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

Based on record review and interviews (iQIES Intake 2740528), the facility failed to ensure alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated for three (3) of four (4) residents (Residents #11, #21, and #37) reviewed. Specifically, it was reported Certified Nurse Aide #31 was heard calling Resident #21 a liar and there was no documented evidence the facility investigated the allegation to rule out abuse; Resident #11 reported to several staff members that Licensed Practical Nurse #36 intentionally did not provide them with their pain medication and the allegation was not reported to administration to ensure an investigation was completed to rule out neglect or mistreatment; and Resident #37 used a broken plate to threaten another resident and there was no documented evidence the incident was investigated to determine root cause and prevent reoccurrence. Findings include: The facility policy Abuse, Neglect, Exploitation or Misappropriate-Reporting and Investigating, revised 01/2026, documented all reports of resident abuse, neglect, exploitation, or misappropriation are thoroughly investigated. Any employee accused of abuse was placed on leave with no resident contact until the investigation was complete. The administrator ensured that the resident or person who reported it was protected from retaliation. 1)Resident #11 had diagnoses including acute osteomyelitis (bone infection), brain bleed, and right leg fracture. The 02/22/2026 Minimum Data Set assessment documented the resident was cognitively intact and had no behavioral symptoms. The 10/18/2024 comprehensive care plan documented the resident was at risk for being a victim related to their dependence on others for activities of daily living and pain. Interventions included assessing the resident for signs and symptoms of abuse and neglect and report to the appropriate resources. The resident had musculoskeletal impairment related to a spinal infection, and fracture of the right leg. Interventions included administering pain medications per order, position for comfort, and refer to physical therapy/occupational therapy as needed. The 10/13/2024 physician order documented 15 milligrams of oxycodone (opiate pain reliever) every three (3) hours for post-surgical pain. The October 2024 Medication Administration Record documented oxycodone 15 milligrams tablet, give one (1) tablet every three (3) hours for post-surgical pain. The medication administration record included a box to record pain level. Licensed Practical Nurse #36 administered oxycodone on the following dates without documented evidence of a pain level: - 10/14/2024 at 3:00 PM - 10/14/2024 at 6:00 PM - 10/14/2024 at 9:00 PM - 10/22/2024 at 9:00 PM The March 2025 Medication Administration Record documented oxycodone 15 milligram tablet four times a day for pain while awake. The medication administration record included a box to record pain level. Licensed Practical Nurse #36 administered oxycodone on: -03/03/2025 at 12:00 PM with a documented pain level of N/A -03/03/2025 at 6:00 PM with a documented pain level of N/A -03/14/2025 at 6:00 PM with a pain assessment of zero out of ten (no pain). During an interview on 04/17/2026 at 8:37 AM Resident #11 stated when they first were admitted to the facility in 10/2024, Licensed Practical Nurse #36 withheld three (3) doses of their oxycodone tablets. They again withheld their oxycodone sometime in March 2025, but they could not remember the exact date. They told Licensed Practical Nurse #15 and Certified Occupational Therapy Assistant #37 that Licensed Practical Nurse #36 had not given her multiple doses of oxycodone. They stated they also informed Director of Nursing #3 about the issue and was told I know. During an interview on 04/17/2026 at 9:29 AM Director of Physical Therapy #38 stated Resident #11 told them that one of the nurses did not give them their pain medication. They could not remember the name of the nurse, and they did not report what the resident told them to administration. During an interview on 04/17/2026 at 10:35 AM Licensed Practical Nurse #15 stated Resident #11 was alert and oriented and knew what their medications looked like. Resident #11 told them that they did not receive their pain medication, and they reported it to Licensed Practical Nurse Unit Manager #8. They could not remember the date the resident reported the omission. During an interview on 04/17/2026 at 10:46 AM Licensed Practical Nurse Unit Manager #8 stated they did not remember Licensed Practical Nurse #15 reporting Resident #11 did not get their pain medications. They recalled Licensed Practical Nurse #15 stating if Resident #11 said they did not receive the medication, then they did not receive it. They stated they did not report that to anyone but had a conversation with the resident about what their medication looked like, and maybe they must have forgotten that it was given to them. During an interview on 04/17/2026 at 11:05 AM Certified Occupational Therapy Assistant #37 stated Resident #11 told them they had not received their pain medication but could not remember anything specific. They stated Licensed Practical Nurse #36 was a part of medication issue and was terminated. During an interview on 4/17/2026 at 12:10 PM Director of Nursing #3 stated they investigated all allegations of abuse, neglect, and mistreatment. If a resident claimed they did not receive their pain medication it should be investigated. If the allegation was found to be true it would have been reported to the Department of Health. They stated they were not informed Licensed Practical Nurse #36 allegedly did not administer narcotics to Resident #11and if they were, the incident would have been investigated. 2) Resident #21 had diagnoses including anxiety, insomnia, and morbid obesity. The 01/20/2026 Minimum Data Set assessment documented the resident was cognitively intact, was independent for most activities of daily living after set-up and had no behavioral symptoms. During an interview on 04/13/2026 at 12:23 PM, Resident #21 stated they had an audio recording of Certified Nurse Aide #31 calling them a liar. In the recording they were also told about an inappropriate relationship between Certified Nurse Aide #31 and a resident (Resident #167). The resident was no longer in the facility. Resident #21 stated they played the audio recording for Social Worker #43, during a care plan meeting. On 04/14/2026 at 2:00 PM, a request was placed with the Administrator for all incidents and investigations related to Resident #167 and Resident #21. There was no documented evidence of an investigation. On 04/15/2026 at 1:00 PM the employee file for Certified Nurse Aide #31 was reviewed. Included in the employee file was an Employee Disciplinary Action Form dated 12/05/2024 documenting they violated the company policy on attitude and conduct by questioning a resident and calling them a liar. Certified Nurse Aide #31 was provided education on the customer service policy, gold service, resident rights, and service standards policy. Attached to the Disciplinary Action Form, was an undated statement from Certified Nurse Aide #31, stating they did not call the resident a liar and a statement dated 12/05/2024 from Social Worker #43, stating the resident reported Certified Nurse Aide #31 called them a liar and they requested the aide no longer provide care to them. During an interview on 04/14/2026 at 1:45 PM, Social Worker #43 stated in 2024 they did not remember hearing a resident concern about an inappropriate relationship between a certified nurse aid and a resident. Initially the Social Worker stated they did not recall hearing an audio tape at a care plan meeting because they would remember that. When asked about Resident #21, Social Worker #43 stated they recalled the audio tape and discussion about a certified nurse aide having an inappropriate relationship with a resident. They could not recall the name of the certified nurse aide involved. They stated Resident #21 had intact cognition, did not fabricate stories, and they believed the resident when they reported the allegation. They reported the audio tape to the Director of Nursing. During an interview on 04/15/2026 at 12:33 PM, the Director of Nursing stated all staff were trained on abuse and neglect. When they were notified of physical, financial, sexual, or emotional abuse and a staff member was involved, the staff member was contacted, removed from the care area, and brought to a conference room. When staff abuse concerned a resident, social work was involved, and an assessment of the resident was completed by a registered nurse and was documented in a progress note. Pending the investigation, if substantiated, the Department of Health was notified. They were never notified of staff having an inappropriate relationship with a resident, and they were not told about an audio recording. The Director of Nursing reviewed the 12/05/2024 counseling memo for Certified Nurse Aide #31's and stated Certified Nurse Aide #31 violated the facility policy on attitude and conduct in a resident care area including questioning a resident and referring to them as a liar. They completed an investigation of the incident which was the three pages (counseling memo, 12/05/2024 statement from Social Worker #43, and the undated statement from Certified Nurse Aide #31). The Director of Nursing stated Certified Nurse Aide #31 called the resident a liar because it had something to do with, breaking the heart of Resident #167. They could not recall asking what breaking the heart of Resident #167 meant. They did not get a statement from Resident #167 or Resident #21, and they should have. They did not complete a thorough investigation to rule out abuse, neglect, or misappropriation and Certified Nurse Aide #31 should have been taken out of work while the incident was investigated. 3) Resident #37 had diagnoses including paranoid schizophrenia (a serious mental illness), depression, and anxiety disorder. The 02/10/2026 Minimum Data Set assessment documented the resident had moderately impaired cognition, no behavioral symptoms, and required supervision with most activities of daily living. The Comprehensive Care Plan initiated 11/10/2025 and revised 04/13/2026 documented the resident exhibited behavioral symptoms such as verbal aggression/abuse, physical aggression/abuse, and hallucinations and delusions. Interventions included modifying the environment to reduce episodes of negative behavior and administer psychotropic medications as ordered. The 03/05/2026 at 6:20 PM Licensed Practical Nurse #15's progress note documented the resident picked up their glass plate, broke it, then proceeded to use a piece of it as a weapon. They said they were going to hurt another resident. The 03/05/2026 at 6:25 PM Licensed Practical Nurse #23's progress note documented they were called to the unit due to the resident breaking a plate and was using a piece of the plate to threaten staff and other residents; the broken plate was taken from the resident by staff; the resident was yelling out they were going to hurt a specific resident and staff; 911 was summoned to assist with the resident; and the resident told two (2) police officers they were going to cut another resident's throat. There was no documented evidence the incident was investigated, or a plan was put in place to protect other residents. During an interview on 04/17/2026 at 11:22 AM, the Director of Nursing stated there was not an investigation completed for the 03/05/2026 event involving Resident #37. They did not think Resident #37's behavior was directed toward a specific resident. After referring to the progress notes they stated the event involved another resident; they did not know who that resident was; that resident should have been identified; and there was nothing put in place to protect that resident. Because the event involved another resident there should have been an investigation. Resident #37 had schizophrenia and often saw things others did not and because it was an isolated incident. 10 New York Codes, Rules and regulations 415.4(b)(1)

Based on observations, record review, and interviews, the facility failed to ensure residents who required dialysis services (filtration of blood when the kidneys do not work) received such services consistent with professional standards of practice for two (2) of two (2) residents (Residents #3 and #16) reviewed. Specifically, Residents #3 and #16 received hemodialysis treatments at a community-based dialysis center and did not have consistent on-going assessments or oversight before and after dialysis treatments and there was no documented evidence the resident's Tesio catheter (access site for dialysis treatment) was routinely assessed. Findings include:The facility policy Dialysis, revised 01/2026, documented the facility had a written agreement with all dialysis center providers and the facility maintained a communication log with the respective centers for all residents that went to dialysis. The communication log was used to communicate the resident's needs and responses to dialysis treatment. 1)Resident #16 had diagnoses including chronic kidney disease with dialysis and diabetes. The 02/15/2026 Minimum Data Set assessment documented the resident had intact cognition and required dialysis. The comprehensive care plan initiated 09/23/2025 and revised 02/27/2026, documented the resident received dialysis on Tuesdays, Thursdays, and Saturdays. Interventions included checking and changing dressing daily to right upper chest Tesio catheter only if ordered by physician, obtain weights and vital signs per protocol, monitor and document peripheral edema (swelling), monitor intake and output, and document any signs of infection to the access site such as redness, swelling, warmth, or drainage and report to the physician. The 03/23/2026 physician orders documented: -hemodialysis double lumen catheter to right chest wall, monitor for bleeding and dressing placement every shift. Document abnormal findings in a progress note. -pre and post dialysis evaluation twice a day, three times a week on Tuesday, Thursday, and Saturday. -dialysis three times a week on Tuesday, Thursday, and Saturday. The 04/2026 Treatment Administration Record documented on 04/16/2026 Licensed Practical Nurse #28 monitored the hemodialysis double lumen catheter dialysis fistula site on the day shift. There was no documented evidence of pre-dialysis communication sheets for 01/03/2026, 01/06/2026, 01/17/2026, and 04/09/2026. The 03/07/2026 dialysis sheet was missing documentation and was not signed. There was no documented evidence of post-dialysis communication on 01/03/2026, 01/06/2026, 01/17/2026, 02/10/2026, 02/12/2026, 02/14/2026, 02/21/2026, 02/24/2026, 03/07/2026, 03/10/2026, 03/12/2026, 03/14/2026, 03/17/2026, 03/24/2026, 03/26/2026, 03/28/2026, 03/31/2026, 04/02/2026, 04/07/2026, 04/09/2026, and 04/11/2026. During an interview on 04/16/2026 at 7:24 AM, Licensed Practical Nurse # 28 stated they were responsible for oversite of residents including residents that went to dialysis. Resident #16 attended dialysis three times a week and had vital signs done before and after dialysis. The pre-dialysis vital signs, list of medications, and other required documentation were documented on a communication sheet and sent to the dialysis center with the resident. Dialysis completed their section and returned it with the resident after treatment. They were not responsible for anything related to the catheter. The catheter was flushed and cared for by the dialysis center. During an observation and interview on 04/16/2026 at 1:54 PM, Resident #16 was in their room in bed. They stated they returned early from dialysis because their dialysis catheter was clotted. When they returned no one looked at their catheter site or took their vital signs. The dressing was observed to the right chest wall and was dry and intact with no drainage noted. They were always sent to dialysis with a folder and most days their vital signs were taken before they left. They stated most days they did not have vital signs completed when they returned from dialysis, and it was rare for any nurse to look at their catheter site. During an interview on 04/17/2026 at 8:09 AM, Licensed Practical Nurse #28 stated Resident #16 attended dialysis Tuesday, Thursday, and Saturday. Prior to dialysis they completed a form to communicate with the dialysis center. The form included resident specific medications and change in condition to ensure the resident was able to tolerate the treatment. There were times when the dialysis center did not complete their portion of the communication sheet prior to sending the resident back to the facility. When that occurred, dietary called for a weight and Licensed Practical Nurse Unit Manager #5 called for a verbal report. They always completed the pre-dialysis form; however, they did not normally complete the post-dialysis form as the resident did not return on their shift. Resident #35 returned on their shift on 04/16/2026 and did not get vitals and they did not observe the dressing to ensure it was dry and intact because there were issues that occurred at dialysis that Licensed Practical Nurse Unit Manager #5 was addressing. During an interview on 04/17/2026 at 1:16 PM, Licensed Practical Nurse Unit Manager #5 stated when they had dialysis residents, vital signs were taken before and after dialysis to ensure the resident was able to receive treatment and did not have any change in condition after treatment. When the resident returned from dialysis, they reviewed communication from the dialysis center to see how the resident tolerated treatment. Resident #16 received dialysis and on 04/16/2026 they were notified by the dialysis center the catheter used for dialysis was clogged. The facility does not flush the catheter; the dialysis center administered that treatment. The facility only observed the catheter site every shift and if it was not clean and dry the supervisor was notified. That was documented on the medication administration record and should only be documented if completed. It was important to complete the pre and post-dialysis vital signs and monitor the dressing to ensure there was not a change in condition. They were not sure why this was not being done consistently. 2)Resident #3 had diagnoses including chronic kidney disease with dialysis and diabetes. The 01/11/2026 Minimum Data Set documented the resident had intact cognition and required dialysis. The comprehensive care plan, initiated 11/21/2025 and updated 4/7/2026, documented the resident received dialysis on Monday, Wednesday, and Friday. Interventions included checking and changing dressing daily at the access site for dialysis treatment only if ordered by physician, monitor and document peripheral edema (swelling), monitor intake and output, and document any signs of infection to access site such as redness, swelling, warmth, or drainage and report to the physician. The 12/29/2025 physician order documented pre and post-dialysis evaluations were required twice a day, three times a week on Monday, Wednesday, and Friday. The 3/18/2026 Physician #45 progress note documented Resident #3 had end stage renal disease and was dependent on dialysis. They attended dialysis 3 times a week on Monday, Wednesday and Friday. There was no documented evidence of pre-dialysis communication forms for Resident #3 on 01/16/2026, 01/19/2026, 01/21/2026, 01/23/2026, 02/04/2026, 02/09/2026, 02/23/2026, 03/03/2026, 03/16/2026, 04/06/2026, 04/08/2026, 04/13/2026, and 04/15/2026. There was no documented evidence the resident's dialysis access site was routinely assessed as planned. During an interview on 04/16/2026 at 11:00 AM, Licensed Practical Nurse #20 stated they were responsible for completing a pre-dialysis assessment and documenting it in the electronic medical record before a resident assigned to them went to dialysis. When the resident returned to the facility, they completed a post-dialysis assessment to ensure the resident was stable and the fistula was patent. The pre and post dialysis assessments were documented in the electronic medical record under evaluations. They communicated with the dialysis center through a form that was sent with the resident to each treatment. Facility nursing staff filled out the pre-treatment information at the top of the form and dialysis sent back a report from the treatment. These were both scanned into the electronic medical record. During an interview on 04/16/2026 at 11:17 AM, Licensed Practical Nurse Unit Manager #21 stated the facility licensed practical nurses were responsible for completing a pre-dialysis assessment and documenting it in the electronic medical record before a resident assigned to them went to dialysis. When the resident returned to the facility, they completed a post-dialysis assessment to ensure the resident was stable, the fistula was patent, vitals, and post weights. The pre and post-dialysis assessments were documented in the electronic medical record under evaluations. That is the only place they would have been, and if they were not there the nurse -did not do them. They communicated with the dialysis center through a form that was sent with the resident in a red folder every time they went to dialysis. They filled out the top of the form and dialysis sent back a report from the treatment. These were both scanned into the electronic medical record in the scanned section. They did not know why some forms were not in the record. 10 New York Codes, Rules and Regulations 415.12(k)

Based on observations and interviews (iQIES intake 2620687), the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for three (3) of four (4) medication carts (Wing Three front and back and Wing Four back medication carts) reviewed. Specifically, Wing Three front medication cart was unlocked and unattended with two (2) medicine cups containing pre-poured medications; Wing Three back medication cart had an undated, unlabeled, open vile of lidocaine (anesthetic), an opened and undated inhaler, one (1) expired insulin pen and one (1) expired insulin vial, and one (1) insulin pen and one (1) insulin vial that were opened and undated; and Wing Four had two (2) opened undated eyes drops, and five (5) opened undated inhalers. Findings included:The facility policy Storage of Medications, last reviewed 01/2026, documented nursing staff were responsible for maintaining medication storage. The facility did not use outdated drugs or biologicals and were returned to pharmacy. Compartments containing drugs and biologicals were locked when not in use, when unattended, or when potentially available to others.The facility policy Security of Medication Cart, last reviewed 01/2026 documented medications carts were securely locked at all times when out of the nurse's view.The facility policy Administering Medications, documented when multi-dose medications were opened the date opened was recorded on the container. Wing Three During an observation and interview on [DATE] at 11:05 AM the Wing Three front medication cart was unlocked and unattended. The first drawer of the medication cart contained two (2) unlabeled cups of pre-poured medications. The first cup contained one (1) round large white pill, two (2) round small white pills, one (1) oval white pill, one (1) round peach colored pill, one (1) round brown pill, and one (1) oval yellow pill. The second cup contained one (1) round yellow pill, one (1) round small red pill, one (1) beige capsule, and one (1) round white pill. Licensed Practical Nurse #6 stated they just walked away for a second to speak to a family member of a resident. They stated the medication cart should never be unlocked and unattended. One (1) resident was not available when they went to administer their medications, and they were waiting for the other resident's inhaler to come from pharmacy to administer their medications. The medicine cups were unlabeled, but they knew who each cup was for. They were unsure what they were supposed to do with the medications that were poured if the resident was not available.During an observation and interview on [DATE] at 9:35 AM the second drawer of the Wing Three back cart contained an opened, unlabeled, and undated vial of lidocaine. Licensed Practical Nurse #7 stated the lidocaine came with ertapenem (antibiotic) and was not labeled or dated when opened. They were unsure if the vial needed to be dated when opened. The third drawer of the cart contained an undated fluticasone/salmeterol inhaler. Licensed Practical Nurse #7 stated it probably should have been labeled when it was opened, but it was not. They were unsure why it was not dated. The small first drawer on the right of the cart contained a Rezvoglar (long acting) insulin with an opened date of [DATE], and a Humulin R (short acting) insulin vial with an opened date of [DATE]. Licensed Practical Nurse #7 stated insulins were good for 28 days after they were opened. They were both expired and needed to be discarded and reordered. They were unsure why expired insulins were in the cart. The drawer contained an opened and undated insulin lispro (short acting) vial and an opened and undated Lantus (long acting) insulin pen. Licensed Practical Nurse #7 stated insulins were required to be dated when opened. They were unsure when they were opened or if they were expired. The pen and vial needed to be discarded and reordered.During an interview on [DATE] at 2:10 PM Licensed Practical Nurse Unit Manager #8 stated when they administered medication, they checked the medication against the medication administration record and popped it into the medication cup prior to checking if the resident was available. Multiple medications cups should not be pre-poured. They were unsure what to do with pre-poured medications if the resident was unavailable. The medication carts should always be locked when unattended for safety. Any insulins, eye drops, open vials, and inhalers should be dated when opened. Insulin was good for 30 days and they were unsure how long nasal sprays or eye drops were good for. Anytime the nurse was given the med keys they looked over the cart. The overnight shift checked the cart for outdates and they audited the carts at the end of every month. Wing Four During an observation and interview on [DATE] at 10:14 AM the first drawer of the Wing Four back medication cart had artificial tears eye drops and latanoprost eye drops that were not dated when opened. Licensed Practical Nurse #9 stated eye drops were supposed to be labeled when opened, with an open date and an expiration date. Eye drops expired 30 days after they were opened. They were unsure why the eye drops did not have open dates. The third drawer of the medication cart contained opened, undated dinium/vilanterol) and albuterol inhalers that were unlabeled when open. Licensed Practical Nurse #9 stated they were never trained that inhalers had to be labeled when opened. They were unsure why the bag they came in had an open date sticker on them. They did not think that inhalers expired, they were good until the medication was finished.During an interview on [DATE] at 11:47 AM Licensed Practical Nurse Unit Manager #5 stated inhalers needed to be dated when they were opened, they were typically good for 30 days. They should have been thrown away if they did not have an open date. Eye drops should also be dated when they were opened, they were good for 30 days. If they were found to be undated, they should be discarded and reordered. 10 New York Codes, Rules and Regulations 415.18(d)

