Every finding on record at The Friendly Home

Based on observations, interviews, and record review conducted during recertification and complaint (#2619460) surveys from 12/11/2025 to 12/19/2025, for three (3) (Resident's #85, #125, and #126) of ten (10) residents reviewed, the facility did not ensure the resident's environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistive devices to prevent accidents. Specifically, Resident #85 was observed over several days to have unopened wine bottles unsecured at their bedside, Resident #85 was not care planned for personal alcohol possession or consumption and there were other residents with wandering tendencies residing on that unit. In addition, Resident #125 had a right-sided transfer bar attached to their bed and a gap of approximately four (4) inches was observed between the transfer bar and mattress, concerning of a potential area of entrapment (where an individual can be caught between components of a bed). The facility could not provide documented evidence that transfer bar and bed safety checks were performed every shift by Nursing staff. Lastly, Resident #126 was known to have wandering and exit seeking behaviors, and eloped (resident leaves the premises or safe area without the facility's knowledge and supervision) from the facility. Prior to Resident #126's elopement, the door was known to not be functioning properly, and the facility was unable to provide documentation that interventions were put in place to keep the resident safe on the unit. This is evidenced by the following:The facility policy Wander Monitor System Alarm, with an unknown date documented the reception desk monitors the main entrance for departures by residents with a wander guard bracelet. The facility policy Missing Member/Elopement dated September 2024, documented alarms do not replace necessary supervision and require maintenance and testing to ensure proper functioning. The Nurse Manager assigns a staff member to observe the resident at times when wandering behavior intensifies and initiates more frequent checks as needed. The facility policy Alcohol in Life Enrichment Programs with an unknown date, included consumption shall be monitored at programs where alcohol was served, the staff were to use a standard measurement of 1 (one) ounce of alcohol per drink, and a maximum drink limit of two (2) per resident. Additionally, the policy included for staff to serve alcohol to residents in designated areas only. The facility policy Transfer Bar with an unknown date, included a transfer bar being defined as a one-piece device attached to the bed frame on one of both sides of the bed that is grasped to aid in bed entry and exit, and bed mobility. The policy included that all staff were responsible to monitor residents with transfer bars to ensure they are in good working order and do not pose an immediate risk of entrapment or injury. Additionally, daily checks of the transfer bar were to be completed to ensure it is placed appropriately and does not pose a risk for entrapment. 1.Resident #126 had diagnoses including dementia, major depressive disorder and muscle weakness. The Minimum Data Set (a resident assessment tool) dated 10/16/2025 revealed the resident had moderate impaired cognitive function and had history of delusions and wandering. The Comprehensive Care Plan initiated on 01/07/2025 documented Resident #126 wore a wander guard bracelet (wearable device for elopement prevention) and had exit seeking behaviors, and interventions included to distract the resident from wandering by offering pleasant diversions. In several progress notes, License Practical Nurse #10 documented the following:- On 08/06/2025, Resident #126 was exit seeking and trying to put the code in for the [NAME] Unit door to open, was stating that they wanted to leave and was trying to get other residents to help them get through the door. - On 08/22/2025, Resident #126 was exit seeking and was stating staff were keeping them at the facility against their will. - On 08/23/2025 and 09/11/2025, Resident #126 was going into other resident's rooms and was exit seeking. In a progress note dated 09/15/2025 at 3:29 PM, Licensed Practical Nurse #7 documented Resident #126 was pacing the hallways and interrupted them several times while trying to complete the medication pass. In a progress dated 09/15/2025 at 6:07 PM, Licensed Practical Nurse #11 documented Resident #126 was not on the unit, they initiated the appropriate policy in response, and Resident #126 returned to the unit around 6:30 PM. Review of the facility's investigation documented Concierge #1 reported hearing the alarm on the main door activate around 5:57 PM. They thought a resident at a party (occurring in the front room) had triggered the alarm, so they deactivated the alarm using a device at the front desk, and Resident #126 walked out of the building. The resident was returned to the facility by the police at 6:40 PM. Review of facility Maintenance Work Orders dated 08/15/2025, 08/21,2025, 09/03/2025, 09/04/2025, 9/14/2025, and 09/15/2025 revealed maintenance requests were made by five (5) different staff documenting the [NAME] unit door was not latching properly and was not secured. The work orders were signed by five (5) different maintenance staff as completed their portion. On 09/03/2025, Maintenance Technician #1 documented the vendor had been contacted. The facility was unable to provide documentation regarding response from the vendor for that date. During an interview on 12/18/2025 at 5:26 PM, Concierge #1 stated that on the evening of 09/15/2025, there was a party in a nearby room to the front door, and sometimes during parties the alarm would sound, and the door would not open due to a resident with a wander guard bracelet being nearby. Concierge #1 said they could just tap a button at the desk to let people in and out of the front door. Concierge #1 stated that on 09/15/2025, they did not know which residents were at a risk of wandering or elopement and had never seen Resident #126 before. When Resident #126 was at the door, they thought that they were a visitor, and they tapped the button at the desk to let them out. Concierge #1 knew that the [NAME] door had not been working as they and other staff had been putting work orders in to have the door looked at and fixed. During an interview on 12/19/2025 at 09:40 AM, Registered Nurse Manager #5 stated prior to Resident #126's elopement, they did not know that there had been a problem with the [NAME] Unit door. After Resident #126 got out of the building, they had staff sit at the door until a part arrived for the door to be fixed. Registered Nurse Manager #5 stated that if they had known the [NAME] Unit door was not functioning properly prior to the elopement, they should have done something more, at least 15-minute checks on the residents. During an interview on 12/19/2025 at 10:42 AM, The Director of Health Services stated that they were aware of the [NAME] Unit door issues in August, Maintenance could not re-create the problem, and they could not figure out what was wrong with the door. The Director of Health Services stated that Resident #126 would put their hat and coat on and would go to the door. When talking with them, one may not know that Resident #126 was a memory care resident. The Director of Health Services stated that the communication piece should have been better and that the team should have met and come up with a plan. 2. Resident #85 had diagnoses that included dementia, reduced mobility, and subdural hemorrhage (internal bleeding inside the skull). The Minimum Data Set, dated [DATE], documented that the resident was mildly cognitively impaired. Review of Resident #85's Comprehensive Care Plan and Kardex (a care plan used by Certified Nursing Assistants for daily care) as of 12/15/2025 did not include that the resident was safe to have alcoholic beverages at their bedside. Review of Resident #85's medical orders did not include self-administration or personal possession of alcoholic beverages. During observations on 12/11/2025 at 11:01AM and 12/12/2025 at 10:07 AM, a four (4)-pack of serving-sized wine bottles were observed unopened and sitting on Resident #85's nightstand. During an observation on 12/15/2025 at 01:51 PM, two (2) serving-sized wine bottles were observed unopened and sitting on Resident #85's nightstand. During an interview on 12/18/2025 at 01:06 PM, Certified Nursing Assistant #5 stated they were aware that Resident #85 had wine in their bedroom. During an interview on 12/18/2025 at 01:28 PM, Licensed Practical Nurse #5 stated they were unaware of residents being permitted to keep alcohol in their rooms and that if they were to find alcohol in a resident's room, they would confiscate it and inform the nurse manager. During an interview on 12/18/2025 at 04:27 PM, Licensed Practical Nurse Clinical Coordinator #3 stated that they were aware that Resident #85 had alcohol in their room and that there were residents with wandering tendencies on the unit. During an interview on 12/19/2025 at 10:04 AM, Registered Nurse Manager #3 stated it was a safety risk for residents to have alcohol kept unsecured in their rooms due to possible medication interactions or a resident accessing the alcohol who was not supposed to have it. During an interview on 12/19/2025 at 12:29 PM, Nurse Practitioner #1 stated it was important to know if a resident drank alcoholic beverage regularly because of medications and adverse effects, changes in medical condition that may be secondary to alcohol use, and if they were sharing it with other residents. They said that residents have a right to alcohol use but should have provider approval. During an interview on 12/19/2025 at 01:25 PM, Medical Director #1 stated that most medications do not have significant interactions with alcohol, and it would not be pertinent for medical providers to know whether residents were drinking alcohol. They said that there would be a safety concern if a resident wandered into a room and consumed alcohol. During an interview on 12/19/2025 at 03:19 PM, the Director of Health Services stated that the facility policy for recreational alcohol included staff measuring alcoholic beverages and moderating resident consumption of alcohol, and it did not include personal alcohol possession. They said that the safety risks of a resident having personal possession of alcohol without staff awareness included medication interactions with alcohol and other residents with wandering tendencies consuming the alcohol. During an interview on 12/19/2025 at 12:42 PM, the Administrator stated they were not aware of residents having alcohol in their room. However, unless contraindicated or a reason that they may not have it, as long as the resident were alert and oriented, they would be allowed to have alcohol in their room. The Administrator stated that it would be monitored by the team and the nursing staff, but they did not know how it would be monitored, and that the resident would not need to be care planned for it. 3. Resident #125 had diagnoses including muscle weakness, osteoporosis, and a thoracic wedge compression fracture (break in a vertebra [a spine bone]). The Minimum Data Set, dated [DATE] revealed Resident #125 had moderately impaired cognition and was independent with bed mobility and ambulation. Review of the Comprehensive Care Plan revealed Resident #125 was independent with using a right transfer bar for bed mobility (as of 06/19/2025), and was at risk for entrapment related to the use of a transfer bar with interventions that included checking the transfer bar daily and ensure bed, transfer bar, wall, and mattress compatibility to prevent entrapment zones and monitor at regular intervals (revised 12/16/2025). In a progress note dated 06/10/2025 at 2:08 PM, Physical Therapist #1 documented recommending a right transfer bar for decreased pain during bed mobility. In a Bed Rail Assessment form dated 06/19/2025, Registered Nurse Manager #3 documented a right side rail placement recommendation and that the side rails/assist bar were indicated and would serve as an enabler to promote independence. Review of Maintenance Work Order #141804 dated 06/27/2025 included a right transfer bar on the bed was needed in Resident #125's room, and the work was completed at 10:13 AM on 06/27/2025. Review of December 2025 Task documentation (certified nursing assistants' documentation) revealed no documented bed safety checks of the transfer bar until 12/16/2025. During an observation on 12/11/2025 at 9:11 AM, Resident #125 was observed dressed in day clothes, sleeping in bed. At 10:19 AM, Resident #125 was not observed in their bed or room, and a gap of approximately three (3) inches was observed between the metal transfer bar and the mattress on the bed frame. At 2:25 PM, a gap of approximately more than four (4) inches was observed from the mattress to the transfer bar. Additionally, the mattress was noted to not be fitted into the bed frame. Registered Nurse Manager #3 was in the room and observed the gap between the transfer bar and mattress. During an observation on 12/12/2025 at 9:36 AM, Resident #125 was observed with a different bed frame and a plastic transfer bar. During an interview on 12/15/2025 at 10:42 AM, Director of Building Services #1 stated they took the bed (observed on 12/11/2025) out of Resident #125's room and put in a new bed. During an interview on 12/15/2025 at 2:31 PM, Registered Nurse Manager #3 stated the process for a resident to get a transfer bar would include a request from the resident or a recommendation from Therapy, followed by a transfer bar evaluation which was done by a registered nurse. Consent would be obtained from the family and then the transfer bar would be put on by Maintenance. Registered Nurse Manager #3 stated they believed quarterly assessments were done through Maintenance to check for entrapment risks, and if a staff member noticed something (with the bed or transfer bar), they should tell someone. Registered Nurse Manager #3 stated Resident #125 had the transfer bar for some time after experiencing a compression fracture, they were independent and did everything themselves, and had been getting weaker so they opted to keep the transfer bar on the bed. Registered Nurse Manager #3 stated they had seen Resident #125 get out of bed (with the previous bed, transfer bar and mattress) and they never saw the mattress move. Registered Nurse Manager #3 stated they ordered Resident #125 a new bed (current bed) because the mattress was moving on the previous one and it had different corners (mattress corner holders), but when there was weight in the bed, the mattress did not move. During an interview on 12/19/2025 at 11:59 AM, Director of Building Services #1 stated a work ticket is entered if a transfer bar was needed in a certain room, on a certain side, and once Maintenance staff completed the work order (places the transfer bar) the ticket is closed. Maintenance staff would obtain a list generated by nursing from the front desk, which included all residents that had a transfer bar. A scheduled ticket would be generated for a quarterly check, and a maintenance technician would go through the list and perform the tests on each transfer bar and bed. Director of Building Services #1 stated when doing the quarterly assessments in August 2025, Resident #125 was not on the list of having a transfer bar (a check was not done), and they did not know why. During an interview on 12/19/2025 at 12:43 PM, Certified Nursing Assistant #7 stated they would know if a resident had a transfer bar because it would be on their Kardex (certified nursing assistants care plans), and they would see them on the resident's bed. Certified Nursing Assistant #7 stated they do safety checks to make sure they are positioned correctly and that the resident can use them, and they document the checks in the Kardex (electronic medical record). During an interview on 12/19/2025 at 2:29 PM, the Director of Health Services stated an evaluation is done by a registered nurse for residents with a transfer bar, the bars would be listed on the resident's care plan and there is a task for the certified nursing assistants to document every shift. Additionally, a tracker (list) of all residents with transfer bars was kept. The Director of Health Services stated at the beginning of the week, they noticed Resident #125 was not on the list and did not have the certified nursing assistant task set up (for transfer bar safety checks to be documented). The Director of Health Services stated somehow the resident got missed (from the list). 10NYCRR: 415.12(h)(2)

