Every finding on record at The Grand Rehabilitation and Nursing At Pawling

Based on interviews and record review conducted during the survey, the facility failed to ensure a resident remained free from accident hazards for one (Resident #5) of three residents reviewed for accidents. Specifically, on 06/16/2025 Certified Nurse Aide #11 turned Resident #5 on their side to provide care and the resident rolled out of bed and onto the floor sustaining a right tibia and fibula fracture (a break in the two long bones of the lower leg). This resulted in actual harm to Resident #5 that was not Immediate Jeopardy.The findings are:Resident #5 had diagnoses of epilepsy (a chronic brain disorder characterized by seizures), chronic obstructive pulmonary disease (progressive lung disease), and cerebral infarction without residual deficits (a stroke without lasting neurological impairments).The Minimum Data Set (a resident assessment tool) dated 05/03/2025 documented Resident #5 was cognitively intact, had impairment on one side of the upper and lower extremity. Resident #5 was totally dependent on two staff for toileting, hygiene and bed mobility. The Comprehensive Care Plan related to risk for functional decline documented Resident #5 required the assistance of two persons for hygiene from 05/29/2024 until 06/16/2025 (when the incident occurred and they were transferred to the hospital). Resident #5 was dependent on two people to assist with incontinence care and lower body dressing.The Certified Nurse Aide Documentation Report (documents directions given to certified nurse aide) for 06/2025 documented Resident #5 was dependent on two staff for toileting hygiene and bed mobility.The Nursing Note, dated 06/16/2025 at 10:36 PM by Licensed Practical Nurse #8, documented that at 10:25 PM, Certified Nurse Aide #11 informed them Resident #5 rolled out of bed and was on the floor. The family and physician were notified. Resident #5 was subsequently transferred to the hospital.The Nursing Note, dated 06/17/2025 at 1:58 AM by Registered Nurse #3, documented Resident #5 was receiving care from Certified Nurse Aide #11 when they rolled off the bed. The on-call nurse practitioner was notified. Resident #5 was assessed and reported pain of 10 out of 10 to their right knee.The facility Incident Investigation dated 06/16/2025 documented Certified Nurse Aide #11 was performing incontinence care on Resident #5 and the resident was lying on their left side in bed when the resident slid off the bed and onto the floor. The investigation documented Certified Nurse Aide #11 failed to follow Resident #5's care plan, which resulted in actual harm to Resident #5.The Hospital Progress Note dated 06/17/2025 documented Resident #5 was admitted after a fall while being cleaned at the facility. Resident #5 complained of right leg pain and was diagnosed with a right tibia and fibula fracture. Resident #5 was not a likely candidate for surgery.Employee Disciplinary Action dated 06/27/2025 documented Certified Nurse Aide #11 received a one-week suspension from 06/17/2026 to 06/27/2026 for violating Resident #5's plan of care and attempting to provide care without another staff member.The Nursing Note dated 06/18/2025 documented Resident #5 was readmitted from the hospital with a right tibia and fibula fracture.Certified Nurse Aide #11 did not return phone calls for interview.Registered Nurse #3 no longer works at the facility.During a telephone interview on 08/12/2026 at 11:18 AM with Administrator #1, they stated they were hired by the facility in October 2025 and were not involved in Resident #5's incident on 06/16/2025.During a telephone interview on 08/12/2026 at 2:07 PM with the Medical Director, they stated they were hired by the facility in September 2025 and were not involved in Resident #5's incident on 06/16/2025.During a telephone interview on 08/20/2026 at 3:30 PM with Licensed Practical Nurse #8vtheyvstated they were the medication nurse on 06/16/2025 when Certified Nurse Aide #11 informed them that Resident #5 rolled out of bed during care and was on the floor. The resident was not moved, and the nursing supervisor was informed. Certified Nurse Aide #11 did not ask for assistance with caring for Resident #5 prior to the incident.During an interview on 08/21/2026 at 2:44 PM with the Director of Nursing, they stated an investigation was initiated following Resident #5's incident on 06/16/2025 which determined Certified Nurse Aide #11 violated the resident's plan of care by providing incontinence care to the resident without another staff member to assist. Resident #5 rolled out of bed, was hospitalized , and returned to the facility with a right tibia and fibula fracture. Certified Nurse Aide #11 was suspended for one week and was provided with in-service education and competency evaluations were done to ensure Certified Nurse Aide #11 performed their tasks adequately. The Director of Nursing stated the facility has not had any other incidents since 06/16/2025 where staff violated the plan of care by providing care by themself. The Director of Nursing failed to provide documentation for the in-services provided to the staff after the incident. 10 NYCRR 415.12(h)(1-2)

Based on observations, interviews, and record review conducted during a survey, the facility failed to ensure the resident's right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility was changed. This was evident for two (Residents #5 and #15) of three residents reviewed for resident rights. Specifically, 1) Resident #5 and their designated representative were not provided with notification nor an opportunity to meet their new roommate prior to receiving one on 02/13/2026, and 2) Resident #15 was cognitively impaired and had their room changed on 02/13/2026 without a documented explanation or plan to address the resident's potential adjustment needs. Resident #5 was exposed to profane, explicit, and graphic language from their roommate that went unaddressed by the facility staff from 02/13/2026 through 08/04/2026, resulting in Resident #5 experiencing psychosocial harm that was not Immediate Jeopardy.The findings are:The facility policy titled Change of Room or Roommate dated 03/02/2026 documented the facility reserves the right to make resident room changes or roommate assignments when found to be necessary by the facility. Reason for a change in room or roommate could include incompatibility of residents in a shared room.1) Resident #5 had diagnoses of major depressive disorder, aphasia (a partial or total loss of language due to brain damage), and epilepsy (a neurological disorder that causes seizures). The Minimum Data Set (a resident assessment tool) dated 06/24/2026 documented Resident #5 had mild cognitive impairment, exhibited no behavior, had trouble sleeping every day, felt depressed half the time, felt tired every day, and was totally dependent on staff for transfers in and out of bed and bed mobility.The Comprehensive Care Plan related to adjustment difficulties, initiated 07/04/2025, documented Resident #5 had a loss of independence and would be provided with emotional support, an opportunity to express themselves, and encouragement of family involvement.The care plan related to activities, initiated 07/11/2025 and last reviewed 07/08/2026, documented Resident #5 preferred the comfort of their bed quite often.The care plan related to major depressive disorder, initiated 08/07/2025 and updated 04/06/2026, documented Resident #5 had a diagnosis of depression but denied feeling depressed.The care plan related to communication, initiated 08/07/2025, documented Resident #5 had difficulty communicating due to their diagnosis of aphasia and required a pen and pencil to communicate. Resident #5's Bed Census List documented they were in the same room and had no room changes since 08/07/2025.The facility Census List documented Resident #15 had a room change and became Resident #5's roommate on 02/13/2026.There was no documented evidence Resident #5 and/or their representative, Resident Representative #3, were provided with written notification of a change in roommate. There was no documented evidence Resident #5 was oriented to or introduced to their prospective roommate prior to the room change on 02/13/2026.The Social Work Note dated 05/21/2026 authored by the Director of Social Work, documented Resident #5 reported concerns with their roommate making noises during the night that kept them awake. The Director of Social Work documented Resident #5's only resolution was to move, and Resident #5 declined to change their room.The Psychiatry Consult dated 05/21/2026 documented Resident #5 reported their sleep was disrupted at night due to their roommate. The consult documented staff reported the roommate slept well at night and that Resident #5's complaints were racially influenced. Resident #5 had attention-seeking behaviors.The Social Work Note dated 05/22/2026 authored by the Director of Social Work documented Resident Representative #3 approached them about concerns with Resident #5's roommate and expressed the roommate was using profane language. Resident Representative #3 questioned the reason Resident #5's roommate was admitted to the facility. The Director of Social Work documented they offered Resident #5 a room change and told Resident Representative #3 that profane language alone was not a reason to move Resident #5's roommate.The Care Plan Meeting Note authored by Social Work Assistant #1 dated 07/09/2026 documented Resident #5 and their designated representative attended the care plan meeting. The note documented Resident #5 spent much of the meeting time complaining about their roommate and requesting that their roommate be moved from the room.There was no documented evidence a care plan was developed and implemented to ensure Resident #5's roommate change adjustment was monitored and any difficulties addressed. 2) Resident #15 has diagnoses of Schizophrenia (a severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking) and dementia.The Minimum Data Set, dated [DATE] documented Resident #15 was severely cognitively impaired, displayed no behaviors, and was independent in transfers in and out of bed, independent in bed mobility, independent in dressing, and independent in toileting.The Comprehensive Care Plan related to psychotropic medication use, initiated 06/11/2025 and last reviewed 07/11/2026, documented Resident #15 received medication related to their schizophrenia diagnosis and their target behavior symptoms would be monitored and documented.The Comprehensive Care Plan related to cognition, initiated 03/06/2026 and updated 05/26/2026, documented Resident #15 was severely cognitively impaired due to their diagnosis of dementia and Schizophrenia. Resident #15 preferred to stay in their room and was unable to effectively communicate their needs.The Psychiatry Consult dated 06/13/2025 documented Resident #15 was disorganized and heard auditory hallucinations.The Nursing Behavior note dated 10/19/2025 documented Resident #15 constantly stood at the door to their room talking. Resident #15 was provided with redirection which had little effect and they continued to get up and stand at the entrance to their room talking.The Physician note dated 11/18/2025 documented Resident #15 occasionally had behaviors.There was no documented evidence a care plan to address Resident #15's behaviors was developed and implemented.Resident #15's Bed Census List documented the resident had a room change and was placed into Resident #5's room on 02/13/2026.There was no documented explanation for Resident #15's room change on 02/13/2026. There was no documented evidence that written notification and explanation of the room change was provided to Resident #15 or their representative. There was no documented evidence Resident #15 was oriented to their new room or introduced to their new roommate prior to having their room and roommate changed. There was no documented evidence a care plan was developed and implemented to ensure Resident #15's room change adjustment was monitored and potential difficulties addressed.The Social Work note dated 03/06/2026 documented Resident #15 could oftentimes be observed speaking to themselves and was repetitive in their conversation.The Psychiatry Consult dated 06/04/2026 documented Resident #15's family members have observed the resident talking to themselves and will be monitored in relation to the resident's schizophrenia diagnosis. Resident #15 would continue psychotropic medication to address their psychiatric symptoms.During observation on 08/06/2026 at 5:46 PM to 5:52 PM, Resident #5 and their roommate Resident #15 were each lying in their bed in the room. The privacy curtain was drawn. Resident #15 was observed loudly and clearly stating the father takes the little boy's penis and puts it in the little girl's vagina. The father takes their own penis and puts it inside the little girl's vagina. Resident #15 moaned and grunted during the iteration and continued to repeat the graphic language and statements during the entire observation. Resident #5 was interviewed during the observation, became tearful, and responded by nodding their head that their roommate's behavior occurred every night. Resident #5 reported they were disturbed by their roommate's behavior, reported the issue to the Director of Social Work, and reported that staff did nothing to intervene and improve their living situation.During observation on 08/10/2026 at 5:23 PM, Resident #5 requested Resident Representative #3 be interviewed in relation to the concerns with their roommate. Resident Representative #3 was interviewed in Resident #5's room with the privacy curtain drawn and stated Resident #5 had been in their current room for more than two years. Resident #5 had a roommate that passed away and the facility decided to place Resident #15 in the room as Resident #5's roommate without any warning, introduction, verbal or written notification. Resident Representative #3 stated the facility did not orient Resident #5 or Resident #15 to each other and did not notify Resident Representative #3 when or for what reason the change occurred. Resident Representative #3 stated they informed the Director of Nursing multiple times that there were roommate incompatibility issues and was told by the facility staff that Resident #5 would have to move. Resident Representative #3 stated facility staff tried no other intervention to make the environment more comfortable for Resident #5. Resident Representative #3 stated they speak with Resident #5 every night by telephone when they were not physically in the facility visiting. Resident #5 cried to Resident Representative #3 every night because they had to hear their roommate say graphic and disturbing things all night long. Resident Representative #3 stated this has affected Resident #5's psychosocial status and the resident was more tearful and depressed. During the interview, Resident #15 was in their bed behind the privacy curtain and could be heard grunting and moaning, saying the n***** word repeatedly, and repeating sexually explicit phrases.During an interview on 08/06/2026 at 4:10 PM and 08/21/2026 at 12:02 PM, the Director of Social Work was interviewed and stated they were also the Grievance Officer and were responsible for investigating resident and family concerns related to their stay in the facility and care received. The Director of Social Work stated they were familiar with Resident #5's complaints about their roommate saying the f*** word once and that Resident #5 and Resident Representative #3 were informed that if Resident #5 had complaints about their roommate, Resident #5 would have to move. The Director of Social Work stated this was facility policy and Resident #5 was not offered any other intervention to address their concerns with their roommate. The Director of Social Work stated they were aware Resident #15 talked to themselves but never heard them use profane language. They stated it would take a toll on a resident's mental health if they were exposed to a roommate who used profane language all the time. Resident #15 was admitted to the facility and had their room changed to Resident #5's room prior to the Director of Social Work's employment with the facility. The Director of Social Work stated they did not know the reason Resident #15's room was changed in February 2026. The Director of Social Work stated they did not orient prospective roommates to each other or provide notification to residents when they were going to have a change in roommate.A telephone interview was conducted on 08/11/2026 at 1:12 PM with the Director of Nursing who stated they did not get involved in room changes and the Director of Social Work was responsible for coordinating room changes and making any necessary introductions. The Director of Nursing stated Resident #15 was quiet and displayed no behaviors prior to their room change into Resident #5's room. The Director of Nursing stated that once a bed became available further down the hall, the interdisciplinary team determined Resident #15 should move into the open bed in the room with Resident #5. There was no issue with the change in roommate until recently. The Director of Nursing stated Resident #5 did not express any concerns to the social work department related to the room change and it was the Designated Representative #3 that had an issue. The Director of Nursing stated their staff did not report any behavior issues or concerns with Resident #15, and they were unfamiliar with any disturbing verbal outbursts and that a resident's behavior is documented in the record when it is disturbing or dangerous. The nursing staff did not document every behavior if it was recurrent and known to staff; however, there should be a behavior care plan in place to address those known behaviors. The Director of Nursing stated Resident #5 was offered a room change, and they were not aware of any psychosocial effect to Resident #5 because of their current roommate incompatibility.A telephone interview was conducted on 08/12/2026 at 11:18 AM with Administrator #1 who stated their employment with the facility was terminated on 08/11/2026. Administrator #1 stated the facility's policy was that any resident who complained about their roommate would have to be the one to move. Resident #5's family complained about Resident #15 and wanted the whole room to themselves. Administrator #1 stated no staff members corroborated the claims made by Resident #5's family that Resident #15 was being verbally disruptive. Administrator #1 stated they did not personally speak with Resident #5. Administrator #1 stated the social work department was responsible for addressing resident concerns with the grievance process, but resident family members were not allowed to file grievances on the resident's behalf if the resident was cognitively intact and expressed no concerns. Administrator #1 stated the nursing department was responsible for room changes, and it was communicated to them when they were hired that the Administrator did not get involved in room change decisions.A telephone interview was conducted on 08/12/2026 at 2:07 PM with the Medical Director who stated they were not involved in room change decisions. The Medical Director stated roommate incompatibility and exposure to disruptive roommates can have a negative effect on a resident's psychosocial and mental status, especially if it goes unaddressed.A telephone interview was conducted on 08/19/2026 at 10:11 AM with the Psychiatric Nurse Practitioner who stated they started working for the facility in April 2026 and were referred to both Resident #5 and Resident #15 for evaluation. The Psychiatric Nurse Practitioner stated they conducted their evaluations during the day and expected that facility staff would communicate any behavior issues outside of the time they were onsite. Resident #15 was always cooperative, pleasant, and responsive during sessions. The Psychiatric Nurse Practitioner stated they did not know Resident #15's psychiatric history and had no previous psychiatry consult in the resident's record to review. The Psychiatric Nurse Practitioner stated facility staff did not report any issues with Resident #15's behavior and Resident #15 received an antipsychotic medication for Schizophrenia. Resident #15's family did express the resident had verbalizations at one point and Resident #15's roommate, Resident #5, also reported the resident was verbally disruptive at night. The Psychiatric Nurse Practitioner stated they did not observe any behaviors from Resident #15 and, along with staff reports that Resident #5 displayed racially motivated attention-seeking behavior, concluded Resident #5 wanted Resident #15 to move because of the color of their skin. The Psychiatric Nurse Practitioner stated Resident #5 did not verbalize or communicate any racial motivation for their reported concerns with their roommate and they were just inferring this based on the information gathered from multiple sources and their own evaluation. 10 NYCRR 415.3(d)(1)(i)

