Every finding on record at Warren Center for Rehabilitation and Nursing

Based on observation, interview, and record review conducted during a survey, the facility failed to ensure that resident environments were as free from accidents or hazards as possible for three (3) (Resident #'s 19, 31, 71) of six (6) residents reviewed for accident and hazards. Specifically, (a.) for Resident #19, medications were observed at their bedside; (b.) Resident #31 was at risk for falls and a fall/tripping hazard was observed in their room; (c.) Resident #71 had medications in their room that were not ordered by a physician.Findings include: The facility policy titled Medication Administration last reviewed 12/2019 documented medications shall be administered in a safe and timely manner, and as prescribed. Only persons licensed or permitted by the State to prepare, administer and document administration of medications may do so. The facility policy titled Fall Management and Prevention last revised 1/2023, documented the interdisciplinary team identified and implemented appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. The facility policy titled Accident-Incidents last reviewed 6/01/2024, documented it was the policy of the facility to monitor and evaluate all occurrences of accident or incidents or adverse events occurring on the facility's premises which was not consistent with the routine operation of the facility or care of a particular resident. An incident was any occurrence not consistent with the routine operation of the center, normal care of the resident, a happening involving visitors, malfunctioning equipment, or observation of a condition which might be a safety hazard. The occurrence may be a fall, skin tear, bruise, new pressure ulcer and may involve abuse, neglect, and mistreatment or an injury of unknown origin. During an observation on 04/08/2026 at 3:38 PM, a medication cup that contained a cream and crushed medication was on Resident #19's bedside table, accessible to residents, visitors and staff.During an observation on 4/08/2026 at 3:25 PM, collagen peptides, alpha lipoic acid, aspercreme were observed at Resident #71's bedside and/or in their window, accessible to residents, visitors and staff. During an interview on 4/08/2026 at 3:25 PM, Resident #71 stated they took collagen peptides and alpha lipoic acid to help with wound healing. They stated it was brought in by their family. Record review revealed the facility provided care for residents with diminished cognitive status. During an interview on 4/09/2026 at 12:00 PM, Director of Nursing #1 stated there were no residents in the facility that self-administered their medications. During an interview on 4/09/2026 at 12:20 PM, Administrator #1 stated self-administered medications would need to be locked up. Resident #31 was admitted to the facility with diagnoses of left femur fracture (serious, high-energy injury, a crack or break in the longest and strongest bone in the body), acute respiratory failure (lungs cannot release enough oxygen into the blood or remove carbon dioxide), and hypertension (high blood pressure). The Minimum Data Set (an assessment tool) dated 4/01/2026, documented the resident was cognitively intact, could be understood, and could understand others. During an observation on 4/08/2026 at 12:25 PM, two (2) floor mats (about two (2) inches thick) were observed stacked on top of each laying on the floor on the right side of Resident #31's bed (right side when standing at the foot of bed). The resident was in bed. There was a sign on Resident #31's wardrobe that documented call don't fall. During an interview on 4/08/2026 at 12:25 PM, Resident #31 stated they were at the facility for rehabilitation after they fad a fall and broke their femur. During an observation on 4/10/2026 at 12:47 PM, the floor mats were observed in the same position as on 4/08/2026. Resident #31 was observed in bed eating their lunch. Their walker was observed by the wardrobe. Resident #31's Comprehensive Care Plan for Falls dated 1/12/2026, documented the resident was at risk for falls/has had an actual fall related to history of falls, ambulating without assistance, rolling out of bed. The goal was: resident would be free from injury through the next review date. Some interventions included: ensure resident was wearing appropriate footwear for movement, maintain clutter-free environment, upper perimeter mattress, bed in lowest position, and non-skid socks as indicated. Resident #31's Comprehensive Care Plan for Self-Care and Mobility dated 1/22/2026 documented the resident required assistance with self-care and mobility related to altered weight baring status, fracture, impaired balance, and limited mobility. The goal was resident's self-care and mobility would improve through the review date. An intervention included: sit to stand partial assist of 1 staff (helper completes less than half of the activity, helper uses own strength to lift or hold the resident's body, arms, or legs, the resident completes more than half of the activity using own physical strength). During an observation on 4/13/2026 at 12:08 PM, Resident #31 was observed in their room walking to and from the bathroom unattended. They placed their oxygen on after they returned from the bathroom. The 2 floor mats were observed sitting up against the wall under the window. During an interview on 4/13/2026 at 12:10 PM, Certified Nurse Aide #2 stated they were not sure if Resident #31 had had any falls since admission. They stated they were not sure if the resident had floor mats before moving to their new room. They stated floor mats should be on both sides of the bed when a resident was in bed. Certified Nurse Aide #2 further stated they should not be stacked on top of each other and left on the side of the bed. During an interview on 4/13/2026 at 12:22 PM, Registered Nurse #1 stated Resident #31 had one fall on 3/03/2026 where they rolled out of the right side of the bed. They added a perimeter mattress to the resident's care plan. Registered Nurse #1 did not see floor mats in Resident #31's care plan. They stated floor mats go on both sides of the bed and should only be put down if the resident was in bed. If a resident was not in bed, they would push them to the side. They stated they were not aware of any reason why 2 floor mats might be stacked on top of each other and placed on one side of the bed. They stated they would not think that it was safe and that Resident #31 was a fall risk. During an interview on 4/14/2026 at 12:05 PM, Director or Nursing #1 stated they had one (1) fall, where they rolled out of bed. They added an upper perimeter mattress for spatial awareness. They stated they, the Assistant Director of Nursing, and the Unit Manager would determine what interventions to put into place after a fall and then put the intervention in the care plan. They stated they were not sure how floor mats were put in Resident #31's room. Director of Nursing #1 stated the floor mats stacked on top of each other could put the resident at a higher risk for falls. During an interview on 4/15/2026 at 1:02 PM, Registered Nurse #1 stated they removed the floor mats from Resident #83's room. They stated the floor mats were put in the resident's room by mistake. During an interview on 4/15/2026 at 1:57 PM, Administrator #1 stated floor mats could become a tripping hazard as someone becomes independent. 