Based on interviews and record review conducted during the Recertification Survey from 12/11/2025 to 12/19/2025, it was determined that for one (Resident #61) of five residents reviewed, the facility did not ensure that PRN (as needed) orders for anti-psychotic drugs (medications used to treat symptoms of psychosis) were limited to 14 days. Specifically, there were several instances in which Resident #61 had as needed (PRN) Haldol (an antipsychotic medication) orders that exceeded the 14 day timeframe. Additionally, over several months, Pharmacist #1 identified through monthly Medication Regimen Reviews the Haldol orders and recommended they be reordered every 14 days. This is evidenced by the following: Resident #61 had diagnoses including dementia, depression, and anxiety. The Minimum Data Set (a resident assessment tool) dated 10/13/2025 revealed Resident #61 was severely impaired cognitively, was on hospice (specialized medical care for people nearing end of life), and received antipsychotic medications. The current Comprehensive Care Plan revealed Resident #61 was nearing end of life, was enrolled in hospice on 05/06/2024 and received antipsychotic medications with interventions including administering medications as ordered. Review of Resident #61's physician orders from 05/01/2025 to 12/19/2025 revealed the following:- Haloperidol Lactate (Haldol) give 0.25 milliliters (0.5 milligrams) by mouth two times a day as needed (PRN) for behaviors, ordered 05/15/2025 (discontinued 09/19/2025).- Haloperidol Lactate (Haldol) give 0.5 milliliters (1 milligram) by mouth every eight (8) hours as needed for agitation/aggression not responsive to nonpharmacological measures, ordered 10/07/2025 (discontinued 11/25/2025). - Haloperidol Lactate (Haldol) give 0.5 milliliters (1 milligram) by mouth every eight (8) hours as needed for agitation/aggression not responsive to nonpharmacological measures for 14 days, ordered 11/25/2025 (current order). Review of the Consultant Pharmacist Medication Regimen Reviews completed by Pharmacist #1 for the previous 11 months included the following:a. On 05/24/2025 Pharmacist #1 noted that Resident #61 had a PRN (as needed) order for Haloperidol 0.5 milligrams two times a day as needed since 05/15/2025. Pharmacist #1 recommended to evaluate the resident, document and reorder every 14 days to continue the need for PRN (as needed) anti-psychotic use. The section used by the medical team to address the recommendation included documentation dated 06/03/2025 by Nurse Practitioner #2 that they agreed (with the recommendation), the resident was on hospice, they would add a note, and it was part of the resident's palliative program. Signatures were also noted on the signature lines for the Director of Nursing (Director of Health Services) and Medical Director.b. On 07/24/2025 Pharmacist #1 noted Resident #61 had a PRN (as needed) order for Haloperidol 0.5 milligrams two times a day as needed since 05/15/2025. Pharmacist #1 recommended to evaluate the resident, document and reorder every 14 days to continue the need for PRN (as needed) anti-psychotic use. The section used by the medical team to address the recommendation included documentation by Nurse Practitioner #2 (date illegible) that they disagreed with the recommendation due to the resident being on hospice and it was for their comfort. Signatures were also noted on the signature lines for the Director of Nursing (Director of Health Services) and Medical Director.c. On 10/24/2025 Pharmacist #1 noted Resident #61 had a PRN (as needed) order for Haloperidol one (1) milligram every eight (8) hours as needed since 10/07/2025. Pharmacist #1 recommended to evaluate the resident, document and reorder every 14 days to continue the need for PRN (as needed) anti-psychotic use. The section used by the medical team to address the recommendation included documentation by Nurse Practitioner #2 dated 11/04/2025 that they disagreed with the recommendation, as the resident was on hospice, the medication was occasionally being used, and they would document the need for three (3) months for quality of life. A signature was noted on the line for the Director of Nursing (Director of Health Services) dated 11/19/2025.d. On 11/24/2025 Pharmacist #1 noted Resident #61 had a PRN (as needed) order for Haloperidol one (1) milligram every eight (8) hours as needed since 10/07/2025. Pharmacist #1 recommended to evaluate the resident, document and reorder every 14 days to continue the need for PRN (as needed) anti-psychotic use. During a telephone interview on 12/19/2025 at 11:42 AM, Pharmacist #1 said they reviewed residents' medications in the electronic medical record monthly and they would look for (but not limited to) duplicate medication orders, that gradual dose reductions were done properly and that PRN (as needed) medications were not used for long periods of time. Pharmacist #1 stated they would generate a report of identified irregularities, which was sent to the facility and the medical prescriber. If the medical prescriber disagreed with a recommendation, they would have to explain why. Pharmacist #1 said the reports were then sent to the Medical Director and were stored in a binder. Pharmacist #1 stated antipsychotic medications had to have documentation on why it was needed and how the resident was benefiting from it, and had to be reordered every 14 days. Pharmacist #1 stated they had provided recommendations in May, July, October and November 2025 with regards to Resident #61's ordered PRN Haldol, and the medical prescriber's response was the resident was on hospice. Pharmacist #1 said there was no exceptions to the regulation with regards to the medication having to be ordered every 14 days. During an interview on 12/19/2025 at 11:04 AM, Nurse Practitioner #2 said they went through the monthly medication regimen reviews done by the pharmacist, they would decide if they agreed or disagreed with the recommendation, write it down on the paper, which would then go to the Director of Nursing (Director of Health Services) and the Medical Director. Nurse Practitioner #2 stated no one had ever come to them with concerns about their decisions (related to medication regimen reviews) after they were turned in. Nurse Practitioner #2 said Haldol was an example of an antipsychotic medication, and it was usually used for residents on hospice for delirium (change in mental abilities) and nausea. Nurse Practitioner #2 stated as needed (PRN) antipsychotic medications had to be reordered every 14 days per the regulation, and either the physician or the mid-level provider (nurse practitioner or physician assistant) would have to enter a new order. Nurse Practitioner #2 said Resident #61 was on hospice and had a current PRN order for Haldol, which was placed on 11/25/2025 and was beyond the 14 days. They did not have an explanation for why the Haldol order was active over the 14 days. Nurse Practitioner #2 confirmed their signature on the Consultant Pharmacist Medication Regimen Reviews for Resident #61 dated 05/24/2025 and 07/24/2025 and stated they thought there was an exception to the regulation for residents on hospice. During an interview on 12/19/2025 at 2:29 PM, the Director of Health Services said when the monthly medication regimen reviews were delivered, they are put in the nurse practitioner's mailbox, who would say what they are doing (agree or disagree). The reviews would then go to the Director of Health Services, who would make sure someone looked at them, and they would either send them back (to the medical provider) if they are blank, or sign them. The reviews would then go to the Medical Director. 10 NYCRR 415.12(l)