Based on observations and interviews (iQIES Intake 2620687), the facility failed to store food in accordance with professional standards for food service safety in one (1) of one (1) main kitchen and 1 (one) of 4 (four) unit pantries (Unit 2 pantry). Specifically, a black substance was observed on the main kitchen cold production reach in cooler door gasket; in the main kitchen walk-in milk cooler along the rim of the ceiling; and on the Unit 2 snack refrigerator door gasket; the cold production reach in cooler did not maintain a safe temperature, the food inside tested at unsafe temperatures; and Food Service Worker #19 attempted to serve Resident #108 a meal tray removed from a food cart with dirty trays. Findings include:The facility policy General Sanitation of Kitchen, revised 01/2026, documented cleaning and sanitation tasks for the kitchen would be recorded, and staff would be trained on the cleaning schedule and how to perform the cleaning tasks.The facility policy Foodborne Safety, revised 01/2026, documented cold food would be stored below 41 degrees Fahrenheit. Food Storage During an observation on 04/13/2026 at 7:36 AM, the cold production reach in cooler internal temperature was 50 degrees Fahrenheit. The refrigerator contained a bag of hard-boiled eggs, a large package of cheese slices, a large package of poultry cold cuts, a tray of liquid supplements and poured juices. The hard-boiled egg temperature was 43.2 degrees Fahrenheit. Equipment Safe/Clean During an observation and interview on 04/13/2026 at 7:36 AM, there was a black substance in the main kitchen cold production reach in cooler door gasket. Food Service Director #16 stated the maintenance department cleaned the refrigerator gaskets.During an observation and interview on 04/13/2026 at 8:10 AM in the main kitchen, there was a black substance along the ceiling crease in the milk walk-in cooler in the main kitchen. Food Service Director #16 stated the maintenance department was responsible for cleaning the ceiling creases.During an observation on 04/14/2026 at 9:20 AM, there was a black substance in the Unit 2 snack refrigerator door gasket.There was no documented evidence of a main kitchen cleaning schedule. The food service communication logbook for maintenance for September 2025 through April 2026 did not include documentation of gasket cleaning or walk in cooler ceiling crease cleaning. Meal ServiceDuring an observation and interview on 04/14/2026 at 1:10 PM Resident #108 changed their mind and wanted their lunch after initially declining. The food cart just left the wing with dirty and uneaten trays mixed throughout the cart. Food Service Worker #19 approached the dirty cart in the hall and pulled several trays out before finding one they stated, looked okay and removed it from the cart. They brought the tray to the unit and handed it to Certified Nurse Aide #17. There was no tray ticket present on the tray. Food Service Worker #19 stated they should not serve a tray removed from a dirty food cart. They removed the tray and stated they were getting a fresh tray.During an interview on 04/16/2026 at 11:44 AM, Certified Nurse Aide #17 stated nursing was responsible for cleaning the unit refrigerators and they tried to clean them often but there was no set schedule. They did not clean the gaskets and did not know who did.During an interview on 04/16/2026 at 11:00 AM, Licensed Practical Nurse #20 stated nursing was responsible for cleaning the unit refrigerators and whoever had time on the unit should clean them. They were not sure who cleaned the gaskets.During an interview on 04/16/202 at 11:17 AM, Licensed Practical Nurse Unit Manager #21 stated the unit refrigerators were clean, and they cleaned them every day. It was nursing's responsibility to clean them.During an interview on 4/17/26 at 9:52 AM, Food Service Director #16 stated there was a set schedule assigned to each kitchen position and the staff assigned to the I position was scheduled to clean the cold production reach in cooler daily, except for the door gaskets. Maintenance came and cleaned door gaskets when food serviced requested. There was a logbook kept in the kitchen that maintenance checked daily. Maintenance should have cleaned the gaskets monthly and as requested in the logbook. They would log any equipment with issues in the logbook or call maintenance directly. They stated if uneaten meal trays were mixed in with dirty trays, they should not be served for infection control reasons. Staff should get a new tray from the kitchen. During an interview on 04/17/2026 at 11:37 AM, Maintenance Director #18 stated kitchen staff were responsible for cleaning the refrigerators and gaskets. They had not received any requests to clean gaskets since being hired at the facility months ago. 10 New York Codes, Rules and Regulations 415.14(h)

Based on observations, record review, and interviews (iQIES Intakes 2626225, 2712590, and 2740528), the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, personal and oral hygiene for two (2) of seven (7) residents (Residents #1 and #2) reviewed. Specifically, Resident #2 was not toileted as planned; and Resident #1 was not provided with oral care as planned.Findings include: The facility policy Resident Care with Activities of Daily Living, last reviewed 01/2026, documented the facility would accurately assist with the residents need for basic activities of daily living functions; would provide adequate toileting maintaining maximum level of toileting and continence; would offer toileting assistance every two (2) to four (4) hours to those on a toileting program; would assist residents to cleanse and freshen the resident's mouth; and the supervisor would be notified of any refusals. 1)Resident #1 had diagnoses including dementia, anxiety, and Parkinson's disease (a progressive neurological disorder). The 01/11/2026 Minimum Data Set assessment documented the resident had moderately impaired cognition, required substantial/maximum assistance with hygiene and toileting, partial/moderate assistance with oral care, did not have broken or loose teeth, and did not reject care. The Comprehensive Care Plan initiated 10/05/2023 and revised 03/17/2026 documented the resident required assistance with self-care and mobility. Interventions included substantial/maximum assistance for personal hygiene and oral care. The undated care instructions documented the resident required substantial/maximum assistance with oral hygiene. Resident #1 was observed with foul breath: -on 04/13/2026 at 10:19 AM -on 04/15/2026 at 8:01 AM On 04/15/2026 at 1:15 AM Certified Nurse Aide #32 documented oral care was completed for Resident #1. During an interview on 04/15/2026 at 9:04 AM the resident stated staff did not brush their teeth and they liked them brushed. During an interview on 04/15/2026 at 9:48 AM, Certified Nurse Aide #33 stated they were responsible for completion of resident care including washing, dressing, shaving, washing hair, nail care, and oral care for their assigned residents. When a resident's level of assistance was substantial/maximum, it required putting toothpaste on the toothbrush and brushing the resident's teeth. They were assigned Resident #1 and did not brush their teeth because it was completed by the night shift when they got the resident up for the day. Resident #1 had never refused care in the past. It was important to perform oral care, so residents did not get mouth disease or cavities. During an interview on 04/16/2026 at 12:50 PM, Certified Nurse Aide #32 stated they worked the overnight shift. Every day when they arrived at their assigned unit, they completed rounds to ensure residents were clean and dry. After rounds, they completed their documentation for care they anticipated to complete when they got the resident up in the morning. They were never told to complete documentation only after the care was completed. They worked on the resident's floor on 04/15/2026 and they did not perform oral care for Resident #1 and did not recall signing for oral care. It was important to perform oral care to prevent cavities and infections in the mouth. During an interview on 04/17/2026 at 8:09 AM, Licensed Practical Nurse #28 stated routine dental care was important for dignity and to prevent infections. It was everyone's responsibility to perform oral care; however, the task primarily fell on the certified nurse aides. If the care plan documented a resident required substantial/maximum assistance for oral care that meant staff had to brush the resident's teeth. They stated Resident #1 was independent with brushing their teeth. During an interview on 04/17/2026 at 1:16 PM, Licensed Practical Nurse Unit Manager #5 stated both certified nursing aides and nurses performed oral care for residents. Care that was completed was documented only after the care was completed. Staff utilized the resident specific care card to determine the level of assistance required when completing care. Substantial/maximum assistance meant the resident required staff to put toothpaste on the toothbrush and brush their teeth. When a resident refused oral care or refused to see the dentist, the refusal should be documented in a progress note. 2)Resident #2 had diagnoses including dementia and assistance for personal care. The 02/27/2026 Minimum Data Set assessment documented the resident was rarely understood, was dependent on most activities of daily living, and was always incontinent of bowel and bladder. The comprehensive care plan initiated 11/05/2025, and revised 02/17/2026, documented assistance was required for self-care and mobility. Interventions included dependence on toileting hygiene and supervision or touching assistance for toilet transfers. The comprehensive care plan initiated 08/19/2023, and revised on 02/17/2026, documented the resident had occasional bladder incontinence. Interventions included check/change brief every three (3) to four (4) hours and as needed. During a continuous observation on 04/15/2026 from 9:13 AM-1:40 PM the resident was seated at a table in the dining area and was not repositioned, taken to the bathroom, or offered to be taken to the bathroom. At 1:40 PM staff walked the resident into the bathroom where their incontinence brief was removed and was observed to be saturated. During a continuous observation on 04/16/2026 from 8:27 AM-1:05 PM the resident was seated at a table in the dining area and was not repositioned, taken to the bathroom, or offered to be taken to the bathroom. At 1:05 PM Certified Nurse Aide #10 asked the resident if they wanted to be changed and Certified Nurse Aide #13 walked the resident to their room. The resident's right buttock and right inner thigh area of their pants had a wet area approximately 12 x 8 inches. The 04/15/2026 and 04/16/2026 toileting hygiene documentation report documented the resident was toileted during the day shift on 04/15/2026 at 12:50 PM and 04/16/2026 at 2:53 PM. During an interview on 04/16/2026 at 1:05 PM, Certified Nurse Aide #10 stated most residents were toileted or repositioned every two (2) to three (3) hours; they were supposed to document each time a resident was taken to the bathroom; and any refusals of care should be reported to a nurse. They took care of Resident #1 on 04/15/2026 and 04/16/2026 during the day shift. The resident should be toileted every two (2) to three (3) hours. On both days, the night shift got the resident up and dressed prior to the start of the 7:00 AM day shift and both days they asked the resident if they needed to be changed, and the resident declined. They never reported the declinations or reapproached the resident because they got busy and forgot. During an interview on 04/17/2026 at 9:10 AM, Licensed Practical Nurse #11 stated residents should be repositioned and toileted every two (2) hours. The aide assigned to that resident was responsible for doing that and the nurse was responsible for making sure it happened. Resident #1 was incontinent and needed assistance to be toileted every two (2) to three (3) hours. They had not noticed the resident sat for a long time in the dining area on either 04/15/2026 or 04/16/2026 and no one reported any care declinations. The resident should not have been sitting for over four (4) hours. 10 New York Codes, Rules and regulations 415.12(a)(3)

Based on observations, record review, and interviews, the facility failed to ensure residents were provided with nutritional and hydration care services consistent with the resident's comprehensive assessment for one (1) of four (4) residents (Resident #3) reviewed. Specifically, Resident #3 was on a renal diet (specialized diet for kidney failure that limits specific minerals) and a fluid restriction. Resident #3's actual fluid intake was not monitored and the resident received extra fluids beyond the allotted restrictions at meals; and was provided with extra food which was limited on their prescribed renal diet. Findings include:The facility diet manual, approved on 9/25/2025, documented the renal diet assured sodium, potassium, and phosphorus were limited to prevent further burden on the kidneys. The diet description documented milk was limited to 4 (four) ounces daily and chocolate was excluded.Resident #3 had diagnoses including end stage kidney disease. The 01/11/2026 Minimum Data Set (assessment tool) documented the resident had intact cognition, was on a therapeutic diet, had kidney disease and received dialysis treatment (blood is filtered through a machine when the kidneys do not work).The comprehensive care plan, initiated 11/21/2025 and updated 4/7/2026, documented the resident had impaired cognitive function related to dementia, had fluid overload related to end stage renal disease, had renal disease requiring dialysis, and was prescribed a renal diet with a 1500 milliliter fluid restriction. The physician orders for Resident #3 documented: -Renal, No Concentrated Sweets Diet -1500 milliliter fluid restriction per day-fluid limited to 1080 milliliters for meals (Breakfast 480 milliliters/ Lunch 360 milliliters / Dinner 240 milliliters. -Serve 420 milliliters for nursing (7:00 AM -3:00 PM shift = 150 milliliters, 3:00 PM-11:00 PM shift = 150 milliliters, 11:00 PM-7:00 AM shift = 120 milliliters). -Every shift document total fluid consumed per shift.-hemodialysis three times a week on Monday, Wednesday, and Friday-Velphoro (medication that lowers blood phosphorus levels) 500 milligram tablet with each meal. The undated Kardex (care instructions) printed on 04/16/2026, documented the resident would be provided with a renal, no concentrated sweets, and 1500 milliliter fluid restriction diet as ordered by the physician.The activities of daily living meal consumption record for March 2026 and April 2026 documented Resident #3's solid and fluid intake varied from 26% to 100% of documented meals. The following meals were not documented:-03/02/2026: dinner-03/03/2026; breakfast, lunch, dinner-03/04/2026: breakfast and lunch-03/05/2026: dinner-03/13/2026: lunch-03/17/2026: dinner-03/23/2026: breakfast, lunch, dinner-03/24/2026: breakfast, lunch-03/25/2026: lunch-03/30/2026: dinner-04/01/2026: breakfast and lunch-04/07/2026: breakfast and lunch-04/10/2026: breakfast and lunch-04/14/2026: dinner The January 2026 through April 2026 medication administration record documented fluid restriction: 1500 milliliters/day, serve 1080 milliliters dietary/day breakfast 480 milliliters, lunch 360 milliliters, dinner 240 milliliters; for nursing/day amount per shift 7:00 AM -3:00 PM shift = 150 milliliters, 3:00 PM-11:00 PM shift = 150 milliliters, 11:00 PM-7:00 AM shift = 120 milliliters. Every shift document total fluid consumed per shift. The designated medication administration boxes for each shift did not include actual fluid consumed and were marked with a check. The 01/11/2026 Registered Dietitian #39 quarterly progress note documented the resident was on a renal, no concentrated sweets diet, and consumed 76% or more of solids and fluids at and between meals. There was no documentation of the resident's prescribed fluid restriction or monthly dialysis laboratory data. There was no documented evidence of the amount of fluids provided at meals or if fluid intake volume was assessed. The 02/03/2026 laboratory results collected 02/02/2026 documented the resident's phosphorus level was 6.2 milligrams per deciliter (normal range 2.5 -5 milligrams per deciliter) and calcium phosphorus product (assesses mineral balance) was elevated to 60.8 (normal value below 55). Registered Dietitian #39 progress notes documented: -on 02/27/2026 the resident was on a fluid restriction and consumed 76-100% of their solids at meals. There was no documented evidence of the amount of fluids provided at meals, fluid intake volume was assessed, or laboratory values were reviewed. -on 04/06/2026 the resident was on a renal, no concentrated sweets diet, and consumed 76% or more of solids and fluids at and between meals. There was no documented evidence of the amount of fluids provided at meals, fluid intake volume was assessed, or laboratory values were reviewed -on 04/10/2026 the resident was on a fluid intake and consumed 76-100% of their solids at meals. There was no documented evidence of the amount of fluids provided at meals or fluid intake volume was assessed. During an observation and interview on 04/14/2026 at 12:41 PM, the resident's lunch meal ticket documented renal restriction diet and 1500 milliliter fluid. The following items were documented on the resident's meal ticket and were received for the lunch meal. -Four (4) ounces (120 milliliters) cranberry juice (consumed 100%)-Eight (8) ounces (240 milliliters) coffee (consumed 100%) The resident consumed the full 360 milliliter lunch fluid allotment at this time. At 1:00 PM, the resident was sitting with their empty tray in front of them and Certified Nurse Aide #41 brought them an eight (8) ounce (240 milliliters) chocolate milk. They consumed all 240 milliliters of the chocolate milk, which brought their lunch fluid consumption to 600 milliliters. Certified Nurse Aide #41 stated the tray ticket told them what diet a resident was on and they did not know what a renal diet was. They would have no idea if a resident was on a fluid restriction because this information was not in the section of the electronic medical record they accessed. During an interview on 04/16/2026 at 11:00 AM, Licensed Practical Nuse #20 stated a renal diet limited sodium, fluids, and potassium. A fluid restriction would limit the amount a resident could drink daily. They know if a resident was on a renal diet or fluid restriction by reviewing the care plan and the physician orders. Certified nurse aides should not give extra fluids without checking with the nurse and they should not have given Resident #3 chocolate milk or extra fluids not listed on their tray ticket. During an interview on 04/16/2026 at 11:17 AM, Licensed Practical Nurse Unit Manager #21 stated a renal diet was low potassium. They stated fluid restrictions were all different. Staff know if a resident was on a fluid restriction by looking at the meal ticket. A nurse aide should not give extra fluid or milk to a resident on a renal diet or fluid restriction, without checking with the nurse first and Resident #3 should not have been given chocolate milk. During an interview on 04/16/2026 at 11:44 AM, Certified Nurse Aide #17 stated they did not know what a renal diet was. A fluid restriction limited fluid to a certain amount. They would know about the renal diet and fluid restriction on the meal ticket, but it did not show up in the nurse aide section of the electronic medical record. They could not document the actual amount of fluid consumed in the electronic medical record, only a percentage range. They should not provide extra fluid to residents on a fluid restriction without checking with the nurse first. During an interview on 4/17/2026 at 7:30 AM, Certified Nurse Aide #17 stated both food and fluid were recorded in percentage only. If a resident drank everything they were given and received more, it was recorded as 76 to 100% for fluids and no specific fluid amount was recorded. Extra fluid intake would not be documented. During an interview on 4/17/2026 at 7:41 AM Licensed Practical Nurse #41 stated if a resident was on a fluid restriction, they recorded fluid intake in milliliters by clicking on the medication administration record and recorded the amount of fluid consumed.During an interview on 04/17/2026 at 7:42 AM, Licensed Practical Nurse Unit Manager #21 stated the nurse aides documented food and fluid intake in percentages. The licensed practical nurse documented fluid intake for those on fluid restrictions in the medication administration record. They opened Resident #3's medication administration record and saw only check marks were recorded and stated that was not how it should have been done. The documentation should have included actual fluid amounts. They did not know why fluid amounts were not recorded as they should have been. They did not complete intake and output records at the facility. During an interview 04/17/2026 at 8:30 AM, Registered Dietitian #39 stated a renal diet was low sodium, low potassium, and low phosphorus. Fluid restrictions were recommended by dialysis, and they broke down what fluids were allotted for meals and nursing in the electronic medical record. They obtained preferences as much as possible to provide the resident with fluids of choice. Staff knew if a resident was on a renal diet or fluid restriction from the electronic medical record. If a resident on a fluid restriction was given extra fluids, it was documented in the progress notes and in the medication administration record in fluid amount. They stated the resident had a right to request extra fluids and milk, and staff should record this in the electronic medical record. They would document this information in their nutrition notes, document the non-compliance on the care plan, and provide the resident with education if a resident was non-compliant with their plan. They did not know if Resident #3 was care planned for non-compliance with their diet. They knew what the resident was drinking daily by looking at the general percentage under tasks in the electronic medical record. Nursing did not calculate actual fluid intake, and any extra fluids would not be captured in the fluid counts. The facility did not record intake and output records. They relied heavily on the task documentation and pieced together the data they had but had nothing concrete to tell them what Resident #3 was drinking daily. During a telephone interview on 04/17/2026 at 10:55 AM, Registered Nurse Charge Nurse #40 at the Dialysis Center stated Resident #3 was on a low potassium, low phosphorus, 1500 milliliter fluid restriction diet. Their phosphorus levels had increased, and they were supposed to be on 2 (two) different phosphate binders, Velphoro one (1) tablet at each meal and Renvela (lowers phosphate) 3 (three) tablets at each meal. Milk was high in phosphorus and facility staff should not have offered extra milk or extra fluids with meals. They should be tracking their fluid intake amounts in volume daily to monitor for compliance.10 New York Codes, Rules and Regulations 415.12 (i)