Based on observations, interviews, and record reviews conducted during a survey, the facility did not ensure an effective discharge planning process that focuses on the resident's discharge goals and preparation for residents to effectively transition to post-discharge care for four of four residents reviewed for discharge (Resident #10, Resident #12, Resident #13, and Resident #15). Specifically, 1) Resident #13 was discharged home on [DATE]. The referral for the resident's post discharge care for intravenous management was not completed before discharge. 2) Resident #10's discharge plan was not developed with specific interventions to assist Resident #10 with their goal to be discharged to the community, 3) Resident #12 had requested to be discharged to another facility closer to home so they can receive dialysis at their previous dialysis center prior to been hospitalized . The discharge plan was not reviewed and revised to reflect the resident goal. Resident #12 was readmitted to the facility on [DATE]. 4) On 03/12/2026, Resident #15's family requested that the resident be discharged to a facility closer to home during a care plan meeting. There was no discharge plan, follow up note or any other documented interventions to support the resident desired goal. The findings are:The facility policy titled Discharge Planning Process dated 03/02/2026 documented that the facility would develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care. The facility would determine the resident's expected goals and outcomes regarding discharge upon admission, routinely in accordance with the Minimum Data Set assessment cycle, and as needed. 1) Resident #13 had diagnoses including malignant neoplasm of the parietal lobe, unspecified convulsions, and hemiplegia.The Minimum Data Set 3.0 (an assessment tool) dated 06/25/2026 documented Resident #13 was cognitively intact, was involved in the assessment and goal setting along with their family and had a goal to be discharged to the community. The Social Work Note dated 06/28/2026 documented the Director of Social Work spoke with Resident Representative #2 regarding Resident #13's discharge, and the plan to return to the community. Resident Representative #2 requested skilled nursing services, occupational therapy, and physical therapy services. The note documented that the Director of Social Work would coordinate the discharge planning and homecare services for Resident #13. The Discharge Planning Note dated 06/30/2026 documented Resident #13 was accepted by a homecare agency, and the nurse was scheduled for the initial home assessment on 07/06/2026. There was no documentation of the specific services that were to be provided. The Nursing Note dated 07/02/2026 documented Resident #13 was discharged home with Resident Representative #2 and homecare services including skilled nursing for intravenous line management and assessments, and intravenous antibiotic administration. The Social Work Note dated 07/02/2026 documented Resident #13 was discharged to the community and homecare services and community referrals were coordinated prior to their discharge. Review of an email communication between the homecare agency and the Director of Social Work dated 07/06/2026 documented that the homecare agency was unaware the resident had an PICC line (peripherally inserted central catheter) and therefore could not administer the antibiotic ordered for the resident. The home care nurse had not received discharge instructions from the facility. The email also documented that the home care agency did not have a contract with the residents' health insurance to complete the intravenous medication administration. The Facility referral did not provide the details of the residents' needs including the management and care of PICC line and the referral was not made to a homecare agency that contracted with the resident's health insurance. During a telephone interview on 08/07/2026 at 10:22 AM, Resident Representative #2 stated they had a discharge care plan meeting on 07/01/2026 with the interdisciplinary team including the nursing department, Director of Social Work, Director of Rehabilitation, and the Ombudsman. Resident Representative #2 stated they were assured during the meeting that all the necessary post-discharge services were in place for the resident's discharge home on [DATE]. Resident Representative #2 stated the facility did not set up the necessary homecare services for Resident #13 when they were discharged home. The homecare agency that visited the home on [DATE] was unable to manage Resident #13's intravenous care and medication, and did not provide any physical or occupational therapy services. Resident Representative #2 stated they had to contact their community provider to set up adequate home care services for Resident #13.During an interview on 08/06/2026 at 4:10 PM and 8/10/2026 at 3:45 PM, the Director of Social Work stated that they were responsible for coordinating Resident #13's discharge on [DATE] to the community with homecare services. The Director of Social Work stated they were on vacation when Resident #13 was discharged home and thought the necessary homecare services had been confirmed. The Director of Social Work was unable to provide any documented evidence that the homecare agency was informed that Resident #13 had an intravenous line or that the homecare agency agreed to provide intravenous line management/care and medication administration to Resident #13. 2)Resident #10 had diagnoses of morbid obesity, heart failure, and osteoarthritis.The Minimum Data Set 3.0 (an assessment tool) dated 05/11/2026 documented Resident #10 was cognitively intact, participated in the assessment and goal setting, and indicated a desire to return to the community.There was no documented evidence that a discharge plan was developed or implemented to address Resident #10's discharge goals. During an interview on 08/04/2026 at 12:15 PM, Resident #10 stated they wanted to return to the community and began coordinating with community agencies to facilitate their discharge plan. During an interview on 08/06/2026 at 4:10 PM, the Director of Social Work stated they were responsible for coordinating discharge planning for residents. Discharge goals were discussed at interdisciplinary care plan meetings and then documented in the resident's care plan. The Director of Social Work stated Resident #10's record should have reflected the resident's desire to return to the community, despite the goal being unrealistic, and this goal should have been discussed during interdisciplinary care plan meetings. They were unable to provide an explanation for the absence of a discharge plan for Resident #10.3) Resident #12 had diagnoses of diabetes, end stage renal (kidney) failure with hemodialysis, and acquired absence of right leg below the knee.The Minimum Data Set 3.0 (an assessment tool) dated 06/28/2026 documented Resident #12 was cognitively intact, was involved in their assessment and goal setting, and had a discharge goal to return to the community. The Social Work assessment dated [DATE] documented Resident #12 was a new admission, and their discharge plan was to return to their home in the community. Review of the Social Work Note dated 07/01/2026 prior to hospitalization documented Resident Representative #1 expressed a desire for Resident #12 to be transferred to another facility closer to home and informed the Director of Social Work that they would seek discharge to an alternate facility if Resident #12 was hospitalized . The Nursing Note dated 07/01/2026 documented Resident #12 was transferred to the hospital after Resident Representative #1 called emergency services. Resident Representative #1 gathered and took all of Resident #12's personal belongings from the facility at the time of the resident's transfer to the hospital. The Nursing Note dated 07/02/2026 documented Resident #12 was admitted to the hospital. The Nursing Note dated 07/10/2026 documented Resident #12 was readmitted to the facility. The Comprehensive Care Plan related to short-term placement in the facility, initiated on 06/22/2026 and revised on 07/17/2026 documented Resident #12's discharge status remained uncertain and Resident Representative #1 was involved in the resident's discharge planning. The revision on 07/17/2026 documented resident will be safely discharged to the community. The only intervention documented and dated 06/22/2026 was to educate the residents and representatives on community resources. There were no additional interventions documented when the care plan was revised on 07/17/2026. There was no documented evidence the discharge plan was reviewed and revised to include Resident Representative #1's goal to transfer Resident #12 to a facility closer to their home. During an interview on 08/06/2026 at 11:30 AM, Resident #12 stated they were admitted to the facility for short-term rehabilitation. Resident #12 stated they were not ready for discharge to their home in the community and wanted to be transferred to another facility closer to their home in the meantime. During an interview on 08/06/2026 at 12:21 PM, Resident Representative #1 stated Resident #12 was unable to be transferred to another facility while in the hospital and they had a care plan meeting with the Director of Social Work following Resident #12's readmission to the facility. Resident Representative #1 stated they informed the Director of Social Work that Resident #12 preferred to receive dialysis services from their community center as the facility was unable to accommodate Resident #12's preferred dialysis schedule. Resident Representative #1 stated they felt the Director of Social Work was dragging their feet and delaying Resident #12's transfer. Resident Representative #1 stated they contacted Resident #12's preferred dialysis center and alternative facility and was informed by them that Resident #12's current facility did not send over the necessary information for the resident to be accepted for transfer and admission. During an interview on 08/06/2026 at 4:10 PM, the Director of Social Work stated they were not aware Resident #12 wanted to transfer to another facility. The Director of Social Work stated they should have held a formal discharge care plan meeting with Resident #12 and Resident Representative #1 upon the resident's return from the hospital but did not. During a telephone interview on 08/12/2026 at 11:18 AM, Administrator #1 stated the social work department experienced turnover multiple times during their employment at the facility from 10/2025 to 08/11/2026. Administrator #1 stated they were not aware of any discharge planning issues during their employment and felt discharge coordination was handled adequately. 10 NYCRR 415.3 (c)(1)(i)