Based on observations, interviews, and record review conducted during a recertification survey from 12/11/2025 to 12/19/2025, for two (2) (Resident #33 and #140) of three (3) residents reviewed for respiratory care, and two (2) (Resident #6 and #88) of five (5) residents reviewed for drugs and medications, the facility did not provide services to meet professional standards of quality. Specifically, Resident #6 had physician's orders for blood pressure to be obtained prior to receiving blood pressure medication, and the facility could not provide documentation the blood pressure was consistently obtained prior to the administration of the medication per the medical order. Resident #33 and Resident #140 had reportable instances of high blood glucose, and the facility could not provide documentation a medical provider was notified per the medical order. Resident #88 had physician's orders for measuring blood glucose levels and obtaining blood pressure and pulse before administering blood pressure medication, and the facility could not provide documentation that the medical provider was notified of blood glucose levels outside parameters as ordered, or that pulses were obtained prior to giving the medication. This is evidenced by, but not limited to: The facility policy Medication Administration, Documentation, and Premedication, dated August 2024 documented licensed nurses should verify physician's orders, check for hold parameters and laboratory values, perform vital signs for medications with parameters, and should document the results prior to administering the medication. 1. Resident #88 had diagnoses including diabetes, dementia, and high blood pressure. The Minimum Data Set (a resident assessment tool) dated 09/30/2025 revealed the resident had severely impaired cognition. Review of Resident #88's current physician orders revealed an order dated 03/25/2025 to measure the blood glucose level before each meal, notify a medical provider via a communication log for blood glucose less than 80 or greater than 300, and to notify a provider via phone call if the blood glucose was less than 70 or greater than 400. In addition, an order dated 10/01/2024 for metoprolol (a medication for high blood pressure) 25 milligrams daily with parameters to hold the metoprolol for a systolic blood pressure less than 100 and a heart rate (HR) less than 60. Review of Resident #88's electronic medical record (including but not limited to Medication Administration Records, Treatment Administration Records, blood glucose monitoring records, progress notes, and provider communication logs) from 09/01/2025 to 12/15/2025, revealed 11 instances of a blood glucose reading less than 80, eight (8) instances of a blood glucose reading less than 70, three (3) instances of a blood glucose reading greater than 300, and two (2) instances in which there was no documentation the resident's blood glucose was checked. The facility could not provide documentation the medical provider was informed via the facility communication log or via phone call. Additionally, there was no documented heart rate for 103 out of 106 administrations of metoprolol. In an observation and interview on 12/18/2025 at 12:00 PM, Licensed Practical Nurse #3 demonstrated checking Resident #88's orders for metoprolol and acknowledged the hold parameters for the medication. Licensed Practical Nurse #3 demonstrated documenting in the Medication Administration Record and stated there was no area to document a pulse (heart rate) with the medication. Licensed Practical Nurse #3 said they checked Resident #88's pulse (heart rate) prior to administration but there was no area to document it. Additionally, Licensed Practical Nurse #3 said if they needed to notify a provider, they would contact the nursing supervisor or nurse manager, write a progress note, and include it in the 24-hour report. In an interview on 12/19/2025 at 11:00 AM, Licensed Practical Nurse #1 stated if a resident had a low blood glucose reading it would be documented in the provider notification log, and if the blood glucose was very low, they would notify the nursing supervisor or nurse manager who would then notify the provider. Licensed Practical Nurse #1 said if a resident had a low blood glucose reading, they would give them juice, and glucose tablets were not utilized at the facility. In an interview on 12/19/2025 at 11:57 AM, Registered Nurse Manager #1 stated if a blood glucose reading was outside of the parameters included in a resident's order, it should be documented in the provider notification log, or the provider should have been called. Registered Nurse Manager #1 said there was no way to confirm the medical provider was made aware of the incident if the communication was not documented. Registered Nurse Manager #1 stated if a medication order had a hold parameter such as a pulse (heart rate), the vital signs should be documented in the Medical Administration Record. In an interview on 12/19/2025 at 03:19 PM, the Director of Health Services stated the licensed practical nurses do not directly notify the medical providers; if they needed to notify a medical provider, they would inform the nurse manager or the supervisor, who would utilize the on-call system to notify a provider. They said that nursing staff document provider notifications in a progress note, 2. Resident #33 had diagnoses including diabetes, pneumonia and heart failure. The Minimum Data Set, dated [DATE], revealed the resident had intact cognition. Review of current physician orders revealed an order dated 11/25/2025 for finger stick blood sugar testing before meals and at bedtime and the medical provider to be notified via written documentation for blood sugars less than 80 or greater than 250. Review of Resident #33's November and December 2025 Treatment Administration Records, and written documentation for notification from 11/26/2025 to 12/18/2025 revealed Resident #33 had 11 blood sugar results over 250 and the facility could not provide documentation the medical provider was informed nine (9) of the 11 reportable instances as ordered. Review of progress notes dated 11/26/2025 through 12/19/2025 revealed no documented evidence that a medical provider was made aware of blood sugar levels over 250 as ordered for the nine (9) reported instances. During an interview on 12/19/2025 at 12:19 PM, Licensed Practical Nurse Clinical Coordinator #1 stated blood sugars greater than 250 should be documented in the record book kept on the unit to notify medical providers. During an interview on 12/19/2025 at 12:27 PM, Registered Nurse Manager #4 stated nursing staff should follow the orders for blood sugar testing and reportable values should be documented and the medical provider should be informed. During an interview on 12/19/2025 at 1:44 PM, the Director of Health Services stated nurses should follow the orders for testing blood sugars and blood sugar parameters. The Director of Health Services said reportable blood sugar values should be documented and the medical provider should be informed. 3. Resident #6 had diagnoses including vascular dementia with anxiety, major depressive disorder, and hypertension (high blood pressure). The Minimum Data Set, dated [DATE], documented the resident had severely impaired cognition. Review of Resident #6 physician's orders revealed an order dated 06/27/2025 for lisinopril 10 milligrams (a medication for high blood pressure) to be given in the morning and hold the medication for systolic blood pressure (the first number in a blood pressure reading) less than 110. Review of Resident #6's electronic medical record (including but not limited to Medication Administration Records, Treatment Administration Records, Weights and Vitals Summary, and progress notes) from 10/01/2025 to 12/19/2025 revealed no documentation blood pressures were obtained prior to administering lisinopril for 66 out of 77 instances. In addition, for one (1) instance in which the medication was held due to outside parameters, there was no documentation of the resident's blood pressure. In an observation and interview on 12/19/2025 at 10:17 AM, Licensed Practical Nurse #3 stated Resident #6's blood pressure was checked before lisinopril was administered for 12/19/2025. Licensed Practical Nurse #3 said the blood pressure could be documented in a progress note but had not written one for Resident #6 because the lisinopril was not held for blood pressure parameters. In an observation and interview on 12/19/2025 at 10:34 AM, Registered Nurse Manager # 1 stated they expected nurses to obtain a blood pressure when there is a blood pressure parameter order for a medication. Registered Nurse Manager #1 said they could not verify Resident #6's blood pressure was obtained and documented daily per the physician's order. Registered Nurse Manager #1 stated nurses should document a blood pressure in the electronic medical record vital signs (Vitals Summary) or a progress note. In an interview on 12/19/2025 at 12:06 PM, the Director of Health Services stated they expected blood pressures to be obtained when there are parameters in a medication order. Director of Health Services #1 said nurses should document the blood pressure in the electronic medical record in vital signs (Vitals Summary) or in a progress note. In an interview on 12/19/2025 at 12:47 PM, Nurse Practitioner #1 said they expected to see vital signs documented and nurses should document the blood pressure in the vital signs (Vitals Summary). Upon review of Resident #6's electronic medical record, Nurse Practitioner #1 could not verify a blood pressure was obtained before the lisinopril was administered on 12/19/2025 and there were no vital signs documented for Resident #6 after 11/30/2025. 10 NYCRR 415.11(c)(3)(i)

Based on observations and interviews, for one (1) of one (1) resident reviewed (Resident #138), the facility failed to ensure the resident was treated with respect and dignity and cared for in a manner and environment that promotes the maintenance or enhancement of the resident's quality of life. Specifically, staff entered the resident's room without knocking or announcing their presence, failed to communicate with the resident during care interactions, and moved the resident's personal items without discussing the action with the resident.The findings include:The facility policy Resident Rights/Facility Responsibilities revised 05/30/2024 included, but was not limited to, the facility will treat each resident with respect and dignity, recognize each resident's individuality, and protect and promote the rights of the resident, including the right to participate in his or her treatment. Resident #138 had diagnoses that included Parkinson's disease, right femur fracture, and dysarthria (a motor speech disorder making it difficult to speak clearly) following a stroke. The Minimum Data Set (a resident assessment tool) dated 11/10/2025, documented the resident was cognitively intact.Review of Resident #138's Comprehensive Care Plan dated 11/20/2025 revealed a communication problem related to dysarthria/Parkinson's disease and used psychotropic medications related to anxiety and depression. Interventions included, but were not limited to, allowing adequate time for the resident to respond, repeating information as needed, refraining from rushing the resident, making eye contact, using simple and brief words or alternative communication tools as needed, provide simple explanations and step-by-step instructions before interactions, and to ask for the resident's assistance rather than telling them what to do. During an observation on 12/12/2025, at 8:41 AM., an unknown staff member entered Resident #138's room without knocking or announcing their presence. When interviewed at that time, Resident #138 stated staff sometimes entered the room without speaking, completed tasks, and left without communicating.During an observation on 12/18/2025, at 12:05 PM., Certified Nursing Assistant #1 entered Resident #138's room carrying the resident's meal tray without knocking or announcing their presence. Certified Nursing Assistant #1 did not communicate with the resident during the interaction, placed the meal tray at the foot of the bed, and removed personal items from the bedside table without discussing the action with the resident or asking for the resident's preference. When interviewed at that time, Certified Nursing Assistant #1 stated it was their usual practice to ask permission to enter a resident's room and to interact with residents during care, but they did not provide an explanation for why those actions did not occur during the observed interaction.During an interview on 12/18/2025 at 12:10 PM, Resident #138 stated they preferred staff ask permission before entering the room and before moving personal items.During an interview on 12/18/2025 at 12:52 PM, Registered Nurse Manager #2 stated they expected staff to knock before entering a resident's room and ask permission to enter.During an interview on 12/19/2025 at 11:46 AM, the Director of Health Services stated staff were expected to knock before entering resident rooms, introduce themselves, communicate with residents during care, and ask questions and offer options prior to completing tasks.10 NYCRR 415.5(a)

