Every finding on record at The Highlands at Brighton

Based on interviews and record review, the facility did not ensure alleged violations involving resident-to-resident physical aggression were reported immediately to the Administrator and the New York State Department of Health for two (2) of four (4) residents reviewed (Resident #4 and Resident #5). Specifically, on 11/24/2025 at 6:00 PM, Resident #4 threw a cup containing ice at Resident #5 during a verbal altercation, striking Resident #5. The facility did not notify the Administrator until 11/28/2025 at 3:00 PM and did not report the incident to the New York State Department of Health until 12/02/2025 at 3:45 PM.The findings include:The facility policy Abuse, Neglect and Mistreatment, last reviewed in October 2024, included all staff were required to report any potential or actual incidents of abuse, mistreatment, or neglect involving a resident to the Director of Nursing, Administrator, or the New York State Department of Health. In compliance with Section 2803-d of the Public Health Law, potential or actual incidents of abuse, mistreatment, or neglect involving a resident would be reported by the Administrator or facility designee to the New York State Department of Health.Resident #4 had diagnoses including anxiety (a mental health disorder causing excessive worry or fear), bipolar disorder (a mental health disorder causing changes in mood and behavior), and failure to thrive (decline in physical health, weight, or functioning). The Minimum Data Set (a resident assessment tool) dated 12/29/2025 documented Resident #4 was cognitively intact.Resident #5 had diagnoses including psychosis (a mental health disorder causing loss of contact with reality), cerebrovascular accident (a stroke caused by interrupted blood flow to the brain), and adjustment disorder (difficulty coping with stressful events). The Minimum Data Set, dated [DATE] documented Resident #5 was cognitively intact.Review of the Nursing Home Incident Intake documented the incident occurred on 11/24/2025 at 6:00 PM, staff became aware of the incident on 11/24/2025 at 6:00 PM, and the Administrator was first notified on 11/28/2025 at 3:00 PM. The record documented the incident was not reported to the New York State Department of Health until 12/02/2025 at 3:45 PM. The investigation report was submitted to the New York State Department of Health on 12/03/2025 at 10:18 AM.Review of the facility incident report dated 11/24/2025 classified the incident as Physical Aggression. The report documented Resident #4 and Resident #5 were involved in a verbal altercation in the dining room which escalated when Resident #4 threw a cup containing ice at Resident #5, striking Resident #5 on the arm. The report documented Resident #4 stated, I do not care, I do not feel bad, I do not like Resident #5 and I will do it again. The facility's immediate response documented Resident #4 and Resident #5 were separated for safety and monitored by staff the remainder of the shift. Both residents were encouraged to refrain from aggressive behaviors and instructed to report aggressive incidents to staff immediately. The record documented the residents were placed in rooms away from each other and were not seated near each other in the dining room. Review of witness statements revealed statements were obtained on 11/24/2025 immediately following the incident. Resident #5 was assessed following the incident and had no observed injuries or signs of emotional distress. The record documented Resident #5 remained pleasant and in good spirits following the incident.Review of notification records documented Resident #4's family member was notified on 11/26/2025 at 3:15 PM and Resident #5's family member was notified on 11/26/2025 at 4:24 PM. The record documented Resident #4's medical provider was notified through the Provider Communication Book on 11/26/2025 at 3:14 PM and Resident #5's medical provider was notified through the Provider Communication Book on 11/26/2025 at 4:24 PM.During an interview on 03/06/2026 at 9:45 AM, the Director of Nursing stated reportable incidents should be reported within two (2) hours if serious bodily injury occurred and within 24 hours if serious bodily injury did not occur. The Director of Nursing stated the incident involving Resident #4 and Resident #5 should have been reported to the New York State Department of Health within 24 hours but was not. The Director of Nursing stated staff delayed reporting while completing the investigation and acknowledged the practice was incorrect.During a telephone interview on 03/06/2026 at 10:55 AM, the Administrator stated reportable incidents were submitted to the New York State Department of Health by the Director of Nursing or the Administrator within 48 hours of the incident occurring. The Administrator stated the incident involving Resident #4 and Resident #5 was not reported timely.Title 10 New York Codes, Rules and Regulations Section 415.4(b)(2),(4)

Based on observations, interviews, and record review, the facility failed to ensure a resident's environment remained as free from accident hazards as possible for one (1) of five (5) residents reviewed (Resident #6). Specifically, the facility did not ensure consistent monitoring and documentation of Resident #6's self-administration of medications as ordered by the medical provider. The facility also did not ensure accurate accountability of medications available to Resident #6 after the resident reported ingesting multiple days' worth of medications.The findings include:The facility policy Medication Administration: Self-Administration of Medication, last reviewed on 10/04/2018, included if the attending physician and interdisciplinary team approved self-administration of medications, the Nurse Manager or Charge Nurse would obtain a physician order for self-administration of medications. The medication nurse would determine daily the correct amount of medications self-administered and would initial the Medication Administration Record (MAR - a medication documentation record) for the daily check and accuracy. Any discrepancy in medication counts should be reported immediately to the Nurse Manager or Charge Nurse.Resident #6 had diagnoses including diabetes (a disease causing high blood sugar), obesity (excess body weight increasing health risks), and psychotic disorder with delusions (a mental health disorder causing false beliefs). The Minimum Data Set (a resident assessment tool) dated 07/07/2025 documented Resident #6 was cognitively intact.Review of the Comprehensive Care Plan dated 09/09/2024 revealed Resident #6 was able to self-administer medications using a medi-set (a weekly medication organization system). Interventions included nurses would check the medi-set every shift, refill the medi-set weekly per provider orders, and notify the medical team if Resident #6 was noncompliant with medications.Review of physician orders active as of 08/19/2025 included the following: Ziprasidone (Geodon) 60 milligrams two (2) times daily for psychosis, ordered 05/24/2024. Divalproex (Depakote Extended Release) 1,500 milligrams daily for psychosis and dementia with behaviors, ordered 09/20/2023. Bictegravir-emtricitabine-tenofovir (Biktarvy) one (1) tablet daily, ordered 09/15/2022. Medi-set training ordered 05/08/2024. The provider order included nursing staff were to check the medi-set after each scheduled medication administration, document in the Medication Administration Record Resident #6 self-administered medications, document every shift compliance with the medi-set and whether prompting was needed, and refill the medi-set every Thursday on day shift.Review of progress notes from 08/01/2025 through 08/19/2025 revealed Resident #6 was noncompliant with medications on 08/02/2025 at 2:00 PM, 08/02/2025 at 10:00 PM, and 08/11/2025 at 4:20 AM. The record did not include evidence a medical provider was notified regarding the medication noncompliance. The record also did not include documentation identifying dates and times the medi-set was refilled.Review of the historical Medication Administration Record for medications administered from 08/01/2025 through 08/19/2025 revealed inconsistent nursing documentation. Some licensed nurses documented medications as given, while other licensed nurses documented medications as given by other.Review of a nursing progress note dated 08/19/2025 (Tuesday) at 8:00 PM documented Resident #6 stated they had taken all medications for the week with the intention to harm themselves because they felt lonely and had no one to talk to. The on-call provider was notified immediately and Resident #6 was transferred to the hospital for further evaluation and treatment.Review of a facility investigative report dated 08/25/2025 revealed staff found Resident #6 lying on the floor on 08/19/2025 at 8:00 PM. Resident #6 stated, I took extra pills and got dizzy. The medi-set was checked and staff observed six (6) days' worth of medications were missing. Vital signs were stable and Resident #6 was alert and responsive during the assessment. Emergency Medical Services transported Resident #6 to the hospital for further evaluation and treatment. The provider, Director of Nursing, and responsible parties were notified.Review of an Emergency Department provider note dated 08/19/2025 at 8:39 PM revealed Resident #6 was evaluated after intentionally ingesting four (4) days' worth of medications, including Biktarvy and Depakote.Review of hospital records documented Resident #6 remained hospitalized from [DATE] through 08/26/2025 and was followed by toxicology services for medication monitoring.Review of a psychiatric evaluation dated 08/22/2025 documented Resident #6 remained at chronically elevated risk for suicide related to chronic medical conditions and trauma history. The psychiatric evaluation documented Resident #6 was also at elevated acute risk following the intentional ingestion of medications. The psychiatric evaluation documented the safety plan included facility staff assisting Resident #6 with medications.During an interview on 02/23/2026 at 2:27 PM, Licensed Practical Nurse #2 stated if a resident was care planned to self-administer medications, nursing staff would check at the end of the shift to ensure the resident took the medications. Licensed Practical Nurse #2 stated staff would document medication administration in a progress note and check 'completed' on Medication Administration Record.During an interview on 02/23/2026 at 2:36 PM, Licensed Practical Nurse Manager #1 stated staff would know a resident could self-administer medications because there would be a provider order identifying refill instructions. Licensed Practical Nurse Manager #1 stated the assigned nurse would refill the medi-set and document the refill in a progress note. Licensed Practical Nurse Manager #1 stated staff found Resident #6 on the floor and found the medi-set empty.During an interview on 02/24/2026 at 12:17 PM, the Director of Nursing stated investigations involving resident events would include resident interviews, staff interviews, and medical record review. The Director of Nursing stated the purpose of the investigation process was to ensure resident safety and determine whether policy or practice failures occurred. The Director of Nursing stated during the investigation involving Resident #6, staff reviewed the Medication Administration Record to determine possible medications ingested. The Director of Nursing stated six (6) days of medications were missing from the medi-set. The Director of Nursing stated they expected documentation identifying when the medi-set was refilled, but staff could not determine when the medi-set was last filled prior to the incident.During an interview on 03/04/2026 at 12:43 PM, Licensed Practical Nurse Manager #1 stated nurses were expected to document every shift whether Resident #6 complied with self-administration of medications and whether prompting was required. Licensed Practical Nurse Manager #1 stated nurses would review the Medication Administration Record, speak with the resident regarding medication administration, and document given by other if the resident self-administered medications.During an interview on 03/06/2026 at 8:50 AM, Licensed Practical Nurse Manager #1 stated staff could not determine when the medi-set was last filled before 08/19/2025. Licensed Practical Nurse Manager #1 stated nurses documenting given may have meant the resident took the medications, but staff should have documented given by other if Resident #6 self-administered the medications. Licensed Practical Nurse Manager #1 stated nurses were expected to complete behavior notes every shift documenting medication compliance, but some nurses completed the documentation and others did not.During an interview on 03/06/2026 at 9:46 AM, the Director of Nursing stated the provider order required nurses to specifically document how Resident #6 performed self-administration of medications and whether prompting was needed. The Director of Nursing stated nursing documentation left opportunities for unanswered questions regarding medication accountability and monitoring. The Director of Nursing stated the investigation relied on the nursing supervisor's findings regarding missing medications and staff did not review documentation to determine when the medi-set was last refilled.Title 10 New York Codes, Rules and Regulations 415.12(h)(1)-(2)

