Every finding on record at The Willows at Ramapo Rehab and Nursing Center

Based on observation, interview and record review conducted during the recertification survey from 03/08/2026 to 03/13/2026, the facility did not ensure action as a fiduciary (trustee) of the resident's funds and hold, safeguard, manage, and account for the residents' personal funds deposited with the facility for one (1) (Resident #29) of two (2) residents reviewed for personal funds. Specifically, the facility restricted Resident #29 to receiving money on two (2) days a week and in an amount lower than the resident wanted.The findings are:Resident #29's diagnoses included surgical amputation of the left leg below the knee and partial right foot, congestive heart failure, and diabetes.The 01/14/2026 quarterly Minimum Data Set (a resident assessment tool) documented Resident #29 had intact cognition.The facility policy, Resident Funds, last approved on 10/02/2025, documents that residents have access to their personal funds 24 hours a day, seven (7) days a week.A 11/04/2025 memorandum from the resident's family member documented they would have no problem if the resident requested $5 or $10 a day, but not every day, and would not approve multiple withdrawals in one day.During an interview on 03/09/2026 at 10:25 a.m., Resident #29 stated that their money was only available on Tuesdays and Fridays. During an interview on 3/11/2026 at 12:25 p.m., Business Office Manager #9 stated personal funds were normally available when a receptionist was at the desk during the day and the nursing supervisor could access funds for the residents at night. The quarterly statements were given to the residents or mailed to the families. The facility limited residents to remove $50 a day. Larger amounts required advance notice to the facility to ensure the funds would be available.During an interview on 3/11/2026 at 12:41 p.m., Receptionist #10 stated when a resident wanted money, they confirmed that the resident had an account and had available money. Residents were limited to $50 a day except for Resident #29. Resident #29 was limited to receiving money on Tuesdays and Fridays at $10 a day. Resident #29 had requested money on Mondays and was refused. The resident's family had requested a limit on how much money the resident could receive each day and the number of days in a week available.During a follow-up interview on 03/11/2026 at 12:48 p.m., Business Office Manager #9 stated Resident #29 was withdrawing money every day and the family wanted a limit on how much money the resident could remove weekly. Business Office Manager #9 stated the resident was upset at first but agreed to the plan. Business Office Manager #9 restricted Resident #29 to withdraw $10 twice a week and sometimes increased it to $15.A record review of Resident #29 personal funds account on 03/11/2026 at 01:03 p.m., documented the resident had a balance of $827.52 on 10/01/2025 and $1089.65 as of 03/03/2026. The facility personal fund receipts and statements documented that the resident had withdrawn $10 or $15 dollars at a time from 10/05/2025 to 03/12/2026.During an interview on 03/11/2026 at 3:30 p.m., Resident #29 stated they did not remember if anyone talked to them about how much money they were allowed to take out. Taking money out on Tuesdays and Fridays worked ok for them, but $25 more a week would be better. They liked to buy food and sodas from the vending machines. They tried to make the money last and sometimes it did not work out. When they ran out of money, it made them not want to be there. It did not make them happy when they could not get money out. They had an allowance when they were a kid, and it made them feel like that again. They had been turned away on other days than Tuesday and Fridays when they wanted to withdraw money.During an interview on 03/11/2026 at 4:15 p.m., Social Worker #1 stated the resident's family member asked by phone call that the resident be restricted on the amount of money to be withdrawn. Social Worker #1 stated that they and Business Office Manager #9 met with the resident to discuss limiting the money taken out each week and the resident agreed to the restriction. Social Worker #1stated they did not document any information about the agreement, when or what the family member requested in the phone calls to the social worker, or the date of the meeting with the resident. During an interview on 03/13/2026 at 10:28 a.m., the Administrator stated no one was restricted in the amount of money they could withdraw each week. The Administrator was not aware of any restriction on Resident #29 ability to withdraw money from the personal funds account.A record review of the resident's electronic health record on 03/13/2026 at 11:00 a.m., documented the resident's family member was listed as the emergency contact and not as power of attorney. 10 NYCRR 415.3(g)(1)

Based on observations, interviews, and record reviews during the recertification survey, the facility did not ensure the residents' right to a safe, clean, comfortable, and homelike environment for two (2) of eight (8) residents (Resident #126 and Resident #170) reviewed for the environment. Specifically, 1) Resident #126 was observed sitting in a wheelchair that was visibly soiled on the frame, cushion, and protective gauze; 2) Resident #170 was observed sitting in a wheelchair that was visibly soiled on the frame, body, and back of wheelchair. The findings included:The facility policy Wheelchair Cleaning Process, dated 10/03/2025, documented that all resident wheelchairs, cushions, and adaptive equipment are routinely cleaned in accordance with the Centers for Disease Control infection control guidelines to maintain a clean and sanitary environment and to prevent the transmission of infectious agents. Any equipment that is soiled will be added to the daily cleaning schedule. 1) Resident #126 had diagnoses that included dementia, dysphagia (difficulty swallowing), and muscle weakness.The Quarterly Minimum Data Set, dated [DATE] documented the resident had severely impaired cognition, was dependent on staff assistance for transfers, and used a manual wheelchair.During an observation on 03/08/2026 at 12:46PM, Resident #126 was sitting in a wheelchair that had dry dirt caked on the frame and cushion. During an observation on 03/10/2026 at 1:11 PM, Resident #126 was sitting in a wheelchair. There was protective white gauze wrapped on the wheelchair where the leg rests attach bilaterally, it was visibly soiled and had a light brown color. 2) Resident #170 had diagnoses that included unspecified psychosis, dysphagia (difficulty swallowing), and cerebral ischemia (restricted blood flow to the brain).The Quarterly Minimum Data Set, dated [DATE] documented the resident had severely impaired cognition, required moderate assistance from staff for transfers, and used a manual wheelchair.During an observation on 03/08/2026 at 11:50 AM, Resident #170 was sitting in a wheelchair that had a white dried substance on the right wheel spokes and the right side of the wheelchair up to the back rest. The right corner of the wheelchair cushion was visibly soiled with a stain and there was a dusty grime on the wheelchair frame.During an interview on 03/11/2026 at 2:16 PM, Registered Nurse Unit Manager #4 stated wheelchairs were cleaned according to a schedule which housekeeping followed. If there was a wheelchair that was very soiled, they would let housekeeping know so they could clean the wheelchair. During an interview on 03/11/2026 at 2:31 PM, the Assistant Director of Housekeeping stated they tried to follow a wheelchair cleaning schedule, but it could be difficult to follow and was inconsistent. Wheelchairs were scheduled daily on the evening shift, but they did not track and confirm which wheelchairs were completed. The Assistant Director of Housekeeping stated that sometimes chairs that were scheduled were not available, but they did not track that either. They took wheelchairs and clean them as needed when they noticed they were soiled. Staff should have reported wheelchairs that needed to be cleaned to housekeeping. 10NYCRR 415.5(h)(2)

Based on observations, interviews, and record reviews during the recertification survey, the facility did not ensure that residents unable to carry out activities of daily living received the necessary assistance with eating for one (1) of six (6) residents (Resident #128) reviewed for nutrition and one (1) of 19 residents (Resident #140) reviewed for dining. Specifically, 1) Resident #128, who had significant weight loss and required maximal assistance with eating was observed receiving only set up assistance during meals; 2) Resident #140, who had a history of weight loss and required moderate assistance with eating was observed receiving mostly only set up assistance during meals. The findings included:The Facility Activities of Daily Living Policy last reviewed 10/03/2025 documented that appropriate care and services are provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with tasks that include dining (eating, including meals and snacks).1)Resident #128 had diagnoses that included multiple sclerosis (disabling disease of the nervous system), dysphagia (difficulty swallowing), and dementia. The Significant Change Minimum Data Set, dated [DATE] documented severely impaired cognition, maximal assistance required from staff for eating, and significant weight loss in the last six (6) months. The Resident requires assistance with activities of daily living care plan, last revised 12/25/25, documented interventions that included substantial/maximal assistance with eating. The weight record for Resident #128 documented a weight of 161 pounds in October 2025 and a weight of 135 pounds in March 2026, a 16% weight loss.The current Certified Nurse Aide Kardex documented maximal assistance with eating. During an observation on 03/08/2026 at 12:40 PM, Resident #128 was in the unit dining room for lunch picking at their meal. Resident #128 struggled to drink water from the plastic cup provided. No assistance from staff with eating was observed.During an observation on 03/09/2026 at 12:49 PM, Resident #128 was in the unit dining room for lunch and just ate half of the sandwich on their plate. Soup and another cup with fluids remained covered with plastic tops. No assistance from staff with eating was observed.During an observation on 03/10/2026 at 12:51 PM, Resident #128 was in the unit dining room for lunch. They only consumed the turkey from their sandwich. No assistance was observed from staff except questioning if they wanted to eat more when removing the tray. 2)Resident #140 had diagnoses that included dementia, severe protein calorie malnutrition, and dysphasia (impaired speech).The Quarterly Minimum Data Set, dated [DATE] documented severely impaired cognition, moderate assistance required from staff with eating, and no significant weight loss in the last 6 (six) months. The Resident requires assistance with activities of daily living care plan, last revised 09/14/2023, documented interventions that included moderate assistance with eating. The weight record for Resident #140 documented a weight of 124 pounds in October 2025 and a weight of 120 pounds in March of 2026, a 3.2% weight loss. The current Certified Nurse Aide Kardex documented moderate assistance with eating.During an observation on 03/08/2026 at 12:42 PM, Resident #140 was in the unit dining room for lunch with their meal tray in front of them. Resident #140 played with wrappers and a spoon; no intake was observed. At 12:53 PM Resident #140 continued to play with their utensils and food. They put a plastic top on the hot food and pushed it down. No assistance or interventions from staff were observed. At 1:07 PM staff removed the plastic cover that Resident #140 pushed into the food, assisted with a few bites, and then they removed the tray. During an observation on 03/09/2026 at 12:49 PM, Resident #140 was served their meal tray and set up assistance was provided. Resident #140 played with silverware and plastic wrappers, picking at food. They did take a few small bites. They attempted to put the spoon in the applesauce, but a plastic lid was covering it, and they were unable to access it. They were then reorganizing items on their tray. No encouragement or assistance from staff was observed. At 1:01 PM Resident #140's intake remained very poor, with an occasional small bite, and they remained sitting in their wheelchair quietly. At 1:08 PM Resident #140 had eaten a minimal amount, no assistance or encouragement was observed from staff, applesauce and juice remain sealed. At 1:10 PM, trays were being cleared, staff put a straw in the juice for Resident #140, left it for them, and took the meal tray. During an observation on 03/11/2026 from 9:11 AM until 9:34AM, Resident #140 was observed in bed with their breakfast tray still in front of them. No food was eaten, all open and set up, but they were not actively eating or drinking, and no assistance was provided by staff. At 9:24 AM Resident #140 remained in bed, looking at a paper pamphlet, not eating, tray remained untouched. At 9:34 AM Certified Nurse Aide #7 entered the room and asked Resident #140 why they weren't eating and encouraged them to eat. Certified Nurse Aide #7 left the yogurt and supplement drink for the resident, took the tray, and left the room. During an interview on 03/11/2026 at 10:58 AM, Certified Nurse Aide #7 stated breakfast trays were distributed to all the residents on the unit between 7:45AM-8:00AM. They stated that Resident #140 required set up assistance for meals. They stated that Resident #140 ate yogurt and drank a supplement drink today but refused the hot food. They stated Resident #140 had a pretty good appetite and did not require any special assistance with meals. During an interview on 03/12/2026 at 10:40 AM, the Director of Rehabilitation stated Resident #128 required maximal assistance and Resident #140 required moderate assistance with eating. Moderate assistance means the staff perform 50% and the resident performs 50% of the task. Maximal assistance means that the staff perform 75% and the resident performs 25% of the task. They would expect nursing to check the documented level of assistance needed and assist at that level. They would also expect nursing to notify rehabilitation if there was a change in the level of assistance required so they could reassess the resident. During an interview on 03/12/2026 at 11:20 AM, Certified Nurse Aide #8 stated that Resident #128 required set up assistance with eating. Resident #128 did not request or want any help with meals, and their appetite was usually about 50%. They were not aware of any weight loss for Resident #128. They did not usually look at the Kardex to determine the level of assistance residents required with eating. They stated they were familiar with the residents that have been here and relied on shift-to-shift report for any changes. They stated if a resident required moderate or maximal assistance with eating, that meant that they required some assistance from staff. During an interview on 03/12/2026 at 11:45 AM, the Dietician stated they were following both Resident #128 and Resident #140 for weight loss. Resident #128 required maximal assistance and Resident #140 required moderate assistance with eating. They stated those were accurate. Resident #128 needed monitoring and assistance because they often thought they ate better than they did. Resident #140 needed assistance and encouragement with eating. Both Resident #128 and Resident #140 may not eat well if they were not provided with the assistance needed as determined and documented on their care plan.During an interview on 03/13/2026 at 1:31 PM, Registered Nurse Unit Manager #4 stated they were aware of the residents at risk for weight loss and those with weight loss from the alerts in the electronic medical record. Weights were also discussed in morning report when all members of the interdisciplinary team were present. The certified nurse aides should know what level of assistance the residents need from report at change of shift and the Kardex. Registered Nurse Unit Manager #4 stated that they were responsible for ensuring that the residents that need assistance were receiving it. Both Resident #128 and Resident #140 needed monitoring and assistance during meals. 10NYCRR 415.12(a)(3)