Based on observations, interviews, and record review conducted during a survey, the facility did not ensure a clean, comfortable, and homelike environment on three (Units 100, 200, and 300) of three units observed for the environment. Specifically, 1) the shower rooms on Units 100, 200, and 300 were being used to store linens and briefs on shower room equipment and had tiles covered in grime and black stains throughout the grout, 2) Unit 100 had a strong odor of urine in the hallway in front of the elevator doors, 3) food and paper debris were on the floor and an excessive amount of resident equipment was stored in common areas creating a cluttered environments on Units 100, 200, and 300, and 4) Resident #4 had a bedside table with drawers that were in disrepair and off track preventing them from being opened or closed and room [ROOM NUMBER] door was unable to swing open without being forcefully shoved, causing the bottom of the door to drag along the floor and make a loud shrill screeching sound.The findings are:The facility policy titled Safe and Homelike Environment dated 03/02/2026 documented the facility will provide a safe, clean, comfortable and homelike environment. Housekeeping and maintenance services would be provided as necessary to maintain a sanitary, orderly and comfortable environment.1) During an observation on 08/06/2026 at 12:52 PM and 08/10/2026 at 9:34 AM, the Unit 200 shower room had a wet towel on the floor, had tile floors and grouting that were discolored and black, had wall tiles with filmy grime throughout, and had a plastic bag with briefs and chucks stored in the shower stall on a shower chair. During an observation on 08/10/2026 at 9:52 AM, the Unit 100 shower room unused resident equipment stored in the shower stalls, excess water buildup on the floor, and had discolored, stained wall and floor tiles covered in a filmy grime. During an observation on 08/10/2026 at 10:00 AM, the Unit 300 shower room had a shower curtain with multiple brown stains, wall and floor tiles discolored and stained brown and black with a filmy grime throughout, a radiator cover with rust, window molding that was damaged and peeling, and tile floors with black and grey stains throughout.2) During observations on 08/04/2026 at 10:15 AM, 08/05/2026 at 12:42 PM, and 08/10/2026 at 9:52 AM, Unit 100 had a strong foul odor of urine emanating through the hallway in front of the elevator doors. 3) During an observation on 08/06/2026 at 11:05AM and 08/10/2026 at 9:52 AM, Unit 100 had plastic wrappers, food debris, and other scraps of garbage on the floor in resident rooms 103, 107, 111, and 119. The unit hallway had multiple unused wheelchairs and a reclining chair positioned on both sides of the hall, creating a cluttered walkway. During an observation on 08/06/2026 at 11:20 AM and 08/10/2026 at 10:00 AM, Unit 300 had multiple wheelchairs, recliners, and walkers stored on both sides of the hallway, creating a cluttered walkway. During an observation on 08/10/2026 at 9:34 AM, Unit 200 had paper debris, used straws, and scraps of garbage on the floor in resident room [ROOM NUMBER]. The unit dining room was being used to store multiple unused wheelchairs and mechanical lifts creating a cluttered environment.4) During observation on 08/10/2026 at 5:20 PM, Resident #4 had a bedside table with drawers that were in disrepair and off track preventing them from being opened or closed and room [ROOM NUMBER] door was unable to swing open without being forcefully shoved, causing the bottom of the door to drag along the floor and make a loud shrill screeching sound.During an interview on 08/10/2026 at 10:12 AM, Housekeeper #1 stated there were four housekeeping staff scheduled daily but the department experienced staff shortages almost weekly. Today, the department only had two housekeepers that showed up and had to split the housekeeping duties for the entire facility. Housekeeper #1 stated they swept and wiped down the bathrooms. They did not have a schedule for deep cleaning resident rooms. Housekeeper #1 stated they went to assist other units with housekeeping tasks when the department was short-staffed. During a telephone interview on 08/10/2026 at 11:03 AM, the Director of Housekeeping stated there used to be up to six housekeepers scheduled per day, but budget adjustments caused the housekeeping staff to be four per day. Housekeeping was responsible for cleaning the resident units, ground floor with administrative offices, and resident common areas daily. The Director of Housekeeping stated it was difficult for the housekeeping staff to get their job done with four staff, especially when staff called out. The housekeeping staff was responsible for cleaning the shower rooms, resident rooms, dining rooms, and nurses' stations. It has been difficult to devise a deep cleaning schedule with four staff members. The Director of Housekeeping stated they have not received any complaints regarding cleanliness of shower rooms or other areas in the facility. During an interview on 08/10/2026 at 10:10AM and a telephone interview on 08/12/2026 at 11:18 AM, Administrator #1 stated their housekeeping budget was decreased, and they went from having six housekeeping staff to four housekeeping staff daily for the whole facility. The housekeeping department was also short of staff frequently on Mondays and staff from other departments assisted with garbage disposal. 10 New York Code Rules and Regulations 415.5 (h)(2)

Based on observations, interviews, and record reviews conducted during a survey, the facility failed to ensure prompt efforts were made to resolve resident grievances for the Resident Council and four (Resident #5, Resident #13, Resident #12, and Resident #8) of four residents reviewed for grievances. Specifically, 1) the Resident Council expressed concerns related to dignity, respect, and nursing care concerns in 05/2026, 06/2026, and 07/2026 and there was no documented evidence of a facility attempt to address or resolve their grievances, 2) Resident #5 and their Resident Representative #3 repeatedly expressed concerns related to roommate incompatibility and there was no documented evidence the facility conducted a grievance investigation or attempted to resolve Resident #5's concerns since 05/2026, 3) Resident #13's Resident Representative #2 reported attending a care plan meeting and expressing their concerns regarding medication administration and staff treatment without being offered the grievance process to resolve their concerns, 4) Resident #12 was not offered an opportunity to file a grievance after expressing roommate compatibility issues to facility staff, and 5) Resident #8 reported concerns related to dignity and respect during staff interactions with other residents on their unit and was not provided with the opportunity to file a grievance to investigate their concerns. The findings include:The facility policy titled Resident and Family Representative Grievance dated 03/02/2026 documented that the facility would support each resident's and family member's right to voice grievances without discrimination, reprisal, or fear of discrimination or reprisal. A resident or family member could voice grievances with respect to care and treatment, the behavior of staff and other residents, and other concerns regarding their stay. The Grievance Official was responsible for overseeing the grievance process, leading any necessary investigations by the facility, issuing written grievance decisions to the resident, and coordinating with state and federal agencies as necessary.The facility policy titled Resident Rights dated 03/02/2026 documented that the resident has the right to grievances, and the facility must make prompt efforts to resolve grievances the resident may have.1) The Resident Council Meeting Minutes dated 05/21/2026 documented resident concerns related to availability of refreshments and water, staff support, delayed assistance, care not meeting their expectations, perceived disrespectful or rude treatment by staff, professionalism, respectful communication, resident care practices, privacy, and overnight noise. The Resident Council Meeting Minutes dated 06/18/2026 documented resident concerns related to timely answering of call bells, perceived disrespectful or rude treatment by staff, availability of water at night, and staff slamming doors at night and early in the morning causing resident sleep disruption. The Resident Council Meeting Minutes dated 07/09/2026 documented resident concerns related to nurse aide control of the air conditioning, inappropriate responses to resident requests ,timely answering of call bells, showers not being provided due to staffing issues, availability of refreshments throughout the day, dietary response to concerns, cold food, and dental services access. There was no documented evidence facility staff informed the Grievance Official of resident concerns during Resident Council Meetings in 5/2026, 6/2026, and 7/2026 to ensure prompt facility response or resolution. There was no documented evidence the Resident Council was provided with the opportunity to file grievances to resolve their care and other concerns regarding their stay. During an interview on 08/05/2026 at 2:04 PM, the Activities Director #1 stated they were present at the resident council meetings, and they documented the minutes for the council. They stated that they were supposed to relay the information to the relevant department heads for resolution after the meetings, but they had not been able to discuss the meeting information from 07/09/2026 with any pertinent department heads yet. Activities Director #1 stated they began working for the facility on 06/27/2026 and they did not know the process of communication between the activities department and other department heads regarding concerns brought by the Resident Council during their monthly meetings. 2) Resident #5 had diagnoses of aphasia (a partial or total loss of language due to brain damage) and epilepsy (a neurological disorder that causes seizures). The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #5 had mild cognitive impairment, exhibited no behavior, had trouble sleeping every day, felt depressed half the time, felt tired every day, and was totally dependent on staff for transfers in and out of bed and bed mobility. The Comprehensive Care Plan related to adjustment difficulties initiated 07/04/2025 documented Resident #5 had a loss of independence and would be provided with emotional support, an opportunity to express themselves, and encouragement of family involvement. The Social Work Note dated 05/21/2026 authored by the Director of Social Work documented Resident #5 reported concerns with their roommate making noises during the night that keep them awake. The Director of Social Work documented Resident #5's only resolution was to move, and Resident #5 declined to change their room. The Psychiatry Consult dated 05/21/2026 documented Resident #5 reported their sleep was disrupted at night due to their roommate. The consult documented staff reported the roommate slept well at night and that Resident #5's complaints were racially influenced. Resident #5 had attention-seeking behaviors. The Social Work Note dated 05/22/2026 authored by the Director of Social Work documented Resident #5's Designated Representative approached them about concerns with Resident #5's roommate and expressed the roommate was using profane language. Resident #5's Designated Representative questioned the reason Resident #5's roommate was admitted to the facility. The Director of Social Work documented they offered Resident #5 a room change and told the Designated Representative that profane language alone was not a reason to move Resident #5's roommate. The Care Plan Meeting Note authored by the Social Work Assistant dated 07/09/2026 documented Resident #5 and their Designated Representative attended the care plan meeting. The note documented Resident #5 spent much of the meeting time complaining about their roommate and requesting that their roommate be moved from the room.There was no documented evidence the Director of Social Work, also the Grievance Official, filed a grievance investigation on behalf of Resident #5's unresolved roommate incompatibility concerns. There was no documented evidence facility staff, or the Grievance Official attempted to promptly address and resolve Resident #5's concerns. 3) Resident #13 had diagnoses of malignant neoplasm of the parietal lobe (a cancerous brain tumor) and left hemiplegia (weakness on the left side of the body).The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #13 was cognitively intact, and their family participated in the assessment and goal setting. There was no documented evidence of a grievance investigation into concerns related to care expressed by Resident #13 and their representative, Resident Representative #1, during their stay. During an interview on 08/07/2026 at 10:22 AM, Resident Representative #1 stated that they had multiple complaints and concerns with the care and services provided to Resident #13 during their stay at the facility. Resident #13 and Resident Representative #1 expressed their concerns related to medication administration, concerns about nursing staff competency and professionalism, care provided, employee background and drug testing, food provided, and rude staff attitudes to administration. Resident Representative #1 stated administration did not address their concerns or offer for them to file a grievance and instead, laughed at their concerns. A care plan meeting was held with the Ombudsman in attendance and Resident #13's and Resident Representative #1's concerns continued to go unaddressed.During an interview on 08/10/2026 at 1:16 PM, the Ombudsman stated that Resident #13 had a difficult stay at the facility and the resident and Resident Representative #1 expressed multiple concerns with care. The Ombudsman stated they attended the care plan meeting with Resident #13 and Resident Representative #1. The Ombudsman stated Resident Representative #1 stayed at the facility throughout the day during Resident #13's stay to ensure staff provided adequate and timely care and administered medications according to physician order. During an interview on 08/06/2026 at 4:10 PM, the Director of Social Work stated that they were the Grievance Officer and responsible for overseeing grievance investigations. Any staff member could file a grievance verbally or in writing. The Director of Social Work stated grievances were important so that the residents and/or family felt like the concerns they voiced were heard and received a response by the facility. The Director of Social Work stated grievance investigations covered various areas of concern such as missing clothing, residents being mishandled during care, dislike of food, the service quality, rude and disrespectful staff, roommate complaints, or care complaints. The Director of Social Work stated they determined when a resident or family member's concern rose to the level of requiring a written grievance investigation. The Director of Social Work stated they tried to address concerns and if they responded to resident concerns, a grievance may not be necessary. The Director of Social Work confirmed there were only two grievances for missing clothing filed since 10/2025 and they had no record of any grievances related to Resident #5, Resident #13, Resident #12, or Resident #8. The Director of Social Work stated they knew about Resident #5's roommate incompatibility issues and did not file a grievance. Resident #13 did have complaints about the rude treatment of staff but believed nursing handled that and the Director of Social Work stated they did not file a grievance for Resident #13 or Resident Representative #1. The Director of Social Work stated they did not attend the Resident Council Meetings and that was the Activities Director's responsibility. The Director of Social Work stated the Activities Director has not reported any concerns to their department related to ongoing concerns expressed by the council related to staffing, care, and staff attitudes and treatment since 03/2026. During a telephone interview on 08/11/2026 at 1:13 PM, the Director of Nursing stated the Director of Social Work notified their department when any grievances related to nursing care were filed. The Director of Nursing stated the Grievance Officer was responsible for determining what concerns rose to the level of requiring a grievance investigation. The Director of Nursing stated they did not recall receiving any grievances recently from the social work department related to care or roommate incompatibility. During an interview on 08/12/2026 at 11:18 AM, the former Administrator stated that the Director of Social Work was responsible for reporting any grievance investigations or care concerns to them during the interdisciplinary morning meeting. Residents were able to file grievances. Family members were only able to file grievances if the facility determined it was in the best interest of the resident. The Administrator was responsible for reviewing the outcome of the grievances and signing off on the investigation. The Administrator was aware that the family of Resident #5 expressed roommate incompatibility concerns but stated the Director of Social Work reported to them that Resident #5 denied having any roommate issues. Since the family had the issue and not the resident, the Administrator stated a grievance was not required to address the roommate incompatibility issues. The Administrator stated Resident #13 and Resident Representative #1 expressed concerns with their stay and wanted Resident #13 discharged from the facility. The Director of Social Work coordinated Resident #13's discharge. The Administrator stated Resident #13 and Resident Representative #1 also expressed concerns related to a particular staff member being intoxicated and other nursing care issues and the facility attempted to resolve their concerns. The Administrator was unable to provide a reason that grievances were not filed to address Resident #13's concerns. The Administrator stated the Resident Council concerns should have been communicated by the Activities Director to the appropriate department heads for them to respond to the council's concerns. The Administrator was responsible for reviewing the meeting minutes and was under the impression the Activities Director was following up to address the concerns that were expressed. 10 NYCRR 415.3(d)(1)(ii)