Based on observations, interviews, and record review conducted during the Recertification Survey from 08/6/2025 to 08/13/2025, for four (4) (Medication Carts on Residential Units A, B, D, and E) of five (5) medication carts reviewed, the facility did not ensure that all drugs and biologicals were stored and/or labeled in accordance with currently accepted professional principles and regulations. Specifically, on the Residential E Unit, there were pre-poured medications for multiple residents and multiple loose medications in the medication cart. On the Residential A Unit, there were multiple loose pills in a medication cart, and an unlocked, unattended medication cart was observed. On the Residential D Unit, medication carts were left unlocked and unattended with medications sitting on top. On the Residential B Unit, a medication cart was left unlocked and unattended. The findings include:The facility policy Medication Administration, dated July 2024, included, but was not limited to, medication carts are secured or controlled by nursing personnel at all times and nursing staff will observe the eight (8) Rights of Medication Administration (a set of principles for nurses to ensure the safe and accurate delivery of medication to patients): right patient, right medication, right dose, right time, right record, right reason, right response, and right route.During an observation on the Residential B Unit on 08/08/2025 at 12:32 PM, a medication cart was observed unlocked and unattended.During an observation on the Residential D Unit on 08/11/2025 at 9:35 AM, a medication cart was observed unlocked and unattended with three (3) bottles of omeprazole (a medication that treats excess stomach acid) on the top of the medication cart.During an observation on the Residential A Unit on 08/11/2025 at 10:33 AM, a medication cart was observed unlocked and unattended.During an observation and interview on the Residential E Unit on 08/11/2025 at 4:33 PM, there were 16 cups labeled with resident names with multiple pre-poured (prepared prior to the scheduled medication pass) medications found on the top of the medication cart, and multiple loose pills were found in the drawers. During an interview at this time, Licensed Practical Nurse #9 stated the entire 08/11/2025 medication pass for 5:00 PM and 8:00 PM were in the medication cups observed on the cart. Licensed Practical Nurse #9 was unable to identify all medications contained in the cups, including but not limited to, levetiracetam (an anti-seizure medication), ziprasidone (an anti-psychotic medication), buspirone (an anti-anxiety medication), and lisinopril (a medication to control high blood pressure). Licensed Practical Nurse #9 stated they did not know the policies or procedures for when a medication cart is to be inspected for expired medications or loose pills. They stated it was unsafe to have loose in the medication cart and to administer medications to a resident they could not identify. Licensed Practical Nurse #9 did not give a response when asked why the medications were pre-poured.During an interview on 8/12/2025 at 2:24 PM, Registered Nurse Manager #1 stated medication carts should be checked weekly for expired medications or loose pills and both should be sent back to pharmacy for disposal. Registered Nurse Manager #1 stated the expectation for a medication pass is to pull medications for one resident at a time, and to administer the medications at the time they were pulled. Registered Nurse Manager #1 stated it is not a safe practice to pre-pour medications. During an interview on 8/13/2025 at 9:49 AM, the Director of Nursing stated the expectation for a medication pass is to monitor and observe the Rights of Medication Administration, assess the resident for appropriate response to medications, and to document in real-time. The Director of Nursing stated it was never appropriate to pull medications prior to the scheduled medication administration time and it was an unsafe practice. 10 NYCRR 415.18 (d), (e)(1-4)

Based on observations, interviews, and record review conducted during a Recertification Survey from 08/06/2025 to 08/13/2025 for two (2) (Residents #69 and #81) of two (2) residents reviewed, the facility did not serve food in accordance with professional standards for food safety. Specifically, Resident Care Aide #1 was observed touching unwrapped pieces of graham crackers with their bare hands and the crackers were then consumed by Residents #69 and #81. This is evidenced by the following:The facility policy Hand Washing, dated June 2024, included hand washing was the most important component on infection prevention and should occur before and after contact with a resident or resident's environment. Hand washing with either commercially available hand sanitizer or soap and water was acceptable. The Resident Care Aide Job Description, revised January 2025, included, but was not limited to, passing water pitchers and nourishments, removing trash, and to demonstrate good customer service with residents, family, and other staff. Resident #69 had diagnoses including cerebral palsy (condition which affects a person's ability to move and maintain balance and posture), muscular dystrophy (genetic disease that causes progressive weakness and loss of muscle mass), and left hand contracture (a permanent tightening and shortening of muscles, tendons, or skin, causing limited movement). The Minimum Data Set (a resident assessment tool), dated 07/10/2025, revealed Resident #69 had severely impaired cognition. Resident #81 had diagnoses including Parkinsonism (a collection of neurological disorders that cause symptoms such as tremor, slow movement, and stiffness), dementia, and protein-calorie malnutrition (a condition caused by inadequate intake of protein and calories). The Minimum Data Set, dated [DATE], revealed Resident #81 had severely impaired cognition.During an observation on 08/06/2025 at 9:59 AM, Resident Care Aide #1 opened a package containing two graham crackers, and with their ungloved (bare) hand, they touched portions of the graham crackers and handed them to Resident #81. Resident Care Aide #1 then proceeded to an unknown resident, and took an empty bottle of Ensure (nutritional drink) from them to dispose. Resident Care Aide #1 did not perform hand hygiene or put on gloves between Resident #81 and the unknown resident. Resident Care Aide #1 then opened another package of graham crackers, and with their ungloved hand, touched portions of the graham crackers and handed them to Resident #69, which the resident consumed. Resident Care Aide #1 did not perform hand hygiene between the unknown resident and Resident #69. During an interview on 08/06/2025 at 10:03 AM, Resident Care Aide #1 stated in their role, they give residents water, snacks, and help them with their meal trays. Resident Care Aide #1 stated they usually wear gloves when assisting residents during meals and should have worn gloves when touching the graham crackers.During an interview on 08/06/2025 at 10:12 AM, Licensed Practical Nurse Manager #3 stated staff should perform hand hygiene anytime they come in contact with residents, including sanitizing their hands after passing out meal trays. Licensed Practical Nurse Manager #3 stated staff should not touch ready to eat food items with their bare hands. They stated Resident Care Aide #1 should not have touched the graham crackers without gloves. During an interview on 08/13/2025 at 12:33 PM with Administrator and Director of Nursing, the Administrator stated they were not aware staff were touching food with their bare hands. The Administrator stated Resident Care Aide #1 had worked in the kitchen and should have known better. 10 NYCRR 415.14(h), 10 NYCRR: Subpart 14-1.80(a)

Based on observation, interviews, and record review conducted during a Recertification Survey from 08/06/2025 to 08/13/2025, for one (1) (Resident #1) of one (1) resident reviewed, the facility did not ensure the resident's right to privacy and confidentiality of their personal and medical records was maintained. Specifically, a computer stationed in a hallway on Residential Unit D was observed open, exposing Resident #1's personal and medical information; there were no staff members present to secure the information for nine (9) minutes. This is evidenced by the following:Resident #1 had diagnoses including chronic respiratory failure, diabetes, and methicillin resistant staphylococcus aureus infection (a bacteria that is resistant to a wide range of antibiotics). The Minimum Data Set (a resident assessment tool), dated 05/30/2025, documented the resident was in a persistent vegetative state (lacking any meaningful interaction with themselves and the environment) and cognition was undetermined. During an observation and interview on 08/11/2025 at 4:35 PM, a computer was stationed in the middle of the hallway approximately five (5) feet from the nurse's station on Residential Unit D. There was no staff present in the area. The computer screen was open, exposing Resident #1's picture, name, date of birth , vital signs, and code status. Additionally, a yellow banner across the top of the computer screen included diagnoses of Extended-Spectrum Beta-Lactamase (ESBL) (enzymes produced by bacteria causing resistance to common antibiotics), Carbapenem-Resistant Enterobacterales (CRE) (a group of bacteria resistant to antibiotics), and Multidrug-Resistant Organism (MDRO) (an infection that occurs when bacteria/fungi becomes resistant to multiple types of antibiotics). At 4:44 PM, the computer screen timed out and went back to the original home screen; the staff person assigned to the computer had not returned. At 4:48 PM, Respiratory Therapist #1 exited a resident room and stated they had been busy on the unit, but they usually closed their computer screen before walking away. Respiratory Therapist #1 stated they received Health Insurance Portability Accountability Act (HIPAA) training in the past which covered maintaining residents' privacy and protecting their medical records. During an interview on 08/12/2025 at 10:46 AM, the Director of Respiratory stated they considered an open computer screen that exposed a resident's medical record a breach of confidentiality because anyone could access their information, and even during busy times, staff should secure their computers before walking away. The Director of Respiratory stated the facility had sent out modules reminding staff about Health Insurance Portability Accountability Act (HIPAA) and they would expect staff to position their computers so the resident's information was only visible to them. During an interview on 08/12/2025 at 12:07 PM, the Director of Nursing stated they would expect staff to follow their training, and when they are not with their computer, to secure their screen to protect the resident's information. Not doing so was a Health Insurance Portability Accountability Act (HIPAA) violation. 10 NYCRR 415.3 (e)(1)(ii)

