Every finding on record at Van Rensselaer Manor

Based on observations, interviews, and record review conducted during the survey, the facility failed to ensure residents were treated with dignity and respect for one (1) of one (1) resident reviewed (Resident #143) and B1 unit. Specifically, staff failed to maintain discretion regarding resident conditions, used inappropriate and unprofessional language in resident care areas, interacted with a resident in a reprimanding manner during medication administration, and displayed non-dignified signage in a public area. These failures had the potential to cause emotional distress and negatively impact resident dignity and the facility environment.Findings include:Facility document titled, Your Rights as a Nursing Home Resident in New York State published by the New York State Department of Health, documented residents had the right to be valued as an individual, to be treated with consideration, dignity and respect in full recognition of their self-worth. Residents had the right to be cared for in a manner that enhanced quality of life, free from humiliation, harassment or threats.During an observation on 03/24/2026 at 11:12 AM, Certified Nurse Aide #5 was observed in the hallway speaking loudly about a resident's condition and care needs in a manner that could be overheard by others. The Certified Nurse Aide was simultaneously transporting soiled linens through the hallway. When questioned, the Certified Nurse Aide acknowledged the information should have been handled discreetly and not discussed aloud in the hallway.During an observation on 03/30/2026 at 2:56 PM, Certified Nurse Aide #6 made a loud, inappropriate remark toward another staff member using unprofessional language, in the presence of four (4) staff members and within approximately 20 feet of two (2) residents.During an observation on 04/01/2026 at 9:24 AM, Licensed Practical Nurse #7 interacted with Resident #143 in a reprimanding and admonishing manner. The Licensed Practical Nurse advised the resident that the way medications were being taken would result in dropping them. After the resident dropped medications, the Licensed Practical Nurse responded in a raised and corrective tone, drawing attention to the situation in the presence of other residents. The interaction was not supportive and had the potential to cause embarrassment to the resident.Record review indicated Resident #143 was admitted with diagnoses including chronic obstructive pulmonary disease, generalized anxiety disorder, and chronic respiratory failure. The Minimum Data Set, dated [DATE] documented the resident was cognitively intact and able to understand and be understood.During an observation on 04/01/2026 at approximately 11:47 AM, the B1 dementia care unit had a large sign posted on the exterior of the double doors stating, please do not let the residents off the unit. The sign was visible to residents, visitors, and staff. The wording broadly referred to residents as a group and implied restriction of movement in a manner that was not person-centered and had the potential to compromise resident dignity and create an institutional environment.During an interview on 04/01/2026 at 11:01 AM, Nurse Practitioner #1 stated the above behaviors were not acceptable and did not uphold resident rights and dignity.During an interview on 04/01/2026 at 11:39 AM, Director of Nursing #1 stated it was not acceptable to admonish residents and staff should place responsibility on themselves and use supportive approaches, such as offering assistance rather than correcting the resident. Director of Nursing #1 stated this approach aligned with de-escalation techniques. Director of Nursing #1 further stated the signage was intended as a reminder for visitors, as residents might not be readily identifiable, but acknowledged the sign might not be a dignified way to communicate and might need to be removed.During an interview on 04/01/2026 at 11:43 AM, Director of Nursing #1 stated it was not appropriate for staff to speak in that manner in the hallway, and it was not dignified.During an interview on 04/01/2026 at 11:44 AM, Director of Nursing #1 stated that the use of such language in a resident care area could be considered abuse.10 New York Codes, Rules, and Regulations 415.3(b)

Based on observation and interview conducted during the survey, the facility failed to provide effective maintenance services on seven (7) of seven (7) resident units. Specifically, several walls were in various states of disrepair. Findings include:During facility tours on 3/24/2026 through 3/27/2026 between the hours of 9:00 AM and 3:00 PM, walls corners and baseboards were found to be in a state of disrepair at seven (7) of seven (7) of the active nursing stations and in seven (7) of seven (7) of the unit dining rooms. Walls in the following resident rooms walls were identified to be in a state of disrepair:A104A112A122B102A205A214A213 During interview, on 3/25/2026 at 1:45 PM, Director of Security #1 stated that the facility had focused on ensuring the safety of the residents when it came to prioritizing repairs and that the facility was currently undergoing renovations where almost all identified items would be replaced. 10 New York Codes, Rules, and Regulations 415.14(h)

Based on observation, record review, and interviews conducted during the survey, the facility failed to ensure alleged violations were investigated, prevented, or corrected according to professional standards for two (2) (Resident #31 and #271) of 12 residents reviewed. Specifically, Resident #271 was found on the floor of their room with an injury of unknown origin; an investigation was started and closed without any documented statements from the resident or persons identifying how the injury occurred. Resident #31 reported a missing tote of clothing; an investigation was started and closed without a documented outcome. Findings include:The policy titled Abuse/Neglect revised 11/2024, documented investigations were to be completed for possible abuse or crime. Interviews were to be obtained from the resident and any person/s who may be able to provide information. The information is reviewed by nursing administration at the onset, during, and at the close of the investigation. The Director of Nursing or Assistant Director of Nursing will review and close the incident. The policy titled Resident Incident/Accident Reporting reviewed 8/2025, documented all resident are reported, investigated, and documented at the time of the incident/accident or at the time of discovery in effort to prevent or decrease reoccurrence. Attachment Checklist for Brises documented, determine if bruise is explained (witnessed fall) or unexplained (possible abuse until determined otherwise). Resident #271 Resident #271 was admitted to the facility with diagnoses of anxiety disorder (persistent and excessive worry that interferes with daily activities), macular degeneration (an eye condition that causes blurred vision or reduced central vision) and unspecified asthma (condition that causes you airways to swell, narrow, and fill with mucous). The Minimum Data Set (an assessment tool) dated 01/30/2026, documented they could usually be understood, usually understand others, and was mildly cognitively impaired. Accident report dated 03/01/2026 at 1:45 PM documented the resident was found lying on floor on 03/01/2026. They had a 3.5x3.5 (three and a half by three and a half) centimeter round purple colored bump on their left forehead. Description was unwitnessed fall on floor with injury and outcome was resident fell asleep and fell forward out of their wheelchair. Accident report included two (2) statements detailing the resident was found on the floor. There were no documented statements from the resident or person/s identifying how the determination was a fall causing the injury. During observation of the B2 unit on 03/23/2026 at 11:30 AM, Resident #271 was in their wheelchair outside of their room appearing well groomed without any signs of distress. There was a round dark purple raised area approximately one-half inch around on the left side of their forehead. During an interview on 03/23/2026 at 11:30 AM, Resident #271 was unable to report how they obtained the injury to their left forehead. During an interview on 3/30/2026 at 3:10 PM, Registered Nurse #3 stated they were not in the facility at the time of Resident #271's injury. They reviewed the Accident report dated 03/01/2026 and they were unable to determine how the outcome for the injury was determined in the accident report. They stated the resident would have been able to provide a statement providing how the injury occurred, but that was not documented. During an interview on 3/31/2026 at 11:44 AM, Director of Nursing #1stated for an unwitnessed fall with injury they would expect to see a resident statement or a statement to determine how the accident was determined to be a fall. They were familiar with Resident #271 and that the resident would have been able to vocalize if they were abused or if they fell. Resident #31 Resident #31 was admitted to the facility with diagnoses of anxiety disorder (persistent and excessive worry that interferes with daily activities), quadriplegia (paralysis below the neck that affects all of a person's limbs) and polyneuropathy (simultaneous malfunction of many nerves throughout the body). The Minimum Data Set, dated [DATE], documented that they were understood, understood others, and was cognitively intact. Accident Report dated 07/07/2025 documented that the resident phoned the social worker on 07/07/2025 and stated they were missing a storage bag containing sweaters and sweatshirts. It was in their room when they were sent to the hospital, and when they were readmitted to the facility, they discovered the bag was missing. The Accident report was closed and there was no documented outcome. During an interview on 03/23/2026 at 3:30 PM, Resident #31 stated some time ago they had a storage bag of clothes go missing. They spoke with Social Worker #1 to report their missing clothing. They did not think an investigation was started and eventually had asked Administrator #1 about their missing clothing they were told there was no justification to reimburse or replace the resident's missing clothing. During an interview on 03/31/2026 at 1:13 PM, Social Worker #1 stated the resident did report the missing clothing. They had started an investigation, but the resident was not able to list items and never logged items to be labeled or placed onto their belongings list in the facility. The resident had a habit of shopping online and having things shipped to facility without having them labeled or logging them as the resident's belongings. They had reviewed all the resident belonging lists with the resident and there were none describing sweaters or sweatshirts. During an interview on 03/31/2026 at 1:18 PM, Director of Social Worker #1 stated they thought they had documented the outcome of investigation. They recalled spending time on the investigation for Resident 31's missing clothing. They stated the investigation revealed the was resident had not been able to describe items, and the items were not logged or labeled through the facility so the facility could not replace or reimburse the resident for their missing items. 10 New York Codes, Rules, and Regulations 415.12(h)(1)(2)

Based on observation, record review, and interviews conducted during the survey, the facility failed to ensure that comprehensive care plans were developed and implemented according to professional standards for three (3) (Residents #94, 132, and 192) of 41 residents reviewed. Specifically, Resident #94 did not have a care plan for Self-Administration of Medication, Resident #132 did not have a care plan for alcohol use, and Resident #192 had a care plan titled Nutrition with an intervention of lab draws yearly that was not implemented. Findings include:The policy titled Care Planning revised 07/2025, documented a comprehensive person-centered care plan would include detailed information and direction to meet an individual needs. The care plan was to have evaluation/monitoring notes with all changes and quarterly reviews. The policy titled Resident Alcohol Use last reviewed 11/12/2025, documented residents may consume alcohol in accordance with their rights, clinical condition, and individualized care plan. The policy titled Medication Administration System, Self Administration of Drugs revised 01/2025, documented a care plan would be in place for self-administration of drugs. Resident #94 Resident #94 was admitted with diagnoses Parkinson's disease (a progressive movement disorder of the nervous system), cerebral infarction (neurological deficit attributed to an acute focal injury of the central nervous system), and Polyarthritis (inflammation in five (5) or more joints). The Minimum Data Set (an assessment tool) dated 03/13/2026, documented they could be understood, understood others, and was cognitively intact. Review of Resident #94's Comprehensive Care Plan active/effective date 12/29/2025, indicated there was no evidence of a care plan for self-administration of medication. During an observation 03/23/2026 at 11:50 AM, Resident #94 was in their wheelchair in their room eating their lunch, appearing well groomed without signs of distress. There were two (2) white bottles of nasal spray on their bedside table. During an observation 03/30/2026 at 2:40 PM, Resident #94 was in their wheelchair in their room watching television, appearing well groomed without signs of distress. There were two (2) white bottles of nasal spray on their bedside table. During an interview 03/23/2026 at 11:50 AM, Resident #94 stated they used nasal spray because the facility was so dry. Their family brings the nasal spray in from home for them. They stated they have been using the nasal spray for a long time. Resident #132 Resident #132 was admitted with diagnoses diabetes mellitus (chronic condition when the body can not properly process blood sugar), coronary artery disease (type of heart disease that occurs when the arteries of the heart cannot deliver enough oxygen-rich blood to the heart), and hyperlipidemia (elevated level of fats in the blood stream). The Minimum Data Set, dated [DATE], documented that they could be understood, understood others, and was cognitively intact. Physician's order dated 02/26/2026 by Medical Doctor #1, documented resident may have one (1) alcoholic beverage each evening 7:00- 11:00 PM as needed (one and a half (1.5) ounces of liquor, or 12 ounces of beer, or four (4) ounces of wine). Resident #132's Comprehensive Care Plan was reviewed. There was no documented evidence supporting Resident #132 allowance of alcohol as indicated in the physician order mentioned above. During an observation 03/23/2026 at 12:26 PM, Resident #132 was in their wheelchair in their room well-groomed without signs of distress. A 12 ounce can of beer was on their personal storage shelf next to an opened bottle labeled red wine vinegar, salt and pepper shakers, and an unopened single shot bottle of liquor was on their dresser. During an interview 03/31/2026 at 1:09 PM, Registered Dietitian #1 stated they would complete a care plan for a resident to consume alcohol They were unsure if about Resident #132 had a care plan for alcohol consumption. Resident #192 Resident #192 was admitted to the facility with diagnoses of unspecified dementia (group of symptoms affecting memory, thinking and social abilities), hypertensive heart disease (elevated bloods pressure), and gout (inflammatory arthritis that causes pain and swelling in your joints). The Minimum Data Set, dated [DATE] documented the resident was usually understood, usually understood others and was severely cognitively impaired. The Physician's Order dated 06/18/2024, documented complete blood count, complete metabolic panel, A1C, and Vitamin D level was to be obtained yearly starting 12/2024. The Comprehensive Care Plan titled Nutrition initiated 06/15/2020 and reviewed 03/25/2026, had the goal Resident's albumin will be more than 3.2 percent for 180 days. Review of laboratory results documented, there were no albumin levels to follow over 180 days. During an interview on 03/31/2026 at 11:45 AM, Registered Dietitian #1 stated the care plan was reviewed. They stated the goal should have been revised because the resident was no longer having regular laboratory tests performed. During an interview on 03/30/2026 at 3:10 PM, Registered Nurse #3 stated for residents that were alert and oriented, they did not complete a care plan for these residents to self-administer medications or to consume alcohol. r During an interview on 03/31/2026 at 11:40 AM, Director of Nursing #1 stated when care plans were reviewed, they would be updated, revised, or resolved based on current resident conditions. The process for residents to self-administer medication and to consume alcohol would include initiation of a care plan for these areas. 10 New York Codes, Rules, and Regulations 415.12(h)(1)(2)

Based on observation record review, and interviews conducted during the survey, the facility failed to ensure that comprehensive care plans were revised according to professional standards for one (1) (Resident #192) of 41 residents reviewed. Specifically, Resident #192 had a care plan titled Nutrition that was reviewed on 3/26/2026 but not revised to reflect the resident's current status. Findings include:Resident #192 was admitted to the facility with diagnoses of unspecified dementia (group of symptoms affecting memory, thinking and social abilities), hypertensive heart disease (elevated bloods pressure), and gout (inflammatory arthritis that causes pain and swelling in your joints). The Minimum Data Set (an assessment tool) dated 12/12/2025 documented the resident was usually understood, could usually understand others, and was severely cognitively impaired. During an interview on 3/31/2026 at 11:45 AM, Dietitian #1 acknowledged they had reviewed the care plan on 3/26/2026 without revision despite no albumin levels being performed every 180 days. They stated the care plan should have been revised to reflect yearly blood draws and would revise the care plan. 10 New York Codes, Rules, and Regulations 415.11(c)(2)(i-iii)

Based on record review and interviews during the survey, the facility failed to ensure that residents were free of unnecessary medications for three (3) (Resident #13, 31, and 231) out of seven (7) residents reviewed. Specifically, Resident #13 and #231 had psychotropic drugs ordered on 03/04/2026 with no end and or renewal date. Resident #13 also had scheduled pain management narcotics ordered two (2) times a day routine and every four (4) hours as needed with no end dates. Findings include: Resident #231 Resident #231 was admitted with diagnoses paraplegia (paralysis of lower extremities), Parkinsonism (a progressive movement disorder of the nervous system) and neuromuscular disfunction of bladder (when a problem with your brain, nerves or spinal cord causes you to lose control of your bladder).The Minimum Data Set (an assessment tool) dated 01/15/2026, documented they could be understood, understand others, and was cognitively intact. Review of physician order by Nurse Practitioner #2 dated 03/19/2025, documented Oxycodone five (5) milligrams, give one and a half (1.5) tablets by oral route once daily for pain as needed; the Medication Administration Record documented a standing order with no documented end date. Resident #31 Resident #31 was admitted to the facility with diagnoses of anxiety disorder (persistent and excessive worry that interferes with daily activities), quadriplegia (paralysis below the neck that affects all of a person's limbs) and polyneuropathy (simultaneous malfunction of many nerves throughout the body). The Minimum Data Set (an assessment tool) dated 01/09/2026, documented that they could be understood, and understand others with intact cogitation. Review of physician order by Medical Doctor #1 dated 02/27/2025, documented Oxycodone five (5) milligrams, give one (1) tablet by oral route every eight (8) hours for pain as needed. The Medication Administration Record documented a standing order with no documented end date. Resident #13 Resident #13 was admitted to the facility with a diagnosis of Atherosclerosis (Plaque builds up in the inner lining of an artery, causing it to become narrow, stiff, and less flexible); Major Depressive Disorder (a serious mental health condition characterized by persistent, severe feelings of sadness, emptiness, or a loss of interest in activities) and status post vascular (veins/arteries) surgery of right lower extremity. The Minimum Data Set (an assessment tool) dated 03/04/2026, documented the resident usually could understand and was understood by others with intact cognition. During an interview on 03/23/2026 at 10:45 AM, Resident #13 stated they were admitted to the facility for rehabilitation after extensive surgery. They required pain medication to manage their pain. Resident #13's Comprehensive Care Plan, dated 03/04/2026, Pain Management Focus documented Administer medications as ordered by Physician. Encourage fluid intake with narcotic use. Monitor behavior and assess for pain/discomfort if change in behavior is noted. On-going assessment of the resident's pain with emphasis on the onset, location, description, intensity of pain and alleviating and aggravating factors. The Medication Administration Record documented Resident #13 had orders for Oxycodone 5 milligram tablet, give one (1) tablet two (2) times daily start date 3/5/2026, no end date. Oxycodone 5 milligram tablet, give one (1) tablet two (2) times as needed start date 3/5/2026, no end date. Lexapro 10 milligram tablet, give one (1) tablet once daily. Start date 3/4/2026 with no end or renewal date. During record review of the 2026 Medication Administration Record the resident was medicated with Oxycodone five (5) milligram tablet on 3/7; 3/9; 3/10; 3/11; 3/12; 3/13; 3/15; 3/17; 3/19; 3/20; 3/22; 3/23; 3/24; and 3/25/2026 with pain score of zero. During an interview on 03/27/2026 at 2:22 PM, Registered Nurse #4 stated as needed narcotics were reviewed on an as needed basis. Resident #13 was a subacute rehabilitation resident, and they anticipated the resident would not be at the facility for long and therefore did not enter an end date. During an interview on 03/27/2026 at 2:39 PM, Nurse Practitioner #2 stated they prescribed narcotics based on the resident's individual needs and would not necessarily give an end date. They further stated practitioners evaluated residents upon admission and as needed. 10 New York Code of Rules and Regulations 415.12(I)(1)

Based on observation, record review and interviews during the survey, the facility failed to ensure that food was stored, prepared, distributed, or served following professional standards for food service safety in seven (7) of seven (7) resident unit nutrition rooms and the central kitchen. Specifically, several items were found without expiration dates and proper food cooling procedures were not followed.Findings include:During inspection in the central kitchen on 3/23/2026 between 11:00 AM and 2:00 PM, the following items were found to be out of compliance with New York State food safety regulations:Cold, facility-made sandwiches were identified without proper expiration dates in the following areas:Sandwich prep station refrigerator in main kitchen;3A Dietary refrigerator;1B Dietary refrigerator;3B nutrition refrigerator.The temperature logs for the dietary refrigerators on all units were not completed for every day.No unit was able to provide temperature logs for resident-owned refrigerators.During kitchen tour a full-size kitchen pan filled with beef stew was identified in the walk in refrigerator. Without a proper cooling log sheet to ensure proper cooling is taking place. During interview, on 03/23/2026 at 1:15 PM, Director of Food Services #1 stated the tray had been in the refrigerator for approximately two (2) hours. When the temperature was checked, the food was still at 105 F, which is greater than the temperature of 70 F required to by food safety requirements.Subsequent to the interview, food was noted to be reheated and broken down into smaller containers for enhanced cooling in keeping with food safety requirements. During record review on 03/24/2026 at 3:00 PM, a cooling log showed the proper handling of the beef stew after the original reheating.During interview, on 03/23/2026 at 2:00 PM, Director of Food Services #1 stated they would dispose of all of the premade sandwiches that could not be confirmed as to have been made during lunch preparation and properly date and time the ones that could be. They would also institute dating procedures in keeping with current food safety regulation on these sandwiches in the future.10 New York Codes, Rules, and Regulations 415.14(h)