Based on observations, interviews, and record reviews, conducted during a survey, the facility did not ensure comprehensive person-centered care plan were developed and implemented for three (Resident #6, Resident #10, Resident #5) of ten residents reviewed for abuse. Specifically, 1) Resident #6 had impaired cognition and limited mobility but no care plan to address their potential for abuse; 2) Resident #10 had intact cognition and limited mobility but no care plan to address their potential for abuse, and 3) Resident #5 was determined to be at risk for abuse and did not have a care plan developed to prevent abuse. The findings are:The facility policy titled Comprehensive Care Plans dated 03/02/2026 documented the facility would develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality.1) Resident #6 had diagnoses of dementia, major depressive disorder, and insomnia.The Minimum Data Set 3.0 (resident assessment tool) dated 06/30/2026 documented Resident #6 was severely cognitively impaired and was dependent on assistance from staff for activities of daily living. There was no documented evidence a care plan related to abuse prevention was developed and implemented for Resident #6. 2) Resident #10 had diagnoses of morbid obesity, heart failure, and osteoarthritis.The Minimum Data Set 3.0 (resident assessment tool) dated 05/11/2026 documented Resident #10 was cognitively intact and required assistance from staff to perform activities of daily living. There was no documented evidence a care plan related to abuse prevention was developed and implemented for Resident #10.3) Resident #5 had diagnoses of aphasia (a partial or total loss of language due to brain damage) and epilepsy (a neurological disorder that causes seizures). The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #5 had mild cognitive impairment, exhibited no behavior, had trouble sleeping every day, felt depressed half the time, felt tired every day, and was totally dependent on staff for transfers in and out of bed and bed mobility.There was no documented evidence that a care plan related to abuse prevention was developed and implemented for Resident #5.During an interview on 08/06/2026 at 4:10 PM, the Director of Social Work stated that they were responsible for developing, implementing, reviewing, and revising abuse prevention care plans for all residents. The Director of Social Work stated all residents were at risk for abuse due to their vulnerable status and should have an abuse prevention care plan in their record. The Director of Social Work stated they were employed by the facility six months ago and have been trying to audit charts as they go along and ensure all residents had abuse prevention care plans; however, there may still be some care plans that were missing. 10 NYCRR 415.11(c)(1)

Based on observations, interviews, and record review conducted during a survey, the facility did not ensure medically related social services were provided to attain or maintain the highest practicable well-being of each resident. This was evident for seven (Residents #s 5, 6, 8, 10, 12, 13, and 15) out of 10 residents reviewed for social services. Specifically, 1) the Director of Social Work was the Grievance Official and there was no evidence that grievances brought to the facility by the Resident Council, Resident #5, Resident #13, Resident #12, and Resident #8 were addressed and resolved as grievances 2) Discharge planning concerns were found related to Residents #13, #15, #12, and #10 were. 3) Resident #15 who had a diagnosis of mental illness was admitted to the facility without proper screening for mental illness 4) room changes were done without proper orientation or consideration for roommate compatibility between Resident #15 and Resident #5. Resident #5 was distressed by Resident #15's behavior and there was no intervention to address the roommate incompatibility. The findings are:The undated facility Social Worker Job Description documented the social worker will assist in preadmission screening and completion of Level I evaluations for residents, discharge planning, resident rights, advocating for resident sand investigating allegations of abuse, and reviews complaints and grievances.1) There was no evidence grievances were filed for the Resident Council and their concerns regarding staffing and staff treatment. There was no evidence a grievance was filed for Resident #5 regarding their roommate incompatibility concerns. There was no evidence a grievance was filed for Resident #13's concerns regarding the care they received. There was no evidence a grievance was filed for Resident #12's concerns regarding roommate incompatibility. There was no evidence a grievance was filed for Resident #8 and their concerns related to staff treatment of other residents on their unit.Refer to F585.2) There was no evidence of adequate discharge planning and post-discharge coordination with community agencies to ensure Resident #13 was safely discharged home with an intravenous line. There was no evidence Resident #15, #12, and #10 received discharge planning evaluation and coordination. Refer to F627.3) There was no evidence Resident #15 was admitted to the facility with proper screening for mental illness. There was no evidence social service coordinated with the appropriate state authority to address Resident #15's serious mental illness before admission to the facility.Refer to F645.4) Refer to 559.An interview was conducted on 08/06/2026 at 4:10 PM and 08/21/2026 at 12:02 PM with the Director of Social Work who stated they took on the role of Director of Social Work approximately six months ago. There was turnover in the department, and the facility experienced multiple changes social work directors prior to the Director of Social Work coming onboard. The Director of Social Work stated the facility had a corporate social worker that helped orient them to the position and checked in with them to see how they were adjusting to the position. The Director of Social Work stated they were provided with enough resources to perform their job duties but stated there was a lot to fix and catch up on from the previous staff turnovers.An interview was conducted on 08/11/2026 at 1:12 PM with the Director of Nursing who stated they did not have any issues with the social work department, and that they felt the Director of Social Work was performing their job adequately.An interview was conducted on 08/12/2026 at 11:18 AM with Administrator #1 who stated they felt the Director of Social Work performed their job adequately and they did not have any concerns reported to their office about the social work department job performance. Administrator #1 stated there was turnover in the department within the past year where one social work director left and Administrator #1 had to fire the last social work director after a few months due to poor performance.10 NYCRR 415.12

Based on observations, interviews, and record reviews during the abbreviated survey, the facility failed to ensure that residents remained free of significant medication errors for one of three residents reviewed for medication administration (Resident #13). Specifically, 1) Resident #13 was admitted on [DATE] and did not receive two doses of clobazam (medication for seizures) on 06/19/2026 or 06/20/2026 as ordered; 2) Resident #13 had an order for midodrine (a medication that increases blood pressure) dated 06/19/2026 with the incorrect parameters ordered to hold the midodrine if the systolic blood pressure was less than 110. Resident #13 received the medication five times (06/19/2026, twice on 06/20/2026, 06/21/2026, and 06/22/2026) from facility staff without staff notifying or clarifying the parameters with the physician. 3) After the midodrine order parameters were corrected on 06/22/2026 to hold the medication if the systolic blood pressure was above 110, Resident #13 received the midodrine five times (once on 6/23/2026, 6/25/2026, 6/27/2026, 6/29/2026, and 07/02/2026) when the resident' blood pressure indicated for the medication to be held. 4)Midodrine was not administered on 06/28/206. There was no documentation for the omission. The Findings are:The facility policy titled Medication Administration dated 03/02/2026 documented medications were administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice.Resident #13 had diagnoses of malignant neoplasm of the parietal lobe (cancer caused by a brain tumor), convulsions (uncontrolled shaking and jerky movements), and left side hemiplegia (weakness on the left side of the body).The Minimum Data Set 3.0 (resident assessment tool) dated 06/25/2026 documented Resident #13 was cognitively intact and received anticonvulsant medication.The physician order dated 06/19/2026 documented clobazam 10 milligrams give one half tablet at bedtime for seizures at bedtime.The physician order dated 06/20/2026 documented Resident #13 was ordered to receive clobazam 10 milligrams (one half tablet) at bedtime for seizures at bedtime.The Medication Administration Record for June 2026 documented that clobazam was not administered to Resident #13 on 06/19/2026 or 06/20/2026 as ordered. The physician order dated 06/19/2026 documented Resident #13 was ordered to receive midodrine HCl oral tablet (medication used to treat symptomatic low blood pressure) 5 milligrams every 8 hours for hypotension, hold for systolic blood pressure lower than 110.The medication administration record for June 2026 documented that Resident #13 was administered midodrine(medication used to treat symptomatic low blood pressure) on 06/19/2026 at 2:00 PM with a blood pressure of 129/68; on 06/20/2026 at 6:00 AM with a blood pressure of 154/82; on 06/20/2026 at 2:00 PM with a blood pressure of 120/66; on 06/21/2026 at 2:00 PM with a blood pressure of 133/72; and on 06/22/2026 at 6:00 AM with a blood pressure of 124/68. There was no documented evidence that the facility staff clarified the parameters on the medication order with the physician. Resident #13 received five doses of the medication with the incorrect parameters.Review of a revised physician order dated 06/22/2026 for Resident #13 documented an order to receive midodrine (medication used to treat symptomatic low blood pressure) HCl oral tablet 5 milligrams every 8 hours for hypotension, hold for static blood pressure higher than 110.The medication administration record for June and July 2026 documented that Resident #13 was administered midodrine on 06/23/2026 at 10:00 PM with a blood pressure of 114/68; on 06/25/2026 at 2:00 PM with a blood pressure of 119/62; on 06/27/2026 at 6:00 AM with a blood pressure of 113/79, 06/29/2026 at 2:00 PM with a blood pressure of 128/74; 07/02/2026 at 6:00AM with a blood pressure of 112/61. The doses were not administered in accordance with the physician's order.On 06/28/2026 Resident #13 did not receive one dose of midodrine (medication used to treat symptomatic low blood pressure) as ordered on 06/28/2026 at 2:00PM. There was no documented evidence that the physician was contacted about omissions, to clarify orders, or obtain revised orders to administer medication outside the ordered parameters from 06/19/2026 to 07/02/2026.During an interview on 08/10/2026 at 3:05PM, the Admissions Coordinator stated that before a resident is admitted they review their list of medications. Once the resident arrives at the facility, the nurses enter the orders in the electronic medical record, and the pharmacy reviews the orders. The medications are then delivered from the pharmacy. They stated that one of the anti-seizure medications was not administered to the resident on admission and on subsequent days because they received no notifications from the pharmacy prior to admission that there would be delays with any of Resident #13's medications. Medication was ordered to be delivered to the facility for the resident. During an interview on 08/10/2026 at 4:35 PM, Registered Nurse #1 stated they were the Nursing Supervisor and worked the day that Resident #13 was admitted to the facility. Resident #13 arrived in the evening, the physician's orders were entered by the floor nurse, and the medications were delivered. Registered Nurse #1 stated Resident #13's medications arrived at the facility at 3AM and there was no medication missing. After the floor nurse entered the physician's orders, the Unit Manager was responsible for double-checking the orders. Registered Nurse #1 stated that midodrine was used to increase blood pressure and the parameters ordered on 06/19/2026 for Resident #13 were incorrect. During a telephone interview on 08/11/2026 at 1:13 PM, the Director of Nursing stated they were unable to explain why the Clobazam doses were not administered to Resident #13 on 06/19/2026 and 06/20/2026. The Director of Nursing stated there should have been a reason documented by the nurse on the administration record or in a progress note. The Unit Managers received the reports of missing doses/omissions and were responsible for following up with the nurse that missed giving the medication. The Director of Nursing stated they could not always get in touch with agency nurses to review medication omissions. The Director of Nursing stated the parameters for midodrine ordered on 06/19/2026 were incorrect and the nurse administering the medication should have noticed the incorrect parameters. The Director of Nursing stated the facility has multiple layers of checking orders between the nurse, physician, and pharmacy to ensure errors are immediately identified and corrected. The Director of Nursing stated they were not aware of these issues with Resident #13's medication orders and administration. During an interview on 08/11/2026 at 2:05 PM, the Medical Director stated the parameters for Resident #13's midodrine order on 06/19/2026 were incorrect. The Medical Director stated the nurses should have known the effect of the medication on the resident's blood pressure and should have questioned the order, but it did not happen. The physicians and pharmacy were also responsible for checking orders for accuracy and they missed these errors for Resident #13. The parameters for the corrected midodrine order dated 06/22/2026 should have been followed by the nurses as ordered. The Medical Director stated they did not know the reason clobazam was not administered to Resident #13 on 06/19/2026 and 06/20/2026. The nurse should have called the physician and wrote a note if they were unable to administer the medication according to physician order.10 New York Code Rules Regulations 415.12(m)(2)

Based on observations, interviews, and record review conducted during a survey, the facility did not ensure the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable well-being of each resident. This was evident for Unit 1, Unit 2, and Unit3 during review of environment and medically related social services. Specifically, 1) the facility reduced the number of daily housekeepers from six to four resulting in environmental issues such as equipment clutter and shower rooms on Unit 1, Unit 2, and Unit 3 that were stained, soiled, and covered with grime, and 2) the Administrator and corporate entity did not adequately staff and supervise the social service department resulting in widespread deficient practice in discharge planning and grievances as well as concerns with room changes resulting in harm to Resident #5. The findings are:The undated facility policy titled Governing Body documented the governing body will appoint an administrator that is responsible for the management of the facility and reports to and is accountable to the governing body. The governing Body refers to individuals such as the Chief Executive Officer and other individuals who are legally responsible for establishing and implementing policies on management and operations of the facility. The governing body will have a process in place for the Administrator to report to the governing body and the Administrator is held accountable.1) Refer to F584.2) Refer to F745.A telephone interview was conducted on 08/12/2026 at 11:18 AM with Administrator #1 who stated they were fired by the facility on 08/11/2026 without being given a reason. Administrator #1 stated the corporate Regional Administrator had issued budget cuts to the housekeeping department within the past year which was a potential reason the facility had environmental concerns. Administrator #1 stated there was a Corporate Social Worker that the Director of Social Work reported to and they were not aware of any issues in the social work department. Administrator #1 stated the social work department had gone through multiple staff changeovers, but they were unaware if there were concerns from prior social workers that needed to be addressed.10 NYCRR 415.26

Based on observations, interviews, and record reviews, conducted during a survey, the facility failed to ensure that the nurse staffing data was posted daily at the beginning of each shift. Specifically, on 08/10/2026 the daily staffing data posted at the facility reception area was dated 08/07/2026. The findings included:During an observation on 08/10/2026 at 9:02AM, the daily staffing data was observed posted at the reception area of the facility and was dated 08/07/2026.During a telephone interview on 08/11/2026 at 1:13PM, the Director of Nursing stated that the staffing data should be posted daily. They stated they were responsible for posting the data daily. The Assistant Director of Nursing would post the staffing if the Director of Nursing were off and the weekend night nursing supervisor should be posting the data on the weekend daily. 10 New York Code Rule Regulations 415.13