Based on observations, record review, and interviews, the facility failed to ensure a resident who displayed or was diagnosed with dementia received the appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being for one (1) of one (1) resident (Resident #47) reviewed. Specifically, there was no documented evidence Resident #47 had an individualized care plan with interventions in place that included person-centered approaches or steps to assist in guiding staff in managing the resident's care. Findings include: The facility policy Care Plans/Comprehensive Person Centered, last reviewed 01/2026, documented the comprehensive person-centered care plan is developed for each resident to include measurable objectives and timetables to meet a residents' medical, nursing, mental and psychosocial needs. The comprehensive care plan should reflect person- centered care with resident specific interventions and should be reviewed and revised as appropriate upon readmission to the facility, quarterly, annually and with any significant change. The facility policy Dementia-Clinical Protocol, revised 01/2026, documented the facility would assess, develop, and implement a person-centered care plan through an interdisciplinary team approach that included the resident, their family, and resident representative. The care plan goals would be agreed upon, and the facility would provide resources necessary for potential success in meeting their goals. The care plan interventions would be related to each residents' individual symptoms and rate of dementia progression. Individualized, non-pharmacologic approaches to care would be utilized to maximize remaining function and quality of life and enhancing the resident's well-being. Resident #47 had diagnoses including dementia and bipolar disorder (intense mood swings). The 07/20/2025 Minimum Data Set assessment documented the resident had severe cognitive impairment; required substantial to maximum assistance or was dependent with most of their daily living activities; required supervision/touch assistance with functional mobility; and was prescribed medications to treat psychiatric diagnoses. The comprehensive care plan initiated on 08/06/2024 and revised on 10/10/2025, documented impaired cognition related to dementia. Interventions included administer medications and ask yes or no questions. The comprehensive care plan initiated on 10/10/2025 documented the resident was at risk for changes in mood due to bipolar disorder and dementia. Interventions included administering psychotropic medications, monitoring changes in mood, and providing support and reassurance. There were no specific person-centered intervention for the diagnosis of dementia. The resident was observed at the following times: -on 04/14/2026 at 9:05 AM, walking up to surveyor, looking at the surveyor and continuing to walk past them and down the hallway into another resident room. Approximately two minutes later the resident exited the room and walked back down the hall toward the surveyor standing in the dining area of Wing 1 near the nursing station. There were no staff interactions with the resident -on 04/15/2026 at 7:41 AM and 11:40 AM, the resident was walking aimlessly up and down the hallway. There were no staff interactions with the resident. -on 04/16/2026 at 9:59 AM and 11:05 AM, the resident was sleeping seated in a chair in the hall with their head leaning back in the chair. There were no resident and staff interactions observed. -on 04/17/2026 at 9:27 AM and 9:59 AM, the resident was seated in chair in the hallway outside of another resident's room making loud vocalizations. They intermittently stood and sat lifting their bottom off the seat a couple of inches each time. They continued yelling and standing/sitting for approximately thirty minutes. There were no resident and staff interactions during this time. During an interview on 11/17/2026 at 10:16 AM, Certified Nurse Aide #34 stated they worked with the resident regularly. They stated residents with dementia required a great deal of one-to-one care and more attention, and they knew the resident enjoyed walking, juice, music, and visits from a male friend who brought in a small dog. During a follow up interview on 04/17/2026 at 12:48 PM, Certified Nurse Aide #34 stated when a resident had a behavior they would refer to the care plan for guidance when determining what to do for them. During an interview on 04/17/2026 at 11:05 AM, Licensed Practical Nurse Unit Manager #12 stated they were responsible for reviewing the care plans of the residents and made recommendations to give to the registered nurses, but they could not make changes to the plans. They stated the comprehensive care plan for the residents should document what they liked and disliked; appropriate ways to assist them; and ensure they had the best quality of life possible. They stated the resident liked music and liked wearing high heeled shoes. During an interview on 04/17/2026 at 12:18 PM, Registered Nurse #35 stated they created the basic care plan when a resident was admitted to the facility. They recently reviewed the resident nursing care plan and verbalized they were at risk because they had dementia. They stated a staff member unfamiliar with the resident would not be able to provide care using the current care plan, indicating that it required revision; as new staff may not know how to manage the resident's behaviors. The resident's likes and dislikes were documented in the activities care plan and all staff could reference that information. They stated the care instructions did not include that information. 10 New York Codes, Rules and Regulations 415.12

Based on observations, record review, and interviews (iQIES Intake 2620687) the facility failed to ensure a system of records and accounts of all controlled drugs was maintained for one (1) of five (5) residents (Residents #28, #40, #57, #99, and #106) reviewed. Specifically, on Unit 1 a controlled substance reconciliation (a system of recordkeeping that ensures an accurate inventory of controlled medications) was not performed between the oncoming and outgoing nurse, narcotic keys were not transferred between nurses in a secured manner, a narcotic medication was signed out as administered, but was not, and a poured controlled substance was insecurely stored in the medication cart; Resident #28's, Resident #40's, Resident #57's, and Resident #99's controlled substance records did not accurately reflect the level of medications on hand; and Resident #106 did not receive an as needed dose of lorazepam that was signed out on the reconciliation sheet. Findings include:The facility policy Controlled Substance/Narcotic Management Protocol, last reviewed 01/2026, documented with each administration the nurse must document the date, time, prior count, and post administration count of the remainder of the medication and sign in the controlled substance log book; in the event a resident does not take a controlled substance that had already been removed from its package, the nurse must destroy the medication in the presence of another nurse; all narcotics would be counted and reconciled at the beginning of every shift with the outgoing and oncoming nurse and both must sign the controlled substance log attesting to the presence of the narcotic as stated from the previous shift; and any discrepancies in the count must be reported to the unit manager or supervisor immediately.The Unit 1 04/12/2026-04/14/2026 Narcotic Count record documented on 04/14/2026 at 7:00 AM Licensed Practical Nurses #11 and #15 signed as the oncoming and outgoing nurses.Resident #40The 04/06/2026 physician order documented Resident #40 was to receive Vimpat (lacosamide; a controlled substance anti-seizure medication) 10 milligrams/milliliter, 20 milliliters by mouth two (2) times a day.The following observations were made on 04/14/2026 at 10:28 AM of the Unit 1 medication cart and medication room:-An opened bottle of Resident #40's Vimpat was in the locked compartment of the Front medication cart. The bottle was marked at 50-millimeter increments starting at 50 and going to 400 and was filled to the 50-milliliter increment. An additional two (2) unopened bottles filled to the 400 milliliter mark were locked up in the medication room for a total of 850 milliliters.-The 04/12/2026- 04/14/2026 Narcotic Count record documented on 04/14/2026 at 7:00 AM 940 milliliters of lacosamide (Vimpat) were remaining.-Resident #40's Vimpat controlled substance administration record documented on 04/14/2026 at 8:00 AM Licensed Practical Nurse #15 signed out 20 milliliters leaving a balance of 940 milliliters. -Resident #40's April 2026 Medication Administration Record documented Licensed Practical Nurse #15 administered the resident 20 milliliters of Vimpat on 04/14/2026 between 7:00 AM and 10:00 AM.During an interview on 04/14/2026 at 10:28 AM, Licensed Practical Nurse #15 stated Resident #40 had a total of 850 milliliters of Vimpat. They did not know why they signed on the narcotic sheet there were 940 milliliters. They last counted the narcotics with Licensed Practical Nurse #11 at 6:00 AM on 04/14/2026 and used 20 milliliters of Resident #40's Vimpat since that count. Resident #99Resident #99's April 2026 Medication Administration Record documented they were scheduled to receive 10 milliliters of Vimpat twice a day. The start date was 03/12/2026. On 04/14/2026 Licensed Practical Nurse #15 documented a 9 (a code meaning other/see nurse notes) for the 7:00 AM - 10:00 AM administration time.The 04/14/2026 at 1:29 PM Licensed Practical Nurse #15's progress note documented the resident did not wake up, this medication was poured but not given.The following observations were made on 04/14/2026 at 10:28 AM during inspection of the Unit 1 medication cart and medication room:-Resident #99's Vimpat administration record documented Licensed Practical Nurse #15 signed out 10 milliliters on 04/14/2026 at 8:00 AM leaving a balance of 120 milliliters.-A 30-milliliter clear plastic cup with an unidentified clear liquid was partially spilt in the bottom of the locked narcotic compartment of the front medication cart.During an interview on 04/14/2026 at 10:28 AM, Licensed Practical Nurse #15 stated the clear liquid was Resident #99's Vimpat. The resident was not awake when they first brought the medication to them, so they held it. They had forgotten they put it in the narcotic compartment. They should have discarded it but did not because the resident did not have a lot of the medication left.Resident #106The following observations were made on 04/14/2026 at 10:28 AM during inspection of the Unit 1 medication cart and medication room:-Resident #106 had a medication card (blister pack) containing 26 lorazepam 0.5 milligram tablets. -Resident #106's lorazepam administration record documented Licensed Practical Nurse #15 signed out one (1) tablet on 04/14/2026 at 8:00 AM leaving a balance of 25 tablets.Resident #106's April 2026 Medication Administration Record documented lorazepam 0.5 milligrams (an anti-anxiety medication) every six (6) hours as needed for anxiety. The start date was 03/31/2026. There was no documented evidence the resident received lorazepam on 04/14/2026.During an interview on 04/14/2026 at 10:28 AM, Licensed Practical Nurse #15 stated they signed out Resident #106's lorazepam at 8:00 AM on 04/14/2026 intending to administer it but did not because the resident was not having any behaviors. They signed it out on the yellow (count sheet) sheet but should not have. Narcotics should be signed at the exact moment they were given.Resident #57Resident #57's April 2026 Medication Administration Record documented the resident was scheduled to receive gabapentin 300 milligrams (a controlled anti-seizure medication) twice a day. The start date was 11/21/2023.The following observations were made on 04/14/2026 at 10:28 AM during inspection of the Unti 1 medication cart and medication room:-Resident #57 had a full card of 30 gabapentin 300 milligram tablets in the medication room and one (1) card with 25 tablets in the medication cart for a total of 55 tablets.-The 04/12/2026- 04/14/2026 Narcotic Count record documented on 04/14/2026 at 7:00 AM Resident #106 had a balance of 56 gabapentin 300 milligram tablets.-Resident #57's gabapentin Control Substance Record documented Licensed Practical Nurse #15 signed out one (1) gabapentin tablet on 04/14/2026 at 8:00 AM leaving a balance of 56 tablets.During an interview on 04/14/2026 at 10:28 AM, Licensed Practical Nurse #15 stated when they signed out the gabapentin at 8:00 AM on 04/14/2026, they must have counted wrong and documented there were 56 tablets.Resident #28Resident #28's April 2026 Medication Administration Record documented they were scheduled to receive one tablet of hydrocodone-acetaminophen tablet 5- 325 milligrams (a narcotic pain killer) three (3) times a day. The start date was 03/26/2026.The following observations were made on 04/14/2026 at 10:28 AM during inspection of the Unti 1 medication cart and medication room:-Resident #28 had two (2) cards of hydrocodone-acetaminophen 5-325 milligrams tablets, each containing 30 tablets and a third card in the medication cart containing six (6) tablets for a total of 66 tablets.-Resident #28's hydrocodone-acetaminophen tablet 5-325 controlled substance administration record documented Licensed Practical Nurse #15 signed out one (1) tablet leaving a balance of 66 tablets.-The Narcotic Count record documented on 04/14/2026 at 7:00 AM Resident #28 had a balance of 68 hydrocodone-acetaminophen 5- 325 milligram tablets.During an interview on 04/14/2026 at 10:28 AM, Licensed Practical Nurse #15 stated narcotics were counted by two (2) nurses to make sure everything was accounted for and the number of pills documented on the count sheets should match the number of pills on hand. A two (2) person count was needed to confirm and agree on what the count was. They stated when they arrived that morning, Licensed Practical Nurse #11 had already filled out the narcotic count sheet with the number of medications and signed it. When they came on duty, they counted the narcotics by themself and co-signed the Narcotic Count record. They were supposed to look at the narcotic count sheet and the yellow controlled substance administration record to make sure both matched what was on hand.During an interview on 04/14/2026 at 1:02 PM, Licensed Practical Nurse #11 stated controlled substance counts were supposed to be done at the beginning and end of each shift by two (2) nurses to verify in writing the count was correct. The nurses should not sign the count sheets if they were not actually counting with someone but did because they were taking responsibility for counting themselves. They counted Resident #40's Vimpat last night when they came in at 11:00 PM and after referring to the bottles stated the count sheet should not say 940 milliliters as there were about 850 milliliters. When counting they roughly looked at the Vimpat bottles because there had not been issues with the count on that unit. They did not have their glasses on and could not see well. At the start of the day shift on 04/14/2026, they recounted the medications and brought out the medications they needed for the day medication pass. When Licensed Practical Nurse #15 arrived, they gave them the medication keys without first counting the narcotics with them. They should not have done that, but at the time they were busy with a tube feeding.During an interview on 04/17/2026 at 9:28 AM, Licensed Practical Nurse Unit Manager #12 stated the controlled substance count should be done with two (2) nurses; during the count both count sheets should be checked to verify the amount of medication matched; nurses should not be signing if they did not actually count with a second nurse; keys should not be exchanged until the count was verified; medications should be wasted if not immediately administered; and medications should be signed out at the time they were to be administered. Signing the Narcotic Count record attests the numbers were accurate. Nurses could prefill this form with the numbers and their signature but would have to make any necessary changes if there was a discrepancy found during the count.During an interview on 04/17/2026 at 11:22 AM the Director of Nursing stated controlled substance counts should be done by two (2) nurses while looking at the medication and both count sheets, and any discrepancies should be reported immediately. The Narcotic Count record should be filled out at the time of the count; the individual medication count sheets should reflect the time of the actual administration; and medications should not be poured and then put back in the cart. Liquid medications usually came in bottles that were marked with increments and levels were visually verified. They would expect that if the count sheet documented there was 940 milliliters of a medication but only 850 milliliters was visualized then that should be caught and reported. 10 New York Codes, Rules and Regulations 415.18

Based on observations, record review, and interviews the facility failed to ensure that residents were free of any significant medication errors for one (1) of one (1) resident (Resident #14) reviewed. Specifically, Resident #14 received Ativan (a medication for anxiety) twice a day and the medication was not administered within the prescribed time frame causing discomfort to the resident. Findings include: The facility policy Administering Medications, last revised 1/2026, documented medications were administered in a safe and timely manner as prescribed. Medications were administered within (1) one hour of the prescribed time unless otherwise specified. If a medication was not administered at the scheduled time, the individual administering the medication should document that in the electronic medication administration record and notify the attending/covering physician. The undated facility medication pass schedule documented the following times: 7:00AM-10:00 AM; 11:00 AM; 1:00 PM; 2:00 PM; 4:00 PM; 7:00 PM-10:00 PM; 10:00 PM; 12:00 AM; and 6:00 AM. Resident #14 had diagnoses including anxiety and depression. The 01/19/2026 Minimum Data Set assessment documented the resident had intact cognition and used an antianxiety medication. The Comprehensive Care Plan, initiated 10/10/2025, documented the resident used psychotropic medications related to anxiety and depression. Interventions included administer medications as ordered by the physician and monitor and document effectiveness and side effects.The updated 04/10/2026 physician order documented Ativan 0.5 milligrams, give two tablets one time a day for anxiety and one tablet at bedtime for anxiety.The February 2026 and April 2026 Medication Administration Record documented Ativan 0.5 milligrams two tablets in the morning from 7:00 AM until 10:00 AM and one tablet at bedtime from 7:00 PM to 10:00 PM. The Medication Administration Record documented Ativan 0.5 milligrams was administered:-on 02/04/2026 at 11:40 PM by Licensed Practical Nurse #29.-on 02/06/2026 at 11:11 PM by Licensed Practical Nurse #30.-on 04/13/2026 at 12:12 AM by Licensed Practical Nurse #24.-on 04/16/2026 at 11:12 AM by Licensed Practical Nurse #9.During an observation and interview on 04/13/2026 at 12:58 PM, Resident #14 stated they had anxiety and received medication for anxiety that should be taken twice a day. There were times when the medication was not administered at the appropriate time which caused an increase in their anxiety, and the anxiety caused them to be short of breath. They asked nursing staff to administer the medication at the prescribed times, and they were told by the nurses the medication could be administered up to eight hours late. During an observation and interview on 04/17/2026 at 8:42 AM, Resident #14 was observed utilizing their nebulizer (respiratory treatment). They stated they were anxious which caused shortness of breath. The Medication Administration Record documented Ativan 0.5 milligrams was administered on 04/17/2026 at 12:45 PM by Licensed Practical Nurse #22.During an interview on 04/17/2026 at 10:47 AM, Licensed Practical nurse #22 stated during medication administration they pulled up each resident one at a time and clicked medications as administered in the electronic medical record after the resident accepted the medication. They were still learning the software system, and most medications should be administered between 7:00 AM and 10:00 AM. There was a one-hour window that medications could be administered making the actual medication administration times 6:00 AM until 11:00 AM when medications were twice a day, and they could be administered between 6:00 PM until 11:00 PM. They administered all medications for Resident #14 including Ativan; however, they did not sign the medications as administered and they should have. They did not know why they did not click that all medications were administered at the time of administration. During an interview on 04/17/2026 at 4:05 PM, Licensed Practical Nurse #9 stated they worked the 3:00 PM shift on unit four and their primary responsibility was medication administration. They stated medications with an administration time from 7:00 PM until 10:00 PM could be administered any time between 6:00 PM and 11:00 PM. When a medication was administered outside that timeframe, they wrote a progress note and notified the medical provider. They worked the evening shift on 04/12/2026 and was not sure why the medication administration record documented the evening dose of Ativan for Resident #14 was administered at 12:12 AM on 04/13/2026. Administration of Ativan at that time would be late and they should have written a progress note and notified the medical provider. They were not sure why the medication was late. They stated they were slow when administering medications.During an interview on 04/17/2026 at 1:16 PM, Licensed Practical Nurse Unit Manager #5 stated the facility had a liberal medication administration policy. When medications were ordered from 7:00 AM until 10:00 PM this allowed the administration of medications one hour before or after that administration time. When a medication was administered outside the prescribed medication times, the supervisor should be notified, and the supervisor notified the physician or nurse practitioner. When a medication was ordered twice a day it was important to administer the medications within the prescribed timeframe to ensure medications were not administered too far apart or too close together. When they were notified that a medication was administered late, they documented that in a progress note. They were not notified of any medications that were administered late in the last week. They stated the Ativan dose administered by Licensed Practical Nurse #24 on 04/13/2026 at 12:12 AM was late; the Ativan dose administered by Licensed Practical Nurse #9 on 04/16/2026 at 11:12 AM was late; and the Ativan dose administered by Licensed Practical Nurse #22 on 04/17/2026 at 12:45 PM was late. They were not notified about any of the late administrations and should have been. A progress note should have been written and the medical provider notified to ensure there was appropriate time between administration of the medication. 10 New York Codes, Rules, and Regulations 415.12(m)(2)

Based on observations and interviews the facility failed to ensure garbage and refuse was disposed of properly for one (1) of one (1) dumpster area located near the loading dock. Specifically, there were several used gloves, empty food containers, and vegetable scraps on the ground around the dumpster.Findings include:The facility policy Dumpster and Waste Disposal, dated 01/2026, documented dumpsters would be maintained in a clean, secure, and sanitary condition. Dumpsters would be cleaned and sanitized on a routine basis and waste would not be placed outside dumpsters.During an observation and interview on 04/14/2026 at 8:20 AM, there were several used gloves, empty food containers, and vegetable scraps on the ground around the dumpsters near the loading dock. The ground near the dumpsters was mostly loose gravel in poor repair. Food Service Director #16 stated maintenance was responsible for keeping the area clean.During an interview on 04/17/2026 at 8:54 AM, Maintenance Director #18 stated the maintenance staff checked the dumpster area and was responsible for cleaning it to prevent animals in the area. 10 New York Codes, Rules and Regulations 415.14(h)