Based on record reviews, observations, and interviews conducted during the survey, the facility failed to ensure medical records were kept in accordance with accepted professional standards and the facility did not ensure that resident identifiable information was not released to the public according to professional standards, complete and accurate for five (5) of five (5) units and one (1) (Resident #271) of one (1) resident. Specifically, a) narcotic count record books for five (5) of five (5) units were incomplete, b) for Resident #271, nebulizer tubing was labeled with date of 03/08/2026 and the treatment administration record was signed weekly for tubing changes through the remainder of 03/2026, and c) two (2) of two (2) laptop computers were left unattended on medication carts with resident identifiable information accessible. Findings include:A review of the narcotic count record book for unit A2 documented blank spaces forOncoming nurse did not sign for 03/23/2026 at 7:00 AM.A review of the narcotic count record book for unit A3 team 2 documented blank spaces forOncoming nurse did not sign for 03/30/2026 at 7:00 AM.A review of the narcotic count record book for unit C3 team 1 documented blank spaces forOff going nurse did not sign for 03/27/2026 at 3:00 PM.Oncoming nurse did not sign for 03/30/2026 at 7:00 AM.During an observation on 03/30/2026 at 11:46 AM on unit A3 Team 1, 7-3 Nurse signed off for 3-11 shift before 3:00 PM.During an observation on 03/30/2026 at 11:49 AM on unit A2, Day nurse Licensed Practical Nurse #3 was observed to sign as off going nurse at 3:00 PM before 3:00 PM.During an observation on Unit B3 on 03/31/2026 at 11:20 AM, surveyor asked to see the narcotic sign off book. Licensed Practical Nurse #2 did not provide the book to the surveyor until they had signed the book in front of the surveyor. They had no explanation on why it had not been signed beforehand or why they would not provide the book to the surveyor until after they had signed it.During an interview on 3/30/2026 at 11:15 AM Registered Nurse #2 stated they were going to sign it at the end of their shift, as they were busy that morning. They further stated that as long as the count was right, it should be okay so they would sign it.During an interview on 03/30/2026 at 11:29 AM, Licensed Practical Nurse #1 stated they knew they should have signed it but forgot to complete it that morning.During an interview on 03/30/2026 at 11:46 AM, Licensed Practical Nurse #5 stated they would usually sign the book like that. They further stated that they had not been told they could not complete that way.During an interview on 03/30/2026 at 11:49 AM, when observed signing off as off going nurse in the narcotic book prior to the end of the shift, Licensed Practical Nurse #3 stated they sign it so they do not forget and understood that they should not do it that way.During an interview on 03/30/2026 at 12:00 PM, Director of Nursing #1 stated they had just completed an education on signing the narcotic books. They stated staff should know they should sign as soon as they receive the keys and not sign until they release the keys to the next nurse.Resident # 271Resident #271 was admitted to the facility with diagnoses of anxiety disorder (persistent and excessive worry that interferes with daily activities), macular degeneration (an eye condition that causes blurred vision or reduced central vision) and unspecified asthma (condition that causes you airways to swell, narrow, and fill with mucous). The Minimum Data Set (an assessment tool) dated 01/30/2026, documented they could usually be understood, usually understand others, and was mildly cognitively impaired. A review of the Treatment administration record for Resident #271 documented signed nebulizer tubing changes for the dates of 03/14/2026, 03/21/2026 and 03/28/2026.During an observation on 03/30/2026 at 1:17 PM, nebulizer tubing for Resident #271 noted to have tag with date of 03/08/2026.Observation on 3/24/2026 at 11:01 AM on unit B2, Team two (2) medication cart noted to have open computer, logged in as Licensed Practical Nurse #6, with resident information accessible. Licensed Practical Nurse #6 was not near the computer, two (2) Licensed Practical Nurses noted to be in Unit Managers office.Observation on 03/30/2026 from 11:08 AM to 11:13 AM of laptop computer located on unit C3 Team two (2) medication cart, laptop computer was open with readable resident information. Nursing staff were not near the computer.During an interview on 03/30/2026 at 11:13 AM, Licensed Practical Nurse #4 stated they would usually minimize their laptop screen or shut the laptop and they had forgotten to do so.10 New York Codes Rules and Regulations 415.22(a)(1-4)

Based on observation and interviews during the survey, the facility failed to ensure that nurse staff posting data was posted on a daily basis at the beginning of each shift in a prominent place readily accessible to residents and visitors. Specifically, the facility entrance lobby was observed on 04/01/2026 at 11:30 AM without the Daily Staff Posting. Additionally, there were no Daily Staff Posting elsewhere throughout the building.Finding is:During an observation on 04/01/2026 at 11:30 AM, the lobby was without the Daily Staff Posting. Additionally, there were no Daily Staff Posting elsewhere throughout the building.During an interview on 04/01/2026 at 11:40 AM, Staffing Coordinator #1 stated they were not responsible for posting the Daily Staffing and referred to the Administrator.During an interview on 04/01/2026 at 11:45 AM, Administrator #1 stated The Daily Staff Posting was posted in the main lobby but was not posted due to an oversight and said the previous day's posting was taken down. They further stated they were aware that Daily Staffing and census should be posted daily. 10 New York Codes, Rules, and Regulations 415.13

Based on observation, record review, and interviews conducted during the survey, the facility failed to ensure that residents were free of accident or hazards according to professional standards for three (3) (Resident #94, 132, and 231) of eight (8) residents reviewed. Specifically, Resident #94 had an over-the-counter nasal spray on their bedside table, Resident #132 had a can of unopened beer on their personal storage shelf as well as an unopened single shot of liquor on their dresser, and Resident #231 had a clear plastic bag of prescription medication in their chair located next to the doorway in their room. Findings include:The policy titled Resident Alcohol Use last reviewed 11/12/2025, documented residents could consume alcohol in accordance with their rights, clinical condition, and individualized care plan. Alcohol would be stored in the medication room to prevent misuse or diversion and provided to a resident only by their assigned nurse. The policy titled Medication Administration System, Self Administration of Drugs revised 01/2025, documented residents were permitted to self-administer medication. There would be a documented resident assessment including verification of the provider order, resident's current medical conditions, understanding of medication purpose, time of administration, reporting of side effects to nurse, and capability of locking and unlocking drawer for storage of medication. Resident #94 Resident #94 was admitted with diagnoses Parkinson's disease (a progressive movement disorder of the nervous system), cerebral infarction (neurological deficit attributed to an acute focal injury of the central nervous system), and Polyarthritis (inflammation in five (5) or more joints). The Minimum Data Set (an assessment tool) dated 03/13/2026, documented they could be understood, understood others, and was cognitively intact. Review of Physician's Orders for Resident #94 revealed there were no documented orders for a nasal spray or self-administration of medication. Review of Resident #94's medical record indicated there was no documented assessment for self-administration of medication. During an observation 03/23/2026 at 11:50 AM, Resident #94 was in their wheelchair in their shared room eating their lunch, appearing well groomed without signs of distress. There were two (2) white bottles of nasal spray on their bedside table. During an observation 03/30/2026 at 2:40 PM, Resident #94 was in their wheelchair in their shared room watching television, appearing well groomed without signs of distress. There were two (2) white bottles of nasal spray on their bedside table. During an interview 03/23/2026 at 11:50 AM, Resident #94 stated they used nasal spray because the facility was so dry. Their family brings the nasal spray in from home for them. They stated they have been using the nasal spray for a long time. Resident #132 Resident #132 was admitted with diagnoses diabetes mellitus (chronic condition when the body can not properly process blood sugar), coronary artery disease (type of heart disease that occurs when the arteries of the heart cannot deliver enough oxygen-rich blood to the heart), and hyperlipidemia (elevated level of fats in the blood stream). The Minimum Data Set, dated [DATE], documented that they could be understood, understood others, and was cognitively intact. Physician's order dated 02/26/2026 by Medical Doctor #1, documented resident may have one (1) alcoholic beverage each evening 7:00- 11:00 PM as needed (one and a half (1.5) ounces of liquor, OR 12 ounces of beer, OR four (4) ounces of wine). Medication Administration Records dated 02/2026 and 03/2026 documented no alcoholic beverages were provided for consumption. During an observation 03/23/2026 at 12:26 PM, Resident #132 was in their wheelchair in their shared room well-groomed without signs of distress. A 12 ounce can of beer was on their personal storage shelf next to an opened bottle labeled red wine vinegar, salt and pepper shakers, and an unopened single shot bottle of liquor was on their dresser. Resident #231 Resident #231 was admitted with diagnoses paraplegia (paralysis of lower extremities), Parkinsonism (a progressive movement disorder of the nervous system), and neuromuscular dysfunction of bladder (when a problem with your brain, nerves or spinal cord causes loss of control of bladder). The Minimum Data Set, dated [DATE], documented they could be understood, understood others, and was cognitively intact. Review of Physician's Orders for Resident #231 revealed there were no documented orders for self-administration of medication. During an observation 03/23/2026 at 2:12 PM, Resident #231 was in their wheelchair in their shared room well-groomed without signs of distress. A clear plastic bag was noted in the chair by the doorway inside the room. The bag contained saline nasal spray, nystatin powder, and a corticosteroid nasal spray all labeled from the hospital. During an interview 03/23/2026 at 2:12 PM, Resident #231 stated the medications had come back with them from the hospital recently and had been in the chair in their room since returning to the facility. They do not administer their own medications During an interview 03/30/2026 at 2:45 PM, Certified Nursing Assistant #1 stated if they found medication at a resident's bedside they would report it to the nurse. They stated one (1) resident may know what to do with the medication, but some may not. They had residents that wander and could get into things on their unit. If they found alcohol at bedside they would report it to the nurse. During an interview 03/30/2026 at 2:48 PM, Certified Nursing Assistant #2 stated if they saw medications, including nasal spray, at a resident's bedside they would bring them to the nurse. If they saw alcohol at the bedside, they would also bring it to the nurse. During an interview 03/30/2026 at 2:52 PM, Licensed Practical Nurse #3 stated if they saw medication including nasal spray at the bedside, they would remove it and educate the resident. They would also report finding medications at beside to their supervisor. Licensed Practical Nurse #3 also stated, a provider order was needed for a resident to consume alcohol, and alcohol should be stored locked up in the medication room. It should not be at the resident's bedside. During an interview 03/30/2026 at 2:56 PM, Licensed Practical Nurse #6 stated they were unaware of any residents with Physician Orders to self-administer medication. They would remove medications if they saw them at a resident's bedside. Licensed Practical Nurse #6 stated, alcohol should not be at a resident's bedside. There needed to be a provider order to consume alcohol, and the alcohol should be stored locked in the medication room. During an interview 03/30/2026 at 3:10 PM, Registered Nurse #3 stated any medication, including over the counter medication, should not be at bedside without a provider order. Residents who self-administered medication would have an order for the specific medication that included instructions if medication was able to be left at the bedside. They stated there was no documented assessment or medication self-administration care plan for alert and orientated residents that they completed. They would do a mini assessment to make sure the resident knew how to administer medication. This mini assessment was not documented, although they said they probably should document it. Residents that could self-administer medications may keep it at their bedside table, although it probably should be in a locked drawer. Registered Nurse #3 stated Resident #94 did not have an order for nasal spray or for self-administration of medication. They believed the order was missed when the resident was readmitted to the facility from the hospital. Resident #94 had orders for nasal spray and for self-administration of nasal spray in the past. Registered Nurse #3 stated Resident #231 should not have any medication in their room. They stated a resident would have a provider order to consume alcohol. They were unaware of alcohol in Resident #132's room. They stated alcohol should be locked in the medication room and provided to the residents when requested. During an interview 03/31/2026 at 11:44 AM, Director of Nursing #1 stated medication should be in the resident's locked drawer if there was an order for self-administration of medication. The process for residents to self-administer medication was a provider order was documented, a care plan was put in place, and a progress note documenting a visualized assessment of the resident self-administering medication by nursing. They stated alcohol was to be kept in medication room locked up and should not be at a resident's bedside. The process for alcohol use was treated the same as an ordered medication and there would be an order from a provider and a care plan in place by either activities or dietary. 10 New York Codes, Rules, and Regulations 415.12(h)(1)(2)

Based on observation, record review, and interviews conducted during the abbreviated surveys (Case #2591142), the facility did not ensure a quality assessment and assurance committee developed and implemented appropriate plans of action to correct identified quality deficiencies. Additionally, the facility did not implement written policies and procedures for feedback, data collection systems, and monitoring, including adverse event monitoring. Specifically, the facility did not follow the policies established to provide performance improvement plans, staff correction, and resident safety. This is evidenced by: Cross reference: F600, F684The facility policy titled, Quality Assurance Performance Improvement with effective date 08/15/2025, and last updated 06/06/2025, documented the Quality Assurance Performance Improvement program would aim for safety and high quality with all clinical intervention and service delivery while emphasizing autonomy, choice, and quality of daily life for residents and family by ensure their data collection tools and monitoring systems were in place and were consistent for proactive analysis, system failure analysis, and corrective action. The scope of the Quality Assurance Performance Improvement program encompasses all types and segments of care and services that impact clinical care, quality of life, resident choice, and care transitions. These include, but were not limited to, customer service, care management, patient safety, credentialing, provider relations, human resources, finance, and information technology. Aspects of service and care were measured against established performance goals and key measures were monitored and trended on a quarterly and/or annual basis. The monitoring process documented that the system to monitor care and services will continuously draw data from multiple sources. These feedback systems would actively incorporate input from staff, residents, families, and others, as appropriate. Performance indicators would be used to monitor a wide range of processes and outcomes and would include a review of findings against benchmarks and/or targets that had been established to identify potential opportunities for improvement and corrective action. The system also maintained a system that would track and monitor adverse events that would be investigated every time they occurred. Action plans would be implemented to prevent reoccurrence. The Overall Performance Improvement Projects would be a concentrated effort on a particular problem in one area of nursing center or on a facility-wide basis. They would involve gathering information systemically to clarify issues or problems and intervening for improvements. Van Rensselaer Manor would conduct Performance Improvement Projects to examine and improve care or services in areas that the nursing center identified as needing attention, with continued follow up and evaluation for improvement. Areas for improvement were identified by routinely and systematically assessing quality of care and service, and included high risk, high volume, and problem prone areas. When a performance improvement opportunity was identified as a priority, the Quality Assurance Committee would initiate the process to charter a Performance Improvement Project team. This charter would describe the scope and objective of the improvement project so the team working on it had a clear understanding of what they were being asked to accomplish. Team members would be identified from internal and external sources by the Quality Assurance Committee or designated project manager, and with relationship to their skills, service provision, job function, and/or area of expertise to address the performance improvement topic. A facility policy titled Supervised Work and Supervised Care, dated , documented that any employee who had failed to follow the facility policy for resident care, medications or treatment, or those who's care was under review would be placed on Supervised Care. The listed actions for Supervised Work included in part: 3. A supervisor must document what their job responsibilities were each time they worked and signed off that they were supervised (see Supervised Work Form); 4. For Nursing, the Charge Nurse was responsible person to supervise the employee. The Supervised Work Tracking Tool stayed with the Supervisor until the employee was cleared; 6. The Department Head was responsible to read the results and notify/discuss it with the Administrator if there was a problem. Additionally documented under Supervised Care, 1. If it was suspected that there was a violation of policy and procedure or a care complaint involving a staff member, they would be put on Supervised Care; 2. Supervised Care Staff Notification Form would be completed and signed by Supervisor and staff member being placed on Supervised Care; 3. Supervised Work form would be initiated and would be ongoing until it had been deemed they could perform their job correctly and safely; 4. One form was completed, it was filed in their personnel file.Resident #3Resident #3 was admitted to the facility with the diagnoses of unspecified dementia, unspecified severity with other behavioral disturbances (memory loss and reduced thinking ability without aggressive or disruptive behavior), hypothyroidism (a condition when the thyroid does not produce enough thyroid hormones to meet the body's needs), and major depressive disorder (a mood disorder that causes persistent feelings of sadness and loss of interest). The Minimum Data Set, dated [DATE], documented the resident was usually able to understand others, was usually understood, and was severely cognitively impaired. A facility Incident and Accident Report, dated 08/01/2025 at 2:00 PM, documented that a blue/gray bruise was noted on Resident # 3's nose. The contributing factors were documented as poor safety awareness, dementia, ill-fitting glasses, wall not padded, and resting their head on the table at times when fatigued. Measures to prevent recurrence were to place mat on wall, check glasses for appropriate fit, and to place staff on supervised care for follow up and education. Statements documented in the Incident and Accident Report documented the following: 1. Registered Nurse #2, dated 08/01/2025, spoke with Resident #3's family member who had visited on 07/30/2025 did not observe any bruising when visiting. 2. Assistant Director of Nursing #1, dated 08/01/2025, documented that they had spoken with Certified Nurse Aide #1 who verbalized that Resident #3 was difficult while providing care, had swung their hands while attempting to provide personal care, and had hit their head on the wall while rolling over. Certified Nurse Aide #1 had not seen an injury at that time. Assistant Director of Nursing #1 documented they discussed how to approach and reapproach when resident's behaviors escalated. 3. Certified Nurse Aide #1, dated 08/19/2025, documented on 08/01/2025, they started to wash Resident #3, and they became combative with Certified Nurse Aide #1, they stopped to dry Resident #3 and put their clothes on. Resident #1 Resident #1 was admitted to the facility with diagnoses of Parkinson's Disease with Dyskinesia, with Fluctuations (a condition that causes muscle tremors and rigidity along with involuntary writhing movements) and Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance (a degenerative neurological disease-causing memory loss and cognitive decline with psychological issues like agitation), and Anxiety. Minimum Data Set (MDS, an assessment tool) dated 08/08/2025, documented Resident #1 could be understood, could understand others and had intact cognition for decisions of daily living. A facility provided incident and accident report dated 08/02/2025 documented that Certified Nurse Aide #1 noticed Resident #1 standing in their room, Certified Nurse Aide #1 assisted the resident to their wheelchair and when they were exiting the resident's room together, Resident #1 grabbed the wall handrail and pulled themselves from the wheelchair. The report documented Certified Nurse Aide #1's accounting was while attempting to reseat the resident, Resident #1 needed to be lowered to the floor to prevent them from falling to the floor. Resident #1's self-propelled standing out of the wheelchair was attributed to gastric distress.The facility's abuse investigation dated 08/26/2025 through 09/03/2025, included video footage dated 08/02/2024 starting at 10:48 AM. Per the video footage, Resident #1 was standing unsupervised in their room. Certified Nurse Aide #1 was viewed entering Resident #1's room without knocking, placing their hands on Resident #1's arms and pulling the resident into their wheelchair. Resident #1 appeared to resist Certified Nurse Aide #1 but was eventually maneuvered into their wheelchair. Resident #1 stood again in their room and Certified Nurse Aide #1 again pulled the resident into their wheelchair. While pulling Resident #1 into their wheelchair a second time, Resident #1 appeared to almost miss the wheelchair and nearly fall. As the video footage continued, Resident #1 was observed being pushed in their wheelchair by Certified Nurse Aide #1 but attempted to block the front wheel with their foot. Certified Nurse Aide #1 was observed turning the wheelchair around so that the resident and the chair could be moved backwards out into the hallway. Certified Nurse Aide #1 continued to pull the wheelchair backwards, and while the wheelchair was moving, Resident #1 stood up, resulting in Resident #1 falling to the floor, and onto their side. Certified Nurse Aide #1 appeared to throw their hands down at their sides and then walk away leaving the resident lying on the floor. As the video footage continued, Resident #1 was observed to have laid on the floor alone for 2 minutes before Certified Nurse #1 comes back into the viewing area, pushing a mechanical Hoyer lift towards where the resident was laying. Certified Nurse Aide #1 was seen walking past the resident, appeared to say something to Resident #1 and then stood in the doorway of the room next to Resident #1's room, at least 5 feet from where Resident #1 was laying. Licensed Practical Nurse #4 was viewed coming down the hall to do vital signs for Resident #1. Certified Nurse Aide #1 left the footage area when Licensed Practical Nurse #1 started attending to Resident #1, and did not return at any time for the rest of the video footage provided. A facility form titled Supervised Care, to Certified Nurse Aide #1, from Assistant Director of Nursing #1, dated 08/01/2025, documented it was an official notification they were on Supervised Care. They had been placed on Supervised Care because they had violated a policy or procedure; or there was a resident complaint regarding their care; or there was an actual or suspected case of abuse. The problem area identified was 'care concerns. At the bottom the signature lines contained a misspelled version of Certified Nurse Aide #1's signature, which was noted to not match any other document signed by Certified Nurse Aide #1, and Assistant Director of Nursing #1's signature. Both signatures were dated 08/02/2025. The Supervised Care audit form provided with the signed document had one line filled out, dated 08/01/2025, filled out by Assistant Director of Nursing #1, reason listed consistent care concerns, and that Administration was aware. There was no documented evidence that any auditing of care by Certified Nurse Aide #1 was completed. During an interview on 08/26/2025 at 12:33 PM, Director of Nursing #1 stated that they started looking at video footage of Unit A1, where Certified Nurse Aide #1 worked, because there had been a notable increase in incident reports of bruising, injuries, and residents falling on the unit, during Certified Nurse Aide #1's shift, and to residents in their assigned areas. When reviewing the incident reports, Director of Nursing #1 noted that the version of events provided by Certified Nurse Aide #1 did not match what other staff members reported, or the injuries noted on residents. Director of Nursing #1 stated that per paperwork they were provided by Assistant Director of Nursing #1, it was their understanding that Certified Nurse Aide #1 on 'supervised care' after Resident #3 had sustained an injury during personal care on 08/01/2025.During an interview on 08/26/2025 at 2:55 PM, Director of Nursing #1 stated that they did not randomly view video footage, but looked at them as part of investigations when there were reportable incidents or when there was an increase in reports of bruising. Director of Nursing #1 stated that no other staff said anything about Certified Nurse Aide #1 being a problem until after the Director of Nursing #1 started asking the staff questions. During an interview on 08/26/2025 at 3:26 PM, Administrator #1 stated that they were not aware of the incident until there were suspicions of multiple cases of abuse related to Certified Nurse Aide #1. When asked if camera footage was a standard part of investigating incidents, Administrator #1 stated that incidents that would lead to looking at video footage included falls with injuries and resident to resident issues. When asked if the Administrator was aware of the care concerns surrounding Certified Nurse Aide #1, Administrator #1 stated that there were over 400 employees at the facility and Administrator #1 couldn't possibly keep track of all of them. Administrator #1 stated that they trusted Director of Nursing #1 and Assistant Director of Nursing #1 to keep track of things. Administrator #1 stated the last Quality Assurance Process Improvement meeting was on 08/21/2025. When asked if this investigation or incident was discussed during the meeting, Administrator #1 stated that they got called away during the meeting, but it was not discussed while they were in the room. Administrator #1 stated that the facility may have had delayed reporting what had happened, but there was a see something, say something attitude in the facility amongst the staff. During an interview on 08/27/2025 at 11:10 AM, Licensed Practical Nurse #4 stated Certified Nurse Aide #1 came to them and stated Resident #1 was ambulating around their room and was not supposed to be. Licensed Practical Nurse #4 told Certified Nurse Aide #1 to go and get them into a chair. Certified Nurse Aide #1 came back and said that Resident #1 was on the floor, so Licensed Practical Nurse #4 got the vital machine and went to take vitals. Resident #1 was mumbling something about the aide, but Licensed Practical Nurse #4 stated they couldn't understand Resident #1. It was the first time Licensed Practical Nurse #4 and Certified Nurse Aide #1 had worked together. Licensed Practical Nurse #4 stated that Assistant Director of Nursing #1 told them to keep an eye on Certified Nurse Aide #1 because there were some concerns about their care, like they suspected Certified Nurse Aide #1 of something. During an interview on 08/27/2025 at 11:27 AM, Assistant Director of Nursing #1 stated that a couple of days to a week before this incident, there was a resident (believed Resident #3 but couldn't be sure) that Certified Nurse Aide #1 had provided personal care to, and turned Resident #3 in a way that caused them to hit their face on the wall causing an injury. Assistant Director of Nursing #1 spoke to the Certified Nurse Aide #1 and thought that perhaps Certified Nurse Aide #1 needed a little more education regarding bed mobility training. Assistant Director of Nursing #1 stated they had no concerns that Certified Nurse Aide #1 was abusing the residents in any way, just maybe needed more teaching. Certified Nurse Aide #1 was young, was relatively new and working on the memory care unit required a special type of person. After Resident #1 was reportedly lowered to the floor by Certified Nurse Aide #1, Assistant Director of Nursing #1 stated that they spoke with Certified Nurse Aide #1 again, and they both agreed that Certified Nurse Aide #1 would benefit from some extra education. Assistant Director of Nursing #1 stated that supervised care did not necessarily mean that they had a one-on-one working with them. There wasn't an abuse concern. The Supervised Care was related to education. It was set up a day or two (07/31/2025 was the date provided) before the event with Resident #1. It was meant to be more of a follow up tool. In general, depending on the directed action from the Supervision of Care, one to one supervision might be a part of it, but it could also be managed with education. It could also mean that a person needs to be removed from care. It depended on the situation and what the goal of the supervised care was. In this specific instance it was about more education and not needed to have eyes on while providing care. During an interview on 08/27/2025 at 4:24 PM, Certified Nurse Aide #1 stated that they were never put on Supervised Care, were not supervised at any time when they were working, and that the Supervised Care form that was supposedly signed by Certified Nurse Aide #1 was forged and offered as proof that the name that was signed was both not their signature, and that their name was spelled incorrectly. Certified Nurse Aide #1 stated they were handed the Supervised Care Form for the first time on 08/19/2025. Certified Nurse Aide #1 stated that had they known that they were on Supervised Care, they would not have been able to provide care to the residents without someone monitoring them.During an interview on 08/28/2025 at 1:26 PM Medical Director #1 stated that they assessed Resident #1 after they had heard what happened. At the time, Resident #1 was very pleasant. Resident #1 denied being injured by anyone, denied having anyone put hands on them, and had no issues with staff. Medical Director #1 stated that they attended Quality Assurance meetings and abuse, and abuse reporting was discussed. During a follow up interview on 08/28/2025 at 2:20 PM, Director of Nursing #1 was asked to explain the process of Supervised Care. Resident A said a staff member was a rough care giver that they have care concerns with the staff member. The Supervised Care Form would be filled out and signed while the staff member was told why it was happening. The staff member would be assigned to someone who would audit the staff member. Once the audits were completed, the staff member would be taken off Supervised Care. The auditing of care lasted about 3 shifts worth usually, unless staff reported that it needed to be extended. The Supervised Form had 3 sections related to the concern raised. It was expected that the supervisor placing the staff member on Supervised Care would fill out the staff notification section which should have had details regarding why the staff member was being placed on Supervised Care. Once the form was filled out, both the supervisor and the staff member would sign the form in front of each other. When looking at Certified Nurse Aide #1's Supervised Care Form, it was noted that the date at the top of the form was 08/01/2025 and the date of the signature lines was 08/02/2025. The only thing written on the reason for supervised care was 'care concerns'. Director of Nursing #1 stated all the questions should have been filled out and that the form should have said more than 'care concerns'. There should have been bruising and rough care mentioned on the sheet if it was filled out at the time. Director of Nursing #1 stated that Assistant Director of Nursing #1 gave Director of Nursing #1 until the investigation had commenced and Director of Nursing #1 had asked Assistant Director of Nursing #1 for all the related information. Director of Nursing #1 stated that Supervised Care meant that the staff member should not have been alone. Education could be a piece of Supervised Care, but it would be in conjunction with hands-on instruction too. Director of Nursing #1 stated that they did not believe that Certified Nurse Aide #1 was really put on Supervised Care and that the form provided to them by Assistant Director of Nursing #1 was either not appropriately documented and implemented, or Certified Nurse Aide #1 wasn't put on Supervised Care at all and the form retroactively documented. Director of Nursing #1 stated there was no documented evidence that any care auditing of Certified Nurse Aide #1 was done, nor was there any education beyond what Assistant Director of Nursing #1 wrote on the Supervised Care Form. During an interview on 08/28/2025 at 3:58 PM, Assistant Director of Nursing #1 stated that they had spoken with Certified Nurse Aide #1 on 8/02/2025 but had filled out the form on 8/01/2025 in preparation for the discussion on 8/02/2025. Because Assistant Director of Nursing #1 was concerned that perhaps Certified Nurse Aide #1 needed a little more education, and was not suspicious of abuse, they wrote care concerns. Assistant Director of Nursing #1 stated the incident with Resident #3 triggered the need for Supervised Care to be implemented, which was why it was dated 08/01/2025. Assistant Director of Nursing #1 was able to sit down with Certified Nurse Aide #1 on 08/02/2025 after Resident #1's fall, and they signed it together on 8/02/2025. When asked what kind of education was provided to Certified Nurse Aide #1, or what the follow up was to the conversation had with Certified Nurse Aide #1, Assistant Director of Nursing #1 stated that they didn't know if any other supervisors did education with Certified Nurse Aide #1 between 08/02/2025 and 08/14/2025. The education that Assistant Director of Nursing #1 did was the review of the Supervised Care plan, time management and maybe to do some audits in the future. During an interview on 09/03/2025 at 10:00 AM, Administrator #1 and Director of Nursing #1 stated that as a Quality Assurance Improvement Process plan, they needed to regroup as a team to look at Supervised Care, the policy, and following up with supervisors to look at and track the issues that needed to be tracked. Administrator #1 stated that they reported to the County Director of Social Services. Annual reports were sent to them, and they came to the building twice a month. 10 New York Codes, Rules and Regulations 415.27(a-c)