Based on observations, interviews, and record reviews during the abbreviated survey, the facility failed to ensure that nursing staff had the appropriate competencies and skill sets to provide nursing services to assure resident safety during medication administration for one of three residents reviewed for medication administration (Resident #13). Specifically, 1) Resident #13 missed two doses of clobazam (medication for seizures) on 06/19/2026 or 06/20/2026 and there was no documented evidence that the physician was notified that the medication was not administered; 2) Resident #13 had an order for midodrine (a medication that increases blood pressure and treats symptomatic low blood pressure) dated 06/19/2026 with the incorrect parameters (ordered to hold the midodrine if the systolic blood pressure was less than 110). There was no documented evidence that facility staff contacted the physician to clarify the incorrect parameters; 3) Resident #13 had an order for midodrine (a medication that increases blood pressure and is used to treat symptomatic low blood pressure) dated 06/22/2026 with the parameter to hold the medication if the systolic blood pressure was above 110. The medication was administered when the blood pressure was within the ordered parameters to hold on 06/23, 06/25, 06/27, 06/29, and 07/02/2026. On 06/28/2026, the ordered midodrine was not administered. There was no documentation that the physician was contacted or a reason for the omission.The findings include:The facility policy titled Medication Administration dated 03/02/2026 documented medications were administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects. Sign the medication administration record after the medication is administered. For medications requiring vital signs, record vital signs onto the medication administration record. Report any adverse effects or refusals. Resident #13 had diagnoses of malignant neoplasm of the parietal lobe (cancer caused by a brain tumor), convulsions (uncontrolled shaking and jerky movements), and left side hemiplegia (weakness on the left side of the body).The Minimum Data Set 3.0 (resident assessment tool) dated 06/25/2026 documented Resident #13 was cognitively intact and received anticonvulsant medication.The physician order dated 06/19/2026 documented clobazam 10 milligrams give one half tablet at bedtime for seizures at bedtime.The physician order dated 06/20/2026 documented Resident #13 was ordered to receive clobazam 10 milligrams (one half tablet) at bedtime for seizures at bedtime.The medication administration record for June 2026 documented that clobazam was not administered to Resident #13 on 06/19/2026 or 06/20/2026 as ordered and there was no documented evidence that the physician was notified. The medication administration record for June 2026 documented that Resident #13 was administered midodrine in error once on 06/19/2026, twice on 06/20/2026, once on 06/21/2026, and once on 06/22/2026. There was no documented evidence that the facility staff clarified the parameters on the medication order with the physician. The physician order dated 06/19/2026 documented Resident #13 was ordered to receive midodrine HCl oral tablet 5 milligrams every 8 hours for hypotension, hold for systolic blood pressure lower than 110.The physician order dated 06/22/2026 documented Resident #13 was ordered to receive midodrine HCl oral tablet 5 milligrams every 8 hours for hypotension, hold for systolic blood pressure higher than 110.The medication administration records for June and July 2026 documented that Resident #13 was not administered midodrine according to the order on 06/23/2026, 06/25/2026, 06/27/2026, 06/29/2026, and 07/02/2026. It was administered with blood pressure readings outside of the ordered parameters. One dose was also omitted on 06/28/2026. There was no documented evidence that the physician was contacted to report the omission, clarify the orders, or obtain additional orders to administer medication outside of the parameters ordered.During an interview on 08/10/2026 at 4:35 PM, Registered Nurse #1 stated that midodrine was used to increase blood pressure and the parameters ordered on 06/19/2026 for Resident #13 were incorrect. The nurse double checking the order should have caught the error.During a telephone interview on 08/11/2026 at 1:13 PM, the Director of Nursing stated they were unable to explain the omissions of clobazam and midodrine for Resident #13 when they were at the facility. The nurse should have documented a reason on the administration record or in a progress note. Additionally, they stated the parameters for the midodrine ordered on 06/19/2026 were incorrect and the nurse administering the medication should have noticed the incorrect parameters. The Director of Nursing stated the facility has multiple layers of checking orders to prevent errors, but this was not caught. The Director of Nursing stated they were not aware of these issues with Resident #13's medication orders and administration until now so there were no incident reports or medication error forms completed. During an interview on 08/11/2026 at 2:05 PM, the Medical Director stated the parameters for Resident #13's midodrine order on 06/19/2026 were incorrect. The Medical Director stated the nurses should have known the effect of the medication on the resident's blood pressure and should have questioned the order, but that did not happen. In addition, the nurse should have contacted the physician and wrote a note if they were unable to administer any of Resident #13's medications or administer them according to the physician order. 10 New York Code Rules Regulations 415.13

Based on observations, interviews, and record reviews conducted during the abbreviated survey, the facility failed to ensure the resident right to receive services with reasonable accommodation of resident needs for one of three residents reviewed for activities of daily living (Resident #10). Specifically, Resident #10 who was care planned to receive showers on Tuesdays and Fridays did not receive showers from 05/02/2026 because the facility did not have a shower bed/stretcher large enough to accommodate them. There was no evidence of the facility's continuous efforts to acquire an equipment that can accommodate the resident's need. The findings included:The Facility Accommodation of Needs Policy implemented 03/02/2026 documented that the facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences, except when the health and safety of the individual or other residents would be endangered.Resident #10 was last admitted to the facility on [DATE] with diagnoses that included morbid obesity, heart failure, and osteoarthritis.The Resident Preference Care Plan last revised 03/13/2026 documented that Resident #10 preferred to have their showers on the day shift on Tuesday and Friday and the resident preference is a shower rather than a bed bath. The Limited physical mobility related to morbid obesity care plan last revised 03/13/2026 documented bariatric lift and wheelchair accommodations. There was no documented evidence of any accommodation for showers or any reference to a bariatric shower bed/stretcher.An email from the Administrator dated 04/20/2026 documented a request for approval from Consultant #1 for an oversized bariatric shower bed. There was no documented evidence of a purchase receipt for the shower bed or email response from Consultant #1. There was a handwritten note on the item description documenting that the item was too small and had to be returned. The Risk for functional decline in mobility and self-care last revised 04/21/2026 documented maximal assistance required for showers. Resident #10 was not safe to use the shower chair/shower bed available at the facility due to the size of the patient. Recommend continuing bed bath for safety at this time.The nursing note dated 05/01/2026 documented that a meeting was held with Resident #10, social work, nursing, and family. It documented that Resident #10 had outsized the shower bed owned by the facility and it was unsafe to shower him on the bed due to the girth of his abdomen. Facility was able to get equipment to hold the resident's weight, however, not to accommodate his width. Resident did not accept this as the primary problem. The facility had called around to get bigger equipment and had no success.The progress notes from 05/02/2026 until 08/07/2026 contained no documented evidence of further searches for larger shower beds, trials of larger shower beds, or meetings with Resident #10 to discuss the status.The Quarterly Minimum Data Set (resident assessment tool) dated 05/11/2026 documented that Resident #10 had intact cognition, no behaviors including refusals of care, required maximal assistance from staff for showers and bathing. The Activities of Daily Living Care Plan last updated 07/22/2026 documented that Resident #10 required assistance with their activities of daily living related to their limited mobility, limited range of motion, and morbid obesity. A care plan note dated 03/10/2026 documented that the bariatric shower bench had a broken side rail. Resident #10 had been informed and would receive a bed bath until it was repaired. A care plan note dated 03/27/2026 documented that Resident #10 had become too wide to safely fit on the shower bed and the facility was looking for a more appropriate and safer alternative. During an interview on 08/04/2026 at 12:15AM, Resident #10 stated that the staff will not give them showers and they really want to receive showers. They stated that the staff have told them that the shower bed cannot accommodate them, but they are within the weight limit for the shower bed. They stated they have not received a shower in 15 weeks now. They do not feel heard by administration.During a telephone interview on 08/11/2026 at 1:13PM, the Director of Nursing stated that the facility has not been able to find a shower bed that Resident #10 can safely use but the facility has made attempts to find one. The shower bed they had was not wide enough. They stated they were not a bariatric facility, so they offered the resident a transfer to a bariatric facility that could accommodate their needs, but the resident declined the transfer. During a telephone interview on 08/12/2026 at 11:18AM, the former Administrator stated that they were aware that Resident #10 needed a larger bariatric shower bed. They were uncertain what size was needed for Resident #10 but stated they could not find one wide enough when they looked. They offered Resident #10 a transfer to another facility that could meet their needs, but they declined the transfer. There were team discussions about the shower bed, but they were uncertain if there was any documented evidence of the attempts made to find an appropriate shower bed or how extensive the search for an appropriate shower bed was. 10 NYCRR 415.3 (e)(1)

Based on interviews and record review conducted during a survey, the facility did not ensure covered individuals reported reasonable suspicion of a crime to the State Agency within 24 hours. This was evident for one (Resident #1) of 10 residents reviewed for abuse. Specifically, Certified Nurse Aide #3 reported to the New York State Department of Health on 07/31/2026 that they witnessed alleged physical abuse of Resident #1 by staff on 07/27/2026. The incident was not reported to the facility administrators. Certified Nurse Aide #3 reported the incident to the New York State Department of Health three days after the alleged incident. The findings are:The undated policy titled Abuse, Neglect, and Exploitation documented the facility will have written procedures that include reporting alleged violations to the state agency and all other required agencies within the specified timeframes.Resident #1 had diagnoses of dementia, dysphagia, and legal blindness.The Minimum Data Set 3.0 (an assessment tool) dated 06/21/2026 documented Resident #1 was severely cognitively impaired and was totally dependent on staff to perform activities of daily living.The Comprehensive Care Plan related to the risk for abuse initiated 02/01/2024 and last revised 04/05/2026 documented Resident #1 was at risk for abuse due to their dependence on others for cares.A New York State Department of Health complaint hotline intake dated 07/31/2026 at 2:58 PM documented Certified Nurse Aide #3 witnessed a licensed nurse strike Resident #1 in the chest on 07/27/2026.There was no documented evidence Certified Nurse Aide #3, a covered individual as an employee of the facility, reported the alleged violations involving abuse and suspicion of a crime to law enforcement authorities and the New York State Department of Health within 24 hours of the alleged occurrence.A telephone interview was conducted on 08/03/2026 at 11:57 AM and 08/04/2026 at 2:06 PM with Certified Nurse Aide #3 who stated they were an agency staff that observed a pattern of alleged mistreatment between certified nurse aides and a licensed nurse towards residents. Certified Nurse Aide #3 stated they reported the allegations of abuse to the facility's corporate compliance telephone hotline by leaving a message. Certified Nurse Aide #3 stated they did not report their allegations to anyone in the facility and did not immediately intervene to separate the alleged perpetrators from residents.A telephone interview was conducted on 08/12/2026 at 1:12 PM with the Director of Nursing who stated certified nurse aides were considered mandated reporters if they witness resident abuse. The Director of Nursing stated the facility's policy was that any staff member who witnessed abuse was required to report it immediately to their supervisor, Administrator, and/or Director of Nursing so that the appropriate agencies can be contacted and an investigation can be conducted.10 NYCRR 415.4(b)(2)

Based on observations, interviews, and record review conducted during a survey, the facility did not ensure a resident with a mental disorder was evaluated prior to admission and determined to need the level of services provided by the nursing facility. This was evident for one (Resident #15) of three residents reviewed for preadmission screening and resident review. Specifically, Resident #15 had a documented history of mental illness and there was no evidence the resident was referred for Level II specialized services prior to admission to the facility. The findings are:The undated facility policy titled Resident Assessment - Coordination with the PASARR Program documented the facility will only admit individuals with a mental disorder who the State mental health authority has determined as appropriate for admission. For a resident who was not screened, the facility must screen the individual using the State's Level I screening process and refer for a Level II evaluation and determination. The Director of Social Work shall be responsible for keeping track of each resident's screening status.Resident #15 was admitted to the facility on [DATE] with diagnoses of schizophrenia and dementia.The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #15 was severely cognitively impaired, displayed no behaviors, and was independent in transfers in and out of bed, independent in bed mobility, independent in dressing, and independent in toileting. The assessment documented Resident #15 was not considered to have a serious mental illness using the state Level II process.The Preadmission Screening and Resident Review Level I Screen dated 03/20/2025 documented Resident #15 did not have a serious mental illness and did not require a Level II evaluation.The Hospital Discharge summary dated [DATE] documented Resident #15 was admitted to the hospital on [DATE] with a significant psychiatric history including schizophrenia. Resident #15's outpatient psychiatrist referred the resident for hospitalization following multiple missed appointments. Resident #15 was found at home in unsanitary and unsafe condition.The Patient Review Instrument dated 06/05/2025 documented Resident #15 had no medical conditions or treatments, was able to eat without assistance and required supervision with mobility, transfers, and toileting, and did not receive physical or occupational therapy.The Comprehensive Care Plan related to psychotropic medication use initiated 06/11/2025 and last reviewed 07/11/2026 documented Resident #15 received medication related to their schizophrenia diagnosis and their target behavior symptoms would be monitored and documented.The care plan related to cognition initiated 03/06/2026 and updated 05/26/2026 documented Resident #15 was severely cognitively impaired due to their diagnosis of dementia and schizophrenia. Resident #15 preferred to stay in their room and was unable to effectively communicate their needs.The care plan related to communication initiated 06/18/2026 documented Resident #15 had difficulty communicating due to their mental health diagnosis.The Social Work Note dated 06/11/2025 documented a Level II referral for Resident #15 in relation to their Schizophrenia diagnosis was sent to the state authority.There was no documented evidence the facility adequately screened Resident #15 for serious mental illness using the preadmission screening and resident review level I process prior to their admission to the facility on [DATE].There was no documented evidence the facility coordinated with the state authority to determine Resident #15's specialized services recommendation and ongoing treatment plan.An interview was conducted on 08/21/2026 at 12:02 PM with the Director of Social Work who stated they coordinated with the appropriate state authorities to ensure residents who require specialized services for mental illness or developmental disability were reevaluated prior to discharge from the facility to their community setting. The Admissions Department was responsible for reviewing the Level I screens for residents prior to their admission to the facility and the Director of Social Work stated they were responsible for reviewing the Level I screens once residents were admitted to the facility. The Director of Social Work stated they reviewed all new admissions to determine if they qualified for a Level II referral based on their mental health history and conditions. Resident #15 was admitted to the facility prior to the Director of Social Work being hired by the facility and the Director of Social Work stated they did not know the resident's Level I screen inaccurately documented Resident #15 did not have a serious mental illness. The Director of Social Work stated they knew Resident #15 spoke to themselves.10 NYCRR 415.11(e)