Based on observations, interviews, and record reviews during the recertification survey, the facility did not ensure that the residents' environment remained as free of accident hazards as possible for one (1) of two (2) residents (Resident #72) reviewed for Accidents. Specifically, Resident #72 had a history of falls and multiple safety interventions in place including keeping the environment well lit and clutter free. Floor mats were determined to be a tripping hazard and not included as an intervention for their safety; however, floor mats were observed in the room and staff reported that they were in use. The findings included:The Facility Managing Fall Risk and Prevention policy dated 06/24/2025 documented based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident #72 had diagnoses that included dementia, obstructive uropathy (a condition blocking urine flow), and cerebral ischemia (restricted blood flow to the brain).The Fall Risk assessment dated [DATE] documented Resident #72 was high risk for falls. Risk factors included one (1) to two (2) falls in the last six (6) months, antihypertensive use, impaired memory recall, total incontinence, and unable to independently stand.The At risk for/history of falls care plan, dated 02/03/2026, documented a goal that resident will remain free of falls. Interventions included, but not limited to, keeping call bell in reach and reminding resident to use it, keeping the environment well-lit and free of clutter, and non-skid socks when not wearing shoes.The Five-Day Minimum Data Set, dated [DATE] documented severely impaired cognition, maximal assistance from staff for transfers, and falls in the last month and falls in the last two (2) to six (6) months prior to admission and/or re-entry. The Resident has had an actual fall care plan last revised 03/10/2025 documented falls on 12/12/2025, 01/11/2026, 01/31/2026, and 03/09/2026. The goal was resident will resume actual activities without further incident. Interventions dated 12/04/2025 included, but not limited to, continuing interventions on the at-risk care plan, monitor/document/and report any pain, bruises, change in mental status or new onset confusion, sleepiness, inability to maintain posture, or agitation. Interventions dated 12/13/2025 included toileting schedule/floor mats. Interventions dated 01/11/2026 included floor mats to both sides of the bed removed tripping hazard.The current Minimum Data Set Kardex had no documented evidence of floor mat use. During an observation on 03/11/2026 at 9:13 AM, Resident #72 was observed in bed. One floor mat was folded up and leaning against the wall by their bed. During an interview on 03/11/2026 at 2:22 PM, Certified Nurse Aide #8 stated they were familiar with Resident #72 and were assigned to provide them with care today. They stated Resident #72 was dependent on staff assistance for care. They stated Resident #72 has improved since they came to the facility and were able to stand and pivot now with assistance. Resident #72 had a history of falls and had floor mats for safety. Resident #72 will not use the call bell, so they need to check on them frequently. During an observation on 03/12/2026 at 9:05 AM, Resident #72 was observed in bed while staff removed their breakfast tray from the bedside table. Two floor mats were observed in the room folded up against the wall on their side of the room. During an interview on 03/12/2026 at 10:08 AM Certified Nurse Aide #8 stated that the floor mats in the room were for Resident #72, not for their roommate. They stated that they were folded up against the wall right now because housekeeping had just cleaned the floor and had to move them to do so. They stated they were going to provide morning care and get them up now, so they were not put back down. During an interview on 03/12/2026 at 10:59 AM, Registered Nurse Unit Manager #4 stated that Resident #72 had floor mats in their room, but they were discontinued previously. The floor mats should not have been in the room or in use as they were previously determined to be a tripping hazard. They removed the floor mats today.10NYCRR 415.12(h)(1)

Based on observation, interview, and record review the facility did not ensure care consistent with professional standards of practice, and the comprehensive person-centered care plan was provided for one (1) of two (2) residents (Resident #69) reviewed for Respiratory Care. Specifically, Resident #69 was administered oxygen at a liter flow greater than the current physician's order.The findings included:An undated, untitled facility policy documented guidelines for safe oxygen administration included review the physician's orders or facility protocol for oxygen administration.Resident #69's diagnoses included dysphagia following other cerebrovascular disease, Alzheimer's disease and chronic obstructive pulmonary disease. The quarterly Minimum Data Set, dated [DATE] document Resident #69 had severe cognitive impairment, was short of breath when lying flat and received oxygen therapy. A physician order dated 03/03/2026 documented two (2) liters of oxygen via nasal cannula continuously every shift for chronic obstructive pulmonary disease. A resident care plan titled oxygen therapy related to ineffective gas exchange two (2) liters via nasal cannula continuously updated 03/04/2026 documented interventions including administer medications as per physician order. During observations on 03/08/2026 at 12:10 PM and 3:21 PM and 03/09/25 at 9:42 AM, Resident #69 was sleeping in bed with oxygen being administered via nasal cannula. The oxygen concentrator was observed running at three (3) liters/minute. During an interview and observation on 03/12/2026 at 9:46 AM, Resident #69 was observed sleeping in bed with oxygen being administered via nasal cannula. Licensed Practical Nurse #6 stated Resident #69's oxygen concentrator was administering between three (3) to four (4) liters/minute and the physician ordered administration rate was two (2) liters per minute. They stated they did not check oxygen concentration levels during medication pass earlier in shift and should have. During an interview and observation on 03/12/2026 at 11:54 AM, Assistant Director of Nursing stated physician orders needed be followed for oxygen administration. Upon review of electronic medical record, the Assistant Director of Nursing stated Resident #69's physician order was for oxygen to be delivered at two (2) liters/minute. They stated nursing staff should check the oxygen concentrator liters/minute administration during medication administration and when the resident taken out of bed or moved to a portable unit. They needed to re-adjust the administration levels to the physician prescribed level if necessary. 10NYCRR 415.12 (k)(6)