Based on interviews and record review conducted during a Recertification Survey from 08/06/2025 to 08/13/2025, for one (1) (Resident #90) of one (1) resident reviewed, the facility did not ensure an incident was thoroughly investigated to rule out abuse, neglect, or mistreatment. Specifically, Resident #90 reported being touched on their leg and foot by a staff member, and the facility could not provide documented evidence that potential abuse, neglect, or mistreatment were ruled out. This is evidenced by the following:The facility policy Abuse, Neglect & Mistreatment, dated October 2024, included the residents shall be free from verbal, mental, sexual and physical abuse, corporal punishment and involuntary seclusion, mistreatment or neglect. Alleged violations involving abuse, mistreatment or neglect will be thoroughly investigated, and investigative outcomes will be documented, and measures will be taken to prevent further potential abuse, mistreatment, or neglect while the investigation is in progress. The facility policy Abuse, Neglect and Mistreatment: Protection of Residents, dated June 2024, included in the event abuse, neglect, mistreatment, or misappropriation of resident property is alleged or has occurred, the facility will take timely and appropriate steps to protect the residents of the facility and to prevent further potential for abuse during the course of the investigation and as the situation subsequently warrants. Resident #90 had diagnoses including Wernicke's encephalopathy (a brain disorder caused by a vitamin deficiency), transverse myelitis (a neurological disorder causing damage to the spinal cord), and muscle weakness. The Minimum Data Set (a resident assessment tool), dated 06/20/2025, revealed Resident #90 was cognitively intact. Resident #90's Comprehensive Care Plan, initiated on 05/13/2025, included the resident had a personality disorder, schizoaffective disorder, and persecutory delusions. Interventions included to assess the resident's coping skills and support systems, and to analyze and document key times, places, circumstances, triggers, and what de-escalates behaviors. During an interview on 08/13/2025 at 10:43 AM, Resident #90 stated earlier in the year, Certified Nursing Assistant #3 touched their leg and two (2) weeks later wiggled the resident's big toe and stated they were checking to see if the resident was breathing. Resident #90 stated Certified Nursing Assistant #3 also touched the back of their calf during the overnight shift on 01/25/2025 when the staff member was by themself. Resident #90 stated they told the nurse, but it was investigated and swept under the rug.Review of a progress note, dated 01/25/2025, Licensed Practical Nurse #7 documented at 7:00 PM Resident #90 informed the writer Certified Nursing Assistant #3 had touched the resident's foot or leg on three (3) occasions, they felt uncomfortable with Certified Nursing Assistant #3, and it made the resident feel weird. Licensed Practical Nurse #7 documented Certified Nursing Assistant #3 was told to swap, if they were assigned to Resident #90's care, until management could address the issue. Review of a progress note, dated 01/28/2025, Licensed Practical Nurse #8 documented they spoke with the resident about their concerns, and Resident #90 stated the certified nursing assistant touched their leg and grabbed their toes, which was done on two (2) occasions to see if the resident was breathing. Resident #90 stated they did not feel unsafe or that it was sexual in nature, but felt it was inappropriate. Review of the facility's investigation revealed a three (3) page file which included Licensed Practical Nurse #7's progress note, Licensed Practical Nurse #8's progress note, and a typed, unsigned statement, dated 01/25/2025, with Certified Nursing Assistant #3's typed name. The facility's investigation did not include additional investigative findings, a statement from Licensed Practical Nurse #7, additional staff/witness statements, or a determination if abuse was ruled out. During an interview on 08/13/2025 at 2:33 PM, the Director of Nursing stated investigations of alleged abuse, neglect, or mistreatment would include the creation of an Accident/Incident report, speaking with the resident, and obtaining additional statements to then determine if immediate action needed to be taken. The Director of Nursing stated if a complaint did not rise to the level of abuse, the immediate course of action would be to notify a supervisor. The Director of Nursing stated Resident #90's statement to Licensed Practical Nurse #7 would not have risen to the level requiring immediate notification to a nursing supervisor and there was no suspicion of abuse. The Director of Nursing stated they did not think Licensed Practical Nurse #7 had a concern that abuse occurred. The resident stated they felt weird and Licensed Practical Nurse #7 reassigned the aide from the resident's care. The Director of Nursing stated the nurse manager could have been made aware by the 24-hour nursing report or a note placed under their door, and once notified, the nurse manager met with the resident, discussed the concern, and at that point it did not rise to the level of abuse. The resident's care plan was modified, and completion of an Accident/Incident report was not indicated. The Director of Nursing stated the facility did an 'unofficial' investigation of the concern. When reviewed at that time, the Director of Nursing stated the investigation provided by the facility was not a complete, thorough investigation and some of the nurse managers at the time of the incident were agency staff and it had been difficult to locate their investigation records.During an interview on 08/13/2025 at 2:34 PM, the Administrator stated during an investigation the facility would assess the resident, collect statements from staff and resident(s), gather as much data as possible, and go from there. The Administrator stated abuse would involve intent. They did not feel there was any intent or malice in this case, and they did not think the allegation rose to the level of abuse because on the night shift, staff must go in and check on the residents. 10 NYCRR 415.4(b)(3)

Based on observations, interviews, and record review conducted during a Recertification Survey from 08/06/2025 to 08/13/2025, for two (2) (Residents #5 and #57) of four (4) residents reviewed, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #5 required staff assistance with shaving and was observed on multiple occasions with a significant amount of facial hair. Resident #57 required staff assistance with showering and hair washing, there was no documented evidence the resident received a shower or had their hair washed for two (2) weeks, and their hair was uncombed and oily with a dry, flaky scalp over multiple days. This is evidenced by the following:1. Resident #5 had diagnoses including end stage renal disease, low back pain, and depression. The Minimum Data Set (a resident assessment tool), dated 06/20/2025, documented the resident was cognitively intact and required supervision and hands on assistance with personal hygiene. Review of Resident #5's current Comprehensive Care Plan on 08/11/2025 did not include measurable goals or interventions related to personal grooming.Review of Resident #5's Personal Care Profile (used by certified nursing assistants to guide care), last revised on 07/30/2025, did not include instructions for personal grooming.During an observation and interview on 08/11/2025 at 10:42 AM, Resident #5 had a significant amount of facial hair around their chin and along their jawline and uncombed, oily hair. During an interview at that time, Resident #5 stated they did not like having facial hair, tried not to think about it, and avoided looking in the mirror. The resident stated there was a staff person who used to help with their care, but lately they seemed rushed. The resident stated they had received a bed bath in recent days, but no one offered to wash their hair or remove their facial hair at the time and they could not remember the last time it was done. Resident #5 stated they required staff assistance due to back and right arm pain with limited range of motion.During an observation and interview on 08/12/2025 at 9:50 AM, Resident #5 was seated in their wheelchair preparing to leave the facility for an appointment. The resident had a significant amount of facial hair measuring approximately 0.5 centimeter in length. During an interview at that time, Resident #5 stated a staff person had helped them get ready for their appointment, but did not offer to remove their facial hair. The resident stated they did not like going to their appointments with facial hair and would try not to think about it, but was reminded of it whenever they rested their face on their hands. During an interview on 08/12/2025 at 10:17 AM, Licensed Practical Charge Nurse #1 stated Resident #5 required assistance with washing their back and securing their corset, but they could wash up independently once set up was provided. Licensed Practical Charge Nurse #1 stated the resident did not have a history of refusing care and they noticed Resident #5 had a significant amount of facial hair. Upon review of the Personal Care Profile, Licensed Practical Charge Nurse #1 stated the resident required hands on assistance with personal grooming and facial hair removal. They stated they offered to remove the resident's facial hair a month and a half ago when they were in pain, but the resident refused at the time, and they had not offered or delegated anyone to assist the resident since then. Licensed Practical Charge Nurse #1 stated the Personal Care Profile was kept in the resident's room and the Certified Nursing Assistants should review and follow it. They stated they would expect staff to provide care and facial hair removal without the resident asking. During an interview on 08/12/2025 at 11:48 AM, the Director of Nursing stated Resident #5 needed to be re-evaluated by physical therapy to determine their level of care needs due to a discrepancy on their Personal Care Profile. The Director of Nursing stated various disciplines had seen the resident daily and someone should have assisted them with removing their facial hair.2. Resident #57 had diagnoses including hemiplegia/hemiparesis (muscle weakness and partial paralysis on one side of the body) affecting the left side, dysphagia (difficulty swallowing), and muscle weakness. The Minimum Data Set, dated [DATE], documented the resident was cognitively intact and dependent with showering and personal hygiene. Review of Resident #57's current Comprehensive Care Plan, last revised on 06/26/2025, included the resident had an activities of daily living (basic daily care tasks) self-care performance deficit related to hemiplegia and staff were to provide a sponge bath when a full bath could not be tolerated. There were no documented interventions related to personal hygiene and grooming. Review of Resident #57's current Personal Care Profile included the resident had left-sided weakness, sensory deficits, and was dependent on staff for transfers, bed mobility, toileting, and dressing. There were no documented interventions related to personal hygiene and grooming. Review of a nursing progress note, dated 07/29/2025, a Licensed Practical Nurse documented Resident #57's last shower and hair wash was on 07/29/2025. During an observation and interview on 08/07/2025 at 9:39 AM, Resident #57 had long, oily hair and a significant amount of facial hair. During an interview at that time, Resident #57 stated they wanted a haircut and their shower day was on Tuesday, but had not received it because the unit was short-staffed. They were told by staff they would get a shower later, but the following day, no one offered. Resident #57 stated they had recently had a stroke and wanted a shave, but they could not do it alone. During an observation and interview on 08/11/2025 at 10:10 AM, Resident #57 was lying in bed with a gown on and their hair was uncombed and oily with a dry, flaky scalp. During an interview at that time, Resident #57 stated they had an appointment to get a haircut, but did not know when it would be because the barber was backed up. The resident stated they used to wash their own hair often, so having a dry, flaky scalp bothered them. They last had their hair washed a couple weeks ago, but they were afraid to ask for help due to the attitudes of staff. During an observation and interview on 08/11/2025 at 4:53 PM, Resident #57 was lying in bed with oily hair and a dry, flaky scalp. During an interview at that time, Resident #57 stated they did not get their hair washed and hoped the staff would wash it the following day. During an observation and interview on 08/12/2025 at 9:18 AM, Resident #57 was sitting up in bed wearing a gown and their hair was uncombed and oily with a dry, flaky scalp. Resident #57 stated they were supposed to get a shower and hair wash, but they were going to therapy and did not think the day shift staff would provide that care because their shower was scheduled for the night shift. During an interview on 08/12/2025 at 9:31 AM, Certified Nurse Assistant #4 stated when Resident #57 was on their assignment, they would wash them up and get them dressed. They stated the resident would not advocate for themself, so staff needed to check on them and anticipate their needs. During an interview on 08/12/2025 at 11:33 AM, the Director of Nursing stated they would expect the staff to anticipate Resident #57's care needs and assist them as needed. If the staff saw their hair soiled and disheveled, they would expect the staff to care for them since the resident could not express their own needs. 10 NYCRR 415.12(a)(3)