Based on observations, interviews, and record reviews during an abbreviated survey, the facility did not ensure that soiled linens were handled, stored, processed, and transported to prevent the spread of infection. Specifically, soiled linens were observed in bags on the floor in three resident rooms (room [ROOM NUMBER], 311, and 322) with residents present in some rooms. Soiled linen and briefs were also found in the shower room on Unit 200. The soiled linen was not transported to the soiled utility room.The Findings include:The facility Infection Prevention and Control Policy, implemented 03/02/2026, documented soiled linen shall be collected at the bedside and placed in a linen bag. When the task is complete, the bag shall be closed securely and placed in the soiled utility room. Soiled linen shall not be kept in the resident's room or bathroom. During an observation on 08/04/2026 at 10:00AM on Unit 200, a clear plastic bag with soiled linen was observed on the floor in room [ROOM NUMBER]. Both residents were in the room. During an observation on 08/06/2026 at 11:20AM on Unit 300, a clear plastic bag of soiled linen was observed on the floor in room [ROOM NUMBER].During an observation on 08/10/2026 at 9:34AM in the shower room on Unit 200, a clear plastic bag with a soiled brief and other soiled items, was observed on the floor. During an interview on 08/10/2026 at 9:45AM, Certified Nurse Aide #6 stated that the bag containing the soiled brief and other items should have been disposed of in the soiled utility room immediately after placing the items in the bag. Certified Nurse Aide #6 stated the clear plastic bag with soiled items should not have been left on the floor. They left to assist the nurse and left the clear plastic bag with the soiled linen. It should have been removed first from the room. During an observation on 08/10/2026 at 10:00AM on Unit 300, a bag of soiled linen was observed stored in a plastic bag on the floor in room [ROOM NUMBER]. Two residents and a guest were present in the room. During an interview on 08/10/2026 at 10:05AM, Certified Nurse Aide # 7 stated that the soiled linen in room [ROOM NUMBER] should not have been on the floor. Certified Nurse Aide # 7 stated that Resident #16, who was able to make their bed placed their soiled linen in the plastic bag and left it on the floor. Certified Nurse Aide# 7 stated they will remove the bag.During an interview on 8/10/2026 at 12:15PM, the Infection Preventionist stated that soiled linens should not be placed on the floor. The linens should be placed in a clear plastic bag, tied up and taken directly to the soiled linen bin. They stated they have been working with staff on improving that practice.10 New York Code Rules and Regulations 415.19 (c)

Based on observations, interviews, and record review conducted during a survey, the facility did not ensure each resident received behavioral health care and services to attain their highest practicable well-being. This was evident for one (Resident #15) of three residents sampled for behavior. Specifically, a care plan was not developed and implemented to address Resident #15's known behaviors related to their Schizophrenia diagnosis, staff did not monitor Resident #15's behaviors, and the facility delayed obtaining psychiatry services for Resident #15 from admission on [DATE] to 04/09/2026 when the facility did not have an in-house psychiatrist. The findings are:The undated facility policy titled Behavioral Assessment, Intervention and Monitoring documented residents will be assessed for a history of mental illness, the nursing staff will document details regarding changes in an individual's mental status and behavior. The interdisciplinary team will thoroughly evaluate new or changing behavioral symptoms and develop a plan accordingly. Resident #15 was admitted to the facility on [DATE] with diagnoses of schizophrenia and dementia.The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #15 was severely cognitively impaired, displayed no behaviors, and was independent in transfers in and out of bed, independent in bed mobility, independent in dressing, and independent in toileting.The Comprehensive Care Plan related to psychotropic medication use initiated 06/11/2025 and last reviewed 07/11/2026 documented Resident #15 received medication related to their schizophrenia diagnosis and their target behavior symptoms would be monitored and documented.The care plan related to cognition initiated 03/06/2026 and updated 05/26/2026 documented Resident #15 was severely cognitively impaired due to their diagnosis of dementia and schizophrenia. Resident #15 preferred to stay in their room and was unable to effectively communicate their needs.The care plan related to communication initiated 06/18/2026 documented Resident #15 had difficulty communicating due to their mental health diagnosis.The Nurse Practitioner note dated 06/13/2025 documented Resident #15 was hospitalized after missing several psychiatry appointments and they were found living in unsanitary conditions.The Physician's Orders dated 06/16/2025 documented Resident #15 received paliperidone palmitate extended-release intramuscular injection 156mg/ml monthly for Schizophrenia.The Nursing Behavior Note dated 10/19/2025 documented Resident #15 constantly stood at the door to their room talking. Resident #15 was provided with redirection which had little effect and continued to get up and stand at the entrance to their room talking.The Physician Note dated 11/18/2025 documented Resident #15 occasionally had behaviors.The Social Work Note dated 03/06/2026 documented Resident #15 could oftentimes be observed speaking to themselves and was repetitive in their conversation.The Psychiatry Consult dated 04/09/2026 documented Resident #15 was evaluated was evaluated for the first time by Psychiatry Nurse Practitioner #1.There was no documented evidence the facility obtained necessary behavioral health services for Resident #15 or coordinated psychiatric services to address Resident #15's diagnosis of Schizophrenia and behavioral health needs from admission on [DATE] to 04/09/2026.The Psychiatry Consult dated 06/04/2026 documented Resident #15's family members have observed the resident talking to themselves and resident will be monitored in relation to the resident's schizophrenia diagnosis. Resident #15 would continue psychotropic medication to address their psychiatric symptoms.There was no documented evidence an individualized care plan with non-pharmacological interventions was developed and implemented to address Resident #15's behaviors.A telephone interview was conducted on 08/19/2026 at 10:11 AM with the Psychiatry Nurse Practitioner who stated they started working for the facility in 04/2026 and Resident #15 was referred to them for evaluation. The Psychiatry Nurse Practitioner stated they did not know Resident #15's psychiatric history and had no previous psychiatry consultation in the resident's record to review. The Psychiatry Nurse Practitioner stated facility staff did not report any issues with Resident #15's behavior and Resident #15 was receiving antipsychotic medication for Schizophrenia. Resident #15's family did express the resident had verbalizations at one point. The Psychiatry Nurse Practitioner stated they conducted their evaluations during the day facility staff did not communicate any behavior issues.An interview was conducted on 08/20/2026 at 3:30 PM with Licensed Practical Nurse #8 who stated Resident #15 had a known behavior of verbal out bursts and auditory hallucinations. Resident #15 was not combative but talked to themselves as if they were in a conversation and would answer themselves. Licensed Practical Nurse #8 stated Resident #15 repeated the same cycle of conversation with themselves, and redirection only diverted their attention temporarily, and they will begin talking to themselves again. Licensed Practical Nurse #8 stated the content of these conversations was always sexual in nature, and it appeared as though Resident #15 was reliving a traumatic experience from their past. License Practical Nurse #38 stated they believed this disturbing behavior would negatively affect the roommate, Resident #5, and they spoke with other nurses about it. Licensed Practical Nurse #8 stated they did not speak with their supervisor or administration.An interview was conducted on 08/20/2026 at 4:24 PM Licensed Practical Nurse #1 who stated Resident #15 had behaviors of yelling and talking as if engaged in a conversation with someone else that is not there. Licensed Practical Nurse #1 stated if they heard Resident #15 being verbally disruptive, they would redirect the resident and ask them to lower their voice. Licensed Practical Nurse #1 stated this was normal routine behavior for Resident #15 and nurses documented and reported behaviors if the resident's behaviors changed or became disruptive.A telephone interview was conducted on 08/21/2026 at 12:02 PM with the Director of Social Work who stated they were not aware of any gaps in psychiatry services for the facility. Resident #15 began exposing themselves in their room and was changed to a private room on 08/20/2026 to maintain their dignity and privacy. The Director of Social Work stated Resident #15 did talk to themselves, but staff could redirect their behavior.A telephone interview was conducted on 08/11/2026 at 1:12 PM and 08/21/2026 at 2:44 PM with the Director of Nursing who stated Resident #15 was quiet and did not display any behaviors. The Director of Nursing stated their staff did not report any behavior issues of concern with Resident #15, and they were unfamiliar with any disturbing verbal outbursts and that a resident's behavior is documented in the record when it is disturbing or dangerous. The nursing staff did not document every behavior if it was recurrent and known to staff; however, there should be a behavior care plan in place to address those known behaviors. The Director of Nursing stated there was a gap in psychiatry services for the facility between their last psychiatrist and the current Psychiatry Nurse Practitioner #1. The Director of Nursing stated the attending physicians monitored residents with psychiatric conditions and who received psychotropic medications when there was no psychiatrist on staff and the facility was able to schedule outside clinic appointments for residents to see the psychiatrist if it was necessary.10 NYCRR 415.12(f)(1)

Based on observation, record review and interviews during the recertification and abbreviated surveys (NY00351988), the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (1) of four (4) residents (Resident #217) reviewed for pressure ulcers. Specifically, Resident #217 reported ongoing loose bowel movements and there was no documented evidence of clinical monitoring and collection of stool for Clostridium Difficile as planned in the 7/22/2024 Nurse Practitioner progress note, and no documented evidence that stool for Clostridium Difficile (a bacterium that causes an infection of the colon) and a Complete Blood Count/Comprehensive Metabolic Panel were collected as planned in the 7/24/2024 Nurse Practitioner progress note. Additionally, Docusate Sodium (stool softener) 100 milligrams was not held for loose stools as per physician order on 7/24/2024, 7/25/2024 and 7/27/2024. Subsequently Resident #217 was transferred to the hospital on 7/29/2024 due to lethargy and slurred speech and was admitted to the hospital with a diagnosis of septic shock. This resulted in actual harm that is not immediate jeopardy for Resident #217. The findings are: The Policy and Procedure titled Lab and Diagnostic Test Results-Clinical Protocol last revised 1/2022, documented the physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. The Laboratory, diagnostic radiology provider, or other testing source will report test results to the facility. The Policy and Procedure titled Medication and Treatment Orders, last revised 1/2025, documented verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date and the time of the order. Verbal orders must be signed by the prescriber at their next visit. Resident #217 was admitted to the facility with diagnoses which included diabetes mellitus, dehiscence of the amputation stump (surgical complication where a closed incision opens) and morbid obesity. The Minimum Data Set (resident assessment) dated 6/7/2024 documented Resident #217 had intact cognition, was dependent on staff assistance with toileting hygiene, had an indwelling catheter and was frequently incontinent of bowel. The Comprehensive Care Plan titled Risk for Fluid and Electrolyte Imbalance, dated 6/8/2024, documented monitor labs and report abnormal findings to the medical doctor. The 6/17/2024 Physician's Order documented administer Imodium A-D Capsule 2 milligrams, 1 capsule by mouth every 6 hours as needed for diarrhea. The 7/3/2024 Physician's Order documented Docusate Sodium 100 milligrams, give 1 capsule by mouth in the morning for constipation, hold for loose stools. The 7/21/2024 at 6:25 PM Nursing Progress Note documented the resident complained of having loose stools all day and requested and received Imodium. The 7/21/2024 at 8:19 PM Nursing Progress Note documented the Imodium was ineffective. The 7/22/2024 at 1:34 PM Nurse Practitioner Progress Note documented the resident was seen for reports of loose stool after each meal. The resident reported it had been occurring for a few weeks. The plan was to order stool test for Clostridium Difficile, start Metamucil and monitor clinically. Review of the resident's electronic medical record revealed no documented evidence the stool test was ordered, or clinical monitoring was started as planned in the Nurse Practitioner's progress note on 7/22/2024. The 7/24/2024 at 7:04 PM Nurse Practitioner Progress Note documented the resident was seen for follow up to complaints of loose stools after meals. The resident reported the loose stools continued. The resident has been recently started on Metamucil and the plan was to order a stool test for Clostridium Difficile, continue Metamucil, and order Complete Blood Count/Comprehensive Metabolic Panel (blood work) for monitoring. Review of the resident's electronic medical record revealed no documented evidence of laboratory results for the stool test or blood work planned in the Nurse Practitioner's progress notes on 7/24/2024. The July 2024 Bowel Movement Record documented on 7/21/2024 Resident #217 had one small loose bowel movement, on 7/23/2024 one large and one medium loose bowel movement, on 7/24/2024 one large loose bowel movement, on 7/25/2024 one small loose bowel movement, on 7/27/2024 one large loose bowel movement, and on 7/28/2024 one small and one large loose bowel movement. The bowel movement record had no documentation on day and evening shifts for 7/22/2024 and 7/26/2024. The July 2024 Medication Administration Record documented Docusate Sodium 100 milligrams was given 1 capsule by mouth every morning and to be held for loose stools. The medication was not held as ordered for loose stool on 7/22/2024, 7/24/2024, 7/25/2024, 7/26/2024 and 7/27/2024. There was no documentation on 7/28/2024 as to if it was administered or held. The July 2024 Medication Administration Record and physician orders revealed no documented evidence the Metamucil was ordered or started as planned in the Nurse Practitioner progress notes. The 7/29/2024 at 12:58 PM Nursing Progress Note documented the resident had slurred speech, the Nurse Practitioner assessed the resident and gave new orders. New orders included to obtain Complete Blood Count/Comprehensive Metabolic Panel/Ammonia level, intravenous hydration and a chest x-ray. An intravenous saline lock was placed, and the staff would continue to monitor. The 7/29/2024 at 4:17 PM Nurse Practitioner Progress Note documented the resident was seen for follow up to complaints of fatigue and slurred speech. The plan was to order Complete Blood Count/Comprehensive Metabolic Panel/Ammonia, start intravenous hydration, order chest x-ray and monitor clinically. There was no nurse progress notes or evidence of monitoring on 7/29/2024 between 12:58 PM and 8:21 PM. There was no evidence the laboratory blood tests, or chest x-ray were completed. The July 2024 Medication Administration Record documented intravenous fluid was administered at 6:38 PM. The 7/29/2024 at 8:21 PM Nursing Progress Note documented Registered Nurse #16 was notified by the assigned Licensed Practical Nurse #17 that the resident was increasingly lethargic. The nurse notified the on-call medical doctor of the findings due to the resident's significantly drastic decline. The Medical Doctor instructed to send the resident to the emergency room for medical work up. The Registered Nurse #16 called 911, and at 9:00 PM the resident was taken to the hospital via ambulance. The 7/30/2024 at 6:18 AM Nursing Progress Note documented the resident was admitted to the hospital for septic shock. During an interview on 6/17/2025 at 2:09 PM, Licensed Practical Nurse #14 stated any registered nurse, or licensed practical nurse could accept orders from the medical doctor or nurse practitioner and process test requisitions and arrange for tests. During an interview on 6/16/2025 at 10:37 AM, Nurse Practitioner #18 stated they followed up with Resident #217 on 7/22/2024 for episodes of loose stool and ordered a stool test for Clostridium Difficile, to start Metamucil and to monitor clinically. The orders on 7/22/2024 were given verbally to the Nurse Manager. The Nurse Practitioner stated they met with the resident again on 7/24/2024 and noted the stool test for Clostridium Difficile was not completed as planned. They ordered the stool test for Clostridium Difficile again, to continue Metamucil, and ordered Complete Blood Count /Comprehensive Metabolic Panel (blood work) for monitoring. Nurse Practitioner #18 stated these orders were communicated with the nurse and put into the electronic medical record. Nurse Practitioner #18 stated they assessed the resident again on 7/29/2024 and noted at that time the laboratory tests were not completed and ordered Complete Blood Count /Comprehensive Metabolic Panel, an ammonia level, to start intravenous (IV) hydration, and a chest x-ray. Nurse Practitioner #18 stated they gave all these orders verbally to the nurse unit manager. Nurse Practitioner #18 stated they were new to the facility and may not have been clear how to order and check the laboratory results. They stated they were an independent practitioner and did not talk to the Medical Director about the condition of the resident. Nurse Practitioner #18 stated since laboratory tests such as stool for Clostridium Difficile, Complete Blood Count /Comprehensive Metabolic Panel and ammonia were not completed, they were unable to diagnose and treat the resident, which resulted in actual harm to the resident. During an interview on 6/17/2025 at 1:50 PM, the Medical Director stated a nurse practitioner can work independently, but in the nursing home setting, a nurse practitioner provides care under a physician. They stated they were not aware of the resident's condition or that the laboratory tests were not completed. They stated Nurse Practitioner #18 should have notified the Medical Director of changes in the resident's condition. 10 NYCRR 415.12