Based on observation, record review and interviews conducted during an abbreviated survey (Case #2591142), the facility did not prevent willful infliction of abuse, neglect, or mistreatment for two (2) (Resident # 1, and 3) of four (4) residents reviewed for abuse, neglect, or mistreatment. Specifically, the facility did not fully investigate an incident that occurred on 08/02/2025 when Certified Nurse Aide #1 lowered Resident #1 to the floor. Video footage captured on 08/02/2025 was viewed by facility staff on 08/14/2025 and showed abusive handling of Resident #1 that resulted in the resident falling to the floor and remaining unattended for four (4) minutes.This is evidenced by: The Facility's Abuse & Neglect Policy, updated on 04/03/2025, documented residents had the right to be free from neglect, verbal, sexual, physical or mental abuse, corporal punishment, exploitation and involuntary seclusion. Record review of the facility's abuse investigation dated 08/15/2025 through 09/03/2025 revealed Certified Nurse Aide #1 was suspended after it was discovered that they were possibly responsible for multiple injuries found on more than one resident in their care assignments. On 07/19/2025, a bruise and an abrasion was noted on Resident #2's forehead which was attributed to rough handling during bed mobility. Additionally, on 08/01/2025, bruising was noted to the right side of Resident #3's face and around their eye and nose that was attributed to Certified Nurse Aide #3 rolling Resident #3 into the wall next to their bed, and ill-fitting glasses. On 08/15/2025, bruising was noted to Resident #4's neck, appeared to be multiple days old, and was attributed to Resident #4 being resistive to care. Resident #3 Resident #3 was admitted to the facility with the diagnoses of unspecified dementia, unspecified severity with other behavioral disturbances (memory loss and reduced thinking ability without aggressive or disruptive behavior), hypothyroidism (a condition when the thyroid does not produce enough thyroid hormones to meet the bodies needs), and major depressive disorder (a mood disorder that causes persistent feelings of sadness and loss of interest). The Minimum Data Set, dated [DATE], documented the resident was usually able to understand others, was usually understood, and was severely cognitively impaired. A facility Incident and Accident Report, dated 08/01/2025 at 2:00 PM, documented that a blue/gray bruise was noted on Resident # 3's nose. The contributing factors were documented as poor safety awareness, dementia, ill-fitting glasses, wall not padded, and resting their head on the table at times when fatigued. Measures to prevent recurrence were to place mat on wall, check glasses for appropriate fit, and to place staff on supervised care for follow up and education. Statements documented in the Incident and Accident Report documented the following: 1. Registered Nurse #2, dated 08/01/2025, spoke with Resident #3's family member who had visited on 07/30/2025 did not observe any bruising when visiting.2. Assistant Director of Nursing #1, dated 08/01/2025, documented that they had spoken with Certified Nurse Aide #1 who verbalized that Resident #3 was difficult while providing care, had swung their hands while attempting to provide personal care, and had hit their head on the wall while rolling over. Certified Nurse Aide #1 had not seen an injury at that time. Assistant Director of Nursing #1 documented they discussed how to approach and reapproach when resident's behaviors escalated. 3. Certified Nurse Aide #1, dated 08/19/2025, documented on 08/01/2025, they started to wash Resident #3 and they became combative with Certified Nurse Aide #1, they stopped to dry Resident #3 and put their clothes on.The Comprehensive Care Plan titled, Activities of Daily Living, dated 10/08/2021, documented that Resident #3 was a one person assist for bed mobility and activities of daily living. The Comprehensive Care Plan titled, Behavior Symptoms: Physical or Verbal Abuse/Resists Care, dated 10/08/2021, documented that Resident #3 had a history of hitting and screaming at staff at times during care, and refusing care. Interventions included allowing Resident #3 time to de-escalate, reapproach the resident if they were refusing care, and place soft object in Resident #3's hands while providing care if combative.Resident #1Resident #1 was admitted to the facility with diagnoses of Parkinson's Disease with Dyskinesia and Fluctuations (a condition that causes muscle tremors and rigidity along with involuntary writhing movements), and Unspecified Dementia without Behavioral Disturbance (memory loss and reduced thinking ability without aggressive or disruptive behavior), Psychotic Disturbance (episodes of hallucinations or false beliefs), Mood Disturbance (a degenerative neurological disease causing memory loss and cognitive decline with psychological issues like agitation), and Anxiety (excessive worry or fear that interferes with daily life). Minimum Data Set (an assessment tool) dated 08/08/2025, documented Resident #1 could be understood, could understand others, and had intact cognition for decisions of daily living. A facility-provided incident and accident report dated 08/02/2025 documented that Certified Nurse Aide #1 observed Resident #1 standing in their room, assisted the resident to their wheelchair, and began to exit the resident's room with the resident in the wheelchair. While exiting, Resident #1 grabbed the wall handrail and lifted themselves up from the wheelchair, prompting Certified Nurse Aide #1 to lower the resident to the floor to prevent a fall. The report documented Certified Nurse Aide #1's accounting was while attempting to reseat the resident. and that the Resident #1's self-propelled standing was attributed to gastric distress.The facility's abuse investigation dated 08/26/2025 through 09/03/2025 included video footage dated 08/02/2024 at 10:48 AM. Video footage (with no audio) showed:- Resident #1 stood unsupervised in their room. Certified Nurse Aide #1 entered Resident #1's room without knocking, placed hands on Resident #1's arms and pulled the resident into the wheelchair. - Resident #1 resisted but was eventually positioned in the wheelchair. - Certified Nurse Aide #1 repeated the maneuver, and on a second (2nd) attempt the resident nearly missed the wheelchair and almost fell.- While the wheelchair was being moved backward toward the hallway by Certified Nurse Aide #1, Resident #1 attempted to block the front wheel with their foot. - While the wheelchair moved, Resident #1 stood up, and fell onto the floor on their side. - Certified Nurse Aide #1 gestured toward the resident, with the staff member lifting the shoulders and placing their hands down at their sides while walking away from the resident, who remained on the floor. - Resident #1 remained on the floor alone for two (2) minutes before Certified Nurse Aide #1 returned with a mechanical hoyer lift. Certified Nurse Aide #1 stood approximately five (5) feet away, spoke briefly and then left the area. - Approximately two (2) minutes later, Licensed Practical Nurse #4 entered the hallway to obtain vital signs for Resident #1. Certified Nurse Aide #1 did not re-enter the viewing area outside of Resident #1's room for the remainder of the recording. During an interview on 8/27/2025 at 4:24 PM, Certified Nurse Aide #1 stated they were putting a machine away and noticed Resident #1 standing up in their room. Certified Nurse Aide #1 stated they assisted Resident #1 into their wheelchair, who sat willingly. Certified Nurse Aide #1 stated they intended to push Resident #1 to the nursing station so they could be watched. As Certified Nurse Aide #1 was going out of the room, Resident #1 grabbed a handrail bar and pulled themselves to a standing position. Certified Nurse Aide #1 stated they assisted the resident to sit back down but Resident #1 did not sit in the chair completely, so Certified Nurse Aide #1 helped lower them to the floor and went to tell the nurse what happened. When asked about the willingness of Resident #1 to be moved in the wheelchair, Certified Nurse Aide #1 stated that Resident #1 willingly sat down but then resisted being taken out of their room by putting their foot in front of the wheels of the wheelchair. Certified Nurse Aide #1 turned the wheelchair around and pulled the resident's wheelchair backwards out of the doorway. When asked if Certified Nurse Aide #1 put their hands on Resident #1, they stated that in the hallway, as the resident grabbed the handrail and stood up, they lost their balance and that was when Certified Nurse Aide #1 grabbed them to lower the resident to the floor. After Certified Nurse Aide #1 lowered the resident to the floor, they went to get the nurse. Certified Nurse Aide #1 stated they went back to Resident #1 and stayed with them until help arrived. Certified Nurse Aide #1 stated that they could not identify the nurses that came to help and believed they were agency nurses. Certified Nurse Aide #1 stated they were standing right there until the resident was off the floor. Certified Nurse Aide #1 stated no statement was taken from them after the incident. Certified Nurse Aide #1 stated they were told to put their statement in the computer but was unable to do so because they couldn't figure out how to do the documentation on the computer. Certified Nurse Aide #1 stated they gave a verbal statement the day Resident #1 fell. Certified Nurse Aide #1 stated that they did not handle residents roughly.Review of video footage revealed Certified Nurse Aide #1 neglected Resident #1 when the resident fell to the floor in the hallway and Certified Nurse Aide #1 walked away. During an interview on 08/27/2025 at 11:10 AM, Licensed Practical Nurse #4 stated Certified Nurse Aide #1 informed the individual that Resident #1 was ambulating around their room when was not supposed to be. Licensed Practical Nurse #4 asked Certified Nurse Aide #1 to place the resident into a chair. Certified Nurse Aide #1 left and returned to state Resident #1 was on the floor. Licensed Practical Nurse #4 stated that when they approached Resident #1 with the vital signs machine, Resident #1 was mumbling something about Certified Nurse Aide #1, but they could not understand. Licensed Practical Nurse #4 did not suspect that the explanation given by Certified Nurse Aide #1 was inaccurate.During an interview on 08/27/2025 at 11:27 AM, Assistant Director of Nursing #1 stated that a couple of days to a week before this incident, Certified Nurse Aide #1 had provided personal care to, and turned Resident #3 in a way that caused them to hit their face on the wall causing an injury. Assistant Director of Nursing #1 spoke to Certified Nurse Aide #1 and Director of Nursing #1 and thought that perhaps Certified Nurse Aide #1 needed a little more education regarding bed mobility training. They stated Certified Nurse Aide #1 was agreeable to more education. Assistant Director of Nursing #1 stated they had no concerns that Certified Nurse Aide #1 was abusing the residents in any way, just needed more teaching. Assistant Director of Nursing #1 stated that no one felt like Resident #1 had been abused at the time of the incident. Assistant Director of Nursing #1 stated that it was a culmination of events that led Director of Nursing #1 to view the video. Assistant Director of Nursing #1 stated that if at any point Resident #1 had given any indication that they had an issue with Certified Nurse Aide #1, they would have treated the situation differently. When asked how, Assistant Director of Nursing #1 stated they would have interviewed the staff member privately, maybe changed their assignment, or called Director of Nursing #1 to have Certified Nurse Aide #1 removed from care if they suspected abuse had taken place. When asked what the expectation was for any Certified Nurse Aide who had lowered a resident to the floor, Assistant Director of Nursing #1 stated that a Certified Nurse Aide should get help. The staff member could call Code Blue, could take three (3) to six (6) steps into the room and pull the call bell, or yell for help. Assistant Director of Nursing #1 stated that perhaps the staff member could go and get help physically but the preference would be to use the call bell system and stay with the resident to assure their safety while waiting for help. Assistant Director of Nursing #1 stated it would not be appropriate to leave a resident unattended on the floor for multiple minutes. When asked to quantify the number on minutes, Assistant Director of Nursing #1 stated maybe less than two minutes would be appropriate. They stated the staff member should alert a nurse and return the resident. During an interview on 08/28/2025 at 2:20 PM, Director of Nursing #1 stated that the actions of Certified Nurse Aide #1 were not acceptable. They stated that it was not the expectation that staff would be unkind or treat residents in an undignified way. It was not acceptable for Certified Nurse Aide #1 to leave Resident #1 on the floor the way that they did. During an interview on 08/26/2025 at 12:03 PM, Registered Nurse #1 stated that staff would treat residents with respect and dignity, that gentle reminders about resident safety was provided, and that physical redirection was never appropriate. Registered Nurse #1 stated they would remove the alleged staff member and enact the chain of command if they ever saw something that looked like abuse.During an interview on 08/26/2025 at 2:55 PM, Director of Nursing #1 stated that video footage was reviewed only as part of investigations involving reportable incidents or an increase in bruising reports. They stated no staff raised concerns about Certified Nurse Aide #1 until Director of Nursing #1 began questioning employees. During an interview on 08/26/2025 at 3:26 PM, Administrator #1 stated they of the incident when there were suspicions of multiple cases of abuse related to Certified Nurse Aide #1. Administrator #1 stated incidents that would lead to looking at video footage included falls with injuries and resident-to-resident issues. Administrator #1 stated they trusted Director of Nursing #1 and Assistant Director of Nursing #1 in their role to keep track of events. Administrator #1 stated there was a 'see something, say something' culture in the facility amongst the staff. 10 New York Codes, Rules, and Regulations 415.4(b)(1)(i)