Based on observations, interviews, and record review conducted during a Recertification Survey from 08/06/2025 to 08/13/2025, for one (1) (Resident #57) of one (1) resident reviewed, the facility did not ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, Resident #57 had a medical order to wear a compression sleeve to their left arm and on multiple observations, did not have the compression sleeve in place. This is evidenced by the following:Review of the facility policy Splints/Braces, last revised October 2024, included, but was not limited to, nursing will add the device to the resident's care plan and Activities of Daily Living (ADL) Sheet/Care Card. The Certified Nursing Assistant will apply the device to the extremity as directed for the specified times as noted on the Activities of Daily Living Sheet/Care Card. The staff will apply and remove the device as directed per the Activities of Daily Living Sheet/Care Card.Resident #57 had diagnoses including hemiplegia/hemiparesis (muscle weakness and partial paralysis on one side of the body) affecting the left side, dysphagia (difficulty swallowing), and muscle weakness. The Minimum Data Set (a resident assessment tool), dated 07/29/2025, documented the resident was cognitively intact, and had limited range of motion in their left upper extremity.Review of the current Comprehensive Care Plan, last revised on 06/26/2025, included Resident #57 had left hemiparesis related to a stroke. Interventions included, but were not limited to, ensure the compression sleeve was applied in the morning and removed at bedtime. Review of the current Personal Care Profile (used by certified nursing assistants to guide care), last revised 08/12/2025, included Resident #57 had left-sided weakness and the resident was to wear a compression sleeve to the left arm during the day and removed at night. When reviewed on 08/11/2025, medical orders included to place a compression sleeve to the left arm in the morning and remove at bedtime. During an observations and interviews on 08/11/2025 at 10:10 AM and 4:53 PM, Resident #57 was lying in bed and was not wearing their compression sleeve. During interviews at these times, Resident #57 stated they had pain in their left arm. During an interview on 08/11/2025 at 4:57 PM, Licensed Practical Charge Nurse #2 stated Resident #57 should have their compression sleeve applied every morning and removed at night. Upon review of the electronic medical record at this time, Licensed Practical Charge Nurse #2 stated the nurse responsible for Resident #57's care on the day shift documented a pain score of 5 out of 10 (moderate pain) in their left arm, but there was no progress note indicating the resident refused to have their compression sleeve applied. Licensed Practical Charge Nurse #2 stated staff should always enter a progress note if the resident refused their compression sleeve. During an observation on 08/12/2025 at 9:18 AM, Resident #57 was sitting up in bed with their left arm resting on a pillow and they were not wearing the left compression sleeve. During an interview at this time, Resident #57 stated they were having pain in their arm.During an interview on 08/12/2025 at 9:31 AM with Social Worker #1 and Certified Nursing Assistant #4, Social Worker #1 stated through working with Resident #57 and from speaking with the family, they learned the resident did not advocate for themself and staff needed to check on them and anticipate their needs. Certified Nurse Assistant #4 stated Resident #57 would tell staff how they felt if staff checked in with them, but would not initiate reports. During an interview on 08/12/2025 at 11:33 AM, the Director of Nursing stated the task of applying the compression sleeve showed on the nurse's work list in the electronic health record and Resident #57 could not express their needs. They would expect staff to apply the resident's compression sleeve as ordered and certainly when the resident reported pain in their left arm. 10 NYCRR 415.12

Based on observations, interviews, and record review conducted during the Recertification Survey from 08/06/2025 to 08/13/2025, the facility did not ensure the posted nurse staffing information included the required information daily, at the beginning of each shift, and was readily accessible to residents, staff, and visitors. Specifically, the posted nurse staffing information did not include the actual number of licensed (Registered Nurses and Licensed Practical Nurses) and unlicensed (Certified Nursing Assistants) nursing staff who were directly responsible for resident care during each shift. This is evidenced by the following:During observations on 08/06/2025 at 4:24 PM and 08/11/2025 at 10:16 AM, the facility's posted nurse staffing information listed numbers next to each nursing title, ranging from 8 to 56, and did not specify if those were the actual hours worked or the total number of licensed and unlicensed nursing staff assigned to each shift. Review of the daily nurse staffing information from 06/01/2025 to 08/11/2025 revealed all dates did not include the total number of Registered Nurses, Licensed Practical Nurses, and Certified Nursing Assistants for each shift.During an interview on 08/12/2025 at 11:26 AM, Staffing Coordinator #1 stated the posted daily nurse staffing information included the number of residents and how many nurses and certified nursing assistants were scheduled for each unit. Staffing Coordinator #1 stated if the posting listed a number eight (8) next to Registered Nurse (RN) on a shift, it meant there was one (1) Registered Nurse who worked eight (8) hours. If there was a number 16 next to Certified Nursing Assistant (CNA), it meant there were 2 Certified Nursing Assistants because they worked 8 hours each, which would account for the number 16. Staffing Coordinator #1 stated they were taught to only document the actual hours worked on the daily posted nurse staffing. During an interview on 08/13/2025 at 11:55 AM, the Director of Nursing stated the posted daily nurse staffing included the resident census for each unit and the actual hours for the registered nurses, licensed practical nurses, and certified nursing assistants scheduled each shift. The Director of Nursing stated the total number of nursing staff was reflected in the actual hours worked, and they were not aware both the total number of staff and the actual hours worked had to be listed on the daily postings. During an interview on 08/13/2025 at 12:33 PM with the Administrator and the Director of Nursing, the Administrator stated they were not aware the posted daily nurse staffing had to include both the total number and the actual hours worked by the nursing staff. 10 NYCRR 415.13

Based on interviews, and record review, conducted during the Recertification Survey 9/27/23 to 10/4/23, it was determined that for one of one resident groups, the facility did not ensure that concerns and recommendations of the residents group relating to resident care and life in the facility were acted upon promptly. Specifically, the facility could not provide evidence that residents' voiced concerns in Residents Council meetings were investigated, and rationales or responses were provided to the residents. This is evidenced by the following: The facility policy, Grievances, dated August 2020, included that a grievance is defined as any alleged violation or dispute between a resident/family and the facility, including interpretation or application of the resident's [NAME] of Rights. The staff of the Social Work department and other departments will be responsive to residents/families regarding the resident's care and quality of life. Prompt review and a timely response will be given to resident/family grievances. All grievances will be given full consideration, and the expression, review and resolution of grievances are an important component in creating a sense of community for residents. Review of the Resident Council Meeting Minutes for June 2023, August 2023, and September 2023 (no meeting in July) included multiple concerns, issues or grievances voiced by residents in attendance such as (but not limited to): Staffing shortages and call bell response times Smoking near the building and cigarettes being thrown around Someone going into a resident's room when unoccupied and items being found moved, broken, or taken. Fruit juices and fluid consumption Cell phone use by staff Food occasionally not cooked thoroughly A bug was found in a resident's food Residents eating food from refrigerators that belong to others Additionally, the meeting minutes did not include facility rationales or responses in subsequent meeting minutes to resident issues, concerns, or grievances, voiced during previous meetings. During a Resident Council meeting on 10/2/23 at 10:30 AM, several residents in attendance said that the facility does not consider the views of resident or act promptly upon grievances or recommendations. During an interview on 10/3/23 at 9:55 AM and again on 10/4/23 at 12:15 PM, the Director of Recreation (DOR) stated that a Recreation staff member attends the meeting and takes notes, which the DOR subsequently types up and sends out any reported concerns to the relevant departments. The DOR said that usually the departments will respond, which should be reported back during the next meeting. When asked where the follow-up responses were on the meeting minutes, the DOR stated that if a follow-up was not included on subsequent meeting minutes, then a follow-up or rationale was probably not discussed. During an interview on 10/3/23 at 1:38 PM, the Director of Social Work (DSW) said that they went to every Resident Council meeting and their role consisted of them guiding the meeting. The DSW stated that, with the DOR, they take the concerns, issues or grievances voiced by the residents and reach out to facility staff responsible to make them aware of the grievances and affect the change. The DSW stated that until recently, the Director of Recreation was putting the resolutions in the meeting minutes but was not sure if follow-up occurred with all of the concerns listed in the meeting minutes. The facility was unable to provide evidence of follow-up to the grievances voiced in the Resident Council Meeting Minutes for June 2023, August 2023, and September 2023. 10 NYCRR 415.5 (c)(6)

Based on interviews, and record reviews conducted during the Recertification Survey 9/27/23 to 10/4/23, it was determined that for one (Resident #85) of three residents reviewed for elopement, the facility did not ensure an alleged elopement was thoroughly investigated. Specifically, Resident #85 left the facility unsupervised on 8/5/23 for an extended period of time, staff were unaware of the resident's whereabouts, and the incident was not investigated. This is evidenced by the following: The facility policy Elopement Prevention, dated August 2023, documented that elopement is when a dependent resident in a licensed facility leaves that facility without staff observation or knowledge of their departure. The Quality Assurance committee will review and discuss all elopement concerns when indicated. The facility policy Eloped Resident, dated August 2023, documented that at the point a resident cannot be located, the nurse in charge of the area will be responsible to notify Nursing Administration/Facility Administration. Upon return of the missing resident staff are to complete an accident/incident report and notify the New York State Department of Health. Resident #85 had diagnoses including dementia with behavioral disturbances and psychotic disorder with delusions. The Minimum Data Set Assessment, dated 7/8/23, revealed the resident had moderately impaired cognition, was independent with mobility, had shown no wandering behaviors, and had not used a wander/elopement alarm. A Wandering Risk Assessment, dated 7/8/23, revealed Resident #85 was independent with mobility, was taking antipsychotic medications, and had no known history of wandering. Review of Resident #85's electronic medical record revealed a Nursing Order dated 6/24/22, that Resident #85 may leave the facility with a responsible party. Review of the Comprehensive Care Plan (CCP), dated 4/28/23, revealed Resident #85 had impaired cognitive function or impaired thought processes related to dementia and major depressive disorder with psychotic behavior. Interventions included, but were not limited to, that the resident preferred to go on outings, going to church, and for staff to cue, reorient, and supervise as needed. The CCP did not include any focus, goal, or interventions that addressed Resident #85's risk for elopement or if they were able to leave the facility independently. Review of Interdisciplinary Progress Notes revealed the following: a. On 8/5/23 at 10:10 AM, Licensed Practical Nurse (LPN) #6 documented that Resident #85 left the building, did not sign out or inform staff that they would be leaving, and that the supervisor was notified. b. On 8/5/23 at 10:54 AM, the Registered Nurse/Infection Control Nurse documented they were notified by the floor and their security department that Resident #85 left the building. Writer attempted to call the resident's cell phone but that it was not accepting phone calls. The resident's family was contacted, and they were able to reach the resident by phone. The resident called the facility and stated they were at [NAME] Park by themselves. RN #1 instructed Resident #85 to return to the facility. c. On 8/5/23 at 1:58 PM, LPN #4 documented that Resident #85 returned to the facility and there were no issues. Review of a Telepsychiatry Visit Note dated 8/15/23 (following the incident), Nurse Practitioner (NP) #1 documented that several weeks ago Resident #85 had eloped to [NAME] Park and their guardian persuaded the resident to return to the facility. The resident's insight was poor to fair and there had not been any other inappropriate or impulsive behaviors. Recommendations included to remind Resident #85 that eloping from the facility would have a negative impact on their acceptance to a lower level of care. Review of a Provider Progress Note dated 9/20/23 at 1:43 PM, Physician Assistant (PA) #1 documented that Resident #85 had stated I ran away a few weeks ago and I am going to do it again. Do not doubt me. The facility was unable to provide an accident/incident report for the alleged incident that occurred on 8/5/23 or any documented interventions to prevent the incident from reoccurring. During an interview on 10/4/23 at 10:06 AM and again at 10:46 AM, Resident #85 stated they had left the facility and took the bus to go to [NAME] Park. Resident #85 stated I'm not going to lie; I did do that. They did not know I was leaving, but they called me, and I came right back. I did not get hurt and I was ok when I got back. During an interview on 10/4/23 at 10:14 AM, Registered Nurse Manager (RNM) #2 stated they did not know if Resident #85 leaving the facility on 8/5/23 was really an elopement. RNM #2 stated they did not think the resident had signed out on the unit or at the front desk and that staff did not know where they were but thought they had gone out with a family member. RNM #2 said the incident was brought up in morning report and reported to Social Work, the Administrator, and the medical team and they have not heard anything about it since. During an interview on 10/4/23 at 11:40 AM, PA #1 stated Resident #85 had told them they ran away. PA #1 said that Resident #85 had come back to the facility on his own and had their cell phone on them. PA #1 said that the resident had been in the facility for a while, had not made any overt attempts to leave and that they did not feel Resident #85 was an elopement risk. During an interview on 10/4/23 at 12:11 PM, the Director of Nursing (DON) stated that they were not familiar with an actual elopement. An elopement would be if they had run away, or they were trying to escape the facility and got out. The DON felt because they knew Resident #85, they did not think the resident would ever run away and could not see them leaving the facility. Resident #85 is out of the building a lot going to festivals, shopping, and church (with family). Resident #85 has verbalized that they did not want to stay at the facility. The DON said that Resident #85 was young and close to their family and friends and had been at the facility for a long time and did not understand why they needed to be in a skilled nursing facility. The DON stated they did not feel the resident was at risk for elopement. During an interview on 10/4/23 at 12:24 PM, the Registered Nurse/Infection Control Nurse stated they were notified by a nurse on 8/5/23 that Resident #85 was not in the building, staff were not sure if the resident had gone out and did not know where the resident was. The staff started calling Resident #85 when they could not find them in the building and the Registered Nurse/Infection Control Nurse was unsure if the resident had signed out and that this instance was different from other times because Resident #85 usually informed the staff when they were leaving the building (with family or friends). The Registered Nurse/Infection Control Nurse stated the incident was reported to the DON. During an interview on 10/4/23 at 12:31 PM, the Administrator that they never missed morning report but that they were not aware of the elopement prior to surveyor interventions. 10 NYCRR 415.4