Based on observations, interviews, and record reviews conducted during the Recertification Survey from 12/11/2025 through 12/19/2025, the facility did not ensure they established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (3) (Residents #11, #69, and #184) of six (6) residents reviewed. Specifically, Resident #11 had catheter care performed, the new drainage bag was observed on the floor uncovered and a nurse stepped on it. Resident #69 was on transmission based precautions (an infection control strategy used to control the spread of air-borne infections) and staff were observed going into the resident's room without wearing personal protective equipment (such as mask, gown, and gloves, worn to protect individuals and staff and reduce the risks of exposure to and spread of infections). Resident #184 was on enhanced barrier precautions (an infection control strategy that uses gloves and gowns during high contact resident care to reduce the spread of infection) and a staff member was observed providing therapy services with the resident and the staff was not wearing appropriate personal protective equipment. The facility policy Transmission-Based Precautions NS-25R, reviewed 07/18/2025, included facemasks were to be used upon entry into a member's room with respiratory droplet precaution, enhanced barrier precautions included the use of gown and gloves during high-contact member care activities for members with wounds, and an example of high-contact member care included transferring. The facility Droplet Precautions sign included standard precautions of wearing eye protection and gloves and/or gown, to put on a face mask before entering the room. The facility Enhanced Barrier Precautions sign included providers, and staff must wear gloves and a gown for high-contact resident care activities including transferring. The facility policy Urinary Catheter Insertion/Maintenance and Removal, dated September 2022, included the procedure of changing a urinary catheter bag, ensuring that the catheter bag was positioned below the level of the bladder and attached to either the resident's leg, bed frame or wheelchair. 1. Resident #69 had diagnoses including dementia, hemiparesis (one-sided muscle weakness), and prostatic hyperplasia (the enlargement of the prostate gland, leading to urinary symptoms). The Minimum Data Set (a resident assessment tool) dated 10/16/2025 revealed the resident was cognitively intact. In a progress note dated 12/11/2025 at 6:03 PM, Nurse Practitioner #2 documented that they saw Resident #69 on 12/11/2025 for a temperature of 101 degrees Fahrenheit, chills and rigors (rising body temperature accompanied by severe shivering) with the cause of the illness unknown. During and observation and interview on 12/12/2025 at 10:48 AM, Certified Nursing Assistant #6 entered Resident #69's room, which had a droplet precaution sign posted outside the room and was seen not wearing a mask, gown or eye protection while in the room. Additionally, personal protective equipment was observed inside the resident's room hanging from a caddy on the door. In an immediate interview, Certified Nursing Assistant #6 stated they would check the care plan to see if a resident was on isolation precautions, they did not wear a mask while in the resident's room, and knew they needed to wear a mask. During an interview on 12/12/2025 at 11:00 AM, Registered Nurse Manager #3 stated staff would know a resident was on precautions as a sign would be on the resident's room door and if the resident was on droplet precautions, personal protective equipment (masks, gowns, gloves, shield) would be outside the resident's room on the door. Registered Nurse Manager #3 said Resident #69 was on standard droplet precautions, and a regular mask, eye shield, gown, and gloves should be worn. 2. Resident #184 had diagnoses including a stage 3 pressure ulcer to the right ankle (a skin injury caused by pressure, characterized by full-thickness skin loss), unsteadiness on feet, and generalized muscle weakness. The Minimum Data Set, dated [DATE], included the resident was cognitively intact. Review of the Comprehensive Care Plan as of 11/04/2025, revealed Resident #184 was at risk for infection related to a chronic vascular ulcer (wound that develops on skin due to problems with blood circulation) on their left medial malleolus (inner side of the ankle) and was on enhanced barrier precautions. Interventions included to initiate isolation precautions and for staff to wear appropriate personal protective equipment including a gown and gloves during high contact care. During an observation on 12/15/2025 at 2:22 PM, Physical Therapy Assistant #1 was in Resident #184's room which had enhanced barrier precaution signage on the door entering the room. Physical Therapy Assistant #1 was not wearing any personal protective equipment, was observed putting a gait belt (a device used to hold someone and prevent falls) around Resident #184's waist, moving an elastic band around the resident's thighs, adjusting the resident's shirt and pants, and touching objects in the resident's room including the tray table and wheelchair. In a Physical Therapy Treatment Encounter Note dated 12/15/2025, Physical Therapy Assistant #1 documented that Resident #184 transitioned to all surfaces within the room with contact guard assist (a technique used in occupational and physical therapy where the therapist maintains light, consistent physical contact with the patient throughout a movement as a safety measure) and stand by assist (a technique used in occupational and physical therapy where the therapist remains in close proximity to the patient but does not have direct contact with the patient). During an interview on 12/19/2025 at 12:46 PM, Physical Therapy Assistant #1 stated for residents on enhanced barrier precautions, if they saw personal protective equipment outside the door, they would wear a gown and mask if they were doing something in close contact with a urinary foley (a tube placed to drain fluid from the bladder), a wound or a tracheostomy (opening in the neck to facilitate breathing when the usual airway is obstructed or compromised), and if they were in direct contact with skin or providing hygiene care. They did not think they would have to wear personal protective equipment if they were assisting a resident that was fully dressed. Physical Therapy Assistant #1 said they did not recall seeing the enhanced barrier protection sign for Resident #184's room, they did not wear any personal protective equipment while in the resident's room and acknowledged they put a gait belt around Resident #184. 3. Resident #11 had diagnoses including neurogenic bladder (a condition that affects bladder function), bacteremia (bacterial blood infection), and presence of a suprapubic catheter (a device that drains urine from the bladder through a hole in the abdominal wall.) The Minimum Data Set, dated [DATE] documented that the resident was mildly cognitively impaired. Review of the Comprehensive Care Plan on 12/15/2025 included that Resident #11 was at risk for infection due to having an indwelling catheter with interventions that included monitoring the resident for pain or signs of infection and enhanced barrier precautions. The Kardex (a care plan used by Certified Nursing Assistants for daily care) included to keep the catheter drainage bag below the bladder and off the floor, and wearing personal protective equipment for resident care. Review of current Physician orders as of 12/15/2025 included to change the urinary drainage bag weekly and as needed. During an observation and interview on 12/16/2025 at 02:10 PM, Registered Nurse #1 irrigated Resident #11's suprapubic catheter and changed their urinary drainage bag. Following the procedure, Registered Nurse #1 was observed to have let the new drainage bag rest on the floor uncovered and stepped on the new bag with their shoe. Registered Nurse #1 stated that they were not aware that they had stepped on the drainage bag and subsequently changed the resident's drainage bag. During an interview on 12/17/2025 at 10:06 AM, the Infection Preventionist stated a sign on the resident's room name plate would indicate if there were any enhanced barrier precautions or droplet precautions for that resident, and if therapy staff were holding on to a gait belt worn by a resident on enhanced barrier precautions, personal protective equipment should be worn. The Infection Preventionist said urine collection bags have a clip and are to be clipped to a wheelchair or bed, so they are not dragged on the ground. The Infection Preventionist stated Registered Nurse #1 thought the urine collection bag was where it was supposed to be (off the ground), and once they became aware they stepped on it, they did the correct thing and changed the bag. 10 NYCRR 415.19

Based on observations, interviews, and record review, the facility failed to ensure medications were stored securely and accessible only to authorized personnel, in accordance with professional standards of practice and State and Federal regulations, for two (2) of four (4) residential units reviewed ([NAME] Place and [NAME] Place). Specifically, multiple loose pills (unsecured medications that were not contained in labeled packaging) were observed in medication carts, and a medication cart was observed unlocked and unattended.The findings include:Review of facility policy Medication Storage revised [DATE] included, but was not limited to, all medications stored and used within the facility shall be properly labeled and securely stored. Licensed nursing staff ensure expired, discontinued, or contaminated medications are removed promptly and disposed of according to facility policy and applicable regulations. Review of facility policy Medication Administration, Documentation, and Premedication revised [DATE] included, but was not limited to, all medication carts are to be locked when not being used and not under direct observation by the assigned nurse. Medications are not to be left unattended. During an observation on [DATE] at 10:27 AM, on the [NAME] Place Unit, a medication cart was inspected and found to have 29 loose pills lying unsecured in the bottom of the second drawer of the cart. Medications included, but were not limited to, anticoagulant, antidepressant, and antihypertensive medications. When interviewed at that time, Licensed Practical Nurse #2 confirmed responsibility for the medication cart and stated medication carts were checked by nursing staff weekly during their shifts and nurses were to notify the nurse manager if loose pills were found and needed to be discarded. During an observation on [DATE] at 4:03 PM, on the [NAME] Place Unit, a medication cart was inspected and found to have one (1) loose pill unsecured within the second drawer of the cart. When interviewed at that time, Licensed Practical Nurse #4 confirmed responsibility for the medication cart and stated medication carts were checked by nursing staff each shift and loose pills should be discarded either by flushing down the sink or putting in a sharps container (a puncture-resistant, leak-proof container for safely disposing sharp medical waste). During an observation on [DATE] at 10:22 AM, on the [NAME] Place Unit, a medication cart assigned to Licensed Practical Nurse #3 was inspected and found to have two (2) loose pills in the drawers of the cart. During an observation on [DATE] at 8:37 AM, on the [NAME] Place Unit, a medication cart was unlocked and unattended in the hallway with a bottle of eye drops setting on top of the cart. There was no licensed nursing staff present at or supervising the medication cart. The cart remained unattended for approximately two (2) minutes, during which time a resident was observed ambulating past the medication cart. During an interview on [DATE] at 10:16 AM, the Director of Health Services stated nursing staff were responsible for routine upkeep of medication carts and nurse managers were expected to conduct routine checks to ensure medications were stored and accounted for appropriately.10 NYCRR 415.18(e)(1-4)

