believed at the time of the 3/12/11 fall there were no low to floor beds available. She stated she was on call for that weekend and was unable to see if there were any low to floor beds available because she wasn't physically present at the facility. She stated the team then discussed the incident at the morning meeting the Monday after it occurred and that they had the nursing staff look at all the resident's in the building to see if any of them had low to floor beds that were no longer needed. She stated this was done and she believed there had not been any found to be available so they had not implemented it after the fall on 3/12/11. She stated they likely waited for one to become available, which happened to be after the 3/21/11 fall out of bed. During interview on 8/16/11 at 2:50 pm the facility's Social Worker stated mobility devices were reviewed at quarterly meetings for their continued presence. During an interview on 8/16/11 at 3:20 pm, CNA # 2 stated he witnessed the resident's fall on 5/2/11. He stated he walked by the resident's room several times and noticed her to be restless, fidgeting and moving her feet around in bed. He stated he thought that maybe she was having a nightmare or needed repositioning so he knocked on the door to go in and reposition her, but that she got startled, sat up quickly and slid on her bottom to the floor in a kneeling position, facing away from the bed towards the door in a praying position. During an interview on 8/17/11 at 11:20 am the Registered Nurse Unit Manager #2 stated that fall risk assessments were done on admission and then after each fall to help them to see what was going on and to help with care planning. She stated they did not do quarterly fall risk assessments because in her opinion they had no significance. She stated that these assessments were geared toward finding out what happened and what was different. She stated she had not known who actually applied the resident's bed buddies to the bed after the 3/21/11 fall and that it had to be someone from maintenance. She stated that on admission, the risks and benefits of side rails were discussed with the resident and/or family and the resident was observed for appropriate use of the side rails on admission by nursing staff. The RNUM then stated that she reviewed resident side rails, by talking with the residents, visually observing the use, and by talking with direct care givers. When asked for documented evidence of these visual assessments done, the RNUM was unable to produce this. She stated documentation of the side rail or bed mobility device presence should be enough to show that she formally assessed such for appropriateness, safety and use. She stated she didn't document this specifically because she had too many residents to do this. Resident #37 The facility failed to assess or reassess the need for mobility rail and device use for this resident and to ensure the safest bed mobility device was in use for this resident. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as understood and able to understand, as having intact cognition and as having total dependence on one personal physical assistance for bed mobility. This MDS did not indicate bed rail use. The MDS dated [DATE] again assessed the resident as understood and able to understand and as having intact cognition, but then assessed her assessed as having total dependence on the physical assistance of two people for bed mobility and as having had no falls. This MDS did not indicate side rail use. There was no documented evidence of an initial side rail assessment done in the medical record. The Nurse Care Plan, a form referenced by CNAs to provide care, was dated 12/3/10 and noted the resident had two side rails up in bed as enabler's and that she required assistance to move to and from a lying position, turning side t