Based on observations, record review, and interviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (2) of three (3) residents (Residents #61 and #146) reviewed. Specifically, staff did not wear the required personal protection equipment while caring for Residents #61 and #146 who were on contact precautions.Findings include: The 04/03/2024 Centers for Disease Control recommendations documented transmission-based precautions are the second tier of basic infection control and are used in addition to standard precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. Use contact precautions for patients with known or suspected infections that represent an increased risk for contact transmission. Use personal protective equipment appropriately. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment The facility precaution sign Droplet/Contact Precautions documented everyone must wash or clean hands with hand sanitizer before entering and leaving the room; wear a mask and eye protection; put on gloves before entering the room and remove before exiting the room; and wash hands after removal of personal protective equipment. 1) Resident #61 had diagnoses including quadriplegia (paralysis), tracheostomy (a surgically created hole in the windpipe), and bladder dysfunction. The 01/14/2026 Minimum Data Set assessment documented the resident had intact cognition, was dependent for all activities of daily living, had an indwelling urinary catheter, a feeding tube, and received tracheostomy care. The revised 12/18/2025 comprehensive care plan documented the resident had colonized extended-spectrum beta-lactamases (enzymes produced by multi-drug resistant bacteria) and a suprapubic catheter (indwelling urinary tube). Interventions included maintaining transmission-based precautions as ordered and place on contact precautions. The 03/16/2026 hospital discharge summary documented the resident was diagnosed with urinary Morganella (bacteria that can cause infection) and enterococcus faecalis (bacteria that can cause severe infections). The resident had bilateral nephrostomy tubes (drains urine directly from kidney) and urinary sepsis (infection). The 03/17/2026 physician order documented maintain contact precautions every shift for infection control. During an observation on 04/13/2026 at 10:47 AM, there was a sign on Resident #61's doorway documenting Contact Precautions and included what type of personal protective equipment was required prior to entering the room. Certified Nurse Aide #25 was in Resident #61's room and was not wearing personal protective equipment. During an interview on 04/15/2026 at 10:20 AM, Licensed Practical Nurse #9 stated any staff entering a precaution room must follow infection control practices and wear the required personal protective equipment such as a gown and gloves. Resident #61 was on contact precautions. During an interview on 04/17/2026 at 10:58 AM, Certified Nurse Aide #25 stated a sign outside a resident's doorway documented if the resident was on urinary or airborne precautions. If there was a doubt about what personal protective equipment should be worn, the staff member should look at the sign. They stated they were not sure why Resident #61 was on contact precautions. They did not know why they did not wear personal protective equipment while in Resident #61's room and they should have. They stated the purpose of wearing personal protective equipment was to prevent the spread of germs by cross contamination. 2) Resident #146 had diagnoses including chronic open wounds of both legs. The 01/21/2026 Minimum Data Set assessment documented the resident had intact cognition, required maximal assistance with most activities of daily living, had skin ulcers (open wounds), had nonsurgical dressings, and was receiving an antibiotic. The 09/19/2025 revised comprehensive care plan documented the resident was at risk for infection related to open skin areas. Interventions included maintain contact precautions per physician orders. The 10/27/2025 physician order documented to maintain contact precautions for weeping wounds and history of multidrug resistant organisms. The 04/2026 Treatment Administration Record documented contact precautions every shift for weeping wounds and history of multidrug resistant organisms. During an observation on 04/13/2026 at 7:52 AM, there was a Contact Precautions sign on the doorway of the resident's room. Certified Nurse Aide #26 left Resident #146's room and did not wear personal protective equipment while in the room. The aide then entered the room without donning a gown or gloves, came out into the hallway with an overbed tray table, and placed it in front of the resident without disinfecting the table. During an observation on 04/13/2026 at 9:54 AM, Certified Nurse Aide #26 entered and exited Resident #146's room without donning a gown or gloves prior to going into the room. During an interview on 04/16/2026 at 9:44 AM, Certified Nurse Aide #26 stated they had received infection control training and knew what type of personal protective equipment to wear by the sign on the doorway. If they had a question about it, they would look at the resident's care plan. Staff should wear a gown and gloves, as directed by the sign, every time they entered Resident #146's room. Resident #146 was on contact precautions due to drainage from their legs and had a Contact Precautions sign on their doorway. Overbed tray tables should not be taken from a precautions room unless necessary and should be sanitized prior to removing it from the room to prevent cross contamination of germs. They were in a rush that morning and did not think to put on a gown and gloves before entering the resident's room. During an interview on 04/17/2026 at 1:22 PM, Infection Preventionist #27 stated infection control education was provided to staff before they assumed the role. They provided on-the-spot reeducation to some staff when performing unit rounds the previous week and saw potential infection control issues. The facility recently had a COVID-19 case and an influenza outbreak that resolved prior to survey. Staff should wear a gown and gloves before entering a resident's room who was on contact precautions to prevent cross contamination of germs. They stated Residents #61 and #146 were on contact precautions. Both residents had a sign outside their rooms informing staff what types of personal protective equipment were required prior to entering the room. There should be a stocked personal protective equipment cart outside each resident's doorway and a designated bin in each room to dispose of the used equipment. 10 New York Codes, Rules and Regulations 415.19(a) (1-3)

Based on record review and interviews during the abbreviated survey (Complaint ID# 2613592), the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfers or discharges from the facility for one (1) of three (3) residents (Resident #2). Specifically, Resident #2 was discharged on 05/19/2025 to the Department of Social Services via family transportation without consulting the Department of Social Services to ensure the plan met the resident's health and safety needs, and preferences. The resident had no identification, and no supportive services in place, and was discharged without proper education and supplies to manage their diabetes and diabetic wounds. This resulted in the likelihood of serious harm, serious injury, serious impairment or death that was Immediate Jeopardy to Resident #2. Findings include:The facility policy Discharge Planning, last reviewed 01/2025, documented the discharge planning program maintained a coordinated program to ensure each resident had a plan of continuing care which met their post-discharge needs. The Discharge Coordinator (Social Worker) was responsible to develop a discharge plan which reflected input from all appropriate disciplines, the resident and the resident's representative. They would initiate all referrals for post discharge care and needs. The attending physician was responsible for overseeing all discharge plans. The facility policy Discharge Medications, last reviewed 01/2024, documented the charge nurse verified the medications were labeled with the current physician orders including instructions for use and reconcile pre-discharge medications with post-discharge medications. The nurse completed the medication disposition record that included: the resident's name, name of the person assisting or administering the medication post-discharge, date of discharge, name of each medication, the prescription number for the medication, the quantity of each medication, the strength of the medication, any special instructions, telephone numbers for the physician, pharmacy and the facility, and the signatures of both the person receiving the medication and the nurse releasing the medication. Resident #2 had diagnoses including diabetes with hyperglycemia (high blood sugar) and diabetic neuropathy (nerve damage). The 04/13/2025 Minimum Data Set (a resident assessment tool) documented the resident was cognitively intact, was moderately depressed, had no behavioral symptoms, required supervision to touching assistance for most activities of daily living, had diabetic foot ulcers, and received insulin injections. The Comprehensive Care Plan documented: -10/17/2024 the resident's placement was short-term, the resident was currently homeless, and discharge was uncertain. The resident's family was working on finding an apartment. Interventions included to assist the resident with applications with community resources, assist with obtaining durable medical equipment and medical supplies prior to discharge, educate the resident and the family about community resources, make appropriate referrals as needed, obtain a discharge order and prescriptions as needed, and provide the resident or representative teaching as needed for medications, diet, wound care, or adaptive equipment.-10/18/2024 the resident had peripheral vascular disease (poor circulation) related to diabetes, injuries to their extremities including multiple toe amputations and peripheral artery disease. Interventions included to monitor blood pressure and vital signs, and report results not within normal limits to the medical provider, monitor laboratory values and report abnormal values to the medical provider, and provide a therapeutic diet and supplements as ordered. The Discharge Medication listing documented two (2) different frequencies for wound care to the resident's wounds. This included:- A 05/12/2025 order to cleanse left third toe wound with wound cleanser and pat dry, apply collagen powder to wound bed, cover with an abdominal pad (absorbent pad) and secure with kerlix (gauze bandage roll) every Monday, Wednesday, and Friday. - A 05/19/2025 order to cleanse left third toe wound with wound cleanser and pat dry, apply collagen powder to wound bed, cover with an abdominal pad (absorbent pad) and secure with kerlix (gauze bandage roll) every Monday and Thursday.- A 05/12/2025 order to cleanse the right plantar medial distal foot with wound cleanser and pat dry, apply collagen powder to wound bed, cover with an abdominal pad (absorbent pad) and secure with kerlix (gauze bandage roll) every Monday, Wednesday, and Friday.- A 05/19/2025 order to cleanse the right plantar medial distal foot with wound cleanser and pat dry, apply collagen powder to wound bed, cover with an abdominal pad (absorbent pad) and secure with kerlix (gauze bandage roll) every Monday, Wednesday, and Friday. The 05/15/2025 physician's order documented to inject 38 units of insulin glargine-yfgn (brand name Semglee) subcutaneous solution 100 unit/milliliters subcutaneously at bedtime for diabetes. The 05/14/2025 Social Worker #4 note documented the resident's sibling called and stated they would be arriving on 05/19/2025 to pick up the resident to take the resident to the Department of Social Services as they were unable to find the resident an apartment in the community. The resident agreed and reported they did not have a primary care provider. Social Worker #4 scheduled a new patient appointment for the resident. The resident did not need services. The 05/19/2025 at 8:14 AM Social Worker #4 note documented they spoke with the resident's sibling who had toured an apartment on Friday and was waiting for a response from the landlord. If they were unable to get the apartment, they would come get the resident and take them to the Department of Social Services later. The 05/19/2025 at 9:45 AM Social Worker #4 progress note documented the resident's sibling stated the application for the apartment was rejected. The resident's sibling spoke with the resident, and they were still going to pick the resident up to take them to the Department of Social Services that day. The resident and the resident's sibling were informed of the primary care appointment scheduled for 05/22/2025 and the resident was happy to be returning to the community.The 05/19/2025 Physician Discharge Summary by Nurse Practitioner #7, included in the resident's Discharge Packet documented the following Treatments/Interventions: 'continue wound care for continuity of healing, Santyl w/DSD 2 times weekly and prn for soiled dressing, elevate legs & offload weaning off narcotic analgesics; only 1 tab po qd prn: #4-0 Rx monitor BS AC &HS; medications as only Rx; discuss with PCP on F/U Support DM with balanced nutrition to support wound healing and glycemic control'. The resident was to be discharged into their sibling's care with a community provider follow up for comprehensive management of their comorbidities and wound care. The resident had a primary care provider appointment on 05/22/2025. The Transfer/Discharge Notice dated for 05/19/2025 documented the resident was discharging to the Department of Social Services. The Team-Discharge and Care Plan Summary Guide, Nursing Discharge Plan signed by Licensed Practical Nurse Manager #8 on 05/19/2025 did not include a list of medications the resident was discharged with. There was no documented evidence the Medication Reconciliation was checked off as completed. The Social Service Discharge Plan, signed by Social Worker #4 on 05/18/2025, documented the resident's discharge destination was the Department of Social Services. The discharge plan checklist had none checked off for home services and documented the resident was to return to independent living. The discharge plan checklist indicated the discharge plan was reviewed with the resident and - a copy was provided to the resident. There is no documented evidence the resident representative was checked off as having received the information and there was no documented evidence of resident or representative signature on the discharge instructions There was no documented evidence Resident #2 was provided education for managing their diabetes or wound care prior to discharge, and there was no documented evidence the resident was provided with the needed supplies to effectively manage diabetes. There was no documented evidence facility staff contacted the Department of Social Services prior to discharge to ensure the resident would be provided with housing and needed services.The 05/22/2025 Hospital Record documented the resident presented at the emergency department as instructed by their primary care provider due to a blood sugar of 474. The primary care provider had informed the Emergency Department the resident's recent labs documented high blood sugars and the resident was recently discharged from a nursing home without insulin or medications sent to a pharmacy. The resident initially refused intravenous insulin and stated their blood sugars ran high, and the nursing home just gave him a shot to fix it. Resident was given 60 units of insulin in Emergency Department to come down to a blood sugar of 231. They were admitted to the hospital overnight for monitoring of blood sugar and elevated troponin. They were discharged from the hospital on [DATE] with medications, including insulin and glucometer, called into pharmacy for family pick up.During an interview on 10/15/2025 at 1:23 PM, Social Worker #4 stated the resident was hesitant to discharge to the Department of Social Services but ultimately decided to go. The resident had no identification or Social Security Card. Nursing was responsible for teaching the residents regarding wound care and diabetic management. The resident had not established with a primary care provider so they could not set them up with home health or wound care and they had to see their new primary care provider to get a referral. During a follow up interview on 10/21/2025 at 10:18 AM, Social Worker #4 stated they had not called the Department of Social Services prior to the resident discharging. They were unaware of how the emergency housing worked at the Department of Social Services and were unaware the resident was denied placement for emergency housing the day of discharge. They stated they would likely call the Department of Social Services for a resident who wanted to go and had no family support, but they would only inquire about general questions as they wouldn't release the resident's name due to the Health Insurance Portability and Accountability Act.During an interview on 10/16/2025 at 1:47 PM, the Director of Social Services stated they provided discharge transfer notices to all residents discharging the facility by the day of discharge listing their discharge date . They stated Resident #2's sibling was having a hard time locating them an apartment for discharge. They stated the family wanted the resident to discharge to the Department of Social Services, so the facility worked to make that happen. Sometimes a resident who did not have a primary care provider in the community needed to be seen by their new primary care before home health orders could be signed, it depended on the home health agency. Nursing was responsible for diabetic teaching. During a follow up interview on 10/20/2025 at 12:38 PM, the Director of Social Services stated nursing was responsible for ensuring the resident was discharged with enough medication to get them to their primary care provider appointment. If a resident needed a glucometer, one could be ordered through the resident's outpatient pharmacy or through a local medical supplier. They believed Nurse Practitioner #7 was aware the resident was being discharged to the Department of Social Services. During a telephone interview on 10/17/2025 at 9:38 AM, the resident's sibling stated they picked up the resident from the facility on 05/19/2025 because they were under the impression (as reported in the initial complaint from the relative, the resident stated the facility was going to kick them out) the resident was going to be discharged to the streets in the same town as the facility (which is over 100 miles from the sibling's residence) due to them being unable to find the resident an apartment. The resident was discharged without insulin and the resident's sibling was unaware the resident had wounds until their doctor's appointment on 05/22/2025. Upon discharge, they were given a bag containing clothing and bandages and were handed pill cards of medications and a prescription for the resident's narcotic medication. The resident had no identification card or Social Security card. The resident's sibling had to obtain identification at the Sheriff's office to be able to present at the Department of Social Services. The resident was declined at the Department of Social Services on 05/19/2025 due to a previous non-paid emergency housing stay. The resident's sibling paid for the resident's hotel that evening and then returned to the Department of Social Services the following day to get the situation straightened out. The resident's sibling paid the resident's participation for the emergency housing, so the resident had a place to stay. The resident also had no food stamps in place when they were discharged and had to be provided groceries by their sibling. On 05/22/2025, the resident had blood work done at the doctor's office. The medical office notified the resident's sibling that evening and advised the resident to go to the emergency room due to high blood sugar. The resident was hospitalized [DATE] to 05/23/2025 due to hyperglycemia. During a telephone interview on 10/17/2025 at 3:42 PM, Nurse Practitioner #7 stated the resident was discharged with their sibling and into the sibling's care. They were unaware the resident was homeless and discharging to the Department of Social Services. It would not have been a safe discharge for the resident to be homeless or go to a hotel by themselves and they would not have signed off on it. A resident who had insulin should receive education prior to discharge and the needed supplies provided or called into the pharmacy. During a phone interview on 10/20/2025 at 10:34 AM, Medical Provider #3 stated a safe discharge included a safe place for the resident to go, they were medically stable, and able to do their medicine by themselves if that was the plan. Residents were sent with the medications they had left in stock, if their insurance allowed, except narcotics. Residents were also sent with 30 days of medications called into their pharmacy of choice. Residents were responsible for their own glucometers, but the facility provided the insulin that was left and a 30-day supply called into the pharmacy. If a resident discharged without insulin and needed it, the result may not be immediate, but hypoglycemia was the most dangerous, so they always made sure the resident and family were educated and had supplies. Wound care orders should be clear and concise, the patient and/or family should be educated prior to discharge, and an outpatient wound care appointment set up. Education should include demonstration by the resident to show comprehension and should be documented. They stated they understood Resident #2 was to be discharged home with their sibling. They were not involved in the discharge for the resident. They would never discharge a resident to a hotel, only to their home or with family/caregiver. During an interview on 10/20/2025 at 12:05 PM, the Director of Nursing stated medications like insulin and the administration were taught to residents who needed it and documented in a nursing note. Wound care was also to be taught to the resident and documented. They were unsure of the process if a resident did not have a glucometer and needed one. The discharge medication list told the name, dosage, how to take it, the last dose given, and when to take it, as well as any wound care orders. Residents were given enough medications and wound care supplies to get them to their primary care provider or wound care provider appointment. The nursing staff should be keeping a copy of all discharge paperwork provided to the resident. They were unaware Resident #2 was discharged without insulin or a glucometer. It was documented the resident was discharged with their sibling. The Director of Nursing stated they did not agree Resident #2 was homeless. During an interview on 10/20/2025 AM at 12:05 PM, the Administrator stated a resident's discharge plan usually came up during the utilization review meetings or by resident or family request. The interdisciplinary team would then set up a care planning meeting with the family to discuss where the resident wanted to be discharged to and any care services that needed to be set up. Leading up to the discharge, a primary care appointment would be set up and the nurse practitioner or medical provider would see the resident to ensure they were safe for discharge medically. The resident was to be sent with their medications, wound care supplies, and be educated on administering their medications. For residents who were non-compliant, the facility would involve family and make sure the family was involved in these conversations prior to discharge. If a resident was homeless and wanted to discharge, the facility would ensure they were alert and orientated, had a safe place to discharge to, and make sure they had the proper equipment to discharge. A resident who had a history of poorly controlled diabetes should have diabetic education provided to them or to their representative/caregiver prior to discharge. The same was for a resident who had a wound. Resident #2 was discharged with their sibling. A resident who required insulin and was discharged without insulin could result in harm. If Resident #2 was to be discharged to the Department of Social Services, the facility providers should have been aware. During a telephone interview on 10/20/2025 at 1:09 PM, Licensed Practical Nurse/Previous Licensed Practical Nurse Unit Manager #9 stated when they did a discharge they would print the discharge instructions, medication list, and go over the medication with the resident or family and then quickly go over the discharge instructions and any follow up appointments. Any medications that were in the medication cart were sent with the resident and they tried to make sure the resident had enough medication until the primary care provider took over the resident's care. Resident #2 did not want to take their dressing off their foot to do wound care with their sibling, so they reviewed it verbally. They were provided with treatment supplies and a medication list as well. They were unaware the resident was discharged without housing; they thought the sibling found an apartment for the resident. A hotel by themselves was not a safe discharge location for Resident #2. They were unable to say if the resident discharged with insulin or a glucometer. During a telephone interview on 10/20/2025 at 2:54 PM, the Medical Director stated a safe discharge included the resident receiving the appropriate medications and ancillary services that met the needs of the resident and their diagnoses to ensure the continuation of the care plan in effect at time of discharge. Safe and secure housing was required to ensure a safe discharge, and the facility would work with social services to ensure safe and secure housing. The medical providers of the facility should know if a resident was discharging with unsecured housing. Residents with a long-standing history of insulin diabetic management or wounds should have verification by the facility that they know how care for it and this should be documented. A resident who required insulin but was not provided insulin at discharge was at risk for their diabetes to be less controlled. It would not be preferable to discharge a resident to the Department of Social Services. 10 NYCRR 415.11(d)(3) __________________________________________________________________________ Immediate Jeopardy was identified, and the facility Administrator was notified on 10/21/2025 at 2:59 PM. Immediate Jeopardy was removed on 10/21/2025 at 4:53 PM prior to survey exit based on the following corrective actions taken:- The pending discharge for 10/29/2025 was reviewed for verification of post-discharge services, receiving locations, and physician notification. - Social Services, the Nursing Management team involved in discharges, Director and Assistant Director of Rehabilitation, and the Recreation Director were educated on discharge planning process to include verification of safety and discharge medication. - A new discharge form was instituted that required medication listed with quantities, medical equipment provided, teaching provided, and discharge location that required both resident/resident representative signature in addition to discharging nurse. - All discharges in the last 30 days were reviewed for safety and called to ensure they had the necessary services in place. - All staff identified for education received education on 10/21/2025, with the exception of staff members who were not available. The individuals who did not receive education will complete education upon their return, prior to the start of their shift. - Interviews were completed on 10/21/2025 to determine compliance with staff training and education including the Director of Social Services, the Recreation Director, the Assistant Director of Rehabilitation, one (1) Unit Manager, and the Director of Nursing.