Based on record review and interviews conducted during an abbreviated survey, the facility did not provide needed care and services that were resident centered and in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for one (1) (Resident #1) of four (4) residents reviewed. Specifically, Resident #1 was not assessed for full range of motion before being manually lifted from the floor and placed in their wheelchair after suffering a fall to the floor. This is evidenced by:The facility's policy and procedure titled, Post Fall Routine, revised 5/2024, documented the purpose of the Post Fall Routine was to assess the resident for injury, to identify and treat any underlying causes and predisposing risk factors, to provide the resident physical comfort and reassurance, and to insure the resident's safety by preventing re-occurrence. The procedures documented were 1. Registered Nurse would assess the resident for any injury related to the fall and provide emergency treatment, as necessary; 2. All resident would be assisted off the floor with a Hoyer lift. The Nursing Supervisor may use discretion for residents who are noncompliant; 3. Determine any causative factors that may have contributed to the fall, i.e. change in mobility, toileting needs and correct immediately; 4. Complete the Resident Incident/Accident in electronic health record. Notify Provider and family. Document in electronic health record; 5. Document on the Care Plan and in the Certified Nurse Aide Instructions new interventions put in place. Nurse to document in progress note notifications and interventions; 6. Monitor resident for 48 hours post-fall; 7. The Resident Incident/Accident Report would be reviewed at the next Interdisciplinary Team Meeting. Document team intervention and update the resident's care plan and Certified Nurse Aide Instructions. Resident #1 was admitted to the facility with diagnoses of Parkinson's Disease with Dyskinesia, with Fluctuations (a condition that causes muscle tremors and rigidity along with involuntary writhing movements) and Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance (a degenerative neurological disease-causing memory loss and cognitive decline with psychological issues like agitation), and Anxiety. Minimum Data Set (MDS, an assessment tool) dated 8/08/2025, documented Resident #1 could be understood, could understand others and had intact cognition for decisions of daily living. Resident #1's Comprehensive Care Plan titled, Vision, dated 11/04/2024,documented encourage resident to ask for assistance as needed, and orient resident to changing surroundings. Resident #1's Comprehensive Care Plan titled, Activity Participation, dated 11/15/2024, documented to respect resident's right to refuse participation or attendance in recreational activities, initiate conversation with resident as frequently as possible, maintain preferred independent leisure activity, and provide escort or transportation as needed. Resident #1's Comprehensive Care Plan titled, Falls, dated 11/04/2024, documented to investigate cause of fall immediately, provide reality orientation, attempt to maintain a high-profile area as often as possible, and report any unsafe behavior to nursing. A facility provided incident and accident report dated 8/02/2025 documented that Certified Nurse Aide #1 noticed Resident #1 standing in their room, Certified Nurse Aide #1 assisted the resident to their wheelchair and when they were exiting the resident's room together, Resident #1 grabbed the wall handrail and pulled themselves from the wheelchair. The report documented Certified Nurse Aide #1's accounting was while attempting to reseat the resident, Resident #1 needed to be lowered to the floor to prevent them from falling to the floor. Resident #1's self-propelled standing out of the wheelchair was attributed to gastric distress. The facility's abuse investigation dated 8/26/2025 through 9/03/2025 (TBD), included video footage dated 8/02/2024 starting at 10:48 AM. Per the video footage, Resident #1 was standing unsupervised in their room. Certified Nurse Aide #1 was viewed entering Resident #1's room without knocking, placing their hands on Resident #1's arms and pulling the resident into their wheelchair. Resident #1 appeared to resist Certified Nurse Aide #1 but was eventually maneuvered into their wheelchair. Resident #1 stood again in their room and Certified Nurse Aide #1 again pulled the resident into their wheelchair. While pulling Resident #1 into their wheelchair a second time, Resident #1 appeared to almost miss the wheelchair and nearly fall. As the video footage continued, Resident #1 was observed being pushed in their wheelchair by Certified Nurse Aide #1 but attempted to block the front wheel with their foot. Certified Nurse Aide #1 was observed turning the wheelchair around so that the resident and the chair could be moved backwards out into the hallway. Certified Nurse Aide #1 continued to pull the wheelchair backwards, and while the wheelchair was moving, Resident #1 stood up, resulting in Resident #1 falling to the floor, and onto their side. There was no video footage of Resident #1 grabbing onto a chair rail and pulling themselves from their wheelchair. Certified Nurse Aide #1 appeared to throw their hands down at their sides and then walk away leaving the resident lying on the floor. As the video footage continued, Resident #1 was observed to have laid on the floor alone for 2 minutes before Certified Nurse #1 comes back into the viewing area, pushing a mechanical Hoyer lift towards where the resident was laying. Certified Nurse Aide #1 was seen walking past the resident, said something to Resident #1 and then stood in the doorway of the room next to Resident #1's room, at least 5 feet from where Resident #1 was laying. Licensed Practical Nurse #4 was viewed coming down the hall to do vital signs for Resident #1. Certified Nurse Aide #1 left the footage area when Licensed Practical Nurse #1 stated attending to Resident #1, and did not return at any time for the rest of the video footage provided. After another minute, Assistant Director of Nursing #1 was viewed coming down the hall. Assistant Director of Nursing #1 was observed to be talking to Resident #1 on the floor. There was visual evidence that a limited range of motion assessment was performed on the resident's arms. Assistant Director of Nursing #1 was observed to have Resident #1's head on their lap while talking to Licensed Practical Nurse #1 and Resident #1. Assistant Director of Nursing #1 took a phone call while kneeling on the floor and holding Resident #1's head. After Assistant Director of Nursing #1 put the phone back in their pocket, Assistant Director of Nursing #1 had Resident #1 bend their knees and with the help of Licensed Practical Nurse #1, they manually lifted Resident #1 from the floor by the resident's arms and placed them in the wheelchair. There was no documented evidence that any other range of motion was tested on Resident #1's legs. During an interview on 8/26/2025 at 3:26 PM, Administrator #1 stated that they were not aware of the incident until there were suspicions of multiple cases of abuse related to Certified Nurse Aide #1. When asked if camera footage was a standard part of investigating incidents, Administrator #1 stated that incidents that would lead to looking at video footage included falls with injuries and resident to resident issues. Administrator #1 stated that they trusted Director of Nursing #1 and Assistant Director of Nursing #1 to keep track of things. Administrator #1 stated the last Quality Assurance Process Improvement meeting was on 8/21/2025. When asked if this investigation or incident was discussed during the meeting, Administrator #1 stated that they got called away during the meeting, but it was not discussed while they were in the room. Administrator #1 stated that the facility may have had delayed reporting what had happened, but there was a see something, say something attitude in the facility amongst the staff. During an interview on 8/27/2025 at 11:27 AM, Assistant Director of Nursing #1 stated that they were called to the unit because Resident #1 was on the floor. Assistant Director of Nursing #1 described where Resident #1 was laying at the time and stated they were alert and able to answer questions. Resident #1 indicated they had stood up on their own and fallen trying to sit down in their wheelchair (missed the chair when sitting). Registered Nurse #1 stated they asked about pain and did an assessment for range of motion. Resident #1 stated they had some gas type pain and because it was slightly after breakfast, that was what Assistant Director of Nursing #1 believed. When asked what the expectation was for any Certified Nurse Aide who had lowered a resident to the floor, Assistant Director of Nursing #1 stated that the Certified Nurse Aide should get help. The staff member could call code blue, could take 3-6 steps into the room and pull the call bell, or yell for help. Assistant Director of Nursing #1 stated that maybe the staff member could go and get help physically but the preference would be to use the call bell system and stay with the resident to assure their safety while waiting for help. Assistant Director of Nursing #1 stated it would not be appropriate to leave a resident unattended on the floor for multiple minutes. When asked to quantify the number on minutes, Assistant Director of Nursing #1 stated maybe less than two minutes would be appropriate. The staff member should get a nurse and a vital sign machine and get back to the resident. During an interview on 8/28/2025 at 2:20 PM, Director of Nursing #1 stated that after a resident has a fall, the Registered Nurse on duty must do an assessment. The assessment would include neurological checks, skin integrity checks, range of motion checks, and assessment for pain. If the staff member suspected an injury, the staff member would not move them. If there was a concern for any particular body system, for example a full respiratory assessment would be done if the resident was short of breath, the staff would be expected to do a focused assessment. While reviewing the video footage, Director of Nursing #1 stated they did not know who Assistant Director of Nursing #1 was talking to on the phone and did not feel like they had done a full assessment on Resident #1 before picking them up off the floor. During an interview on 8/28/2025 at 3:58 PM. Assistant Director of Nursing #1 stated they checked Resident #1 for range of motion, cognitive changes, neurological checks, pain and discomfort, facial grimacing, and asked Resident #1 questions. Assistant Director of Nursing #1 stated they were the house supervisor the day the incident occurred. They stated that they believed the telephone call they took was regarding an admission coming to the facility. After reviewing the video footage of the assessment done by Assistant Director of Nursing #1, they stated that they believed they had done a full body range of motion assessment, indicating that having Resident #1 bend their knees prior to pulling them to their feet was a satisfactory assessment. When for the policy of how facility staff would pick up a resident off the floor after a fall, Assistant Director of Nursing #1 stated that if the resident was a mechanical lift, that would need to be used, and that it depended on the resident's body mechanics allowed for it. When asked if staff were allowed to manually life a resident like Assistant Director of Nursing #1 had, they stated that it was considered sufficient practical to life someone off the floor the way they did. 10 New York Codes, Rules, and Regulations 415.12

Based on record review and interviews conducted during an abbreviated survey, the facility did not ensure each resident was treated with respect and dignity, and care in a manner and in an environment that promoted maintenance or enhancement of their quality of life for one (1) (Resident #1) of four (4) residents reviewed. Specifically, Resident #1 was left alone on the floor after fall for upwards of four (4) minutes after Certified Nurse Aide #1 physically abused them by causing the resident to fall from their wheelchair.This is evidenced by:Cross referenced to F600The facility's undated Resident Handbook, presented as the facility dignity policy, documented 'as a nursing home resident, you have the right to: dignity, respect and a comfortable living environment; quality of care and treatment without discrimination; freedom of choice to make your own, independent decisions; be informed in writing about services and fees before you enter the nursing home; the safeguard of your property and money; safeguards in admission transfer and discharge; privacy in communications; choose your own schedule, activities and other preferences that are important to you; receive visitors of your choosing at the time of your choosing; an easy to use and responsive complaint procedure; be free from abuse including verbal, sexual, mental and physical abuse; be free from restraints; exercise all of your rights without fear of reprisals. Resident #1 was admitted to the facility with diagnoses of Parkinson's Disease with Dyskinesia, with Fluctuations (a condition that causes muscle tremors and rigidity along with involuntary writhing movements) and Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance (a degenerative neurological disease-causing memory loss and cognitive decline with psychological issues like agitation), and Anxiety. Minimum Data Set (MDS, an assessment tool) dated 08/08/2025, documented Resident #1 could be understood, could understand others and had intact cognition for decisions of daily living. Resident #1's Comprehensive Care Plan titled, Vision, dated 11/04/2024,documented encourage resident to ask for assistance as needed, and orient resident to changing surroundings. Resident #1's Comprehensive Care Plan titled Activity Participation, dated 11/15/2024, documented to respect resident's right to refuse participation or attendance in recreational activities, initiate conversation with resident as frequently as possible, maintain preferred independent leisure activity, and provide escort or transportation as needed. Resident #1's Comprehensive Care Plan titled Falls, dated 11/04/2024, documented to investigate cause of fall immediately, provide reality orientation, attempt to maintain a high-profile area as often as possible, and report any unsafe behavior to nursing. A facility provided incident and accident report dated 8/02/2025 documented that Certified Nurse Aide #1 noticed Resident #1 standing in their room, Certified Nurse Aide #1 assisted the resident to their wheelchair and when they were exiting the resident's room together, Resident #1 grabbed the wall handrail and pulled themselves from the wheelchair. The report documented Certified Nurse Aide #1's accounting was while attempting to reseat the resident, Resident #1 needed to be lowered to the floor to prevent them from falling to the floor. Resident #1's self-propelled standing out of the wheelchair was attributed to gastric distress.The facility's abuse investigation dated 8/26/2025 through 9/15/2025, included video footage dated 8/02/2024 starting at 10:48 AM. Per the video footage, Resident #1 was standing unsupervised in their room. Certified Nurse Aide #1 was viewed entering Resident #1's room without knocking, placing their hands on Resident #1's arms and pulling the resident into their wheelchair. Resident #1 appeared to resist Certified Nurse Aide #1 but was eventually maneuvered into their wheelchair. Resident #1 stood again in their room and Certified Nurse Aide #1 again pulled the resident into their wheelchair. While pulling Resident #1 into their wheelchair a second time, Resident #1 appeared to almost miss the wheelchair and nearly fall. As the video footage continued, Resident #1 was observed being pushed in their wheelchair by Certified Nurse Aide #1 but attempted to block the front wheel with their foot. Certified Nurse Aide #1 was observed turning the wheelchair around so that the resident and the chair could be moved backwards out into the hallway. Certified Nurse Aide #1 continued to pull the wheelchair backwards, and while the wheelchair was moving, Resident #1 stood up, resulting in Resident #1 falling to the floor, and onto their side. Certified Nurse Aide #1 appeared to throw their hands down at their sides and then walk away leaving the resident lying on the floor. As the video footage continued, Resident #1 was observed to have laid on the floor alone for 2 minutes before Certified Nurse #1 comes back into the viewing area, pushing a mechanical Hoyer lift towards where the resident was laying. Certified Nurse Aide #1 was seen walking past the resident, said something to Resident #1 and then stood in the doorway of the room next to Resident #1's room, at least 5 feet from where Resident #1 was laying. Licensed Practical Nurse #4 was viewed coming down the hall to do vital signs for Resident #1. Certified Nurse Aide #1 left the footage area when Licensed Practical Nurse #1 stated attending to Resident #1, and did not return at any time for the rest of the video footage provided. After another minute, Assistant Director of Nursing #1 was viewed coming down the hall. Assistant Director of Nursing #1 was observed to be talking to Resident #1 on the floor. There was visual evidence that a limited range of motion assessment was performed on the resident's arms. Assistant Director of Nursing #1 was observed to have Resident #1's head on their lap while talking to Licensed Practical Nurse #1 and Resident #1. Assistant Director of Nursing #1 took a phone call while kneeling on the floor and holding Resident #1's head. After Assistant Director of Nursing #1 put the phone back in their pocket, Assistant Director of Nursing #1 had Resident #1 bend their knees and with the help of Licensed Practical Nurse #1, they manually lifted Resident #1 from the floor by the resident's arms and placed them in the wheelchair. There was no documented evidence that any other range of motion was tested on Resident #1's legs. Resident #1 was left on the floor, unattended for a minimum of four (4) minutes, between 10:49 AM and 10:53 AMDuring an interview on 8/26/2025 at 12:03 PM, Registered Nurse #1 stated that they expected that staff would treat residents with respect and dignity. As the unit manager, Registered Nurse #1 stated that they did gentle reminders about resident safety and handling them. Registered Nurse #1 stated that they had regular staff, therefore abuse wasn't an issue on their unit. If residents were acting up, the staff would check for the resident for a urinary tract infection because the unit was pretty calm and everyone got along. Registered Nurse #1 stated that there should never be physical redirection with residents. Registered Nurse #1 stated they would remove a Certified Nurse Aide and enact the chain of command if they ever saw something that looked like abuse.During an interview on 8/27/2025 at 11:27 AM, Assistant Director of Nursing #1 stated that they were called to the unit because Resident #1 was on the floor. Assistant Director of Nursing #1 described where Resident #1 was laying at the time and stated they were alert and able to answer questions. Resident #1 indicated they had stood up on their own and fallen trying to sit down in their wheelchair (missed the chair when sitting). Registered Nurse #1 stated they asked about pain and did an assessment for range of motion. Resident #1 stated they had some gas type pain and because it was slightly after breakfast, that was what Assistant Director of Nursing #1 believed. Assistant Director of Nursing #1 stated that if at any point Resident #1 had given any indication that they had an issue with Certified Nurse Aide #1, they would have treated the situation differently. When asked how, Assistant Director of Nursing #1 stated they would have interviewed the staff member privately, maybe changed their assignment, or called the Director of Nursing to have Certified Nurse Aide #1 removed from care if they suspected abuse had taken place. When asked what the expectation was for any Certified Nurse Aide who had lowered a resident to the floor, Assistant Director of Nursing #1 stated that the Certified Nurse Aide should get help. The staff member could call code blue, could take 3-6 steps into the room and pull the call bell, or yell for help. Assistant Director of Nursing #1 stated that maybe the staff member could go and get help physically but the preference would be to use the call bell system and stay with the resident to assure their safety while waiting for help. Assistant Director of Nursing #1 stated it would not be appropriate to leave a resident unattended on the floor for multiple minutes. When asked to quantify the number on minutes, Assistant Director of Nursing #1 stated maybe less than two minutes would be appropriate. The staff member should get a nurse and a vital sign machine and get back to the resident. During an interview on 8/28/2025 at 2:20 PM, Director of Nursing #1 stated that the actions of Certified Nurse Aide #1 were not acceptable. It was not the expectation that staff would be unkind or treat residents in an undignified way. It was not acceptable for Certified Nurse Aide #1 to leave Resident #1 on the floor the way that they did. New York Codes, Rules, and Regulations Title 10 S415.5(a)

Based on observation, interview, and record review conducted during the Abbreviated survey (Complaint #NY00379718) completed on 6/10/2025, the facility did not ensure the resident's right to be free from abuse, neglect or mistreatment for one (1) (Resident #2) of three (3) residents reviewed for abuse, neglect and mistreatment. Specifically, a Certified Nurse Aide #3 did not follow Resident #2's care plan for dietary meal consistency when they provided Resident #2 with a regular chicken consistency that caused Resident #2 to choke and required back thrusts and mouth sweeps to clear their throat and mouth. This is evidenced by: The facility policy and procedure titled, Abuse/Neglect, revised 4/2025, documented the following: it is the policy of the facility that all residents have the right to be free from neglect, verbal, sexual, physical or mental abuse, corporal punishment, exploitation and involuntary seclusion. The facility education titled, Reportable Incidents / Examples, undated, provided by Director of Nursing #1, documented the following: Neglect may include, but is not limited to: failure to carry out physician orders, failure to follow the care plan, or failure to provide adequate hydration and nutrition. The facility policy and procedure titled, Dining Room Duties: Serving Meal Trays, revised 11/2016, documented the following: it is the policy of the facility that each resident will be provided with a dignified, pleasant dining experience at each meal to enhance socialization, increase mental awareness, stimulate appetite, provide optimal nutritional intake (based on individual preferences and needs); and foster the highest level of independence - safely and efficiently. Serving meal trays included check meal ticket (resident specific information identifying resident name, diet, and food items on tray) to assure the correct resident, item and consistency. Residents unhappy with the meal should be offered a substitute. Call kitchen to order substitutes as necessary, state you name, the unit you are calling from, the resident's name who needs a substitute and item requested. The facility policy and procedure titled, Therapeutic Dining, revised 3/2025, documented the following: it is the policy of the facility that each resident will be evaluated for a diet consistency and need for feeding strategies to allow safe nutritional intake, to provide staff with concise instructions for resident diet restrictions and feeding strategies. Resident #2 had diagnoses including dementia with agitation (a behavior change characterized by restlessness, excessive movement, and sometimes aggression, often triggered by changes in routine, environment, or cognitive decline), chronic obstructive pulmonary disease (a condition caused by damage to the airways or other parts of the lung, causing breathing problems), and malignant neoplasm of the bladder (bladder cancer). The Minimum Data Set (a resident assessment tool) dated 2/23/2025 documented Resident #2 was cognitively severely impaired, sometimes understood and sometimes understands, did not exhibit behaviors of rejection of care, required supervision or touching assistance for eating (helper provides verbal cues and / or touching / steadying and / or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.) and required a mechanically altered diet (a change in texture of food or liquids). Review of the comprehensive care plan dated 8/22/2023 documented the following: Nutrition / Hydration Comfort Care as evidenced by dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage). Documented interventions included provide the least restrictive diet necessary to allow optimal intake, mechanically altered diet. Review of the Dietary - Quarterly Nutritional Assessment for Resident #2 dated 2/24/2025 documented the following: regular diet, mechanical soft consistency with ground meats, thin liquids, had impaired swallowing, and required partial / moderate assist with supervision or touching assistance. Review of Resident #2's meal ticket, undated identified by Director of Nursing #1 as the meal ticket that was on Resident #2's meal tray on 5/04/2025 supper meal documented regular mechanical soft with ground meats, extra sauce / gravy, included three (3) each chicken tenders - must be minced. Review of, Nursing Home Investigative Report, completed by Director of Nursing #1 on 5/04/2025 at 9:06 PM, revealed the following: • The alleged abuse, neglect or mistreatment occurred as a result of a care plan violation on 5/04/2025 resulting in Resident #2 having a choking episode and required back thrusts and mouth sweeps to clear their throat and mouth of chicken. This was related to Resident #2 being given the wrong food consistency; served regular consistency chicken tenders and resident's diet is mechanical soft with ground meats. • Facility initiated an investigation and suspended Certified Nurse Aide #3 pending the investigation. • The facility investigation statements revealed Certified Nurse Aide #4 reported they witnessed Certified Nurse Aide #3 swap out a tray that belonged to Resident #2 and before they could report what they witnessed to the nurse, Resident #2 started to choke, and they immediately reported what they witnessed. A statement by Licensed Practical Nurse #2 documented, Certified Nurse Aide #4 notified them Certified Nurse Aide #3 swapped out Resident #2's meal tray with someone else's whose food was not of mechanical sot / minced consistency, and they asked Certified Nurse Aide #3 if they had swapped out Resident #2's tray and Certified Nurse Aide #3 informed them they may have but they do not remember because they get confused. • The facility's investigation conclusion documented statements were obtained from all staff involved, the findings of the investigation documented, Certified Nurse Aide #3 was feeding Resident #2 the wrong meal consistency food (served regular and diet is mechanical soft, minced meat). The facility concluded that Resident #2 choked from Certified Nurse Aide #3 feeding them the wrong food consistency. During a telephone interview on 6/05/2025 at 12:42 PM, Certified Nurse Aide #3 stated during the supper meal on 5/04/2025, Resident #3 was served a fish sandwich, and requested chicken, they noticed Resident #2 had minced chicken on their plate, so they took the food plate from Resident #2's tray and gave it to Resident #3. They stated Resident #4 had regular chicken tenders on a plate and didn't want them because they were eating pancakes, so they took Resident #4's food plate of chicken tenders and gave it to Resident #2. They stated they did intentionally swap the meal plates but mistakenly did not read Resident #2's meal ticket consistency and provided them with the wrong consistency and they choked and needed attention from the nurse to clear their mouth and throat. They stated they should not have swapped residents' meal plates and should have called the kitchen for an alternative plate for Resident #3 when they asked for a different meal. During a telephone interview on 6/05/2025 at 1:38 PM, Certified Nurse Aide #4 stated they heard Certified Nurse Aide #3 state they were going to switch Resident #2's plate and they observed the plate that was in Certified Nurse Aide #3's hand and informed Certified Nurse Aide #3 not to give Resident #2 the food (regular chicken) that was on that plate because it wasn't the correct consistency for Resident #2. Certified Nurse Aide #4 stated they did not know where Certified Nurse Aide #3 got the plate of food from and didn't realize they were going to feed Resident #2 after they informed them it was the wrong consistency. They stated Resident #2 started coughing and choking and the nurses had to respond to assist Resident #2 to clear their throat. During a telephone interview on 6/05/2025 at 2:16 PM, Licensed Practical Nurse #2 stated on 5/04/2025 Resident #2 was choking on regular chicken at supper and stated they were unable to continue the interview at this time. During a telephone interview on 6/05/2025 at 2:50 PM, Registered Nurse #3 stated they interviewed staff on 5/04/2025 related to Resident #2's choking incident. They stated upon investigating the staff interviews, they learned Certified Nurse Aide #3 swapped out three (3) resident's meal plates and mistakenly didn't identify Resident #2 was to have minced meat and was not to receive regular chicken fingers, which caused Resident #2 to choke, and Director of Nursing #1 was aware. During another telephone interview on 6/09/2025 at 12:35 PM, Licensed Practical Nurse #2 stated they were in the dining room, heard Certified Nurse Aide #3 shout 'spit it out' and observed them pulling Resident #2 away from the dining room table. Upon assessing Resident #2, they observed the resident flushed and unable to communicate. They were unable to provide the Heimlich maneuver because of the high back wheelchair, so they instead completed a finger sweep and pulled two (2) pieces of chicken out of the resident's mouth. They stated Certified Nurse Aide #4 informed them Certified Nurse Aide #3 took another resident's plate of food that was a regular consistency, told Certified Nurse Aide #3 they were not to feed Resident #2 that consistency, and yet Certified Nurse Aide #3 started feeding Resident #2 the regular consistency anyway. This resulted in Resident #2 choking on the food. Licensed Practical Nurse #2 stated they immediately informed Registered Nurse #3. During an interview on 6/09/2025 at 11:53 AM, Nurse Practitioner #1 stated they assessed Resident #2 after the choking episode and was aware they received the wrong meal consistency. They further stated that they would have expected Certified Nurse Aide #3 to have read the meal ticket and provided the meal consistency that was indicated on their meal ticket. They stated they were not aware Certified Nurse Aide #3 swapped three (3) resident meal plates and stated Certified Nurse Aide #3 was negligent with their actions. During a telephone interview on 6/10/2025 at 10:37 AM, Medical Director #1 stated Certified Nurse Aide #3 should have ensured they provided the correct consistency meal according to their plan of care and meal ticket. They stated they were not aware Certified Nurse Aide #3 swapped three (3) resident meal plates and stated Certified Nurse Aide #3 was negligent with their actions. During an interview on 6/10/2025 at 11:36 AM, Director of Nursing #1 stated they would have expected Certified Nurse Aide #3 to have called to the kitchen when Resident #3 wanted an alternative meal. They stated staff should not swap resident meals plates because of specific diet plans, food consistencies and potential food allergies. They stated Certified Nurse Aide #3 was negligent with their actions. During an interview on 6/10/2025 at 12:08 PM, Administrator #1 stated they would have expected Certified Nurse Aide #3 to have called to the kitchen when Resident #3 wanted an alternative meal. They stated staff should not swap resident meals plates because of specific diet plans, food consistencies and potential food allergies. They stated Certified Nurse Aide #3 was negligent with their actions. 10 New York Codes, Rules and Regulations 415.4 (b)(1)(i)

