Every finding on record at The Grand Rehabilitation And Nrsg At River Valley

Based on observations and interviews during the abbreviated survey (2725858) the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents. Specifically,1) on 3/3/2026 at 10:20am observed on unit 3 East a treatment cart left unlocked and unattended with Nystatin cream left on top of the cart. This cart was under the responsibility of Licensed Practical Nurse # 1. 2) On unit at 5 East at 11:00 am observed medication cart on the unit left unlocked and unattended; while Licensed Practical Nurse # 2 was passing medication to the resident in room [ROOM NUMBER].The findings include:Review of the facility's Security of Medication Cart policy dated 10/97 and last reviewed 1/25 documented it is the policy of the facility to have the medication cart secured during medication passes. The nurse must secure the medication cart during medication pass to prevent unauthorized entry. Medication carts must be securely locked at all times when out of the nurse's view.On 3/3/2026 at 10:20am treatment cart was observed unlocked and unattended with Nystatin cream on top of the cart; treatment cart was located near room [ROOM NUMBER].During an interview with Licensed Practical Nurse # 1 on 3/3/2026 at 10:25 am they acknowledged that they left the treatment cart unlocked with nystatin cream on top of the cart. Licensed Practical Nurse # 1 stated the cart should have been locked, and they do not have an excuse for why they did not lock the cart. Licensed Practical Nurse # 1 moved the nystatin cream from on top of the cart and placed it inside the treatment cart and locked the cart.On 3/3/2026 at 11:00am Licensed Practical Nurse # 2 was observed in room [ROOM NUMBER] giving medication to the resident in the room. Medication cart was parked at the entrance doorway of room [ROOM NUMBER] unlocked and unattended.During an interview with Licensed Practical Nurse # 2 on 3/3/2026 at 11:02am they stated they are aware the medication cart was left unlocked, and it needs to be locked. Licensed Practical Nurse # 2 stated they normally do lock the cart.During an interview with the Assistant Director of Nursing on 3/3/2026 at 2:23pm they stated the nurses know better and should always lock the carts. They were probably trying to take a shortcut, but the nurses are aware the carts should be locked when they are not present at the cart.10 NYCRR 415.18(e)(1-4)

Based on observation, interviews and record review conducted during an abbreviated survey (2725858), the facility did not ensure infection prevention and control standards were maintained. Specifically, 1) on 3/2/2026 observed Certified Nurse Aide #1 not applying personal protective equipment to go into Resident # 2's room who had a contact precaution sign on the door. 2) On 3/3/2026 Observed Certified Nurse Aide #2 going into Resident # 3's room on droplet precaution with appropriate personal protective equipment, Certified Nurse Aide #2 exited the room wearing the mask in the hallway.Findings include:Review of the facility's infection control policy dated 8/17 and last reviewed on 1/2025 documented transmission-based precautions will be used whenever measures more stringent than standard precautions are needed to prevent the spread of infection.Review of the facility's Personal Protective Equipment for Healthcare Personnel dated 10/97 and last revised/reviewed 5/2025 documented it is the policy of the facility to utilize a variety of barriers, as appropriate, when working in the healthcare setting. The selection of personal protective equipment is based on the nature of the resident interaction and/or the likely mode(s) of transmission. Supplies necessary for adherence to proper personal protective equipment shall do readily accessible in resident care areas donning/doff procedure with policy.During an observation on 3/2/2026 at 12:04 pm Certified Nurse Aide # 1 went into Resident # 2's room with no PPE (Personal protective equipment) applied before entering the room. There was a sign on Resident # 2's door indicating that the resident was on contact precaution.During an interview on 3/2/2026 at 12:05 pm with Certified Nurse Aide #1 they stated they think Resident #2 was on contact precautions because of something with their head. Certified Nurse Aide #2 acknowledged that they did not have any PPE (Personal protective equipment) on when they entered the room and they should have applied it because the resident is on contact precautions. They did not apply for personal protective equipment because they forgot to and they were rushing to answer Resident #2's call bell.During an observation on 3/3/2026 at 10:37am Certified Nurse Aide # 2 applied personal protective equipment to enter Resident # 3's room. Resident # 3 had a sign on their door indicating that they were on droplet precautions. At 10:50 am Certified Nurse Aide # 2 observed in the hallway with the mask on their face after coming out of Resident # 3 room.During an interview on 3/3/26 at 10:51am Certified Nurse Aide # 2 acknowledged that they were wearing the mask in the hallway, and it should have been removed. Certified Nurse Aide # 2 stated the facility does train them on infection control, but they cannot remember the last time they were trained. Certified Nurse Aide # 2 stated they know when the residents are on precautions, they need to apply personal protective equipment and remove it after they are done.415.19 (b)(1)

Based on interview and record review the facility did not ensure individual financial records were available to residents through quarterly statements. This was evident for (6) six residents (Residents #18, #103, #127, #140, #157, and #160) reviewed for personal funds. Specifically, there was no documented evidence Residents #18, #103, #127, #140, #157, and #160 were provided with quarterly statements for personal need accounts managed by the facility. The findings include:The policy titled Deposit of Resident Funds dated 01/2025 documented the resident was provided with a confidential quarterly statement of funds on deposit with the facility and activity since the previous statement.On 01/20/2026 at 12:26 PM, Resident #127 was interviewed and stated they did not know how much money was in their account and had not received an account statement in the past year.On 01/20/2026 at 2:12 PM, Resident #140 was interviewed and stated they had not received quarterly statements for their personal funds account managed by the facility.On 01/27/2026 at 11:58 AM, Resident #103 was interviewed and stated they did not know their personal fund account balance and had not received quarterly statements since approximately 06/2025.On 01/28/2026 at 9:02 AM, the Administrator was interviewed and stated they took over responsibility of resident banking within the facility and disbursed funds from resident personal needs accounts upon resident request. The facility's former Finance Coordinator was responsible for resident banking but resigned in 11/2025. Residents were provided with their account balances upon request. The Administrator stated the corporate finance office operated offsite and were responsible for providing residents or their representatives with quarterly statements for personal needs' accounts managed by the facility. They stated there were no onsite staff members or other disciplines that helped to deliver the statements to residents. The Administrator stated they did not know when the last quarterly statements were sent out and would have to contact the corporate finance office to find out more information. At 5:07 PM, the Administrator stated they were unable to provide documented evidence that quarterly personal funds statements were provided to residents. 10 NYCRR 415.26(h)(5)(ii)(a-c)

Based on observation and interviews conducted during the recertification survey from 01/20/2026 to 01/28/2026 the facility did not ensure residents were provided food and drink that was palatable, and at a safe and appetizing temperature. Specifically, due to food temperature complaints from residents at the resident council meeting on 01/21/2026 at 11:11AM a test tray temperature was taken of egg salad that had a holding temperature of 70 degrees Fahrenheit, and during the observation of a lunch meal service in the kitchen, the egg salad and yogurt temperatures were held at 58 degrees Fahrenheit. The findings include:According to the United Stated Food and Drug Administration food code, cold holding of cooked eggs and egg containing foods should be at 41 degrees Fahrenheit or below.During Resident Council meeting conducted 01/21/2026 at 11:11 AM multiple residents at the meeting voiced concerns about foods being overcooked, and undercooked and at times food did not arrive hot.During an observation on 01/23/2026 at 1:04 PM, the last lunch tray was served on the second floor, and the cook used the facility thermometer to test the temperatures of the lunch main meal on one tray and alternate meal on a second tray. The alternate meal tray had a covered plate containing an egg salad sandwich, a cold item, with a holding temperature of 70 degrees Fahrenheit, and a bowl of stewed tomatoes, a hot item, with a holding temperature of 126.7 degrees Fahrenheit. During the observation, the cook was interviewed and stated the second floor was the last unit to get lunch service. Cold food items should be kept well below 70 degrees Fahrenheit. Usually, the egg salad sandwich would be kept separate from the stewed tomatoes and not stored under the same cover. The [NAME] stated the kitchen decided to change the presentation of the food and this might have affected the holding temperatures.During an observation on 01/27/2026 at 11:27 AM of the lunch meal service, yogurts, and pre-portioned cups of egg salad were held on a rack to be used on meal trays during the assembly of the meal. The temperature taken of yogurt by the acting Food Service Director documented it was at 51 degrees Fahrenheit, and the egg salad was 43 degrees Fahrenheit. At that time, the acting Food Service Director was interviewed and stated the procedure was to keep the rack of cold foods in the walk-in refrigerator until just before meal tray assembly started. They stated the current rack had been out of the walk-in refrigerator for less than ten (10) minutes. The documented temperature logs of the walk-in refrigerator were within normal limits, and the acting Food Service Director was not sure why the temperatures were elevated and attempted to use another thermometer to measure the temperatures. The temperatures continued to remain above the standard 41 degrees Fahrenheit. They stated they typically did not obtain and track cold food temperatures on the temperature log.10 NYCRR 415.14 (d)(1)(2)

