Every finding on record at The Valley View Center for Nursing Care and Rehab

Based on record review, and interviews during an abbreviated survey (2603474), the facility did not ensure a comprehensive care plan was developed and implemented to maintain the Resident's highest practicable physical, mental, and psychosocial well-being for two (2) of three (3) residents (Resident #1, #4) reviewed for behaviors. Specifically, 1) Resident # 1 had severe cognitive impairment with documented nursing progress notes of wandering behavior, physical and verbal aggression and refusal of cares had no behavior care plan initiated There was no behavior care plan documented in the Electronic Medical Record during the survey. When requested the Facility did not provide a behavioral care plan for the resident. 2) Resident #4 had severe cognitive impairment with inattention and disorganized thinking with documented behaviors verbal/disruptive behaviors no documented evidence of a behavior care plan initiated for the resident.The Findings include:A review of the facility's Comprehensive Care Plan Policy dated 02/1999 and last reviewed 3/2019 documented this plan of care is initiated by the Nursing Care Manager of Nursing Care Supervisor entering into the electronic medical record, for guidance of the Certified Nursing Assistant in regard to bed mobility, transfer, eating, nutrition and toilet use. A care plan is started as soon as possible to address pain, falls, Activities of Daily Living needs, discharge planning and potential development of pressure ulcers. A comprehensive care plan will be developed within (7) days after completion of the comprehensive assessment. The Comprehensive care plan will include measurable goals and timetables to meet the resident's medical, nursing, mental and psychosocial needs that are identified by, but not limited to, comprehensive assessment. It will depict services that are to be furnished to attain or maintain the resident's highest practicable well-being. The services furnished will meet the professional standards of quality for disciplines involved in providing care. Resident #1 was admitted to the facility with diagnosis that include but not limited to Alzheimer's disease, Type 2 diabetes, and difficulty walking.An annual minimum data set ( an assessment tool) dated 8/10/2025 documented the resident had a brief interview of mental status score of 4; indicating severe cognitive impairment with inattention and disorganized thinking with behaviors of delusions and wandering that occurs 1 to 3 days. Wander/elopement alarm coded a zero (0) indicating it was not used.A Review of Resident #1's care plans did not include documented evidence of a behavior care plan for Resident # 1 in the electronic medical record.Review of Certified Nurse aide documentation from 8/1/2025-8/31/2025 documented on 7am- 3pm shift that the resident had a behavior of wandering on 8/11/2025, 8/19/2025 and 8/25/2025. 7 am- 3pm shift documented that Resident # 1 was resistive to care on 8/3/2025, 8/4/2025, 8/7/2025, 8/11/2025, 8/19/2025, 8/21/2025 and 8/15/2025. 3pm-11pm shift documented Resident # 1 has a behavior of wandering on 8/2/2025 and 8/5/2025 and a behavior of resistive to care on 8/1/2025,8/2/2025, 8/5/2025, 8/7/2025, 8/11/2025, 8/17/2025, 8/22/2025 and 8/30/2025. 11pm-7am shift documented Resident # 1 had a behavior of wandering on 8/1/2025,8/3/2025,8/8/2025,8/15/2025, 8/17/2025,8/24/2025 and 8/25/2025 and resisted care on 8/1/2025, 8/3/2025, 8/8/2025, 8/9/2025, 8/11/2025, 8/15/2025, 8/17/2025,8/24/2025, 8/25/2025, 8/26/2025, 8/29/2025, 8/30/2025 and 8/31/2025.Review of Nursing progress notes from 8/1/2025-8/31/2025 indicated the resident had behaviors of wandering and aggression on 8/10/2025, 8/11/2025, 8/13/2025, 8/17/2025, 8/27/2025.Review of a Nursing Progress Note dated 8/27/2025 at 2:06 pm documented Resident is with much confusion and agitation this shift. Resident was fixated that staff took their wallet and took it to laundry room, writer called spouse to calm them down; it took resident about an hour to calm down after phone call, but lunch time the resident was fixated that they worked at the hospital last night and started to become agitated and resistive with staff. Writer called wife spouse again and provider. Continue with 30-minute visuals.During an interview with Certified Nurse Aide # 1 on1/7/2025 at 12:52pm they stated Resident # 1 is confused and wanders up and down the hallway and is very repetitive. Resident # 1 sun downs during the 3-11pm shift. Resident # 1 would refuse cares most of the time. If Resident # 1 allows staff to provide care, it takes a while to complete care.During an interview with Licensed Practical Nurse # 1 on 1/8/2025 at 10:31am, they stated Resident # 1 had dementia, acted out with behaviors, was physically aggressive and resisted care. Resident # 1 wanders around in their wheelchair and sometimes can be verbally redirected. Resident 4 was admitted to the facility on and has diagnosis including but not limited to encephalopathy, syncope and collapse, and difficulty in walking.An admission Minimum Data Set, dated [DATE] documented Resident # 4 had a brief interview of mental status score of 1; indicating the resident had severe cognitive impairment with inattention and disorganized thinking. Residents had no behaviors present and were independent with eating and required maximum assistance with toileting, moderate assistance with bed mobility and maximum assistance with transfers.Resident #4's Potential for Elopement care plan dated 1/3/2026 documented interventions that included: Involve in structured activities, assure resident has proper identification including facility phone number and location, 15-minute visuals, Wander guard placed Wander guard # 67, expires in 90 days (4/6/26).Review of the resident physician orders dated 1/3/2026 documented the resident was an Elopement Risk.Review of Certified Nurse aide documentation from 12/17/2025-1/12/2026 documented on 1/7/26 on 7:00 am - 3:00 pm shift, shifts of wandering, verbally abusive behavior, socially inappropriate/disruptive behavior, and resist care. 1/7/26 11:00 pm - 7:00 am verbally abusive behavior, physically abusive behavior, and socially inappropriate/disruptive behavior. 1/8/26 at 3:00 pm - 11:00 pm shift documented wandering, verbally abusive behavior, physically abusive behavior, socially inappropriate/disruptive, and resist care. 1/9/26 11:00 pm - 7:00 am Wandering, verbally abusive behavior, physically abusive behavior, socially inappropriate/disruptive behavior, resists care. 1/11/26 7:00 am - 3:00 pm documented verbally abusive behavior, physically abusive behavior, socially inappropriate/disruptive behavior and resists care. 1/11/26 3:00 pm - 11:00 pm shift documented verbally abusive behavior and resists care.Review of nursing progress notes 12/17/2025-1/12/2026 documented the resident had behaviors on 1/3/2026, 1/6/2026, 1/7/2026, 1/8/2026, and 1/9/2025.Review of a nursing progress note dated 1/6/2026 at 6:51pm documented 3-11pm resident frequently attempting to leave unit, staff monitor for safety.Review of a nursing progress note dated 1/8/2026 at 6:32 am documented Resident # 4 was verbally and physically aggressive with staff when staff trying to assist them with morning cares.There was no documented evidence of a behavior care plan initiated for Resident #4 in the Electronic medical record.During an interview on 1/22/2025 at 9:04 am with Unit Manager # 1, they stated upon admission care plans are initiated and they are updated/revised with any significant changes. Development of a behavior care plan would depend on the type of behavior. If the resident is combative, hitting, spitting, or been physical/verbally aggressive, it would trigger a behavior care plan for the resident. Resident # 1 was confused and had to be redirected. The resident did not have behaviors. He was difficult with cares if you want to call that a behavior. However, they were private and did not want anyone to see them and that was a challenge. Unit Manager # 1 stated the nurse care manager or Supervisor can update and revise care plans. The floor nurse will report to the manager or supervisor if a care plan needs to be updated, but floor nurses do not update or revise the care plan. Resistance to care can be found in an ADL care plan and it would state that the resident can be non-complainant with care, or it could be noted as a comment under care. Surveyor asked how staff would care for the resident if he resisted care and Unit Manager stated they would wait and give Resident # 1 time and reapproach him for care. The Unit Manager #1 stated per diem staff will care for the residents based on shift reports received, progress notes, and the care plan. Unit Manager #1 stated they heard about the incidents on 8/11/2025 and 8/27/2025 involving Resident #1 when the resident eloped. Unit Manager #1 stated they were not present during the incidents. If they were present, they would have initiated a care plan to address the wandering. Based on the time of the incidents the supervisors should have updated the care plans after the incident. When asked if care plans should be initiated and updated timely Unit Manager #1 responded absolutely. Care plans should be developed and updated to properly care for residents.Unit manager #1 reviewed Resident #1's chart/care plans and acknowledged that there was no behavior care plan. There was also no documentation in the note section of the Activities of Daily Living Care Plan that identified the resident was resistive to care. [10 NYCRR 415.11(c)(1)]