Based on observations, interviews, and record review, review conducted during recertification and complaint (#2691821) surveys from 12/11/2025 to 12/19/2025, the facility failed to ensure residents were free of significant medication errors for three (3) of six (6) residents reviewed (Residents #33, #88, #154). Specifically, Resident #33 received insulin outside of administration parameters included in the medical order. Resident #88 received insulin outside of administration parameters included in the medical order and received insulin without documented evidence a blood glucose measurement was obtained prior to administration. Resident #154 did not receive medications and treatments in accordance with physician orders for multiple days after returning to the facility following a hospitalization. The findings include:The facility policy Medication Administration, Documentation, and Premedication revised August 2024 included, but was not limited to, licensed nursing staff were to check for hold parameters for medications, check laboratory values prior to administering any medications with ordered hold parameters and documents results prior to administration. 1. Resident #154 had diagnoses including Parkinson's disease with dyskinesia (a movement disorder of the nervous system with involuntary uncontrollable movements), localized edema (tissue swelling), and difficulty walking. The Minimum Data Assessment (a resident assessment tool) dated 09/19/2025 revealed the resident was cognitively intact. Review of Resident #154's electronic medical record from 12/04/2025 to 12/10/2025 revealed the following:- In a nursing progress note dated 12/05/2025 at 4:28 PM, Registered Nurse Supervisor #1 documented Resident #154 was transferred to the hospital for evaluation following a fall.- In a nursing progress note dated 12/06/2025 at 10:34 AM, Licensed Practical Nurse #3 documented Resident #154 returned from the hospital.- A hospital after-visit summary dated 12/06/2025 at 7:47 AM, indicated no new medications were prescribed during the emergency department visit and instructed the facility to follow up with Resident #154's primary care provider regarding continuation of medications.- In a nursing progress note dated 12/10/2025 at 3:52 PM, Registered Nurse Supervisor #1 documented Resident #154 had not received any prescribed medications since returning from the hospital. Review of the Medication and Treatment Administration Records from 12/06/2025 through 12/10/2025 revealed Resident #154's previously prescribed medications and treatments were placed on hold and not administered on these consecutive days following the resident's return from the hospital, including:- Carbidopa-levodopa 20-100 milligrams, 1.5 tablets once in the morning at 6:00 AM and one (1) tablet in the afternoon at 1:00 PM daily for Parkinson's disease (ordered on 10/01/2024).- Hydrochlorothiazide 12.5 milligrams, once daily at 6:00 AM for localized edema (ordered on 10/01/2024).- Apply below the knee TED stockings (compression stockings used to help control leg swelling), applied to both legs in the morning at 6:00 AM and taken off both legs in the evening. There was no documented evidence the medications were discontinued by a medical provider, or if the primary care provider was contacted to clarify continuation of orders. During an interview on 12/19/2025 at 10:35 AM, Licensed Practical Nurse Clinical Coordinator #1 stated when a resident returns from the hospital, medications and treatments are expected to be resumed unless there is documentation in the hospital discharge paperwork indicating otherwise. During an interview on 12/19/2025 at 11:14 AM, Registered Nurse Manager #1 stated Resident #154 had returned from the hospital and was on the unit from 12/06/2025 to 12/10/2025, medications were not given during this time, and missing medications used to treat Parkinson's disease could place the resident at increased risk for falls with injuries. 2. Resident #88 had diagnoses including diabetes, dementia, and high blood pressure. The Minimum Data Set, dated [DATE] revealed the resident had severe cognitive impairment. Review of current physician orders revealed Resident #88 was prescribed the following:- Humalog insulin (a fast-acting insulin given with meals), six (6) units two (2) times daily at lunch and dinner for hyperglycemia, hold for blood glucose less than 105 milligrams/deciliter (ordered on 12/05/2025).- Finger-stick blood glucose before meals. For blood glucose less than 80 milligrams/deciliter or greater than 300 milligrams/deciliter, place in medical book. For blood glucose greater than 400 milligrams/deciliter or under 70 milligrams/deciliter, call medical (ordered on 03/26/2025). Review of Resident #88's Medication Administration Records, Treatment Administration Records, blood glucose monitoring records, progress notes, and medication administration audit reports from 10/01/2025 to 12/18/2025 revealed the following: - On 10/07/2025, the resident's blood glucose was 73 milligrams/deciliter at 11:03 AM; six (6) units of Humalog were administered at 12:18 PM with no documented evidence of a repeat blood glucose measurement or interventions for low blood glucose.- On 10/15/2025, the resident's blood glucose was 60 milligrams/deciliter at 11:36 AM; six (6) units of Humalog were administered at 12:33 PM with no documented evidence of a repeat blood glucose measurement or corrective intervention.- On 11/05/2025, six (6) units of Humalog were administered at 10:56 AM without documented evidence a blood glucose measurement was obtained prior to administration.- On 12/11/2025, six (6) units of Humalog were administered at 12:40 PM without documentation of a blood glucose measurement at lunchtime as ordered. During an interview on 12/18/2025 at 1:28 PM, Licensed Practical Nurse #5 stated a resident's blood glucose should be checked within 30 minutes of a meal if they are receiving mealtime insulin and insulin should never be given without checking the blood glucose first. During an interview on 12/19/2025 at 11:00 AM, Licensed Practical Nurse #1 stated a resident's blood glucose should be checked within 30 minutes but no more than 45 minutes before a meal when mealtime insulin was ordered. During an interview on 12/19/2025 at 11:57 AM, Registered Nurse Manager #1 stated insulin should be administered within 10 minutes of checking a resident's blood glucose. During an interview on 12/19/2025 at 1:25 PM, Medical Director #1 stated they would expect a blood glucose measurement be obtained closer to the time of insulin administration. During an interview on 12/19/2025 at 3:19 PM, the Director of Health Services stated a blood glucose measurement should be taken within 30 minutes of a meal but no more than 45 minutes when mealtime insulin was to be administered. They stated if checked more than 45 minutes prior, it should be rechecked before administering insulin. 3. Resident #33 had diagnoses including diabetes mellitus, pneumonia and heart failure. The Minimum Data assessment dated [DATE] revealed the Resident was cognitively intact. Review of current physician orders dated 11/25/2025 revealed Resident #33 was prescribed the following:- Humalog insulin, four (4) units before meals. Nutritional baseline insulin, in addition to sliding scale coverage per blood glucose result. Hold if blood glucose is less than 100 milligrams/deciliter and/or patient is not eating. - Finger-stick blood sugar (glucose) before meals and at bedtime. For blood glucose less than 80 milligrams/deciliter or greater than 250 milligrams/deciliter place in medical book. For blood glucose greater than 500 milligrams/deciliter call medical. Review of Resident #33's Medication Administration Records, Treatment Administration Records, blood glucose monitoring records, progress notes, and medication administration audit reports from 12/01/2025 to 12/18/2025 revealed on 12/12/2025 at 11:30 AM, the resident's blood glucose was 91 milligrams/ deciliter, and four (4) units of Humalog were administered despite the ordered hold parameter. During an interview on 12/19/2025 at 12:19 PM, Licensed Practical Nurse Clinical Coordinator #2 stated if Resident #33's blood glucose value was 91 milligrams/ deciliter insulin should have been held, the medical provider notified in the medical provider communication book, and the nurse manager notified. During an interview on 12/19/2025 at 12:27 PM, the Registered Nurse Manager #4 stated nursing staff were expected to follow blood glucose and insulin orders as prescribed. Registered Nurse Manager #4 stated insulin should not have been administered if Resident #33's blood glucose was 91 milligrams/deciliter. During an interview on 12/19/2025 at 1:44 PM, the Director of Health Services stated nursing staff were expected to follow blood glucose and insulin orders as prescribed, including administration parameters. 10 NYCRR 415.12(m)(2)

Based on observations, interviews and record review conducted during the Recertification Survey from 12/11/2025 to 12/19/2025, for two (2) (Residents #5 and #156) of five (5) residents reviewed, the facility did not provide the residents who were unable to carry out activities of daily living, the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, Resident #5 was observed to have hair that was disheveled, greasy, dirty and uncombed for several days and the facility was unable to provide documentation as to when they had a shower. In addition, Resident #156 had a decline in their eating ability and the facility did not reassess the resident's self-feeding needs or determine whether increased assistance or adaptive equipment was required. This is evidenced by the following:The facility's policy Activities of Daily Living dated October 2022, documented residents were given the appropriate treatment and services to maintain or improve their ability to carry out the activities of daily living such as hygiene and dining (meals and snacks). Staff were to provide ongoing observation and assessment of resident's function, document any decline in function, confer with the intradisciplinary team to implement services to regain/maintain status and implement interventions recommended by the intradisciplinary team. The policy also documented the resident decision to refuse care, and treatment must be documented in the clinical record and staff were responsible to attempt to identify the underlying cause of the refusal. 1. Resident #156 had diagnoses including gastroesophageal reflux disease (GERD, a chronic condition where stomach acid flows back into the esophagus), dementia, and major depressive disorder. The Minimum Data Set (a resident assessment tool) dated 11/05/2025 documented the resident had moderately impaired cognition and required setup/clean-up assistance with eating. Review of the Comprehensive Care Plan revised on 09/22/2025, revealed Resident #156 had self-care deficit related to activities of daily living and potential risk for alteration in nutrition. Interventions included, but were not limited to, the resident was able to feed themselves after setup, preferred to eat in their room, physical therapy/ occupational therapy evaluation and treatment per physician orders, and to monitor food intake at each meal. Review of Resident #156's Kardex (care plan used by certified nursing assistants to guide care) current as of 12/19/2025 revealed staff were to provide setup assistance during meals and observe and report changes in the resident's functional abilities. Review of a progress note dated 11/21/2025, Social Worker #1 documented the interdisciplinary team met with Resident #156's family member on 11/19/2025 for an annual care conference and the resident presented with a gradual overall decline. The resident had poor vision, the family member reported they sometimes found Resident #156 with food on them and was using their hands more often to eat. Staff also noticed an increased amount of food on the floor after meals and the team would continue to provide support as needed/appropriate. Review of interdisciplinary progress notes from 11/19/2025 to 12/18/2025 did not include documented evidence of reassessment or evaluation of Resident #156's self-feeding needs following the decline identified during the care conference. During an observation on 12/11/2025 at 12:44 PM, Resident #156 was in their room by themselves eating the lunch meal with their fingers. They were wearing a clothing protector and had multiple food items on it. During an observation on 12/16/2025 at 12:35 PM, Resident #156 was eating the lunch meal by themselves, not wearing a clothing protector, and had food items on their shirt and pants. While feeding themselves, Resident #156 spilled a beverage on their pants, which was observed by nursing staff. During observations on 12/18/2025 at 11:58 AM, Resident #156 was in their room by themselves during the lunch meal and was licking the clothing protector. At 12:06 PM, the resident was eating pasta with their fingers. During an interview on 12/19/2025 at 10:15 AM, Occupational Therapist #1 stated if a resident was identified to have a change in their abilities, including using their hands to eat or dropping food at meals, nursing and medical should determine if a therapy referral was necessary. Occupational Therapist #1 said they did not have Resident #156 on their list, and they did not have an order to re-evaluate them. During an interview on 12/19/2025 at 12:43 PM, Certified Nursing Assistant #7 said they would know the level of assistance a resident required by looking at their Kardex, and if they noticed a resident was eating with their fingers or spilling items on themselves, they would offer to help and they would let the nurse know. Certified Nursing Assistant #7 stated they were familiar with Resident #156 who would sometimes eat with their hands which was new, and the resident would sometimes have a little bit of food on their clothing protector. During an interview on 12/19/2025 at 1:07 PM, Registered Nurse Manager #3 stated if staff noticed a change in a resident's functional abilities, a nurse leader should be notified so a therapy order could be obtained. Registered Nurse Manager #3 stated they were not aware of Resident #156's change in status discussed during the annual care conference on 11/19/2025 and a therapy evaluation should have been ordered directly following the care conference to evaluate if Resident #156 needed more assistance with meals. During an interview on 12/19/2025 at 2:29 PM, the Director of Health Services stated if a decline in a resident's functional ability was identified during a care conference, the interdisciplinary team should review if a therapy consult was appropriate, and if the resident needed any adaptive equipment. 2. Resident #5 had diagnoses including dementia, transient ischemic attack (short period of symptoms similar to a stroke), and hypertension. The Minimum Data Set, dated [DATE] documented the resident had severe impairment of cognitive function and required substantial/maximum staff assistance with showering/bathing. The Comprehensive Care Plan revised on 10/20/2025 included Resident #5 required one (1) staff assistance with showering and their shower day were to be given on Thursday's during the day shift. Review of the Task documentation (certified nursing assistant documentation related to showering/bathing) noted bathing Thursday day shift and included documentation of Not Applicable on (Wednesdays) 11/21/2025, 11/28/2025, 12/05/2025, and 12/12/2025. There was not any documentation for Thursdays. Review of progress notes from 11/20/2025 through 12/17/2025 revealed there was no documentation of Resident #5 being offered, received, and/or refused a shower/hair wash. On 12/18/2025 at 1:19 PM, Licensed Practical Nurse #7 documented Resident #5 refused a shower and hair wash. During observations on 12/11/2025 at 12:59 PM, 12/15/2025 at 12:41 PM, 12/17/2025 at 09:08 AM, and 12/18/2025 at 12:42 PM Resident #5's hair was disheveled, not combed, greasy and dirty in appearance. During an interview on 12/18/2025 at 12:13 PM, Certified Nursing Assistant #5 stated that they did take care of Resident #5 occasionally and that Resident #5 was on their assignment for the day. Certified Nursing Assistant #5 stated that they had never given Resident #5 a shower, they did not know how the resident got their hair washed and or when Resident #5's shower day was. During an interview on 12/18/2025 at 12:28 PM, Licensed Practical Nurse #7 stated if a resident refused a shower, the certified nursing assistants would tell them, and it should be documented. Licensed Practical Nurse #7 said Resident #5 would refuse showers and they had been to the hairdresser a couple weeks before and had their hair washed. During an interview on 12/19/2025 at 09:40 AM, Registered Nurse Manager #5 stated they did not know the last time Resident #5 had their hair washed and stated their hair looked straggly and gross. During an interview on 12/19/2025 at 10:42 AM, the Director of Health Services stated residents get reviewed on admission and a preference sheet gets completed for how often and when a resident would like a shower or not at all. When a resident is given a shower or if they refused, it should be documented in the electronic record. The Director of Nursing stated that generally if a shower is care planned for day shift then one should be provided in the morning. 10 NYCRR 415.12(a)(3)