Based on observation and interview, the facility did not ensure food was stored and prepared in accordance with professional standards for food service safety. Specifically, 1) unlabeled foods were stored in the kitchen walk in refrigerator, freezer, and cooks prep counter 2) expired foods were stored in the walk-in refrigerator, emergency food supply, and Resident #5's personal refrigerator and 3) staff were observed not wearing beard nets while in the kitchen.The findings include: The policy last reviewed 01/2024 titled Food Receiving and Storage documented all foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date).The policy last reviewed 01/06/2026 titled Resident Personal Refrigerators documented staff will monitor and discard any expired or improperly stored items.The policy last revised 11/2020 titled Dress code/Professional Appearance Policy documented beards and mustaches must be neat and closely trimmed to a 1/4 of an inch, if longer a beard net is required.During the initial tour of the kitchen on 01/20/2026 at 9:16 AM with the acting Food Service Director, the following was observed:The main walk-in refrigerator contained a plate of unlabeled food, the freezer contained a bag of unlabeled tortellini, and a pan of unlabeled white smooth consistency type food was on the cook's counter. The walk-in refrigerator contained pans of grape jelly, chopped lettuce, and chopped tomato with a discard date of 01/17/2026; a pan of hard-boiled eggs with a discard date of 01/16/2026; and four (4) gallons of whole milk with an expiration date of 01/05/2026. In the emergency food supply storage, there was a case of honey thick apple juice with an expiration date of 11/07/2025 and a case of rice cereal with an expiration date of 11/21/2025.During an observation and interview with the acting Food Service Director on 01/22/2026 at 9:15 AM a cook was in the kitchen preparing chicken with the beard net not covering their moustache and a recreation staff was filling containers for a beverage cart with no beard net. They stated staff had been educated on wearing hair and beard nets and produced an in-service sign in completed 05/15/2025.During an observation on 01/22/2026 at 10:33 AM Resident #5 had a personal refrigerator in their room that contained two (2) individual servings of Lactaid milk dated 12/09/2025, a carton of whole milk dated 10/15/2025, two (2) cartons of whole milk dated 11/29/2025, and one (1) carton of 2% milk dated 10/22/2025.During an interview with the acting Food Service Director on 01/20/2026 at 9:16 AM they stated the plate of unlabeled food was probably dietary staff saving food to eat later, it should not have been there, and the evening cook should have removed it. They stated the pan of unlabeled white smooth consistency type food on the cook's counter was pancake batter, but the cook stated it was alfredo sauce. The acting Food Service Director stated it was the evening cook's responsibility to discard any expired items. They stated the expired whole milk had just been delivered by the company that morning but must have been delivered by mistake. They stated deliveries were usually left at the door and no one from the kitchen had time to check it in when it was delivered. They stated the expired honey thick apple juice and rice cereal had been overlooked in the emergency food supply.During an interview on 01/22/2026 at 1:05 PM Certified Nurse Aide #6 stated Resident #5's personal refrigerator had a thermometer at one time, but not sure where it is now or who was keeping a record of the temperatures. They stated they thought the Certified Nurse Aide assigned to the resident each shift cleaned out Resident #5's personal refrigerator.During an interview on 01/22/2026 at 1:29 PM Licensed Practical Nurse Unit Manager #5 stated Resident #5's personal refrigerator was grandfathered in to allow them to have it since the previous administration did not want personal refrigerators in their rooms. They stated they were not sure who monitored/cleaned the personal refrigerator.10 NY CRR 415.14(h)

Based on observation, record review and interview the facility did not ensure proper disposal of garbage and refuse. Specifically, three (3) garbage/recycle dumpsters were left open and there were cardboard boxes spilling over the top of the dumpsters and litter on the ground around the dumpsters.The findings are:The policy titled Food-Related Garbage and Refuse Disposal reviewed 1/2024 documented outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. During an observation of the garbage area on 01/20/2026 at 10:14 AM with the acting Food Service Director, one (1) of three (3) dumpsters had the lid closed. The remaining two (2) dumpsters were open. There was observed litter on the ground including a plastic unused garbage bag, plastic straws, used blue and white plastic gloves, carboard, and spilled food. There was also a plastic bag full of garbage on the ground between the two (2) open dumpsters.During an observation of the garbage area on 01/22/2026 at 4:17 PM three (3) dumpster lids were open. The dumpster to the right was spilling over with cardboard boxes and one box on the ground. The middle dumpster was full of garbage and boxes, including a bag hanging over the side of the dumpster. Various litter was observed scattered in front of the dumpster including an empty bottle of tube feeding formula, straws, gloves, plastic, napkins, and a plastic bag of garbage partly under the dumpster. The third dumpster was partially full. There were cardboard boxes trapped under it and scattered around was a milk carton, used gloves, and other debris.During an interview with the acting Food Service Director on 01/20/2026 at 10:14 AM, they stated the garbage, and recycling was picked up several times a week. They stated the dumpsters were usually left open during the day. They stated staff typically filled one (1) dumpster and closed the lid before they used the next dumpster.During an interview on 01/28/2026 at 4:00 PM the Housekeeping Director stated the garbage is picked up four (4) times a week for both recycling and garbage. They stated the dumpster lids were left open all day starting around 7AM and it was the responsibility of the last housekeeper to close the lids at 11PM. They stated staff tried to fill one dumpster and close it before moving to fill the next dumpster. 10 NYCRR 415.14(h)

Based on interview and record review the facility did not ensure residents were informed of items and services the resident may be charged for and the amount charged for those items and services for (2) two of (3) three residents (Residents #13 and #157) reviewed for Beneficiary Notification. Specifically, there was no documented evidence the facility provided Resident #13 and Resident #157's representative with a Skilled Nursing Facility Advanced Beneficiary Notification informing them of the cost to continue receiving skilled services once their Medicare Part A coverage ended.The findings include:The facility list of residents discharged from Medicare Part A services (with benefit days remaining) from 07/20/2025 to 01/20/2026 documented Resident #13 was discharged from services on 09/30/2025, Resident #157 was discharged from services on 12/04/2025, and both Resident #13 and Resident # 157 remained in the facility after their Medicare Part A coverage ended.The Notice of Medicare Non-Coverage dated 09/25/2025 documented Resident #13's signature affirming notification the resident's Medicare Part A services would end 09/30/2025.The Notice of Medicare Non-Coverage dated 12/04/2025 documented Resident #157 was cognitively impaired and a telephone call to the resident's representative on 12/01/2025 went unanswered.There was no documented evidence Resident #13 and Resident #157's representative were provided with a Skilled Nursing Facility Advanced Beneficiary Notification informing them of the cost to continue skilled services after their Medicare Part A coverage ended.On 01/28/2026 at 1:58 PM, Resident # was interviewed and stated they did not receive any notices from the facility with the cost of their skilled services once their Medicare Part A coverage ended.On 01/28/2026 at 2:31 PM, the Assistant Administrator was interviewed and stated the Minimum Data Set Coordinator was responsible for providing the Advanced Beneficiary Notification forms to qualifying residents. The Assistant Administrator stated the coordinator position was vacant when Resident #13's and Resident #157's Medicare coverage ended, and the Advanced Beneficiary Notification forms had not been issued to them or their representative.10 NYCRR 415.3(h) (2)

Based on record review and interview the facility did not ensure the accuracy of the preadmission screening for 1 (one) of thirty-eight residents reviewed for preadmission screening. Specifically, on the preadmission screen for Resident #81, number 23 was marked yes indicating that Resident #81 had a serious mental illness. However, the categorical determinations, numbers 27 to 30, were not completed as instructed to determine if a level two screen was indicated. The findings included:The policy titled Preadmission Screening and Resident Review Requirements last reviewed 01/2025, documented all individuals applying for a new admission to the facility must be screened to identify serious mental illness or mental retardation/developmental disability per regulations. The admissions department will review the screen form completed by the referring entity to determine if the Level I review reflects the need for a Level II referral. If, after the resident is admitted , the social worker determines that a Level II determination was required and not done, the social worker will make Level II referral to the appropriate agency.Resident #81 was admitted with diagnoses that included schizophrenia (a serious mental illness that affects a person's thought process and behavior), depression, and anxiety disorder. The preadmission screen dated 03/21/2025 documented in number 23 that Resident #81 had a serious mental illness but categorical determinations numbers 27 to 30, were not completed.During an interview on 01/22/2026 at 4:10 PM, the Assistant Director of Social Work stated screens should be reviewed for accuracy by the Admissions Department prior to admission. Once a resident was admitted , social work checked screens for accuracy. They stated preadmission screen numbers 27 to 30 should have been completed for Resident #81 once it was determined that Resident #81 had a serious mental illness as indicated by number 23 being marked yes. During an interview on 01/28/2026 at 2:38 PM, the Director of Admissions stated the admissions department reviewed preadmission screens for accuracy prior to the resident being admitted . They stated after a resident is admitted the social worker should check the screen again for accuracy. If an error is found, they should have the screen corrected. NYCRR 415.11 (e)