Based on record review and interviews during an abbreviated survey (2603474) the facility did not ensure the resident environment was free of accident hazards and that each resident received adequate supervision to prevent elopement for 1(Resident #1) out of 3 residents reviewed for elopement. Specifically, on 8/11/2025 the resident was found off their unit in the kitchen by a dietary staff resident was placed on 15-minute visual checks and identified on the elopement risk assessment to be a high risk for elopement. On 8/27/2025, Resident# 1 was captured on video surveillance exiting the building through the fire exit doors at 3:04pm and returned into the building at 3:15pm.The facility's resident monitoring: visual checks policy dated 1/2010 and reviewed 7/26/2011 documented it is the policy of the facility that all resident's receive appropriate monitoring as the need arise to ensure their safety and protection.Resident #1 was admitted to the facility on [DATE] with diagnosis that include but not limited to Alzheimer's disease, Type 2 diabetes, and difficulty walking.An annual minimum data set (an assessment tool) dated 8/10/2025 documented the resident had a brief interview of mental status score of 4; indicating severe cognitive impairment with inattention and disorganized thinking and behaviors of delusions and wandering that occurs 1 to 3 days. Resident # 1 had no impairments to the upper extremities and impairments on both sides of their lower extremities. Resident uses a wheelchair for locomotion. Resident requires supervision with eating and a maximum assist with toileting. Requires supervision with bed mobility and transfers. Resident is frequently incontinent of urine and always incontinent of bowel. No wander/elopement alarm coded a zero (0); indicating it was not used.Review of an elopement risk assessment dated [DATE] documented Resident #1 had a history of an attempted elopement within the last six months, resident exhibited wandering behavior, resident is cognitively impaired or demonstrated impaired decision making, resident had verbalized they want to go home or other statements indicating desire to leave unit/building, and resident is independently mobile for a total score of 19; which indicated the resident was a high risk for elopement.There was documented evidence of elopement measures/interventions put in place for 15-minute visuals, 30-minute visuals and 1 to 1 monitoring.Review of visual checks documentation indicated there were omissions on 8/12/2025, 8/13/2025 and 8/14/2025. There is no documentation on the day of the incident 8/27/2025 when the resident eloped from 3:00pm-3:30pm.Review of physician orders documented the following:-Order dated 10/28/2024 and last renewed on 8/14/2025 documented Incapable (Resident is incapable of making own decisions)-Order dated 8/11/2025 documented 15 Minute Visuals Schedule: Every Day at 7:00 am-3:00 pm; 3:00 pm-11:00 pm; 11:00pm-7:00 am.-Order dated 8/11/2025 Medical Alert: Elopement Risk-Order dated 8/27/2025 documented 1 on 1 Supervision Schedule: Every Day at 7:00 am-3:00 pm; 3:00 pm-11:00 pm; 11:00pm-7:00 amReview of all care plans with no care plan in place to address the behavior of wandering.A review of a potential for elopement care plan dated 3/5/2024 documented the resident had a potential for elopement related to confusion/dementia resulting in attempts to leave on the elevators with interventions dated 3/5/24 provide divisional activity, 1 to 1 to vent feelings, identify concerns, redirect resident, assure resident has proper identification including facility phone number and location, and discuss with family/support persons attempt to leave. Intervention dated 8/11/2025 documented 8/27/2025 1 to 1 ordered for elopement. Interventions dated 8/28/2025 documented wander guard on 8/28/2025- # 52 left ankle with expiration 2/24/2026, and unit changed on 8/28/2025 to H811 B.Review of witness statements from 8/11/2025 documented that staff on glenmere ground were not aware that Resident # 1 was off the unit and found in the kitchen by a dietary volunteer.Review of the video surveillance for 8/27/2025 at 3:04 PM revealed Resident #1 ambulating with the wheelchair out of the exit fire door on the west wing hallway. The resident is able to exit the facility with the wheelchair and seen self-propelling in the wheelchair on the lawn in the back of the building.Review of a Nursing Progress Note dated 8/27/2025 at 2:06 pm documented Resident is with much confusion and agitation this shit. At beginning of shift resident was fixated that staff took their wallet and took it to laundry room, writer called spouse to calm them down; it took resident about an hour to calm down after phone call, but lunch time the resident was fixated that they worked at the hospital last night and started to become agitated and resistive with staff. Writer called wife spouse again and provider. Resident made no attempts to leave unit or go on the elevator this shift, continue with 30-minute visuals.During an interview with the Occupational Therapy Supervisor on 1/7/2026 at 11:30 am they stated on 8/27/2025 when the incident occurred that afternoon they were leaving from work and observed Resident # 1 near the end of the employee parking lot and heard someone approach him which was staff member in social services. They were concerned because they knew the resident should not be outside because they were confused. The staff member from social services approached the resident and ask them if they needed assistance. Occupational Therapy Supervisor stated they called therapy to have a therapist come to main entrance because that staff member was wheeling Resident # 1 up to the main entrance. Therapist met them and reported to the security guard that Resident # 1 was found outside. Therapist brought him back to glenmere ground which was their unit at the time. They know Resident # 1 from working on the unit and knew that Resident # 1 is very confused and should not be alone outside by their self.During an interview with the Director of Nursing on 1/8/2026 at 1:09pm they stated If someone attempts to elope they are evaluated. Interventions that are put in place for the elopement, but it depends on different factors that are involved with determining interventions that are put in place. If a resident eloped off their unit and they have a diagnosis of dementia they may initiate 15-30 minutes with extreme of 1 to 1 until they can make the determination of moving them to the dementia unit. The incident with Resident # 1 occurred at the change of shift and they were made aware approximately 1 hour later that same day. After they were informed that Resident # 1 was found outside they watched the cameras that day as well. It took a while to figure out which door the resident exited out of. Resident went out the west end exit door with his wheelchair and then he went on the sidewalk and roadway and pushed his wheelchair to the front [NAME] in rehab called someone in rehab. The person from rehab brought him inside. She took him to his unit. They do not believe at that moment anyone was aware the resident left the unit. The doors do alarm and did go off at the time of the incident, but they are not sure if the staff heard the alarm because it was change of shift. The staff were congregated near nurse station during change of shift. They believe Resident # 1 had been on visuals for a period and need to look in his chart. Prior to this the resident never made it outside. They cannot remember off the top of their head if the resident ever wanders. An elopement risk assessment is completed after a resident wander. An elopement assessment is completed on admission. They looked into the 8/11/2025 incident and the resident was found by the kitchen area and 15-minute visuals were initiated. Therefore, the visual checks would have been ongoing since 8/11/2025. On 8/27/2025 the resident was switched to 30-minute visuals and once they returned back to their unit they were placed on one to one. Surveyor reviewed visual checks documentation with Director of Nursing. Director of Nursing acknowledged that there was no documentation of completion of 15-minute visuals for Resident # 1 on 8/12/2025, 8/13/2025, and 8/14/2025. Stated if a resident was placed on visuals there also would be an order in Sigma (an electronical medical record).During an interview with the Administrator on 1/9/2025 at 2:15 pm they stated they are trying to think about the incident. The Director of Nursing texted them to inform them that Resident # 1 was found outside. The Director of Nursing stayed the day of the incident to make sure Resident # 1 was alright. They know the door did alarm at the time incident when Resident # 1 exited out of the door. Maintenance did check the fire exit after the incident. The incident occurred during change of shift and the resident was placed on one to one. After the incident occurred to prevent a reoccurrence maintenance checked the doors and added cameras in the last month and Resident # 1 was moved upstairs for safety Off the top of their head, they do not recall the amount of time the resident was outside. They believe that training was done but they are not sure they will have to look into the post incident report. They will update the surveyor with the amount of time the resident was outside. Administrator reported that Resident # 1 exited at 3:04pm and returned back into the front door of the building at 3:15 pm. 10 NYCRR 415.12(h)(2)

Based on observation and interview during the recertification survey conducted from 7/15/25 to 7/25/25, the facility did not ensure that a clean, comfortable, and homelike environment was provided. Specifically, during observation of the Forest Unit, resident rooms [ROOM NUMBERS] had leaking radiator units. Wallpaper throughout the Forest Unit hallways and common areas was torn or missing, ceiling trim had rust stains and a baseboard in room [ROOM NUMBER]B was missing. The Forest Unit shower room had low water pressure and low hot water temperature. During observation of the Town Hall Common area, approximately 25% of the ceiling fluorescent light fixtures were non-functioning. The findings included: The policy titled Resident Living Area Cleaning dated 10/2021 documented all building service workers and building services supervisors will maintain the cleanliness and sanitary conditions within resident rooms, bathrooms, lounge areas, dining rooms and any area that is specifically designated as resident space. The policy titled Maintenance Repair Requisition, revised 8/16/2007, documented all staff members will be responsible for completing maintenance repair requisitions whenever they become aware of any mechanical or equipment damage, failures, or malfunctions or any issues that could impact resident or staff safety. This includes all night lights in resident rooms and stairwell lighting in all buildings. During observation on 07/15/2025 at 12:28 PM in resident room [ROOM NUMBER], a wet towel was on the floor in front of the radiator. The radiator / air conditioning was in off mode. During observation on 07/16/2025 at 09:00 AM in resident room [ROOM NUMBER], a wet sheet was in front of the radiator. The radiator was in off mode.During a Resident Council meeting on 7/16/25 at 11:30 AM residents stated concerns regarding low water pressure on units and hot water taking an extended time to reach a comfortable temperature. They stated these concerns had been discussed during monthly meetings and concerns were reported to certified nurse assistants. They stated Maintenance staff presented to unit/s to address concerns, however due to the buildings being old, the pressure and hot water concerns quickly returned. They stated mixers were added to the shower rooms a few years ago which made the pressure and hot water concerns worse. Resident Council members stated due to hot water taking an extended time to heat up cares were often rushed. Resident Council members stated lighting in the Town Hall common area was not sufficient during activities, which caused difficulty when reading bingo cards and documents. They stated the Town Hall Common area had many non-functioning florescent lights bulbs which had been discussed with the Activities Director during their last meeting.During observation on 07/17/2025 at 11:22 AM and 7/18/25 at 9:06 AM in resident room [ROOM NUMBER], a wet sheet was in front of the radiator. During observation on 07/18/2025 at 9:09 AM in resident room [ROOM NUMBER]B, a baseboard was missing between the wall and radiator.During observation on 07/18/2025 at 9:23 AM a wet towel was on the floor in front of the radiator in room [ROOM NUMBER]. During interview and observation on 7/18/25 at 11:21 AM rooms [ROOM NUMBERS] had leaking radiators. Towels/sheets were in front of the radiator units absorbing the leaking water. The Plant Operations Manager stated radiators were leaking water due to condensation. They stated radiator unit drip pans could become clogged which caused leakage to the floor. They stated they were not aware of the leaking radiators and did not recall receiving a maintenance requisition for room [ROOM NUMBER] or room [ROOM NUMBER]. They stated there was no set schedule for radiator maintenance in resident rooms and that the maintenance department relied on unit staff to report concerns. During observation of the Forest Unit hallway there were numerous areas of torn and/or peeling wallpaper, scuffed walls and doors, and areas or rust marks on the ceiling trim. There was a missing baseboard in Resident room [ROOM NUMBER] B between the rear wall and radiator. The Plant Operations Manager stated they were aware of environmental concerns on the unit and plans were upcoming in the future, date unknown, for the unit to be renovated. During observation of the Forest Unit shower and tub/bath basin rooms the shower had low water pressure. The Plant Operations Manager stated shower heads can become clogged which can lead to low water pressure. The shower hot water temperature was measured during observation. A maintenance staff member measured the hot water temperature from 11:37 AM to 11:47 AM. The highest temperature recorded during this time was 91.9 degrees Fahrenheit. The Plant Operations Manager stated they were not aware of Resident Council concerns regarding weak water pressure on units in the [NAME] building and/or hot water taking a long time to become hot. The Plant Operations Manager stated non-emergent environmental / maintenance concerns were reported to the maintenance department through a software program provided on computers in the facility which all staff members could access. Urgent concerns were communicated by telephone at to the Security Department switchboard who would then notify maintenance staff. During observation of the maintenance work order request software program with the Plant Operations Manager, they were unable to locate requests regarding the leaking radiators in rooms [ROOM NUMBERS] or the missing baseboard in room [ROOM NUMBER]A. A work order requesting shower head replacement on the Forest Unit was dated as entered and completed on 7/1/25 During a review of maintenance work order requests provided by the Plant Operations Manager for dates 4/1/25-7/18/25, six work order requests were placed regarding low water pressure in the [NAME] building, including one for the Forest Unit.During an interview and observation on 7/18/25 at 12:07 PM approximately 25% of the fluorescent ceiling lights were not functioning/not illuminated. The Plant Operations Manager stated they were made aware of poor lighting concerns discussed at Resident Council meeting by the Activities Director on July 14, 2025. They stated the concern was discussed with the Administrator during a tour of the area on July 14, 2025, and the Plant Operations Manager and Administrator determined that the current lighting level was adequate, despite approximately 25% of the fluorescent light bulbs being not illuminated/non-functioning. The Plant Operations Manager stated the ceiling is high and a scissor lift, scaffolding or a contractor would be needed to change the fluorescent lightbulbs. They stated they had not contacted a contractor regarding replacing non-functioning fluorescent bulbs and were not aware of any non-functioning florescent light bulbs being changed since they began employment at the facility three years ago. The Plant Operations Manager stated the Town Hall Common area lighting concerns expressed by Resident Council were not considered an emergent situation and facility maintenance staff were currently working on more emergent concerns throughout the facility. They stated they were not aware of a work order being placed regarding nonfunctioning lightbulbs in the area. They stated they had not placed an order for an illumination meter to more accurately determine the lighting in the Town Hall Common area. During interviews on 07/18/25 at 11:49 AM and 7/21/25 at 12:04 PM, Unit Manager Registered Nurse #5 stated they entered a maintenance order for the leaking radiator in room [ROOM NUMBER] earlier this morning when it was reported by a certified nursing assistant. They stated they were not aware that room [ROOM NUMBER] also had a leaking radiator, as staff had not reported any concerns. They stated they conducted environmental rounds every morning. They stated sometimes they just looked inside the door of resident rooms and therefore may not have seen towel/sheet present or a puddle of water from leaks in room [ROOM NUMBER] or 619. They stated when they observed a concern or a concern was reported, they entered a maintenance work order request. Unit Manager Registered Nurse #5 stated they were aware of environmental concerns, including low water pressure, radiator leaks and torn/peeling wallpaper throughout the unit. They stated wallpaper replacement and scuff mark cleaning was requested at the last Round Table meeting with the Administrator, Manager and unit heads.10 NYCRR 415.5(h)(2)