Based on observations, interviews, and record reviews conducted during a Recertification Survey 9/27/23 to 10/4/23, it was determined that for two (Resident #56 and #99) of 30 residents reviewed for care planning, the facility did not develop a comprehensive, person-centered care plan for each resident that included services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being or any specialized services. Specifically, Residents #56's comprehensive Care Plan (CCP) did not address their status as a current smoker, and Resident #99's CCP did not address the resident's current skin issues. This was evidenced by the following: Review of facility policy Care Plan, Interdisciplinary, dated 6/7/19, included that the care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being including the resident's right to refuse treatment. It will be prepared by the interdisciplinary team and be periodically reviewed and revised by the team. The care plan will be oriented towards preventing avoidable decline in function or functioning levels and it will identify and attempt to manage risk factors and build on resident's strengths. Each discipline shall review the care plans at least every 92 days. Any change is care plan involving/affecting another discipline shall be conveyed to that discipline and common goals agreed upon. 1.Resident #56 had diagnoses including tobacco use, traumatic brain injury and seizures. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident was cognitively intact. Review of the Resident Smoking List provided by the facility on 9/27/23 revealed Resident #56 listed as a current smoker. In an interdisciplinary progress note, dated 6/16/22, Licensed Practical Nurse (LPN) #4 documented that the fire alarm sounded, and staff smelled smoke outside of Resident #56's room and that smoke was in the resident's room and their bathroom. In a letter dated 6/17/22 to the resident's family located in Resident #56's electronic medical record, the Administrator documented that the facility requested the family to stop bringing Resident #56 cigarettes, as they were enabling resident to smoke which included that the resident was doing so inside the facility. Review of a Resident Smoking Contract, that was signed by Resident #56 was dated 6/20/23 and an Occupational Therapy (OT) smoking initial evaluation was completed on 8/31/23 (over a year after the incident involving smoking in their room) In an interview on 9/28/23 at 9:38 AM, the Administrator stated residents should be care planned for smoking and most of the residents are independent and have smoked their entire lives. During an interview on 10/2/23 at 10:22 AM, Resident #56 stated they have been smoking at this facility since admission four years ago. In an interview on 10/3/2023 at 11:53 AM, Registered Nurse Manager (RNM) #2 stated Resident #56 has been smoking at this facility for a while. RNM #2 said that care plans are updated quarterly, and they can always go in and add something if needed. During an interview on 10/3/23 at 1:17 PM, LPN #3 stated Resident #56 had a smoking evaluation in either July or August, and their care plan should have been updated once they had the evaluation but was unsure if this was done. LPN #3 said the Kardex (care plan used by the Certified Nursing Assistants (CNAs) for daily care) is updated at the same time as the CCP, and they check the CCP against the Kardex and MDS to make sure all information matches. The facility was unable to provide documented evidence that Resident #56's CCP and CNA Kardex had included that Resident #56 had a nicotine dependence with goals and interventions and a history of smoking in their room. 2. Resident #99 was admitted to the facility with diagnoses that included diabetes, protein-calorie malnutrition, and stroke. The MDS assessment dated [DATE], included that the resident had a deep tissue injury, and required pressure ulcer care and dressings to the feet. In an observation on 9/29/23 at 10:09 AM Resident #99 was in bed with Prevalon boots (cushioned boots to prevent heel breakdown) on both feet and a dressing applied to their right foot. Review of Resident #99 electronic medical record revealed that in medical progress notes dated 8/15/23 and 9/15/23, the physician documented that the resident had multiple wounds and to continue wound care and monitor-unfortunately breakdown and infections has continued to be problematic due to how frail and chronically ill the resident has been. Review of the Wound Assessment Note dated 9/28/23 and signed by Physician Assistant (PA) #1, included that Resident #99 had mixed vascular and deep tissue injury wounds to both feet, requiring twice daily dressing changes. Additionally, interventions included Prevalon boots (to both feet) at all times with heel in open space for offloading, nutritional supplements, use of a low air loss mattress and a turn and repositioning program were also listed. Review of Resident #99's CCP did not include any care plan related to skin issues/ current wounds, history of, goals and/or interventions or preventive measures for skin breakdown. During an interview on 10/3/23 at 2:13 PM, LPN #8 stated they and the unit nurse manager are involved with creating and revising resident CCPs and should provide a 'head to toe picture' of the resident and information related to things such as fall prevention, ventilators, and nutrition information. LPN #8 stated they would revise the care plan when there was a change to the resident or their care. In a follow-up interview at 2:53 PM, LPN #8 stated they spoke with Nursing Leadership who said that a deep tissue injury, or a wound should be listed on the CCP. During an interview on 10/4/23 at 11:19 AM, RNM #3 stated that they and the charge nurse are involved with developing and revising CCPs. RNM #3 stated information related to (but not limited to) diagnoses, falls, pain, edema or skin issues and preventative measures should be included on CCPs and any changes in the resident's care. Additionally, RNM #3 said they have quarterly care plan meetings with residents' families and the interdisciplinary teams. RNM #3 stated the CCP should include wounds, interventions and prevention of. During an interview on 10/4/23 at 11:47 AM, the DON said they would expect venous wounds and deep tissue injuries to be on a resident's CCP and that they were aware of Resident #99 who has had skin issues for about a year. 10 NYCRR 415.11 (c)(1) 47641

Based on observations, interviews, and record reviews conducted during the Recertification Survey 9/27/23 to 10/4/23, it was determined for one (Resident #19) of four residents reviewed for activities of daily living (ADLs), the facility did not provide the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #19 was observed on several days to be unshaven and had fingernails that were long and unclean. This is evidenced by the following: Resident #19 had diagnoses including dementia with behavioral disturbance, depression, and rheumatoid arthritis. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment, required extensive assistance with personal hygiene, total dependent for bathing and had behavioral symptoms not directed toward others, and rejection of care on one to three days in the lookback period. Review of the Comprehensive Care Plan dated 9/28/23, revealed Resident #19 has a compromised ability to complete ADLs due to decreased mobility and active symptoms of depression which impeded their ability to participate in ADLs. Interventions included, but not limited to that the resident is dependent on staff for assistance with hygiene. Review of the Personal Care Profile (care plan used by the Certified Nursing Assistants (CNAs) to provide daily care), revised on 9/10/23, revealed Resident #19 required assistance with a bed bath and nail care on Tuesday, day shift. Review of Resident #19's Electronic Medical Record-task documentation (area used by CNAs to document daily care provided) from 9/20/23 to 10/3/23 revealed the resident required extensive assistance or was totally dependent on staff to complete personal hygiene and did not include any documented evidence that the resident refused care. During observations on 9/28/23 at 11:45 AM, 9/29/23 at 1:22 PM, 10/2/23 at 9:01 AM, 10/3/23 at 1:50 PM, and 10/4/23 at 10:05 AM, Resident #19 had several days growth of grey stubble on their face and their fingernails were long with brown debris underneath. During an interview on 10/3/23 at 2:22 PM, CNA #1 stated Resident #19 needed total assistance with their care. They stated they had given the resident a bed bath that morning. CNA #1 stated they were going to shave Resident #18, but the resident's electric razor did not work, and they were going to use a regular razor, but their family was visiting at that time. During an interview on 10/3/23 at 2:31 PM, Resident #19's representative stated there had been issues with the resident not being shaved and having long nails. Resident #19's representative stated they have asked for the resident's nails to be trimmed, but it was not always done and that the shaving was on and off. They said that they did not know the electric razor was not working, probably needed to be charged and that Resident #19 would not know this, but staff should. During an interview on 10/4/23 at 10:14 AM, Registered Nurse Manager #2 stated that residents should always be kept clean just like we would want. Staff do not have to wait until shower days to assist residents with shaving or trimming nails. 10 NYCRR 415.12(a)(3)