Based on record review and interview the facility did not ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for (2) two (5) five residents (Resident #18, Resident # 157) reviewed for care planning. Specifically, 1) there was no documented evidence that Resident #18's comprehensive care plan was reviewed and/or revised with the quarterly Minimum Data Set completed on 8/25/2025 and 11/18/2025 and 2) there was no documented evidence that a care plan meeting was conducted between 09/2025 and 01/2026 for Resident #157. The findings are: The policy titled Care Plans, Comprehensive Person-Centered, last reviewed January 2025 documented the Interdisciplinary Team must review and update the care plan at least quarterly, in conjunction with the required quarterly Minimum Data Set Assessment. Resident #18 had diagnoses that included paroxysmal atrial fibrillation, type 2 diabetes mellitus and anemia. The 11/18/2025 Quarterly Minimum Data Set (assessment tool) documented Resident #18 was cognitively intact. There was no documented evidence that the care plan was reviewed and revised after the completion of the 08/25/2025 and 11/18/2025 Minimum Data Sets. During an interview on 1/28/2026 at 10:57 AM, the Director of Nursing stated resident care plans should be reviewed every quarter. They stated care plans needed to be reviewed to determine if the resident had changes and to determine if care plan interventions needed to be updated. 2)Resident #157 had diagnoses that included abscess of the head/scalp, chronic osteomyelitis of the skull, and hemiplegia. There was no documented evidence that a care plan meeting was held between 09/2025 and 01/2026. The 01/02/2026 Quarterly Minimum Data Set (assessment tool) documented Resident #157 had moderately impaired cognition. During an interview on 1/27/2026 at 12:50 PM the Director of Social Work stated care plan meetings were held every quarter, and the Minimum Data Set Coordinator would send a list of residents that were due for care plans meetings. They stated they did not have a quarterly team care plan meeting for Resident #157 between 09/2025 or 01/2026 due to the facility not having a Minimum Data Set Coordinator. 10 NYCRR 415.11(c)(2)(i-iii)

Based on interview, observation and record review the facility did not ensure the resident environment remains as free of accident hazards as is possible for one (1) of seven (7) residents (Resident # 54) reviewed for Accidents. Specifically, there was no documented evidence that hazards and risks were evaluated and analyzed and that care plan interventions were monitored for effectiveness and/or modified when necessary for Resident #54 who was observed in their room on 01/28/2026 with a lighter in their possession. Additionally, the 06/15/2025 Annual Minimum Data Set Assessment documented Resident #54 did not use tobacco.The findings include:The undated details of smoking policy documented residents would be evaluated on admission, quarterly, to determine if they are a smoker, non-smoker, and/or desire to smoke. Evaluation will also include smoking safety and understanding of policy. If a smoker the evaluation will include ability to smoke safely with or without supervision (per a completed smoking evaluation) and residents identified as smokers may not have or keep any smoking articles including cigarettes, tobacco etc. in resident rooms or on their person.Resident #54 had diagnoses including but not limited to Paraplegia and Multiple Sclerosis.The 05/18/2022 care plan titled Resident is a Smoker and Aware the Facility is a Non-Smoking Facility. The resident refuses to give staff their lighter. Risks explained, return demonstration of the understanding. Assess the residents' physical and mental ability as needed for ability to understand and follow policy. Remove lighter and keep it in a secure location. Instruct resident. The resident chooses to be non-adherent.The 03/20/2023 unnamed contract signed by Resident #54 documented that by signing they agreed to comply with policies and procedures of the facility. The contract documented the resident agreed to not keep smoking materials such as lighters and/or matches in their room.The 06/15/2025 Annual Minimum Data Set Assessment documented Resident #54 was cognitively intact, had no behaviors, had functional limitation in range of motion to both upper extremities and did not use tobacco. The 12/02/2025 Quarterly Minimum Data Set Assessment documented Resident #54 was cognitively intact, had no behaviors, and had functional limitation in range of motion of to both upper extremities.During observation on 01/22/2026 at 8:30 AM Resident #54 was sitting in a wheelchair outside the gate surrounding the facility. Resident #54 was to the left of the entrance midway between the entrance and the corner block. Resident #54 was smoking.During interview on 01/27/2026 at 5:33 PM the Director of Nursing stated resident cigarettes and lighters were to be kept at the front desk.During interview on 01/28/2026 at 10:25 AM the Nurse Practitioner stated Resident #54 was physically safe to go out and cognitively safe to go out on leave of absence for smoking. Preventing Resident #54 from smoking would aggravate them. They stated Resident #54 was advised not to smoke but once they go beyond the gate, they can do whatever. They stated Resident #54 in the past may have smoked in their room.During interview on 01/28/2026 at 10:54 AM Certified Nurse Aide #7 stated Resident #54 is a smoker and keeps their cigarettes and lighter in their room because they are responsible. During interview on 01/28/2026 at 11:45 AM the Receptionist stated staff at the front desk did not keep any resident cigarettes and lighters. They stated they did not have a list with the names of residents in the facility that smoked and did not know which residents were smokers.During interview on 01/28/2026 at 1:09 PM the Social Work Director stated the front desk staff were responsible for keeping cigarettes and lighters in a locked drawer at the front desk.During interview on 01/28/2026 at 3:30 PM Resident #54 stated they were a smoker and reported that they smoked outside the facility behind the gated area. Resident #54 stated they kept cigarettes and a lighter in a bedside drawer. Resident #54 stated when they wish to smoke, they retrieve their cigarettes and lighter and inform staff they would be going downstairs. They stated they went outside past the gate when they smoked. Resident #54 stated they had been doing this without any issues or concerns.During interview and observation on 1/28/2026 at 5:34 PM Resident #54 stated they kept smoking items in their room. Resident #54 stated they did not have cigarettes with them at that time because they ran out of cigarettes. Resident #54 had a blue lighter in their fanny pack.During interview on 01/28/2026 at 5:45 PM the Administrator stated smoking materials should be kept at the front desk and should not be held by the residents.10 NYCRR 415.12 (h)(1)

Based on observations, record reviews and interviews conducted during the recertification survey from 1/20/2026 to 1/28/2026, the facility did not ensure specialized care needs for the provision of respiratory care in accordance with professional standards of practice for one (1) of one (1) residents (Resident #34) reviewed for respiratory care. Specifically, Resident #34 was administered oxygen without a medical order from 01/06/2026 to 01/22/2026.The findings include:The facility policy, Administering Medications last reviewed 1/2025 documents that medications must be administered in accordance with the orders, including any required time frame. The individual administering the medication must verify the right resident, right medication, right dosage, right time and right route of administration before giving the medication. The individual administering the medication must sign the resident's medication administrative record after giving each medication and before administering the next one. The facility policy, Oxygen Administration, last reviewed 1/2025 documents to verify that there is a physician's order for this procedure and to review the physician's orders or facility protocol for oxygen administration.Resident #34 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, respiratory failure, and heart failure.The admission Minimum Data Set (assessment tool) dated 1/13/2026 documented the resident had intact cognition, required supervision/touching assistance or partial/moderate assistance for activities of daily living. The resident experienced shortness of breath or trouble breathing when lying flat or on exertion.The care plan titled, Alteration in Cardiovascular Function, dated 1/10/2026 documented an intervention to provide oxygen per medical doctor orders.The care plan titled Resident at Risk or has an Alteration in Respiratory Function, dated 1/10/2026, documented an intervention to assess oxygen needs and provide as ordered by a medical doctor. During an observation on 1/20/2026 at 10:37 AM, Resident #34 was in their room receiving oxygen at four (4) liters per minute via nasal canula from an oxygen concentrator. During an observation on 1/21/2026 at 9:15 AM Resident #34 was sitting in their room receiving oxygen at four (4) liters per minute via nasal canula from a tank on their wheelchair. During an observation and interview on 1/22/2026 at 10:42 AM, Resident #34 was receiving oxygen at four (4) liters per minute via nasal canula from a tank on their wheelchair. The room oxygen concentrator was on at four (4) liters per minute. The resident stated they just returned to the room and had not switched back to the oxygen concentrator. Resident #34 stated they had been on oxygen at four (4) to five (5) liters per minute before coming to the facility.During a record review on 1/22/2026 at 12:41 PM, no oxygen orders were documented in the resident's medication administration record or in the physician orders from their admission on [DATE] to 1/22/2026. During an interview on 1/22/2026 at 2:38 PM, Licensed Practical Charge Nurse #14 reviewed Resident #34's electronic medical record and stated there was not a documented order for oxygen. They stated the resident arrived at the facility receiving oxygen at four (4) liters via nasal canula continuously and the oxygen administration was continued. The medical administration record takes its input from the physician orders, therefore there was no record of the oxygen being administered.During an interview on 1/22/2026 at 2:59 PM, Medical Doctor #1 stated orders were generally put in by medical providers or written down and put into the system by a nurse. A resident's medications and orders were reviewed on admission and entered into the facilities system by the medical doctor or nurse. Resident #34's oxygen administration was correct and not entered into the electronic health record. During an interview on 1/27/2026 at 5:52 PM, Registered Nurse #15 stated the resident was on oxygen continuously. The resident arrived at the facility receiving oxygen at four (4) liters per minute via nasal canula and the oxygen administration was continued. During an interview on 1/28/2026 at 10:57 AM, the Director of Nursing stated they expected the nurses to follow orders. There should have been an order for oxygen, and it was an oversight that the order was not entered.10 NYCRR 415.12(k)(6)