Based on observation, record review, and interview during the abbreviated (NY00339441) survey the facility did not ensure residents at risk for pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to prevent new ulcers from developing and promote wound healing for 1 of 5 residents (Resident #293) reviewed. Specifically, Resident #293 developed a Stage 2 (partial-thickness skin loss) facility-acquired pressure ulcer when incontinence care was not provided routinely or as planned and treatments to the area were not consistently administered. Subsequently, the pressure injury progressed to an unstageable pressure ulcer (full thickness tissue loss in which the base of the wound is covered with dead tissue). Findings include: The facility policy, Prevention of Pressure Ulcers/Injuries, revised 1/2024, documented residents' skin was to be inspected daily when staff were performing or assisting with personal care or activities of daily living. Any signs of developing pressure injuries would be identified. Inspect pressure points (heels buttocks, elbows, sacrum), wash skin after any episode of incontinence using pH balanced cleanser, keep skin clean and free of exposure to urine or fecal matter, moisturize dry skin daily, and reposition the resident as indicated on their care plan. Residents who were chair/bed bound or dependent on staff for positioning would be repositioned at least every 2 - 3 hours or more frequently, as needed. All staff was responsible for reporting any changes to a resident's skin. All alterations in skin integrity would be reported immediately to the nurse, Unit Manager and/or Nursing Supervisor as well as the medical professional. Treatment orders would be obtained and initiated as ordered. Resident #293 had diagnosis including non-traumatic subarachnoid hemorrhage (bleeding in the brain) from a ruptured aneurysm. The 3/30/2024 Minimum Data Set assessment documented the resident had moderately independent decision making skills, had unclear speech, rarely/never understood others or made self-understood, did not reject care, was dependent on staff for all activities of daily living, was frequently incontinent of bladder and bowel, was at risk for pressure ulcers, did not have current unhealed pressure ulcers, had moisture associated skin damage (damage from prolonged moisture on the skin), applications of ointments/medications other than to feet, and had a pressure reducing device for the chair. The comprehensive care plan documented: - initiated 3/26/2024 and revised on 4/8/2024 the resident had impaired skin integrity related to moisture associated skin damage of the coccyx (tailbone) and buttocks and a Stage 2 pressure ulcer to the right buttocks. Interventions included monitor/document/report signs and symptoms of infection, document wound measurements weekly, apply zinc ointment (protects from moisture) to the buttocks with each incontinent episode and cover with abdominal pad (a thick, absorbent dressing), no tape, encourage to turn and position every 2-3 hours, air mattress, and no incontinence pads over the air mattress. - initiated 3/26/2024 the resident had bowel incontinence related cerebral vascular accident (brain injury). Interventions included check resident every 2-4 hours and as needed and assist with toileting as needed. Provide peri-care after each incontinent episode. The resident's Kardex (care instruction) active as of 6/27/2024 documented keep skin dry, clean, and well lubricated; provide peri-care after each incontinent episode; incontinence brief check/change every 3-4 hours and as needed; check resident every 2-4 hours and as needed, assist with toileting as needed; and apply zinc oxide to buttocks and coccyx every shift and with each incontinence episode. The 4/1/2024 through 4/7/2024 certified nurse aide Documentation Survey Report did not document the resident was provided toileting hygiene on 4 of 7 dates (7 of 18 shifts). The 4/7/2024 at 9:07 AM Licensed Practical Nurse #20 progress note documented a certified nurse aide (unidentified) informed them at 8:00 AM that Resident #293 had dried feces on their buttocks, their bed was soaked with urine from the night before. The resident was cleaned, and they now had a skin tear to their right buttock. The 4/7/2024 at 12:00 PM Registered Nurse Unit Manager #47 wound assessment documented the resident had moisture associated skin damage to the right buttock measuring 7 centimeters x 5 centimeters. There was scant amount of serosanguinous (blood tinged serum) exudate (drainage) present. The wound had no odor, and the surrounding tissue was bright red and macerated (moisture damage). The resident tolerated the assessment and dressing change well (there was no documentation of what the dressing was). The 4//7/2024 at 9:35 PM Physician Assistant #22 progress note documented they were notified by staff that Resident #293 had skin irritation on the buttocks due to urinary incontinence that had developed into a Stage 2 pressure ulcer. Zinc ointment was to be applied to the area with each incontinence episode and wound care was to follow up with the resident. The 4/8/2024 Initial Wound Evaluation and Management Summary completed by Wound Physician #23 documented the referring provider requested a wound care assessment. The resident had a Stage 2 pressure ulcer on the right buttock that measured 8 centimeters x 4 centimeters x 0.1 centimeter with light serous (clear fluid) drainage. The development of the wound and the context surrounding the development were considered. Relevant conditions including dementia, urinary incontinence, and fecal incontinence were addressed. The treatment pan included: off-load wound; reposition per facility protocol; turn side to side in bed every 1-2 hours if able; apply zinc ointment every shift and as needed; and evaluation by wound care specialist within 7 days with further intervention as indicated. A 4/8/2024 physician order documented cleanse right buttock with wound wash and pat dry. Apply zinc every shift and as needed for wound care. The 4/2024 Treatment Administration Record documented cleanse right buttock with wound wash and pat dry. Apply zinc every shift and as needed for wound care with a start date of 4/8/2024 and a discontinue date of 4/15/2024. There was no documented evidence the treatment was administered 4/9/24 on the 11:00 PM-7:00 AM shift; on 4/10/2024 on the 3:00 PM-11:00 PM and 11:00 PM-7:00 AM shifts; on 4/11/2024 on the 3:00 PM-11:00 PM shift; on 4/12/2024 on the 7:00 AM-3:00 PM shift; and on 4/14//2024 on the 11:00 PM-7:00 AM shift. The 4/8/2024 through 4/15/2024 certified nurse aide documentation of care did not document the resident was provided with toileting hygiene on 6 of 8 days (9 of 24 shifts). The 4/15/2024 Wound Evaluation and Management Summary completed by Wound Physician #23 documented a Stage 2 pressure ulcer of the right buttocks that measured 7 centimeters x 3.5 centimeters x 0.1 centimeter. Treatment included: off-load wound, reposition per facility protocol, turn side to side in bed every 1-2 hours if able, and application of zinc ointment every shift and as needed. The wound had improved as evidenced by decreased surface area. The 4/15/2024 physician order documented cleanse bilateral buttocks with wound cleanser, pat dry. Apply barrier cream every shift and as needed for wound care. The 4/2024 Treatment Administration Record documented cleanse bilateral buttocks with wound cleanser, pat dry. Apply barrier cream every shift and as needed for wound care with a start date of 4/15/2024 and a discontinue date of 4/17/2024. The treatment was not documented as completed on 4/16/2024 on the 11:00 PM-7:00 AM shift. Physician orders documented: -On 4/17/2024 cleanse bilateral buttocks with wound cleanser, pat dry. Apply Vitamin A&D every shift and as needed for wound care. -On 4/19/2024 cleanse bilateral buttocks with wound cleanser, pat dry. Apply barrier cream every shift and as needed for wound care. The 4/16/2024 through 4/22/2024 certified nurse aide documentation of care did not document the resident was provided with toileting hygiene on 6 of 7 dates (10 of 21 shifts). The Comprehensive Care Plan initiated on 4/8/2024 and revised on 4/19/2024 documented the resident had an actual pressure ulcer related to impaired mobility and incontinence. On 4/15/2024 the resident had a Stage 2 pressure ulcer on the right buttocks and moisture associated skin damage on both buttocks; on 4/19/2024 the moisture associated skin damage was improved. The skin was pink, and there was a small scab on the right buttock. Interventions included pressure relieving devices for bed; assess wound weekly; document wound measurements, wound bed appearance, odor, drainage, and surrounding tissue; monitor wound daily for signs and symptoms of infection; monitor/document/report to physician as needed, changes in skin status. The 4/22/2024 Wound Evaluation and Management Summary completed by Wound Physician #23 documented a Stage 2 pressure ulcer of the right buttocks that measured 6.5 centimeters x 6.0 centimeters x 0.1 centimeters. Treatment included: off-load wound, reposition per facility protocol, turn side to side in bed every 1 - 2 hours if able, and application of house barrier every shift and as needed. The wound was improved as evidenced by decreased surface area. The 4/23/2024 through 4/29/2024 certified nurse aide documentation of care did not document the resident was provided with toileting hygiene on 4 of 7 dates (5 of 21 shifts). The 4/29/2024 Wound Evaluation and Management Summary completed by Physician #23 documented an unstageable (full thickness tissue loss in which the base of the wound is covered with dead tissue) pressure ulcer of the right buttocks that measured 1.0 centimeter x 2.0 centimeter x unknown due to necrotic tissue (dead tissue that appeared black in color). Treatment included: off-load wound, reposition per facility protocol, turn side to side in bed every 1-2 hours if able, application of honey (medical grade honey used for wound healing) once a day and as needed, and application of barrier cream to peri wound every shift. The progress of the wound and the context of the wound were considered. Relevant conditions including fecal incontinence were addressed through treatment changes or investigations. The wound was chronic and stable with an insignificant amount of necrotic tissue and no signs of infection. The 4/29/2024 physician order documented cleanse right buttocks with wound cleanser and pat dry. Apply barrier cream to peri-wound (surrounding area of wound). Apply honey to wound bed and cover with border gauze daily and as needed every shift for wound care. The 4/2024 treatment administration record documented apply barrier cream to peri-wound. Apply honey (medical grade honey used for wound treatment) to wound bed and cover with border gauze daily and as needed every shift for wound care with a start date of 4/29/2024 and a discontinue date of 5/3/2024. There was no documentation the treatment was administered on 4/29/2024. A 5/2/2024 at 7:30 PM Registered Nurse #48's progress note documented they were notified by the front desk receptionist the resident's family called Emergency Medical Services and had the resident sent to the hospital. The registered nurse attempted to speak with the family, but the family dismissed them. The resident was sent to the hospital per the family wishes. The on-call provider and the Director of Nursing were notified. During an interview on 6/28/2024 at 11:02 AM, Licensed Practical Nurse #20 stated Resident #293 was on hourly checks and toileted every 2-3 hours. The resident was incontinent, and staff would check on them frequently and their incontinence brief would already be soaked with urine. They remembered on 4/7/2024 the certified nurse aides notified them during AM care that the resident had dried stool on them and had a small skin tear. They notified a supervisor, and a treatment was started. They did not recall who the supervisor was. During an interview on 6/28/2024 at 11:36 AM, Nurse Practitioner #25 stated they knew Resident #293 and a Stage 2 pressure ulcer was not usually from a single incident. A Stage 2 was not significant and was like the surface of the skin that came off. They stated it was not likely that Resident #293 sustained any harm from the incident, but the family was upset, and it was corrected immediately. During an interview on 6/28/2024 at 11:58 AM, Licensed Practical Nurse Unit Manager #6 stated they expected dependent residents to be checked and changed every 2 - 3 hours and as needed. They were not aware of staff not providing appropriate care, and they did not remember much about Resident #293. They expected staff to follow the resident's care plan and Kardex (resident care instructions). Staff should check the Kardex at the beginning of each shift in case changes were made to care. During an interview on 6/28/2024 at 12:13 PM, the Director of Nursing stated Resident #293 was dependent on staff for all their care, and they did not remember any family complaints about incontinence. They stated Resident #293 never had an order to be up, out of bed, or for a specific amount of time and it was not in their care plan or Kardex. Resident #293's pressure ulcer could have developed from not being toileted or repositioned as planned, but usually a one-time occurrence would not have caused it. During an interview on 7/9/2024 at 8:48 AM, Licensed Practical Nurse #47 stated all treatments were highlighted in the computer to let the unit nurse know what was due. They usually did the treatments after the morning medication pass or after lunch. The nurse doing the treatment should sign for it after completion. They always signed for the treatment if they did it and would document any refusals in a progress note. Resident #293's treatment frequently to their buttocks frequently changed. They did not know why the treatment was not signed for on 4/3/2024, 4/5/2024, and 4/10/2024. During an interview on 7/9/2024 at 9:01 AM, Licensed Practical Nurse #48 stated Resident #293 was admitted with a wound to their bottom, and it had improved by the time the resident was sent to the hospital. They were unsure why there were times the treatment was not signed for. Sometimes the nurse reported to work at 6:00 AM and that was why they signed for it on the night shift as being done. If a treatment was not done regularly, the wound could get worse. If something was not signed for, technically it was not done. During an interview on 7/9/2024 at 9:25 AM, Certified Nurse Aide #49 stated Resident #293 was dependent for all care, was able to help with turning, and only needed assistance of 1 at times. If there was only 1 nurse aide on duty, the unit nurse assisted with care. Sometimes there was not time to sign for provided care by the end of the shift. They did not remember if Resident #293 had an open area on their buttocks. During an interview on 7/9/2024 at 10:13 AM, Certified Nurse Aide #50 stated they documented care that was provided twice a shift unless they were the only one assigned to the unit. The unit nurse assisted with care during the night. During 4/2024, the 2nd aide on the unit frequently got pulled to another unit during the shift and that may have been why the care did not always get signed for by the end of the shift. Resident care came before documentation. The aides were allowed to put stock barrier cream on a resident, but the nurse would have to do it if there was a physician order. During an interview on 7/9/2024 at 4:56 PM Wound Physician #23 stated the definition of an unstageable pressure ulcer was one covered with necrotic (dead) tissue and could not be accurately staged. It had to be a Stage 3 or 4 under the necrosis. They expected all physician orders to be followed or staff were to notify them if a treatment could not be done and the reason why, so they could provide further guidance to the nurses. Resident #293's buttock wound was small and had dead tissue over it. They were not sure why they did not debride it (remove dead tissue) prior to hospitalization . Without debridement they could not determine what the actual stage of the wound was or if it worsened. The resident did not return to the facility from the hospital. They were unable to determine if the missing treatments made the wound worse as the residents many comorbidities could come into play in that aspect. 10NYCRR 415.12(c)(1)

Based on observations, record review, and interviews during the recertification survey conducted 6/24/2024-6/28/2024, the facility did not ensure a safe, clean, comfortable, and home-like environment for 4 of 4 Units (Units 100, 200, 300, and 400) reviewed. Specifically, floors, walls, ceilings, and resident chairs were damaged or unclean on Units 100, 200, 300, and 400; drain flies were observed in the Unit 200 shower room; and there was no negative air pressure in Units 200, 300, and 400 soiled utility rooms (negative pressure rooms have a lower air pressure, created by ventilation, to reduce the flow of potentially contaminated air or odors from leaking into the surrounding areas). Findings include: The facility policy, Housekeeping Responsibilities, reviewed 1/2022, documented the facility would maintain a clean, safe, and sanitary environment for the residents. Routine cleaning included daily cleaning of all horizontal surfaces with an acceptable grade disinfectant/germicide. A schedule of cleaning tasks and the employees responsible was to be maintained by the Housekeeping Supervisor. The following observations were made on Unit 100: - on 6/24/2024 at 10:33 AM, the floors were sticky when walking on them. The left side of the hall outside of room [ROOM NUMBER] had paint scraped off on both sides of the doorframe. - on 6/24/2024 at 10:44 AM, resident room [ROOM NUMBER] had a call bell out of reach of the resident lying in bed. There was a very strong odor of urine in the room. - on 6/24/2024 at 11:26 AM, Resident #52's wheelchair was ripped on the inside back rest and both arm rests. - on 6/24/2024 at 12:07 PM, Resident #44's reclining wheelchair had a soiled footrest. - on 6/24/2024 at 3:00 PM, the Unit 100 shower room had a missing call bell cord. There were miscellaneous items in the room including two fall mats, a wheelchair, and pads on the floor by the toilet. The following observations were made on Unit 200: - on 6/24/2024 at 2:05 PM, the soiled utility room had no negative pressure. - on 6/24/2024 at 2:18 PM, the shower room had no call bell cord, and there were two drain flies in the room. The following observations were made on Unit 300: - on 6/24/2024 at 11:10 AM, the shower room toilet seat cover was in disrepair and was worn through. - on 6/24/2024 at 11:17 AM, the soiled utility room had no negative pressure. The following observation was made on Unit 400: - on 6/24/2024 at 12:32 PM, the soiled utility room had no negative pressure. There was a 2 inch x 2 inch hole cut into the solid ceiling of the room. There was no documented evidence of work orders for any of the environmental issues identified during the tour of the facility. During an interview on 6/27/2024 at 9:21 AM, Housekeeper #4 stated they were assigned to work on Unit 100. They swept and mopped resident room floors, cleaned the resident room bathrooms, dusted the blinds, and replaced curtains if they were dirty. They also swept and mopped the hallways. It had been difficult to clean the unit floors due to residents with urinary incontinence issues. They stated they were responsible for cleaning and disinfecting the floors as needed if they appeared dirty. They used bleach for the floors. Nursing staff was responsible for cleaning wheelchairs, and certified nurse aides were responsible for cleaning body fluids. They stated the floors in the facility should not be sticky and could be caused by urine. During an interview on 6/28/2024 at 9:48 AM, Licensed Practical Nurse Unit Manager #3 stated the Maintenance Department was responsible for painting walls. The walls could use a paint touch-up. Work order tickets could be placed via the unit computers, or through a separate phone application, and the work orders went directly to the Maintenance Department. Work order requests would be submitted for things like leaky air mattresses, beds that were not working, plugged toilets, leaky sinks, unclean and damaged walls, and unclean and damaged wheelchairs. They stated the 11:00 PM to 7:00 AM nursing staff were responsible for cleaning wheelchairs, but this was not always completed. They should have been overseeing that wheelchairs were cleaned, and they had check sheets for the cleaning. The wheelchair for resident #52 was in disrepair and they should contact the Therapy Department to get a new chair. Licensed Practical Nurse #3 stated repairs should be completed within 24 hours unless it was urgent, and it should be completed immediately. During an interview on 6/28/2024 at 11:24 AM, the Maintenance Director stated they were responsible for overseeing maintenance for the entire building. They oversaw two maintenance technicians, a floor technician, and the housekeeping supervisor. All staff could use the hallway computers to place a work order, and the work orders would be sent immediately to the Maintenance Director. Work orders could also be created though an application on the phone, and orders completed this way went directly to the maintenance staff. Work order categories included floor care; electrical repair; heating, ventilation, air conditioning; call system; paint touch-ups; floors needing buffing, stripping, and waxing; and housekeeping mopping and sweeping. Priority work order tickets should be completed immediately or within 24 hours, painting work orders would usually take a couple of days, and resident equipment work orders would take a day and sometimes less. Maintenance staff were constantly on the resident units, and if they observed something they could create their own work orders. Nursing staff was educated on using the computers to submit work orders. The goal of the facility staff was to make and maintain a homelike environment for the residents. 10 NYCRR 415.29(j)(1)

Based on observation, record review and interviews during the recertification and abbreviated (NY00340701, NY00330066, NY00333069, and NY00328237) surveys conducted 6/24/2024 - 6/28/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 4 of 11 residents (Residents #56, #80, #90, and #127) reviewed. Specifically, Resident #127 had untrimmed fingernails and was not wearing their glasses; and Residents #56, #80, and #90 had unclean and untrimmed fingernails. Findings include: The facility policy, Resident Care with Activities of Daily Living, reviewed 1/2022, documented the facility was to accurately assist with residents' needs to support basic activities of daily living function. The supervisor was to be notified if the resident refused care and to report other information in accordance with facility policy and professional standards of practice. The facility policy, Care of Fingernails/Toenails, reviewed 1/2024, documented nail care included daily cleaning and regular trimming. The supervisor was to be notified if the resident refused care. The facility policy, Care of the Visually Impaired Resident, reviewed 1/2024, documented assistive devices to maintain vision included glasses and any other device used by the resident to assist with visual impairment. Residents who had lost or damaged their devices would be assisted in obtaining services to replace the devices. The supervisor was to be notified if the resident refused care. 1) Resident #127 had diagnoses including cerebral infarction (stroke), dementia, and need for assistance with personal care. The 5/4/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, was dependent on staff for showering/bathing and personal hygiene and wore corrective lenses. The Comprehensive Care Plan documented: - on 11/24/2023 the resident required assistance with self-care and mobility related to limited mobility and deconditioning. Interventions included substantial/maximal assistance for showering/bathing, and supervision or touching assistance for personal hygiene. - on 11/24/2023 and revised 3/4/2024 the resident had impaired visual function. Interventions included glasses, ensure the resident wore their glasses which were to be clean, free from scratches, and in good repair, and report any damage to nurse/family. Remind the resident to wear glasses as needed. The care instructions as of 6/27/2024 documented the resident wore glasses, required substantial/maximal assistance for showering/bathing, and supervision or touching assistance for personal hygiene. There was no documentation the resident's glasses were kept in another location for safe keeping, or if the resident required nail care from licensed nurses. Resident #127 was observed: - on 6/24/2024 at 11:06 AM, in their room with long, unkept fingernails and was not wearing glasses. The resident stated staff did not trim their fingernails. - on 6/25/2024 at 11:14 AM, in their room with long, unkept fingernails and was not wearing glasses. - on 6/26/2024 at 10:14 AM, in their room with long, unkept fingernails and was not wearing glasses. At 11:17 AM staff brought the resident to the unit dining area and seated them in front of the nurse's station. They were not wearing glasses. - On 6/27/2024 at 9:52 AM, in their room not wearing glasses. The Activities of Daily Living documentation task for the resident wearing their glasses was signed off as yes: - On 6/24/2024 at 9:35 AM by Certified Nurse Aide #17. - On 6/25/2024 at 11:15 AM by Certified Nurse Aide #17. - On 6/26/2024 at 2:59 PM by Certified Nurse Aide #18. - On 6/27/2024 at 8:05 AM by Certified Nurse Aide #17. The Activities of Daily Living documentation task for showering/bathing and personal hygiene was signed off as being done on 6/25/24 by Certified Nurse Aide #17. During an interview on 6/26/2024 at 10:14 AM Certified Nurse Aide #18 stated they were not sure of the resident's shower day. There was a shower list at the nurse's station, and they would check. They stated the resident's shower day was Tuesdays during the 7:00 AM - 3:00 PM shift. Sometimes the resident refused care, would state no and then staff would reapproach them. During an interview on 6/27/2024 at 9:56 AM Licensed Practical Nurse #16 stated they were not sure if the resident wore glasses. They looked through the resident's dresser drawers and nightstand drawer and stated they thought the resident's daughter took the glasses home because they were broken. During an interview on 6/27/2024 at 10:23 AM Certified Nurse Aide #17 stated the resident's shower day was on Tuesdays. They usually did that task first thing in the morning because the resident was hard to get up once they went back to bed, as they spent most of their time in their room. The resident's fingernails were cleaned in the shower. They did not trim the resident's fingernails because they thought the resident was diabetic and they did not see why the nurses would not know that. They never saw the resident wear glasses. They stated they did not know why they signed the Activities of Daily Living tasks that the resident was wearing their glasses. The nurses would probably know if the resident wore glasses or not. During an interview on 6/27/2024 at 10:55 AM Licensed Practical Nurse Unit Manager #19 stated the licensed practical nurses did skin checks on residents and would also be looking at fingernails while doing so. The certified nurse aides were supposed to trim residents' fingernails and they should be notifying the nurse if they were unable to or if a resident refused. If a resident was supposed to be wearing glasses and they could not find the glasses or they were broken, they should notify the nurse. They were not sure if Resident #127 wore glasses, but they could be broken, or family could have taken them home. Certified nurse aides should not be signing for tasks they were not completing. During an interview on 6/28/2024 at 9:42 AM Licensed Practical Nurse Unit Manger/Supervisor #6 stated fingernails should be trimmed by the certified nurse aides during the residents' showers or with daily care. Certified nurse aides could trim diabetic residents' fingernails. They stated the resident was not diabetic and their nails should be getting trimmed. If a resident had adaptive equipment such as glasses, then it would be documented in the care instructions. If a resident had glasses and they were missing or broken the certified nurse aides should be notifying the nurse. They stated the unit secretary kept the glasses in a locked drawer for safe keeping at the nurse's station. Most routine staff would know the glasses were kept there but some staff would probably not know this. 2) Resident #80 had diagnoses including right hemiplegia (weakness of the right side of the body). The 6/21/2024 Minimum Data Set assessment documented the resident was cognitively intact, had functional limitations in both arms, and was dependent for personal hygiene. The 12/26/2023 updated Comprehensive Care Plan documented the resident required assistance with self-care and mobility due to right sided weakness. Interventions included dependence with personal hygiene. The 6/26/2024 Activities of Daily Living documentation report documented the resident was provided daily personal hygiene care and daily shower/bathing care most every day during the month of June 2024. The following observations of Resident #80 were made: - on 6/24/24 at 12:59 PM, their fingernails were long with brown debris underneath. - on 6/27/24 at 11:55 AM, their fingernails were long with brown debris underneath. - on 6/28/24 at 9:00AM, their fingernails were long with brown debris underneath. During an interview on 6/24/2024 at 12:59 PM, Resident #80 stated their nails were too long, they poked their palms, and they wanted them cut. During an interview on 06/28/24 at 9:23 AM, Certified Nurse Aide #7 stated fingernails should be cleaned and trimmed on shower days or whenever nails were long or soiled. If a resident refused nail care, they would report to a nurse. Nail care was important as long, soiled fingernails could cause scratches which could lead to infection. They noticed Resident #80's fingernails were long and soiled and planned to groom them that day. During an interview on 6/28/2024 at 9:37 AM, Licensed Practical Nurse #5 stated they were not sure what the nail care policy was but expected certified nurse aides to provide nail care daily, and if not done, it was reported to them for follow-up. Proper fingernail care was important for the prevention of infection that could occur through scratches or by a resident putting soiled fingernails in their mouth. They were not aware of the condition of Resident #80's fingernails, but the resident often refused, and those refusals should be documented by the certified nurse aide in the hygiene task. They had not received any recent report the resident refused fingernail care. During an interview on 6/28/2024 at 10:28 AM, Licensed Practical Unit Manager/Supervisor #6 stated fingernails should be trimmed and cleaned on shower day and whenever needed. They expected any refusals to be reported to the team leader so a second attempt could be made. If a resident continued to refuse it should be reported to them so it could be documented, and care planned. Proper nail care was important for dignity and to prevent skin injury and infection. They were aware that Resident #80's fingernails were long and that the resident had a history of giving them and other staff difficulty about personal care. They did not see any documented refusals for fingernail care or a behavioral care plan. 3). Resident #90 had diagnoses including dementia and need for assistance with personal care. The 1/4/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, was dependent on staff for personal hygiene, and did not reject care. The comprehensive care plan revised 6/26/2024 documented Resident #90 required assistance with self-care and mobility related to cognitive impairment. Interventions included dependence for personal hygiene. The June 2024 resident care instructions documented the resident was dependent for personal hygiene. Resident #90 was observed with long fingernails on both hands and brown debris underneath: - on 6/25/2024 at 9:18 AM, walking in the hallway. - on 6/26/2024 at 7:45 AM, eating breakfast. - on 6/27/2024 at 8:52 AM, walking in the hallway. The 6/27/2024 Unit 100 staff assignment sheet documented Resident #90's shower day was Thursday on the 7:00 AM - 3:00 PM shift and was marked as completed. During an interview on 6/27/2024 at 10:15 AM Certified Nurse Aide #14 stated the resident required total care and they cared for the resident that day. Certified nurse aides were responsible for nail care unless the residents were diabetic. Nail care should be done on day shift or any chance they get if they were soiled. They had showered the resident that day but did not do nail care. The resident's fingernails had a brown substance under them and should have been cleaned. During an interview on 6/27/2024 at 1:59 PM Licensed Practical Nurse Unit Manager #3 stated the certified nurse aides were responsible for cleaning Resident #90's fingernails and they were usually cleaned on shower days. The resident's fingernails had a brown substance under them, they should have been cleaned on their shower day, and it was undignified for them to be dirty. During an interview on 6/28/2024 at 11:47 AM the Director of Nursing stated personal hygiene should be completed every day per the residents' preferences. Fingernails should be cleaned and trimmed daily, and it was undignified if not completed. Certified nurse aides and nurses could clean and trim fingernails and it was not appropriate if Resident #90's fingernails were not clean. 10NYCRR 415.12(a)(3) 46276 50561