Based on interviews and record review conducted during the recertification survey from [DATE] to [DATE], the facility did not ensure a resident received behavioral health services to attain their highest practicable well-being, in accordance with the comprehensive assessment and plan of care. This was evident for one (1) (Resident #9) of one (1) resident reviewed for Behavioral/Emotional Status. Specifically, Resident #9 had a physician order for a psychiatry and psychology consultation after making an inappropriate sexual comment to another resident on [DATE]. Resident #9 was not evaluated by a psychiatrist or psychologist in accordance with the physician order. The findings included:A facility policy titled Behavior Health Services, revised 04/2024 documented the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care.Resident #9 diagnoses included displaced intertrochanteric fracture of left femur, bilateral osteoarthritis of hip and hypertension. The admission Minimum Data Set (a resident assessment tool) dated [DATE] documented Resident #9 was cognitively intact, reported feeling down, depressed, and hopeless several days and had no behaviors, hallucinations, or rejection of cares. A physician order dated [DATE] documented psychology consult and follow up as needed.A resident care plan dated [DATE] documented resident has a potential for a psychosocial well-being problem (actual or potential) related to recent admission. Interventions included consult with pastoral care, social services, and psychological services. A physician order dated [DATE] documented psychiatry consult and follow up as needed.A nursing note dated [DATE] documented It was reported that Resident #9 was overheard saying to another resident having sex with you would be the best thing ever. Resident was redirected. Referred to Social services. Physician notified. Resident will follow up with psychiatry.A resident care plan dated [DATE] documented resident exhibits behavior symptoms such as socially inappropriate (making sexual comments to another resident. Interventions included enhanced monitoring for behaviors, initiate psychiatric evaluation as needed weekly and initiate psychology evaluation as needed.A physician order dated [DATE] documented enhanced monitor every shift for inappropriate behaviors.A nursing note dated [DATE] documented Resident #9 was scheduled for pulmonary appointment and declined to go. When encouraged, Resident #9 became upset and voiced, four of my family died from lung cancer anyway, so why would I go? Necessity of appointment was explained to resident but still declined. Physician notified.A nursing note dated [DATE] documented Resident #9 was speaking with another resident when staff went to explain the nurse needed the other resident. Resident became upset, aggressive and attempted to grab staff to interfere. During a brief interview on [DATE] at 11:41 AM, Resident #9 stated they did not wish to be interviewed. Resident #9 stated too many people around here talking about me and they either like me or don't. Resident #9 stated they had no concerns. During an observation and brief interview on [DATE] at 9:16 AM Resident #9 was observed in their room sitting in wheelchair, completing breakfast. WHen asked how they were feeling, Resident #9 stated good. Don't worry if there was a problem I would be out there letting people know. I advocate for myself. During an observation on [DATE] at 12:34 PM, Resident #9 was in day/dining area engaging with staff/residents appropriately. During an observation on [DATE] at 10:39 AM, Resident #9 was presented in their wheelchair on unit hallway. When asked how they were, Resident #9 responded I am alive and self-propelled to day area. During interviews on [DATE] at 10:42 AM and 12:48 PM, Registered Nurse Unit Manager #5 stated Resident #9 made an inappropriate sexual comment to another resident on [DATE]. They stated they immediately contacted the Social Work Department and physician who requested a psychiatry and psychology consult for Resident #9. They stated since [DATE], Resident #9 also had periods of upset when they were to attend a community physician and when they were separated from sitting next to the resident they had made the sexual comment to on [DATE]. Registered Nurse Unit Manager #5 stated they were unable to locate a psychiatry or psychology consult note in the electronic medical record from [DATE] to present and did not know if the consults had taken place. They stated psychology consults were requested by email from the Assistant Director of Nursing who was no longer with the facility, and they were unaware if they received an email to consult with Resident #9. They stated the psychiatry consultant recently had an emergency and they were not aware if they consulted Resident #9. They stated they were not aware why the psychology consult did not take place and that Resident #9 would be seen today. During an interview on [DATE] at 12:54 PM, the Director of Nursing stated the Consultant Psychiatrist usually services the facility once a week and were not aware when the Consultant Psychiatrist last visited the facility. The Director of Nursing stated they were unaware if Resident #9 was seen by psychiatry or psychology since [DATE] and were unable to locate a psychiatry or psychology consult note for Resident #9 in the electronic medical record. They stated they have reached out to the psychiatry consultant group and will have the consultant psychologist see Resident #9 today. During an interview on [DATE] at 1:32 PM, the Psychology Consultant stated the unit facility staff provide a verbal report of residents with a physician order for a psychology consult during their one to two facility weekly visits. They stated routine visits usually occur within 24-48 hours and crisis residents were seen immediately. They stated they had not been asked to consult with Resident #9 since [DATE] until today and confirmed that their co-worker psychologist, who shares the facility. also had not been requested to consult with Resident #9. 10 NYCRR 415.12(f)

Based on observations and interviews during a recertification survey from 3/08/2026 to 3/13/2026, the facility did not ensure that food was stored in accordance with professional standards for food service safety. Specifically, six (6) food items were not properly identified in the kitchen refrigerators, freezers, and food storage areas and one dietary cook was not wearing a beard net while actively preparing food.The findings include:The policy titled Food Receiving and Storage last approved 09/12/2025, documented that refrigerated foods are labeled, dated and monitored.On 3/08/2025 at 11:28 a.m., the initial inspection of the kitchen was conducted with the Dietary Supervisor, and the following were observed:One (1) tray of apple and pineapple cups not labeled with identification in the snack refrigerator.One (1) tray of cottage cheese cups, three (3) apples in cups and two (2) oranges in cups were not labeled with identification in the snack refrigerator.One (1) tray of pudding cups not labeled with identification in the portable tray rack.Three (3) peanut butter cups not labeled with identification in the portable tray rack.One (1) bag of mixed vegetables not in its original container and not labeled with identification in the freezer.Five (5) plates of lettuce not labeled with identification in the freezer.During an observation and interview on 03/08/2026 at 11:35 a.m., Dietary [NAME] #1 was observed leaning over and slicing chicken breasts without wearing a beard net. Dietary [NAME] #1 stated they were aware they had to wear a beard net and would normally wear one but forgot that morning. During an interview on 03/08/2026 at 11:36 a.m., Dietary Supervisor #2 stated food needed to be labeled, dated and all staff were to wear hair and beard nets if needed.10NYCRR 415.14(h)

Based on record review, and interviews conducted during the abbreviated Survey #2637567, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan for one (1) of three (3) residents (Resident #1) reviewed for neglect. Specifically, Certified Nurse Aide #1 did not provide Resident #1 with staff assistance for meeting their activities of daily living needs during the evening shift on 10/06/2025, despite documenting such care was given. Subsequently, Resident #1 was last seen on 10/06/2025 at 9:12 PM in their room sitting fully clothed in their wheelchair and at 11:51 PM, Resident #1 was found in their room lying face down on the floor between the bed and wheelchair, with their head under the bed and their oxygen nasal cannula dislodged. Resident #1 was short of breath, non-verbal and had lacerations (cuts) on their forehead and neck. Resident #1 was pronounced deceased at 12:20 AM at the facility. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy.The findings include: The undated facility policy and procedure titled Supporting Activities of Daily Living documented: Residents are provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Resident #1 was admitted to the facility with diagnoses including but not limited to pneumonia (lung infection), coronary artery disease (narrow coronary arteries), and heart failure (weak heart muscle). The 09/27/2025 care plan titled Cognitive Function/Dementia documented keep the resident's routine consistent and try to provide consistent caregivers as much as possible to decrease confusion. The 09/27/2025 care plan titled Oxygen Therapy documented change resident position every two (2) hours to facilitate lung secretion/movement/drainage. The 09/27/2025 care plan titled Mixed Bladder Incontinence documented change brief every three (3)-four (4) hours and as needed. The 09/27/2025 care plan titled Bowel Incontinence documented check every two (2) hours and assist with toileting as needed. The 09/27/2025 care plan titled Stage Two (2) Pressure Ulcer on the Sacrum documented monitoring/reminding/assistance to turn/position at least every two (2) hours, more often as needed or requested. The 10/01/2025 five (5)-day admission Minimum Data Set (a resident assessment tool) documented Resident #1 had severe cognitive impairment, was dependent for toileting, transfers, upper and lower body dressing and received substantial to maximal assist for bed mobility, received oxygen, and was admitted with one (1) stage two (2) pressure ulcer. Review of facility video surveillance revealed on 10/06/2025 at 3:40 PM, Resident #1 was wheeled into their room by Designated Representative #2. At 4:06 PM, Certified Nurse Aide #1 entered Resident #1's room and exited the room at 4:06 PM carrying a food tray in their hand. At 4:12 PM Licensed Practical Nurse #3 entered and exited Resident #1's room. At 5:12 PM, Certified Nurse Aide #2 entered Resident #1's room carrying a food tray and exited the room. At 5:46 PM, Certified Nurse Aide #2 entered Resident #1's room and exited carrying a food tray. At 6:58 PM, Licensed Practical Nurse #3 entered Resident #1's room carrying medication and exited at 7:02 PM. At 7:21 PM, Certified Nurse Aide #2 entered Resident #1's room and exited the room at 7:22 PM. At 9:09 PM, Licensed Practical Nurse #3 entered Resident #1's room carrying medication and exited the room at 9:12 PM. The October 2025 Certified Nurse Aide Accountability Record dated 10/06/2025 revealed Certified Nurse Aide #1 documented at 10:34 PM, they provided Resident #1 with one (1) staff assistance with upper and lower body dressing, two (2) staff assistance with chair to bed transfer via mechanical lift, turning and repositioning, and at 10:35 PM, two (2) staff assistance with tub/shower transfer via mechanical lift, supervision or touching assistance with eating, and one (1) staff assistance with toileting hygiene. Review of the facility video surveillance revealed that on 10/06/2025, no staff entered Resident #1's room between 9:12 PM and 11:51 PM. Review of the facility video surveillance revealed that on 10/06/2025 at 11:51 PM, Certified Nurse Aide #3 entered and exited Resident #1's room. At 11:52 PM, Certified Nurse Aide #3 returned to the room with Licensed Practical Nurse #2. At 11:56 PM, Registered Nurse Supervisor #1 arrived on the unit and entered Resident #1's room. On 10/07/2025 at 12:16 AM, paramedics arrived on the unit. Licensed Practical Nurse #2's nursing progress note dated 10/07/2025 documented at 11:50 PM, Certified Nurse Aide #3 called them to Resident #1's room. They observed Resident #1 lying face down on the floor between the bed and wheelchair. The upper part of the body was under the bed, and the legs were sprawled out behind the resident facing the wheelchair and the right leg was folded in. Resident #1 was not verbally responsive but was breathing. Registered Nurse Supervisor #1 was immediately called. When Registered Nurse Supervisor #1 arrived, staff attempted to get Resident #1 from the floor but, due to the position of Resident #1's head and neck, which were wedged between the bottom of the bed frame, they were unable to do so safely. Oxygen was applied and 911 was called. The 10/06/2025 Incident/Accident Report Preliminary Investigative Findings, prepared by the Director of Nursing, revealed video surveillance showed Licensed Practical Nurse #3 entering Resident #1's room at 9:00 PM. Certified Nurse Aide #1 did not perform evening care and safety checks. The 10/06/2025 Incident/Accident Report Summary/Conclusion, prepared by the Director of Nursing, documented, based on comprehensive investigation and evaluation of all evidence including staff and resident interview, physical assessment, medical record review by the Medical Director, video surveillance, and reenactment, the facility concluded Resident #1 had a medical event that made them fall forward out of the wheelchair landing under the bed. Resident #1 was not able to get themselves up from a lying position and attempts to get out from under the bed and the mattress frame led to lacerations and bruises. Resident #1 was pronounced deceased at 12:20 AM at the facility. During an interview on 10/16/2025 at 4:49 PM with Resident #1's roommate, Resident #4 stated on the night of the incident, they last saw Resident #1 sitting in the wheelchair between the bed and window facing towards the television, but could not remember the exact time, as they fell asleep. Resident #4 stated Resident #1 was always in bed early in the evening and they did not know why Resident #1 was not in bed that evening after their family left the facility. During an interview on 10/06/2025 at 1:06 PM, Designated Representative #2 stated Resident #1 received supper daily between 5:00 PM - 5:30 PM but on 10/06/2025 supper was not provided until Resident #1's spouse located staff and requested Resident #1's meal tray. They stated for ten (10) days prior to 10/06/2025, Resident #1 was always in bed, in nightclothes for supper. They stated on 10/06/2025, they were concerned that Resident #1 was not in bed but did not address with staff because staff were busy serving supper. During an interview on 10/17/2025 at 11:37 AM, Certified Nurse Aide #1 stated they were not given report by the nurse and did not receive an assignment sheet on 10/06/2025. Certified Nurse Aide #1 stated they knew their 10/06/2025 assignment by memory since they often floated to the unit. Certified Nurse Aide #1 stated they did not provide care for Resident #1 on 10/06/2025. Certified Nurse Aide #1 stated they did not document cares were provided for Resident #1 on 10/06/2025 and stated the documentation was entered by someone else. Certified Nurse Aide #1 stated Licensed Practical Nurse # 3 had not discussed Resident #1 with them during the shift. During an interview on 10/17/2025 at 12:46 PM, Licensed Practical Nurse #3 stated on 10/06/2025 when they administered medications around 9:00 PM, they noticed Resident #1 was not changed, was in street clothing and sitting in their wheelchair. Licensed Practical Nurse #3 stated they asked Certified Nurse Aide #1 to change Resident #1. Licensed Practical Nurse #3 stated they later asked Certified Nurse Aide #1 if they completed their assignment and Certified Nurse Aide #1 responded yes. Licensed Practical Nurse #3 stated they were busy and did not return to Resident #1's room to check if Certified Nurse Aide #1 had provided care. During an interview on 10/17/2025 at 3:42 PM, the Medical Director stated they were informed of the 10/06/2025 incident where Resident #1 slipped from the chair onto the floor. They stated Resident #1 had trouble breathing, and staff had difficulty getting the resident out from under the bed. They stated they were sure something could have been done to prevent the situation. The Medical Director stated they were not informed of injuries, but if Resident #1 did have injuries such as lacerations or bruises, that would be considered harm to the resident. During an interview on 10/17/2025 at 3:36 PM, Registered Nurse Supervisor #4 stated they made rounds on the unit during the 10/06/2025 evening shift. They stated Licensed Practical Nurse #3/Certified Nurse Aides #1 and #2 did not report any concerns or request assistance with the workload during the shift. During an interview on 10/20/2025 at 9:32 AM, the Director of Nursing stated they spoke to Certified Nurse Aide #1 about the incident and Certified Nurse Aide #1 told them they knew their assignment by memory and Resident #1 was not on their assignment. The Director of Nursing stated they told Certified Nurse Aide #1 assignments could change daily. The Director of Nursing stated Certified Nurse Aide #1 told them they did not document completed cares for Resident #1. During an interview on 10/20/2025 at 12:45 PM, Certified Nurse Aide #9 stated Resident #1 was always in bed wearing a gown at the start of the night shift. They stated Resident #1 slept throughout the night and would not attempt to get out of bed. During a follow up interview on 10/24/2025 at 3:26 PM, Licensed Practical Nurse #3 stated that 10/06/2025 was the first time they had worked with Resident #1. They stated they did not receive report from the day shift nurse or supervisor for Resident #1. They stated Resident #1 did not have a pressure ulcer, was not on fall precautions and was incontinent of bladder. They stated at approximately 5:00 PM, Resident #1 was stable and visiting with family. They stated they were not aware that Resident #1 was usually in bed by dinner time. They stated the incident could have been prevented if they checked to see that Certified Nurse Aide #1 provided cares to Resident #1 as requested. During an interview on 10/24/2025 Registered Nurse Supervisor #14 stated Resident #1 was incontinent, not on fall precautions and did not know if Resident #1 had a pressure ulcer. They stated the incident could have been prevented if Licensed Practical Nurse #3 followed up to confirm that Certified Nurse Aide #1 completed the requested tasks after they identified Resident #1 was still up in their wheelchair. They stated Certified Nurse Aide #1, who was assigned to Resident #1, should have cared for Resident #1 from the start of the shift. They stated they were not aware that Resident #1 was usually in bed before dinner time but when they rounded the unit in the past, Resident #1 was always in bed at the start of the night shift. 10NYCRR 415.12