Based on observation interview and record review during Recertification and Abbreviated Surveys (#723126) the facility did not ensure that the Minimum Data Set accurately reflected the resident status for two (2) of six (6) residents (Resident #162, and Resident #157) reviewed for general skin issues. Specifically, 1) the 09/29/2024 Minimum Data Set Assessment did not reflect documented refusal of care/s for Resident #162 and 2) Resident #157 had a chronic ulcer to the scalp, that was not reflected in the 11/28/2025 and 01/02/2026 Minimum Sata Set Assessments. The findings included: The policy titled Minimum Data Set Assessment Coordinator last reviewed 01/2024 documented a registered nurse shall be responsible for conducting and coordinating the development and completion of the resident assessment. Everyone who completes a portion of the assessment must certify the accuracy of that portion of the assessment by dating and signing the assessment and identifying each section completed. 1) Resident #162 had diagnoses that included diabetes mellitus, heart failure, and morbid obesity. The Quarterly Minimum Data Set, dated [DATE] documented Resident #162 had intact cognition and no behaviors including refusal of care, medications, or activities of daily living. The Nursing Note dated 09/23/2024 documented Resident #162 refused an intravenous catheter for intravenous infuvite. The Nursing Note dated 09/27/2024 documented resident refused milk of magnesia. The resident stated they have not eaten in days. The quarterly Note dated 09/27/2024 documented the resident presents aggressive/combative and is resisting/refusing care. The September Medication Administration Record documented refusals of Eliquis on 09/22/2024, 09/24/2024, and 09/25/2024. The Certified Nurse Aide Activities of daily living documentation for September 2024 documented behavior symptoms on 09/23/2024, 09/24/2024, 09/26/2024 and 09/27/2024. During an interview on 01/28/2026 at 2:46 PM, the Regional Minimum Data Set Coordinator stated that the behaviors should have been on the Minimum Data Set. They stated they did have someone new at the time, and the information may have been entered incorrectly. 2)Resident #157 had diagnoses that included urinary abscess of head/scalp, unspecified open wound of the head, and chronic osteomyelitis of the skull. The Physician's Note dated 11/26/2025 documented Resident #157 had a chronic right scalp infection with greenish-brown exudate noted. The Physician's Order dated 11/26/2025 documented cleanse right temporal area with normal saline solution pat dry, apply clean dry dressing daily Monday through Friday. The Physicians Order dated 11/27/2025 documented Gentamicin Sulfate external ointment apply to right scalp topically in the AM for osteomyelitis of the scalp. The Five-Day Minimum Data Set, dated [DATE] documented Resident #157 did not have other ulcers, wounds and skin problems. The Treatment Administration Record documented cleanse right temporal area with normal saline and apply a clean dry dressing was administered on 12/30/2025 and 12/31/2025. The Quarterly Minimum Data Set, dated [DATE] documented Resident #157 did not have other ulcers, wounds and skin problems. During an interview on 01/28/2026 at 2:59 PM the Regional Minimum Data Set Coordinator stated staff that entered information in the Minimum Data Sets made mistakes. They stated the Minimum Data Set Coordinator position had been vacant, and corporate staff were trying to complete the assessments. The Regional Coordinator stated they were overseeing the staff, but it was hard for them to keep up. NYCRR 415,11 (b)

Based on staff interviews and review of facility documentation conducted during the abbreviated (NY00371494, NY00364683) surveys, it was determined that the facility did not ensure that a performance review of every certified nurse aide was completed at least once every 12 months, and that each certified nurse aide received no less than twelve hours of in-service education per year. This was evident for 2 of 3 Certified Nurse Aides (#3, #5) reviewed for completion of performance evaluations and in-service education. Specifically, the facility did not ensure that Certified Nurse Aide #3 and #5 had a performance evaluation completed at least once every 12 months and received no less than twelve hours of in-service education per year. The findings are: The facility policy, In-service training program, Nurse Aide, reviewed January 2024 documented that the facility will complete a performance review of Nurse Aides at least every 12 months, in-service training will be based on the outcome of the annual performance reviews addressing weaknesses identified in the reviews, and annual in- services must be no less than 12 hours per employment year. On 2/14/25 at 10:05 during an interview with Director of Human Recourses, the surveyors requested performance reviews for Certified Nurse Aides #2, #3, and #5. The Director of Human Recourses stated they do not have performance reviews for any clinical staff. They stated in their 2 years at the facility, they have never received a performance review for clinical staff. On 2/14/25 at 10:29 AM during an interview, the Director of Nursing stated they do not complete performance evaluations. On 2/14/25 at 11:04 AM during an interview, the Administrator stated they do not complete performance evaluations for the Certified Nurse Aides. On 2/14/25 at 11:28 AM during an interview, the former Staff Educator stated they had never completed or received a performance evaluation for any Certified Nurse Aide. Mandatory Annual Education Packets reviewed for Certified Nurse Aides #2, #3, and #5 did not ensure they had completed the required number of in-service education per year. On 2/14/25 at 1:40 PM during an interview with the Former Staff Educator and a review of Certified Nurse Aide #5's education packet, they stated Certified Nurse Aide #5 completed 7.5 hours of training and might have completed more but the tally of education minutes was not up to date. They stated every Certified Nurse Aide should complete 12 hours of training each year. On 2/14/25 at 1:40 PM during an interview with the Former Staff Educator and a review of Certified Nurse Aide #3's education packet, they stated Certified Nurse Aide #3 completed 9 hours of training and might have completed more but the tally of education minutes was not up to date. They stated every Certified Nurse Aide should complete 12 hours of training each year. 10NYCRR 415.26

Based on record review and interview during an abbreviated survey (NY00364683), the facility did not ensure the resident's representative was informed of a significant change in the resident's physical status or a need to alter treatment significantly for 1 of 3 residents (Resident #2) reviewed for abuse. Specifically, Resident #2 was a victim of sexual abuse on 12/13/24 by Resident #3, and there was no documented evidence that Resident #2's representative was notified of the incident until 12/16/24. The findings are: The facility policy, Abuse Prevention Program reviewed 3/2024 documented the Administrator or Director of Nursing Services or designated person will keep the resident and his or her representative informed of the progress of the investigation. Resident #2 had diagnoses including unspecified dementia, anxiety, and muscle weakness. The 11/21/24 Quarterly Minimum Data Set (assessment tool) documented Resident #2 had severe cognitive impairment and required assistance with activities of daily living. The facility accident incident report dated 12/13/24 at 8:48 PM documented that Certified Nurse Aide #2 observed Resident #3 touching Resident #2's left breast. The facility conclusion documented that there was reasonable cause to believe that resident abuse neglect or mistreatment may have occurred. The accident incident report documented the Resident's family member was notified at 3:45 PM with no date documented. There was no documented evidence that the Resident's family member was notified when the incident occurred on 12/13/24. On 2/14/25 at 11:47 AM during an interview with Certified Nurse Aide #2 who witnessed the incident on 12/13/24, they stated they observed Resident #3 touching Resident # 2's left breast. Review of Certified Nurse Aide #2's written statement confirmed their interview. There was no documented evidence in the Nurse's Notes that Resident #2's son was notified of the incident from 12/13/24 until 12/16/24. The 12/16/24 Nurse's Note documented the Assistant Director of Nursing spoke with Resident #2's son regarding the incident. On 2/14/25 at 1:25 PM during an interview with the Assistant Director of Nursing, they stated they did not notify Resident #2's family until 12/16/24. On 2/19/25 at 9:40 AM during an interview and review of the accident/incident report with the Director of Nursing, the accident incident report documented the Resident's family member was notified at 3:45 PM with no date documented. There was no documented evidence that the Resident's family member was notified when the incident occurred on 12/13/24. The Director of Nursing stated the Resident's family member should have been notified when the incident occurred. On 2/19/25 at 11:31 AM during a follow-up interview, the Director of Nursing stated they confirmed that the Registered Nurse Supervisor who completed the accident incident report did not reach the Resident's family on 12/13/24 and did not document as such. The Director of Nursing additionally stated they do not know if or when a facility staff member called the Resident's family prior to 12/16/24 for the incident which occurred on 12/13/24. The Director of Nursing reiterated that the Resident's family member should have been notified when the incident occurred. 10 NYCRR 415.3(f)(2)(ii)(c)