Based on observation, record review and interview conducted during the recertification survey from 7/15/25-7/22/25, the facility did not ensure that staff evaluated the effectiveness of interventions and/or provided immediate interventions to assure the safety of residents to prevent abuse for 1 of 3 residents (Resident #218) reviewed for Abuse and prevent the potential for abuse for 1 of 6 residents (Resident #145) reviewed for Accidents. Specifically, 1. on 4/25/24 Resident # 218 with a history of wandering in/out of other resident rooms was found seated in the bed in Resident #147's room, while Resident #147 stood/masturbated in front of and pushed their penis against the face/mouth of Resident #218. Additionally, after the 4/25/24 incident, staff did not consistently document 15-minute visuals for Resident #218 as per the 4/25/24 incident and accident report/physician order and 2. Resident #145 with a history of wandering was observed on multiple occasion wandering in/out of other resident rooms and sleeping in other resident beds. Subsequently on 07/15/25 Resident #145 entered Resident #134's room and Resident #134 began yelling for Resident #145 to get out of their room. The findings included:A policy titled Preventing Resident Abuse, revised 4/19, documented the facility will not condone any form of resident abuse. The facility's policies and procedures as well as training programs will be monitored in order to assist in preventing resident abuse. 1) Resident #218 had diagnoses including Alzheimer's disease, osteoarthritis, and atrial fibrillation.Resident #218's care plan titled Potential for Abuse Physical/Verbal/Emotional dated 4/6/22 documented potential for abuse as evidenced by cognitive impairment, Alzheimer's, and psychiatric disorders. Interventions included: if abuse is suspected, immediately remove resident(s) from area/person for safety. Immediately contact nurse case manager/nurse supervisor/nursing administrator/administration if allegations of abuse are seen or reported. Frequent visualization of resident to monitor whereabouts and safety. Intervene as needed to ensure the safety of resident(s) and others.Resident #218's quarterly Minimum Data Set, dated [DATE] documented severe cognitive impairment, verbal behaviors towards others/wandering behaviors 1-3 days and use of antidepressant medication. Resident's #147 diagnoses included unspecified dementia, unspecified severity, with agitation, and psychotic disorder with delusions due to known physiological condition and major depressive disorder.Resident #147's admission Minimum Data Set, dated [DATE] documented severe cognitive impairment and verbal behavioral symptoms toward others 1-3 days.Resident #147's care plan titled Potential for Abuse dated 2/16/24 documented the following interventions: behavior notes weekly and as needed, Psychiatry evaluation and treatment as per physician orders, intervene as needed to ensure the safety of resident(s) and others, talk with resident in calm manner, divert attention and take to another location as needed.Resident #218's Care Plan notes dated 3/22/24 documented Resident #218 wanders in/out of other's rooms. Takes other's belongings. Goals and interventions reviewed and ongoing. The 4/5/24 at 10:01 AM Nurse Note documented Resident #218 has a history of ambulating on/off the unit at will, taking random things from random rooms. Redirection effective but short lasting due to dementia.The 4/5/24 at 9:50 PM Nurse Note documented Resident #218 ambulates on/off the unit at will daily. Can be combative with cares. Difficult to redirect. Safety maintained through monitoring.The 4/12/24 at 11:05 AM Nurse Note documented Resident #218 wanders on/off the unit all day going in/out of rooms, often taking belongings that do not belong to them. Can become aggressive when redirected.The 4/19/24 Nurse Note documented Resident #218 self ambulates on/off the unit at will. Continues to wander in/out of other resident rooms and take their personal belongings. Difficult to redirect.There was no documented evidence that Resident #218's care plan was reviewed and/or revised to address ongoing wandering in/out of other resident rooms. The Accident/Incident Report dated 4/25/24 at 5:30 PM documented Registered Nurse #30 was looking for Resident #218 to administer their medications. They found Resident #218 in the room with Resident #147 who was masturbating into Resident #218's face, standing in front of them. The report documented the physician was notified on 4/26/24 and Resident #218 was assessed by the physician on 4/27/24. No injuries found. Nurse Supervisor notified. Resident #218 was placed on fifteen-minute visuals. Staffing at time of incident was three certified nursing assistants and one nurse. Sexually transmitted disease testing ordered by nurse practitioner with all negative results. The Nurse Progress Note dated 4/25/24 at 6:09 PM, documented: Resident #218 was found sitting on the bed in Resident #147's room. Resident #147 was standing in front of Resident #218 with their penis in their hand, stroking themselves into Resident #218 face. Writer requested Resident #147 to back away from Resident #218 and then immediately removed Resident #218 from the room. They walked Resident #218 to the end of the unit, farthest from the room of Resident #147, and sat Resident #218 down in recliner chair and asked them if they were ok, if they had any pain or discomfort. They denied all and said they were good. They examined Resident #218 for signs / symptoms of injury and found noting and then told the nurse on the Grand unit and notified the Nurse Supervisor. Resident #218's care plan titled Behavior Problem was updated 4/25/24 to include 15-minute visuals.There was no documented evidence on the 15-minute visual logs that 15-minute visuals for Resident #218 were conducted on 4/26/24 3:00 PM-11:00 PM, 4/27/24 11 PM-6:45 AM, 4/28/24 2:30 PM-2:45 PM and 1:15 AM-6:45 AM, and on 4/29/24 12:15 PM-12:45 PM.The Nurse Progress Note dated 4/28/24 at 2:20 PM documented Resident #218 was in the [NAME] Unit sunroom. Resident #147 was also in the sunroom with a sitter. Resident #218 was redirected off of the unit by staff/sitter. During interview on 07/21/2025 at 11:52 AM Unit Manager Registered Nurse # 9 stated when the unit has four certified nurse assistants on duty during the day shift, there is sufficient redirection. Unit Manager Registered Nurse #9 stated there are day shifts when only three certified nurse assistants are present during the day shift. Unit Manager Registered Nurse #9 stated the unit has many residents who wander and redirection for all residents can be difficult. They stated many of the unit residents move quickly and constantly go in and out of other residents' rooms. They stated a request for additional staffing has been discussed with the Supervisor. During an interview on 07/21/2025 at 4:58 PM, the Director of Nursing stated residents on the dementia unit wander frequently and were observed and redirected by the unit staff. The Director of Nursing stated that to prevent further incidents between Residents #147 and #218, they asked certified nurse assistants to increase unit rounds and Resident #218 was no longer allowed on the same unit as Resident #147.During an interview on 7/22/25 at 1:23 PM, Registered Nurse #30 stated they remembered the incident and immediately separated the residents. They assessed Resident #218 for fear or anxiety. No change in resident status. Registered Nurse #30 stated they called the Director of Nursing immediately because they were aware that incidents involving abuse needed to be reported immediately.During an interview on 07/22/2025 at 4:41 PM the Administrator stated Resident #147 is territorial of their area and can be difficult to manage. 2) Resident #145's diagnoses included unspecified dementia with other behavioral disturbance, type II diabetes mellitus, and psychotic disorder with hallucinations.Resident #145's care plan titled Behavioral Problems dated 9/25/24 documented Alzheimer's, as evidenced by physically abusive behavior, socially inappropriate or disruptive behaviors, rummaging through other's belongings, moves bowels on the floor, wandering. Interventions included monitor behavior to assist in determining cause: times, places, situations, activity underway, noise levels, persons involved, length of period of upset, activities. Modify environment, situations, and / or treatment to minimize episodes as needed. Anticipate needs. Activities. Discuss behavior with staff, care plan team and resident if appropriate.The behavior notes dated 6/17/25 to 7/17/25 documented Resident #145 wanders into peers' rooms and sleeps in their beds, continue to redirect. Resident #145 found sleeping in beds of other residents on 6/21/25, 6/23/25, 6/26/25, 6/27/25, 7/3/25, 7/7/25, 7/8/25, 7/9/15 7/14/25, and 7/15/25.Resident #145's quarterly Minimum Data Set, dated [DATE] documented severe cognitive impairment, wandering behaviors, and physical, verbal, and other behavioral symptoms towards others.During an interview and observation on 07/15/2025 at 11:00 AM. Resident #145 was observed entering Resident #134's room. Resident #134 was present in the room and yelled for Resident #145 to get out of room. Resident #134 stated Resident #145 frequently wandered into their room and attempted to sleep in their roommate's bed. Resident #145 left the room when Resident #134 yelled to get out. Resident #145 returned to a chair outside the day room. Staff were not present in the unit hallway at the time of observation.During an observation on 07/15/2025 at 12:36 PM Resident #145 was observed entering Resident #61 and Resident #205's room and using the bathroom. Staff did not observe Resident #145 entering Resident #61 and Resident #205's room, as they were present in the day room and at the lower end of the unit. During an observation on 07/15/2025 at 1:55 PM Resident #145 was observed sleeping in Resident #210's bed. Staff were present in the dining room assisting with lunch and did not observe Resident #145's wandering or provide redirection. During interviews on 07/18/2025 at 10:06 AM Unit Manager Registered Nurse #9, stated the unit usually had two resident activities daily, depending on activities staff availability. They stated Resident #145 is a wanderer and frequently wandered into other residents' rooms to sleep in empty beds. They stated Resident #145 could become agitated when woken up. They stated Resident #145 did not attempt to sleep in an occupied bed. Unit Manager Registered Nurse # 9 stated when the unit has four certified nurse assistants on duty during the day shift, there is sufficient redirection. They stated there are days shifts when only three certified nurse assistants are present during the day shift. Unit Manager Registered Nurse #9 stated Resident #145 did not attend morning activities and preferred to sleep after breakfast. They stated Resident #145 would participate in afternoon activities at times, especially if music was involved. They stated Resident #145 preferred to stay in the unit hallway and did not frequently sit in the day room. During an interview on 07/22/2025 at 9:26 AM, Activities Specialist #28 stated Resident #145 occasionally participated in afternoon activities and enjoyed music and exercise. They stated Resident #145 did not usually attend morning activities as they preferred to sleep after breakfast. They stated Resident #145 was cooperative during activities. They stated Resident #145 often participated in afternoon activities 3-4 times a week and if they observed weeks when Resident #145's attendance was low, individualized activities were attempted. During an observation and brief interview on 07/22/2025 at 9:37 AM Resident #145 was observed sleeping in Resident # 31's room. There was no staff present in the unit hallway to provide Resident #145 with supervision or redirection. Unit Manager Registered Nurse #9 stated staff was not present to provide redirection in unit hallways due to most residents being in morning activity and certified nurse assistants were providing cares. They stated the unit started shift with three certified nurse assistants assigned and they had to request a fourth certified nurse assistant be sent to the unit. They stated they could only try to supervise all the residents. During an interview on 07/22/2025 at 9:49 AM Certified Nurse Assistant #29 stated Resident #145 frequently wandered into other residents' rooms. They stated Resident #145 frequently attended afternoon activities and did not attend morning activities. They stated they could adequately supervise residents on the unit. 10 NYCRR 415.4(b)(1)(i)