49831 Based on observation, interview, and record review during the recertification and abbreviated (NY00340613, NY00328237, and NY0330066) surveys conducted 6/24/2024-6/28/2024, the facility did not ensure each resident received food and drink that was palatable, attractive, and at a safe and appetizing temperature for 2 of 2 meals (6/26/2024 breakfast meal and 6/26/2024 lunch meal) reviewed. Specifically, the breakfast and lunch meals were not served at safe and appetizing temperatures. Findings include: The facility policy, Policy and Procedure Food Temperatures, reviewed 01/2023, documented the temperatures of all food items would be taken and properly recorded prior to service of each meal. All hot food would be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 degrees Fahrenheit. Hot food items would not fall below 135 degrees Fahrenheit after cooking, unless it was an item which would be rapidly cooled to below 41 degrees Fahrenheit and reheated to at least 165 degrees Fahrenheit (for a minimum of 15 seconds) prior to serving. Temperatures would be taken periodically to assure hot foods stay above 135 degrees Fahrenheit and cold foods stay below 41 degrees Fahrenheit during the holding and plating process and until food left the service area. The facility policy, Food Preparation and Service, reviewed 01/2024, documented the danger zone for food temperatures was between 41 degrees Fahrenheit and 135 degrees Fahrenheit and promoted the rapid growth of pathogenic microorganisms that could cause foodborne illness. During an interview on 6/24/2024 at 10:49 AM, Resident #111 stated the food was not good. During Resident Council Meeting on 6/25/2024 at 10:30 AM, two anonymous residents stated the facility served food that was bland with no taste, and the hot foods were often served cold. During an observation on 6/26/2024 at 7:17 AM, Resident #111's breakfast meal tray was tested . A replacement tray was provided to Resident #111. Food temperatures on the tray were measured. The cheesy scrambled eggs were measured at 134 degrees Fahrenheit, the Super cereal was measured at 136 degrees Fahrenheit, the first can of diet cola was measured at 64.7 degrees Fahrenheit, and the second can of diet cola was measured at 64.9 degrees Fahrenheit. During an interview on 6/26/2024 at 12:35 PM Resident #63 stated the food was bland and had no taste, the hot foods were not hot, and the cold foods and drinks were not always cold. During an observation on 6/26/2024 at 12:39 PM, Resident #63's lunch meal was tested . A replacement tray was provided to Resident #63. Food temperatures on the tray were measured. The pureed barbecue chicken was measured at 129 degrees Fahrenheit, the pureed macaroni and cheese was measured at 123 degrees Fahrenheit, the pureed seasoned spinach was measured at 124 degrees Fahrenheit, the pureed fruit cocktail was measured at 69 degrees Fahrenheit, the honey thickened water was measured at 63 degrees Fahrenheit, the first 8 ounce container of 2% honey thick milk measured at 60 degrees Fahrenheit, and the second 8 ounce container of 2% honey thick milk measured at 62 degrees Fahrenheit. During an interview on 6/28/2024 at 10:13 AM Food Service Director #15 stated they tested food palatability for two test trays per week. Milk that measured at either 62 degrees Fahrenheit or 63 degrees Fahrenheit would not be acceptable and should not be served to residents. Hot foods that measured at 123 degrees Fahrenheit and 129 degrees Fahrenheit would not be acceptable and should not be served to residents. If residents were served food that measured outside the acceptable temperature range, they could become sick with a foodborne illness. 10NYCRR 415.14(d)(2)

Based on observation, interview, and record review during the recertification and abbreviated (NY00330066 and NY00331744) surveys conducted 6/24/2024-6/28/2024, the facility did not provide one or more rooms designated for resident dining and activities that were adequately furnished and had sufficient space to accommodate all activities for 2 of 4 dining rooms (Units 100 and 400). Specifically, Units 100's and 400's dining rooms had tables that did not accommodate residents' social and physical needs with inadequate space for dining or activities, and residents were lined up in the hallways during meals. Findings include: The facility policy, Preparing the Resident for a Meal, reviewed 1/2024, documented residents should be encouraged, not forced, to eat in the dining room to provide each resident the opportunity to socialize and make friends. Be sure the room was comfortable (i.e., not too warm, or cold) and had a relaxing environment (free of odors, loud noises, and bright lights). The following observations were made on Unit 100. The unit census was 36 residents. - During the lunch meal on 6/24/2024 between 11:31 PM and 12:16 PM the dining area had 6 square tables measuring approximately 3 feet x 3 feet. Two tables were placed together at the back of the room and 2 tables were placed together in the front of the room near the hallway. One square table was against the right side of the wall towards the back of the room and one square table was against the wall in the front of the room near the hallway. There were approximately 10 residents seated in the dining room. One resident was observed sitting in a reclining chair that was positioned sideways next to the back table near the wall. Two residents were seated at the back table with 2 square tables pushed together. One resident had a walker, the other a wheelchair. There were no other residents seated at the table. The meals were served on food trays that were approximately 12 inches long and were not removed during the meal. Residents seated at the tables were in wheelchairs, reclining chairs, or had assistive devices such as walkers and there was no room for ambulatory residents to sit. At 11:31 AM in the Unit 100 common area, there were approximately 10 residents seated at the tables in the common area and all other residents were lined up in the hallway, seated with bedside tables, across from the nursing station. The residents appeared cramped and were approximately 1/2 inch apart from one another. There was no music playing and no conversations between residents. Staff did not engage the residents in conversations. The following observations were made on Unit 400. The unit census was 39 residents. - on 6/24/2024 between 11:57 AM-12:18 PM there was no dining area on the unit. Several residents were lined up in the hallway eating on bedside tables. No conversations were observed between the residents. Other residents were eating in their rooms. - on 6/26/2024 at 8:08 AM, several residents were observed sitting lined up in the hallway eating breakfast served on bedside tables. During an interview on 6/26/24 at 11:31 AM, Certified Nurse Aide #12 stated the main dining room was closed and had not been utilized in a couple of months due to staffing. They stated residents with wheelchairs were placed at the tables and the other residents that were feeders or needed supervision were lined up in the hallway. During an interview on 6/28/2024 at 10:00 AM, Licensed Practical Nurse Supervisor #6 stated the main dining room was not being utilized and they had not seen it used in the 2 years since they had been employed at the facility. They stated they thought the units would be less congested if the main dining room was opened to residents. During an interview on 6/28/2024 at 11:47 AM, the Director of Nursing stated the main dining room had been closed since the COVID-19 outbreak and there had been discussions amongst management to re-open it. They stated they thought residents were lined up in the hallways for lack of space and thought being lined up in the hallway was not a dignified dining experience for the residents. 415.29(e)(3)

Based on observations, record review, and interviews during the recertification and abbreviated (NY00330066) surveys conducted 6/24/2024-6/28/2024, the facility did not ensure residents had the right to a dignified existence for 2 of 18 residents (Resident #28 and #44) reviewed. Specifically, Residents #28 and #44 were referred to with undignified labels (feeders); and Resident #44 was assisted with eating while staff stood over them. Findings include: The facility policy, Quality of Life-Dignity, reviewed 1/2024, documented residents would be treated with dignity and respect at all times. Ttreated with dignity meant the resident would be assisted in maintaining and enhancing their self-esteem and self-worth and staff should speak respectfully to residents at all times, including addressing the resident by their name of choice and not labeling or referring to the resident by their room number, diagnosis, or care needs. 1) Resident #28 had diagnoses including dementia, cerebral infarction (stroke), and bipolar depression. The 4/26/2024 Minimum Data Set assessment documented the resident had severely impaired cognition and required extensive assistance of one for eating. The comprehensive care plan, revised 3/4/2024, documented Resident #28 required assistance with self-care related to dementia and limited mobility, and was dependent for eating. The 6/24/2024-6/28/2024 Unit 100 staff assignment sheet documented Residents #28 and #44 as Feeders. During an observation on 6/24/2024 at 12:00 PM, Resident #28 was on Unit 100, seated in a reclining chair in the dining area. Licensed Practical Nurse #3 was observed assisting the resident with eating. Certified Nurse Aide Instructor #13 asked if a nurse aide student could assist with the resident and the Licensed Practical Nurse Unit Manager #3 stated no, the resident was a difficult feeder. Certified Nurse Aide Instructor #13 asked if there were other feeders they could assist with eating. The conversation could be heard by others in the vicinity. 2) Resident #44 had diagnoses including dementia without behavioral disturbances, adult failure to thrive, and protein-calorie malnutrition. The 5/28/2024 Minimum Data Set assessment documented the resident had severe cognitive impairment and was dependent on staff for eating. The comprehensive care plan revised 3/5/2024 documented Resident #44 required assistance with self-care and mobility related to confusion and dementia. Interventions included the resident was dependent on staff for eating. During an observation on 6/24/2024 at 12:11 PM, Resident #44 was seated in a recliner chair in the Unit 100 hallway. Certified Nurse Aide #12 placed the resident's lunch tray on a bedside table and stood over the resident while feeding them. During an interview on 6/27/2024 at 9:10 AM Certified Nurse Aide #12 stated Resident #44 was a feeder. They stated feeder meant the resident was dependent on staff for eating. They stated they should not have stood over the resident when assisting them with eating as it was undignified. 10NYCRR 415.5 (a)

Based on interview and record review during the recertification survey conducted 6/24/2024-6/28/2024, the facility did not ensure that residents with newly evident or possible serious mental disorders, intellectual disabilities, or a related conditions were referred for a Level II Pre-admission Screening and Resident Review (PASARR, a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities were not inappropriately placed in nursing homes for long term care and a Level II PASARR identifies the specialized services required by the resident) for 1 of 2 residents (Resident #101) reviewed. Specifically, there was no documentation Resident #101 was referred for a Level II Preadmission Screening and Resident Review when the resident was newly diagnosed with a serious mental health disorder. Findings include: The New York State Department of Health Instruction Manual for DOH-695 (2/2009) documented if a Residential Health Care Facility resident is newly diagnosed with a mental illness, a new SCREEN and Level II referral must be completed within 14 calendar days. Resident #101 was admitted to facility 8/22/2022 with diagnoses of anxiety and depression. The 6/4/2024 Minimum Data Set assessment (a health assessment screening tool) documented resident had intact cognition, had no behaviors, was independent with most activities of daily living, had active diagnoses including schizophrenia, and was taking an antipsychotic and antidepressant medication daily. The Preadmission Screening and Resident Review dated 8/22/2022 documented the resident did not have a serious mental illness. The resident's face sheet documented the resident's schizoaffective disorder diagnosis had an onset date of 1/25/2024. A 1/25/2024 at 12:47 PM progress note by Nurse Practitioner #25 did not include documentation of newly diagnosed schizoaffective disorder. The Comprehensive Care Plan initiated 11/1/2023 and revised on 1/25/2024 documented the resident had diagnoses of anxiety, depression, and psychosis. Interventions included administer psychotropic medications as ordered, encourage resident to remain social with peers and staff, encourage participation in activities offered, monitor for changes in mood, provide support and reassurance, and psychological services as needed. A 3/3/2024 physician #46 progress note documented a current diagnosis of schizoaffective disorder and was receiving antipsychotic medications. There was no documented evidence a new Screen Level I had been completed when the resident was diagnosed with schizoaffective disorder and no documented evidence of a Level II referral. During an interview on 6/28/2024 at 11:26 AM, Director of Social Work #9 stated they did not review The Preadmission Screening and Resident Reviews until after a resident had been admitted . Any new resident diagnosis was reported to the interdisciplinary team at the daily morning meeting. They would not initiate the process to get a new Preadmission Screening and Resident Review for a newly reported serious mental health diagnosis, but they would start the referral process for a psychiatric evaluation. The only time they would obtain a new screen was if a resident were transferring to another facility as a lateral transfer. They would contact the Regional Director of Social Work who was responsible to complete those screens. They believed Resident #101 had a serious mental illness diagnosis that was not new. After they referred to the medical record, they stated they did not see a schizophrenia diagnosis at the time of admission, that a serious mental illness was indicated on the initial screen, or that a new screen was performed. They did not believe a new screen was necessary, but they might need to be educated on the process. It was important residents were screened appropriately for the safety of all residents and to ensure appropriate placement as people should be placed in the least restrictive environment possible. During an interview on 6/28/24 at 12:35 PM the Director of Nursing stated new mental health diagnoses were brought forward during team meeting each morning or whenever needed. 10NYCRR 415.11(e)

Based on observation, record review, and interviews during the recertification and abbreviated (NY00330066) surveys conducted 6242024-6/28/2024, the facility did not ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 1 of 7 residents (Resident #111) reviewed. Specifically, Resident #111 had a physician order for a chopped consistency diet and was served a whole sandwich. Findings include: The facility policy, Food Consistencies and Definitions, reviewed 1/2024, documented diets with a chopped consistency were nearly regular textures with exception of very hard, sticky, or crunchy foods. Foods should be tender and easy to break into pieces with a fork. Lunch/Dinner foods such as meatballs, thinly sliced deli meat, and grilled cheese sandwiches should be chopped. The policy did not include definitions for a mechanical soft diet. The facility policy, Accuracy and Quality of Tray Line, revised 1/2024 documented all meals would be checked for accuracy by the Food and Nutrition staff, and by the service staff prior to serving the meal to the individual. The meal would be checked against the therapeutic diet spread sheet to assure that foods were served as listed on the menu. All meals would be checked for accuracy of following the therapeutic diet extension. 1) Resident #111 had diagnoses of Alzheimer's disease, gastro-esophageal reflux disease (backflow of stomach contents to the esophagus), and dysphagia (difficulty swallowing). The 4/12/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, required supervision/touch assistance with eating, did not have a swallowing disorder, and received a mechanically altered diet. The comprehensive care plan initiated 4/20/2023 and revised 5/5/2023 documented the resident had oral/dental health problems and was edentulous (lacking teeth). Interventions included diet per registered dietitian recommendation and physician order. The Comprehensive Care Plan initiated 4/20/2023 and revised 3/29/2024 documented the resident was at risk for malnutrition related to dysphagia and potential chewing difficulty due to being edentulous (no teeth). Interventions included provide diet and consistency per physician order, regular chopped texture; monitor for chewing and swallowing problems; and refer to the Speech Language Pathologist as needed. The 3/29/2024 physician order documented Resident #111 was to receive a regular diet, chopped consistency, and thin liquids for dementia with behaviors. The 4/24/2024 at 9:30 AM Speech Language Pathologist #26 discharge summary documented the resident had initially been evaluated for reports of food getting ''stuck' when swallowing. Discharge recommendations included close supervision, small bites, slow rate of eating, remain upright for 30 minutes after meals, and mechanical soft/chopped texture consistency for solids and thin liquids. The 4/29/2024 at 11:21 AM Registered Dietitian # 11 Nutrition Assessment documented the resident continued a regular diet with regular textures and no new issues with chewing or swallowing. The care plan was reviewed and updated. The 6/2024 resident care instructions documented the resident required supervision/touch assistance with eating and was to receive diet and consistency per physician order regular, chopped textures and thin liquids. During the lunch meal observation on 6/24/2024 at 11:31 AM, the resident's meal ticket documented a regular-chopped diet with 3 ounces of chopped chicken, 1/2 chopped biscuit, 1/2 cup of chopped vegetables, and 1/2 cup of chopped mixed fruit. There were X's marked through all the items on the meal ticket. The resident's meal tray included a whole meatball hoagie, 1/2 cup of spinach, 1/2 cup of mixed fruit, and a whole grilled cheese sandwich. The resident ate a few bites of each sandwich before leaving the table. The food was not chopped or cut up. During an interview on 6/27/2024 at 9:35 AM, Certified Nurse Aide #27 stated a chopped consistency diet meant the food should be cut up, a whole meatball sub sandwich was not a chopped diet item and should be cut lengthwise and crosswise. A whole grilled cheese sandwich should be cut up. They were unsure if Resident #111 had a chopped diet. They stated if a resident received the wrong food consistency they could choke or aspirate (inhale food into the lungs) the food. During an interview on 6/27/2024 at 2:11 PM Resident Assistant #29 stated they knew how to care for a resident by looking up their profile in the computer. They thought Resident #111 had a regular diet. A chopped consistency diet should be cut up. They had received diet consistency training during orientation. During an interview on 6/28/2024 at 8:24 AM Licensed Practical Nurse Unit Manager #3 stated they were responsible for overseeing staff on the unit and staff knew how to care for a resident by looking up their profile in the computer. If a resident's diet changed, the speech pathologist would send an email and they would communicate it to staff. Licensed Practical Nurse #3 stated Resident #111 was on a chopped consistency diet, their food should be cut up, and it could be a choking risk if they consumed whole sandwiches. During an interview on 6/28/2024 at 8:48 AM Registered Dietitian #11 stated if they saw a resident with the wrong consistency diet, they would remove it and alert nursing and speech therapy. They were familiar with Resident #111 who had a regular diet with chopped consistency, and they should not receive whole sandwiches. A whole meatball sub needed to be cut and if whole, could cause a choking hazard to the resident. They referred to the speech pathologist for any changes in diet consistencies. During an interview on 6/28/2024 at 9:18 AM Speech Language Pathologist #26 defined a dysphagia diagnoses as one that made it difficult for a resident to swallow food. Their duties included evaluating residents for swallowing deficits. They were familiar with Resident's #111, they were on a regular diet with a chopped consistency, had no teeth, required their foods to be chopped or cut and not doing so could put them at a higher risk for choking. During an interview on 6/28/2024 at 10:13 AM the Food Service Director stated they were responsible for checking meal tickets before the trays left the kitchen and were brought to the units on 6/24/2024. They stated they had just hired an employee for the M job position, which was a nutritional service aide position on the tray line. They had just started orientation and they were responsible for checking meal tickets before they were delivered. The Food Service Director stated nursing was also responsible for checking meal tickets once the trays were delivered to the unit. An X marked on a meal ticket meant the resident ordered the alternative meal and a whole sandwich was inappropriate for a chopped diet consistency. Employees were oriented upon hire regarding diet consistencies. During an interview on 6/28/2024 at 11:47 AM, the Director of Nursing stated nurses and aides should be checking meal tickets for the correct diet consistencies when they arrived on the units. Chopped diets were typically ordered if a resident had chewing problems. Resident #111 required a chopped diet and a whole grilled cheese sandwiches or meatball subs would not be appropriate as the resident could choke or aspirate (inhale food contents into the lungs). During an interview on 6/28/2024 at 12:17 PM Family Nurse Practitioner #25 stated that dysphagia diagnoses were for residents with neurologic disorders such as cerebral infarctions (strokes), Parkinson's Disease (a progressive disease involving the brain and spinal cord) and any other neuro-muscular disorder. They stated Resident #111 had no teeth, required a chopped diet, and should not be receiving whole meatballs or whole sandwiches. Staff should have cut them up. Having no teeth put the resident at a higher risk for choking or aspiration. 10NYCRR 415.14 (d-e)