Based on interviews and review of facility documentation conducted during the abbreviated (NY00371494, NY00364683) surveys the facility did not ensure that residents were free from abuse. This was evident for 2 (Residents #1, #2) of 3 residents reviewed for abuse. Specifically, 1) Registered Nurse Supervisor observed Certified Nurse Aide #3 pushing Resident #1's arm, and 2) Resident #3 was observed by a Certified Nurse Aide touching Resident #2's breast. The findings are: The facility policy titled Abuse Prevention Program reviewed 3/2024 documented the residents have the right to be free from abuse and will be protected from abuse. It documented the Administrator or Director of Nursing Services, or designated person will keep the resident and his or her representative informed of the progress of the investigation. An alleged violation of abuse will be reported immediately, but not later than two hours if the alleged violation involves abuse or 24 hours if the alleged violation does not involve abuse. Resident #1 originally admitted on [DATE] and readmitted on [DATE] with diagnoses of Dementia in other diseases classified elsewhere, mild, with mood disturbance and Cognitive communication deficit. Quarterly Minimum data set (an assessment tool) dated 1/7/2025 indicate that the resident is severely impaired to make decisions regarding tasks of daily living. The 10/9/24 Care Plan, Resident is at risk for potential abuse related to cognitive impairment documented the goal that the resident will not experience any form of abuse or neglect. Interventions included to assess the resident for signs and symptoms of abuse and or neglect and report to appropriate resources, investigate all allegations of abuse and neglect promptly. Resident #2 had diagnoses including unspecified dementia, anxiety, and muscle weakness. The 11/21/24 Quarterly Minimum Data Set (resident assessment) documented Resident #2 had severe cognitive impairment and required assistance with activities of daily living. The 10/9/24 Care Plan, Resident is at risk for potential abuse related to cognitive impairment documented the goal that the resident will not experience any form of abuse or neglect. Interventions included to assess the resident for signs and symptoms of abuse and or neglect and report to appropriate resources, investigate all allegations of abuse and neglect promptly. Resident #3 had diagnoses including schizophrenia, dementia, and major depressive disorder. The 9/30/24 Quarterly Minimum Data Set (resident assessment) documented Resident #3 had moderately impaired cognition and required supervision with ambulation and other activities of daily living. The 10/9/24 Care Plan, Resident is at risk for potential abuse, neglect related to cognitive impairment documented the goal that the resident will not experience any forms of abuse or neglect through the review date. Interventions included investigate all allegations of abuse and neglect promptly. Review of the accident and incident report dated 2/7/2025 revealed that Certified Nurse Assistant #3 had an altercation with Resident #1 and in their attempt to push the resident in their wheelchair through doors to exit the dining room Resident #1 put their arms out to stop their wheelchair from exiting of the room, and the Certified Nurse Assistant #3 pushed their arm forcefully out of the way. This event was witnessed by Registered Nurse Supervisor #1, they stopped Certified Nurse Assistant #3 and evaluated the resident and reported the incident to the Director of Nursing. On 2/13/25 at 10:51am in an interview with Registered Nurse Supervisor who was the supervisor on the day of the incident, stated while they were walking in the hallway, they heard Resident #1 cursing and observed Certified Nurse Aide # 3 attempting to wheel Resident #1 through the doorway from the dining room into the hallway, they observed Resident #1 forcefully holding the door jam to prevent Certified Nurse Aide #3 to wheel Resident #1 out of the dining room, and observed Certified Nurse Aide #3 forcefully push Resident #1's left arm off of the door jam. Registered Nurse Supervisor #1 stated they observed scratches on the Certified Nurse Aide #3 arms but no bite marks. Stated they assisted Resident #1 into the hallway, completed a quick head to toe assessment and did not see any injuries to Resident #1. On 2/14/25 at 11:47 AM during an interview with Certified Nurse Aide #2 who witnessed the incident on 12/13/24, they stated they observed Resident #3 touching Resident #2's left breast. The facility accident incident report dated 12/13/24 at 8:48 PM documented that Certified Nurse Aide #2 observed Resident #3 touching Resident #2's left breast. The facility conclusion documented that there was reasonable cause to believe that resident abuse neglect or mistreatment may have occurred. On 2/14/25 at 1:20 PM during an interview, the Director of Nursing stated they could not rule out that abuse may have occurred. On 2/18/25 at 3:55 PM, during a follow-up interview, the Director of Nursing stated that after investigation of the incident, they could not rule out that abuse may have occurred. 10NYCRR 415.4(b)(1)(i)

Based on interviews and review of facility documentation conducted during the abbreviated (NY00364683) survey, the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made to either the State Survey Agency or local law enforcement in accordance with State law through established procedures. This was evident for 2 of 3 residents (Residents #2, #3) reviewed for abuse. Specifically, Certified Nurse Aide # 2 observed Resident #3 touching Resident #2's breast on 12/13/24 at 8:48PM and the facility did not report the incident to the State Survey Agency until 12/14/24 at 3:59 PM, the facility also never notified law enforcement, although the facility could not rule out abuse. The Finding is: The Facility Policy, Abuse Prevention Program reviewed 3/2024 documented residents have the right to be free from abuse and will be protected from abuse. It documented the Administrator or Director of Nursing Services, or designated person will keep the resident and his or her representative informed of the progress of the investigation. An alleged violation of abuse will be reported immediately, but not later than two hours if the alleged violation involves abuse or 24 hours if the alleged violation does not involve abuse. The facility policy, Reporting suspicion of a crime, reviewed January 2024 documented that each covered individual must report to the state survey agency and at least one local law-enforcement agency, any reasonable suspicion of a crime against the resident of the facility. Examples of crimes that would be reportable include but are not limited to sexual abuse. Resident #2 had diagnoses including unspecified dementia, anxiety, and muscle weakness. The 11/21/24 Quarterly Minimum Data Set (an assessment tool) documented Resident #2 had severe cognitive impairment and required assistance with activities of daily living. Resident #3 had diagnoses including schizophrenia, dementia, and major depressive disorder. The 9/30/24 Quarterly Minimum Data Set (an assessment tool) documented Resident #3 had moderately impaired cognition and required supervision with ambulation and other activities of daily living. The facility accident and incident report dated 12/13/24 at 8:48 PM documented that Certified Nurse Aide #2 observed Resident #3 touching Resident #2's left breast. The facility conclusion documented that there was reasonable cause to believe that resident abuse neglect or mistreatment may have occurred. During an interview on 2/14/25 at 11:47 AM Certified Nurse Aide #2 stated that on 12/13/24, they observed Resident #3 touching Resident # 2's left breast. Review of Certified Nurse Aide #2's written statement confirmed their interview. During an interview on 2/14/25 at 1:20 PM, the Director of Nursing stated the incident occurred on 12/13/24 at approximately 8:45 PM, but they did not report to the State Survey Agency until 12/14/24 around 3:00 PM, although the facility could not rule out that abuse may have occurred. The Director of Nursing stated nobody besides them and the Administrator have access to the Health Commerce System for reporting to the State Survey Agency. The Director of Nursing additionally stated they did not call law enforcement. During a follow-up interview on 2/18/25 at 3:55 PM, the Director of Nursing stated the facility should report to the State Survey Agency if abuse cannot be ruled out within 2 hours. The Director of Nursing stated when they investigated the incident, they could not rule out that abuse may have occurred. The Director of Nursing further stated that they only call law enforcement if at least one of the residents involved in an incident is alert and oriented. 10 NYCRR 415.4(b)(2)