Based on record review and interviews the facility did not ensure that they initiated and completed a thorough investigation of alleged violations of abuse to prevent further potential abuse for one of three residents (#218) reviewed for abuse and three of four residents (#19, #99 and #25) reviewed for resident rights. Specifically, 1) on 4/25/24 at 4:30 PM, Registered Nurse # 30 was looking for Resident #218 and located them in Resident's #147's room. Resident #147 was standing in front of Resident #218 masturbating in their face. There was no documented evidence the Accident/Incident Report was completed until 6/19/24 and 2) the facility did not complete an investigation after Resident #19 reported a missing ring and 3) Resident #99 reported a missing purse. Additionally, there was no documented evidence that a thorough complete investigation was conducted after Resident # 25 reported a missing wallet. The findings included: The policy titled Resident Abuse and Neglect revised 4/19, documented it is the facility policy that all reports of abuse, mistreatment, neglect, exploitation and injuries of unknown origin be promptly and thoroughly investigated by facility management. The policy titled Accident and Incident Reporting reviewed 7/23, documented it is the facility policy that an Accident / Incident report will be initiated and completed for all accident/incidents. To perform a systematic review of all resident accidents/incidents and/or injuries in order to determine potential hazards and a corrective action to maintain a safe and secure environment. The Policy and Procedure titled Grievances, dated 6/19, documented the facility will promptly resolve all grievances, keeping the resident and resident representative informed throughout the investigation and resolution process. The facility grievance process will be overseen by the Director of Social Services, who will be. Responsible for receiving and tracking grievances. The grievance process is intended to support. Each residence has rights. To voice grievances. Examples of care management include funds, lost clothing, or violation of rights. 1) Resident #218 had diagnoses including Alzheimer's disease, osteoarthritis, and atrial fibrillation. The annual Minimum Data Assessment, dated 4/27/24, documented Resident #218 had severely impaired cognition, required set up for eating, was dependent with toileting and required partial to moderate assist with all other activities of daily living. The care plan titled Potential for Abuse Physical/Verbal/Emotional dated 4/6/22 documented potential for abuse as evidenced by cognitive impairment, Azheimers and psychiatric disorders. If abuse is suspected, immediately remove resident(s) from area/person for safety. Immediately contact nurse case manager/nurse supervisor/nursing administrator/administration if allegations of abuse are seen or reported. Frequent visualization of resident to monitor whereabouts and safety. Intervene as needed to ensure the safety of resident(s) and others. The Resident-to-Resident Incident Report dated 4/25/24 at 5:30 PM for Resident #218, stated Registered Nurse #30 was looking for Resident #218 to administer their medications They found the resident in the room with a male resident who was masturbating into Resident #218's face. The physician was notified on 4/26/24 and the resident was seen by the physician on 4/27/24. No injuries found. Nurse Supervisor notified. The resident placed on fifteen-minute visuals. There were three certified nursing assistants and one nurse staffed at the time. Sexually transmitted disease testing ordered by the nurse practitioner with all negative results. The supervisory review section, dated 6/18/24, documented Resident #218 was found with Resident #147's penis in their mouth. Immediately separated by staff and taken off unit. Staff Nurse/Nurse Supervisor spoke with the resident who showed no signs or symptoms of distress/fearfulness. Hall monitor aware to keep Resident #218 off the Forest unit/away from #Resident #147. The Assistant Director of Nursing review section, signed 6/19/24, documented the incident was not the result of abuse/mistreatment/neglect. Explanation was documented as accidental. Seen by the Nurse Practitioner. Urines for sexually transmitted diseases ordered. All negative. Resident was monitored for any changes in behavior. The Accident/Incident Report was initialed by the Nurse Manager (dated 6/14/24), Director of Nursing (dated 6/19/24) and Medial Director (dated 6/21/24). There was no Administrator signature or date. A statement obtained from Certified Nursing Assistant #31 was dated 4/25/24. A statement obtained from Certified Nursing Assistant #32 was dated 5/23/24. A statement obtained from Certified Nursing Assistant #33 was dated 5/23/24. During an interview on 7/22/25 at 1:23PM, Registered Nurse #30 stated they remembered the incident and immediately separated the residents. They assessed Resident #218 for fear or anxiety. They stated there was no change in resident status. Registered Nurse #30 stated they called the Director of Nursing immediately. During interviews on 07/21/2025 at 4:54 PM and 7/22/25 at 1:57 PM the Assistant Director of Nursing stated they were aware of the incident when it occurred and that the Unit Manager was responsible for the investigation, which was started right away. They stated they did not know why the accident and incident report was not signed as reviewed by the Administrator or why the report/investigation review was not completed until 6/19/24. They stated they were aware that certified nursing assistant witness statements were not obtained until May 23 and 24, 2024. They stated they did consider the incident abuse at the time. During an interview on 07/21/2025 at 4:58 PM, the Director of Nursing stated the incident report/investigation would have been reviewed around the time of occurrence either directly/verbally with the Administrator or at the facility's weekly round table meetings. They stated they were not able to remember exactly when the incident was reported to Administrator. They stated they did not know why the accident and incident report was not signed as reviewed by the Administrator or why the report/investigation review was not completed until 6/19/24. They stated the witness statements may not have been able to be completed immediately due to the certified nurse assistants not working at the facility again until May 23 and May 24, 2024, but they were not sure. They stated they were unable to determine if the incident was considered abuse. During an interview on 07/22/2025 at 4:41 PM, the Administrator stated they did not recall this specific accident and/or incident. They stated they did not recall verbally discussing the accident/incident with the Director of Nursing or other staff, The Administrator stated they did not receive an Accident/Incident Report to review and sign. 2) Resident #19 had diagnoses that included anxiety, hypertension, and depression. The Quarterly Minimum Data Set, dated [DATE] documented Resident #19 had intact cognition and no behaviors. During an interview on 07/16/2025 at 11:12 AM, Resident # 19 stated they were missing their Dottie ring. They stated it was lost less than a year ago. They stated they informed Registered Nurse Unit Manager #18, but they did not hear anything further about it. The 2024 and 2025 Facility Missing Items logs had no documented evidence of missing items. During an interview on 7/18/25 at 2:45 PM Registered Nurse Unit Manager #18 stated Resident#19 did report a missing ring sometime during the last year, the Dorothy ring. They stated when a resident was missing an item, they were to fill out a missing item form which was on green paper and give that form to administration. They stated they could not recall if they completed a missing item form for this item. They stated it was the Unit Manager's responsibility to complete the form. During an interview on 7/22/2025 at 2:11 PM, the Director of Social Services stated the Nurse Care Manager was responsible for completing the missing item form which was on a paper and different from the grievance form. After completing the form, it should be given to administration and then the Administrator should sign off once the investigation was completed. They stated they were not currently aware of any missing items. During an interview on 07/22/2025 at 02:41 PM, Registered Nurse Unit Manager #7 stated that they completed a green missing item form if a resident reported a missing item. They would also collect statements from staff and then provide the form and statements to the Assistant Director of Nursing for review. They stated the last item reported missing was Resident #99's purse. They stated they completed the process as described but the item was still missing. During an interview on 07/22/2025 at 02:59 PM, the Assistant Director of Nursing stated when an item is lost, the nurse completes the missing item form and gathers statements from staff. The nurse gives those documents to the Assistant Director of Nursing, and they will review them. They then communicate their findings to the Administrator and the Administrator will decide how to proceed. They stated the decisions could be police notification, replacement of the missing property or monetary reimbursement for the value of the item. During an interview on 07/22/2025 at 03:13 PM, the Administrator stated that the missing item form had been replaced. There is a new policy for missing items which is not being followed. They stated once a missing item is reported an investigation should be conducted and the resident should be informed of the status of the investigation. They stated the facility could reimburse residents for lost items and law enforcement may be notified 3) Resident #99 had diagnoses of Chronic Atrial Fibrillation, Presence of a Pacemaker, and Type 2 Diabetes. The 1/12/25 annual Minimum Data Set documented, Resident #99 was cognitively intact. There was no documented evidence in the Concern Log for 2023, 2024, and 2025 to indicate Resident # 99 had missing items. During an observation on 7/22/25 at 4:35 PM, Resident #99 had a locked drawer, which is functional. During an interview on July 22, 2025, at 4:00 PM, Resident #99 stated that a purse had been missing since before Easter. They stated they left the room at approximately 2:00 PM for an event that concluded at 4:00 PM and upon returning to the room, the resident noticed their purse was missing from the bed area. A request was made to speak to the supervisor, who responded along with the nurse care manager. They stated the incident was also mentioned in the monthly resident council meetings. They stated the missing purse contained the resident's grandmother's rosary beads ([AGE] years old), a $20 bill, a debit card, and a pacemaker card. During an interview with the Social Worker on 7/22/2025 at 2:11 PM, they stated the facility resident's missing items process is not with Social Services. They stated nursing staff oversees the process. During an interview with Nurse Manager r#7 on 7/22/25 at 4:10 PM, they stated they were aware of the missing purse. They stated per protocol they filled out the form and took it to the administrator's office. They stated they did not follow up. During an interview with the Administrator on 7/22/25 at 4:20 PM, they stated they were unaware of Resident #99's missing purse and/or wallet. 10NYCRR 415.4(b)(3)