Based on observations and interviews, the facility failed to maintain a sanitary environment for one (1) (first floor) of two (2) resident use floors. Specifically, a large reach in-style ice machine was located in an area that was also used to store garbage and trash.The findings are:When observed on 12/11/2025 at 11:59 AM, there was a large reach-in style ice making machine with a lid and holding bin in the first-floor trash compactor room adjacent to the main kitchen corridor. The ice machine was observed to have a blue plastic scoop and holder mounted on the side and the room was used for temporary storage of garbage from the facility. A large roll-up door to the outside of the building separated this room from the outdoors where the dumpster and compactor were located. There was no marking or signage on the ice machine to indicate the ice was not for human consumption. During an interview at that time the Director of Building Services stated the ice machine should be moved and could not control garbage or debris in the air. When interviewed on 12/15/2025 at 11:30 AM, the Food Service Director stated the ice machine was moved into the compactor room about a year ago because the previous director wanted more room. The Food Service Director also stated the ice machine was not in a good spot and could be moved as it should not be around trash.10 NYCRR 415.29

Based on record review and interviews conducted during a Recertification Survey, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and an antibiotic stewardship program (processes to ensure that individuals are receiving appropriate antibiotics, at the correct dose, and for the proper length of time) that included antibiotic use protocols and a system to monitor antibiotic use. Specifically, the facility could not provide evidence of on-going surveillance and tracking of infections since June 2023 and there was no evidence that the facility had been maintaining an antibiotic stewardship program. This is evidenced by the following: The Facility Assessment, dated October 2023, documented that the facility's infection prevention and control program included surveillance and tracking of infections to monitor for trends and clusters, investigate contributing factors, provide staff education, and monitoring to reduce further spread of infection. Additionally, the program was to ensure the careful use and management of antibiotic use through antibiotic stewardship. The facility policy, Infection Control-Antibiotic Stewardship, dated October 2022, revealed the careful use and management of antibiotics was required to reduce adverse outcomes for residents. Additionally, Infection Prevention Nurse was to track all antibiotics in real time, observe for trends, and prepare written reports that included antibiotic utilization and compliance with facility protocols. Review of Infection Control Tracking forms (line list- a tracking tool used to monitor infections and antibiotic use) provided by the facility included January 2023, February 2023, April 2023, May 2023, and June 2023. There was no documented evidence for the tracking of infections or antibiotic use from July 2023 to December 22, 2023. During an interview on 12/21/23 at 12:31 PM, the Assistant Director of Nursing/Infection Preventionist stated that the line list was managed electronically in a shared drive (a folder used to store and access files for use by more than one individual) and they were unable to locate the line list. The Assistant Director of Nursing/Infection Preventionist stated the Information Technology department had been working to locate the line list but was also unable to locate the folder. During an interview on 12/22/23 at 9:15 AM, the Director of Health Services (Director of Nursing) stated they would expect the Infection Preventionist to maintain a line list to appropriately monitor and prevent the spread of infections. The facility had an infection control tracking system in a shared drive, but no one was able to access it. The Director of Health Services thought the Infection Preventionist had been tracking the current COVID-19 cases and other infections but was unsure how this had been documented since they were unable to access the shared drive. 10 NYCRR 415.19(a)(1-3)

Based on record review and interview conducted during the Recertification Survey, it was determined that for four (Employees #1, #3, #4, and #5) of five newly hired employees the facility did not implement written policies and procedures to prevent abuse, neglect, exploitation, and misappropriation of resident property related to screening prospective employees. Specifically, the results of a nurse aide registry abuse screening were not documented for newly hired employees prior to starting work. The findings are: A review of facility policy, Administrative Policy #20A Abuse Prohibition, last reviewed November 22, 2022, included that it is the responsibility of Human Resources to screen all potential employees for a history of abuse, neglect or mistreatment of residents. On 12/20/23 from 9:03 AM to 9:47 AM, newly hired employee files were provided to the surveyor for review and included the following: 1) Employee #1 was hired on 10/2/23 as a Dining Services Associate and the results for a nurse aide registry screen for prior abuse findings were dated 10/19/23. 2) Employee #3 was hired on 11/6/23 as a Member Care Assistant and the results for a nurse aide registry screen for prior abuse findings were dated 12/20/23. 3) Employee #4 was hired on 12/4/23 as a Laundry Assistant and the results for a nurse aide registry screen for prior abuse findings were dated 12/20/23. 4) Employee #5 was hired on 11/20/23 as a Unit Secretary and the results for a nurse aide registry screen for prior abuse findings were dated 12/20/23. During an interview on 12/20/23 at 9:26 AM, the [NAME] President of Human Resources stated that a nurse aide registry screen was printed for Employee #1 prior to today because they realized they were a Certified Nursing Assistant in the past. The [NAME] President of Human Resources further stated that they would look into the other employees to see what happened with their nurse aide registry screen. During an interview on 12/20/23 at 2:31 PM, the [NAME] President of Human Resources stated that they felt confident that the nurse aide registry screen was completed for the other employees prior to hire because it is part of the facility process to do this. The [NAME] President of Human Resources also stated that they asked the staff member who checks Prometric (used to run the nurse aide registry screening) and was told that since the results were blank, the form (which shows the date and results of the check) was not printed. The [NAME] President of Human Resources further stated that they have a checklist where they record that Prometric is checked for new employees and provided the checklists to the surveyor for review. Review of form titled, FSL New Hire Onboarding Checklist, for Employees #1, #3, #4, and #5 included that under section Day of New Hire Appointment that a box next to Print Prometric was checked for each employee. Further review of this form included that there was no documentation of the results of the nurse aide registry screen for prior abuse findings for Employees #1, #3, #4, and #5 prior to or on their date of hire. In an additional interview at this time, the [NAME] President of Human Resources stated that they do not have the printout of the original Prometric results. 10NYCRR: 415.4(b)

Based on record review and interviews conducted during a Recertification Survey, the facility did not ensure that the individual designated as the facility's current Infection Preventionist (individual responsible for the facility's Infection Prevention and Control Program) had completed specialized training in infection prevention and control. Specifically, the facility's designated Infection Preventionist did not have documented evidence of completing specialized infection prevention and control training. This is evidenced by the following: The facility policy, Infection Control Program, dated 12/13/23, defined the Infection Preventionist as a person whose primary training was either in nursing, medical technology, microbiology, or epidemiology and who had acquired additional training in infection control. The policy revealed the Infection Preventionist was responsible for monitoring the rate of infections, maintaining records of all communicable diseases and nosocomial (infections that developed during the process of receiving health care) infections, and defining, analyzing, and reporting incidents related to failures in infection control practices to the Director of Health Services, Medical Director, and Quality Assessment and Assurance committee. During an interview on 12/21/23 at 12:31 PM, the Assistant Director of Nursing/Infection Preventionist stated they were the facility's designated Infection Preventionist. While they were working on obtaining the required infection control and prevention training, they had not completed the specialized training. During an interview on 12/22/23 at 9:15 AM, the Director of Health Services (Director of Nursing) stated that they were not responsible for managing the facility's infection prevention and control program and the Assistant Director of Nursing was the designated Infection Preventionist. The Assistant Director of Nursing had been in the Infection Preventionist role since the end of July 2023, had been working on the required infection control and prevention training, but had not completed the specialized training. The Director of Health Services stated they would expect the person responsible for managing the infection prevention and control program to have completed the required training. 10 NYCRR 415.19(a)

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two of five medication carts reviewed for medication storage, the facility did not ensure that all drugs and biological were properly stored in accordance with State and Federal Laws. Specifically, two expired medications were stored in medication cart #1on [NAME] Place resident care unit and a medication cart on [NAME] Place had multiple loose unlabeled pills. In addition, one of the medication drawers in the cart on [NAME] Place contained a large amount of debris at the bottom of the drawer. This is evidenced by the following: During an observation on 12/21/23 at 12:03 PM on [NAME] Place, medication cart #1 had a bottle, approximately one-quarter filled, of bisacodyl (laxative) tablets with an expiration date of September 2023 and a full bottle of sorbitol solution (laxative) with an expiration date of August 2023 were stored in the cart. During an observation and interview on 12/21/23 at 9:18 AM on [NAME] Place, there were more than 15 loose, unlabeled pills of varying colors, sizes and shapes stored in a drawer in medication cart #2. Additionally, medication cart #2 was found to have approximately one-quarter inch of scoopable debris covering the bottom of the drawer. When interviewed, License Practical Nurse #2 stated they were unable to identify any of the pills at the bottom of the medication drawer (or the debris) and all nurses were responsible to keep the medication cart clean. During an interview on 12/21/23 at 9:34 AM, Registered Nurse #1/Nurse Manager stated every nurse was responsible for checking the medication carts for cleanliness and expired medications. During an interview on 12/21/21 at 12:26 PM, License Practical Nurse #1 stated they checked medications for expiration dates at the time they administered them. They stated it was the night shift nurse's responsibility to check the medication cart for expired medications. During an interview on 12/26/23 at 12:53 PM, Licensed Practical Nurse #3/Clinical Coordinator stated the night shift nurse was responsible for checking the medication carts and rooms for expired medications once monthly and when found they should be removed. 10 NYCRR 415.18(e)(1-4)

Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #53) of one resident reviewed for tube feedings (nutrition administered via a tube inserted directly into the stomach via the abdomen due to the residents' inability to consume food and drink by mouth), the facility did not provide appropriate treatment and services to prevent potential complications for a resident who receives enteral feedings (tube feedings), as outlined by the resident's person-centered comprehensive care plan and physician orders. Specifically, the facility was unable to provide documented evidence that the resident had received the correct tube feeding and water intakes as ordered by the physician to ensure the necessary nutrition and prevent complications. This is evidenced by the following: The January 2023 facility policy, Gastrostomy (feeding) Tube Feeding, included that all patients with Gastrostomy tubes will have their intake and output measured each shift. The amount of tube feeding, and water administered should be documented at the end of the shift by the Registered Nurse or Licensed Practical Nurse and recorded on the Intake and Output Record. Resident #53 has current diagnoses including dysphagia (difficulty swallowing), a gastrostomy tube, and pulmonary congestion (excess fluid in the lungs). The Minimum Data Set Assessment, dated 9/29/23, revealed the resident had severely impaired cognition and received 51% or more of their calories via tube feedings. The current Comprehensive Care Plan for tube feedings, included interventions for calculating caloric needs, fluid requirements (that were based on adjusted body weight), tube feed tolerance and hydration status, and recording intake and output. Current physician orders included the resident was to have nothing by mouth and had a feeding tube with feedings to include: a. Glucerna 1.5 calories (nutritional supplement) via gastrostomy tube, to start the tube feeding at 4:00 PM at 60 milliliters per hour for 16 hours and stop the tube feeding at 8:00 AM for a total of 960 milliliters per day. b. Give 200 milliliters of water flushes via the gastrostomy tube every four hours and 30 milliliters water flush before and after feedings and 10 milliliters between medications. Review of a medical note dated 12/18/23 the Nurse Practitioner documented Resident #53 was evaluated for reported fever, dyspnea (difficulty breathing), and runny nose, chest radiograph was concerning for pulmonary congestion (a condition caused by too much fluid in the lungs). Review of the November 2023 and December 2023 Intake and Output Records revealed that from 11/1/23 to 11/30/23 there was no documented intakes (Glucerna or water) on 42 shifts of 90 shifts (3 shifts per day). From 12/1/23 to 12/20/23 there was no documented intakes for 32 shifts of 60 shifts. The 24-hour daily total of intake for every day 11/1/23 through 12/20/23 was blank. During an observation and interview on 12/21/23 at 3:54 PM, Licensed Practical Nurse #4 was unable to start the tube feeding at 4:00 PM. When interviewed at this Licensed Practical Nurse #4 stated that Resident #53's feding tube was clogged and they were attempting to unclog the tube. At 4:23 PM the feeding still had not been started. During an interview on 12/26/23 at 9:10 AM, the Registered Dietitian stated the residents current tube feed and ordered water flushes (additional water provided to a resident in their daily regimen), were monitored through the Intake and Output Record and were reviewed daily to make sure the resident was getting the adequate amount of tube feeding and flushes (and prevent complications). The Registered Dietitian stated that when the Intake and Output Records are not completed the unit nursing staff should be notified and in the past the Director of Nursing has been involved with the issue of incomplete documentation. Review of the Intake Record for November 2023 and December 2023 with the surveyor, the Registered Dietician stated that they had brought it to the attention of the Unit Nurse Manager. The Unit Nurse Manager was not available for interview. During an interview on 12/26/23 at 10:09 AM Licensed Practical Nurse #3 Clinical Coordinator stated that tube feeding documentation was the nurse's responsibility. Review of the Intake Records from November 2023 and December 2023 with the surveyor, Licensed Practical Nurse #3 Clinical Coordinator stated that incomplete Intake and Output Records have been an issue in the past, that the Nurse Manager had addressed it and that the staff should be written up for not completing the records. 10 NYCRR 415.12(g)(2)

Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #53) of six residents reviewed for Activities of Daily Living, the facility did not ensure that a resident with limited range of motion received the appropriate treatment and services to prevent further decline. Specifically, Resident #53 had contractures (deformities that result when muscles, joints, tendons, or other tissues tighten or shorten) to both hands and was not provided the hand devices (hand rolls) per their plan of care to prevent a decline. Additionally, the facility could not provide documented evidence that Resident #53 received range of motion per their plan of care. This is evidenced by the following: Resident #53 had diagnoses including central nervous system lymphoma (malignant cancer cells that affect the brain and/or spinal cord), brain tumor (swelling caused by an abnormal growth of tissue), and encephalopathy (a disease that affects brain function). The Minimum Data Set Assessment, dated 9/29/23, revealed the resident had severely impaired cognition, required total assistance from staff for activities of daily living, and had a functional limitation in range of motion to both upper extremities. The current Plan of Care (used by the Certified Nursing Assistant to provide care) included range of motion to the right ankle and right shoulder for contractures in the morning and evening and bilateral (affecting both sides) hand devices that may be removed for hygiene and self-care. An Occupational Therapy Discharge Summary, dated 9/29/23, documented recommendations for nursing assistance with all activities of daily living, including assistance with the use of hand devices to both upper extremities during daytime hours and passive range of motion to right and left shoulder to prevent further contractures. In a medical note, dated 12/12/23 at 5:22 PM, Physician #1documented the resident had contractures of both hands. During observations on 12/19/23 at 10:55 AM; 12/21/23 at 11:13 AM, 12:39 PM, and 3:30 PM; and on 12/22/23 at 8:30 AM, 11:55 AM, and 2:28 PM, Resident #53 was not wearing the recommended bilateral hand devices. The devices were observed on the resident's dresser in their room during all the observations. During an interview on 12/22/23 at 9:30 AM, Registered Nurse #2 Nurse Manager stated the Certified Nursing Assistants were expected to follow the resident's Plan of Care. There was no system in place for staff to document when range of motion was performed, and it was assumed that a resident was assisted with range of motion if it was documented on the Plan of Care to be done. During an interview on 12/22/23 at 2:25 PM, Certified Nursing Assistant #2 stated Resident #53 was to get out of bed at 10:00 AM and back to bed at 2:00 and had no need for range of motion. Certified Nursing Assistant #2 stated they always referred to the Plan of Care to ensure there were no updates. During an interview on 12/26/23 at 8:37 AM, the Rehabilitation Director stated Resident #53 was totally dependent on staff for their activities of daily living and the current recommendation was for range of motion twice daily. They said they expected that the Certified Nursing Assistants assisted the resident with range of motion in the morning and evening when performing care. During an observation and interview on 12/26/23 at 9:00 AM, the Rehabilitation Director and Licensed Occupational Therapist #1 were in Resident #53's room and confirmed the hand devices located on the resident's dresser were the recommended equipment for the resident. The Rehabilitation Director stated they would expect that Resident #53 would be assisted out of bed and the hand devices used during daytime hours. When interviewed at 10:24 AM, the Rehabilitation Director stated Resident #53 needed the hand devices to prevent further decline. During an interview on 12/26/23 at 10:09 AM, Licensed Practical Nurse #3 Clinical Coordinator stated the bilateral hand devices and range of motion were a part of the Plan of Care and they expected that Resident #53 would have the bilateral hand devices on daily and that range of motion would be done per the resident's care plan. 10 NYCRR 415.12(e)(2)

Based on observation, interview, and record review conducted during the Recertification Survey, it was determined that for one of one main kitchen the facility did not properly maintain essential equipment. Specifically, a high-temperature mechanical dish machine did not reach the required final rinse temperature to properly sanitize dishes. The findings are: Observations on 12/19/23 at 9:27 AM included facility staff starting breakfast dishes by running them through the [NAME]-brand mechanical dish washing machine in the main kitchen. Further observations included that after several racks of dishes were run through the machine, the final rinse temperature displayed on the temperature screen after each of four runs was: 140 degrees Fahrenheit, 141 degrees Fahrenheit, 146 degrees Fahrenheit, and 144 degrees Fahrenheit, respectively. Additional observations included dietary staff removing dishes that had come out of the machine onto the clean side drainboard and place them away, even though the dish machine had not reached a proper final rinse sanitization temperature (180 degrees Fahrenheit). In an interview at this time, the Dining Services Director stated that it was a high temperature machine and that the rinse temperature was showing low. The Dining Services Director further stated that they would contact their dish machine vendor to look at the machine. In an interview on 12/21/23 at 8:32 AM, the Director of Facilities stated that their vendor came in to look at the dish machine, said nothing was wrong with the machine, and perhaps it was a fluctuation in the temperature of the water being supplied by the kitchen's boiler. The Director of Facilities further stated that they have a sensor that measures the boiler supply temperature which is graphed and indicated with a yellow line on the graph. The Director of Facilities provided the surveyor with a printout of boiler supply temperatures from 11/20/23 through 12/20/23. Review of the graphic printout included that the boiler supply temperatures fluctuated significantly throughout this time period, ranging from approximately 80 degrees Fahrenheit to approximately 146 degrees Fahrenheit. The Director of Facilities stated that the boiler was set at about 140 degrees Fahrenheit previously, and this morning they turned it up to 160 degrees Fahrenheit after seeing the fluctuations in temperature on the printout for the boiler supply temperature. On 12/21/23 at 9:07 AM it was observed that the manufacturer's nameplate located on the [NAME]-brand mechanical dish machine identified that the required final rinse temperature should be 180 degrees Fahrenheit. In an interview at this time, the Dining Services Director stated that they noticed they were having issues with the rinse temperature at breakfast and lunch, and that dinner was okay. Record review on 12/21/23 at 9:59 AM revealed a service report from the facility dish machine vendor dated 12/20/23 which included the following notes: 1) Upon arrival I found the incoming water temp was at 125 degrees which is why when they are running the unit constantly and are not reaching the required final rinse temp of 180 degrees. 2) Spoke with (Dining Services Director) and the head engineer and they are looking into the issue as the printout of the 3 month temps on the kitchen water supply have been dipping to a low of 85 degrees and not maintaining the 140 degrees needed for the unit to work properly. 3) Unit temps when running up to 5 racks at once maintains all temps but after that it starts to dip down. 10NYCRR: 415.29(b), 415.14(h); Subpart 14-1.112(a), 14-1.113(a), 14-1.113(b)

Based on observations and interview conducted during the Recertification Survey completed on 3/2/22, it was determined that for four ([NAME], Porter, [NAME], and [NAME]) of six resident units and one of one main lobby, the facility did not ensure that the resident's environment remained free of accident hazards. Specifically, hot liquids were accessible to residents and a heating surface exceeding 125°F was not adequately protected from accidental contact. The findings are: The facility policy, Dining Services Policy #49 Coffee on the Neighborhoods, effective July 2017 with a revision date of July 2019, included: Coffee will be available on the neighborhoods for Members, Families, and Staff. The temperature of the coffee will be monitored regularly to ensure safety of the Members. The coffee machines are set to dispense coffee at 155-160°F. The policy also included that dining services associates are responsible for the following procedure: Check the temperature of the coffee from the machine daily by dispensing 2 cups of coffee and recording the temperature of the 2nd cup. Record the temperature on the temperature sheet. If the temperature exceeds 160°F, contact Dining Services Management and the Nurse Supervisor on the neighborhood and lock out the machine. 1. Observations and interviews on 2/24/22 from 9:23 a.m. to 3:50 p.m. revealed the following: a) There was a 'Folgers' coffee and hot water dispensing machine in the [NAME] Unit dining area across from the nurse station, and the hot water was 183°F (degrees Fahrenheit) using a digital ThermaWorks Thermapen. When interviewed, a dining services representative stated that the machine stays on all the time. When interviewed, Licensed Practical Nurse (LPN) #1 stated that they have some resident who wander, but they never used the machine. b) There was a 'Folgers' coffee and hot water dispensing machine in the Porter Place dining area and the hot water was 169°F using a digital ThermaWorks Thermapen. When interviewed, Registered Nurse Manager (RNM) #1 stated there are some residents who wander, but the evening and night shift staff have a key and turn the machines off. c) There was a 'Folgers' coffee and hot water dispensing machine in the Porter North dining area and the hot water was 185°F using a digital ThermaWorks Thermapen. When interviewed, LPN #2 stated that the machines are kept locked out except during meal service. d) There was a 'Folgers' coffee and hot water dispensing machine in the [NAME] Place dining area across from the nurse station and the hot water was 167°F using a digital ThermaWorks Thermapen. At this time the Thermpen was checked for proper calibration using crushed ice and water, and the device read 32°F. When interviewed, the Registered Nurse (RN) stated there are a few residents who wander and if any resident wants coffee, they are encouraged to ask staff for help. e) There was a 'Folgers' coffee and hot water dispensing machine in the [NAME] Place dining area across from the nurse station and the hot water was 167°F using a digital ThermaWorks Thermapen. When interviewed, RNM #2 stated that they do not have anyone on the unit that was a wandering concern. During an interview on 2/24/22 at 4:10 p.m., the Director of Dining Services (DDS) stated that they had stopped using the coffee machines during the COVID outbreak when there was no communal dining or visitation, and that they had just started using them again a few weeks ago. When asked for current temperature logs, the DDS stated that there were none because they haven't been taking temperatures. The DDS also stated that the nurses on the units are supposed to lock out the machines daily around 7-7:30 p.m. 2. On 2/24/22 at 11:18 a.m. and 3:48 p.m., and on 2/25/2022 at 8:50 a.m. a gas fireplace was observed to be in operation without a barrier. The glass panel was 283°F on 2/24/22 and 276° F on 2/25/22 when using a digital ThermaWorks Thermapen. The open area that included the gas fireplace had upholstered chairs and was located across from the Admissions Office. During an interview on 2/24/22 at 11:15 a.m., a maintenance staff member stated that the lobby receptionist used a remote control to turn the fireplace on and off. During an interview on 2/25/22, the Director of Building Services stated that the fireplace was being used as a secondary heat source for the lobby personnel. 10NYCRR: 415.29(a)(1)