Based on record review and interview during abbreviated survey #2637567, the facility did not ensure accurate documentation of medical records in accordance with accepted professional standard and practice were maintained for one (1) (Resident #1) of three (3) residents reviewed for activity of daily living care. Specifically, Certified Nurse Aide #1 documented in the electronic medical record activity of daily living cares on [DATE] that had not been provided. Additionally, although Resident #1 expired on [DATE] at 12:20 AM and their remains were removed from the facility at approximately 3:00 AM, Licensed Practical Nurse #10 documented hourly rounding was completed for Resident #1 on [DATE] from 11:45 PM-6:45 AM.The findings included:Resident #1 was admitted to facility with diagnoses including but not limited to Pneumonia, Coronary Artery Disease, and Heart Failure.The [DATE] Five-day admission Minimum Data Set (MDS) documented Resident #1 had severe cognitive impairment, was dependent for toileting, transfers, and upper and lower body dressing and received substantial to maximal assist for bed mobility. It further documented Resident #1 was on oxygen. Resident #1 was admitted with one (1) stage two (2) pressure ulcer and had a foot infection.Review of the [DATE] comprehensive care plan titled Assistance with Activities of Daily Living revealed the resident was dependent with personal care and toileting hygiene with two (2) staff assistance, chair to bed transfer with two (2) staff assistance via Mechanical Lift.The [DATE] evening Assignment Sheet revealed Certified Nurse Aide #1 was assigned to assignment #2.The [DATE] Certified Nurse Aide Accountability Record documented Resident #1 received care from Certified Nurse Aide #1 on [DATE] at 10:34 PM for bed transfer with mechanical lift, turning and repositioning and at 10:35 PM toileting hygieneThe [DATE] Hourly Rounding Sheet revealed Licensed Practical Nurse #10 documented hourly rounding was completed for Resident #1 on [DATE] from 11:45 PM-6:45 AM. Resident #1 expired on [DATE] at 12:20 AM and their remains were removed from the facility at approximately 3:00 AM.During an interview on [DATE] at 11:37 AM, Certified Nurse Aide #1 stated Resident #1's name was not on the assignment sheet on [DATE]. Certified Nurse Aide #1 stated they did not provide care for Resident #1 on [DATE]. They further stated they did not document cares provided for Resident #1 on [DATE] and stated the documentation was entered by someone else. During an interview on [DATE] at 12:43 PM, the Director of Nursing stated certified nurse aide documentation could only be completed by the certified nurse aide using their username and password which they created. They further stated they did not have access to any of the certified nurse aide passwords and certified nurse aides were instructed not to share their passwords. During an interview and observation on [DATE] at 12:02 PM, Certified Nurse Aide #11 stated they were required to enter their username and password to access the electronic medical record software. They stated no other staff member could enter documentation under their name unless they had their password. They stated they never share passwords. Certified Nurse Aide #11 was observed logging into the electronic medical record. Certified Nurse Aide #11 had to enter their username and password in order to document in the system. During an interview on [DATE] at 11:40 AM, Licensed Practical Nurse #10 stated they did not have time to start their documentation on the [DATE] Hourly Rounding Sheet early in the shift due to the incident and police presence. Licensed Practical Nurse #10 stated they started documenting at approximately 2:30 AM to 3:00 AM and should have removed Resident #1's name from the Hourly Rounding Sheet after they expired.During an interview on [DATE] at 12:20 PM, the Director of Nursing stated Resident #1 was removed from the unit by the Medical Examiner at approximately 3:00 AM on [DATE]. The Director of Nursing stated they are unaware why Licensed Practical Nurse #10 documented hourly rounding after Resident #1 was removed from the unit. The Director of Nursing stated Licensed Practical Nurse #10 should have drawn a line through the boxes for times after Resident #1 left the unit. 10 NYCRR 415.22 (a) (1-4)

Based on observations, interviews and record review completed during a complaint investigation (NY00374056) the facility did not maintain infection prevention and control practices in accordance with guidelines for enhanced barrier precautions for one (Resident #2) of three residents reviewed for infection control practices. Specifically, Resident #2 was on enhanced barrier precautions, as indicated by signage posted on the wall outside of their room. On three separate occasions, staff provided hands-on care without wearing gowns.Record review:The facility policy titled Enhanced Barrier Precautions, dated 1/28/25 documented that enhanced barrier precautions are utilized to reduce the transmission of multi-drug-resistant organisms to residents. The policy listed examples of high contact resident care activities requiring gown and glove use one of which was device care or use, as well as dressing a resident.Resident #2's quarterly review minimum data set assessment dated [DATE] documented active diagnoses of sepsis, other chronic osteomyelitis, and gastrostomy malfunction. It indicated that the resident had a feeding tube. It further documented that upon admission Resident #2 had a stage 2 unhealed pressure ulcer, and two stage 3 pressure ulcers.Resident #2's care plan dated 3/31/25 for pressure ulcer development to left heel related to disease process, history of ulcers, and immobility. The goal documented was the residents' pressure ulcer will show signs of healing and remain free from infection. One of the interventions is Enhanced Barrier Precautions.Resident #2 had a medical order for Enhanced Barrier Precaution dated 6/16/25.Observations:On 7/23/25 at 9:42am observed Respiratory Therapist #4 at bed side of Resident #2, they were wearing gloves, but no gown and Resident #2 was dressed only in a brief and noted to be diaphoretic, their head neck and chest were damp. Observed Respiratory Therapist #4 lean over the severely contracted Resident #2 as they were adjusting mask and resident's head as well as moving resident's arms so that they could auscultate lung sounds with a stethoscope. Respiratory Therapist #4 also used a pulse oxygen meter which required movement of resident's arm and hand to place the meter on the resident's finger.On 7/23/25 at 9:45am observed Registered Nurse Manager #5 takeoff gown and proceed to exit Resident #2's room, but they stopped and returned to bedside. At 9:50am observed Registered Nurse Manager #5 at the bedside of Resident #2 assisting Licensed Practical Nurse #6 change the resident's damp gown, Registered Nurse Manager #5 had not put a gown back on and was wearing only gloves when providing this bed side assistance.On 7/23/25 at 10:03am observed Respiratory Therapist #4 at the bedside of Resident #2 changing the equipment to a BiPap mask and machine, Resident #2 was now wearing a hospital gown, and Respiratory Therapist #4 had on gloves but no gown. At 10:05 am Respiratory Therapist #4 left the bed side of Resident #2 and returned at 10:07am in a gown and continued to set up the Bipap.Interviews:On 7/23/25 at 10:21am at the unit nurse's station in an interview with Registered Nurse Manager #5, they stated they were not aware that Respiratory Therapist #4 was not wearing a gown, and they were not sure they needed to wear one, they would have to look into that. They stated that if they saw staff providing care to Resident #2 without a gown on, they would tell the staff member they had to wear a gown.On 7/23/25 at 11:20am in an interview with Licensed Practical Nurse #6 they stated that Respiratory Therapist #4 must have been in a rush, because they usually wear a gown. Licensed Practical Nurse #6 stated that they should have said something when they noticed Respiratory Therapist #4 without the gown. Licensed Practical Nurse #6 stated that Registered Nurse Manager #5 had taken off their gown to leave the room and retrieve a blood pressure machine and when Registered Nurse Manager #5 returned to the bedside to assist them they had forgotten to put a new gown on. Licensed Practical Nurse #6 stated they know they have to say something when someone is not wearing gown. Licensed Practical Nurse #6 added that the staff is aware - there is a sign at the door.On 7/23/25 at 11:45am in an interview with Respiratory Therapist #4 they stated they are new here, and that at their prior facility the enhanced barrier precaution signs were on the door not on the wall. Respiratory Therapist #4 stated they had never seen Resident #2 prior to that day. Respiratory Therapist #4 stated they were in a rush and didn't see the sign, but did notice it after the fact. Respiratory Therapist #4 stated they didn't notice that Resident #2 was not wearing a top, but they did notice resident was diaphoretic. Respiratory Therapist #4 also stated they didn't notice that other staff that were in the room assisting them were wearing a gown. Respiratory Therapist #4 further stated they did not think they needed to wear a gown if they were only listening to breath sounds. On 7/23/25 at 12:13pm in an interview with the Director of Nursing they stated that the staff need to wear gowns when proving care for residents on enhanced barrier precautions. Director of Nursing stated that Respiratory Therapist #4 was probably not aware, they are new. Director of Nursing also stated that they were surprised that Registered Nurse Manager #5 forgot to put the gown back on after leaving Resident #2's bedside.0n 7/23/25 at 3:14pm in an interview with the Medical Director they stated when a resident is on enhanced barrier precaution If you are touching them you need to wear a gown. Medical Director stated that you never know what you are going to do when you walk into a resident's room, so if there is a sign you need to put a gown on. Medical Director stated wearing a gown is also for your own safety.On 7/24/25 at 12:05pm in an interview with the Infection Preventionist they stated that they were new to the facility and that their plan was to continue education on plans already in place. Infection Preventionist stated they did not get a chance to do training on Enhanced Barrier Precaution this year, but the staff members in question had received training within the year. Infection Preventionist stated they reviewed when each staff member had last received training on Enhanced Barrier Precaution and Licensed Practical Nurse #6 and Registered Nurse Manager #5 were both trained in December of 2024, and Respiratory Therapist #4 was trained on Enhanced Barrier Precaution in February of 2025. Infection Preventionist stated they reviewed what Enhanced Barrier Precaution means, that they have started to do an in-service in response to this incident, and that they will ensure that the staff understand the policy and importance of Enhanced Barrier Precaution.10 NYCRR415.19