Based on record review and interviews conducted during the Recertification and Abbreviated surveys (NY00339190) from 06/10/25 to 06/17/25, the facility did not ensure there was sufficient nursing staff to attain or maintain the highest practicable physical and psychosocial well-being of each resident. Specifically, the facility did not provide adequate nurse staffing per the Facility Assessment Staffing Plan to meet the needs of the residents on sixty-nine of ninety days reviewed. This was evidenced by the nurse staffing schedules dated April 26, 2024, May 7, 2024, December 1 through December 31, 2024, weekends from January 1, 2025 through March 31, 2025, and May 10-June 10, 2025. Additionally, residents expressed concerns that there were not enough nurse aides to provide them with necessary care and assistance, residents were observed in bed late into the day shift, and nursing staff expressed concerns about low staffing. The findings included: The July 2024 Facility Assessment Staffing Plan documented: Unit 100: Day shift: one (1) Licensed Practical Nurse Unit Manager, two (2) Licensed Practical Nurses, two (2) Certified Nurse Aides. Evening shift: two (2) Licensed Practical Nurses, two (2) Certified Nurse Aides. Night shift: 0.33 Supervisor, one (1) Licensed Practical Nurse, two (2) Certified Nurse Aides. Unit 200: Day shift: one (1) Registered Nurse Unit Manager, two (2) Licensed Practical Nurses, two (2) Certified Nurse Aides. Evening shift: two (2) Licensed Practical Nurses, two (2) Certified Nurse Aides. Night shift: 0.33 Supervisor, one (1) Licensed Practical Nurse, two (2) Certified Nurse Aides. Unit 300: Day shift: one (1) Registered Nurse Unit Manager, two (2) Licensed Practical Nurses, two (2) Certified Nurse Aides. Evening shift: one (1) Licensed Practical Nurse, two (2) Certified Nurse Aides. Night shift: 0.33 Supervisor, one (1) Licensed Practical Nurse, two (2) Certified Nurse Aides. The Nurse Staffing Schedules reviewed documented the facility did not meet facility minimum staffing 4/26/2024 and 5/7/2024 (two of two days), December 1, 2024 through December 31, 2024 (twenty-eight of thirty-one days), January 1, 2025 through March 30, 2025 (twenty-three of twenty-six weekend days), and May 10, 2025 through June 10, 2025 sixteen of thirty-one days. During interview on 06/10/25 at 10:15 AM Resident #13 stated if the unit is short staffed, they don't get a shower. They stated in April and May they only received one shower per week. During observation and interview on 06/10/25 at 11:36 AM Resident #6 stated they had not been washed yet and had a soiled brief since 5:00 AM. They stated the night Certified Nurse Aide knew they were soiled but told them they did not have time to change their brief. During a resident interview on 6/10/25 at 12:55 PM, Resident #46 stated when there was not enough staff, it was hard to get someone to assist them to get their brief changed, to get washed and dressed, and to be transferred out of bed. They stated they frequently call the corporate main office number to ask for assistance. The corporate office would call the facility to get a staff member to wash, dress, and get them out of bed. They stated they felt afraid to have a bowel movement because they might have to stay soiled for long periods of time. They stated on weekends, the staff told them they could not get them out of bed due to short staffing. During interview on 06/10/25 at 01:12 PM, Resident # 57 stated there was not enough staff at the facility. During the Resident Council meeting on 06/11/25 at 10:58 AM, Resident #78 stated their roommate waited three hours for their overfilled colostomy bag to be emptied, and many times there was only one Certified Nurse Aide for forty residents. Resident #39 stated their roommate waited six hours for their adult brief to be changed. Resident #89 stated staff was overworked. Resident #13 stated showers were canceled when staff was low and not rescheduled. They stated residents go several weeks without a shower. During interview on 06/11/25 at 12:42 PM, the Administrator stated the Assistant Administrator who had been the Acting Administrator in July 2024 had reviewed the July 2024 Facility Assessment Staffing Plan based on resident needs, and stated the Staffing Plan accurately documented the minimum staffing requirement for the facility During interviews on 06/11/25 at 03:53 PM, 06/11/25 at 04:38 PM, and 06/13/25 at 11:06 AM, the Staffing Coordinator reviewed the Facility Assessment Staffing Plan and the Nurse Staffing Schedules for 4/26/24 and 5/7/24, December 1 through 31 2024, weekends from January 1, 2025 through March 30, 2025 and daily staffing schedules from May 10, 2025 through June 10, 2025. They stated the facility did not provide the minimum staffing required for the shifts/units per the Facility Assessment Staffing Plan. They stated there were a lot of callouts and vacations, and majority of the facility staff are per diem staff who only work when they want to work. During interview on 06/12/25 at 09:31 AM Registered Nurse Unit Manager #6 stated they scheduled resident showers two times a week, they do the best they can to get them done but they are not always able to get them done. They stated they should have three Certified Nurse Aides on day shift but most of the time they have one or two. During interview on 06/12/25 at 11:30 AM, Certified Nurse Aide #2 stated often there was only one Certified Nurse Aide on the unit. They stated residents had to wait hours to be changed and got frustrated because they had to wait so long. They stated nurses tried to help when they could but they had to give medications and administer treatments and document notes. They stated the facility did not pay extra to Certified Nurse Aide who worked alone, and the facility did not send out texts to offer extra money or a bonus to get staff to come in like some other facilities do. During interview on 06/12/25 at 11:37 AM, Licensed Practical Nurse #3 stated they were usually the only nurse on the unit and frequently work with one Certified Nurse Aide, so the residents wait a long time for assistance with activities of daily living. They stated they tried to help with resident care, but they were responsible for administering medications and treatments and had to document everything, so they did not have a lot of extra time to help with cares. During interview on 06/13/25 at 11:48 AM, the Assistant Administrator and Administrator stated they were aware of low staffing. They stated they had trouble hiring new staff and had trouble getting staff to come in to work. They stated they rarely offered bonuses for staff to come in last minute and only as a last resort. They stated they did not provide extra pay to staff who worked alone, such as when only one of two Certified Nurse Aides or when only one of two Licensed Practical Nurses works on a unit. When asked if they have considered decreasing new admissions, they stated they would not be able to stop taking new admissions without corporate directive. During observation on 06/15/25 at 12:40 PM, Resident #19 was still in bed, and not dressed. During observation and interview on 6/15/25 at 12:42 PM, Resident #6 stated they had their brief changed at 4:00 or 5:00 AM, and had not been changed since then. They stated they urinated and needed to be changed. During observation and interview on 6/15/25 at 12:44 PM, Resident #19's family member was observed feeding Resident #19 in bed. They stated they would like their mother to be out of bed but stated the low staffing ratio caused this issue. During interview on 6/15/25 at 01:21 PM, the Director of Nursing stated they wanted to hire more staff, but no one wants the job. They stated they were doing the best they can with the staff they have. During follow-up observation and interview on 06/15/25 at 02:29 PM, Resident #6 was observed in bed, and had not had a brief change. They stated they had a bowel movement, and their adult brief was soiled and wet. During a follow-up interview, on 6/16/25 at 10:41 AM, Resident #46 stated sometimes the Certified Nurse Aide told the resident there was not enough staff to get them out of bed and only washed and changed the resident on those days. They stated they need two staff for transfers with the mechanical lift. They stated they had a bowel movement yesterday morning around 9:00 AM and was not changed until after 12:00 PM. They stated they had rung the bell after having the bowel movement and a Certified Nurse Aide answered the call bell but did not come to change their brief until later. Resident #46 stated they told the Assistant Administrator that they want to get out of bed every day and the Assistant Administrator told them to tell the head nurse. Resident #46 stated they told the unit manager, and the unit manager tried but often stated there were not enough staff to get them out of bed. During interview on 6/16/25 at 10:59 AM, Certified Nurse Aide #5 stated they have often worked at the facility without another Certified Nurse Aide and do not like to be the only Certified Nurse Aide working on a unit because they do not feel it is safe for the residents and very difficult to meet all the resident's care needs. They stated if they transfer a resident without the sufficient assistance, there could be an accident. During follow-up interview on 6/16/25 at 3:07 PM, Licensed Practical Nurse Unit Manager #1 stated that to have more staff in the facility would be much better for the residents. There would be less wait time for resident cares to be completed such as toilet hygiene, brief changes, and getting out of bed. During interview on 6/16/25 at 3:16 PM, Certified Nurse Aide #7 stated if the staffing were better, the resident care would be better. Stated they have worked as the only Certified Nurse Aide on duty and the residents had to wait longer for cares to be provided and some residents did not get out of bed that day. During follow-up interview on 6/17/25 at 1:12 PM, the Assistant Administrator and Administrator stated that after reviewing the Facility Assessment Staffing Plan, they determined that it does not document a sufficient number of staff to provide care to the residents. 10 NYCRR 415.13