Based on observation, interview and record review conducted during an Abbreviated survey (Complaint #NY00378218) completed on 6/10/2025, the facility did not ensure that all alleged violations involving abuse, neglect, mistreatment including injuries of unknown source, were reported immediately, but not later than two hours after the allegation was made to the facility's Administrator and the State Survey Agency for one (1) (Resident #5) of three (3) residents reviewed. Specifically Resident #5 was found to have an injury of unknown source to their right eye, and it was not reported within the required timeframe. This is evidenced by: The facility policy and procedure title, Resident Incident / Accident Reporting, date revised 9/2023 documented the following: all resident incident / accidents are reported, investigated and documented at the time of the incident / accident or upon discovery, in an effort to prevent or decrease recurrence. Accident - any happening that results in bodily injury, including but not limited to falls, fractures, lacerations, burns, skin tears and bruises. At the time of an incident / accident or upon discovery, staff are to notify the Nursing Supervisor. The Registered Nurse is responsible to assess and assure appropriate medical attention follow-up. The facility policy and procedure titled, Abuse/Neglect, revised 4/2025, documented the following: it is the policy of the facility that all residents have the right to be free from neglect, verbal, sexual, physical or mental abuse, corporal punishment, exploitation and involuntary seclusion. Investigate all reported incidents and accidents and resident complaints for potential abuse, neglect and possible crime. Once an incident has been reported, notify the Director of Nursing or Administrator and begin the investigation. As soon as the investigation begins and there is reasonable cause to believe it is reportable to the Department of Health using the current annual, a determination must be made if it meets the two (2) hour or twenty-four (24) hour reporting mandate. If physical injuries, provider to be notified to determine level of follow-up needed. Review of facility form undated titled, Reportable Incidents/Examples, documented the following: Notify the Supervisor and Administrator immediately - Reportable incidents must be reported to the Department of Health by Administration Immediately, examples included injury of unknown origin; resident has a new bruise, fracture, skin tear without explanation. Resident #5 had diagnoses including dementia (a generalized term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), hypertension (a condition in which the force of the blood against the artery walls is too high), and Peripheral Vascular Disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). The Minimum Data Set (a resident assessment tool) dated 4/25/2025 documented Resident #5 was cognitively severely impaired, usually understands and usually understood. The undated comprehensive care plan for Resident #5 identified as current by Director of Nursing #1 documented that Resident #5 required substantial / maximal assistance with dressing and may be resistant to care; cognition deficit as evidenced by short term memory loss with difficulty with decision making and difficulty memory recall and behavior symptoms dated physical / verbal abuse with resistance to care as evidenced by refusal of hands on care, verbally and physically aggressive to staff and others. Review of Resident #5 ' s Progress Notes dated 3/01/2025 through 6/09/2025 documented the following: - Dated 4/08/2025 at 5:26 PM: Registered Nurse #4 documented the following: purpura (is a medical term describing purple - colored spots or patches on the skin caused by bleeding under the skin due to broken blood vessels) noted below the resident ' s right eye, no pain noted when assessed. - Dated 4/14/2025 at 4:33 PM: Nurse Practitioner #2 documented the following: ecchymosis (the medical term for bruises) to right lower eye, per nursing they rub vigorously. - Dated 4/16/2025 at 8:22 PM: Registered Nurse #3 documented the following: bruise right eye Nurse Practitioner assessed resident ' s right eye and determined a bruise. The bruise is purple with yellow area surrounding and fading in color, measures six (6) centimeters by three (3) centimeters under right eye. The area above the right eye lid measures two (2) centimeters by (0.5) centimeters. Resident denies pain or discomfort and resident denies any harm or wrongdoing. Family was aware last week while visiting resident and states the purple has been there for over a week and resident did not know how it happened as they had already asked him. - Dated 4/16/2025 at 9:22 PM: Nurse Practitioner #2 documented the following: ecchymosis below left eye is resolving turning purple/green/yellow, on better view can now observe ecchymosis to upper medial lid. Resident has no pain on palpation, no asymmetry of the periorbital ring. Resident does not recall how this developed. - Dated 4/18/2025 at 9:59 AM: Medical Director #1 documented the following: Visit date 4/17/2025, resident was seen as requested by Director of Nursing regarding the new skin lesion around Resident #5 ' s eye. Per Director of Nursing, no report of a fall, Nurse Practitioner #2 ' s progress notes reviewed from 4/14/2025 and 4/16/2025. Assessment documented, a small and dissipating ecchymosis (a discoloration of the skin resulting from bleeding underneath) below the right lower eyelid is present and Resident #5 was unable to recall what had happened. Etiology questionable (the cause or origin of the condition was not clearly understood or identified). Review of the facility ' s Accident form dated 4/16/2025 Registered Nurse #3 documented, estimated date 4/11/2025 at 12:00 PM bruise right eye, possible cause resident rubbed their eye too hard and the multiple eye scrubs made the area further purple. Registered Nurse #3 was on unit doing rounds and Nurse Practitioner #2 and administration were looking at Resident #5 ' s right eye and requested them to complete an incident report for area noticed last week. Statements documented on the Accident report included the following: - Dated 4/17/2025 Licensed Practical Nurse #3: On 4/08/2025, Resident #5 had a linear dark red/purple area, intact skin under right eye. The area was slightly crescent in shape and followed the large droopy bag under their right eye. Registered Nurse #4 was made aware, daughter was present the next day and inquired with staff, explained the area was referred to as a purpura area. - Dated 4/17/2025 Certified Nurse Aide #5: They saw Resident #5 ' s eye and asked Registered Nurse #4 what happened to their eye and Registered Nurse #4 informed them they had a purpura area. - Dated 4/17/2025 Nurse Practitioner #1: Was told by staff on 4/16/2025 they suspected a bruise to Resident #5 ' s eye that staff were calling a purpura and informed Administration as soon as possible. - Dated 4/18/2025 Nurse Practitioner #3: They observed Resident #5 walking past them and observed their eye and asked Nurse Practitioner #2 what happened to Resident #5 ' s eye. Nurse Practitioner #2 replied that it was being documented as purpura by nursing but the way it was shaped it looked like they may have had an injury to their right eye, and it appeared to be bruised. Nurse Practitioner #2 agreed it was a bruise but does not know where it came from. During an interview on 6/10/2025 at 9:05 AM, Nurse Practitioner #1 stated Registered Nurse #4 should have reported the discoloration around Resident #5 ' s eye to the provider for an assessment and the Director of Nursing or Administrator because it was an injury of unknown origin on 4/08/2025, and the facility should have reported it to the New York State Department of Health within the regulatory guidelines. During an interview on 6/10/2025 at 9:46 AM, Registered Nurse #3 stated Registered Nurse #4 should have reported the discoloration around Resident #5 ' s eye to the provider for an assessment and the Director of Nursing or Administrator because it was an injury of unknown origin on 4/08/2025, and the facility should have reported it to the New York State Department of Health within the regulatory guidelines. During an interview on 6/10/2025 at 10:16 AM, Medical Director #1 stated they were not aware Registered Nurse #4 identified Resident #5 had a discolored area on their right eye on 4/08/2025 and would have expected Registered Nurse #4 to have reported the discoloration around Resident #5 ' s eye to the provider for an assessment and the Director of Nursing or Administrator because it was an injury of unknown origin on 4/08/2025, and the facility should have reported it to the New York State Department of Health within the regulatory guidelines. During an interview on 6/10/2025 at 11:35 AM, Director of Nursing #1 stated Registered Nurse #4 should have reported the discoloration around Resident #5 ' s eye to the provider for an assessment and the Director of Nursing or Administrator because it was an injury of unknown origin on 4/08/2025, and the facility should have reported it to the New York State Department of Health within the regulatory guidelines of 24 hours. During an interview on 6/10/2025 at 11:56 AM, Administrator #1 stated they were not aware Registered Nurse #4 identified Resident #5 had a discolored area on their right eye on 4/08/2025 and would have expected Registered Nurse #4 to have reported the discoloration around Resident #5 ' s eye to the provider for an assessment and the Director of Nursing or them because it was an injury of unknown origin on 4/08/2025, and the facility should have reported it to the New York State Department of Health within the regulatory guidelines of 24 hours. 10 New York Codes, Rules and Regulations 415.4(b)(2)

Based on observation, interview and record review conducted during an Abbreviated survey (Complaint #NY00379718 and #NY00378218) completed on 6/10/2025, it was determined the facility did not ensure that all violations of abuse, neglect, mistreatment were thoroughly investigated for two (2) (Resident #2 and #5) of three (3) residents reviewed. Specifically, (1.) An incident involving Resident #2, who was fed regular chicken consistency by Certified Nurse Aide #3, was not thoroughly investigated to determine where the Certified Nurse Aide retrieved the regular consistency meal; and (2.) Resident #5's injury of unknown origin was not investigated thoroughly. Reference F 600 D and F 609 D This is evidenced by: The facility policy and procedure titled, Abuse/Neglect, revised 4/2025, documented the following: it is the policy of the facility that all residents have the right to be free from neglect, verbal, sexual, physical or mental abuse, corporal punishment, exploitation and involuntary seclusion. Investigate all reported incidents and accidents and resident complaints for potential abuse, neglect and possible crime. Statements from staff must be done immediately, and the person conducting the investigation will use the employee statement to determine the need for an interview. The facility policy and procedure titled, Resident Incident / Accident Reporting, revised 9/2023, documented the following: Accident - any happening that results in bodily injury, including but not limited to falls, fractures, lacerations, burns, skin tears and bruises. The purpose is to document occurrence of incident / accidents, identify unsafe practices, reduce preventable incident / accidents through root cause analysis, and provide education and follow-up to prevent further occurrences. Obtain resident and staff statements regarding the event, an investigation regarding the circumstance of the incident or accident must be conducted by the nursing supervisor by obtaining and reviewing statements from all staff who have the potential to be knowledgeable of the incident or accident. Follow up interviews will be conducted as necessary. (1.) Resident #2 had diagnoses including dementia with agitation (a behavior change characterized by restlessness, excessive movement, and sometimes aggression, often triggered by changes in routine, environment, or cognitive decline), chronic obstructive pulmonary disease (a condition caused by damage to the airways or other parts of the lung, causing breathing problems), and malignant neoplasm of the bladder (bladder cancer). The Minimum Data Set (a resident assessment tool) dated 2/23/2025 documented Resident #2 was cognitively severely impaired, sometimes understood and sometimes understands, did not exhibit behaviors of rejection of care, required supervision or touching assistance for eating (helper provides verbal cues and / or touching / steadying and / or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.) and required a mechanically altered diet (a change in texture of food or liquids). Review of the comprehensive care plan dated 8/22/2023 documented the following: Nutrition / Hydration Comfort Care as evidenced by dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage). Documented interventions included provide the least restrictive diet necessary to allow optimal intake, mechanically altered diet. Review of the Dietary Quarterly Nutritional Assessment for Resident #2 dated 2/24/2025 documented the following: regular diet, mechanical soft consistency with ground meats, thin liquids, had impaired swallowing, and required partial / moderate assist with supervision or touching assistance. Review of Resident #2's meal ticket, undated identified by Director of Nursing #1 as the meal ticket that was on Resident #2's meal tray on 5/04/2025 supper meal documented regular mechanical soft with ground meats, extra sauce / gravy, included three (3) each chicken tenders - must be minced. Review of, Nursing Home Investigative Report, completed by Director of Nursing #1 on 5/04/2025 at 9:06 PM, revealed the following: • The alleged abuse, neglect or mistreatment occurred as a result of a care plan violation on 5/04/2025 resulting in Resident #2 having a choking episode and required back thrusts and mouth sweeps to clear their throat and mouth of chicken. This was related to Resident #2 being given the wrong food consistency; served regular consistency chicken tenders and resident's diet is mechanical soft with ground meats. • The facility's investigation conclusion documented statements were obtained from all staff involved, the findings of the investigation documented, Certified Nurse Aide #3 was feeding Resident #2 the wrong meal consistency food (served regular and diet is mechanical soft, minced meat). The facility concluded that Resident #2 choked from Certified Nurse Aide #3 feeding them the wrong food consistency. Review of Resident #3's meal ticket, undated identified by Dietary Typist #1 as the meal ticket that was provided on 5/04/2025 supper meal documented, their diet: regular diet mechanical soft / hamburger ground on roll, extra sauce / gravy and food items included 1 fish sandwich, sweet potato tots and soup. Review of Resident #4's meal ticket, undated identified by Dietary Typist #1 as the meal ticket that was provided on 5/04/2025 supper meal documented, their diet: regular no added salt / mechanical soft / regular chicken and bacon and regular bagel with cream cheese / extra sauce / gravy and food items included (3) chicken tenders, mango sauce, dipping, sweet potato tots. During a telephone interview on 6/05/2025 at 12:42 PM, Certified Nurse Aide #3 stated during the supper meal on 5/04/2025, Resident #3 was served a fish sandwich, and they requested to have chicken. Certified Nurse Aide #3 stated they noticed Resident #2 had minced chicken on their plate, so they took the food plate from Resident #2's tray and gave it to Resident #3. They stated Resident #4 had regular chicken tenders on a plate and didn not want them because they were eating pancakes, so they took Resident #4's food plate of chicken tenders and gave it to Resident #2. They stated they did intentionally swap the meal plates but mistakenly did not read Resident #2's meal ticket consistency and provided them with the wrong consistency and they choked and needed attention from the nurse to clear their mouth and throat. They stated they should not have swapped residents' meal plates and should have called the kitchen for an alternative plate for Resident #3 when they asked for a different meal. During a telephone interview on 6/05/2025 at 2:50 PM, Registered Nurse #3 stated they interviewed staff on 5/04/2025 related to Resident #2's choking incident. They stated upon investigating the staff interviews, they learned Certified Nurse Aide #3 swapped out three (3) resident's meal plates and mistakenly did not identify Resident #2 was to have minced chicken tenders and was not to receive regular chicken tenders, which caused Resident #2 to choke. They stated Director of Nursing #1 was aware that Certified Nurse Aide #3 swapped out three (3) resident meal plates. They stated they did not request Certified Nurse Aide #3 to update their written statement to clarify they swapped out three (3) resident meal plates and they did not review Resident #3's and Resident #4's dietary plan to ensure they received the appropriate diet meal plan and correct consistency. Additionally, they stated they did not add Resident #3 and Resident #4 to the investigation. During an interview on 6/09/2025 at 10:06 AM, Therapy Department Director #1 stated they were not aware Certified Nurse Aide #3 swapped three (3) resident meal plates and was not aware how Resident #2 received regular consistency chicken which caused them to choke. They stated they would have expected Director of Nursing #1 to have informed them Resident #3 and Resident #4's supper plates were also swapped, and they would have assessed the meals they received to ensure the food was appropriate according to their meal plans. They stated all staff were expected if they want an alternative meal, they were to call the kitchen for a tray and should never swap resident meal plates between the residents to ensure consistency and diet restrictions are followed. They stated the facility did not complete a thorough investigation. During an interview on 6/09/2025 at 11:53 AM, Nurse Practitioner #1 stated they were not aware Certified Nurse Aide #3 swapped three (3) resident meal plates and would have expected a thorough investigation to include a review of Resident #3 and Resident #4's dietary plan to ensure they received the correct diet and consistency. During a telephone interview on 6/10/2025 at 10:37 AM, Medical Director #1 stated they were not aware Certified Nurse Aide #3 swapped three (3) resident meal plates and would have expected a thorough investigation to include where Certified Nurse Aide #3 obtained the regular chicken from that Resident #2 was fed. They stated they would have expected Director of Nursing #1 to have thoroughly investigated Resident #3 and Resident #4's meal tickets and dietary plan to ensure they also received the correct consistency and dietary plan and would have expected Director of Nursing #1 to have had the information documented in the investigation. During an interview on 6/10/2025 at 11:36 AM, Director of Nursing #1 stated they were not aware where Certified Nurse Aide #3 got the regular chicken tenders from that they fed Resident #2. They stated they did not complete a thorough investigation to determine where they retrieved the regular consistency chicken tenders from. They stated they were informed Certified Nurse Aide #3 swapped out meal plates that also involved Resident #3 and #4 and identified they were all mechanical soft, and did not identify Resident #4 had regular chicken tenders on their meal plan, that was provided to Resident #2. They stated they had not completed a thorough investigation and should have thoroughly reviewed and included Resident #3's and Resident #4's information in the investigation based on the interviews. During an interview on 6/10/2025 at 12:08 PM, Administrator #1 stated the facility did not complete a thorough investigation and would have expected Director of Nursing #1 to have identified where Certified Nurse Aide #3 obtained the regular chicken tenders from that Resident #2 was fed and have thoroughly reviewed and included Resident #3's and #4's information in the investigation. They stated they were not aware Certified Nursing Aide #3 swapped out 3 resident meal plates and they should have been informed. (2.) Resident #5 had diagnoses including dementia (a generalized term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), hypertension (a condition in which the force of the blood against the artery walls is too high), and Peripheral Vascular Disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). The Minimum Data Set (a resident assessment tool) dated 4/25/2025 documented Resident #5 was cognitively severely impaired, usually understands and usually understood. The undated comprehensive care plan for Resident #5 identified as current by Director of Nursing #1 documented the following, Resident #5 required substantial / maximal assistance with dressing and may be resistant to care; cognition deficit as evidenced by short term memory loss with difficulty with decision making and difficulty memory recall and behavior symptoms dated of physical / verbal abuse with resistance to care as evidenced by refusal of hands on care, verbally and physically aggressive to staff and others. Review of Resident #5's Progress Notes dated 3/01/2025 through 6/09/2025 documented the following: • Dated 4/08/2025 at 5:26 PM Registered Nurse #4 documented the following: purpura a medical term describing purple - colored spots or patches on the skin caused by bleeding under the skin due to broken blood vessels) noted below the resident's right eye, no pain noted when assessed. • Dated 4/14/2025 at 4:33 PM Nurse Practitioner #2 documented the following: ecchymosis (the medical term for bruises) to right lower eye, per nursing they rub vigorously. • Dated 4/16/2025 at 8:22 PM Registered Nurse #3 documented the following: bruise right eye Nurse Practitioner assessed resident's right eye and determined a bruise. The bruise is purple with yellow area surrounding and fading in color, measures six (6) centimeters by three (3) centimeters under right eye. The area above the right eye lid measures two (2) centimeters by (0.5) centimeters. Resident denies pain or discomfort and resident denies any harm or wrongdoing. Family was aware last week while visiting resident and states the purple has been there for over a week and resident did not know how it happened as they had already asked him. • Dated 4/16/2025 at 9:22 PM Nurse Practitioner #2 documented the following: ecchymosis below left eye is resolving turning purple/green/yellow, on better view can now observe ecchymosis to upper medial lid. Resident has no pain on palpation, no asymmetry of the periorbital ring. Resident does not recall how this developed. • Dated 4/18/2025 at 9:59 AM Medical Director #1 documented the following: Visit date 4/17/2025, resident was seen as requested by Director of Nursing regarding the new skin lesion around Resident #5's eye. Per Director of Nursing, no report of a fall, Nurse Practitioner #2's progress notes reviewed from 4/14/2025 and 4/16/2025. Assessment documented, a small and dissipating ecchymosis (a discoloration of the skin resulting from bleeding underneath) below the right lower eyelid is present and Resident #5 was unable to recall what had happened. Etiology questionable (the cause or origin of the condition was not clearly understood or identified). Review of the facility's Accident form dated 4/16/2025 Registered Nurse #3 documented, estimated date 4/11/2025 at 12:00 PM bruise right eye, possible cause resident rubbed their eye too hard and the multiple eye scrubs made the area further purple. Registered Nurse #3 was on unit doing rounds and Nurse Practitioner #2 and administration were looking at Resident #5's right eye and requested them to complete an incident report for area noticed last week. Statements documented on the Accident report included the following: • Dated 4/17/2025 Licensed Practical Nurse #3: On 4/08/2025 Resident #5 had a linear dark red/purple area, intact skin under right eye. The area was slightly crescent in shape and followed the large droopy bag under their right eye. Registered Nurse #4 was made aware, daughter was present the next day and inquired with staff, explained the area was referred to as a purpura area. • Dated 4/17/2025 Certified Nurse Aide #5: They saw Resident #5's eye and asked Registered Nurse #4 what happened to their eye and Registered Nurse #4 informed them they had a purpura area. • Dated 4/17/2025 Nurse Practitioner #1: Was told by staff on 4/16/2025 they suspected a bruise to Resident #5's eye that staff were calling a purpura and informed Administration as soon as possible. • Dated 4/18/2025 Nurse Practitioner #3: They observed Resident #5 walking past them and observed their eye and asked Nurse Practitioner #2 what happened to Resident #5's eye. Nurse Practitioner #2 replied that it was being noted as purpura but the way it was shaped it looked like they may have had an injury to their right eye, and it appeared to be bruised. Nurse Practitioner #2 agreed it was a bruise but does not know where it came from. During an interview on 6/10/2025 at 9:05 AM Nurse Practitioner #1 stated they recalled staff were referring Resident #5's eye discoloration as a purpura area and it looked like a bruise, therefore they reported it to either the Deputy Administrator or the Director of Nursing, unable to recall who they reported it to. They stated Registered Nurse #4 should not have diagnosed it as a purpura area and reported it to the provider for an assessment and initiated an investigation on 4/08/2025. During an interview on 6/10/2025 at 9:05 AM Certified Nurse Aide #6 stated they worked the night shift providing care to Resident #5 on 4/07/2025 into the morning of 4/08/2025 and they were not interviewed or asked any questions from the facility concerning the bruise on Resident #5's right eye. They stated they do not know how the resident's eye was bruised. During an interview on 6/10/2025 at 9:33 AM Certified Nurse Aide #8 stated they were assigned to Resident #5 on 4/08/2025 day shift and they were not asked any questions for the investigation of Resident #5's bruised right eye. They stated they had not observed Resident #5 rubbing their eyes and did not know how the bruise was obtained. During an interview on 6/10/2025 at 9:46 AM Registered Nurse #3 stated they were notified by the Deputy Administrator #1 and Assistant Director of Nursing #1, Resident #5 had a bruise on their right eye and the nursing staff were identifying it as a purpura area and was directed to complete the Accident / Incident form and investigation. They stated the facility's process for investigating an injury of unknown origin is to interview all staff members assigned to the Resident's unit for the date the unknown injury is identified and the previous 24 hours to rule out abuse. They stated they believed the staff were aware of the area approximately one (1) week prior to Nurse Practitioner #2 determined it was a bruise / injury of unknown origin. They stated they picked the date 4/11/2025 and did not review the progress notes prior to 4/11/2025 and did not identify Registered Nurse #4 had documented on 4/08/2025 Resident #5 had a purpura area beneath their right eye. They stated they had not interviewed Registered Nurse #4 because they were no longer employed at the facility, and did not interview Certified Nurse Aide #6, #7, and #8 the assigned staff members for Resident #5 for the 24 hours prior to the documented purpura and they should have. They stated they did not complete a thorough investigation to rule out abuse. Additional interview attempts contact Registered Nurse #4, Nurse Practitioner #2, and Certified Nurse Aide #6 were not successful. During an interview on 6/10/2025 at 10:16 AM, Medical Director #1 stated they were not aware Registered Nurse #4 identified Resident #5 had a discolored area on their right eye on 4/08/2025 and would have expected Registered Nurse #4 to have notified a provider to assess the area and should not have diagnosed it as a purpura area. They stated they would have expected Director of Nursing #1 to have ensured a thorough investigation was completed by interviewing staff on 4/08/2025 and 4/07/2025 on the unit to rule out abuse and potentially determine how the injury of unknown origin occurred. During an interview on 6/10/2025 at 11:35 AM, Director of Nursing #1 stated they would have expected Registered Nurse #4 to have notified the provider on 4/08/2025 to assess Resident #5's discolored right eye and to have initiated an investigation. They stated Registered Nurse #3 should have reviewed the progress notes and completed a thorough investigation starting with staff scheduled on 4/08/2025. Upon review of the staff assignment sheets dated 4/08/2025 and 4/07/2025 they stated Certified Nurse Aide #6, #7, and #8 were assigned to Resident #5 and should have been interviewed and were not. They stated the facility did not complete a thorough investigation to rule out abuse. During an interview on 6/10/2025 at 11:56 AM, Administrator #1 stated they were not aware Registered Nurse #4 had documented Resident #5 had a purpura area beneath their right eye on 4/08/2025 and would have expected them to have notified a provider to complete an assessment and determine if the discoloration was a purpura area or bruise. They stated since Registered Nurse #4 had identified the discoloration of Resident #5's eye on 4/08/2025 they would have expected the facility investigation to have obtained statements or interviews from staff assigned to Resident #5 on 4/08/2025 and 4/07/2025. Upon review of the assignment sheets and the Accident Report of staff interviewed, they stated Certified Nurse Aide #6, #7, and #8 were assigned to Resident #5 and should have been interviewed and were not. They stated the facility did not complete a thorough investigation to rule out abuse. 1010 New York Codes, Rules and Regulations 415.4(b)(3)