Based on observation and interview conducted during the recertification survey from 7/15/2025 to 7/22/2025, the facility did not ensure proper storage in accordance with professional standards for food safety. Specifically, multiple containers of unmarked, undated food were observed in facility refrigerators and freezers, multiple containers of food were in the dry storage area without a date to indicate when they had been opened, a kitchen staff's personal drink item was observed in a refrigerator which stored resident foods, and a malodor was present in the meat refrigerator where food was stored.The findings include:The policy titled Refrigerator Non-Medication Cleaning and Monitoring last revised on 03/2025, documented all food in refrigerators will be monitored for proper food labeling. The policy titled Infection Control/Handling Leftovers last revised on 08/2020, documented all unused food that has not been served, may be used within 48 hours from the time of preparation. All food shall be dated.During observation of the kitchen and interview on 07/15/2025 at 9:57 AM, the dairy refrigerator had two bags of liquid eggs which were unlabeled, undated and not in their original container. The meat freezer had one container of french toast, one bag of round waffles, one bag of meatballs, and one bag of chicken tenders which were unlabeled/undated and not in their original container. Mobile #2 refrigerator had sandwiches which were unlabeled/not properly dated and there was an unlabeled and undated half liter container of [NAME] Donuts iced drink which belonged to kitchen staff. The Food Service Supervisor identified the food in each of the containers and bags and stated the items were not labeled or dated properly.During observation of the dry storage area and interview on 07/15/2025 at 11:16 AM there was one bag of open graham crackers, one bag of open classic pasta, one bag of open spaghetti noodles, one gallon of open vegetable oil, one gallon of open vanilla syrup, one quart of open brown/season mix, and one box of open baking soda that did not contain a date to indicate when they had been opened. The Acting Dietary Director stated the items were not dated when they were opened. They also stated kitchen staff would need to remove their personal drink item from the refrigerator that was being used for resident/s food. During observation on 7/22/2025, at 12:20 PM, a malodor was observed in the meat refrigerator where food was stored. During an interview at the time of finding, the Acting Dietary Director confirmed there was an odor and stated that it could not be determined where the order was coming from. During a subsequent interview on 07/22/2025 at approximately 12:30 PM, the maintenance supervisor confirmed the odor and stated the compressor would be assessed to determine where the odor may be coming from.10 NYCRR 415.14 (h)

Based on observation and interview conducted during the recertification survey from 7/15/25 to 7/22/25, the facility did not ensure all mechanical and electrical equipment was in safe operating condition. Specifically, water was observed leaking from the kitchen dishwasher which allowed standing water to be present on the floor in and around the dishwasher. The findings include:During observation of the kitchen and interview on 07/21/2025 at 1:46 PM the dishwasher was leaking water which allowed standing water to be present on the floor in and around the dishwasher. The Acting Dietary Director stated the standing water had been present for some time and they were working with maintenance to see if they should install a new drain or provide a path in the floor for the water to flow. During an interview of 7/22/2025 at 11:01 AM the Maintenance Supervisor stated the facility had a computer program for reporting maintenance issues. After a maintenance issue is entered, maintenance staff evaluate the problem and see what is needed to repair the equipment. They stated the dishwasher was leaking water in a different area and the water was not able to flow into the floor drain as designed. They stated the floor drain was obstructed by debris and standing water around the dishwasher had been a problem in the past. They stated maintenance had not been able to repair the water leak or clean the floor drain. They stated maintenance would need to contact an outside contractor to repair the leak and clean the floor drain to prevent further standing water.

Based on observation and interview conducted during the recertification survey from 7/15/25 to 722/25, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of infection for 1 of 4 residents reviewed for nutrition. Specifically, Licensed Practical Nurse #12 was observed without the use of a gown when they administered medications via gastrostomy tube to Resident #14 who was on enhanced barrier precautions.The findings included:The policy titled Infection Control Practices Precaution Guidelines, revised 11/2023, documented residents suspected or known to have an infection, and/or transmissible disease will be clinically managed to prevent and control outbreaks and cross contamination. Enhanced barrier precautions guidelines include the use of a gown for high contact resident care Resident #14's diagnoses included dysphagia, and encounter for attention to gastrostomy. A significant change Minimum Data Set (assessment tool) dated 6/20/25 documented Resident #14 had severe cognitive impairment.During an observation and interview on 07/16/2025 at 9:30 AM, Licensed Practical Nurse #12 administered medications via gastrostomy tube to Resident #14 without wearing a gown. Licensed Practical Nurse #12 stated they were aware they did not wear a gown or follow personal protective guidelines when they administered medications to a resident on enhanced barrier precautions. They stated they forgot. During an interview on 07/21/2025 10:39 AM, the Director of Nursing stated during any close interaction, including medication administration, with a resident on enhanced barrier precautions, staff were expected to wear a gown. They stated staff should be supervised by Nurse Unit Managers to ensure proper personal protective equipment policies were followed. They stated infection control guidelines were reviewed during annual mandatory in-services. During an interview on 07/21/2025 at 11:17 AM, Unit Manager Registered Nurse #5 stated the expectation was that all staff wear personal protective equipment while cares were provided for residents on enhanced barrier or other precautions. They stated Licensed Practical Nurse #12 should have worn a gown when they administered medications through a gastrostomy tube for Resident #14. They stated they were responsible for supervising staff and in-servicing staff if concerns were identified. 10 NYCRR415.19

Based on observation, interview, and record review during the Recertification Survey from 7/15/2025-7/22/2025, the facility did not ensure reasonable accommodation of resident needs and preferences. Specifically, one of four residents (Resident #187) reviewed for accommodation of needs and one of five residents (Resident #119) reviewed for call devices, were observed on multiple occasions with the call bell device not within the resident's reach. The findings include:Resident #187 had diagnoses including but not limited to cerebrovascular accident, peripheral vascular disease, and coronary artery disease. The Annual Minimum Data Set, dated [DATE] documented Resident #187 had moderately impaired cognition and received maximum and/or dependent staff assistance for most activities of daily living.Resident #187's Fall Care Plan initiated 8/19/2019 documented the call bell must remain within the residents reach and ensure prompt staff response. During an observation and interview on 7/16/2025 at 10:06 AM Resident #187 was observed sitting in a wheelchair in their room, their call bell was observed across the room and not within their reach. Resident #187 stated their call bell was often out of reach. During an observation on 7/18/25 at 8:37 AM Resident #187 was observed sitting in a wheelchair in their room with a bedside table in front of them. Resident #187's call bell was on the bed behind the resident and not within their reach. Resident #119 had diagnoses including but not limited to anoxic brain damage, anxiety disorder, and unspecified epilepsy.The Annual Minimum Data Set, dated [DATE] documented Resident #119 had severely impaired cognition and was dependent on staff for assistance with activities of daily living.Resident #119's Fall Care Plan initiated 3/22/2016 documented the call bell must remain within the residents reach and ensure prompt staff response. During an observation on 7/15/2025 at 10:47 AM Resident #119 was observed in bed. Resident #119's call bell was hanging on the wall and was not within their reach. During an observation on 7/17/2025 at 10:58 AM Resident #119 was observed in bed. Resident #119's call bell was wrapped on the lower part of the bed rail and was not within their reach. During an observation on 7/18/25 at 12:45 PM, Resident #119 was observed in bed. Resident #119's call bell was hanging on the wall and not within their reach. During an interview on 7/21/2025 at 1:12 PM Registered Nurse Unit Manager #20 stated Resident #119 was not always able to use their call bell, as their ability varied. They stated on 7/20/25 there was a progress note that documented Resident #119 rang for assistance, so they could use it at times. They stated call bells should be accessible to all residents even if their capacity was limited. NYCRR 415.5 (e)(1)

Based on observations, interviews, and record reviews conducted during a recertification survey the facility did not ensure each resident was free from misappropriation of resident property for two of four residents (#19, and #99) reviewed for resident rights. Specifically, 1) Resident #19 reported a missing ring and 2) Resident #99 reported a missing purse which contained rosary beads, a twenty dollar bill, debit card and pacemaker card. The findings include: The Policy and Procedure titled Grievances, dated 6/19, documented the facility will promptly resolve all grievances, keeping the resident and resident representative informed throughout the investigation and resolution process. The facility grievance process will be overseen by the Director of Social Services, who will be. Responsible for receiving and tracking grievances. The grievance process is intended to support. Each residence has rights. To voice grievances. Examples of care management include funds, lost clothing, or violation of rights. 1) Resident #19 had diagnoses that included anxiety, hypertension, and depression. The Quarterly Minimum Data Set, dated [DATE] documented Resident #19 had intact cognition and no behaviors. During an interview on 07/16/2025 at 11:12 AM, Resident # 19 stated they were missing their Dottie ring. They stated it was lost less than a year ago. They stated they informed Registered Nurse Unit Manager #18, but they did not hear anything further about it. The 2024 and 2025 Facility Missing Items logs had no documented evidence of missing items. During an interview on 7/18/25 at 2:45 PM Registered Nurse Unit Manager #18 stated Resident#19 did report a missing ring sometime during the last year, the Dorothy ring. They stated when a resident was missing an item, they were to fill out a missing item form which was on green paper and give that form to administration. They could not recall if they completed a missing item form for this item. They stated it was the Unit Manager's responsibility to complete the form. During an interview on 07/22/2025 at 02:59 PM, the Assistant Director of Nursing stated when an item is lost, the nurse completes the missing item form and gathers statements from staff. The nurse gives those documents to the Assistant Director of Nursing, and they will review them. They then communicate their findings to the Administrator and the Administrator will decide how to proceed. They stated the decisions could be police notification, replacement of the missing property or monetary reimbursement for the value of the item. During an interview on 07/22/2025 at 03:13 PM, the Administrator stated that the missing item form had been replaced. There is a new policy for missing items which is not being followed. They stated once a missing item is reported an investigation should be conducted and the resident should be informed of the status of the investigation. They stated the facility could reimburse residents for lost items and law enforcement may be notified 2) Resident #99 had diagnoses of Chronic Atrial Fibrillation, Presence of a Pacemaker, and Type 2 Diabetes. The 1/12/25 annual Minimum Data Set documented, Resident #99 was cognitively intact. There was no documented evidence in the Concern Log for 2023, 2024, and 2025 to indicate Resident # 99 had missing items. During an observation on 7/22/25 at 4:35 PM, Resident #99 had a locked drawer, which is functional. During an interview on July 22, 2025, at 4:00 PM, Resident #99 stated that a purse had been missing since before Easter. They stated they left the room at approximately 2:00 PM for an event that concluded at 4:00 PM and upon returning to the room, the resident noticed their purse was missing from the bed area. A request was made to speak to the supervisor, who responded along with the nurse care manager. They stated the incident was also mentioned in the monthly resident council meetings. They stated the missing purse contained the resident's grandmother's rosary beads ([AGE] years old), a $20 bill, a debit card, and a pacemaker card. During an interview with Nurse Manager r#7 on 7/22/25 at 4:10 PM, they stated they were aware of the missing purse. They stated per protocol they filled out the form and took it to the administrator's office. They stated they did not follow up. During an interview with the Administrator on 7/22/25 at 4:20 PM, they stated they were unaware of Resident #99's missing purse and/or wallet. NYCRR 415.4 (b)