Based on observations, interviews and record review conducted during a Recertification Survey 9/27/23 to 10/4/23, it was determined that for three (Residents #21, #34, and #85) of twelve residents reviewed for accidents, the facility did not ensure that the resident's environment remained as free of accident hazards as is possible. Specifically, Resident #21 was observed smoking under the non-sprinkler awning and within 10 feet of the building; Resident #34 had cigaarette butts on their person and discarded cigarette butts in their trash can in their room; and Resident #85 eloped from the facility and the facility did not reevaluate the resident's risk for elopement or develop a comprehensive care plan (CCP) that addressed the incident with follow up measures to prevent reoccurrence. This is evidenced by the following: 1. Resident #85 had diagnoses including dementia with behavioral disturbances and psychotic disorder with delusions. The Minimum Data Set (MDS) Assessment, dated 7/8/23, revealed the resident had moderately impaired cognition, had shown no wandering behaviors, and did not use a wander/elopement alarm. Review of the facility policy Elopement Prevention, dated August 2023, defined resident elopement as when a dependent resident in a licensed facility leaves that facility without staff observation or knowledge of their departure. Diagnoses pertinent to the risk of elopement include dementia and manic depression. Once a resident has been identified as a high-risk, appropriate interventions should be implemented that could include supervision and periodic checks as possible. Once preventive measures have been implemented, everything needs to be documented in the resident's chart and communicated to everyone involved with the resident's care. Areas include the resident's care plan, listing all interventions that are used to prevent reoccurrence. Unit Managers will be responsible for monitoring the resident's status and the Quality Assurance committee will review and discuss all elopement concerns when indicated. Review of Resident #85's CCP, dated 4/28/23, revealed the resident #85 had impaired cognitive function or impaired thought processes related to dementia and major depressive disorder with psychotic behavior. Interventions included, but were not limited to, to engage in simple structured activities with no overly demanding tasks, going on outings, church, getting hair done and ordering food. Staff need to cue, reorient, and supervise as needed. The CCP included the resident was at risk for falls, uses a wheelchair for long distances and expresses a desire to return home. The CCP did not include if they were able to safely leave the facility independently. A Wandering Risk Assessment, dated 7/8/23, revealed Resident #85 was independent with mobility, was on antipsychotic medications (medications for mental illness with potential serious side effects), had no known history of wandering and was at low risk for elopement. Review of Resident #85's electronic medical record revealed a nursing order dated 6/24/22, that the resident may leave the facility with a responsible party. Review of interdisciplinary progress notes included the following: a. On 8/5/23 at 10:10 AM, Licensed Practical Nurse (LPN) #4 documented that Resident #85 left the building, did not sign out or inform staff that they would be leaving and that they notified the supervisor. b. On 8/5/23 at 10:54 AM, the Registered Nurse (RN)/Infection Control Nurse (ICN) documented they were notified by the floor and security that Resident #85 left the building. Writer attempted to call the resident's cell phone that was not accepting phone calls. The resident's family was contacted and were able to reach the resident by phone. The resident called the facility and stated they went alone to the park (approximately 2&1/2 miles away) and was instructed to return to the facility. c. On 8/5/23 at 1:58 PM, LPN #4 documented that Resident #85 returned to the facility and there were no issues. d. On 9/29/23 at 5:53 PM, RN #3 documented that Resident #85 was dressed, and by the nurse's station and stated they were going to church by myself. RN #3 wrote that they informed Resident #85 that they were not allowed to leave the facility by themselves. In a Telepsychiatry Visit Note dated 8/15/23, Nurse Practitioner (NP) #1 documented that several weeks ago Resident #85 had eloped to the park and their guardian persuaded the resident to return to the facility. NP #1 wrote that the resident's insight was poor to fair, and recommendations included to remind Resident #85 that eloping from the facility would have a negative impact on their acceptance to a lower level of care. Review of a medical progress note dated 9/20/23 at 1:43 PM, Physician Assistant (PA) #1 documented that Resident #85 told PA #1 that I ran away a few weeks ago and I am going to do it again. Do not doubt me. The assessment and plan related to dementia with psychosis included that unfortunately Resident #85 was decompensating and the concern was when they had any setbacks, their lack of coping mechanisms triggered them to mania which appeared to be the case at that time. During an interview on 10/4/23 at 10:06 AM and again at 10:46 AM, Resident #85 stated they had left the facility to go to the park and took the bus to get there. Resident #85 stated they usually sign out (when going out to church) but they did not sign out that day. During an interview on 10/4/23 at 10:14 AM, Registered Nurse Manager (RNM) #2 stated they did not know if Resident #85 leaving the facility on 8/5/23 was really an elopement. RNM #2 said that staff did not know where the resident was and thought they had gone out with a family member. The incident was brought up in morning report and had been reported to Social Work, the Administrator, and the medical team. RNM #2 stated they did not feel Resident #85 was an elopement risk. During an interview on 10/4/23 at 12:11 PM, the Director of Nursing (DON) stated that they were not familiar with an actual elopement but thought that an elopement would be if a resident ran away trying to escape the facility and got out. The DON stated that Resident #85 had verbalized that they wanted to be out of the facility and did not understand why they needed to be in a skilled nursing facility. The DON stated resident was all talk and did not feel the resident was at risk for elopement. During an interview on 10/4/23 at 12:24 PM, the RN/ICN stated they were notified by staff on 8/5/23 that Resident #85 was not in the building and that staff did not know where the resident was. The RN/ICN stated this instance was different from other times because Resident #85 usually informed the staff when they were leaving the building with family and that they had reported the incident to the DON at the end of their shift. During an interview on 10/4/23 at 12:31 PM, the Administrator stated they were not aware of the elopement prior to 10/4/23 and if there was an elopement it would have been discussed in morning report which they never miss. 2. Resident #21 had diagnoses including prostate cancer with metastases, diabetes and chronic obstructive pulmonary disease (COPD). The MDS assessment dated [DATE] documented the resident was cognitively intact and was not a tobacco user. Review of the CCP, dated 3/14/23, Resident #21 had been cleared by therapy to safely smoke outside of the facility. During an observation on 9/28/23 at 8:30 AM Resident #21 was observed outside facility entrance under the non-sprinkler awning within 10 feet of the front door of the facility in a wheelchair, with a lit cigarette in hand, and ashes covering their lap. A sign was posted in the area that read no smoking within 25 feet of the building while other signs posted read smoke free facility. In an observation on 9/29/23 at 9:32 AM Resident #21 was outside smoking under the non-sprinkler awning. There where cigarette ashes on their pajama pants. 3. Resident #34 had diagnoses including tobacco use, diabetes and altered mental status. The MDS assessment dated [DATE] documented that the resident was cognitively intact. The MDS assessment dated [DATE] documented Resident #34 was not a tobacco user. Review of the CCP, dated 5/22/23, Resident #34 was cleared by therapy to safely smoke outside of the facility. In an observation and interview on 9/27/23 at 2:30 PM Resident #34 was outside the facility smoking approximately three to four feet from the building. Resident #34 demonstrated that when done with the cigarette they placed the cigarette butts into the fanny pack they were wearing which contained multiple butts at the time. Resident #34 stated they leave them there for a long time, so they know they are fully out. At 3:07 PM Resident #34 stated they keep their cigarette butts in their fanny pack and every evening they pick up all the cigarette butts off the ground from other residents and visitors and place those in their fanny pack and then they empty all the butts into the trash can located in their room or occasionally into the trash outside. Resident #34 stated they have been bringing the cigarette butts into the facility to dump in their trash since they were admitted (approximately nine months ago). The resident stated they, (meaning themselves and other residents) usually smoke in the designated area unless it is raining, then we come underneath the awning to smoke. Resident #34 stated most of the residents are in wheelchairs and the sidewalks have potholes, so it is hard to get to the designated smoking area. In an observation on 9/28/23 at 8:08 AM Resident #34 was in bed. A trash can with no lid was next to the resident and contained approximately 10 cigarette butts and other flammable material such as Styrofoam cups, tissues, and paper masks. In an interview on 9/29/23 at 1:40 PM Resident Care Assistant (RCA) #1 stated they knew that Resident #34 put cigarette butts in their pocket and then threw them away in their room trash can but did not think that they ever told anyone about it. In an interview on 10/03/23 at 11:00 AM LPN Charge Nurse #1 (Resident #34's unit) stated they were unaware that Resident #34 had been throwing cigarette butts into their purse and then into the trash can in their room. LPN Charge Nurse #1 stated that if they had known this was occurring would have intervened due the risk of a fire. In an observation on 10/03/23 at 11:10 AM a cigarette butt was in the trash can at the reception desk. In an interview on 9/28/23 at 10:31 AM the Director of Facilities Management (DFM) stated the cigarette disposals are on their property. The DFM said the garbage can outside the front entrance is made of stone and is fire retardant, but the interior is a plastic can and most of the garbage cans in resident rooms are plastic and not fire retardant, some have covers while some do not. During an interview on 9/28/23 at 10:29 AM Housekeeper #1 stated they had seen cigarette butts in a resident's trash can before and informed RNM #2. During an interview on 10/03/23 at 12:50 PM RNM #2 stated they were aware of residents smoking under the awning and that staff can visually see residents better at that location than in the designated smoking areas. In an interview on 10/4/23 at 12:56 PM with the DON and the Administrator the Administrator stated they tell residents not to smoke under the awning and know that it is a problem but is unsure what can be done about it. Both the DON and Administrator stated they were unaware that residents were throwing cigarette butts in the trash inside the facility. The undated facility Smoking Policy / Clean Air Policy documented that the facility is smoke free. Smoking by residents, visitors, and staff is prohibited on the facility property with the following caveats: Residents who are deemed safe to smoke via OT evaluation must follow facility safety rules. New and short-term residents should not smoke on facility property. This is part of their admission agreement and integral to their medical care plan. Residents who insist on smoking will be assessed by OT for their ability to smoke safely on admission and at least quarterly thereafter. Residents will be shown where the designated smoking areas are. 10 NYCRR 415.12(h)(1) 39181 47641