Based on record review, and interviews conducted during abbreviated survey (NY00331188) the facility did not ensure that the Comprehensive Care Plans were reviewed and revised in a timely manner for 1(Resident #2) of 4 residents reviewed for Abuse. Specifically, Resident #2's Behavior Care Plan initiated 4/22/22 documented that they were two assists with cares due to history of accusatory behaviors and the care plan was not reviewed and revised to populate these interventions onto Certified Nurse Aides tasks/documentation. Certified Nurse Aide #2 was unaware of Resident #2's plan of requiring two person assists and they provided care to Resident #2 without another staff member present. Resident #2 accused Certified Nurse Aide #2 of alleged abuse after cares were provided. The Findings are: The Facility policy titled Care Plans, Comprehensive Person-Centered last revised on 3/2022 documented that the comprehensive person-centered care plan describes the services that are furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being including which professional services are responsible for each element of care. The Interdisciplinary team reviews and updates the care plan when the resident has been readmitted to the facility from a hospital stay and at least quarterly. Resident #2 was admitted with diagnoses including but not limited to depression, paranoid schizophrenia, depression, and morbid obesity. The 11/26/23 Quarterly Minimum Data Set (an Assessment Tool) documented that Resident #2 had intact cognition, was dependent with toileting, shower/bathe, personal hygiene, and supervision with bed mobility. Resident #2 had behavioral symptoms directed toward others and rejected care daily The 4/22/22 Behavior care Plan documented Resident #2 exhibited behavior such as verbal aggression/physically abusive/aggression, hallucinations, delusions and socially inappropriate. Resident was accusatory toward staff. Interventions included that Resident #2 was to be 2 person assists for all cares and has to always have 2 staff in the room. Review of Certified Nurse Aide Kardex dated January 2024 revealed there were no documented evidence that the 2 person assist for cares task was initiated prior to 1/8/24. The Certified Nurse Aide Kardex revised on 1/8/24, documented that Resident #2 requires 2 staff for showering/bathing, and personal hygiene. During an interview on 2/20/25 at 12:52 PM, Resident #2 stated that on 1/7/24 Certified Nurse Aide #2 provided care in their room without any assistance from another staff member. Resident #2 asked the surveyor to find Certified Nurse Aide #2 and to apologize because they did not want them to lose their job. Resident #2 stated that they do not remember having ointment or cream on their bottom when Certified Nurse Aide #2 provided care. Resident #2 stated that they could not tell if Certified Nurse Aide #2 inserted their finger into their rectum and that due to a childhood trauma of being forced to have anal sex, anytime anyone gets close to their bottom, it triggers them. During an interview on 2/20/25 at 3:29 PM, Certified Nurse Aide #2 stated that on 1/7/24, they provided care to Resident #2 without any assistance from other staff. Certified Nurse Aide #2 stated that at that time, they were not aware that Resident #2 was a 2 person assist for cares because it was not on the certified nurse aide Kardex and therefore they provided cares by themselves. Certified Nurse Aide #2 stated that if a resident was a 2 person assist for cares, it will be on the certified nurse aide documentation/Kardex. Certified Nurse Aide demonstrated to surveyor in a wiping motion the action during pericare provided to Resident #2. Certified Nurse Aide #2 denied inserting their finger in Resident #2's rectum. During an interview on 2/21/25 at 3:02 PM, the Assistant Director of Nursing #1 stated that unit managers initiate, review, and revise the care plans. The Assistant Director of Nursing #1 stated that as per the Behavior Care Plan, Resident #2 was a 2 person assist for cares and the 2-person assist should have been carried over to the Certified Nurse Aide Documentation. The Assistant Director of Nursing #1 stated that whoever initiated the behavior care plan should have added the 2 person assist to the Certified Nurse Aide task so that they could be aware of Resident #2's plan of care. The Assistant Director of Nursing #1 stated that Resident #2 is 2 person assist due to history of accusatory behaviors. The Assistant Director of Nursing #1 stated that there is no other way for the Certified Nurse Aide to know a resident is 2 person assist other than it being added to the certified nurse aide task. During an interview on 2/24/25 at 11:21 AM, the Director of Nursing stated that the Registered Nurse managers are responsible for initiating and revising the Care Plans. The Director of Nursing stated that Resident #2 is a 2 person assist due to history of accusatory behaviors and paranoia. The Director of Nursing stated that the Behavior Care Plan was initiated on 11/22/22 and had not been revised. The Director of Nursing stated when the behavior care plan was updated on 1/8/2024 after the incident in the Electronic Medical Record, the nurse should have activated the tasks for certified nurse aides so that the task could have transfer over to certified nurse aide Kardex/documentation. The Director of Nursing stated they do not know why the nurse who updated the care plan did not activate Certified Nurse Aide action. The Director of Nursing confirmed the plan of care was only triggered for nurses and not for certified nurse aides. The Director of Nursing stated that after the incident that occurred on 1/7/24, they updated the Behavior Care Plan to activate the certified nurse aide task to populate on the certified nurse aide Kardex/documentation. The Director of Nursing stated that unfortunately the intervention on the plan of care were not in the certified nurse aide documentation prior to incident on 1/7/24. 10 NYCRR 415.11(c)(1)

Based on observations and interviews conducted during the recent recertification survey, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, 1. Cold foods were stored in a soiled, unsanitary refrigerated unit, 2. Cold foods to be served at activities events were stored in an unsanitary manner in a refrigerated unit, 3. Unlabeled, defrosted, uncooked, ground beef was stored in a refrigerated unit, 4. cooling logs were being utilized to ensure that foods were cooled in a safe and timely manner, 5. 2 of 7 nourishment refrigerators were not maintained at safe temperatures for food safety, and 5. Two food service staff did not follow safe food handling practices while recording food temperatures. The findings are: The initial tour of the kitchen was conducted on 11/08/2023 at 10:23 AM and the following were noted: 1) A chest freezer was in use as a refrigerated unit. The chest freezer unit was observed with external soiling which included grimy, black-ish colored smears, and yellow-ish colored dried debris. The interior of the unit was heavily soiled with yellow-ish colored spills that were wet-to-the-touch, and dried yellow-ish, brown-ish, red-ish, orange-ish, pink-ish and black-ish colored grime, dried spills, and raised -to -the-touch debris. The rubber gasket was soiled with grime and black-ish colored mold. In an interview at that time, the Food Service Director (FSD) stated that the porter cleans the chest freezer every 2 days, and it looked like it should be cleaned again. The FSD was asked if the chest freezer was in a sanitary condition for food storage and stated no, they then revised their initial statement, and stated that their process is to clean the chest freezer unit after every meal, the unit is emptied, and cleaned, and it did not look like it had been cleaned after the dinner meal last night. 2) A walk-in refrigerated unit contained: a. A heavily soiled, blue, cloth-like grocery bag was observed stored on a shelf next to other food items. In an interview at that time, the FSD stated the bag had stains, and they did not know when it was last washed. The FSD stated that the bag belonged to recreation and contained items for the resident's Coffee Social, which included coffee creamer, whipped cream, and syrups. The FSD stated that the Activities department did not have a separate refrigerator for food storage. b. A box labeled custom ground beef and dated 11/1/2023 contained a 10-pound package of defrosted ground beef. The manufacturers labeling on the box documented that the beef was packaged on 10/26/2023. No other dating and labeling were found on the box. In an interview at that time, the FSD was asked the significance of the 11/1/2023 labeling. The FSD stated that was the date the beef had been pulled from the freezer. FSD stated that they do not typically hold the ground beef more than 2-3 days after being pulled from the freezer and the beef was still safe to eat. The FSD then revised their statement and stated that the date of 11/1/2023 may have been the received date. The FSD did not offer any explanation as to why the ground beef was not labeled with a received by, pulled by, and use by date. The FSD stated that they were not sure the beef was safe to eat, and they would throw the beef away. A follow up inspection of the kitchen was conducted on 11/13/23 at 9:22 AM and the following were noted: 3) The FSD was asked by surveyor to produce the cooling logs for the meatloaf prepared the previous week. The FSD stated that they needed to talk to their administrator before providing the cooling logs and left the kitchen. At that time, the cook was asked for the cooling logs. The cook (Cook #1) looked in their cooks' drawer and stated that they could not find the cooling log, they thought it was in a folder, they thought that they must have done some cleaning, and maybe they put it somewhere. In a subsequent interview conducted on 11/13/23 at 11:35 AM, the FSD stated the cooling log would have been in the cooks' drawer in a black binder, and they proceeded to look in the cooks' drawer for the black binder and cooling logs. The FSD then stated that no binder or cooling logs were found in the cooks' drawer, they have been cleaning for a couple of days, and they want to check with the cook on duty when the meatloaf was made last Tuesday. Subsequently, no cooling logs were produced, and no explanation was provided. 4) Observations of the nourishment refrigerators were conducted on 11/13/2023 at 10:33 AM, the FSD was in attendance, and the following were noted: c. The Team 7 nourishment refrigerator thermometer reading was 45 degrees Fahrenheit (F). The temperature log documented daily temperatures ranging from 38-42 degrees (F). The refrigerator contained properly dated and labeled foods brought in by visitors for residents N.S. and J.C. Foods included meatloaf, multiple containers of yogurt, and pudding. In an interview at that time, the FSD stated they could not be sure at what time the last temperature had been recorded and they would discard the foods and inform maintenance and administration. d. The Team 3 nourishment refrigerator thermometer reading was 46 degrees (F). The temperature log documented daily temperatures ranging from 40-42 degrees (F). The refrigerator contained milk, yogurt, and pudding. At that time, at the surveyors' request, the FSD checked the temperatures of those foods, and the following were noted: The temperature readings of (3) 4 oz. containers of Upstate Farms yogurt were 44 degrees (F), 46 degrees (F), and 48 (F) degrees. The temperature readings of (2) 4 oz. vanilla pudding were 48.2 degrees (F) and 48.7 degrees (F) The temperature reading of (1) 4 oz. container of low-fat milk was 51.4 degrees (F). In an interview at that time, the unit Licensed Practical Nurse (LPN #1) stated that they had just changed the thermometer in that refrigerator, as the previous thermometer had read 44 degrees (F). 5) During an observation of meal service food temperatures conducted on 11/13/23 at 11:41 AM the following were observed: e. The cook (cook #1) was observed wearing gloves, they placed their hands into a drawer to retrieve alcohol wipes while still wearing the gloves, and then proceeded to sanitize the thermometer probe and check the temperature of a hot food item. In an interview at the time, cook #1 stated they should have removed their gloves and washed their hands. f. The FSD was observed assisting cook #1 by opening alcohol wipes with their bare hands and handing the wipes to cook to sanitize the thermometer probe. In an interview at that time, the FSD stated they had just washed their hands, they should have put on gloves immediately after and before touching something that was going to touch the thermometer. 10 NYCRR 415.14(h)