Based on observation, interview, and record review conducted during the recertification from 7/15/25 to 7/22/25, the facility did not ensure all alleged violations of abuse were reported immediately, but not later than 2 hours to the state survey agency for 1 of 3 residents reviewed for Abuse (Resident #218). Specifically, there was no documented evidence that an allegation of abuse was reported to the facility Administrator or to the state survey agency after a 4/25/24 incident where Resident # 218 with a history of wandering in/out of other resident rooms was found seated in the bed in Resident #147's room, while Resident #147 stood and masturbated in front of Resident #218.The findings included:The policy titled Resident Abuse and Neglect, revised 4/19, documented it is the facility policy that all reports of abuse, mistreatment, neglect, exploitation and injuries of unknown origin be promptly and thoroughly investigated by facility management. NOTE: Federal Regulations (42 CFR 483.13) and New York State (NYS) Regulations (10 NYCRR 415.4) require the reporting of alleged violations of abuse, mistreatment, exploitation and neglect, including injuries of unknown origin, immediately to the Facility Administrator/designee.Resident #218 had diagnoses including Alzheimer's disease, osteoarthritis, and atrial fibrillation.The annual Minimum Data Assessment, dated 4/27/24, documented Resident #218 had severely impaired cognition.The Resident-to-Resident Incident Report dated 4/25/24 at 5:30 PM for Resident #218, stated Registered Nurse #30 was looking for Resident #218 to administer their medications. They found the resident in the room with a male resident who was masturbating into Resident #218's face, standing in front of her. Nurse supervisor notified.During an interview on 7/22/25 at 1:23PM, Registered Nurse #30 stated they called the Director of Nursing immediately because they were aware that incidents involving abuse needed to be reported immediately.During interviews on 07/21/2025 at 4:54 PM and 7/22/25 at 1:57PM the Assistant Director of Nursing stated the incident was not reported to the New York State Department of Health. They stated the Director or Assistant Director of Nursing would have been responsible for reporting. They stated they did consider the incident abuse at the time.During an interview on 07/21/2025 at 4:58 PM, the Director of Nursing stated the incident was not reported to the New York State Department of Health. During an interview on 07/22/2025 at 4:41 PM, the Administrator stated they did not recall this specific accident and/or incident. They stated they did not recall discussing the accident/incident with staff and did not recall reporting to the New York State Department of Health. 10 NYCRR 415.4

Based on observation, interview and record review conducted during a recertification survey, from 7/15/2025-7/22/2025 the facility did not ensure that comprehensive person-centered care plans were developed and/or implemented for each resident to meet the resident's medical and/or nursing needs for 1 of 4 residents (#214) reviewed for range of motion. Specifically, for Resident #214 with muscle weakness a care plan was not developed to address left-hand contracture and/or the use of a left-hand roll as per occupational therapy recommendation The findings includeResident # 214 had diagnoses which included Dementia. A Quarterly Minimum Data Set (assessment tool) dated 6/15/25 documented Resident #214 had severely impaired cognition, no functional limitation in range of motion, and received substantial/maximal assistance with all other activities of daily livingThe Occupational Therapy Discharge Note dated 6/20/2025, documented staff/caregivers were educated and instructed on the use of a left upper extremity handroll schedule, range of motion, hygiene, and skin checks for irritation. During observation on 07/15/2025 at 2:02 PM, 7/16/2025 at 12:20 PM, 7/17/2025 at 3:20 PM, and 7/18/2025 at 9:03 AM Resident #214 was resting in their wheelchair. Their left hand was contracted and did not have a hand roll in place. There was no documented evidence that a care plan was developed, and physician orders were obtained to address contracture management and the use of a left-hand roll as per Occupational Therapy recommendation.During an interview on 7/18/2025 at 9:05 AM Licensed Practical Nurse #6 stated the resident had a contracted left hand and had been receiving therapy. They stated they did not know the outcome of therapy. They stated if the resident needed an intervention such as a hand roll it should have been care planned.During an interview on 7/18/25 at 10:15 AM Registered Nurse Unit Manager #5 stated when therapy recommended the hand roll and educated the staff, an order should have been placed, a care plan should have been developed, and it should have been documented on the Certified Nurse Aide Assignment Instructions. They stated they were only covering the unit and did not know why these things did not occur. They stated the Licensed Practical Nurse called them earlier this morning regarding the resident's hand being contracted and they contacted therapy. During an interview on 7/18/25 10:29 AM the Assistant Director of Nursing stated if Occupational Therapy recommended a hand roll was to be worn, it was the Unit Managers responsibility to develop a care plan for contracture management and add the use of the hand roll to the Certified Nurse Aide Assignment Instructions. 10 NYCRR 415.11(c)(1)

Based on interview, and record review conducted during the recertification and abbreviated survey (813417) from 7/15/25 - 7/22/25, the facility did not ensure Comprehensive Care Plans were revised to reflect the resident's current condition for 1 of 6 residents (Resident #227) reviewed for Accidents. Specifically, for Resident #227, there was no documented evidence that comprehensive care plans were reviewed and/or revised to include safety interventions recommended by occupational therapy after a 1/18/2024 fall.The findings include:The policy titled Falls Standard of Care and Comprehensive Planning, reviewed 3/2019 documented care plans will be updated in the Electronic Medical Record as soon as the fall investigation is complete.Resident #227's diagnoses included Alzheimer's disease, dependence on renal dialysis, and history of falling.The quarterly Minimum Data Set, dated [DATE] documented Resident #227 was cognitively intact, required a wheelchair for ambulation and was dependent for toileting and transfers. A nursing note dated 1/18/24 documented at 3:45 PM the resident was sitting on the floor in front of a tipped wheelchair. The residents back was against the seat of the wheelchair. No complaints of pain on passive range of motion.An occupational therapy note dated 1/19/24 documented recommend the additional mechanical lift pad only be placed right before outside trips and removed immediately after appointments to reduce Resident 227's risk of sliding forward. Nurse Case Manager made aware of this safety recommendation.There was no documented evidence in the fall care plan to address the 1/19/24 occupational therapy recommendation to place an additional mechanical lift pad right before outside appointments and remove the additional pad immediately after appointments to reduce the risk of falling forward.During an interview on 07/22/2025 at 8:45 AM, Occupational Therapist #9 stated they assessed Resident #227 on 1/19/24 after a 1/18/24 fall. They stated Resident #227 attended out-patient dialysis three times a week and required a mechanical lift for transfers. They stated the dialysis center used a different mechanical lift which required the use of 2 lift pads. They stated the use of an additional pad could have been a factor in Resident #227 sliding out of wheelchair. They stated Resident #227 had poor core strength which could also lead to the resident sliding out of wheelchair. Occupational Therapist #9 stated after the 1/19/24 they recommended removal of one of the mechanical lift pads upon Resident #227's return from dialysis. They stated the safety recommendation was discussed with the unit nursing staff. During an observation of resident care plans, Occupational Therapist #9 stated they were unable to locate the recommended safety care plan intervention. Occupational Therapist #9 stated the Unit Manager Nurse would be responsible for adding the updated care plans safety recommendations to the resident care plan.During an interview on 07/22/2025 at 10:23 AM the Unit Manager Registered Nurse #20 stated they were aware of safety intervention suggested by the occupational therapist status post Resident's #227 fall on 1/18/24. They stated they were not able to locate a care plan update that included the safety intervention of removing the dialysis mechanical lift pad when Resident #227 returned to the building after dialysis appointments. They stated they were responsible for entering any new interventions and should have added it to the care plan. 10 NYCRR 415.11(c)(2)(i-iii)

Based on observation, interview, and record review during the Recertification Survey from 7/15/2025-7/22/2025, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one of three residents (#6) reviewed for mood and behavior and one of four residents (#171) reviewed for positioning. Specifically, 1) Resident #6 did not receive follow up psychiatric services as ordered and recommended by the physician and 2) Resident #171 was observed seated in their wheelchair with their legs/feet unsupported and dangling above the footrests.The findings include: 1) Resident #6 had diagnoses including but not limited to unspecified dementia, psychotic disorder, and anxiety disorder. The physician order dated 10/16/2024 documented psychiatric consultation in house follow up in one-month last visit 10/16/2024. There was no documented evidence of a psychiatric follow up after the 10/16/2024 consultation. The care plan titled Psychotropic Drug Use with a 3/25/2024 revision date documented continue psychiatric medications and follow up with psychiatry services. The physician order dated 4/3/2025 documented psychology consultation in house for possible gradual dose reduction, evaluate effectiveness. There was no documented evidence of a psychology consultation as per the 4/3/2025 physician order. The Annual Minimum Data Set (assessment tool) dated 4/27/2025 documented Resident #6 had severely impaired cognition, no behaviors, and received antipsychotic medication. The physician order renewal 7/14/2025 documented Xanax 0.25 milligrams every week prior to baths for anxiety disorder and Rexulti 0.5 milligrams once daily for major depressive disorder. During an observation on 07/17/2025 at 11:03 AM, Resident #6 was sitting in the common area on the unit with other residents. They hit and pushed all water containers and cups on the table in front of them onto the floor. During an observation on 7/21/25 at 10:15 AM, Resident #6 was in their wheelchair in the room alone facing the television which was on. They stated, help me, help me, give me a kiss. Resident #6 was redirected and reassured. During an interview on 7/21/25 at 10:25 AM, Covering Registered Nurse Unit Manager #24 stated the last psychiatry consultation was on 10/16/2024. They stated they were uncertain why the last consultation was in October even though follow up had been ordered one month after that visit. During an interview on 7/22/2025 at 11:03 AM, Registered Nurse Unit Manager #18 stated Resident #6 was alert, responsive, and confused. They stated Resident #6 could be combative especially prior to baths/showers. They stated psychiatry had recommended a follow up visit one month after the 10/16/2024 consultation, and it was ordered but not completed. They stated the April 2025 psychology consultation was not completed as per order. They stated there was no documented evidence explaining why the consultation/s were not completed. During an interview on 07/22/2025 at 3:43 PM, the Director of Nursing stated Resident #6 last saw psychiatry in 10/2024. They stated there was an order for follow up in one month and they would have expected a November 2024 follow up. They stated the provider had recommended and ordered a psychological consult for Resident #6 in April 2025, but that was not completed either. They stated they could not provide a reason why the consultations were not completed. 2) Resident # 171 had diagnoses including Dementia, Stroke, and Hemiplegia The Annual Minimum Data Set, dated [DATE] documented Resident #171 had severely impaired cognition and required partial to maximal assistance for all activities of daily living. There was no documented evidence in the July 2025 Care Instructions to address Resident #171's position when in the wheelchair. During observation on 07/15/2025 at 1:59 PM, 7/16/2025 at 9:12 AM, 7/16/2025 at 3:14 PM, 7/18/2025 at 12:20 PM Resident #171 was seated upright in a special wheelchair that had the ability to rock back. The wheelchair had leg/footrests. Resident #171's feet did not reach the footrests and were dangling unsupported. The wheelchair did not have a leg board. During an interview on 7/18/2025 at 11:46 AM Certified Nurse Aide #4 stated they now saw how the resident's legs were dangling and were unsupported. They stated at one time the resident had a black thing (leg board) that went behind the legs. They stated they would have to call therapy to have them check the residents chair positioning. During an interview on 7/18/25 at 12:45 PM Licensed Practical Nurse #6 stated they usually placed a pillow to keep the resident's feet from dangling. They stated if there were positioning concerns, they would need to call therapy, so they could evaluate. During an interview on 7/21/2025 10:40 AM Occupational Therapist # 9 stated after their last assessment, the resident was issued a leg board for positioning. They stated the Unit Nurse Care Manager would be responsible for letting the Certified Nurse Aide's know which devices should be in use. They stated if the resident did not use the leg board it could affect how comfortable they were in the chair. During an interview on 7/21/25 at 11:09 AM the Director of Nursing stated it was the Unit Nurse Care Managers responsibility to ensure that Certified Nurse Aides had the information needed to care for residents regarding the use of positioning devices. They stated the Unit Nurse Care Manager should ensure staff had the care instructions documented in care plans and if appropriate the Certified Nurse Aides assignment instructions. 10NYCRR 415.12