Based on record review and interviews during an abbreviated survey (NY00364683), the facility did not ensure the comprehensive care plan was reviewed and revised in a timely manner for 1 of 3 residents (Resident #2) reviewed for abuse. Specifically, Resident #2 was a victim of witnessed sexual abuse on 12/13/24, and there was no documented evidence of the care plan having been revised to reflect the abuse incident or any new intervention. The Findings are: The facility policy, Care planning - Interdisciplinary team, reviewed January 2024 documented the facility care planning interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. The interdisciplinary team must review and update the care plan when there has been a significant change in the resident's condition, when the desired outcome is not met, when the resident has been readmitted and at least quarterly. Resident #2 had diagnoses including unspecified dementia, anxiety, and muscle weakness. The 11/21/24 Quarterly Minimum Data Set (an assessment tool) documented Resident #2 had severe cognitive impairment and required assistance with activities of daily living. The 10/9/24 Care Plan, Resident is at risk for potential abuse related to cognitive impairment documented the goal that the resident will not experience any form of abuse or neglect. Interventions included to assess the resident for signs and symptoms of abuse and or neglect and report to appropriate resources, investigate all allegations of abuse and neglect promptly. There was no documented evidence of Resident #2's care plan being revised to reflect the abuse incident or new intervention. The 12/16/24 Physician's note documented incident with Resident #2, Resident #2 showed no overt signs of distress or discomfort. Plan: Resident's son was informed; staff will increase monitoring and prevent further contacts with Resident #2. On 2/14/25 at 4:02 PM during an interview, Registered Nurse Supervisor #7 stated Resident #2's Care Plan should have documented the incident and the intervention to be separated from the perpetrator. On 2/14/25 at 4:55 PM during an interview, the Director of Nursing stated no Care Plan Notes or new interventions were documented related to the abuse incident on 12/13/24. They stated the Care Plan should have been updated. 10 NYCRR 415.11 (c)(2)(i-iii)

Based on observations, interviews, and record review conducted during the recertification survey 9/27/2023 - 10/3/2023, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food safety. Specifically, 1) A dietary aide did not handle cleaned and sanitized dishware in a sanitary manner; 2) Equipment used for food service preparation, storage, and service was not maintained in a sanitary condition; 3) A cook did not properly sanitize a thermometer being used to check meal time food temperatures; 4) One dry storage room was being used to store dry foods and large quantities of multiple chemicals; 5) Cold foods temperatures were not maintained at 41 degrees Fahrenheit (F) or less. The findings are: The initial tour of the kitchen was conducted on 09/27/2023 between 9:50 AM and 11:50 AM with the Food Service Director (FSD) in attendance. The following were noted: 1) At 10:22 AM dietary aide (DA #1) was observed on the clean end of the dairy kitchen dishwasher using a gloved hand to push away water from the dishwasher counter (used to hold racks of clean dishes). DA #1 then touched cleaned and sanitized plate covers without use of proper hand hygiene and changing their soiled gloves. When asked the purpose of wiping the dishwasher counter with their gloved hand and then touching the plate covers, DA#1 stated they were checking the plate covers to make sure they were clean, and they would change their gloves. 2) At 10:29 AM a metal storage rack in the dairy side kitchen was observed to be rusted and held an accumulation of dust. The rack held 2 empty coffee pots and 5 empty, large Tupperware-style beverage containers which were stored upside down allowing for the open tops of the pots and containers to be in contact with the rusted, dusty metal rack. The FSD was interviewed at that time and stated that the rusted, dusty metal rack was not appropriate. 3) At 10:35 AM Three (3) large, standing storage bins for flour, rice, and breadcrumbs were observed in the dairy kitchen. The top of the flour bin was observed to be heavily soiled with brown-ish and red-ish colored dried spills, dried food debris, and dried, raised, yellowish-colored matter of unknown origin. The flour bins' clear plastic sliding lid was soiled with sticky, clear dried spills. The front of the flour bin was heavily soiled with dried, raised, yellow-ish colored matter of unknown origin and dried black-ish colored areas. The scoop for the bin was attached to a hook on the front of the flour bin. The flour scoop was covered with flour, and the rim of the scoop was in contact with the soiled front of the bin. At that time the FSD was interviewed and stated that the flour bin should be cleaned every other day, the bin did not look like it was cleaned every other day, and they would be counseling their pot washer about that. The FSD stated that the flour should have been washed before being put back on the flour bin. The FSD stated that the black-ish colored areas on the front of the flour bin may have come from mopping in the area. The tops of the bins used for storing breadcrumbs and rice were soiled with dried brown-ish colored spills, sticky yellowish spills on their sliding lids, and had pink-ish, yellow-ish, and black-ish colored soiling on the fronts of the bins. At that time the pot washer responsible for cleaning the bins was interviewed and asked the possible risk related to the soiled food storage bins. The pot washer observed the 3 storage bins, and stated that the bins were grimy, and the scoop rim touching the grimy bin could cause cross contamination and possible sickness. 4) At 11:00 AM, a 3-shelf pot rack with plastic racks was observed to be heavily soiled with sticky-to-touch, blackish colored grime. The racks were holding 3 extra-large pots stored face side down with their rims in contact with the soiled racks. In an interview at that time the FSD stated that the food contact surfaces should not be in contact with the shelves as they are unsanitary. 5) At 11:10 AM, an observation of the dairy side cooks' area revealed a 20 slot cooks' rack used to hold trays of prepared foods. The slots were heavily soiled with an accumulation of yellow-ish colored, raised, dried soiling, and raised brown-ish soiling. In an interview at that time the FSD stated that the soiling was due to spillage, the rack was supposed to be cleaned weekly, and the rack had not been cleaned in the last 2 months based upon the amount of spillage. The FSD stated that the soiling is a risk for cross contamination if it drops into food. The FSD stated that they are responsible for oversight of staff to ensure the cleaning of kitchen equipment. 6) At 11:19 AM, during an observation of the lunch meal food temperature checks in the dairy kitchen, the cook (cook #1) was observed wiping their food thermometer with a dry chix wipe (chix food service towels are a non-woven, low-lint material) and proceeding towards placing the thermometer into a large pan of green beans. Surveyor asked cook #1 to stop that action. In an interview at that time, cook #1 stated they use the chix wipes to sanitize the thermometer, and to prevent the prevent food from cross contamination and possible harm to the residents. Cook #1 stated they usually use a chix in sanitizer solution, but another staff member had left the dry chix wipes for them today. Cook #1 stated that the risk of using the dried chix without sanitizer solution would be that the thermometer would not be sanitized and there would be a risk of food contamination. 7) At 11:37 AM, during an inspection of the dairy kitchen refrigerator seven (7) plastic shelving racks were observed to be heavily soiled with both dried and sticky to the touch black-ish colored grime. The shelves held a variety of cold food items intended for resident use. At that time the FSD was asked the potential risk from the soiled shelving. The FSD stated that there was a risk of bacterial cross contamination. The FSD stated that the soiling occurred from humidity, moisture, and food spillage. The FSD stated that if the staff had seen this, they should have brought it to their attention immediately. A follow up inspection was conducted on 09/28/23. The findings were: 8) At 10:44 AM, an observation of the downstairs dry food storage room was conducted with the FSD in attendance and revealed that the room was also being used to store chemicals. A variety of chemicals were observed on shelves a few feet away from shelves of dry food items. Those chemicals included, but were not limited: Eight (8) 5-gallon containers of Santec Red heavy duty surface cleaner. Four (4) 5-gallon containers of Kleer-it for grease traps and drains. Three (3) 5-gallon containers of rapid dry drying agent for dish machines. Two (2) 5-gallon containers of clean slate Ajo manual dish soap Nine (9) one-gallon clean slate automatic dish machine detergent by Bristol. At that time the FSD stated that they thought the chemicals were stored separately from the food. 9) At 11:08 AM, the meat kitchen tray line was preparing to serve the lunch meal. Surveyor asked staff to check the temperatures of the cold food alternates which were being stored in the meat cooler. Temperature checks revealed: Egg salad sandwich: 45.9 degrees (F) Tuna salad sandwich 47.2 degrees (F). At that time the FSD stated they would move the sandwiches into the freezer. In an interview on 9/28/23 at 11:15 PM a Dietary Aide (DA #2) stated that the tuna salad and egg salad had been made last night. At that time Surveyor requested to obtain temperatures of additional items in the meat cooler which revealed: Tuna salad in metal pan: 43.8 degrees (F) Ground chicken in a metal pan: 43.8 (F). The meat cooler thermometer was checked and read 41 degrees F. In an interview on 9/28/23 at 11:38 AM the FSD stated that the door to the meat cooler does not always close with a full seal, and they had reported this to the maintenance director. The FSD stated they would discard all leftovers, and the tuna salad, egg salad, and ground chicken. The FSD stated that that the meat cooler has been unreliable since they came to the facility over a year ago, and they had spoken to the administrator about it but did not have any documentation of this. Surveyor review of the September 1st to 28th temperature log for the meat cooler revealed one reading of 47 degrees on 9/4/2023, one reading of 60 degrees F on 9/9/2023, and readings of 42 degrees F on 9/15 and 9/19/2023. No documented evidence was provided that a maintenance order was submitted to address the meat cooler temperatures greater than 41 degrees (F). In an interview on 9/28/23 at 2:28 PM the Administrator stated that they were not aware of any issues with the meat cooler. On 9/28/2023 in the afternoon, the FSD produced a maintenance order dated 4/3/2023 which documented the meat cooler was 60 degrees, and the response from maintenance documented added more r22 and brought back within operating pressures. Cooler now dropping temperature. No documented evidence was provided that there was communication from the kitchen to maintenance regarding meat cooler temperatures greater than 41 degrees (F) after 4/3/2023. S483.60(i)(2)