Based on interviews and record review conducted during a Recertification and complaint investigation (#NY 684) Survey, completed on 3/2/22, it was determined that for one (Resident #346) of three residents reviewed, the facility did not permit a resident to return to the facility following an acute transfer to the hospital. Specifically, the resident was transferred to the hospital and upon receiving a referral from the hospital for a readmission, the facility determined they could not meet the resident's needs without proper notification per the regulation. This is evidenced by the following: Resident # 346 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. A discharge MDS assessment dated [DATE] was coded as discharge, return not anticipated. A medical provider note, dated 1/14/21, documented an evaluation of Resident #346 for acute leukocytosis and the need to transfer the resident to the hospital. The plan was reviewed with the resident who agreed with the transfer to the hospital on 1/14/21. A review of the facility 'Notice of Transfer or Discharge form, dated 1/15/21, included that Resident #346 was transferred to the hospital. The notice did not include the medical reason for transfer or discharge, did not indicate if it was a transfer (short term) or a permanent discharge notice, did not include any reason why the facility could not meet the resident's needs upon readmission requests and did not include appropriate appeal timeframes. The form was signed by a facility representative and dated as mailed on 1/18/21. Review of a Social Work progress note, dated 1/28/21 and labeled as 'late entry', documented that Resident #346's representative left a message on 1/15/21 that a bed hold was requested for one day and would let the facility know further after discussing with the hospital. When interviewed 3/1/22 at 8:47 a.m. The Director of Social Work (DSW) stated that if the resident/representative does not hold the bed they are no longer considered their resident and a discharge notice is not provided. When asked to clarigy, the DSW stated if the facility decided not to readmit the resident, they should be given a discharge notice and rights to appeal. When interviewed on 3/1/22 at 8:59 a.m. The Admissions Coordinator (AC) stated that a resident transfer (to the hospital) becomes a discharge when the family gives up the bed hold and a discharge notice and right to appeal should be provided by Social Work. The AC stated Resident #346 was not offered a bed (readmission) because there was a medical issue, something the facility could not meet. When interviewed on 3/1/22 at 11:10 a.m., The DSW stated they did receive a hospital referral for readmission but felt they could not meet the resident's needs. After a complaint was filed, a notice of discharge and appeal rights, dated 1/28/21, was provided to the resident representative. A readmission 'statement of intent' dated, 1/29/21 documented the facility's intent to readmit the resident provided the resident's clinical needs could be met and the resident provided proof of Medicaid eligibility was issued after surveyor intervention. Resident #346 did not return to the facility. 415.3 (h)(4)(iii)

Based on observations, interviews and record review conducted during a Recertification Survey, completed on 3/2/22, it was determined that for 2 Residents (#22 and #106) of 26 residents reviewed for care planning, the facility did not develop and implement a comprehensive person- centered care plan that included measurable objectives to meet the resident's medical, nursing, mental and psychological needs as identified in the comprehensive assessments. Specifically, Resident #22's Comprehensive Care Plan (CCP) did not include the resident's suprapubic (SP) urinary catheter or [CONDITION(S)] with [CONDITION(S)] (excess fluid), and Resident #106 CCP did not include the use of a [CONDITION(S)] (medications that affect mental function and behavior) medication. This was evidenced by: 1.Resident #22 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Assessment, dated 11/11/21, revealed the resident was moderately impaired cognitively, had an indwelling urinary catheter and had recevied a daily diuretic (medication to reduce excess fluid). The Care Area Assessment Summary (CAAS-provides guidance to the facility about specific areas of concern for a resident as identified on the MDS Assessment that may need interventions included in the CCP) included that the resident had an indwelling urinary catheter and to proceed to the CCP. Review of the current CCP revealed Resident #22 was risk for skin breakdown and interventions included that the resident used a urinal independently, spilling on occasion and instructions for staff to ensure the urinal is emptied. The CCP included an activities of daily living deficit with an intervention that included the resident had a Foley catheter (a tube going into the bladder via the urethra vs a SP catheter that goes into the bladder via the abdomen.) The Resident Plan of Care (care plan used by the Certified Nursing Assistants for daily care), dated January 2019, included that Resident #22 required total assist with dressing, had a SP catheter and for the nurse to change over from a leg bag to drainage bag and vice versa and to elevate legs when in recliner. The current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an observation on 2/24/22 at 10:00 a.m., Resident #22 was sitting in a recliner chair with both feet on the floor. Both feet were swollen with [CONDITION(S)]. The resident was holding a urinary catheter tubing in their hand, the drainage bag was not covered and sitting on the floor. During an observation on 2/28/22 at 9:13 a.m., Resident #22 was sitting in the recliner with their legs elevated wearing yellow skid socks and no TED stockings. In an interview on 2/28/22 at 1:24 p.m., the Licensed Practical Nurse (LPN) stated the care provided to the SP catheter should include cleansing the SP catheter site and applying a dry sterile dressing, monthly changes by the Nurse Practitioner, flushing the tube as needed and changing the drainage bag. In an interview on 2/28/22 at 1:29 p.m. the Registered Nurse Manager (RNM) stated they were responsible for developing the CCP and that they should include areas identified in the CAAS if relevant. The RNM stated Resident #22's SP catheter and the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The RNM stated if a resident had [CONDITION(S)] and on a diuretic, depending on etiology, it should also be addressed on the CCP. 2.Resident #106 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Assessment, dated 1/20/22, documented that Resident #106 had dementia, received an antipsychotic medication daily, and per staff assessment, had poor memory, poor recall and had moderately impaired decision-making skills. Review of the CAAS revealed that Resident #106 was on [CONDITION(S)] medications and instructions to proceed to a care plan. Review of the current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the CCP, dated 1/14/22, did not address the resident's use of a [CONDITION(S)] medications, measurable goals or person-centered nonpharmacological approaches to use. During random observations on 2/28/22 and 3/1/22 during the day shift, Resident#106 was seen well-groomed, taking part in activities both in and out of their room. No behaviors were observed. During an interview 2/28/22 at 2:16 p.m., RNM #2 stated that [CONDITION(S)] medications and interventions should have been added to Resident #106's CCP. During an interview on 2/28/22 at 2:10 p.m., the Staff Educator, and Acting Director of Nursing (ADON), stated the development and revisions of the CCP were completed by the RNM. The ADON stated they expected the CCP to be developed based on the initial assessments, ongoing assessments and revisions completed based on the resident's response to the CCP. The ADON stated a SP catheter should be addressed on the CCP for potential problems, catheter management and signs and symptoms of potential problems. The ADON stated they would expect heart failure to be addressed on CCP as there was a potential alteration in fluid status and breathing. The ADON also stated they would expect [CONDITION(S)] medications, especially an antipsychotic, and their clinical indications to be addressed on the care plan. [10NYCRR 415.11 (c)(1)]

Based on interview and record review during a Recertification Survey, and complaint investigation (#NY 684), completed on 3/2/22, it was determined that for two (Residents #146 and #346) of three residents reviewed, the facility did not provide evidence that a valid written notification of transfer or discharge was sent to the residents or resident representatives in a timely manner. Specifically, Resident #146 was not provided a notice of transfer or discharge following a hospital admission and Resident #346 was not provided a valid notice of discharge that included the reason for the discharge, complete and correct appeal information and did not supply evidence of a reason for inabilty to return as per the regulations. This is evidenced by the following: 1.Resident #346 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Assessment, dated 12/7/20, revealed the resident was cognitively intact. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 'Notice of Transfer or Discharge' form, signed by the facility on 1/15/21 did not include whether it was a transfer (short term with a return anticipated) or discharge (permanent discharge with a return not anticipated), the reason for transfer or discharge, or accurate appeal notice. The form indicated it was mailed on 1/18/21. When interviewed on 3/1/22 at 8:47 a.m. and again at 11:10 a.m., the Director of Social Work (DSW) stated that when a resident is transferred to the hospital, the admissions office calls the hospital to see if the resident had been admitted and follows up with the family. The DSW said that if the resident/representative wants to hold the bed then a notice of transfer and bed hold is provided and if the resident/representative does not want to hold the bed they are no longer our resident so typically no discharge notice is provided. The DSW later stated that if the facility decides not to readmit the resident, then a discharge notice and appeal rights should be sent. After reviewing the Notice of Transfer or Discharge form for Resident #346 the DSW stated that the form was not complete, that no reason for the transfer was identified and that you could not tell if the resident was a transfer or a discharge. The DSW said they thought that the reason the facility chose not to re-admit Resident #346 was related to the resident's respiratory needs. In an interview on 3/1/22 at 8:59 a.m., the Admissions Coordinator stated that transfers to the hospital become discharges when the resident or family give up the bed hold. The Admissions Coordinator said that Resident #346 was not offered a bed for readmission from the hospital as there was a medical issue the facility could not meet. Review of the resident's Electronic Medical Record did not reveal any reason for the facility's inability to care for Resident #346 if readmission was requested. 2.Resident #146 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Assessment, dated 12/6/21, revealed the resident was cognitively intact. The MDS assessment dated [DATE] revealed that the resident was transferred to the hospital with a return not anticipated. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility was unable to provide documented evidence that Resident #146 or their representative was notified in writing of the resident's transfer or discharge from the facility and the reason for transfer or discharge. In an interview on 3/1/22 at 3:25 p.m. the Admissions Coordinator stated that their only role for notice of transfer or discharges is when covering for Social Work and they attempt to do it within 24 hours of the transfer or discharge. The Admissions Coordinator stated that they did not have any evidence that a written transfer or discharge notice was provided to Resident #146 or their family. Resident #146 did not return to the facility. 10 NYCRR 415.3(h)(1)(iii)(a-c)