Based on observation, record review, and interview during the recertification survey conducted 7/15/2025 to 7/22/2025, the facility did not ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers for one of three residents (Residents #171) reviewed for pressure ulcers. Specifically, heel booties were not applied as per physician order and care plan for Resident #171 who was assessed at risk for pressure ulcers. The findings include:The policy & procedure titled Pressure Ulcers Prevention dated 11/2010 documented staff were to identify risk factors for pressure ulcer development and take measures to prevent the formation of pressure ulcers.Resident #171 had diagnoses including Dementia, Stroke, and Hemiplegia.The Quarterly Minimum Data Set (an assessment tool) dated 6/8/25 documented Resident #171 had severely impaired cognition, functional impairment on both sides of the upper and lower body, was dependent with all activities of daily living and was at risk for developing pressure ulcers.The Physician order dated 6/23/25 documented heel boots at all times to bilateral feet.During observation on 07/15/2025 at 1:59 PM, 07/16/2025 at 9:15 AM, and 3:14 PM, and on 7/18/25 at 12:20 PM and 3:00 PM Resident #171 was out of bed in a wheelchair with no offloading boots on their feet. During observation on 7/18/2025 at 8:57 AM and 7/21/25 at 9:00 AM Resident #171 was in bed asleep. Resident #171 did not have heel booties in place.A review of the current Certified Nure Aide Instruction documented the resident should have heel boots at all times.During an interview on 7/18/25 at 11:46 AM Certified Nurse Aide #4 stated they thought the boots were to be worn only when the resident was in bed. After reviewing the Certified Nurse Aide Instructions, they stated the resident should be wearing the heel boots at all times.During an interview on 7/18/25 at 12:45 PM Licensed Practical Nurse #6 stated they had spoken with the unit manager a few days ago and advised them the heel boots were missing. They stated at times when the heel boots went to the laundry they did not come back. They stated if the heel boots were missing, the unit staff should contact the Rehabilitation Department. During an interview on 7/21/25 10:35 AM Physical Therapist #10 stated they were asked to see the resident on Friday related to the resident's missing bilateral heel boots. They stated the resident needed to have their heel boots because they were dependent and were at risk for skin breakdown. During an interview on 7/21/25 at 11:09 AM the Director of Nursing, stated it was the Nurse Care Managers responsibility to ensure Certified Nurse Aides had the information needed to care for the resident They stated that information should include positioning and the use of off-loading devices. During an interview on 07/22/2025 at 11:38 AM the Nurse Practitioner (wound care nurse) stated heel booties were ordered by the physician for pressure relief of the heels. They stated the medical provider had given orders for the heel boots to be worn at all times. They stated the resident should have the heel boots on at all times, except when receiving care, during showers or if the resident was not tolerating them.10NYCRR 415.12(c)(1)

Based on observation, record review, and interviews conducted during the Recertification Survey from 07/15/2025 to 07/22/2025, the facility did not ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion for 1 of 4 residents (Resident #10) reviewed for Position/Mobility. Specifically, Resident #10 with functional limitation in range of motion was observed on multiple occasions without the use of a left-hand splint as per Occupational Therapy recommendation. The findings included:The policy and procedure titled Care Planning, Orthotic Device, Splints Skin Integrity Monitoring dated last revised 10/10 documented the orthotist/designee will evaluate appropriateness and proper fit of the brace and splint. They will work in collaboration with the referring physician, unit manager and the therapist are to assess the effectiveness and fit of the brace or splint.Resident #10 had diagnoses including Cerebral Infarction and Dementia.The Quarterly Minimum Data Set, dated [DATE] documented Resident #10 had severely impaired cognition, was dependent with all activities of daily living and had functional limitation in range of motion on both sides of the upper and lower extremities.An Occupational Therapy progress note dated 6/21/2025 documented that the long-term goal for the resident is to increase the range of motion to the left wrist and hand by 20 degrees to enable a splinting/positioning device to promote functional positioning. Occupational Therapy recommends the Left-Hand Splint to be worn at all times but removed for cares and range of motion. Occupational Therapy staff provided an in-service education to the unit nursing staff for bilateral hand range of motion stretches as well as hand splints.There was no documented evidence in the electronic medical record of a care plan and physician orders to address contracture management and the use of a left-hand splint.During observations on 07/16/2025 at 10:10 AM, and 07/18/2025 at 10:31 AM Resident #10 was noted with a contracted left hand and did not have a left-hand positioning device in place. During an interview on 07/21/2025 at 10:23 AM, Certified Nurse Aide #25 stated Resident #10 had contractures of their hands. Certified Nurse Aide #25 stated nursing staff received an in-service on the hand braces about a month ago.During an interview on 07/21/2025 at 11:24 AM, Registered Nurse Unit Manager #26 stated there was no order for left-hand splints, no care plan for contractures and no certified nurse aide accountability for the resident to wear the splint every day as per Occupational Therapy recommendation.During an interview on 07/21/2025 at 4:45 PM, the Medical Director stated the procedure was for Physical and Occupational Therapy to make recommendations. They stated the nurse supervisor was responsible for entering orders into the electronic health record and the medical director or one of the nurse practitioners were to sign off on orders.During an interview on 07/22/2025 at 09:59 AM, the Director of Nursing stated recommendations from Physical and Occupational Therapy or other disciplines were supposed go to the unit manager or nurse supervisor to be implemented. They stated orders would be entered by nursing into the electronic health record and Certified Nurse Aide accountability. They stated an order would be implemented while waiting for a medical provider signoff. They stated managers or supervisors were responsible for entering care plans and orders. They stated for Resident #10 the Licensed Practical Nurse or Registered Nurse would be responsible for applying/removing hand splints and braces since they were more complex for proper placement. 10 NYCRR 415.12

Based on observation, record review, and interview during the Recertification Survey conducted from 07/15/2025- 07/22/2025, the facility did not ensure that residents were free of medication error rates less than 5% for 1 of 4 residents (Resident #114) reviewed for Medication Administration. Specifically, Licensed Practical Nurse #11 crushed 3 medications and administered them all at once via gastrostomy tube, then combined 3 liquid medications and administered them all at once to for Resident #114 via gastrostomy tube.The findings included:The policy titled Medication Treatment Administration, which was last reviewed on 10/17, documented medications are to be crushed and administered separately, whether administered via oral or gastrostomy route.Resident #114 had diagnoses including Major Depressive Disorder, Epilepsy (seizure disorder), and Gastrostomy status.The care Plan titled Tube Feed last updated on 09/28/19, documented administer medication as ordered.The physician orders dated 7/7/2025 documented Famotidine 20mg tablet give one tablet by gastrostomy tube daily. Lamotrigine 100mg tablet give one tablet by gastrostomy tube daily. Hydrocortisone 5mg tablet give one tablet by gastrostomy tube daily. Potassium chloride 20meq/15ml oral liquid give 22 milliliters by gastrostomy tube once daily. Lactulose 10gram/15ml oral solution give 30 milliliters by gastrostomy tube twice a day. Keppra 100mg/ml oral solution give 10 milliliters by gastrostomy every 12 hours.During the medication administration task on 7/18/2025 at 9:11 AM Licensed Practical Nurse #11 crushed a Hydrocortisone 5-milligram tablet, Lamotrigine 100-mg tablet, and Famotidine 20-mg tablet, and combined the crushed tablets in a cup with water. Licensed Practical Nurse #11 then poured Keppra 100mg/Milliliter (10 milliliter), Potassium chloride 20 meq. (22 milliliter), and Lactulose 10 g (22 milliliters) into a medication cup. Crushed tablets were administered first, followed by a water flush through the gastrotomy tube. All Liquid medications were then administered, followed by a flush.During an interview on 07/22/2025 at 11:21 AM, Licensed Practical Nurse #11 stated they combined all the tablets, administered them and then flushed. They then put all three liquids in a cup, administered them, and then flushed.During an interview on 07/22/2025 at 11:29 AM, the Director of Nursing stated the Nurse should have administered the medication one at a time and flushed after every medication. They stated the Nurse would need to be educated.10 NYCRR 415.12 (m) (2)