Based on record review and interview during the abbreviated survey (NY00304388), the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 3 residents reviewed (Resident #1). Specifically, Resident #1 had a history of aspiration (inhalation of foods/fluids into the lungs) risk, was on an altered consistency diet (chopped solids) and required supervision and assistance with eating. On 4/26/2023, the resident was provided a sandwich and was not supervised while eating. Subsequently, approximately 30 minutes later, the resident was found without signs of life (no pulse or respirations), with food in their mouth, and was pronounced deceased . The resident had an autopsy that concluded their airway was completely obstructed by a food bolus (soft mass of chewed food). The facility's failure to provide adequate supervision placed 45 residents in the facility who were on altered consistency diets at risk. This resulted in actual harm and Immediate Jeopardy and Substandard Quality of Care to resident health and safety for Resident #1. Findings include: The facility's Preparing the Resident for a Meal Policy, reviewed 1/2023, documented staff were to review the resident's care plan and provide for any special needs of the resident. Resident #1 had diagnoses including Alzheimer's disease, stroke, and dysphagia (difficulty swallowing). The 3/12/2023 Minimum Data Set (MDS) assessment documented the resident's cognition was moderately impaired, they coughed or choked during meals or when swallowing medications, and they required extensive assistance of 1 staff with eating. The 7/25/2022 speech language pathologist (SLP) #21's discharge summary (discontinuation of services) documented the resident achieved their highest potential and was discontinued from therapy. Recommendations included chopped solids, thin liquids, and close supervision for intake. To facilitate safety and efficiency, it was recommended the resident use the following strategies during eating: alternating liquids/solids; bolus size modification; rate modification, and an upright posture during meals and after meals for 30 minutes. The resident needed short, direct comments to facilitate follow-through and consistent words/verbal directions to increase comprehension. There was no documentation SLP #21's recommendations were added to the resident's comprehensive care plan (CCP). The 11/22/2022 SLP #18's quarterly screening documented the resident should continue their current diet consistency of chopped solids and thin liquids. The CCP, updated 11/23/2022, documented the resident required assistance with activities of daily living (ADL) related to weakness and extensive assistance with eating. The 4/26/2023 5:20 AM, licensed practical nurse (LPN) Supervisor #6's progress note documented they were called to the unit to assess the resident who was sitting in their wheelchair non-responsive, and without a pulse or respirations. The Assistant Director of Nursing (ADON), the on-coming nursing Supervisor (LPN #10), and on-call medical provider (nurse practitioner (NP) #20 were notified. The 4/26/2023 5:30 AM, Accident and Incident Report, completed the Director of Nursing (DON) documented the resident was found in the hallway without a blood pressure, pulse, or respirations. The undated and unsigned Investigative Report included with the Accident and Incident Report documented on 4/26/2023 at approximately 5:00 AM, the resident requested a snack from certified nurse aide (CNA) #7 who set the resident up at a table across from the nursing station and gave them a tuna fish sandwich and strawberry milk shake. LPN #8 was nearby passing medications while CNA #7 continued to provide care for other residents. CNA #7 went on a break and told LPN #8 the resident was eating a sandwich. At approximately 5:30 AM, the resident was found unresponsive in their wheelchair in the hallway with some tuna fish in their mouth and had no pulse or respirations. The snack given was within the limits of the resident's diet order, LPN #8 or CNA #7 were in the area the entire time, and there was no evidence the resident was coughing/choking. The report documented there were no CCP violations, and it was likely the resident suffered an acute medical event. Statements obtained by the facility which were included with the Accident and Incident Report documented: - LPN Supervisor #6 noted they were called to the unit by CNA #11 to evaluate the resident. The resident was observed in the hallway, their mouth was wide open, their tongue was out and swollen, and their mouth was full of tuna fish. The resident had no pulse or respirations. LPN Supervisor #6 asked CNA #11 where the unit staff (LPN #8 and CNA #7) were, and CNA #11 stated they did not know. As they wheeled the resident to their room, LPN #8 arrived and stated they were passing medications. CNA #7 arrived soon after. - CNA #7 noted the resident asked them for something to eat and drink around 4:50 AM, and they gave them a tuna fish sandwich and milkshake and set them up in the hallway. CNA #7 told LPN #8, who was in the hallway, they were going on break and when they got back from break, they saw CNA #11 and LPN Supervisor #6 with the resident. The resident was pale and had tuna fish in their mouth. - LPN #8 noted around 5:20 AM, they gave the resident a glass of water and continued with the medication pass. About 20 to 30 minutes later, CNA #11 yelled something was wrong with the resident. They ran to the resident and checked for a pulse. The 5/26/2023 Autopsy Report documented the resident was found with a food bolus that completely obstructed the airway at the level of the epiglottis (a flap of cartilage behind the tongue). During an interview on 10/16/2023 at 3:28 PM, SLP #18 stated when the resident's SLP services were discontinued in 7/2022, they needed to be monitored for tolerance of their meal, needed a small bolus size, upright posture, and they were not sure how their recommendations got documented on the CCP. The resident required direct supervision while eating at the time of the assessment and up until the day they expired. During an interview on 10/17/2023 at 12:04 PM, LPN #8 stated on 4/26/2023, they saw the resident at 5:30 AM as they were starting their medication pass. That was a busy time of the morning because they were also assisting residents with getting up. They saw the CNA (did not recall who) give the resident a tuna fish sandwich near the nursing station and the CNA never asked them to watch the resident when they went on break. They did not know what level of assistance or supervision the resident required with eating however the resident was kind of with it and could eat on their own. They recalled seeing the resident headed towards the kitchenette just prior to the incident and they continued to pass medications down a different hallway. They overheard another CNA (they did not recall who) passing through the unit yelling out that they thought the resident had passed away. When they approached the resident, they looked like they had thrown up in their mouth. They checked for vital signs. During an interview on 10/17/2023 at 12:22 PM, CNA #11 stated the resident was a night owl and always scooted around the units in their wheelchair at all hours of the day and night. The resident required supervision for care and always ate in the same place across from the nursing station, so it was easy to keep an eye on them. On 4/26/2023, they were working on another unit and they went to the resident's unit to look for something in the kitchenette. As they approached the hallway leading to the resident's unit, they saw the resident slouched in the wheelchair in the hallway next to the kitchenette. They checked the resident's pulse and could not find a pulse and there was a ton of tuna in their mouth. The nurse on the unit (LPN #8) responded and verified the resident had no pulse at this time, CNA #7 returned to the unit. When they and CNA #7 provided postmortem care, the tuna sandwich was so deep in the resident's throat that they needed to use a mouth swab to scoop the tuna fish out. During an interview on 10/17/2023 at 12:52 PM, LPN Supervisor #6 stated on 4/26/2023, they were coming down the hallway from another unit towards the resident's unit early in the morning and saw CNA #11 near the resident in the hallway. The resident had no pulse and their color was grey. A little tuna fish was on their mouth and part of the sandwich was still in their hand. They called out for staff on the unit and LPN #8 came from around the nursing station. They notified the ADON, called the on-call medical provider (NP #20), and directed the CNAs to provide postmortem care. During an interview on 10/17/2023 at 3:10 PM, the DON stated determining a resident's supervision level for eating was multidisciplinary and included SLP, occupational therapy (OT), and nursing. If a resident was not provided the needed level of supervision with eating and there was an incident related to lack of supervision, that was a CCP violation. If a resident required extensive assistance with eating, staff would have to hand the resident the food or hand them a mug to drink from. The resident could hold some items in their hand and feed themselves. The resident ate in the common area so they could be supervised and would wheel themselves around in the wheelchair while eating. They were not sure if the resident required constant supervision while eating and that would be documented in the CCP and/or the therapy evaluations. When the resident ate on the night shift, they expected them to be across from the nursing station/common area so staff could keep an eye on them. During the investigation, the DON stated they believed LPN #8 said they were at the medication cart passing medications and they were not sure where CNA #7 was while the resident ate the sandwich. If CNA #7 asked LPN #8 to watch the resident while they ate, they expected the resident would be supervised by LPN #8. They were aware the resident was not in line of sight while eating their sandwich as they had peddled off. The resident was found with no pulse or respirations and there was no proof they choked as they only had some tuna fish on their mouth. If they had been choking, the resident would have tried to get up and there was no indication that occurred. During an interview on 10/18/2023 at 8:45 AM, CNA #7 stated the resident frequently asked for food and drink on the night shift, they could not eat in their bedroom, and needed to be in the common area to be supervised while eating. They were not aware of any therapy recommendations or strategies they were supposed to provide to the resident when they were eating. The resident was known to leave the unit in their wheelchair and often wheeled to other units. On 4/26/2023, they gave the resident a sandwich and a milk shake and sat them across from the nursing station with a bedside table. They let LPN #8 know the resident was eating and they were going to take a break. When they left the unit, LPN #8 was in the hallway in line of sight of the resident. They returned from break approximately 5 minutes later and saw CNA #11 near the resident and the resident looked like they had expired. There was a little bit of tuna fish on the resident's mouth. They stated they recalled removing tuna fish from the resident's mouth using mouth swabs when providing postmortem care. During an interview on 10/18/2023 at 9:09 AM, the ADON stated they were called and notified by LPN Supervisor #6 the resident had expired. They directed LPN #6 to notify the on-call medical provider (NP #20). They were not aware the resident had food in their mouth when they were found. They stated they expected the resident to be in line of sight when eating. During an interview on 10/18/2023 at 11:35 AM, the Administrator stated the level of assistance a resident required with eating was determined by SLP and nursing assessments. Residents requiring extensive assistance with eating did not eat in their rooms and staff provided assistance with eating. The resident required assistance with eating because they had a stroke, and one arm was not functioning. They were aware of the incident on 4/26/2023 and was told the resident was supervised, had finished their sandwich, and asked the nurse for a drink of water. They never suspected a choking incident because the resident was capable to get up on their own and if they were in distress, believed they would have been out of their chair, or the chair tipped over. During a follow-up interview on 10/18/2023 at 11:58 AM, the DON stated the physical/ occupational therapists (PT/OT) and speech language pathologist typically sent an email to the Nurse Manager of the unit with therapy recommendations. If the unit had a RN Manager, they would update the CCP. If the unit had an LPN Manager, the LPN needed to notify an RN to update the CCP. They were not aware the SLP recommendations from 7/2022 were not added to the CCP and they should have been. During an interview on 10/18/2023 at 1:00 PM, attending physician #19 stated if a resident had concerns with eating the therapist (SLP) would evaluate the resident and make determinations. They did not recall being notified regarding the 4/26/2023 incident, were not aware of the autopsy report, and it was possible that lack of supervision when eating contributed to the resident's death. During an interview on 10/19/2023 at 9:45 AM, the Director of Therapy stated they received recommendations from the SLP and the recommendations were also sent to dietary/kitchen staff, the MDS Coordinator, the social worker, and regional/corporate staff. They were not aware specific details of the SLP recommendations were not being sent to the nursing staff to update the CCPs until they looked into it during the survey. 10 NYCRR 415.12(h)(1) ---------------------------------------------------------------------------------------------------------------------------------------- Immediate Jeopardy was identified, and the Administrator was notified on 10/18/2023 at 3:38 PM. Immediate Jeopardy was removed on 10/20/2023 at 1:30 PM prior to survey exit based on the following corrective actions taken: - 100% of staff on duty were educated according to the approved training plan. - Staff from various departments (nursing, therapy, activities) were interviewed and confirmed participation and understanding of the education. - The facility developed a plan to educate any staff not working prior to the start of their shift. - Adequate supervision at meals was verified via dining observations which included residents eating in their rooms.

Based on observation, record review, and interview during the abbreviated survey (NY 212) conducted on 5/10/21, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 3 residents reviewed (Resident #1). Specifically, Resident #1 had a history of seeking out the unit showers and wandered unsupervised to another unit where they were found in the shower. This resulted in actual harm to Resident #1 as they sustained first and second degree [CONDITION(S)] from the shower water. Findings include: The Routine Resident Checks policy dated 1/2021 documented the residents will be maintained in a safe environment that protects residents from actual harm. During the off-shifts or timeframes identified by the facility, assigned staff will make daily physical rounds on residents at least every shift. Staff must document on the rounding log as indicated that the rounds were complete. The staff's initials and signatures indicate the resident was physically seen and safety, pain, positioning, and toileting was addressed as needed. Staff will physically observe their resident at least every shift or the timeframe ordered. Resident #1 had diagnoses including non-Alzheimer's dementia, [CONDITION(S)], and [CONDITION(S)]. The 1/27/21 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, had difficulty focusing attention, and disorganized thinking was continuously present. The resident required extensive assistance of two staff for toileting, dressing, and bathing. The resident required supervision of one staff for ambulation on and off the unit and received anti-psychotic medications. The comprehensive care plan (CCP) dated 5/27/20 and most recently updated on 7/24/20, documented the resident had an inability to understand their surroundings related to cognitive impairment. Interventions included to provide support and frequent checks to ensure the resident was in their room. When the resident was out of their room they had behaviors of running and looking for a shower on all wings of the facility as the shower was soothing to them. Staff were to offer food or activities of interest while the resident was wandering to help keep the resident occupied, were to administer [CONDITION(S)] medications as ordered, and were to distract the resident from showering by offering pleasant diversions and activities of interest. The 3/3/21 and 3/4/21 licensed practical nurse (LPN) #11's progress notes documented the resident continued to run in the hall looking for a shower. Redirection was done with little effect. The 3/28/21 LPN #3's progress note documented the resident spent 90% of the day running down the hall to other units to find a shower. The resident ran out of their room more than 20 times that shift. Staff redirected but moments later, the resident was running down the hall again. There was no documented medical was notified when attempts at re-directing the resident away from the shower were unsuccessful. The 4/2/21 psychiatric nurse practitioner's (NP) progress note documented the resident was seen for a follow-up. The resident had a rather intractable [CONDITION(S)] in spite of intervention. The resident continued to engage in negative behaviors on a fairly regular basis and required near constant supervision and redirection though they did have frequent episodes requiring 1:1 supervision. The resident made little eye contact and appeared to have significant cognitive impairment. Their insight and judgement were impaired. The 4/5/21 through 4/6/21 Hourly Rounding Log for the resident's unit documented hourly rounding was to be completed for every resident on the unit daily from 2 PM to 6 AM the next day (evening and night shifts). There was no documentation the resident's hourly rounding was completed on 4/5/21 beginning at 2 PM through 6 AM on 4/6/21. The 4/6/21 at 4:08 AM LPN #10's progress note documented at 4:01 AM, the Supervisor brought the resident back to the unit after finding the resident on another wing in the shower. The resident had [CONDITION(S)] to the thighs and was being assessed by the Supervisor. The 4/6/21 registered nurse supervisor (RNS) #7's progress note documented they found the resident in the shower sitting on the floor. The water was immediately turned off. The resident sustained a 1st degree burn (outer layers of skin, redness, pain, and swelling) to their face, 1st to 2nd degree [CONDITION(S)] (both outer and underlying layers of skin, blisters) on the lower abdomen and perineum (groin) area, 2nd degree burn to the left inner thigh, and 2nd degree burn on right thigh which had sloughed off (peeled skin away). Approximately 10% of the resident's body surface area (BSA) was an open area, and 20% BSA was involved. A dressing was applied to the right thigh and the rest of the intact blisters were open to air. The 4/6/21 at 4:53 AM, LPN #10's progress note documented the resident continued to exit seek and run off the unit. One of the certified nurse aides (CNA) was with the resident doing 1:1, sitting in the resident's doorway. The 4/6/21 wound physician's consultation documented the resident sustained a hot water superficial 2nd degree burn to the right medial thigh that measured 17 centimeters (cm) x 18cm. The area was dry. The treatment was [MEDICATION(S)] ointment daily and as needed for 30 days. The left medial thigh had a superficial 2nd degree burn that measured 7 cm x 5 cm, was dry, and the treatment was to apply [MEDICATION(S)] ointment daily and as needed for 30 days. The physician documented it was not possible to keep a dressing on the area without it sliding and traumatizing the area and this was discussed with staff. The Director of Nursing's (DON) undated investigation summary documented the resident was a Wing 1 resident who was found in the Wing 4 shower at approximately 4:15 AM on 4/6/21 and had sustained left and right 2nd degree thigh [CONDITION(S)]. Water temperatures were checked and never exceeded the temperature requirements. The facility suspended the CNA who worked that night as they did not completed safety checks on the resident. The resident was planned to have a psychiatric NP follow-up. Statements obtained by the facility and included with the investigation documented: - LPN #10's statement dated 4/6/21, documented the resident was asleep in bed at 12:00 AM. The CNAs did bed checks through the night. At 4:01 AM, the resident was brought back to the unit by the Supervisor from Wing 4 where the resident was found in the shower. LPN #10 did not hear or see the resident leave the unit. - CNA #9's statement dated 4/6/2021, documented the last time the resident was toileted or changed was unknown. - CNA #8's statement dated 4/6/21, documented the resident was last toileted or changed at 1 AM or 1:15 AM and CNA #8 thought they saw the resident again at 2 AM rounds but documented it could have been 3:15 AM when she started 2 AM rounds. The 4/6/21 DON's Summary of Investigation documented the resident had an obsession with showers and after the incident, action was taken was to put keypad locks on the showers. The resident continued to be obsessed with showers. On 4/28/21 at 10:30 AM, the resident was observed with LPN #3 awake in her room lying in bed. The resident had a flat affect, provided responses slowly and in single word answers. The resident allowed their legs to be observed. The right thigh had an oval shaped area with varying shades of red and pink skin approximately 6 x 8 inches in dimension and was not measured at the time of the observation. There were areas where dried skin around the edges was peeling and in the center were darker shades of red [NAME] mark like spots. There was no drainage. The left thigh had a pink area approximately the size of two fingers width and length. On 4/28/21 at 12:30 PM, Resident #1 was observed running towards the double doors of wing 4, staff were close behind calling out the resident's name. Staff caught up to the resident at the double doors and were able to redirect them to a chair by the nurse's station. When interviewed on 4/28/21 at 10:40 AM, LPN #3, who was caring for the resident that day, stated she was not working when the resident's accident happened. The resident needed to be checked on frequently for safety. The resident was able to get themselves out of bed, their [CONDITION(S)] was getting worse, but they still got up and wandered. She stated the resident had a fascination with water and so they had to keep an eye the resident. When interviewed on 4/28/21 at 4:08 PM, the DON stated on the evening and night shifts, each wing had a book where hourly rounding was documented on all residents. The staff on the resident's wing (Wing 1) did not document hourly rounding for the entire night shift on 4/6/21 (11:00 PM to 7 AM). The staff said they saw the resident at 2:30 AM and other times during the shift but they were not sure how long the resident was in the shower. The DON saw the resident's skin in the morning of 4/6/21. The resident's abdomen and face were bright red, and both thighs were red, and it looked as though the resident rubbed their skin with the shower wand. The resident was watched closely by staff. The DON stated LPN #10 did not see the resident leave the unit on the night of the incident. The resident had a fixation with showering since they were admitted . At first, the resident was allowed to shower by themselves, but then would sit on the drain and flood the floor, so then they limited them to daily showers. When interviewed on 4/29/21 at 2:18 PM, RNS #7 stated on the night of the resident's accident, RNS #7 was the Supervisor and the nurse on wing 4. RNS #7 stated they were the person who found the resident in the shower. The resident was found because another resident wanted to use the bathroom so RNS #7 went in there to see if the room was free and found Resident #1 in the shower. RNS #7 stated they did not hear the water running from outside of the room and found Resident #1 because RNS #7 entered the bathroom. Resident #1 was sitting on the floor, holding the sprayer toward their thigh, and the water was mostly hitting the right thigh. The room was very steamy. RNS #7 stated there was a point where the shower knob would not turn any hotter, but the water was very hot. RNS #7 spoke with the staff on the resident's wing when RNS #7 returned the resident and the staff said they did not see the resident leave the unit. RNS #7 stated it was possible the resident was gone for a long time. The resident was impulsive and would run out of their room and staff had to chase the resident. RNS #7 stated for rounds, staff were supposed to walk through the unit and check every resident each hour then sign the rounding sheet. When interviewed on 4/30/21 at 9:09 AM, CNA #8 stated the night of the resident's incident CNA #8 did not realize that Resident #1 was in the shower until the Supervisor brought the resident back to the unit. CNA #8 stated they thought they saw the resident first at a little after 11:00 PM. The resident was lying in bed asleep at that time. CNA #8 thought they saw the resident again around 2:00 or 2:30 AM, but when CNA #8 spoke to her co-worker, the co-worker said it was 3:00 AM. The resident was still in their bed at that time. The next time CNA #8 saw the resident was when the Supervisor brought the resident back to Wing 1. It was very busy from 2:00 AM until the resident was returned to the wing. CNA #8 did not know the time the resident left the wing. The resident was very quick and was attracted to the shower all the time. LPN #10 did not help the CNAs that night with the hourly checks. CNA #8 thought all resident's were to be checked every 2 hours but the rounding sheets said every hour. CNA #8 could not find the rounding book that night, did not have time to look for it, then forgot about it. CNA #8 stated before the resident's incident, the resident was always sneaking into the shower and if they could not get in the shower on Wing 1, the resident went to another wing. The staff had to hunt the resident down or chase them. CNA #8 stated all staff were aware of this about the resident. When interviewed on 4/30/21 at 10:48 AM, CNA #9 stated they always worked the nightshift but never on Wing 1. The night of the resident's accident was CNA #9's second time working on Wing 1. CNA #9 was not familiar with the resident at all. The first time she worked on Wing 1 the resident slept in the hall in the recliner all night. CNA #9 did not know if the resident was on hourly or more frequent checks. CNA #9 did not see Resident #1 until they brought them back from the shower on the other wing. When interviewed on 4/30/21 at 12:15 PM, LPN #10 stated he worked as an agency nurse at the facility for 4 or 5 weeks when the resident's accident happened. LPN #10 stated some of the residents on the wing required a higher level of care and Resident #1 was one of them. The night of the accident there were 2 CNAs who were rounding. LPN #10 was not sure when they saw the resident last. LPN #10 started working at 10:00 PM or 11:00 PM that night and did not see the resident leave the unit at all. The resident was known to run, but usually the aides caught them. LPN #10 had to catch the resident as well at times. The Supervisor brought Resident #1 back to Wing 1. LPN #10 was not aware there was a book on the desk to sign his initials for hourly rounding on all residents. LPN #10 was just told the resident was a runner and that was what LPN #10 observed. When interviewed on 5/10/21 at 11:23, NP #13 stated they was very familiar with Resident #1. NP #13 stated the resident's burn was extensive and NP #13 observed it on 4/6/21. NP #13 stated the psychiatric NP followed the resident closely and the resident used showering as a coping mechanism. The resident ran to the shower some days as frequently as 15-20 times and their management had been very difficult, especially when first admitted . She stated the staff followed the resident around and they listened more now, but they had to learn how to manage her. She did not believe the resident required 1:1 supervision but required close supervision. There were days the resident was able to be redirected and others where they were not which made it hard to predict the resident's behavior, but the resident had come to the facility with the behavior of seeking out the shower. Walking with the resident only caused the resident to seek out the showers further so staff would sit in front of the resident's doorway to observe them. She was unsure how long the resident had been missing from their unit. She stated the resident needed watched frequently. When interviewed on 5/10/21 at 12:07, the attending physician stated she was notified of the resident's burn. She had most recently seen the resident on 4/28/21 and saw each resident every 60 days. On a normal day the resident did not speak with her. She had a CNA with her when she made rounds on the resident and was redirectable when last seen but wanted to wander into other residents' rooms. Initially the resident was very difficult to redirect but had improved since then. The resident was no danger to herself when calm but when agitated needed someone to follow her around. Some days the resident was very labile. The resident could be impulsive and responded better to some staff than others. When interviewed on 5/10/21 at 1:28 PM, the DON stated frequent checks was listed in the resident's care plan meant rounds were to be done every hour. The DON stated rounds were done on all residents every hour on the evening and night shifts. The DON stated hourly rounding included making sure the residents were in their rooms. The DON was unable to state how long the resident had been off the unit the night of the incident. The DON stated when Resident #1 was admitted , they required 1:1 supervision but had improved and the level of supervision was decreased. Searching for a shower was not a new behavior for the resident; they had that behavior since admitted . Leaving the unit to find a shower was new for the resident. The DON had not been told the resident had ever left the unit before to find a shower on another unit. The DON stated staff were aware that they could not all be in resident rooms at the same time and they were expected to work together so one of the staff was always present in the common areas so residents could be observed if out of their rooms. 10NYCRR 415.12(h)(2)