Based on observations, interviews, and record review conducted during the Recertification Survey 9/27/23 to 10/4/23, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility did not follow state and federal guidelines related to the cohorting of residents for two (Residents #101 and #8) of two residents reviewed for Transmission Based Precautions (TBP). Additionally, for three (Units B, C, and D) of five units observed for Infection Control (IC) practices, multiple staff from various disciplines were observed not wearing face mask or not wearing their face mask correctly, including on a unit with multiple confirmed COVID-19 positive cases. This is evidence by, but not limited to the following: The New York State Department of Health (NYSDOH) Health Advisory: Nursing Home Testing, Cohorting and Visitation Guidance, dated 10/13/22, stated the purpose of the health advisory was to provide nursing homes with updated information on masking, cohorting, visitation and nursing home staff and resident testing requirements based on guidance issued by the Centers for Medicare and Medicaid Services (CMS). The health advisory included that the Centers for Disease Control and Prevention (CDC) recommended that residents with suspected or confirmed SARS-CoV-2 (COVID-19) infection be placed in a single person room. Although the NYSDOH is aligning with the CDC guidance on cohorting, nursing homes must exhaust all efforts to separate disparate testing roommates, meaning in rare circumstance when no other options are available, the exposed roommate can be left in place until such time that alternate accommodations are available. Additionally, nursing homes must fully inform residents and families of circumstances and offer transfer out of facility if unwilling to cohort. The facility policy, Covid/Droplet/Contact Precautions, dated revised in June 2023, included that education is provided to the resident, visitors, and staff regarding the needs for precautions, and cohorting may occur at the discretion of the interdisciplinary team, in conjunction with medical leadership, infection prevention coordinator, and the director of nursing (DON) based on current evidence-based recommendations. Issue #1: Resident #101 had diagnoses including Alzheimer's, vascular dementia, and diabetes. The Minimum Data Set (MDS) assessment dated [DATE], included Resident #101 was severely impaired cognitively, required extensive assistance of staff for most of their activities of daily living. Review of laboratory results in the electronic medical record (EMR) identified COVID-19 PCR (polymerase chain reaction) nasal swabs were sent for Resident #101 on 9/19/23, 9/30/23 and 10/3/23, all of which resulted negative for COVID-19. Resident #8 had diagnoses including COVID-19 positive, repeated falls and weakness. The MDS Assessment, dated 8/23/23, documented that Resident #8 was cognitively intact. Review of laboratory results in the EMR identified a COVID-19 PCR nasal swab was obtained on Resident #8 on 9/29/23, which resulted positive for COVID-19. Contact and droplet precautions were put in place on 9/29/23 by the Infection Control Nurse (ICN). Review of interdisciplinary progress notes dated 9/20/23 through 10/3/23, did not include any documentation that Resident #101 reported any issues or concerns, or that the resident was experiencing COVID-19 related symptoms, such as coughing. In a nursing progress note dated 9/30/23 at 2:03 PM, Registered Nurse (RN) #2, documented Resident #101's family was in the resident's room, and had concerns regarding COVID-19, the resident's roommate and Personal Protection Equipment (PPE). RN #2 explained to the family that they were unable to discuss another resident's health information. RN #2 documented that Resident #101's family was concerned and would call the Nurse Manager on Monday to discuss their concerns. During an observation on 9/29/23 at 12:55 PM, Resident #101 was observed sitting in the dining room with the Unit Charge Nurse, who was assisting the resident with lunch. During an interview on 10/3/23 at 10:23 AM, Licensed Practical Nurse (LPN) #1 said a COVID-19 swab (third one) was obtained from Resident #101 today and they were awaiting the results. LPN #1 stated Resident #101's roommate (Resident #8), tested positive for COVID-19 on 9/29/23. During an interview on 10/3/23 at 10:27 AM with LPN #2 (Charge Nurse) and Registered Nurse Manager (RNM) #1, LPN #2 stated if a resident is found to be COVID-19 positive, they are notified by the ICN, who provides the staff with direction, the resident is immediately placed on isolation precautions with a sign on their door (that the room is a 'Hot Spot' and to use precautions), and PPE is placed on the door. LPN #2 stated that the decision to move a resident from the room due to a COVID-19 positive result for just one of the residents is made by the ICN. LPN #2 stated that Resident #101 is still in their room with their COVID-19 positive roommate, and they did not believe that Resident #101 was symptomatic (exhibiting any symptoms of the virus). LPN #2 stated that they have had multiple staff members who tested positive for COVID-19 who had contact with many residents. RNM #1 stated that discussions related to COVID-19 positive and COVID-19 negative residents sharing a room (co-horting) should be referred to the ICN. RNM #1 stated that they have private rooms available on the unit, but they prefer to keep those rooms open to new admissions. RNM #1 stated the reason (for co-horting) was likely a combination of keeping the room open and the ICN's guidance. Neither LPN #2 nor RNM#1 had spoken with Resident #101's family about their reported concerns. During an interview on 10/3/23 at 11:24 AM and again on 10/4/23 at 9:21 AM, the ICN confirmed that four residents on Unit C had tested positive for COVID-19. The ICN said Resident #101's COVID-19 tests were all negative. The ICN said Resident #101 had been coughing before any testing had been done and that several staff members that had been around Resident #101 tested positive. The ICN said that Resident #101 and Resident #8 had been in close proximity to each other and that the two residents had the same amount of exposure and that they thought Resident #8 was symptomatic which why they kept the residents together. The ICN stated the decision to move residents (when one tests positive and one negative) is situational, on a case-by-case basis, and is based on what is available. The ICN stated it is the decision of the interdisciplinary team when residents are moved (due to COVID-19). The ICN stated that they followed guidance from the medical team (including Physician Assistant (PA) #1) and the State Health Department. The ICN stated Resident #101's last exposure to a COVID-19 positive staff member was on 10/1/23 and they were seeing positive COVID-19 results three to five days after exposure. The ICN said the front of Unit C is where all the COVID positive residents are and that they are trying to keep the back of the unit clean. During an observation on 10/3/23 at 3:35 PM, Resident #101 was observed in bed with a Hospice Aide sitting in the room. The privacy curtain was open 3/4th of the way and both residents were in view of each other and neither wearing masks. Resident #101 was not coughing (approximately 10 minutes) and the Hospice Aide stated that they had been siting there for approximately 30 minutes and the resident had not coughed at all. During an interview on 10/4/23 at 10:35 AM, RNM #1 stated that they were not aware that Resident #101's family had concerns related to COVID-19. RNM #1 said interventions used to prevent further exposure when one resident becomes COVID-19 positive included the use of PPE and distancing of six feet or more but was unsure of any facility policy related to the use of the privacy curtain between residents. RNM #1 stated there was another co-horting situation on the unit in which one resident was COVID-19 negative and their roommate was COVID-19 positive. During an interview on 10/4/23 at 11:47 AM, the DON stated that they would follow the guidance from the ICN regarding residents whose roommate tested positive for COVID-19 while they tested negative and included the decision to keep room assignments was to minimize further exposure. The DON stated that Unit C had the ability to isolate residents due to more space and were not at full capacity. The DON said interventions should include staff wearing full PPE when going into COVID-19 rooms, performing hand hygiene, and keeping the door shut. The DON stated if a COVID-19 positive resident was symptomatic or if they were receiving nebulizer treatments, the curtain should be closed between the residents. Issue #2: During an interview and observation on 9/29/23 at 9:31 AM, the Director of Respiratory (DOR) confirmed that there was staff exposure on Unit D and that universal masking was required throughout the entire building due to the potential for staff to float between units. Masking signs were observed throughout the building. During an observation on 9/29/23 at 12:32 PM, the DON was in the hall on Unit B with their face mask not covering their mouth or nose. The DON stated at that time that they should pull the mask up (around their nose). During an observation and interview on 10/03/23 at 9:18 AM, Certified Nurse Assistant (CNA) #1 entered a resident's room on Unit B without a face mask on and began assisting the resident into their wheelchair. LPNM #1 stated at that time that all staff should be wearing face masks. During an interview on 10/03/23 at 11:25 AM, the ICN confirmed that there were four confirmed cases of COVID-19 in the building (in addition to several staff). During an observation on 10/3/23 at 10:15 AM, isolation precaution signs and personal protective equipment (PPE) were on Resident #8 and Resident #101's room door on Unit C. During an observation on 10/03/23 at 1:23 PM, CNA #2 was walking in the hall (near a resident) on Unit C. A face mask was hanging off their face and not covering their mouth or nose. During an observation on 10/04/23 at 9:14 AM, CNA #2 was again walking in the hall of Unit C with their face mask not covering either their mouth or nose. During an interview on 10/04/23 at 9:21 AM, the ICN stated that face masks should be worn and worn correctly (covering both their mouth and nose) throughout the entire building except for staff's personal offices. During an interview on 10/04/23 at 9:43 AM, the DON and the Administrator both said that all staff should be wearing a face mask in resident care areas and that if non-direct care staff were in their office area, staff should apply their mask when they encounter staff who work throughout the building. During an observation and interview on 10/04/23 at 10:03 AM, Physical Therapist (PT) #1 was observed on Unit C outside of two TBP for COVID-19 rooms without wearing a face mask. PT #1 said they could not find a face mask. A bedside table was observed outside the unit doors prior to entering the unit that held surgical and KN95 (respirator) face masks. Once on the unit, a full box of face masks was located on two separate resident room doors in a bright yellow PPE holder. Both PPE holders were located directly next to the unit's entrance/ exit doors. During an interview on 10/04/23 at 10:35 AM, RNM #1 stated they have staff that did not want to comply with wearing a face mask but that all staff should unless they are eating or drinking. 10 NYCRR 415.19(b)(1)

Based on observations, interviews, and record reviews conducted during the Recertification Survey from 9/27/23 to 10/4/23, it was determined that for two (Resident's #21 and #85) of five residents reviewed for dignity, the facility staff did not promote and treat each resident with respect and dignity in a manner and an environment that promotes maintenance or enhancement of their quality of life. Specifically, Resident's #21 had their personal belongings in bedside drawers in their room opened and contents reviewed by staff without their permission or explanation as to what staff were looking for. Additionally, for Resident #85 the facility staff were heard discussing the resident's private and protected health information (also known as HIPAA-Health Insurance Portability and Accountability Act) in a setting where others could overhear. This is evidenced by the following: 1.Resident #85 had diagnoses including human immunodeficiency virus (HIV), dementia, and psychotic disorder with delusions. The Minimum Data Set (MDS) Assessment, dated 7/8/23, revealed the resident had moderately impaired cognition. During an observation on 9/28/23 at 11:20 AM, Physician Assistant (PA) #1 and another staff member were standing in front of Resident #85 who was seated in the hallway outside of the nurse's station. There were three other residents seated nearby and two New York State Department of Health (NYSDOH) surveyors standing at the nurse's station. PA #1 was encouraging Resident #85 to take their medications when Resident #85 asked if they had AIDS (Acquired Immune Deficiency Syndrome)? PA #1 responded, yes, but it is undetectable if you continue to take your medications. At no time did PA #1 ask Resident #85 go to a private area to discuss issues related to their health. During an interview on 10/4/23 at 10:06 AM, Resident #85 stated that they would want a staff member to speak to them about their health information in private. During an interview on 10/4/23 at 10:14 AM Registered Nurse Manager (RNM) #2 stated normally they do not hear providers having those conversations in common areas and especially something like that you would not want to discuss in a common area but instead in private. RNM #2 stated that Resident #85 will get up and go with you to have a conversation if you ask. During an interview on 10/4/23 at 11:40 AM PA #1 stated that Resident #85 will yell and ask questions when they walk by which they try to answer. PA #1 stated they would normally have a conversation about a resident's health in private, but that Resident #85 can yell, and you have to answer them right away. During an interview on 10/4/23 at 12:11 PM, the Director of Nursing (DON) stated that conversations related to resident's private health information should be held as private as can be, certainly not in the hallway. They would expect everyone to be aware of where they were speaking to residents and that a private place was offered when speaking to a resident about private health information. 2.Resident #21 had diagnoses that included diabetes, chronic obstructive pulmonary disease (COPD), and prostate cancer. The MDS assessment dated [DATE] documented that the resident was cognitively intact. During an observation and interview on 9/28/23 at 11:07AM, RNM#2 entered Resident #21's room during an interview with surveyors, without knocking, and without asking permission and began looking in the top drawer of the resident's dresser. RNM#2 did not address the resident, request permission, or explain what they were looking for. Resident #21 asked RNM#2 what they were looking for and RNM#2 responded only that they would be back. RNM#2 returned to the resident's room several minutes later and stated to the resident that they were checking to see if the drawer was locked. Resident #21 stated to RNM#2 at the time, That wasn't the answer I was looking for. Wouldn't you ask someone if it was okay (to open their drawer) and tell them what you are looking for? When interviewed on 10/4/23 at 10:14 AM, RNM#2 stated that they had not asked Resident #21's permission before opening their personal drawers but that they did talk to the resident later. RNM#2 stated that they had been checking to see if the drawer was locked due to reports of residents who smoke not locking up their cigarettes. RNM #2 stated they were just checking to see if drawers were locked and if not if residents had a key to the drawer. 10 NYCRR 415.5(a)