Based on observations, record review and interviews conducted during the Abbreviated Surveys (NY00342238 and NY00364422), the facility did not ensure that there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, 1) The facility did not provide adequate staffing to meet the needs of the residents, and as per their Facility assessment dated 6/2018 and revised on 4/9/2025; 2) Upon review of the nursing staffing schedule on 6/2/2024 (3pm-11pm), there were a total of 27 Certified Nurse Aides and a total of 5 Licensed Practical Nurses in the facility and the Facility Assessment documented that there must be 29-32 Certified Nurse Aides and 6-9 Licensed Practical Nurses in the building on the evening shift,; 3) On 12/8/2024(11pm-7am), there were a total of 21 Certified Nurses' Aides, and one nurse covered 2 units in which the Facility Assessment does not indicate that one nurse should cover more than one unit; 4) On 2/9/2025(3pm-11pm shift), there were a total of 24 Certified Nurse Aides and a total 4 Licensed Practical Nurses in the facility and the Facility assessment dated 6/2018 and revised on 4/9/2025 documented that there must be 29-32 Certified Nurse Aides and 6-9 Licensed Practical Nurses in the building on the evening shift,; 5) On 2/15/2025(11pm-7am shift)), there were a total of 14 Certified Nurse Aides and a total of 3 Licensed Practical Nurses in the facility and the Facility assessment dated 6/2018 and revised on 4/9/25 documented that there must be 18-22 Certified Nurse Aides and 6-8 Licensed Practical Nurses in the building on the night shift. Additionally, due to insufficient staffing on 6/2/2024, 2/9/2025, and 2/15/2025, 41 Residents did not receive their medications which included but not limited to antibiotics, anticoagulants, insulins, and psychotropics. The Findings are: Review of the Facility-Wide assessment dated 6/2018 and revised on 4/9/2025 that did not have a signature of approval and did not have a date that it was reviewed by the Quality Assurance Agency/Quality Assurance and Performance Improvement documented nursing staff as follows: Certified Nurse Aides - Total number needed or average or range per day on days and evening shifts for the facility was 29-32 Certified Nurse Aides, and on night shift 18-22 Certified Nurse Aides. Licensed Practical Nurses- Total number needed or average or range per day on days and evening shifts for the facility was 6-9 Licensed Practical Nurses, 6-8 Licensed Practical Nurses on the night shift. Upon review of the staffing schedule dated 6/2/2024, there were a total of 27 Certified Nurse Aides and a total of 5 Licensed Practical Nurses in the facility on the evening shift. Upon review of the staffing schedule dated 2/9/2025, there were a total of 24 Certified Nurse Aides and a total 4 Licensed Practical Nurses in the facility on the evening shift. Upon review of the staffing schedule dated 2/15/2025, there were a total of 14 Certified Nurse Aides in the facility and a total of 3 Licensed Practical Nurses on the night shift. During an interview on 4/10/2025 at 10:38 am, Resident #1 stated that due to insufficient staffing, there has been multiple occurrences where there was no nurse on their unit to pass medications, and they did not receive their medications. Resident #1 stated that they have mentioned to administration numerous times and has mentioned it during Resident council meetings. During an interview on 4/10/2025 at 12:41 pm, Resident #60 stated that they recall a time where the nurse on their unit left the unit to go to another floor and they did not have a nurse. Resident #60 stated that they have not experienced getting medications but know of other Residents who did not get their medications. During an interview on 5/28/2025 at 12:52 pm, Certified Nurse Aide #10 stated that staffing is bad and that somedays it is not enough staff, and it is difficult to provide good care to the Residents. During an interview on 4/10/2025 at 1:35 pm, Licensed Practical Nurse # 11 stated that they there have been times that there were not enough nurses on the overnight shift and must split units, that nurses splitting units happens very often where two nurses would split 3 units, and that sometimes there is only one nurse for three units. Licensed Practical Nurse #11 stated that they get asked to do overtime every single day, and that the mandating list moves quickly and can work back to back and would work a double shift and gets mandated on the weekend due to inadequate staffing. Licensed Practical Nurse stated that sometimes it can be 1 Nurse passing medications to 40 Residents on some units. During an interview on 01/29/2025 at 08:29 AM, the Staffing Coordinator stated that they were unaware that the facility assessment indicated that the minimum amount of Certified Nurse Aide that can work on the night shift was 3. The Staffing Coordinator stated that although it is difficult and the units are heavy, the units can operate with only 2 Certified Nurse Aides. The Staffing Coordinator reviewed the schedules for 12/23/2024, 12/29/2024, 1/5/2025, and 1/18/2025, and confirmed that as per the facility assessment, the units were inadequately staff and did not meet the minimum requirements for staffing. During an interview on 4/10/2025 at 1:41 pm, Registered Nurse Care Manager #6 stated that they have complained to Nursing and Administration about staffing. Registered Nurse Care Manager #6 stated that on the weekdays and the weekends, they must be nursing supervisor and pass medications. Registered Nurse Care Manager #6 stated that the facility never have staff on reserve to come in if they do not have enough staff and that when call staff is called to come in, they refuse because they are so tired from working. During an interview on 4/10/2025 at 4:49 pm, the Union President stated that they receive multiple complaints a day from staff stating that they are working short staffed, and that the facility is mandating employees and then change the paperwork to document that they volunteered, and they tell them that they can't leave because there is no one to take the keys. The Union President stated that they have had Residents report to them that staffing is bad especially on the 11-7 am shift, and that they have complained about not getting medications. During an interview on 4/11/2025 at 10:34 AM, the Director of Staff Resources stated they complete the schedule based on the staff schedules that they have, and when they are short staffed, they will call everybody, and most of the times they refuse, and once they call everybody, they will consult with nursing and ask them what they're going to do with the staffing. The Director of Staff Resources stated that there were only 4 nurses working the entire shift in the facility and that A100 did not have a nurse on that unit for the 11pm-7am shift. During an interview on 5/11/2025 at 10:58 am, the Director of Nursing stated Units A and C have 18 residents when at maximum capacity and that when they're at maximum capacity, one nurse goes between both units to pass medications. The Director of Nursing stated that that on 12/8/2024 11-7 am shift, A100 did not have a nurse, and that based on the schedule, that would be considered insufficient staffing. The Director of Nursing stated that on 2/9/2025 on the 3-11 pm shift, there were only 4 Licensed Practical Nurses and 2 Nursing supervisors and 1 covered 2 units, and that is not normal or ideal, and that on 2/15/2025 11-7 am there were 4 Licensed Practical Nurses and 2 Nursing Supervisors and 1 covered 2 units. The Director of Nursing stated that they ideally want one nurse to cover each unit, but it is not always possible, and they must sometimes split nurses up to cover 2 units. The Director of Nursing stated that the acuity level on the dementia units is higher and that they should have more than one nurse, and that the daily minimum staffing is not accurate because the range of census on units goes up and down, and that they split the units between nurse because they have no staff. During an interview on 4/11/2025 at 4:12 pm, the Administrator stated that if they don't have enough nurses to cover units then they will pull the Assistant Director of Nursing to pass medications. The Administrator stated that when they revised the Facility Assessment, they do address staffing with the Director of Nursing, and that it should be signed and reviewed with Quality Assurance Agency/Quality Assurance and Performance Improvement. The Administrator stated that the staffing requirements on the Facility Assessment needs to be updated because it is inaccurate because they have units that are closed and the census is low on some units, and the staffing needs have changed. 10NYCRR 415.13(a)(1)(i-iii)

Based on observations, record review and interviews conducted during the Abbreviated Surveys (NY00342238 and NY00364422), the facility did not ensure that residents had the right to a dignified existence by promoting resident independence and dignity while dining for 1(Resident #6) of 3 residents observed for residents' rights. Specifically, Licensed Practical Nurse #7 was observed standing over Resident #6 while assisting them to eat their dinner. The findings are. The facility's policy titled residents rights dated 2//5/2021 documented resident have a right to dignified experience and be treated with respect, kindness, and dignity. Resident #7 was admitted with diagnoses including but not limited to Alzheimer's disease with late onset hemiplegia and hemiparesis, and dysphagia. The 3/23/25 Quarterly Minimum Data Set(MDS-an assessment tool) documented that Resident #6 had severely impaired cognition, and dependent with eating. On 5/14/25 at 6:01 pm, Licensed Practical Nurse #6 was observed standing over Resident #6 while assisting them to eat their dinner. During an interview on 5/14/25 at 6:05 PM, Licensed Practical Nurse #6 stated that they know that while assisting residents with their meals, they should be sitting down and at eye level, but they are the only nurse on the floor and must be in the dining room, and they wanted to make sure all the Residents eat and it's easier to stand up so that they can go back and forth between the residents. During an interview on 5/14/25 at 6:15 PM, the Director of Nursing stated that staff should not be standing up while assisting Residents with their meals, and they have the right to have a comfortable dining experience. 10 NYCRR 415.3(d)(1)(i)

Based on record and interviews conducted during the Abbreviated Surveys (NY00342238 and NY00364422), the facility did not ensure that a facility-wide assessment was conducted to thoroughly assess the needs of its residents and to determine the required resources to provide the care and services to its residents during its day-to-day operations, did not address what is considered sufficient, particularly on the weekends, how the care required on a weekend shift is different than the care required on other shifts, and did not include behavioral health services necessary to meet resident needs. Additionally, the facility assessment did not have the date that it was reviewed with Quality Assurance and Performance Improvement (QAPI). Specifically, the Facility assessment dated 6/2018 and last revised on 5/12/2025 did not include the minimum staffing requirements for Certified Nurses' Aides and Licensed Practical Nurses and did not include the number of staff needed for behavioral healthcare and services, and the Facility assessment dated 6/2018 and last revised on 4/9/2025 did not include the amount of staff needed for behavioral healthcare and services, did not have a signature of approval and did not have the date that it was reviewed with Quality Assurance and Performance Improvement (QAPI). The Findings are: The Facility assessment dated 6/2018, last revised on 5/12/2025 documented that that Payroll-Based Journal (PBJ) reports and staffing needed to be seen for further information to identify the facility resources needed to provide competent support and care for their Resident population every day and during emergencies, and that the facility will follow the minimum staffing requirements for Certified Nurses' Aides, and Licensed Practical Nurses. Also, the Facility will maintain daily average staffing hours equal to 3.5 hours of care per resident day by a Certified Nurse Aide, Registered Nurse, or Licensed Practical Nurse. Of the average 3.5 hours, no less than 2.2 hours of care per resident per day shall be provided by a Certified Nurse Aide, and no less than 1.1 hours of care per resident day shall be provided by a Registered Professional Nurse or Licensed Practical Nurse. The Facility assessment dated 6/2018, last revised on 5/12/2025 did not have the date that it was reviewed with Quality Assurance and Performance Improvement (QAPI). The Facility assessment dated 6/2018, last revised on 5/12/2025 did not include nights and weekends as part of day-to-day operations in addition to emergencies, and did not document sufficient the staff with the appropriate competencies and skill sets necessary to care for their residents. During an interview on 5/14/2025 at 6:30 PM, the Administrator stated that the Facility Assessment correlates with the regulations and that they did not feel it was necessary to include the exact number of staffing needing to care for the Residents because people can refer to the Payroll-Based Journal (PBJ) for staffing. The Administrator stated that due to the issues with staffing in the facility, they did not document the exact number of Certified Nurses Aides or Licensed Practical Nurses on the Facility Assessment because staffing in the facility changes often. The Administrator was unable to provide documented evidence that the Facility Assessment was reviewed by the Quality Assurance and Performance Improvement. The Administrator stated that the Facility Assessment should be signed and dated and stated that the Facility assessment dated 6/2018 and last revised on 4/9/2025 should have been signed and dated. 10 NYCRR 415.26