Based on interview and record review conducted during the recertification survey from 9/27/2023 to 10/3/2023, the facility did not ensure that all alleged violations involving abuse were reported timely for one (Residents #4) of two residents reviewed for abuse. Specifically, Resident #4 was observed in another resident's room inappropriately touching the other resident and the facility did not report the incident to the New York State Department of Health (NYSDOH). Findings include: Review of a facility policy and procedure (P&P) titled Abuse Prevention Program/Abuse and Neglect Clinical Protocol/Abuse investigation and reporting last reviewed 1/2023, documented sex abuse was non-consensual sexual contact of any type with a resident. All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and or injuries of unknown origin shall promptly report to local, state and federal agencies. All allegation of abuse neglect or mistreatment will be reported immediately but no later than 2 hours if the allegation involves abuse. Resident #4 had diagnoses including Schizophrenia, Traumatic Brain Injury, and Bipolar disorder. The Minimum Data Set (MDS, an assessment tool) dated 7/2/2023, documented the resident was cognitively intact; required supervision with bed mobility, transfers and eating; and limited assistance with toilet use. A review of the medical record behavior note dated 9/19/2023, documented at approximately 1:44 AM the resident was observed in another resident's room at the foot of the bed. Resident #4 had their pants down and was rubbing the other resident's leg with his left hand and had his right hand inside his pull up. A resident to resident incident report was initiated and Resident #4 was moved to another unit. A review of the Accident/Incident report dated 9/19/2023, documented Resident #4 was found in the room of Resident #99 on 9/19/2023. Resident #4 had their hand on Resident #99's leg and Resident #4's pants were lowered. A review of Resident #99's progress note dated 9/19/2023, documented Resident #99 was inappropriately touched by another resident and Resident # 99 did not have capacity to consent. During an interview on 10/02/2023 at 12:25 PM, the Administrator stated they were aware of the incident and thought the Director of Nursing (DON) did an investigation. During an interview on 10/02/2023 at 1:45 PM, the DON stated they were notified and investigated, but since Resident #99 slept through the incident, they did not consider it abuse and did not report it. 415.4(b)(4)

Based on observation, interview, and record review during a recertification survey the facility did not ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team. This was identified for 1 of 6 residents (Resident # 59) reviewed for accidents. Specifically, Resident # 59 had a fall on 2/4/23 and a fall with injury on 2/28/23 and the Fall Care Plan was not revised. Findings include: Resident # 59 had diagnoses including arthritis, lymphedema, and peripheral neuropathy. The Annual Minimum Data Set (MDS-an assessment tool) dated 8/26/23, documented the resident's cognition was intact. Resident #59 needed limited assistance of one person for bed mobility, transfer, and toileting. The Accident/Incident (A/I) reports dated 2/4/23 and 2/28/23, documented Resident #59 falls when getting up to ambulate with their walker. The fall care plan created 10/7/19, documented the resident had an actual fall related to decreased mobility, depression, psychoactive drug use, and use of psychoactive drug use. It further documented the resident had an actual fall while out on pass on 11/10/19 and on 9/24/21 an actual fall with no injury. There was no documented evidence the fall care plan was reviewed and revised for the falls Resident #59 had on 2/4/23 and 2/28/23. During an interview on 10/03/23 at 3:18 PM, the Director of Nursing (DON) stated the Assisted Director of Nursing (ADON) and DON were responsible for updating care plans. The DON stated when they reviewed the electronic medical record there were no updates made to the fall care plan. The DON stated the registered nurse (RN) that completed the A/I reports should have updated the care plans but did not. 415.11 (c)(2)(i-iii)

Based on observation, interviews and record review, conducted during an abbreviated survey the facility did not ensure that a resident who was admitted to the facility without a pressure ulcer received the necessary care and services to prevent the development of a pressure ulcer. Specifically, a resident who had a left ankle fracture was not provided with ongoing assessment, monitoring, and treatment of [REDACTED]. This resulted in the subsequent development of an avoidable stage 3 pressure ulcer to her left calf area. This was evident for 1 of 3 resident ' s sampled (Resident #1). This resulted in actual harm that is not immediate jeopardy. Complaint # NY 834 The finding is: Resident #1 is a [AGE] year old female who was admitted to the facility 5/29/2014 with [DIAGNOSES REDACTED]. She has a history of Embolism and [MEDICAL CONDITION] and most recently on 9/18/2014 she sustained a [MEDICAL CONDITION] ankle which required a soft cast on 9/17/2014. The Minimum Data Set (MDS), a resident assessment tool dated 6/9/2014 documented residents Brief Interview for Mental Status (BIMS) total score, 13/15 which indicated resident was cognitively intact. It further documents Resident is total dependent with assistance for bathing, personal hygiene and toileting and required extensive assistance of two people for transfer with Hoyer lift and was high risk for developing pressure ulcers. Review of the "Nursing Interim Review/Assessment" , dated 5/30/2014 documented that the resident skin status was intact, and was at risk for pressure ulcers due to Obesity and [MEDICAL CONDITION]. Review of the Interim Physician's Order Form dated 9/30/2014 documented: "Keep left lower extremity elevated on pillows, maintain splint, and may remove every day for hygiene, non-weight bearing. " Review of the facility Policy and Procedures for skin/observation documented that observation of entire body for every resident is to be done on weekly basis. Observations are to be performed by Licensed Nurses weekly, then they complete a weekly skin observation form which would include any location, type or stage of a skin impairment. The Comprehensive Care Plan (CCP) dated 9/18/2014 documented the resident has "fractures of bilateral malleoli left ankle." Interventions included: monitor resident daily for cast complications, swelling, pain, impaired circulation and report to MD (physician). It further documented: " splint daily okay remove every other day for skin evaluation " . Review of resident's Orthopedic Consult dated 9/18/2014 recommended leave splint in place, non-weight bearing obviously, may remove splint every other day for skin checks and hygiene. The 10/30/2014 consult recommended, " you may remove splint daily for hygiene, and skin checks (underlined), especially her heel. Then replace the splint. The CCP dated 11/2014 documented that resident was at risk for developing skin breakdown related to immobility and soft cast use. The care plan included interventions to, "Inspect skin daily during care and bathing and report any changes to charge nurse " . Review of the Medical Progress Note dated 12/9/2014 reveals a Physician evaluation was conducted and documented resident had [MEDICAL CONDITION] in extremities and her skin was intact. The Weekly Skin Assessment which are completed by Certified Nursing Assistants, (CNA) on shower days and cosigned by nursing dated 12/13/2014, 12/24/2014, 12/27/2014 12/31/2014 and 1/3/2015 documented that there were no skin impairments. The Nursing Aide Accountability Sheet for November and December of 2014 did not document the resident had a splint or that it was to be removed during bath, cares, or weekly skin checks. The cast monitoring sheets completed twice daily by nursing staff dated 12/6/2014 through 1/5/2015 did not identify any skin issues/problems or problems with the resident ' s soft splint/cast. Review of the Treatment Administration Sheet (TAR) dated 12/8/2014 documented, keep left lower extremity on pillow, may remove for hygiene, maintain splint. There were no signatures for the month of 12/2014 on the TAR. There was no documented evidence that the residents soft cast was applied/reapplied and removed during showers, cares, or skin assessments. On 1/5/2015 at 11:45 PM, a nursing progress note by the Licensed Practical Nurse (LPN) documented, "CNA on rounds reported small amount of blood on resident ' s pillow. " Pressure ulcer noted by LPN and the soft splint/cast was noted to be digging into residents left calf area, the Nursing Supervisor was informed. On 1/6/2015 nursing supervisor documented at 2:30 AM resident complaining of pain with pressure at left knee area, when soft splint was unwrapped and removed resident's calf area noted to have a 4X3 centimeter (cm) ulceration which was oozing with slough in center area. MD and family notified. Review of the Wound Care Record dated 1/9/2015 documented resident's wound located on left calf, as unstagable 2.0 X 2.4 X 0.8 cm facility acquired pressure ulcer. On 2/6/2015 at 10:00 AM, the Director of Nursing (DON) stated that during her first week of work at the facility this was discovered. She stated she immediately ordered a full house skin assessment for all residents, and immediately began inservicing all staff on weekly skin observations, cast/splint monitoring, and documentation of same. Nurses and aides involved with the care and monitoring of the resident received written disciplinary action. She stated that the charge nurse has not been available for disciplinary action because she has been off. On 2/20/2015 at 10:30 AM, LPN #1 stated that she did cast monitoring and that included checking color of toes, warmth, any drainage, pain and color. She stated that she had never observed around top of splint or at pressure areas of splint for any skin discoloration. She stated that she did sign the weekly skin assessment on 1/5/2015 and did not see any red areas. She did not recall if the splint had been taken off for any of these observations. On 2/20/2015 at approximately 12:00 PM resident was observed in her bed lying on her right side on an airmattress with no complaints of pain. Observation of the left calf wound found no necrotic tissue measured approximately 0.1 x 1.0 x 0.1 cm in depth. there was pink granulation tissue with no order or drainage. On 2/20/2015 at 2:15 PM, CNA # 1 stated that she did not recall the date and thinks it was sometime just before Christmas that resident 's daughter pointed out to her a red area where the splint was pressing into the resident skin. She stated it was not open at that time and went to get the charge nurse who along with the daughter placed a gauze in the area to keep the splint away from the resident sore area. She stated she was on vacation and returned to work after 1/6/2015. She further states she never removed the splint during cares for bed baths or showering. On 3/2/2015 at 1:30 PM, the Physician was interviewed and stated that he was not aware that nursing was not removing the splint for cares and skin assessment. He stated that he last saw the resident on 12/9/2014 and did not remove the splint at that time. He stated that the nurses should have alerted him of any problem and he would have assessed the problem immediately. The Charge Nurse was not available for interview. 415.12(c)(1)(2)