Based on observation, interview and record review conducted during an Abbreviated survey (Compliant #NY00379178) completed on 6/10/2025, the facility did not ensure that all residents comprehensive person-centered care plans were implemented as planned, consistent with resident's rights and meet their preferences, goals and medical, physical, and psychosocial needs that are identified in the comprehensive assessment for one (1) (Resident #1) of three (3) residents reviewed. Specifically, the resident was not provided with two (2) staff members for incontinent care and bed mobility as care planned. This is evidenced by: The facility policy and procedure titled Care Planning revised date 5/2023 documented that residents will have a comprehensive person-centered care plan identifying resident ' s strengths, goals, life history and preferences in place to guide their care and Certified Nurse Assistant instructions provide detailed information and instructions to meet each resident ' s individual needs. Resident #1 had diagnoses including dementia with agitation, generalized anxiety disorder and major depressive disorder. The Minimum Data Set (a resident assessment tool) dated 4/11/2025 documented Resident #1 was cognitively severely impaired, rarely / never understood and rarely / never understands, does not exhibit behaviors of rejection of care, and is dependent and requires assistance of two (2) or more helpers for toileting hygiene (maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement) and requires assistance of two (2) or more helpers for bed mobility (roll from lying on back to left and right side and return to lying on back on the bed). The comprehensive care plan identified as current by the Director of Nursing documented at risk for skin breakdown as evidenced by decreased mobility and incontinence, interventions dated 7/01/2023 included toilet use required support of two (2) plus person physical assist, incontinent bowel and bladder and bed mobility support of two (2) plus person physical assist. The Certified Nurse Assistant Assignments Summary (a guide used by staff to provide care) identified as current by the Director of Nursing documented Resident #1 was incontinent and required two (2) plus person physical assist incontinent care and bed mobility. During an incontinence care observation on 6/04/2025 at 10:11 AM, Certified Nurse Aide #1 was observed to remove Resident #1 ' s soiled brief and provide incontinent care of feces and urine cleaning Resident ' s buttocks and peri area turning and positioning Resident #1 from back to right side, to back to left side while providing incontinent care and applied a clean brief turning and positioning Resident #1 without a second person assist. While being turned and positioned Resident #1 observed to intermittently state. ' hey, hey, hey. ' During an interview on 6/04/2025 at 1:50 PM, Certified Nurse Aide #1 reviewed Resident #1 ' s care plan and stated the care plan documented the resident required two (2) persons assist for incontinent care and bed mobility. They stated they did not ask for any assistance to provide the observed incontinent care and should have. They stated Resident #1 required two (2) persons assist for incontinent care and bed mobility because the resident was totally dependent and often has behaviors, therefore a second assist is for the resident ' s safety. During an interview on 6/04/2025 at 2:01 PM, Certified Nurse Aide #2 stated Resident #1 required two (2) persons assist for incontinent care and bed mobility because the resident was totally dependent and would have expected Certified Nurse Aide #1 to have asked for assistance and followed the plan of care. During an interview on 6/04/2025 at 2:10 PM, Licensed Practical Nurse #1 stated Resident #1 requires two (2) persons assist for incontinent care and bed mobility because the resident is totally dependent on staff and doesn ' t assist with turning and positioning. They stated it is for the resident ' s safety that two (2) persons provide the care and would have expected Certified Nurse Aide #1 to have asked staff for assistance and followed the plan of care. During an interview on 6/04/2025 at 2:24 PM, Registered Nurse #1 stated Resident #1 required two (2) persons assist for incontinent care and bed mobility because the resident was totally dependent on staff and did not assist with turning and positioning. They stated it was for the resident ' s safety that two (2) persons provided the care and would have expected Certified Nurse Aide #1 to have asked staff for assistance and followed the plan of care. During an interview on 6/04/2025 at 3:16 PM, Director of Nursing #1 stated care plans were developed based on resident needs. Upon review of Resident #1 ' s plan of care, they stated the resident required two (2) persons assist for incontinent care and bed mobility and would have expected Certified Nurse Aide #1 to follow the plan of care and have a second person assisting with the care provided. During an interview on 6/10/2025 at 12:13 PM, Administrator #1 stated they expected all staff to follow a resident ' s plan of care. 10 New York Code, Rules and Regulations 415.11 (c)(1)

Based on observation, interview and record review conducted during an Abbreviated survey (Compliant #NY00379178) completed on 6/10/2025, the facility did not ensure provision of a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (1) (Resident #1) of one (1) resident reviewed for infection control practices. Specifically, Resident #1 was on Enhanced Barrier Precautions (interventions designed to reduce transmission of multi-drug-resistant organisms including mask, gown and glove use during high contact resident care activities) and staff did not wear proper personal protective equipment while providing incontinent care of urine and feces. Additionally, the facility did not have transmission-based precaution policies to prevent the spread of infections, when and how isolation should be used for a resident; including but not limited to the type and duration of the isolation, depending upon the infectious agent or organism involved. This is evidenced by: The facility policy and procedure titled, Infection Control, revised 10/2024, documented the following: it is the policy of the facility to follow the Federal regulations, and the purpose is to adhere to principles and rules of infection control, to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. The Medical Director, Infection Control Nurse and Nursing Supervisors determine what procedures (such as isolation) should be applied to an individual resident. Control Specific Isolation is used by facility - see Specific Card(s) which explain what is to be used and for what purpose per Centers for Disease Control and Prevention (the national public health agency of the United States) recommendations. Preventing the spread of infection included, initiate appropriate isolation and/or control in a timely manner and *Enhanced Barrier Precautions per Centers for Disease Control and Prevention. *Note to reader: Enhanced Barrier Precautions is an infection control strategy that uses targeted gown and glove use during high-contact resident care activities to reduce the transmission of multidrug-resistant organisms; it is a supplement to standard precautions and existing isolation guidelines, aiming to reduce the spread of microorganisms that can cause infections. The facility specific card (signage) for Enhanced Barrier Precautions, documented everyone must clean their hands, including before entering and when leaving the room, providers and staff must also: Wear gloves and gown for the following high-contact resident care activities included dressing, providing hygiene, changing briefs or assisting with toileting. Resident #1 had diagnoses including dementia with agitation (a behavior change characterized by restlessness, excessive movement, and sometimes aggression, often triggered by changes in routine, environment, or cognitive decline), generalized anxiety disorder (a mental health condition characterized by excessive worry and anxiety about a wide range of everyday situations) and major depressive disorder (a mood disorder characterized by persistent low mood, loss of interest or pleasure in activities, and other symptoms that interfere with daily functioning). The Minimum Data Set (a resident assessment tool) dated 4/11/2025 documented Resident #1 was cognitively severely impaired, rarely / never understood and rarely / never understands, did not exhibit behaviors of rejection of care, and was frequently incontinent of bowel and bladder (having no or insufficient voluntary control over urination or defecation). Review of the comprehensive care plan identified as current by the Director of Nursing documented the following: Infection Control Precautions dated 9/04/2024 as evidenced by Multidrug-Resistant Organisms, extended-spectrum beta-lactamase-producing bacteria (these are bacteria that produce an enzyme that makes them resistant to certain common antibiotics) in urine. Documented interventions included staff to wear personal protective equipment per precaution card posted outside resident room. Review of the Physician Order Activity Detail Report for Resident #1 dated 4/01/2025 through 6/04/2025 documented the resident had extended-spectrum beta-lactamase-producing bacteria in urine and was on Enhanced Barrier Precautions as of 8/30/2024. During an observation on 6/04/2025 at 10:11 AM, an Enhanced Barrier Precaution signage was posted on the wall outside of Resident #1 ' s room under their name tag. A bin with personal protective equipment next to Resident #1 ' s room door included gloves and gowns. During an incontinence care observation on 6/04/2025 at 10:11 AM, Certified Nurse Aide #1 was observed to enter Resident #1 ' s room, apply gloves, and did not put on appropriate personal equipment (a gown). Certified Nurse Aide #1 then removed Resident #1 ' s soiled brief, provided incontinent care by cleaning Resident #1 of feces and urine, turned and positioned the resident during care, and applied a clean brief. At no time did Certified Nurse Aide don (put on) a gown as recommended by the Enhanced Barrier Precaution signage. During an interview on 6/40/2025 at 10:19 AM, Certified Nurse Aide #1 stated the Enhanced Barrier Precaution signage outside Resident #1 ' s room door - hanging beneath Resident #1 ' s name tag - meant staff were to wear gloves and a gown while providing any hands-on care to a resident who was on precautions in that room. They stated they did not know if Resident #1 was on precautions or if it was their roommate. They stated they would need to ask the charge nurse. During another interview on 6/04/2025 at 1:50 PM, Certified Nurse Aide #1 stated they were informed precaution signage for a particular resident was posted under the resident ' s nametag located on the wall outside the resident ' s room. They stated they were informed Resident #1 was on precautions related to their history of urinary tract infections, and that they should have worn a gown while providing care to Resident #1 to prevent cross contamination to their uniform and potentially cross contamination to other residents. During an interview on 6/04/2025 at 2:24 PM, Registered Nurse #1 stated Certified Nurse Aide #1 informed them they were not wearing a gown while providing incontinent care to Resident #1 during the observation this morning and they should have. They stated Resident #1 was on Enhanced Barrier Precautions related to history of urinary tract infections and has extended-spectrum beta-lactamase-producing bacteria in their urine and expected all staff to follow the precaution guidelines posted outside the resident ' s rooms for infection control purposes. During an interview on 6/04/2025 at 3:16 PM, Director of Nursing #1 stated Resident #1 was on Enhanced Barrier Precautions and would have expected Certified Nurse Aide #1 to have worn a gown while providing care for infection control purposes, to prevent the potential of cross contamination to other residents. They stated they would have expected Certified Nurse Aide #1 to know Resident #1 was on Enhanced Barrier Precautions because the signage was posted beneath Resident #1 ' s name outside the room. Director of Nursing #1 stated they did not have a specific facility policy and procedure for Enhanced Barrier Precautions, and that the facility did not have specific infection control policies and procedures for each type of transmission-based precaution such as airborne precautions, droplet precautions, and contact precautions. During an interview on 6/05/2025 at 10:18 AM, Deputy Administrator #1 stated the facility did not have specific infection control policies and procedures for each type of transmission precaution, such as contact precaution, airborne precaution, droplet precaution and Enhanced Barrier Precautions. They further stated the facility ' s Infection Control Program referred staff to follow the Centers for Disease Control guidelines for Enhanced Barrier Precautions. During an interview on 6/05/2025 at 10:50 AM, Registered Nurse #2 stated they were the facility ' s Infection Preventionist, and Certified Nurse Aide #1 should have been wearing a gown while providing care to Resident #1 because the resident was on Enhanced Barrier Precautions related to Multidrug-Resistant Organisms in their urine. They stated the requirement to wear a gown while providing care was to prevent any cross contamination to another resident. They stated the facility did not have an Enhanced Barrier Precaution Policy. Additionally, they stated the facility did not have specific infection control policies and procedures for each type of transmission-based precaution such as airborne precautions, droplet precautions, and contact precautions. During a phone interview on 6/10/2025 at 10:16 AM, Medical Director #1 stated they would have expected Certified Nurse Aide #1 to wear a gown while providing care to Resident #1 and follow the Enhanced Barrier Precautions procedure to prevent cross contamination for infection control. They stated they recall reviewing specific signage the facility uses to notify staff what type of personal protective equipment to wear depending on the type of precaution such as airborne precautions, contact precautions, droplet precautions and Enhanced Barrier Precautions, but did not recall reviewing specific policies for each transmission-based precaution. They stated they were not aware the facility did not have transmission-based precautions, when and how isolation should be used for a resident, including but not limited to the type and duration of the isolation, depending on the infectious agent or organism involved. During another interview on 6/10/2025 at 11:36 AM, Director of Nursing #1 stated they did not know why the facility did not have policies and procedures written for each transmission-based precaution to prevent the spread of infections and they had initiated a process to develop the policies and procedures. During an interview on 6/10/2025 at 12:13 PM, Administrator #1 stated they would have expected Certified Nurse Aide #1 to wear a gown while providing care to Resident #1 and follow the Enhanced Barrier Precautions procedure to prevent cross contamination for infection control. They stated they were not aware the facility did not have transmission-based precautions policies, including a policy for airborne precaution, droplet precaution, contact precaution, and enhanced barrier precaution. They stated they would have expected the Infection Control Preventionist Nurse and Director of Nursing #1 to have policies in place. 10 New York Codes, Rules and Regulations 415.19(a)(2)