Based on observations, interviews, and record reviews during the Recertification and Abbreviated Surveys (NY00339190, NY00364897, NY00368159, NY00372669, NY00377396, NY00356909, and NY00373290) from 6/10-6/17/2025, the facility did not ensure that residents unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for 9 of 9 residents (Residents #46, #14, #74, #216, #364, #214, #78, #314, #165, and 13) reviewed for Activities of Daily Living and 3 additional residents (Residents #61, 76, and 6) observed during the sufficient staffing task. Specifically, 1) Resident # 46 was not provided timely incontinence care and was not gotten out of bed daily. 2) Resident #14 was not provided consistent incontinence care and showers. 3) Resident #74 was observed with long dirty finger nails, clothes soiled with food and a noticeable urine odor. Additionally, Residents #78 and #13 were not showered as planned; Residents #214, #216, #165, #364 and #314's Certified Nurse Aide Accountability Records were noted with multiple omissions over multiple day for activity of daily living that included showers, personal hygiene, and toileting; and on 6/15/25, a Sunday afternoon at 12:45 PM, Resident #6 was in bed, stated they had urinated and had not been changed since 5:00 AM; Resident #76 was in bed and their sheets and hospital gown were soaked with urine; Resident #61 was out of bed in a chair with a strong odor of urine and rings of dried urine were observed on the bedsheet. Findings include: The Facility Policy Activities of Daily Living reviewed 1/2025 documented the purpose of this procedure is to accurately assist with the residents need for support for basic ADL(activities of daily living) function. The procedures included those for toileting for ambulatory and non-ambulatory residents, hair care, dressing and undressing, skin inspection and cleanliness, oral care, peri care, personal care and infection prevention. Documentation should be completed after the care is provided. 1. Resident #46 had diagnoses including severe morbid obesity, anxiety, and depression. The 3/12/25 annual Minimum Data Set (resident assessment) documented the resident's cognition was intact. Resident #46 had an impairment to lower extremity on one side and was dependent on staff for toileting hygiene and transfers. The 6/4/25 Care Plan, at risk for functional decline in mobility and self-care, documented intervention included to provide dependent assistance with footwear/toileting hygiene, and chair to bed transfers with 2-person mechanical lift. The 6/12/25 Kardex documented the resident required a mechanical lift with 2 staff for transfers. The resident wore incontinence brief and used a urinal. During a resident interview on 6/10/25 at 12:55 PM, Resident #46 stated when there was not enough staff, it was hard to get someone to assist them to get their brief changed, to get washed and dressed, and to be transferred out of bed. They stated they frequently called the corporate main office number to ask for assistance. The corporate office would call the facility to get a staff member to wash, dress, and get them out of bed. They stated they felt afraid to have a bowel movement because they might have to stay soiled for long periods of time. They stated on weekends, the staff told them they could not get them out of bed due to short staffing. During an observation and resident interview, on 6/15/25 at 12:45 PM, Resident #46 was observed visibly soiled through the sheets. The resident stated they told the Certified Nurse Aide 30 minutes ago and was still dirty. During a follow-up observation and resident interview, on 6/15/25 at 2:29 PM, Resident #46 was observed clean and dry, but was still in bed. The resident stated they had requested to get out of bed when they were cleaned earlier. During a follow-up resident interview, on 6/16/25 at 10:41 AM, Resident #46 stated that sometimes the Certified Nurse Aide told the resident there were not enough staff to get the resident out of bed that day. They only washed and changed the resident, but did not take the resident out of bed those days. They stated they need two staff for transfers with the mechanical lift. They stated they had a bowel movement yesterday morning around 9:00 AM and was not changed until after 12:00 PM. They stated they had rung the bell after having the bowel movement and a Certified Nurse Aide answered the call bell but did not come to change their brief until later. Resident #46 stated they told the Assistant Administrator that they want to get out of bed every day and the Assistant Administrator told them to tell the head nurse. Resident #46 stated they told the unit manager, and the unit manager tried but often stated there were not enough staff to get them out of bed. When interviewed on 6/16/25 at 10:59 AM, Certified Nurse Aide #5 stated they were assigned to Resident #46 and was told the resident got out of bed every day and required a 2-person assist and mechanical lift. They stated they worked the night shift and Resident #46 had a large bowel movement around 2:00 AM and they changed the resident with the assistance of another Certified Nurse Aide. They stated they planned to get resident out of bed this morning. During a follow-up resident interview on 6/16/25 at 2:52 PM, Resident #46 stated that on 12/17/24 and 12/25/24 (Christmas Day) they could not get out of bed when their family came to visit, which made them feel angry. They stated they felt depressed and anxious every morning, not knowing if they would be able to get out of bed that day. 2. Resident #14 had diagnoses including heart failure, chronic kidney disease, and lymphedema. The Quarterly Minimum Data Set, dated [DATE] documented intact cognition, no behaviors, and dependent on staff assistance for all activities of daily living except eating and oral hygiene, which were documented as set up assistance. The Annual Minimum Data Set, dated [DATE] documented intact cognition, no behaviors, dependent on staff assistance for most activities of daily living except eating and oral hygiene which were documented as set up assistance, and maximal assistance for personal hygiene and upper body dressing. The Care Plan for at risk for functional decline in mobility and self-care, initiated 10/5/2023 and reviewed 2/27/2025, documented the resident was dependent on assistance from staff for all activities of daily living except oral hygiene and eating. Their shower days were Sunday and Thursday. The Care Plan for bowel incontinence, initiated 1/5/2023 and revised on 3/6/2025, documented the resident's incontinence would be managed in a timely manner. Interventions included checking the resident every 2-4 hours and assisting with toileting as needed. The Care Plan for bladder incontinence, initiated 1/7/2023 and revised on 3/6/2025, documented a goal that the resident would remain free from skin breakdown due to incontinence and brief use. Interventions included brief check and change every 3-4 hours and apply incontinence devices as appropriate. The May 2025 Certified Nurse Aide Accountability Record for Resident #14 contained no documented evidence that toileting hygiene was completed on 5/18 and 5/25/2025. Toileting hygiene was documented for one shift only on 5/4-5/6, 5/11, 5/17, 5/22, 5/27, and 5/29/2025. There was no documented evidence that personal hygiene was completed on 5/18 or 5/25/2025. Personal hygiene every shift was documented for one shift only on 5/4-5/6, 5/11, 5/17, 5/22, 5/27, and 5/29/2025. There was no documented evidence that showers were completed on 5/1, 5/5, 5/19, and 5/29/2025. The June 2025 Certified Nurse Aide Accountability Record for Resident #14 documented the resident was given a shower on 6/9/25 for the first time that month. During an interview and observation on 6/10/25 at 1:39 PM, Resident #14 was observed in bed with messy, unkept hair, and poor grooming. Resident #14 stated that they did not receive enough assistance with activities of daily living. There was rarely enough staff to get them out of bed and they usually receive incontinence care once a day. They stated showers were rarely given. During an interview and observation on 6/12/25 at 10:18 AM, Resident #14 was in bed and stated they were changed last around 5:00 AM and were waiting to be changed. They stated they used to get out of bed, but it was a rare occurrence now as there was not enough staff. During an observation on 6/12/25 at 10:33 AM, two Certified Nurse Aides arrived to provide care for Resident #14 and get them out of bed. At 6/12/25 at 11:16 AM, Resident #14 was observed out of bed. During an interview and observation on 6/13/25 at 12:56 PM, Resident #14 was observed in bed. Resident #14 stated they had not been changed since 4:00 AM and were waiting to be changed. They stated they did not know who their assigned aide was. During an interview on 6/13/25 at 1:14 PM Registered Nurse Unit Manager #10 stated the nurse would have to assist with cares for Resident #14 if there were only 2 Certified Nurse Aides assigned to the unit. Residents should be checked every 2-3 hours even with only 2 Certified Nurse Aides. They stated that they also assisted with cares as needed. Resident #14 did not call for assistance much, but since they were incontinent, they should have been checked every 2-3 hours. During an interview on 6/16/25 at 9:24 AM Resident #14 stated that the staff told them they would get them up yesterday and Friday, but never did. During an interview on 6/16/25 at 9:35 AM, Registered Nurse Unit Manager #10 stated of the 40 residents on Unit 300, approximately 18 were independent or required limited assistance. The remaining residents on the unit required 1-2 assist, with many requiring a mechanical lift. During an interview on 6/16/25 at 9:45 AM Certified Nurse Aide #12 stated that the information for the residents' level of care was on the Kardex (care instructions) in the computer. They were supposed to document on the Certified Nurse Aide Accountability record in all the sections for the care provided. The tasks that they did not complete should be documented as not attempted or not available if the resident was out of the facility. If a shower was not given, they would document not attempted with a reason. They stated that not all residents were gotten out of bed when there were only 2 Certified Nurse Aides on the unit for the shift. They stated there were times when they were the only Certified Nurse Aide and they were not able to complete all tasks. They need 2 people to provide Resident #14 care. During the day shift, they usually checked and changed Resident #14 after breakfast or before lunch. They tried to provide care at least one time for them during their eight-hour shift. They stated sometimes Resident #14 they refused to get out of bed, but sometimes they did not have enough help to get them out of bed. They stated they prefer to have a third person when getting them out of bed. They were not sure when Resident #14 was showered and had not showered them. During an interview on 6/17/25 at 3:04 PM, the Director of Nursing stated that the Licensed Practical Nurse and Unit Manager oversee the Certified Nurse Aides and should ensure that the activities of daily living are met according to the tasks assigned for each resident. Residents get showers twice a week and as requested. They are aware that they have gotten bed baths instead of showers. They were not aware that the showers were not being given consistently twice a week. They stated they do review the Certified Nurse Aide documentation and are aware that there are a lot of omissions. Three signatures should be there for 3 shifts when a task is indicated every shift. However, the care takes priority over the documentation. Residents have the right to get out of bed when they want. Their preference should be followed for dressing and getting out of bed. Certified Nurse Aides should be making rounds to check and change the residents every 2-4 hours and as needed. 3. Resident #74 was admitted to the facility with diagnoses including non-Alzheimer's dementia, diabetes mellitus and depression. The Minimum Data Set (MDS) dated [DATE] documented the Resident #74 had moderately impaired cognition and needed substantial staff assistance with personal hygiene and shower/bathe self. The Comprehensive Care Plan for Resident Requires Assist with Activities of Daily Living last updated on 09/13/2024, documented cut fingernails weekly. The Comprehensive Care Plan last updated on 3/20/25, documented the resident required substantial assistance with personal hygiene and shower/bathing. During observation on 6/10/25 at 1:07 PM Resident #74 was sitting in their wheelchair. The resident had long and dirty fingernails on both hands. The resident stated that the staff took care of their fingernails and did not remember when they were clipped last time. During observation on 6/11/25 at 12:16 PM Resident #74 was sitting at the overbed table in front of untouched lunch meal tray. The resident's clothes were soiled with food, and noticeable urine odor. During an interview on 6/17/25 at 10:16 AM Certified Nurse Aide #7 stated that they provide all personal care assistance for Resident #74, which included facial hair care, clipping and trimming of fingernails. Certified Nurse Aide #7 stated that they believed the resident was not diabetic that was why when the resident's fingernails were long, they clipped and filed them. Certified Nurse Aide #7 stated that they did not remember when they clipped the resident's fingernails last time. They stated that they did not remember what the resident's appearance and clothes were before lunch on 6/11/25. During an interview on 6/17/25 at 10:34 AM Licensed Practical Nurse Unit Manager #1 stated that Resident #74 was diabetic and that was why they clipped their fingernails on 6/11/25. Licensed Practical Nurse Unit Manager #1 stated nurses took care of fingernails for diabetic residents. They stated that they did not remember when the resident's fingernails were clipped previously, and it was not documented. 10NYCRR 415.12 (a)(3)

Based on observation, interview, and record review conducted during the recertification and abbreviated (NY00356909, NY00339190) surveys from 6/10/25 to 6/17/25, the facility did not ensure resident's right to a safe, clean, comfortable, and homelike environment. Specifically, 1) Maintenance Care Logs dated January 2024 to present documented more than five hundred (500) reports of television and television remote controls not working properly and many not repaired timely. Additionally, Resident #314's family reported during April and September 2024 visits Resident #314 did not have a functioning television in their room, and 2) the closet door in Resident #39's room had broken hinges which prevented proper attachment. The findings are: The Policy dated January 2025 titled Maintenance Service, documented the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner. During an interview on 06/10/25 at 11:51 AM, Resident #46 stated every time they moved to a different room, the television did not work. The Maintenance Care Logs reviewed from January 2024 to the present date documented more than five hundred (500) reports of televisions and television remote controls not working properly and many not repaired timely, with some lag times up to several days. During a telephone interview on 6/12/25 at 1:08 PM, a family member of Resident #314 (room [ROOM NUMBER]) stated during visits they observed the resident's television was not working. The Maintenance Logs dated 4/11/24, 4/12/24, and 9/10/24 documented install a new television in room [ROOM NUMBER], as the family was upset about the situation. During an interview on 06/11/25 at 03:02 PM, the Director of Maintenance reviewed the Maintenance Log reports of televisions and television remote controls not working. They stated all staff are responsible for reporting broken items via the computer on Maintenance Care. When reviewing lag times for repairing televisions and television remotes, they stated sometimes they run out of batteries for the infrared channel changers. They stated they must prioritize leaks and other safety issues over television issues. They stated they have only one helper, and no other staff can replace the batteries besides the maintenance staff. 2. During an interview and observation on 06/11/25 at 9:17 AM, Resident #39 stated their closet door had been broken for over two years and they told multiple staff members. They stated they hold the door closed with a chair as it falls if not propped. Resident #39 was observed moving the chair. The chair was propped against the closet door. The closet door was not attached at the hinges. During an observation in room [ROOM NUMBER] B on 6/12/25 at 9:38 AM a chair was observed propped against the closet door to prevent it from falling. There were no documented work orders in the Maintenance Repair logs to address the closet door, During an interview on 6/12/25 at 3:07 PM, the Director of Maintenance assessed the closet door in room [ROOM NUMBER] B and stated the door needed repair and removed it from the room. They stated when a repair is needed, staff enter the work order in the computer program used for reporting needed repairs, but they had not received a recent work order for this closet. When work orders are received, they prioritize them, complete the work, and mark the work completed. They stated a broken wardrobe door would be prioritized for repair because it is a safety hazard. They stated they have not been auditing the rooms routinely to assess for safety issues. During an interview on 06/17/25 at 09:00 AM the Administrator stated there is a maintenance program that should be used for reporting any needed repairs. They stated maintenance and housekeeping both round on the units, but there is no formal tool in use to audit the rooms for safety. 10 NYCRR 415.5(h-i)(1-3)