Based on record review, observation and interview during the 11/8/2023 -11/17/2023 recertification survey, it could not be ensured that for 3 of 3 residents (Resident # 35, #126 and #129) reviewed for dignity that the residents' rights and/or that care was provided in a dignified manner. Specifically, Residents #35, #126 and #129 were not provided a dignified dining experience. The findings are: Resident #35 was admitted with diagnoses including dementia. The Minimum Data Set (MDS, an assessment tool) dated 10/25/23 documented Resident #35 had severely impaired cognition. Resident #126 had diagnoses including Alzheimer's Disease, dysphagia, and muscle weakness. The Minimum Data Set (MDS, an assessment tool) dated 9/21/23 documented Resident #126 had severely impaired cognition. Resident #129 had diagnoses including depression and anxiety. The Minimum Data Set (MDS, an assessment tool) dated 9/15/23 documented Resident #129 had severely impaired cognition. During a meal observation on 11/15/23 from 9:30 AM to 9:45 AM, Residents #35, #126, and #129 were eating in the hallway. The 3 residents were lined up in a row, each resident was in a wheelchair with an overbed table in front of them with their breakfast trays. Resident #126 sat directly behind Resident #35. Resident #129 sat directly behind #126. There was no social interaction observed during this time. When interviewed during the observation, Resident #129 stated they did not like eating in the hall and preferred to eat in the dining room. When interviewed on 11/15/23 at 9:37 AM, Licensed Practical Nurse (LPN) #5 stated the 3 residents ate in the hall because they were on 30 minute monitoring and the staff could keep an eye on them. During an observation on 11/16/23 at 8:58 AM, Residents #35, 126, and 128 were lined up in the hall eating breakfast. 10 NYCRR 415.3(d)(1)(i)

Based on record review and interview during the recertification and abbreviated surveys (NY 309477) conducted from 11/8/2023 through 11/17/2023, the facility did not ensure a thorough and complete investigation was conducted for 1 of 3 residents (Resident #70) reviewed for abuse/neglect. Specifically, for Resident #70 the facility did not conduct a complete and thorough investigation, including a root cause analysis to determine why physician recommended magnesium citrate scheduled for 1/10/2023 and 1/11/2023 was not administered for management of the residents' constipation. Subsequently on 1/12/2023 Resident #70 required manual dis-impaction. The findings are: An undated protocol titled Abuse and Neglect - Clinical Protocol documented that abuse included the deprivation by an individual, including a care taker, of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being, and neglect was defined as the failure of the facility, its employees or service providers, to provide goods and services to a resident that are necessary to avoid physical harm, pain, emotional anguish, or emotional distress. The protocol Cause Identification documented the staff, with the physicians input as needed, will investigate alleged abuse and neglect to clarify what happened and identify possible causes. Resident #70 was admitted with diagnoses including anemia, thyroid disorder, anxiety disorder, and depression (other than bipolar). The 5-day Minimum Data Set (MDS: an assessment tool) dated 11/25/2022 documented Resident #70 was cognitively intact for decision making, received total dependence with one person assist for toilet use, was always incontinent of bowel and bladder and did not have a toileting program. The physician progress note dated 1/9/23 at 8:10 AM by Physician #3, documented Resident #70 complained of constipation and had not been able to move their bowels for the past 7 days. The plan was to give Magnesium Citrate (laxative) 150 milliliters (ml) to be taken in the morning and 150 ml to be taken in the evening, and if the resident was constipated to inform the physician. A physician order dated 1/10/23 documented Magnesium Citrate oral solution give 240 ml by mouth 2 times a day for constipation for 1 day, to start on 1/10/23. The nursing progress notes dated 1/10/2023 at 2:52 PM and 5:36 PM documented they were waiting on pharmacy for Magnesium Citrate. A physician order dated 1/11/23 documented Magnesium Citrate oral solution give 240 ml by mouth 2 times a day for constipation for 1 day, to start on 1/11/23. The nursing progress notes dated 1/11/2023 documented at 11:44 AM and 5:40 PM, the Magnesium Citrate had not been delivered. There was no documented evidence in the January 2023 MAR that the Magnesium Citrate was administered on 1/10 and 1/11/23. Further review of the nursing progress notes revealed no documented evidence the physician was notified when the Magnesium Citrate was not delivered and no evidence the pharmacy was contacted. The investigation report dated 1/17/2023 revealed that on 1/26/2023 the facility was notified by the Ombudsman that Resident #70 alleged that on 1/12/2023 they were mistreated, and a nurse abused them, and stated that a Registered Nurse (RN #2) pushed their hand in their rectum and it felt like she just yanked it out, then RN #2 left the room. Resident #70 stated they were not informed of what RN was going to do ahead of time, and RN just did it. The incident was reported to the Department of Health on 1/27/2023, an investigation was completed, no findings of abuse were identified. A physician progress note dated 1/27/23 at 10:51 AM, by Physician #1, documented the resident was being seen regarding being dis-impacted on 1/12/23, due to an allegation of abuse. The resident had been very uncomfortable and had not had a bowel movement in over 7 days despite increasing laxatives and enemas and the head nurse dis-impacted her. Physician #1 documented the resident needed to be dis-impacted. In an interview on 11/16/23 at 12:03 PM, Licensed Practical Nurse LPN #2 stated they were responsible for medication administration to Resident #70 on the 7:30 AM-3:05 PM shift and stated the order for Magnesium Citrate the medication was not available. LPN #2 stated that when a medication was not available, they would call the pharmacy and tell them that the medication was not available and would document this. LPN #2 stated that they would text the physician to inform them that the resident did not get the prescribed dose of medication. There was no documented evidence produced that the pharmacist and/or physician had been contacted regarding the unavailable Magnesium Citrate. In an interview on 11/16/23 at 1:02 PM LPN #3, the nurse responsible for medication administration of the 5 PM dose of Magnesium Citrate for Resident #70 on the evening shift (3:30 PM - 11:30 PM) on 1/11/2023, stated they documented in the progress notes on 1/11/23 at 17:41 that they were awaiting delivery of the Magnesium Citrate. LPN #3 stated they did not remember if the pharmacy or physician was contacted. In an interview on 11/16/23 at 4:29 PM, the Director of Nursing (DON) stated that they were not aware of the order for Magnesium Citrate for constipation. DON stated that when a medication is unavailable the staff are to contact the pharmacist to find out the estimated time of arrival of the medication, if the medication is not given on the nurse's shift, they are to inform the nursing supervisor, contact the physician and inform them, document, and implement the physicians' instructions, and endorse this information to the next shift. DON stated that for a medication that was not administered, and the physician was not notified, and the pharmacy was not contacted to find out why the medication was not delivered, that would fall under the category of medication omission When asked if the medications should have been reviewed as part of the incident investigation , the DON stated that the resident already had other protocols in place, and they did not pick up on the order for magnesium citrate being unavailable. In a telephone interview on 11/20/2023 at 3:02 PM the resident's primary care physician (Physician #1) stated that they were told by RN #2 after the occurrence that the resident's stool was impacted, half-way in/ half out. Physician #1 stated they were not aware the Magnesium Citrate had not been received and administered prior to dis-impaction, and stated nursing should have notified them and the pharmacy. 10 NYCRR 483.12