Based on record review and interview during an abbreviated complaint survey (Case #NY00357407), the facility did not ensure personnels ability to provide emergency basic life support, including cardiopulmonary resuscitation (CPR), to residents requiring such care prior to the arrival of emergency medical personnel in accordance with the resident's advance directives and subject to related physician orders for one (Resident #1) of three residents reviewed. Specifically, the facility did not ensure Resident #1's advance directive status was known during a significant change in the resident's respiratory condition on [DATE]. The facility failed to initiate cardiopulmonary resuscitation in a timely manner for a resident that was a full code and was in cardiopulmonary arrest (a resident without a pulse or respiration). This resulted in Immediate Jeopardy Past Noncompliance for Resident #1 with the potential for serious harm to the health and safety of all residents in the facility and Substandard Quality of Care. This is evidenced by: The facility's policy titled, Cardiopulmonary Resuscitation, dated 5/2023 and updated on [DATE], documented the facility would provide emergency cardiopulmonary resuscitation with current standards of practice in accordance with resident end of life determination. Facility policy and procedure titled, resident identification for CPR, revised 10/2024, documented that the facility would identify all residents who had chosen cardiopulmonary resuscitation (CPR) by a resident wearing a green wristband alert bracelet. Additionally, residents who were to be given CPR would have a lime green sticker on their care plan, inside of their wardrobe, and on the spine of their chart indicating 'resuscitate.' The resident's name plate outside of their door would be printed on green paper, and the resident's electronic health record would include a lime green heart with a green box with an 'R' inside. Resident #1 could sometimes understand and was sometimes understood by others with severely impaired cognition for daily decision making. Resident #1's advance directive status was a full code. Resident #1 Medical Orders for Life Sustaining Treatment (Molst, a medical order form that allows patients to specify which treatments they want or don't want at the end of their life), dated [DATE], documented the resident wanted the facility to attempt cardiopulmonary resuscitation (CPR) when the resident was found with no pulse and or was not breathing. Resident #1's advance directive dated [DATE] documented the resident was a full cardiopulmonary resuscitation. Orders stated attempt cardiopulmonary resuscitation, check medical alert bracelet every shift, trial mechanical intubation. Review of facility Incident and Accident report initiated [DATE] and review of corresponding times on facility video that captured view of the hallway of the resident floor documented the following: - Incident: Treatment ordered but not administered. - Incident reason: Failure to identify resident. - Description: Delayed care. - Measures to Prevent Recurrence: Staff education on resident code status and protocol. - Licensed Practical Nurse #1 found Resident #1 unresponsive in their room on [DATE] at 5:36 PM, and called Registered Nurse #1 to the room. - On [DATE] at 5:37 PM, Registered Nurse #1 arrived on the floor and both Licensed Practical Nurse #1 and Registered Nurse #1 went back into Resident #1's room. Registered Nurse #1 assessed the resident's vital signs for 60 seconds and made the determination that the resident had expired. - Registered Nurse #1 statement read in part, 'Upon arrival to unit on an unrelated matter regarding staffing the nurse on duty reported to me that the resident had expired. The resident was assessed via auscultating for heart and lung sounds which were noted as not present for 60 seconds. There was no palpable pulse noted to left wrist as well. Skin color was observed as mottled and skin was cool to touch. The process for discharging resident including making family, coroner, and funeral home aware was initiated. Upon completion of that process and review of resident chart, resident code status was observed as full code and cardiopulmonary resuscitation was initiated with no positive effect.' - Licensed Practical Nurse #1 statement read in part, 'Registered Nurse #1 assessed the resident and stated, the resident is gone. We both went into the office and Registered Nurse #1 stated they would take care of everything. I said OK, let me know what else I need to do. I went back to the medication cart and finished passing medications.' - On [DATE] at 5:42 PM, Registered Nurse #1 left the unit. - On [DATE] between 6:15 PM and 6:20 PM, Registered Nurse #1 went to the nurse supervisor office and stated to Registered Nurse #2 and #3 that Resident #1 had passed away. Registered Nurse #3's statement read in part, 'this writer responded by stating [to Registered Nurse #1] that the resident was a full code and needed cardiopulmonary resuscitation (CPR), I then learned CPR had not been started. At this time, [Registered Nurses] went to the unit to initiate CPR while supervisor Registered Nurse #1 went to get the Medical Director who was in house in their office. Upon entering [Resident #1's] room, upon assessment, resident was laying in bed with no pulse and absent of respirations, compressions were then started around 6:25 PM, approximately 5 rounds of CPR given. Resident was absent of all vital signs. Medical Director gave permission to stop CPR around 6:35 PM and resident was pronounced at approximately 6:40 PM. Director of Nursing #1 notified shortly after.' Review of a facility memorandum statement by Director of Nursing #1 on [DATE] at 9:32 AM documented the following: - At the time of the incident, Licensed Practical Nurse #1 informed Director of Nursing #1 that they knew Resident #1 was a full code. Licensed Practical Nurse #1 stated that they told Registered Nurse #1 that the resident was a full code and hold compression be stated and a Code Blue be called overhead. It was stated that Registered Nurse #1 would handle it. Registered Nurse #1 then went to nursing supervisor's office where Registered Nurses #2 and #3 questioned what was going on. Registered Nurse #1 told them a resident passed away and was a Full Code. [When questioned] why a Code Blue was not called overhead, Registered Nurse #1 stated that the resident was already dead. Registered Nurses #2 and #3 told Registered Nurse #1 that a Code Blue should have been initiated, to call the provider and they both went up to the unit and started cardiopulmonary resuscitation (CPR) compression, while Registered Nurse #1 called Medical Director #1 who came up and pronounced the resident deceased around 5:45 PM. During an interview on [DATE] at 2:14 PM, Licensed Practical Nurse #1 stated they had given Resident #1 a nebulizer treatment on [DATE] around 5:00 PM, and when they went back to discontinue the treatment, the resident was unresponsive. They then informed Registered Nurse #1, who was coming on the unit. Registered Nurse #1 went to the room and assessed the resident, then stated Resident #1 expired. Licensed Practical Nurse #1 asked Registered Nurse #1 if they needed to do anything and was told Registered Nurse #1 would take care of everything. They stated that it wasn't until Registered Nurse #1 left the unit that Licensed Practical Nurse #1 checked the chart at approximately 5:50 PM and realized Resident #1 was a full code. They stated they were getting ready to call another Registered Nurse Supervisor when Nurse Supervisors arrived on the unit, called a code, and started cardiopulmonary resuscitation (CPR) on Resident #1. Licensed Practical Nurse #1 stated the attempt was not successful. Licensed Practical Nurse #1 further stated that there was 'a considerable time lapse' between when the resident was found unresponsive and when the code was called; the code should have been called immediately when the resident was found unresponsive. They stated that both Registered Nurse #1 and Licensed Practical Nurse #1 should have done that and should have checked the resident's chart for the advanced directives, but the resident was deceased . Licensed Practical Nurse #1 stated that they had been suspended from the facility pending the outcome of an investigation because they hadn't followed the policy and procedure on Advanced Directives. During an interview on [DATE] at 4:30 PM, Registered Nurse #2 stated Registered Nurse #1 never called the code [for cardiopulmonary resuscitation] for Resident #1 when they identified the resident was unresponsive on [DATE]. They reported to both Registered Nurses #2 and #3 that they had just discovered the resident was a full code and should have initiated cardiopulmonary resuscitation (CPR). Upon hearing of the incident, Registered Nurses #2 and #3 supervisors went to the unit, found the resident unresponsive, and initiated the code. They stated that the resuscitation attempt was unsuccessful, and Director of Nursing #1 and Administrator #1 were notified; both responded to the building. They further stated that Medical Director #1 was at the facility and pronounced Resident #1 deceased at approximately 6:57 PM. They further stated that the procedure for finding a resident unresponsive was to identify whether the resident was a full code or 'do not resuscitate;' once they identify the resident is a full code, staff were to call a code on overhead pager with room number for code team to respond; 911 would be called and the physician would be notified. Registered Nurse #1 stated residents have a green band on that identify them as a full code, and Resident #1 had the band on, so Registered Nurse #1 should have identified the resident as a full code; no delay should have occurred. During an interview on [DATE] at 3:29 PM, Registered Nurse #1 stated the following: - On [DATE] at around 5:50 PM, they were informed by Licensed Practical Nurse #1 that Resident #1 had expired. Registered Nurse #1 reported they had just given the resident Intravenous fluids (IV) and the resident was alert and responsive. Upon going to Resident #1's room, Registered Nurse #1 assessed the resident for 60 seconds and determined the resident was deceased . Registered Nurse #1 called the family and informed them the resident had expired and then called the funeral home and left the unit. Once they began to put in a nursing note and call the physician, they realized the resident had been a full code and should have had cardiopulmonary resuscitation (CPR). They reported this to two Registered Nurse Supervisors [Registered Nurse #2 and #3] who immediately went to the unit and called a code and initiated cardiopulmonary resuscitation. Registered Nurse #1 went to the Medical Director, who was still in the building, and informed them that the resident had been a full code, and the code had not been started because the resident was found without pulse or respiration by Licensed Practical Nurse #1. The physician then called the code. When the resuscitation attempt was unsuccessful, and the physician pronounced Resident #1 deceased , Director of Nursing #1 suspended Registered Nurse #1 for not initiating cardiopulmonary resuscitation when they became aware the resident was unresponsive because Resident #1 was a full code. Licensed Practical Nurse #1 had not called a code and told Registered Nurse #1 the resident was deceased . Registered Nurse #1 stated they followed their nursing judgement and had been trained on Basic Life Support. They further stated they hadn't realized until after being told by Licensed Practical Nurse #1 the resident was deceased that Resident #1 was a full code and by then they had left the unit. During an interview on [DATE] at 9:00 AM, Director of Nursing #1 stated the following: - Both Licensed Practical Nurse #1 and Registered Nurse #1 were suspended. - Both Licensed Practical Nurse #1 and Registered Nurse #1 were aware Resident #1 was a full code and neither initiated cardiopulmonary resuscitation upon finding Resident #1 unresponsive. - The resident was found unresponsive on [DATE] at 5:36 PM by Licensed Practical Nurse #1, who notified Registered Nurse #1 at 5:37 PM. Registered Nurse #1 then assessed the resident for 60 seconds and determined the resident was deceased . The medical provider was not notified, and no resuscitation was started. - Licensed Practical Nurse #1 disagreed with Registered Nurse #1's findings and felt cardiopulmonary resuscitation should have been started but did not take any action. -Registered Nurse #1 left the unit, went to the nursing office, and did not initially inform any other supervisor or the physician that the resident was deceased . - Re-education for all staff for resuscitation following medical orders and assessment was started facility wide. During an interview on [DATE] at 3:01 PM, Medical Director #1 stated Registered Nurse #1 came to their office on [DATE] at approximately 6:30 PM and said Resident #1 had expired and had been a full code. Medical Director #1 stated they were still in the building doing charting and hadn't heard the code called. Registered Nurse #1 said a code wasn't called because the resident wasn't breathing when the Licensed Practical Nurse #1 came to them and said the resident was found unresponsive and they weren't aware the resident was a full code; as of result, other nurses went to the room and started cardiopulmonary resuscitation (CPR) and called 911. They further stated that Registered Nurse #1 had not followed protocol by pronouncing the resident, calling the family and the funeral home prior to advising the Medical Director of what had taken place. Medical Director #1 stated Cardiopulmonary Resuscitation (CPR) was performed for 15 minutes before it was discontinued, and Resident #1 was pronounced dead. During an interview on [DATE] at 9:15 AM, Administrator #1 stated the following: - Licensed Practical Nurse #1 and Registered Nurse #1 were being terminated for not following facility policy and procedure and physician's orders. - Staff education was ongoing. Staff that were unavailable or per diem status had been contacted by phone or email to report for in service prior to beginning their shift. Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement at the time of this survey: 1. Beginning on [DATE] at 7:00 PM, both Director of Nursing #1 and Administrator #1 responded to the facility when informed of Resident #1 death. Cardiopulmonary Resuscitation (CPR) reeducation was begun with all facility staff. This included all departments and was completed with 100 percent of staff throughout the building on [DATE]. This included the following units: Nursing, Dietary, Maintenance, Housekeeping, Security, and Administrative Personnel. 2. Education with Power Point on Policy and Procedure for Cardiopulmonary Resuscitation with post-test requiring 100 percent score. All staff from all departments had post-test completed on [DATE]. 3. Reeducation done on the spot for anyone unable to verbalize education on cardiopulmonary resuscitation (CPR) and how to identify 'full code' or 'do not resuscitate' status for residents during mock codes until 100 percent was achieved; completed on [DATE]. 4. Two mock codes blue drills conducted beginning from [DATE] to [DATE]. 5. Mock codes were scheduled to be performed weekly for 4 weeks and monthly for 4 months. 6. Facility Quality Assurance reviewed for improving cardiopulmonary resuscitation (CPR) education with updating of the policy and procedure and orientation of all staff on hire. 7. Reeducation of all staff on how to identify residents' status on Advanced Directives was completed on [DATE] by 9:00 AM. 8. Reeducation of all staff on reporting other staff if policy and procedures are not followed by Supervisors or staff was completed on [DATE] by 9:00 AM. 9. Beginning on [DATE] at 7:00 PM, 100 percent facility-wide education on cardiopulmonary resuscitation was completed on all facility staff before beginning their shift; completed on [DATE] by 9:00 AM for all staff prior to providing resident care on units. 10. By [DATE] at 9:00 AM, 100 percent of all staff had been notified by phone or email to report for reeducation and in-servicing on policy changes with cardiopulmonary resuscitation before beginning their shift and completing posttest required with a score of 100 percent. 11. Reporting to New York State Department of Health completed within regulation. 12. Facility investigation of the incident with Resident #1 and staff failure to follow advanced directives and start cardiopulmonary resuscitation (CPR) began on [DATE]. Investigation was completed and ready for review on [DATE] at 9:00 AM. 13. Licensed Practical Nurse #1 removed from resident care on [DATE] and suspended pending outcome of the investigation on failure to institute cardiopulmonary resuscitation (CPR) to Resident #1. 14. Registered Nurse #1 removed from resident care on [DATE] and suspended pending outcome of the investigation on failure to institute cardiopulmonary resuscitation to Resident #1. 15. Immediate Jeopardy Template signed by Director of Nursing #1 and Administrator #1 on [DATE] at 7:00 PM. 10 New York Codes, Rules and Regulations 415.3 (e)(2)(iii)