Based on interview, record review, and observation during abbreviated surveys (NY 528 and NY 928), the facility did not ensure residents had the right to be free from abuse and did not immediately protect residents from abuse for 1 of 3 residents (Resident #1) reviewed. Specifically, certified nurse aide (CNA) #6 hit Resident #1 resulting in the resident falling to the floor, then hit and kicked the resident while the resident was on the floor. Additionally, CNA #6 was permitted to work the remainder of the shift. Resident #1 was sent to the emergency room and evaluated for a minor closed head injury, contusion to the head, and cervical strain with [MEDICATION NAME] and lumbar pain associated with a sprain. This resulted in actual harm to Resident #1. Findings include: The facility's abuse policy dated 3/2020 documented each resident had the right to be free from verbal, physical, and mental abuse, and each resident would be treated with dignity and respect. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was intact. The comprehensive care plan (CCP) dated 6/19/2020 documented Resident #1 had limited physical mobility, needed assistance with activities of daily living (ADL) related to muscle weakness and spasms to bilateral legs. The resident had behaviors, was socially inappropriate, verbally aggressive/abusive, and non-compliant with the rules of the facility. Interventions included to determine the cause of the behaviors, remove the resident from situations when necessary, and provide psychological services as needed. The facility's incident report dated 6/27/2020 at 1:10 AM, documented an unobserved physical assault/altercation occurred between Certified Nurse Aide (CNA) #6 and Resident #1. Licensed Practical Nurse (LPN) #3 and Registered Nurse Supervisor (RNS) #2 entered the unit and observed Resident #1 and CNA #6 wrestling on the floor. LPN #3 and RNS #2 attempted to separate the resident and CNA #6. An ambulance and the police were called. Statements obtained by the facility as part of the investigation included: - Resident #1's statement documented they had a previous issue with CNA #6 and the last time the resident asked her for something, CNA #6 slammed the resident's door. On 6/27/2020, Resident #1 rang the call bell and when no one answered, the resident went to the nursing station. CNA #6 was sitting at the desk. CNA #6 called the resident a crack head, knocked the resident down, hit and kicked the resident, and placed her knee on their chest. - Resident #4's, statement documented they witnessed the incident reported on 6/27/2020. They heard CNA #6 state she was not going to answer Resident #1's call bell because she had an issue with Resident #1 the prior week. Resident #4 heard Resident #1 and CNA #6 arguing. CNA #6 called Resident #1 a crack head, used foul language, and made a threat. Resident #4 heard a boom and saw CNA #6 on top of Resident #1, with her knee on Resident #1's chest while punching the resident in the head. Resident #1 was swinging back at CNA #6. RNS #2 and LPN # 3 attempted to grab CNA #6 off of Resident #1. CNA #6 continued to kick and punch Resident #1 during that time. - CNA #6 reported she had a previous issue with Resident #1 and on 6/27/2020, she told the nurse she was not answering the call bell because of the prior issue. CNA #6 was at the nursing station and Resident #1 approached her and began berating her. CNA #6 called the resident a crack head and Resident #1 threatened her, she put up her hand to protect herself, and the resident fell . Resident #1 tried to hit her with a stool, so she leaned on top of the resident while the resident was on the ground. - RNS #2's statement documented on 6/27/2020, she arrived on the unit and heard CNA #6 screaming that she was being bit and was using foul language. Resident #1 reported CNA #6 pushed, punched and kicked them several times. When interviewed on 7/20/2020 at 8:05 AM, the Director of Nursing (DON) stated the actual time of the incident was at 1:00 AM on 6/27/2020. The video surveillance time was not accurate and there was a three-hour difference between the time on the video and the actual time. The surveyor observed the video surveillance of the incident which documented the date was 6/26/2020 (actual date 6/27/2020 as video surveillance was three hours different from the actual time): - From 9:57 PM to 9:59 PM (actual time 6/27/2020 at 12:57 AM to 12:59 AM), Resident #1 was sitting in a wheelchair in front of the nursing station. CNA #6 was behind the nursing station desk. Resident #1 got up from the wheelchair and slowly walked to the nursing station. Resident #1 and CNA #6 engaged in conversation. - At 9:59 PM (actual time 6/27/2020 at 12:59 AM), CNA #6 lifted her right arm, reached for something on the desk, pulled back her arm and made forceful contact with the resident's face. Resident #1 fell to the floor. CNA #6 remained at the nursing station, moving things on the desk, while the resident remained lying on the floor. - At 10:00 PM (actual time 6/27/2020 at 1:00 AM), CNA #6 was standing kicked her right leg forward, towards the resident's face, then turned her body facing the desk, leaned into the desk and kicked backward while the resident remained on the floor. Resident #4 was then noted to arrive in a wheelchair at the nursing station. CNA #6 thrust her right foot and leg forward towards Resident #1 who remained on the floor. CNA #6 then kicked a foot stool backward and kicked her foot forward towards the resident. CNA #6 grabbed the stool, bent over, and continued to kick her foot forward towards the resident while the resident remained lying on the floor (the surveyor was unable to see whether she made contact with the resident at this time). - At 10:00:35 (actual time 6/27/2020 at 1:00:35 AM and 1:00:38 AM), RNS #2 and LPN #3 arrived at the scene. CNA #6 continued to thrust her hand forward punching at the resident with a closed fist. RNS #2 and LPN #3 attempted to remove CNA #6 from the resident and had difficulty pulling her off the resident. Once in a standing position, CNA #6 began pointing her right hand towards Resident #4 and appeared to be yelling at the resident and slammed her hand down on the nurse's station desk. - At 10:02 PM (Actual time 6/27/2020 at 1:02 AM), Resident #1 remained on the floor and CNA #6 remained behind the nursing station within a few feet of the resident until Emergency Medical Services (EMS) arrived. The hospital record dated 6/27/2020 at 2:59 AM, documented Resident #1 reported they were assaulted by a CNA at the nursing facility. The resident had complaints of moderate pain to the head, neck and lower back. The resident received [MEDICATION NAME] (narcotic pain medication) at 4:02 AM. The hospital imaging (scans and x-rays) did not show any relevant findings and the impression was no acute traumatic injury was identified. The general instructions documented the resident had a minor closed head injury, contusion to the head and cervical strain with [MEDICATION NAME] and lumbar back pain associated with sprain. During an observation and interview on 7/8/20 at 9:49 AM, Resident #1 was in bed in their room. Resident #1 stated they had pain in the left shoulder, back and right knee. Resident #1 reported they were assaulted by a CNA. The resident stated they were receiving pain medication however it did not help a lot and they continued to have pain. The Director of Nursing (DON) was interviewed on 7/8/2020 at 11:34 AM and stated Resident #1 had mobility issues and multiple behaviors. She was not aware that CNA #6 and Resident #1 had an incident prior to the 6/27/2020 incident. She was notified of this incident at 6:00 AM on 6/27/2020, and at that time, she placed CNA #6 on administrative leave. The DON stated video surveillance showed the resident had slow mobility and it took a while for the resident to ambulate to the nursing station. CNA #6 pushed Resident #1 to the floor and kicked the resident. The DON stated it was not visible on the video but Resident #4 reported CNA #6's knee was on Resident #1's chest. The DON stated after the incident, CNA #6 went to the emergency room to be evaluated and when she returned, RNS #2 allowed CNA #6 to work the rest of the shift. She stated CNA #6 should not have been permitted to work in the facility after the incident with Resident #1. CNA #6 was interviewed via telephone on 7/9/2020 at 10:43 AM, and stated she was the victim of an assault by Resident #1. She stated they had a prior incident on 6/25/2020 that was a verbal altercation and on 6/27/2020, she asked the nurse to answer the resident's call bell due to their previous altercation. The resident came to the desk and made threats against her and she did not walk away as she was the only person on the unit. She stayed at the nursing station and told the resident to go back to their wheelchair. She stated the resident was very close to her and was yelling and threatening her. She stated the resident hit her, but she could not state where on her body she was hit. She put her right hand up and the resident fell . She did not hit or push the resident, she just put her hand up. When the resident fell behind the desk, the resident picked up a stool and tried to hit her with it, so she was forced to restrain the resident. She held down the resident's arm and her leg was stretched over the resident's chest, not resting on the chest just over it then the resident bit her leg. She stated she did not think she hit the resident but may have. She was trying to restrain the resident and protect herself. LPN #3 was interviewed via telephone on 7/9/2020 at 11:38 AM, and stated on 6/27/2020, she was in the nursing office when CNA #6 told her she was not going to answer Resident #1's call bell due to the resident being rude to her a few days earlier. LPN #3 answered the call bell and the resident asked for pain medications. LPN #3 needed to clarify the orders with RNS #2 so she left the unit to speak to RNS #2. When she and RNS #2 returned to the unit, they heard CNA #6 yelling to get the resident off her. She observed Resident #1 lying on the floor and CNA #6 was positioned with each leg on either side of the resident's head and the resident had a hold of both her legs. She tried to separate them but could not get them apart. She did not see CNA #6 hit or kick the resident but did see CNA #6's knee on the resident's chest before the resident bit her. Both the resident and CNA #6 used foul language. Resident #1 and CNA #6 separated themselves and RNS #2 notified Administration, the police, and an ambulance. The surveyor attempted to contact RNS #2 via the telephone and via a certified letter and no response was received. When interviewed on 7/22/2020 at 9:38 AM, the nurse practitioner (NP) stated she saw the resident the day after the incident occurred. The resident presented with bruising on the lower back and left arm that was not present a few days earlier. The resident was very anxious and had an increase in their post-traumatic stress disorder symptoms. She ordered anti-anxiety medication and made a referral for psychological services. The resident had complaints of pain and received pain medication that was effective. 10NYCRR 415.4(b)(2)(3)

Based on record review and interview during the abbreviated survey (NY 956) the facility did not ensure treatment and care was provided in accordance with professional standards of practice for 1 of 3 residents (Resident #5) reviewed for [MEDICATION NAME] (blood thinning medication). Specifically, Resident #5's lab work to monitor blood clotting was not checked as ordered. The resident experienced a gastrointestinal (GI) bleed and was hospitalized with complications from the GI bleed. This resulted in actual harm to Resident #5 that was not immediate jeopardy. Findings include: The Anticoagulants, [MEDICATION NAME] Policy, dated 9/2015, documented labs were drawn per physician order [REDACTED]. After each lab draw, the nurse would make an entry on the anti-coagulant flowsheet which was maintained in the lab section of the chart. If the resident showed signs or symptoms of bleeding, medical was to be contacted immediately. Resident #5 was admitted to the facility on [DATE] and had a history of [REDACTED]. The resident's cognition was intact per the 6/20/2018 Minimum Data Set (MDS) assessment. The 8/6/2018 lab report documented the resident's International Normalized Ratio (INR, measure of blood clotting time) was elevated at 4.4 (normal=2-3.5). The 8/7/2018 nurse practitioner's (NP) progress note documented the resident had an elevated INR (blood clots more slowly, increased risk of bleeding). The NP documented [MEDICATION NAME] time (PT, measure of blood clotting) was 51.3 seconds (normal) and INR was 4.4 (high). The NP documented the resident was recently on antibiotics and the plan was to hold the [MEDICATION NAME] for 48 hours and then resume the same dose, and to recheck INR in one week. The 8/2018 Medication Administration Record [REDACTED]. The resident's lab reports included: - On 8/13/2018, PT was normal at 39.8 seconds and INR was normal at 3.4. The documented plan was to continue [MEDICATION NAME] 2.5 milligrams (mg) daily and recheck INR in one week (8/20/2018). - On 8/20/2018, PT was normal at 39.4 seconds and INR was normal at 3.3. The documented plan was to continue [MEDICATION NAME] 2.5 mg daily and recheck INR in 2 weeks (9/3/2018). - On 9/5/2018, PT was normal at 28.2 seconds and INR was normal at 2.4. The documented plan was to continue the same [MEDICATION NAME] 2.5 mg daily and recheck INR in 2 weeks (9/19/2019). On 9/6/2018, a physician's orders [REDACTED]. There was no documentation in the medical record of a lab report and no entry on the resident's anti-coagulant flow sheet of a PT/INR lab result after 9/5/2018. The 9/24/2018 the NP progress note at 10:37 AM, documented over the past 12 hours the resident had a change in mental status, confusion, and decreased bowel sounds. The plan included intravenous (IV) fluids, check labs (complete blood count, CBC and comprehensive metabolic panel, CMP) and to obtain a flat plate of the abdomen. There were no nursing progress notes from 9/4/2019-9/24/19 documenting the resident's physical condition. The 9/24/2018 at 4:33 PM licensed practical nurse (LPN) Manager #3's progress note documented the resident was lethargic and not looking good that morning. The resident complained of being tired. A flat plate, IV fluids, and stat labs were ordered. The 9/24/2018 at 6:51 PM, registered nurse (RN) #1's progress note documented the resident had a change in condition which included abnormal vital signs, altered mental status, and unresponsiveness starting that morning. The resident's blood pressure was 100/62 and oxygen saturation was 41% and increased to 90% after administering oxygen (liters not documented). The resident was on [MEDICATION NAME] and the last INR was 2.4 on 9/5/2018. The resident had abdominal tenderness with black, tarry stools. IV fluids were administered, and oxygen was applied. RN #1 documented the resident's flat plate showed no impaction or obstruction on 9/24/2018 and the lab results came back with a panic high potassium level of 7 milliEquivelents per Liter (mEq/L, normal=3.5-5 mEq/L), a decreased hemoglobin (measure of red blood cells) of 7.5 milligrams per deciliter (mg/dL, normal=12-15.5mg/dL), and a decreased hematocrit (volume of red blood cells to volume of blood) of 28.8% (normal=37-48%). The plan was to send the resident to the hospital. The hospital history and physical documented the resident arrived at the local hospital on [DATE] at 7:34 PM with complaints of black stools, dyspnea (difficulty breathing) and elevated blood pressure. The PT was high at 51.2 seconds and INR was high at 5.5. The hospital's lab report documented an INR above 5-5.5 appeared to be associated with an unacceptably high risk of bleeding. The clinical impression was a GI bleed associated with blood loss and [MEDICATION NAME] coagulopathy (impairment of the blood's ability to coagulate). The resident was transferred to a larger medical center in another city. On 9/25/2018 at 2:27 AM, the admission note from the hospital where the resident was transferred to documented the resident was treated with 4 units of fresh frozen plasma and vitamin K (aids in blood clotting). The resident's secondary [DIAGNOSES REDACTED]. The resident's respiratory status declined during hospitalization and she passed away on 9/27/2018. On 5/29/2019 at 10 AM, a representative from the lab was interviewed and stated the last PT/INR result they had for the resident was on 9/5/2018. The representative stated a PT/INR was not drawn for the resident after that date. On 6/6/2019 at 1:06 PM, LPN Manager #3 stated in an interview, to track PT and INRs, the facility used an anti-coagulant flowsheet that was filed in each resident's chart who was on [MEDICATION NAME]. She stated they also kept track of pending PT/INRs on a white board in the unit nursing office. She stated when a result was received, they informed the NP in person or by phone. The nurses entered any orders the NP gave as a result of the PT/INR. She stated when labs were ordered, the nurses wrote it in the lab book and[NAME] Clerk #4 completed a lab slip and faxed it to the lab. She stated she and[NAME] Clerk #4 were responsible for making sure the labs were done as ordered and she did not recall the resident's PT/INR not being drawn as ordered. LPN Manager #3 stated labs were drawn on Monday, Wednesdays and Fridays at the facility so the PT/INR order entered on 9/6/2018 would have been drawn on 9/21/2018. She stated on the day she saw the resident before she went to the hospital, she was not responding per her usual, so she had the NP see her and he ordered a flat plate and labs. On 6/6/2019 at 2 PM,[NAME] Clerk #4 stated in an interview, she completed the lab slips faxed them to the pharmacy after the nurses wrote the lab orders in the lab book. She stated she kept the faxes for a while and then shredded them and the ones from 9/2018 would have been shredded already. She stated the phlebotomists (a person who draws blood) also signed the lab book when they came in but the signatures from 9/2018 would also have been shredded by now. She stated she did not check to ensure the lab slips that she faxed were responded to by the lab. She stated routine labs were drawn on Mondays, Wednesdays and Fridays so this resident's lab would have been scheduled for 9/21/2018. On 6/10/2019 at 10:10 AM, the NP stated in an interview, when he saw the resident and orders the PT/INR to be checked in two weeks she was stable so that was an appropriate order. He stated routine labs were drawn on Mondays, Wednesdays, and Fridays so that order that was entered on 9/6/2018 would have been drawn in two weeks on the next day labs were drawn. He stated because it was routine it was okay if it was a day or two after the two weeks because of lab scheduling. He stated if the resident had signs of bleeding he would have changed the order and had it drawn on a day that was not the regular lab day. He stated he did not recall any specifics as to why the PT/INR ordered on [DATE] was not drawn in two weeks. 10NYCRR 415.12