Based on observation, record review and interviews conducted during the recertification survey from 11/8/23 to 11/17/23, the facility did not provide an ongoing program of activities for 1 of 4 residents (Resident #39) reviewed for activities. Specifically, Resident #39 was not provided opportunities to consistently participate in independent activities of their choice and to be regularly reassessed for their preferences. Findings include: Resident #39 was admitted with diagnoses including Multiple Sclerosis and optic neuritis. The annual Minimum Data Set (MDS: an assessment tool) dated 4/11/2023 documented the resident was cognitively intact for decision making. Preferences for daily activities included music, keeping up with the news, and getting fresh air. The MDS documented the resident was totally dependent on staff for activities of daily living except for eating, for which the resident received extensive assistance. The resident had participated in the assessment. The resident's Care Plan for Activities dated 7/14/2021, and updated 4/28/2023, documented the resident preferred self-directed activities, the goal was for the resident to engage in daily independent activities of choice, and interventions were to encourage independent activities of choice, and to respect leisure lifestyle activities. Observation and interview conducted on 11/08/23 at 3:06 PM revealed Resident #39 liked to watch television in their room. Resident #39 stated that the Activities staff did not visit them, they did not have any activities in their room, and they would like to speak with activities if they could do something. In an interview on 11/15/23 at 9:34 AM the Director of Activities stated Resident #39 had expressed a preference not to attend group activities, and to their knowledge the resident's preference was to watch TV and movies in their room. The Director of Activities stated that they kept track of the resident's attendance at activities by documenting in the EMR (Electronic Medical Record) after the activity was completed. The surveyor requested to see the resident's Activities attendance records. In a follow up interview on 11/15/23 at 12:55 PM, the Director of Activities stated that when gathering the resident's Activities attendance records, they were unable to find evidence that the resident had been provided with independent activities of their choice since 2/2023. 10NYCRR 415.15(f)(1)

48045 Based on observation, record review, and interviews conducted during the recertification and abbreviated surveys (#NY00326212 and NY00309477) from 11/8/23 to 11/17/23, the facility did not ensure 1 of 3 residents (Resident #70) reviewed for abuse/neglect and 1 of 3 (Resident #63) reviewed for medications, received care and treatment in accordance with professional standards. Specifically, 1) Resident #70's medications for constipation was not given timely, the physician and pharmacy were not notified when the medication was unavailable; and 2) Resident #63 was not provided their medication with meals as ordered. Findings include: 1) Resident #70 was admitted with diagnoses including anemia, anxiety disorder, and constipation. The 5-day Minimum Data Set (MDS: an assessment tool) dated 11/25/2022 documented the resident was cognitively intact for decision making. Functional status indicated total dependence with one person assist for toilet use. The resident was always incontinent of bowel and bladder and did not have a toileting program. The physician progress note dated 1/9/23 at 8:10 AM by Physician #3, documented the resident complained of constipation and had not been able to move bowels for the past 7 days. The plan was to give Magnesium Citrate 150 milliliters (mL) to be taken in morning and 150 mL to be taken in evening, and if the resident was constipated to inform the physician. The physician progress note dated 1/9/23 at 8:20 AM by Physician #3, documented following up on constipation for resident not able to move bowel for the past 7 days despite interventions. The plan was to have the resident take [NAME] 8 oz every 10 minutes until the resident had moved bowels. Review of physician orders revealed no new orders for 1/9/23. The nursing progress notes dated 1/1/23 through 1/9/23 documented no evidence of gastro-intestinal concerns and no complaints of constipation. The physician progress note dated 1/10/23 at 8:34 AM by Physician #1, documented the resident had a history of constipation and was complaining of severe constipation and rectal pain and was found to have hemorrhoids which were treated. The resident's Miralax dose was increased, and she was to be given Magnesium Citrate. If this did not work, Lactulose would be added. A physician order dated 1/10/23 documented Magnesium Citrate oral solution give 240 ml by mouth 2 times a day for constipation for 1 day, to start on 1/10/23. The nursing progress notes dated 1/10/2023 documented: - at 10:28 AM, Resident #70 continues to report no bowel movement since 12/31/22. The physician ordered Magnesium Citrate 8 ounces (oz) to be given twice a day for one day. - at 2:52 PM, waiting on pharmacy for Magnesium Citrate Oral Solution. - at 5:36 PM, waiting on pharmacy for Magnesium Citrate. A physician order dated 1/11/23 documented Magnesium Citrate oral solution give 240 ml by mouth 2 times a day for constipation for 1 day, to start on 1/11/23. The nursing progress notes dated 1/11/2023 documented at 11:44 AM and 5:40 PM, the Magnesium Citrate had not been delivered. Further review of the nursing progress notes revealed no documented evidence the physician was notified when the Magnesium Citrate was not delivered and no evidence the pharmacy was contacted. The nursing progress note dated 1/12/2023 at 9:25 AM documented Resident #70 had been reporting that they had not moved their bowels. They had a very large bowel movement, and the consistency was dry and clay like. The nursing progress note dated 1/12/2023 at 11:12 AM documented the Magnesium Citrate was given (2 days after originally ordered). A physician progress note dated 1/27/23 at 10:51 AM, by Physician #1, documented the resident was being seen regarding being disimpacted on 1/12/23, due to an allegation of abuse. The resident had been very uncomfortable and had not had a bowel movement in over 7 days despite increasing laxatives and enemas and the head nurse disimpacted her. Physician #1 documented the resident needed to be disimpacted. In a telephone interview on 11/16/23 at 11:19 AM, RN #2 stated that Certified Nurse Aide (CNA) #1 came to them about 9 AM on 1/12/23 and told them that the resident could not move their bowels and they were straining and needed help. Registered Nurse (RN) #2 stated they observed the resident's anus, it was dilated and filled with clay, pasty stool, and it was not impacted hard stool. RN #2 stated that they put a glove on and using their index finger they ran the index finger around the perimeter of the resident's anus and the stool came out. RN #2 stated that resident had been taking medications for constipation, but they did not recall specifics and had not given the resident an enema. RN #2 stated that she was trying to help the resident and saw that they could fix the problem. In an interview on 11/16/23 at 12:03 PM, Licensed Practical Nurse LPN #2 stated they were responsible for medication administration to Resident #70 on the 7:30am-3:30pm shift and stated the order for Magnesium Citrate the medication was not available. LPN #2 stated that when a medication was not available, they would call the pharmacy and tell them that the medication was not available and would document this. LPN #2 stated that they would text the physician to inform them that the resident did not get the prescribed dose of medication. There was no documented evidence produced that the pharmacist and/or physician had been contacted regarding the unavailable Magnesium Citrate. LPN #2 stated RN #2 told them that they removed the stool manually. In an interview on 11/16/23 at 1:02 PM LPN #3, the nurse responsible for medication administration of the 5 PM dose of Magnesium Citrate for Resident #70 on the evening shift (3:30PM - 11:30PM) on 1/11/2023, stated they documented in the progress notes on 1/11/23 at 17:41 that they were awaiting delivery of the Magnesium Citrate. LPN #3 stated they did not remember if the pharmacy or physician was contacted. In an interview on 11/16/23 at 4:29 PM, the Director of Nursing (DON) stated that they were not aware of the order for Magnesium Citrate for constipation. DON stated when a medication was unavailable the staff were to contact the pharmacist to find out the estimated time of arrival of the medication. If the medication was not given on the nurse's shift, they were to inform the nursing supervisor, contact the physician and document. Then they would implement the physician's instructions and provide this information to the next shift. The DON stated that for a medication that was not administered, and the physician was not notified, and the pharmacy was not contacted to find out why the medication was not delivered, that would fall under the category of medication omission. In a telephone interview on 11/20/2023 at 3:02 PM the resident's primary care Physician #1 stated that they were told by RN #2 after the occurrence that the resident's stool was impacted, half-way in/ half out. Physician #1 stated they were not aware the Magnesium Citrate had not been received and administered prior to disimpaction, and stated nursing should have notified them and the pharmacy. 2) Resident #63 was admitted to the facility with diagnoses including but not limited to end stage renal disease, heart disease, and diabetes. The quarterly Minimum Data Set (MDS- a resident assessment tool), dated 9/20/23, documented Resident #63 had a brief interview of mental status score of 15 (cognitively intact). A physician order dated 10/8/23, documented Resident #63 was ordered Sevelamer 800 mg (a medication that binds to phosphorus in foods, often given to people who suffer from end stage renal disease requiring dialysis whose bodies cannot excrete phosphorus), with the directions to give 2 tablets by mouth with meals. On 11/14/23 at 12:56 PM, Registered Nurse Unit Manager (RNUM) #1 was observed giving Resident #63 their lunch tray and did not provide Resident #63 their Sevelamer medication with their lunch. During an interview on 11/14/23 at 1:11 PM, Licensed Practical Nurse (LPN) #6 stated they were Resident #63's medication nurse for the shift. LPN #6 stated residents got their meal trays often without them knowing and they were late with Resident #63's Sevelamer often because of this. LPN #6 stated the medication should have been given with meals as ordered, and then stated they were going to give Resident #63 their Sevelamer now. During an interview on 11/14/23 at 1:19 PM, Registered Nurse Unit Manager (RNUM) #1 stated they passed the tray to Resident #63 and the resident should have gotten the Sevelamer with meals. During an interview on 11/15/23 at 12:58 PM, the facility's Medical Director stated they were unaware of the specifics of the medication Sevelamer, however it was prescribed by the resident's nephrologist and if the medication was ordered to be given with meals, the expectation was for it to be given with the resident's meals. 10NYCRR 415.12

Based on observation, record review and interview conducted during the recertification survey, the facility did not ensure that residents were provided the appropriate treatment to improve and/or prevent a further decline in range of motion (ROM) for 1 of 2 residents, (Resident #120) reviewed for positioning and limited mobility. Specifically, Resident # 120 was not provided soft booties as per physical therapy recommendations. Resident #120 was admitted with diagnoses and medical conditions including but not limited to encephalopathy, cerebral vascular accident (Stroke), and generalized muscle weakness. The 11/05/2020 risk for chronic pain related to contractures and impaired mobility care plan, revised 11/10/23, did not include use of soft booties or monitoring the effect(s) of their use. The 11/8/2020 alteration in musculoskeletal status related to contracture of bilateral hand and feet care plan, revised on 11/10/23, directed supportive devices as recommended. The 9/14/2021 Physical Therapy (PT) evaluation documented Resident # 120 was referred to skilled PT due to noted bilateral (left and right) foot drop (the inability to raise the front part of the foot due to weakness or paralysis of the muscles that lift the foot). The 10/18/2021 PT discharge summary documented the resident was to always use soft boots to both ankles, keep ankles in a neutral position to prevent pressure sores and contracture (permanent stiffness and loss of movement in a joint) to ankles and heels. Nursing caregivers were instructed in use of soft boots and that the resident was always tolerating use. The 8/13/2023 quarterly Minimum Data Set (MDS: an assessment tool) revealed Resident #120 had severe cognitive impairment, required extensive assistance with all activities of daily living (ADLs), and had functional limitation of both upper and both lower extremities. There was no documented evidence in the current physician's order for the use of bilateral soft booties. Review of the September, October, and November 2023 Certified Nurse's Aide (CNA) task reports revealed there were no directives for the use of bilateral soft booties. The 11/6/2023 nursing progress note stated refer resident to PT for contracture management. Observations on 11/9/2023 at 1:48 PM revealed that Resident #120 did not have soft booties on (two soft booties were noted on the windowsill next to resident's bed) and on 11/16/2023 at 11:14 AM Resident #120 was in a wheelchair in the activity room and was not wearing soft booties. An interview was conducted on 11/16/2023 at 8:51 AM with the Director of the Rehabilitation who stated walking rounds were conducted on 10/29/2023 just prior to residents annual MDS review and the resident was referred to the rehabilitation department due to contracture of the bilateral ankles. The Director of Rehabilitation stated the cause was immobility and the residents' not being able to position themselves. The Director of Rehabilitation also stated the resident had soft booties to maintain a neutral alignment of the ankles and they were to be used at all times; their review of resident chart revealed there was no physician's order, and no documentation in the care plan or on CNA tasks assignment directing use of soft booties. 10 NYCRR 415.12