Based on observations, interviews, and record reviews conducted during a Recertification Survey 9/27/23 to 10/4/23, it was determined that the facility did not post the nurse staffing information to include the total number and the actual hours worked of licensed and unlicensed nursing staff directly responsible for resident care per shift, the posting was not consistently updated with staffing changes and it had not been posted according to the posting requirements. Specifically, there were no Registered Nurse (RN) hours posted, the information titled Staffing Levels was posted outside the Administration Office in the administrative hallway and not accessible to residents and visitors and the information had not been updated consistently for past two months. The finding is: During observations on 9/27/23 and 9/28/23 New York State Department of Health surveyors were unable to locate the posted nurse staffing information as part of the Standard Recertification Process. In an interview on 9/27/23 at 9:33 AM Registered Nurse Manager (RNM) #2 stated that the unit started out with six Certified Nursing Assistants (CNAs) however one CNA went home (before end of shift). The facility Staffing Levels provided for 9/27/23 did not reflect this change with the incorrect number and hours of CNAs worked on that unit for that shift. During an observation and interview on 9/29/23 at 3:21 PM the DON stated the night shift supervisor fills out the staffing for the next day and any one of us (administration) will look at it before leaving to make changes for the evening and night shifts. Review of Staffing Levels forms for August 2023 and September 2023 with the DON, revealed no changes made to the staffing sheets to indicate any assignment changes or call-ins. The DON stated at the time that the sheets had not been updated as needed. The DON stated they were told by Administration not to include RN hours on the staffing sheets. The DON said that the way the facility is laid out was that residents and visitors could come in the main door and go right to a unit or the elevator without walking by the administrative hallway and did not know that nurse staffing was regulated to be posted in a prominent place (visible to residents and visitors) and changes updated per shift. In an interview on 9/29/23 at 3:52 PM and again on 10/4/23 at 12:56 PM the Administrator stated they do not handle staffing or Staffing Level forms, which is the responsibility of the nursing department but that they have always been posted outside of the DONs office (administrative hall). The Administrator stated they were not aware that they should be updated per shift and posted in a prominent place. 10 NYCRR 415.13

Based on observation, interview, and record review during an Abbreviated Survey (#NY00291632, NY00306557, NY00292581, NY00304169, NY300511) the facility did not ensure resident's electronic medical records (EMR) were readily accessible to survey staff. Specifically, for nine (Residents #1, #2, #3, #4, #5, #6, #7, #8 and #9) of nine residents reviewed, the facility did not grant surveyors access to resident's EMRs, including but not limited to resident face sheets, care plans, interdisciplinary progress notes, Minimum Data Set Assessments, physician orders, medication administration records (MAR), labs and consults in a timely manner. This was evidenced by: During an interview with the Director of Nursing (DON) on 1/31/23 at 8:30 a.m. access to the facility's EMR for Residents #1, #2, #3, #4, #5, #6, #7, #8 and #9 was requested by New York State Department of Health (NYSDOH) surveyors to investigate resident complaints filed with the NYSDOH. In an interview on 1/31/23 at 10:30 a.m., the Executive Assistant stated the facility uses Point Click Care EMR and the E-record for their medical records. The Executive Assistant stated they would notify the IT (Information Technology) department of the request for surveyor access. At 11:00 a.m., the Executive Assistant stated surveyors should have received emails with passwords containing the necessary links. Review of links at this time revealed no access to resident's full medical records. The only access surveyors had was to view a list of residents. At 4:00 p.m., the Executive Assistant stated they did not know why access still had not been given to survey team and would ensure the survey team would have access by next day. In an interview on 2/1/23 at 8:30 a.m., the DON was informed that surveyors continued to be unable to access the resident's EMR. Paper documentation of resident's interdisciplinary progress notes, physician orders, MARs, treatment administration records (TARs), care plans and blood glucose monitoring records were requested. At 10:15 a.m., the DON stated that they were told by their IT staff that they could not grant the level of access that was requested due to security concerns. At 11:00 a.m., the DON stated that IT informed them they should give the surveyors the DON's password and sit with the surveyors to review resident medical records. Review of printed paperwork provided by the facility as resident records did not include any dates, times, or staff signatures. In an interview on 2/1/23 at 11:30 a.m., the Administrator stated they did not know why the IT department would not give surveyors access and that they notified the CEO of the company. The Administrator stated it was their expectation that the NYSDOH had full access to resident's medical records including EMR. On 2/1/23 at 12:15 p.m. the surveyors were granted access to residents EMR (approximately 27.5 hours after requested). State Operations Manual Rev.208, 10.21.22 includes: S483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized. S483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is, including but not limited to, required by law and for health oversite activities. 10 NYCRR 415.22

Based on observations, interviews and record reviews conducted during the Recertification Survey, completed on 12/6/21, it was determined that for one of one main kitchen, the facility did not maintain equipment in safe operating condition. Specifically, the low temperature dishwashing machine and five of six bimetallic food thermometers were not working properly. This is evidenced by the following: Review of a facility policy, Thermostat Calibration, dated 4/16/15, included that the thermometer may be the single most important tool you have to protect food. To calibrate a thermometer, fill a container with ice. Add clean tap water until the container is full. Put thermometer stem into the ice water so that the sensing area is completely submerged. Wait until the indicator stops moving. Hold the calibration nut securely with a wrench and rotate the head of the thermometer until it reads 32 degrees (°) Fahrenheit (F). This is the responsibility of both the day and evening cook. During observation and interviews on 12/6/21 at 8:56 a.m., the temperature gauge on the low temperature dish machine (ADS model Af-B) used for pot and pan washing, was partially filled with water and the temperature needle was not moving, stuck in place between 150 to 160°F. The gauge was cloudy and discolored with some dark colored debris on the face obscuring the numbers. The temperature specification data plate directed a minimum of 130°F for washing. When interviewed the Dietary Supervisor said they did not know the required washing temperature, only that the machine was low temperature and used chlorine for sanitizing. The Dietary Supervisor then used a chlorine test strip and the sanitizing concentration read 100 parts per million (ppm). The Director of Food Service (DFS) stated at this time that the minimum temperature should be 110-120°F and that the sanitizing agent is chlorine. The DFS said staff do not log the temperature of the machine and rely on the color change of the chlorine test strip to determine if the machine is working properly. Review of an EcoLab service report, dated 10/8/21, did not include a check of water temperature. In an observation and interview on 12/6/21 at 9:22 a.m., Cook #1 said they had calibrated in-use thermometers earlier that morning using the ice point method of calibration. Cook#1 set up the ice bath and placed six facility thermometers, five bimetallic [NAME] model #6096-1 thermometers, one [NAME] digital thermometer and the surveyor's AquaTuff 351 probe thermometer in the ice bath. Cook#1 discarded two of the bimetallic thermometers saying they were broken. The Dietary Supervisor came to assist and read the remaining bimetallic thermometers as: 26°F, 28°F, and 28°F. The surveyor's thermometer read 32°F. The Dietary Supervisor proceeded to recalibrate the three thermometers. The DFS said that each cook recalibrates facility thermometers at the beginning of their shift (morning cook works breakfast and lunch and another cook works the supper meal) and signs for the calibration on a work sheet. The DFS said there is no place on this sheet to document the different types of thermometers calibrated or adjusted and no actual thermometer log for calibration/maintenance of all thermometers. The DFS said they needed to redesign the work sheet. In an interview on 12/6/21 at 1:46 p.m., the DFS said they had called a different vendor for a new quote to provide preventative maintenance for equipment.

Based on observations, interviews, and record reviews conducted during the Recertification Survey, completed [DATE], it was determined that for one (Resident #216) of 25 residents reviewed, the facility did not ensure that the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive would be honored. Specifically, the physician's orders did not match the resident's Medical Orders for Life Sustaining Treatment (MOLST) wishes. Review of the facility policy MOLST/Advance Directives dated as last reviewed on [DATE], revealed that a MOLST will be completed for all residents whether they wish for Do Not Resuscitate (DNR) or not. The Social Worker (SW) will initiate the form with the resident and their family, notify the medical staff and the form will be placed in the physician's mailbox for completion. The MOLST is then completed by the physician verifying the residents wishes and signing the form. Resident #216 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set Assessment, dated [DATE], revealed the resident was moderately impaired of cognitive function. Review of the MOLST form, dated [DATE], and signed by Resident #216 revealed the resident's wishes were DNR and Do Not Intubate (DNI). Review of a medical progress note, dated [DATE], revealed that Resident #216 was judged to have capacity for the advance care planning discussion, and wished for DNR/DNI and to refer to the completed MOLST form. Review of Resident #216's Electronic Medical Record (EMR) revealed that the resident was listed there as Full Code. The physician orders, [DATE], documented that Resident #216 was a Full Code (indicating wishes for CPR). During an interview on [DATE] 10:46 a.m., the Director of Social Work (DSW) stated that the medical team completed the MOLST forms. The DSW reported they were not involved in those conversations. During an interview on [DATE] 10:52 a.m., the Director of Nursing (DON) stated that social work takes care of the MOLST forms and advanced directives, takes the paperwork to medical, and that the hard copy goes in the resident's chart and the unit clerk puts the information in the EMR. During an interview on [DATE] at 10:55 a.m., Registered Nurse Manager (RNM) #1, stated that a resident's code status was both in the EMR and in the paper chart. During a joint interview with the Certified Nursing Assistant (CNA) and the Licensed Practical Nurse (LPN) on [DATE], at 11:00 a.m., the CNA stated that they did not know where to look for a resident's code status. The LPN stated that a resident's code status was in the EMR and the MOLST form was in the paper chart. The LPN stated that in the event of an emergency they would check the MOLST form first, then the computer. 10 NYCRR 415.3 (e)(1)(ii)