Based on interviews, observations and record review conducted during an abbreviated survey, it was determined that the facility failed to provide an environment that is free of accident hazards over which the facility had control. Specifically, the facility failed to have a system in place to monitor the functionality of alarmed, emergency exit doors to prevent residents from exiting these doors undetected into unsafe, unsupervised areas of the facility. This was evident for one (Resident #1) of twenty-two exit-seeking residents who wear wander guard bracelets (personal alarm devices). Resident #1, who is mobile in a geri chair (high back chair with wheels and a tray which can be used as a recliner) and known by facility staff to frequently attempt to exit the east side emergency exit door, exited the door while the alarm was non-functional. The resident fell backwards down an interior stairwell, sustaining a contusion to his left temporal area. The resident was subsequently discovered in the laundry room of the facility, which is located eight (8) flights of stairs below the exit door. The facility was unaware of the resident's whereabouts for approximately forty minutes. In addition, all twenty-two (22) exit-seeking residents are at risk for serious harm. This resulted in actual harm that is Immediate Jeopardy and Substandard Quality of Care. Complaint ID Number: NY 287 The findings are: Resident #1 is an [AGE] year-old-male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS)(a resident assessment tool) dated 08/12/2010, the resident has long-and -short term memory loss and has moderately impaired skills in daily decision-making. Behavioral symptoms are documented as wandering daily, and behavior is not easily altered. It further revealed that the activity of walking in his room or corridor did not occur and requires one person physical assist for transfers. A review of the Comprehensive Care Plan (CCP) initiated on 06/21/2010 revealed that the resident is a wandering and elopement problem due to his impaired safety awareness. An interview with the LPN (Licensed Practical Nurse) Unit Manager conducted on 09/13/2010 at 11:00 AM revealed that "the resident is very busy all over the unit in and out of rooms all day". She further stated that the resident has backed into the same emergency exit door many times but the alarm has always sounded and staff were able to redirect the resident away from the door before it could open. She also stated that she did not know why the door did not alarm on the day of the incident and does not know who is responsible for checking the alarms on these doors. On the CCP dated 9/5/2010 " quarterly review " or after the 9/8/2010 fall revealed that no new interventions or modifications were developed following the resident's multiple attempts to exit the facility through the emergency exit doors. A review of the facility Investigation dated 09/08/2010 revealed that at approximately 6:40 PM the resident was found in the basement by a housekeeper. Security staff brought the resident back to the unit. The facility staff subsequently found the resident's geri chair in the interior stairwell at the east end of unit four. The geri-chair was found on the landing of the stairwell in an upside-down position with the tray intact. The alarm on the door of this emergency exit was not sounding. Corrective actions included resident to be placed on one to one supervision; recommended psych evaluation; and fourth floor east side emergency door needs to be repaired as soon as possible. Resident #1 was observed and interviewed on 09/13/10 at 11:15AM. The resident was alert but not oriented to self, time or place. He did not recall the incident of 09/08/2010. The surveyor observed a large eccymotic area on the left temporal side of the resident's head. The resident's right knee was swollen, eccymotic, and multiple small abrasions were noted on his arms and legs. In addition, there were large bruises under his left arm and on the spinal area. An interview was conducted with the Director of Nursing on 09/08/2010 at 12:00 Noon. She stated that the facility did not call the New York State Department of Health to report this incident because she had ruled out that abuse, neglect or mistreatment of [REDACTED]. She said she did not consider this an elopement because the resident never left the building. She further stated that she had not checked the doors and did not come to the facility that evening because the Supervisor and Maintenance were taking care of the problem. An interview was conducted on 09/13/10 at 12:15 PM with the housekeeper who discovered the resident after he exited the unalarmed, emergency door. He stated that he found the resident in the laundry room, which is located eight flights down from where the geri chair was discovered. The housekeeper stated that he found the laundry room open at about 6:00 PM on the date of the incident. He further stated that as he entered the laundry room, he found Resident #1 sitting in a chair, with no shirt. He did not observe any injury to the resident. He states that he called security staff who came and took the resident back to his unit. The housekeeper did not know the resident or how the resident found his way down to the laundry room. An interview was conducted with the facility's Maintenance Director on 09/13/2010 at 1:30 PM. He stated that he was called by facility staff at about 8 PM on 09/08/2010. He was told that the east emergency door was not alarming. He further stated, "I came to the facility, checked the system but could not find the problem so I called the alarm company". He then revealed that a technician from the alarm company discovered that the fuse for the emergency door had burnt out; which left both the east and west doors unlocked and unalarmed but did not affect the other unit doors. The Maintenance Director further stated that the alarm company replaced the fuse at about 11 PM on 09/08/2010 and that all the alarms have been functioning since then. He added, "I do not know what caused the fuse to blow." He also stated he usually checks the alarms each day he is in but was unable to produce any documented evidence that the alarms are checked. An observation and tour was conducted on 09/09/2010 at 1:45 PM. The internal stairwell into which Resident #1 had exited, was observed at this time. The tour revealed that there are eight (8) flights of stairs from the 4th floor unit to the basement, where the laundry room is located. A review of photographs that were taken by the facility of the resident ' s geri chair after it was discovered in the stairwell revealed that the geri chair rolled down one (1) flight of stairs and landed backwards on the bottom of the first flight of stairs, with the tray table intact. Each floor of the facility has two (2) flights of stairs in the interior stairwell that connects it to the floor above or the floor below. The steps on the stairs are concrete. The stairway itself has metal railings. At the basement level, where the resident was discovered, there were two (2) unalarmed doors, one leading outside and the other leading to the basement itself. An interview was conducted with the facility Administrator on 09/13/2010 at 4:00 PM. He stated that he did not put a plan in place, or initiate any interventions, in order to prevent a similar accident from occurring. He stated, "What are we suppose to do? It's unfortunate he got a little bump on his head. Are we supposed to have a back-up to the backup? " The Administrator then stated," We have fixed the problem of the blown fuse and the alarms are working now and we have not done anything else". 415.12(h)(1)

A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Based on observations, interviews and record review conducted during an abbreviated survey, it was determined that the facility Administrator failed to ensure that the necessary care and services were implemented in order to provide an environment that is free from accidental hazards over which the facility had control. Specifically, an exit-seeking resident who is independently mobile in a geri chair, exited through a non-functional, alarmed, emergency door undetected. The resident fell backwards in the chair, down an interior stairwell. He sustained a contusion to his left temporal area as a result of this fall, as well as bruises and lacerations. The resident was subsequently discovered by a housekeeper in the laundry room of the facility, which is located in the basement, eight (8) flights of stairs below the resident ' s assigned unit. The facility was unaware of the resident ' s whereabouts for approximately 40 minutes. The administrator did not thoroughly investigate this incident. In addition the Administrator did not ensure alarmed emergency doors were routinely checked for functionality. In addition, all exit-seeking residents at the facility are at risk for serious injury. This resulted in actual harm that is Immediate Jeopardy. Complaint ID Number: NY 287 The findings are: During an abbreviated survey a deficiency for Accidents and Supervision (F323) was cited at the Immediate Jeopardy level and Substandard Quality of Care. Please refer to that citation. An interview was conducted with the facility ' s Administrator on 9/13 /10 at 4:00 PM. During the interview, the Administrator admitted that he did not put a plan in place, or initiate any interventions, to prevent a similar incident from occurring. He stated, " What are we suppose to do? It ' s unfortunate he got a little bump on his head. Are we supposed to have a back up to the back up? We have fixed the problem of the blown fuse and the alarms are working now. " 415.26