Based on observations, interviews and record reviews conducted during the recertification survey conducted from 11/8/2023 to 11/17/2023, it was determined that for one of four (Resident #82) reviewed for respiratory care, the facility did not ensure that the resident received proper respiratory treatment and care consistent with professional standards of practice, and the comprehensive person-centered care plan. Specifically, Resident #82 did not receive continuous oxygen 3L/min via nasal cannula as per physician order. Findings include: Resident #82 was admitted to the facility with diagnoses including cerebral infarction, respiratory failure and anxiety. The 8/15/2023 Minimum Data Set Assessment documented Resident #82 had severely impaired cognition and required oxygen therapy. The 3/18/2023 physician order documented continuous oxygen 3L/min via nasal cannula. The November 2023 Medication Administration Record (MAR) documented continuous oxygen 3L/min was administered every shift from 11/1/2023 through the 11/15/2023 day shift. The 4/28/2023 revised Comprehensive Care Plan (CCP) titled Shortness of Breath documented continuous oxygen. During an observation on 11/14/2023 at 01:38 PM Resident #82 was noted to be in their wheelchair, not wearing the nasal cannula for oxygen. The oxygen tubing and cannula were noted by the nightstand. The oxygen concentrator was on and running. During an observation on 11/14/2023 at 03:20 PM Resident #82 was noted to be in their wheelchair sleeping. The nasal cannula for oxygen was not on the resident. The nasal cannula was on the floor by the nightstand table near the window. The oxygen concentrator was on. During an interview conducted on 11/15/2023 at 09:29 AM Physician (#2) stated that the purpose of the oxygen was to maintain the resident's saturation rate. The expectation was that staff would check the oxygen saturation rate if the resident had removed the oxygen and make sure the resident had an oxygen saturation above 88%. During an observation on 11/15/2023 at 09:59 AM Resident #82 was noted to be dressed and sitting in the wheelchair. The nasal cannula for oxygen was not on the resident. The tubing was wrapped around the tube feeding pole and the cannula was in the nightstand drawer. During an interview conducted on 11/15/2023 at 10:08 AM Licensed Practical Nurse (LPN) #1 stated that if a resident removed their oxygen, the staff would check the oxygen saturation level, speak with the nurse manager and check to make sure the resident was doing ok. [10 NYCRR 415.12(k)(6)]

Based on interviews and record review during an abbreviated survey (NY00307050), the facility did not implement a comprehensive person-centered care plan for 1 of 3 residents (Resident #1) reviewed for accidents. Specifically, resident #1 who required 2-person physical assistance with transfers was transferred from bed to wheelchair with the assistance of one person by Certified Nurse Aide (CNA#1). Subsequently, resident #1 sustained an 8 cm laceration to the right arm during the transfer which required sutures. The findings are: Resident #1 was admitted to the facility on [DATE] with diagnoses including but not limited to Cerebral Infarction, right artificial shoulder and knee joints, and psoriatic arthritis. The Minimum Data Set (MDS; a resident assessment tool) dated 12/07/2022 documented intact cognition and Brief Interview of Mental Status (BIMS) score of 15/15. The assessment documented the resident required extensive 2-person physical assistance for transfers Review of the Accident/Incident Report and Facility Investigation dated 12/15/2022 documented the resident fell during transfer from bed to wheelchair, struck his/her right arm on a waste basket, sustained a laceration to the right arm, and was transferred to emergency department. The facility conclusion documented that CNA. #1 transferred the resident alone without required assistance, as a result the resident lost her balance and sustained a laceration to right arm requiring sutures A review of the Fall Risk Care Plan dated 12/01/2022 documented that the resident was at high risk for falls. Interventions included anticipate and meet the resident's needs, call light in reach, assure proper footwear, follow fall protocol, and care plan. Review of the Activities of Daily Living (ADL) Care Plan dated 12/01/2022 documented a goal that the resident's functional status will improve by the review date. Interventions included to provide extensive assistance of 2 people for bed mobility and transfers, extensive assistance of 1 person for dressing, locomotion in wheelchair and toilet use. Review of the Physical Therapy Progress Notes dated 12/13/2022 documented the resident's transfer status as Moderate Assistance, which meant the resident required extensive assistance of 1 or 2 staff for ambulation and transfer. A review of the CNA Kardex dated 12/01/2022 documented to provide 2-person extensive assistance with transfers. A review of the CNA Accountability dated 12/2022 documented CNA #1 provided 2-person extensive assistance with transfers prior to the date of the incident. During an interview conducted on 01/09/2023 at 10:00 am with CNA#1, CNA#1 stated they were the regular aide for the resident and was aware that the resident required 2 staff to assistant with transfers. CNA#1 stated that they transferred the resident to the wheelchair without another person's assistance, and the resident leaned over and fell . During an interview conducted on 01/09/2023 at 12:15 pm with the Registered Nurse Unit Manager (RNUM #1). RNUM #1 stated they were called to assess the resident after the fall. The resident was noted with a laceration and the physician was notified. RNUM #1 stated that CNAs are responsible for following residents' plan of care. During an interview conducted on 01/09/2023 at 1:20 pm with the Director of Rehab (DOR), the DOR stated the resident was inconsistent with their ability to help during transfer and so to be safe on the the unit, the resident requires 2-person assistance for transfer. During an interview conducted on 01/09/2023 at 1:35 pm with the Director of Nursing (DON). The DON stated they initiated the Accident/Incident Report and Facility Investigation on 12/15/22 at the time of the incident. The conclusion of the investigation was that the CNA #1 did not follow the plan of care and transferred the resident alone without the required assistance of 2. As a result, the resident lost her balance and fell , and sustained a laceration to right arm requiring sutures. During an interview conducted on 1/30/23 at 3:30 pm, with Licensed Practical Nurse(LPN#1) who stated that the CNA assignments are created every day by the nurse on the unit. LPN #1 stated that the staff have a morning meeting huddle at the start of each shift to inform the staff of any changes or concerns. LPN #1 stated that each CNA receives a written list of their assigned residents with their transfer status. LPN#1 also stated that they remind the CNAs daily to review the Kardex prior to performing any cares to check the status of their residents. 415.11 (c) (1)

Based on interviews and record review conducted during an abbreviated survey (NY00307050), the facility did not ensure that 1 of 3 residents' (Resident #1) environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance to prevent accidents. Specifically, a Certified Nurse Assistant (CNA #1) transferred resident #1 who was care planned and required 2-person physical assistance for transfer from bed to wheelchair by themselves (physical assist of 1). The resident sustained an 8 cm laceration to the right arm during the transfer which required sutures. The findings are: A review of the undated facility policy and procedure titled, Accidents/Incidents-Investigating and reporting documented accidents will be documented, investigated, reported, and reviewed per policy. Resident #1 was admitted to the facility on [DATE] with diagnoses including but not limited to Cerebral Infarction, presence of right artificial shoulder and knee joints, and psoriatic arthropathy. The Minimum Data Set (MDS; a resident assessment tool) dated 12/07/2022 documented intact cognition and Brief Interview of Mental Status (BIMS) score of 15/15. The assessment documented the resident required extensive 2-person physical assistance for transfers. A review of the Accident/Incident Report and Facility Investigation dated 12/15/2022 documented the resident fell during transfer from bed to wheelchair, struck her right arm on a waste basket, sustained a laceration to the right arm, and was transferred to emergency department. The facility conclusion documented that CNA.#1 transferred the resident alone without required assistance, as a result the resident lost his/her balance and sustained a laceration to right arm requiring sutures. A review of the Admission Fall assessment dated [DATE] documented the resident was at high risk for falls. A review of the Fall Risk Care Plan dated 12/01/2022 documented the resident is at high risk for falls. Interventions included anticipate and meet the resident's needs, call light in reach, assure s/he is wearing proper footwear, follow fall protocol. A review of the CNA#1 Kardex dated 12/01/2022 documented to provide extensive assistance of 2 staff for transfers. A review of the Physical Therapy Progress Notes documented the resident's transfer status on 12/13/2022 was Moderate Assistance, which meant the resident required extensive assistance of 1 or 2 staff, and her ambulation status on 12/13/22 was 10 feet with Moderate Assistance, which meant the resident required extensive assistance of 1 or 2 staff. During an interview conducted on 01/09/2023 at 10:00 am with CNA#1, CNA#1 stated they were the regular aide for the resident and was aware that the resident required 2 staff to assistant with transfers. CNA#1 stated that they transferred the resident to the wheelchair without another person's assistance, and the resident leaned over and fell . During an interview was conducted on 01/09/2023 at 1:20 pm, with the Director of Rehab (DOR). The DOR stated the resident was inconsistent, and required extensive assistance of 1 or 2 people, the week prior to 12/15/2022. The DOR stated that to be safe on the unit, the resident required 2-person assistance for transfers on the unit. During an interview conducted on 01/09/2023 at 1:35 pm with the Director of Nursing (DON). The DON stated they initiated the Accident/Incident Report and Facility Investigation on 12/15/2022 at the time of the incident. The conclusion of the investigation was that the CNA#1 did not follow the plan of care and transferred the resident alone without the required assistance of 2 people. As a result, the resident lost his/her balance and fell , and sustained a laceration to right arm requiring sutures. An interview was conducted on 01/30/2023 at 3:30 pm, with Licensed Practical Nurse(LPN#1) who stated that the CNA assignments are created every day by the nurse on the unit. LPN#1 stated that the staff have a morning meeting huddle at the start of each shift to inform the staff of any changes or concerns. LPN#1 stated that each CNA receives a written list of their assigned residents with their transfer status. LPN#1 also stated that they remind the CNAs daily to review the Kardex prior to performing any cares to check the status of their residents. 415.12 (h) (2)