Based on record review and interviews, during a recertification survey, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #59) of 3 residents reviewed for hospitalization s. Specifically, for Resident #59, the facility failed to follow the Nurse Practitioner's readmission plan for the resident to have a Foley catheter (a tube inserted into the bladder to drain urine). The facility failed to notify the physician/nurse practitioner (NP) on multiple occasions for directions based on condition changes related to the resident's Foley catheter and urinary status, and did not obtain a urine specimen timely to determine the presence of an infection. urologisThis resulted in a hospitalization in the ICU for urosepsis (a disease that is caused by an infection in the urinary tract involving of an accumulation of pus-forming bacteria or their toxins in the blood of the urinary tract) acute urinary retention and septic shock (dramatic drop in blood pressure that can lead to severe organ problems and death). This resulted in actual harm that is not immediate jeopardy. This is evidenced by: Resident #59: Resident #59 was readmitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 11/22/20, documented the resident's cognition could not be assessed, required extensive assistance with toileting, had an indwelling urinary catheter, and was diagnosed with BPH (bilateral prostatic hypertrophy - prostate gland enlargement) a condition in which the flow of urine is blocked due to the enlargement of prostate gland) and [CONDITION(S)] (a condition where urine flow has been partially or completely blocked). A consult form from the urologist dated 8/24/2020, documented that Resident #59 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The urologist's assessment documented the resident would need a Foley catheter if the resident was unable to empty his bladder. The Policy and Procedure (P&P) Change in Condition reviewed 2/17 documented the MD/NP (Medical Doctor/Nurse Practitioner) will be notified when there is a change in a resident's condition. The resident will be treated based on the findings of the MD/NP's evaluation and treatment orders. The resident's care plan will be modified to reflect any new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Hospital Transfer Discharge Summary dated 11/15/20 documented Resident #59 was admitted to the hospital for COVID-19 and had urinary retention. A NP readmission note dated 11/16/20, documented Resident #59's assessment and plan included BPH (prostate gland enlargement common condition as men get older that can cause uncomfortable urinary symptoms, such as blocking the flow of urine out of the bladder and bladder, urinary tract or kidney problems) with a plan to follow up with the urologist for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A voiding trial (assesses the bladders ability to empty) would be completed next week. Finding #1 The facility failed to notify the physician/nurse practitioner on multiple occasions to obtain direction regarding the resident's Foley catheter and the development of urinary symptoms. The P&P titled Catheters reviewed 3/2020, documented that catheters would be used to manage urinary continence, collect a urinary specimen and manage retention. It documented to obtain an MD order for the catheter including the type, size, frequency of changing and any other treatments. The Policy for Suspected UTI (urinary tract infection) Protocol dated revised 9/2016 documented that residents will be monitored for UTI's. The Protocol's Purpose documented; To provide prompt and effective treatment that can be started as soon as possible to maintain the resident's optimal health and well-being, prevent complications and negative medical outcomes. It documented a list of the symptoms of a UTI (Temp >100 or Chills, Flank or suprapubic pain, Change in behavior/mental status, Change in urine color, Change in urine odor, Change in continence, Frequency, Urgency, and Burning) and directions to initiate the Protocol if there is evidence of the symptoms of a UTI. It documented that the physician/nurse practitioner will be notified if there is evidence of a change in a resident's condition or onset of acute UTI. It also documented a care plan would be developed based on history: indwelling catheters, poor fluid intake and incontinence. Nursing Notes (NN) documented; - 11/16/2020 at 2:49 PM, the resident was readmitted to the facility with a Foley catheter inserted for urinary retention. - 11/16/2020 at 7:48 PM, the resident had a Foley catheter in place, and it was draining dark urine. - 11/16/2020 at 10:21 PM, the Foley catheter was clogged and leaking and the supervisor was made aware. It documented the resident would be monitored for voiding without a Foley catheter. The medical record did not include documentation that the physician/Nurse Practitioner were notified for direction when the resident's foley clogged and was removed and that the urine was foul smelling on 11/16/2020. Nursing Notes documented: - 11/16/2020 at 10:44 PM, Urine foul smelling will put on a UTI PROTOCOL, Symptoms checked for change in urine odor. The interventions for increase fluids, add to I&O (intake and output) and vital signs (VS) were checked. Evaluate for 24 hours. If symptomatic obtain order for UA/C&S (urinalysis/culture and sensitivity) from MD. -11/17/2020 at 6:20 AM, UTI PROTOCOL- no symptoms checked, Interventions for increase fluids and VS were checked. ASK MD for UA/C&S if 3 symptoms checked or 2 symptoms checked with catheter. Day 1/7 Readmit, UTI Protocol - Resident c/o (complaints of) general discomfort. Resident given Tylenol 650 mg po (orally) prn (when needed) with a positive effect. Resident asleep at this time. Evaluate for 24 hours. If symptomatic obtain order for UA/C&S from MD. - 11/17/2020 at 11:19 AM, documented the Registered Nurse spoke to the MD via telehealth for the resident's readmission and no new orders were received. A MD Note dated 11/17/20 at 11:41 AM, documented the resident was seen via telemedicine and had issues with urinary retention while hospitalized . It documented while hospitalized the resident had a failed voiding trial and required a Foley catheter to be placed. The MD's plan documented - to continue use of the Foley catheter due to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing Notes documented; - 11/17/2020 at 1:58 PM, UTI PROTOCOL - Symptoms checked for urgency: ASK MD for UA/C&S if 3 symptoms checked or 2 symptoms checked with catheter. Interventions for increase fluids and VS. Evaluate for 24 hours. If symptomatic obtain order for UA/C&S from MD. Day 2/7 Readmission. Resident continues to ring for the bathroom excessively and doesn't go. Resident denies dysuria (pain in urination) when he does go and is afebrile. No need for a UA C&S. The NN documented the resident had complaints of urgency and continued to ring for the bathroom excessively and doesn't go, - 11/18/2020 at 3:10 PM, the resident continued to ring the bell for the bathroom and no urination evident, - 11/19/2020 at 1:42 PM, the resident frequently requested toileting, had urgency and went a couple of times, - 11/22/2020 at 1:40 PM, documented the resident complained of feeling tired since hospitalization and required increased assistance with ADL's, - 11/26/2020 at 1:59 PM, the resident refused to get OOB (out of bed) and had a poor appetite and, - 11/27/2020 at 10:49 PM, the resident had his call light on every 15 minutes and could not recall if someone had changed his brief. It documented the brief was dry. -11/29/2020 at 4:44 AM, resident continuously ringing stating he needs to be changed resident dry most of the time resident 11/30/2020 at 6:16 AM, resident asymptomatic at this time. No c/o pain/discomfort noted. No sob(short of breath)/respiratory distress. Resident ringing excessively during shift. - 12/1/2020-12/6/2020, NN did not include information regarding the resident's urinary status. - 12/7/2020 at 2:24 PM, the resident had foul green smelling discharge from his penis and the UTI protocol was initiated; UTI PROTOCOL, there were no symptoms checked. ASK MD for UA/C&S if 3 symptoms checked or 2 symptoms checked with catheter, the intervention for VS was checked, Evaluate for 24 hours. If symptomatic obtain order for UA/C&S from MD. - 12/8/2020 at 4:17 AM, UTI PROTOCOL, there were no symptoms or interventions checked, ASK MD for UA/C&S if 3 symptoms checked or 2 symptoms checked with catheter: Evaluate for 24 hours. If symptomatic obtain order for UA/C&S from MD. No drainage noted coming out of penis at this time. - 12/8/2020 at 1:01 PM, the resident had a scant amount of foul smelling green penile discharge and continued to have foul smelling urine; - 12/8/2020 at 10:57 PM, the resident complained of a burning sensation when urinating. - 12/9/2020 at 10:54 PM, Day 1/7 unit change. Unable to obtain UA and C&S specimen at present. No c/o voiced. Review of the medical record from 12/7/2020 - 12/8/2020 did not include documentation that the MD/NP was notified of the foul-smelling green discharge, foul smelling urine, or the resident's complaint of burning with urination. A NP note dated 12/9/2020 at 12:16 PM, documented the resident complained of burning with urination, malodorous urine, and green penile discharge. It documented a UA (urinalysis) C&S (culture and sensitivity) was ordered and staff would attempt to obtain this today. Nursing Notes documented: - 12/12/2020 at 2:50 PM, the resident was incontinent of green colored foul-smelling urine. A catheterization to obtain a urine sample was attempted and unsuccessful; - 12/12/2020 at 3:53 PM, a urine sample was obtained; - 12/14/2020 at 6:42 AM, the resident was awake all shift and ringing call bell every 5-10 minutes requesting to be changed although he was dry; - 12/14/2020 at 7:45 PM, the resident requested to be changed multiple times throughout the shift, however the resident was dry; - 12/15/2020 at 7:48 PM, the resident frequently rang bell to be changed, even when he hasn't voided; - 12/17/2020 at 5:52 AM, the resident frequently ringing bell every 15 minutes throughout entire shift requesting to be changed. It documented the resident was incontinent 2 times and the resident would continue to be monitored; - 12/17/2020 at 3:20 PM, the resident requested to be changed throughout the entire shift and was incontinent 2 times and; - 12/18/2020 at 2:13 PM, the resident asked to be changed minutes after being changed, and resident's briefs were dry when checked. A review of the medical record dated 12/10/2020 - 12/18/2020 did not include documentation that the MD/NP were notified about the resident's complaints or ongoing requests to be changed or difficulty with urination. Nursing Notes documented; - 12/18/2020 at 8:04 PM, urine culture results were received, the MD was notified and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] - 12/18/2020 at 11:27 PM, the resident received [MEDICATION(S)] (antibiotic) for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] - 12/22/2020 at 1:30 PM, Medical Note documented: Called to unit to see resident because he lost consciousness on the toilet. Per staff he was having a BM when he began bleeding from his penis. When I entered resident's room staff was using lift to bring resident to bed. Resident slowly regained consciousness and denied pain. Vital signs per nurse's note. Resident was hypotensive and [CONDITION(S)]. Requesting water. Blood clot noted at tip of penis. Resident was resting comfortably in bed when staff left his room. Medication to hold: [MEDICATION(S)], due to bleeding. New order to monitor vital signs q 2 hours, when not sleeping x 12 hours. - 12/22/2020 at 2:25 PM, NN documented; Call to room and found resident unresponsive on toilet. Resident was transferred back to bed, noted to have blood coming from genitals with clots evident, flushed (red) T98.6. Oxygen placed for comfort at 3L O2 stat (oxygen saturation) 96%, R 26, breathing heavily states that he has no difficulty breathing, states no pain but wants to urinate but is unable to. His brief continues to have blood clots. Supervisor and Nurse Practitioner present. VS 68/42, 98.6, 104, 20, 97%. - 12/22/2020 at 8:33 PM, NN documented; Was called to the unit, resident hypotensive and temperature of 101.3, resident lethargic during assessment, call placed to HCP (health care proxy) and MD who were updated with change in condition, order obtained and in agreement with sending resident to the (named) hospital for evaluation, VS: 101.3, 80, 20, 93% 3L, 60/44. A Hospital Discharge Summary dated 12/31/20 documented Resident #59 was admitted to the hospital on 12/22/20 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had altered mentation due to [CONDITION(S)]. The resident was treated with IV (intravenous) medications for the septic shock and infection, kidney function improved with stabilization of the resident's blood pressure, and a Foley catheter was placed for urinary retention. Finding #2 The facility did not ensure a urine for urinalysis and culture and sensitivity ordered by the NP on 12/9/2020 was obtained in a timely manner. A NP note dated 12/9/2020 at 12:16 PM, documented a UA (urinalysis) and C&S (culture and sensitivity) was ordered and the staff would attempt to obtain this today. A laboratory activity report dated 12/12/2020 documented a urine specimen collection date of 12/12/2020 for a UA C&S was obtained at 3:45 PM. A document titled, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders documented a straight catheter could be used as needed for urinary retention. It documented an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . It documented on 12/14/2020 at 8:45 AM, the order was renewed to perform straight catheterization for urinary retention. Nursing Notes documented: - 12/09/2020 at 01:11 PM, the resident needed a UA C&S and it was unable to be obtained; - 12/10/2020 at 01:29 PM, unable to obtain UA and C&S at that time; - 12/11/2020 at 10:55 PM, unable to obtain UA and C&S, resident incontinent of urine; - 12/12/2020 at 04:21 AM, unable to obtain UA and C&S as resident was incontinent of urine and; - 12/12/2020 at 2:50 PM, a catheterization to obtain a urine sample was attempted and was unsuccessful and; - 12/12/2020 at 3:53 PM, a urine sample was obtained. Review of the medical record from 12/9/20 through 12/12/2020 at 2:50 PM did not include documentation that the MD/NP were notified that the UA C&S ordered on 12/9/2020 was not obtained. On 12/22/2020 at 8:33 PM, Resident #59 was sent to the hospital and was admitted to the Intensive Care Unit (ICU) for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interviews: During an interview on 4/2/2021 at 11:01 AM, Registered Nurse Unit Manager (RNUM) #3 stated the resident should have a care plan in place for urinary retention and the discontinuation of a Foley catheter. The expectation was that the care plan would be updated upon arrival to the facility or the unit within 24 hours of transfer. RNUM #3 stated the resident should have been monitored and assessed for urinary retention and this should have been documented in the medical record. RNUM #3 stated the expectation was when a resident returned to the facility with a Foley catheter, an order would be obtained, and the MD would be notified immediately if the catheter became clogged or leaking to obtain orders to provide care and services to the resident. RNUM #3 stated when the resident was transferred to her unit on 12/9/20 she was unaware of the resident's history of urinary retention or that a Foley catheter was removed at the facility. She stated the MD/NP should have been contacted when the resident had green foul-smelling drainage from his penis. RNUM #3 stated when a UA and C&S was ordered, the expectation was to obtain a urine sample within 24 hours of the order and if unable to be obtained, a straight catheterization would be completed per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she was unsure why the MD/ NP was not made aware or why a straight catheterization was not completed. During an interview on 4/2/2021 at 2:15 PM, Licensed Practical Nurse (LPN) #10 stated the expectation was when a resident arrived to the facility with a Foley catheter without an order, the MD/NP would be made aware and orders would be obtained. LPN #10 stated prior to removing a catheter for being clogged or leaking, the MD/NP should be made aware and orders received. LPN #10 stated when a Foley catheter was removed a resident should be monitored for abdominal distension or discomfort, the amount, color and odor of urinary output and complaints of discomfort or the inability to urinate made by the resident. She stated monitoring after the discontinuation of a urinary catheter should be documented in the medical record and reported to the physician. LPN #10 stated if a resident had green foul-smelling drainage from his penis, she would report this to the MD/NP. She stated when a UA and C&S was ordered and unable to be obtained, she would catheterize the resident per the MD orders. During an interview on 4/2/2021 at 2:18 PM, NP #1 stated when a resident returned to the facility from the hospital they were assessed and evaluated by a MD or NP. NP #1 stated the nursing staff should have requested an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She would expect nursing to have informed the telehealth physician on 11/17/2020 that the Foley catheter had been removed and requested further instructions for urinary retention care. NP #1 stated she would expect the resident to be monitored closely for urinary retention and this should be documented in the medical record and any symptoms of urinary retention should have been reported to the MD/NP. NP #1 stated she expected the MD/NP to be notified immediately of green foul-smelling drainage from the penis and that the resident should not have been placed on the UTI protocol in place of contacting the MD/NP. NP #1 stated she expected the nursing staff to obtain a UA and C&S within a few hours of the order being placed, secondary to the resident's history of urinary retention and symptoms. During an interview on 4/2/2021 at 3:32 PM, the Medical Director stated when a resident was admitted to the facility with a Foley catheter and documented urinary retention, the catheter should not have been removed. The Medical Director stated the MD/NP should have been notified the catheter was removed and would expect symptoms to be monitored due to the resident's urinary incontinence . She stated the symptoms that should be monitored and recorded were abdominal distension, change in urine odor, frequency and or urgency of urination. The Medical Director stated she would have expected the MD/NP be notified of green foul-smelling drainage from the resident's penis as well as the resident's urgency and difficulty with urination. She would have expected the resident to be catheterized to obtain the UA C&S after 24 hours of the order being placed, and the MD/NP should have been notified if the sample was unable to be collected. The Medical Director stated the lack of communication with the physician's definitely lead to the resident's UTI. 10 NYCCR 415.12

Based on observation, record review and interviews during abbreviated surveys (Case #s NY 675 and NY 686), the facility did not ensure residents' right to be free from abuse for 2 (Residents #s 3 and 2) of 3 residents reviewed for abuse. Specifically, on 2/23/19 the facility did not ensure Resident #3, who had severe cognitive impairment, was free from sexual abuse when she was assaulted by Resident #4 who had moderately impaired cognition. Additionally, on 3/14/19 the facility did not ensure Resident #2, who was cognitively intact, was free from sexual abuse when she was assaulted by Resident #1, who was also cognitvely intact. Due to Resident #2's inability to express her feelings during an interview on 10/4/19, and Resident # 3's severe cognitive impairment and inability to express her feelings, it was determined that actual harm occurred as a result of the assault, using the reasonable person concept referenced in Appendix Q of the State Operations Manual. This is evidenced by: The Policy and Procedure for Abuse dated 5/2017 documented that all residents had the right to be free from sexual abuse including resident to resident incidents. Finding 1: Resident #3: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident had severely impaired cognition, could usually understand others and could usually make herself understood. Resident #4 was last admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 3/1/19 documented the resident had moderately impaired cognition, could sometimes make himself understood and could sometimes understand others. The Comprehensive Care Plan (CCP) dated 12/7/17 documented Resident #3 was a victim of resident to resident sexual abuse. The care plan was updated on 2/23/19 and documented the resident was inappropriately touched by Resident #4. The Accident/Incident Report dated 2/23/19 documented Resident #4 was witnessed by Dietary Aide (DA) placing his hand down Resident #3's shirt. Nurses Notes dated 2/23/19 through 3/2/19 documented Resident #3 was monitored after the incident involving Resident #4 and no ill effects noted. Resident #3 did not recall the incident. During an Interview on 10/21/19 at 11:54 AM the DA stated she witnessed Resident #4 with his hand down Resident #3's shirt. She intervened and told Resident #4 to stop, then reported the incident to nursing. During an interview on 10/4/19 at 2:00PM Registered Nurse Unit Manager (RNUM) #1 stated Resident #4 had socially inappropriate behavior since admission on 3/23/18. CCPs were in place for Resident #4 because of his history of wandering and masturbating in the dining room. RNUM#1 stated (MONTH) 23, 2019 was the first time Resident #4 displayed sexual behavior with Resident #3. During an interview on 10/4/19 at 3:52PM the Director of Nursing (DON) stated the facility was unaware of Resident #4's behaviors when he was admitted because they were not identified on the Patient Review Instrument (PRI). The DON also stated Resident #3 was assessed after the incident and there was no injury and Resident #3 did not recall the incident. Finding 2: Resident #2: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident was cognitively intact, could usually make herself understood and usually understood others. Resident #1: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident was cognitively intact. The Comprehensive Care Plan (CCP) for Resident to Resident abuse dated 10/5/18 documented Resident #2 may have been inappropriately touched by Resident #1. The CCP was updated on 3/14/19 for Resident to Resident victim of opportunity by Resident #1. An Accident and Incident Report dated 3/14/19 documented Resident #s 1 and 2 were sitting in the TV lounge when a Physical Therapist Assistant (PTA) witnessed Resident #1 put his hand down Resident #2's shirt. The residents were separated to different TV lounges by the PTA and Licensed Practical Nurse (LPN) #1. Resident #1 stated he was sorry, and Resident #2 denied pain or injury but stated she felt afraid when the incident occurred. Nursing Notes dated 3/14/19 through 3/29/19 documented staff monitored Resident#1's behavior and his proximity to Resident #2 for 6 shifts. Resident #1 continued to be monitored for behavior, was started on an antidepressant, and was moved to a different unit. The CCP for Resident to Resident Aggressor potential dated 10/5/18 was initated for Resident #1, and updated on 3/14/19 as actual Aggressor. During an interview on 10/21/19 at 11:33AM LPN #1 stated he witnessed Resident #1 putting his hand inside Resident's #2's shirt and he helped to separate the two residents. During an interview onn 10/4/19 at 3:45PM Resident#2 was unable to express her thoughts, which was consistent with the 8/9/19 MDS which identified the resident as having severely impaired cognition. During an interview on 10/4/29 at 3:52PM the DON stated Resident #2 had difficulty communicating and it was difficult to know how she was feeling. Immediately after the incident with Resident #1 she stated she was afraid, but Resident #2 no longer seemed to recall the incident. 10 NYCRR 415.4(b)(1)(i)

Based on record review and staff interview, during the abbreviated survey (Case #NY 033), it was determined that for 1 (#1) of 7 residents reviewed, the facility did not ensure that the resident environment remained as free of accident hazards as possible and each resident receives adequate supervision and assistance devices to prevent accidents. Specifically, the facility did not ensure that the resident was assessed/reassessed for the safe use of Posey rolls on her bed, and did not ensure that a concave mattress was in place as care planned for. Subsequently the resident fell from bed and sustained fractures. This is a repeat deficiency from the recertification survey dated 3/15/11. This resulted in actual harm that was not immediate jeopardy. This was evidenced by: Resident #1: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident to have moderately impaired cognition, and required a one person extensive assistance with transferring. It was also documented on the MDS that the resident had dementia. The physician's Physical Examination Form dated 12/28/10, documented that the resident had a clinical [DIAGNOSES REDACTED]. The Resident Care Plan (Care Card), which the Certified Nursing Assistants (CNA) used to know what care this resident required, and dated 10/19/11, documented that the resident's bed was to have a concave mattress and Posey roll guards (tube-shaped pads which created an elevation along the edge of the mattress used to prevent rolling out of bed). The right side of the bed was to be against the wall. The Comprehensive Care Plan (CCP) for "Risk for Falls", dated 1/2/11, did not list Posey roll guards as an intervention. The CCP titled "Actual Falls" documented the the Interdisciplinary Team (IDT) met on 9/28/11 and reviewed the resident's care plan. Documented additions to the CCP included chair alarm with Dycem. On 10/18 the IDT met again and reviewed the resident's CCP. Additions documented to the CCP included landing mat to the left side of the bed, do not leave alone in room while in wheelchair and see if enough room in bedroom to rearrange. There was no documentation of Posey rolls or a concave mattress. The Fall Risk assessment dated [DATE], documented that the resident had more than two falls in the previous 3 months, and experienced intermittent confusion. The resident was assessed to be a high risk for falls. A nurses note dated 10/19/11 at 8:00 pm, documented that the resident had gotten herself out of bed and stated "this is not my room". The resident was assisted by staff to the wheelchair and placed in the television area. The resident was alert but was confused to place and time. The 24 Hour Report Sheet dated 10/19/11, documented that the resident had gotten herself out of bed without assistance. A nurses note dated 10/21/11 at 10:00 pm, documented that the resident self-transferred out of bed, then was assisted to the bathroom. The 24 Hour Report Sheet dated 10/21/11, documented that staff were to monitor the resident for transferring without assistance and that the resident had self transferred at 9:30 pm. A nurses note date 10/22/11 at 2:20 pm, documented that the resident had self-transferred twice and was placed in the dining room so she could be monitored for safety. The 24 Hour Report Sheet dated 10/22/11, documented that staff were to monitor the resident for transferring without assistance and that the resident had self transferred twice on the day shift and once on the night shift. A nurses note dated 10/23/11 at 2:45 am, documented that the resident had attempted to self-transfer, refused to go to bed, and was awake all shift. A nurses note dated 10/27/11 at 6:00 am, documented that the resident was found on the floor in her room. She had a 1.5 centimeter (cm) laceration to her head and an 8 cm hematoma surrounding her left eye. There was also a 0.5 cm laceration under the left side of her nose. The resident appeared to have blood coming from her nose and mouth and the fifth digit on her left hand was bent and appeared to be broken. The resident had stated that she turned over and rolled out of bed. The physician was notified and the resident was transferred to the hospital. A nurses note dated 10/27/11 at 9:15 am, documented that the facility had received notification that the resident had been admitted to the hospital with [REDACTED]. It was also documented that current interventions for fall prevention included Posey rolls and the use of a concave mattress. An Incident and Accident (I&A) form dated 10/27/11 at 4:10 am, documented that this resident sustained [REDACTED]. The circumstance that may have contributed/caused the incident to occur was documented that the resident rolled over in bed. The resident stated that she had turned over and rolled out of bed. A Registered Nurse assessed the resident's injuries, the physician was notified and the resident was sent to the hospital via ambulance. Under the section titled "Preventive Devices" documented the following devices: bed against wall, floor mat, Posey roll, bed alarm, chair alarm and concave mattress. It was documented that these devices were in place at the time of the fall, contrary to the findings. A Unit/Supervisor Follow-Up for I&A form dated 10/27/11, documented that the care planned concave mattress was not in place. The Preventative Devices In Place Prior to the Incident/Accident section of the form documented that the right side of the resident's bed was against the wall, a floor mat and bed alarm were in place, and the resident used a concave mattress. A written statement from a Registered Nurse Supervisor (RNS) dated 10/27/11 at 4:10 pm, documented that when she checked the resident's room, the Posey rolls were in place but there was no concave mattress on the bed. The hospital Emergency Department (ED) Admit-Transfer record documented that the resident arrived at the ED on 10/27/11 at 5:23 am. The Chief Complaint section documented, "I tried to get out of bed and fell ." The quotes were part of the statement. The History of Present Illness section of the report documented that the resident was trying to get out of bed in the middle of the night to use the bathroom, then fell out of bed. The resident had sustained injury to her face and complained of back pain, and a fifth finger on the left hand displayed deformity. The resident also complained of right hip pain and was not able to bear weight. A Computerized Topography Scan (CT Scan) of the resident's head showed hematomas around the left frontal scalp and around the eyes. An X-ray of the left hand showed a displaced and angulated fracture of one finger, and a questionable hip fracture. The X-ray also showed a compression fracture of the thoracic spine (at T10). The [DIAGNOSES REDACTED]. The medical record revealed that there was no assessment of the resident's functional status (for use of the Posey rolls) or need for the device. During an interview on 11/8/11 at 1:23 pm, the Registered Nurse Manager (RNM) stated that the Posey rolls were put in place as part of her care plan several months ago and was done at the insistence of the resident's family because the resident had a history of [REDACTED]. The resident was also supposed to have a concave mattress in place, but when she fell out of bed on 10/27/11 it was noticed that the resident did not have the concave mattress. The resident had a room change in late 9/11 or early 10/11 and the RNM stated that she believed that was when the oversight was made resulting in the resident not having the concave mattress. The RNM stated that the resident was not assessed for safe use of the Posey rolls. The Posey rolls had been in place when the resident had previously gotten herself out of bed. The resident would have had to either climb over, or go around the Posey rolls to get out of bed. The resident would not have been capable of accidentally rolling over the rolls. During an interview on 11/8/11 at 2:47 pm, the Director of Nursing (DON) stated that the Registered Nurse Supervisors (RNS) reviewed 24 Hour Reports and that they should have been aware that the resident was self-transferring out of bed. The RNS's and RNM's were responsible for being aware of what was going on with residents on a daily basis and where to assess and intervene for resident safety and condition. The RNS's and the RNM should have evaluated whether or not the Posey rolls were a safe intervention for this resident, especially after the resident was noted to be self-transferring out of bed. The DON also stated that she did not know that the resident did not have the concave mattress on her bed until after the resident fell on [DATE]. During an interview on 11/8/11 at 4:00 pm, a Licensed Practical Nurse (LPN) stated that this resident was constantly self-transferring both from her wheelchair and from bed. During an interview on 11/8/11 at 4:09 pm, a CNA stated that in the week or two prior to the resident falling out of bed on 10/27/11, she noticed that the resident was transferring herself out of bed more frequently than usual. She stated that on two occasions the resident's bed alarm sounded and she entered the resident's room to find the resident climbing over the Posey rolls on her bed. She said she put the resident back to bed and notified the nurses. 10NYCRR 415.12(h)(1)(2)