10 New York Codes, Rules, and Regulations 415.12(h)(2)

Based on record review and interviews conducted during the survey, the facility did not ensure each resident was treated with respect, dignity and care in a manner and in an environment that promotes maintenance or enhancement of their quality of life for three (3) (Resident #'s 6,# 10 and #52) of twenty-three (23) residents reviewed. Specifically, (a.) Resident #6 was placed in their room in the active dying phase without staff contact or interventions. (b.) Resident #10 was observed using a bedside commode without privacy curtain closed; and (c.) Resident #52 asked to use the bathroom and was told to soil their brief because staff had no time to toilet them.Findings include: The Facility's Policy Titled Resident Rights, revised 5/28/2024, documented Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to a dignified existence; be treated with respect, kindness, and dignity. CMS Regulation 42 Code of Federal Regulations 483.1, documented certified long-term care facilities must protect resident rights, focusing on dignity, self-determination, and quality of care; the right to be treated with consideration, dignity, and respect, including a comfortable, private living environment. Resident #6Resident #6 was admitted to the facility with diagnosis of End Stage Renal Disease (a permanent kidney failure requiring regular dialysis (a procedure that filters waste and toxins from the blood) or a kidney transplant to maintain life); Dementia unspecified (symptoms of cognitive decline such as memory loss and impaired thinking), and Anxiety Disorder (a mental health condition characterized by persistent, excessive, and uncontrollable worry about every day, routine things). The Minimum Data Set (an assessment tool) dated 11/20/2025, documented they could be understood, understand others, and was cognitively intact. During an observation on 04/07/2026, 04/08/2026, 04/09/2026 and 04/10/2026, Resident #6 was noted to have transitioned into the active dying phase. They were in their room, lights out, no stimuli, they were across bed with feet partially hanging off bed. On 4/10/202, Resident #6 was restless, moaning, deep respirations, and dry mucosa. Several staff walked by room throughout day and did not enter room. The Medication Administration Record documented Lorazepam Concentrate two (2) milligram/milliliter. Give 0.25 milliliter by mouth every six (6) hours as needed for anxiety for 14 days. Morphine Sulfate (Concentrate) Solution 20 milligrams/milliliter. Give five (5) milligrams by mouth every four (4) hours as needed for pain for 14 Days. Lorazepam 0.25 milliliter was administered on 4/7/2026 at 05:10PM, 4/9/2026 at 12:34 AM, and 4/10/2026 at 09:11AM. Morphine 5 milligrams were administered on 4/7/2026 at 05:10 PM, 4/8/2026 at 02:45 AM, 4/9/2026 at 02:15 PM and 4/10/2026 at 09:11AM. During an interview on 4/10/2026 at 02:10 PM, Administrator #1 was made aware Resident #6 was restless and moaning. They stated staff should be assessing end-of-life residents throughout the day and administering comfort medications. They are also assessed regularly by the nurse practitioner.Record review revealed that shortly after the interview with Administrator #1, Resident #6's Lorazepam and Morphine orders were discontinued and replaced with standing routine orders for Morphine and Lorazepam every four (4) hours. On 4/13/3026 at 10:20 AM, Resident #6 was observed with soft music playing, no moaning, no facial grimace, respirations with periods of apnea. A fellow resident was at their bedside. Resident #10Resident #10 was admitted to the facility with diagnoses of fracture of the upper end of the left humerus (a break in the top part of the left arm bone near the shoulder joint, often resulting from falls or trauma), dementia (a group of conditions that cause a progressive decline in cognitive abilities), and anxiety (mental health condition characterized by excessive fear or anxiety that interferes with daily activities). The Minimum Data Set, dated [DATE], documented the resident had moderate cognitive impairments, could be understood, and could understand others. During an observation on 4/07/2026 at 2:24 PM, Resident #10 was noted to have a bedside commode and landing strips on floor, parallel to bed on the left side. The landing strips were caked with brown material consistent with feces, and other stains that were unidentifiable. There were also several soiled tissues on the floor that appeared to have been meant to be in the garbage bin but instead landed on the floor. During an observation on 04/08/2026 10:32 AM, Resident #10 was self-toileting themselves on the bedside commode, in an open area, no curtains drawn, attempting to wipe themselves. They threw tissue onto the floor instead of garbage bin.Resident #52Resident #52 was admitted to the facility with diagnoses of Malnutrition (resulting from a lack of proper nutrition), Anxiety (a feeling of fear, dread, and uneasiness, often accompanied by physical symptoms like rapid heart rate, sweating, and tension); and Depression (a serious, common mental health disorder characterized by persistent sadness, loss of interest in activities, low energy, and feelings of worthlessness lasting at least two weeks). The Minimum Data Set, dated [DATE], documented the resident had moderate cognitive impairments, could be understood, and could understand others. During an interview on 04/13/2026 at 10:35 AM, Resident #52 stated the previous evening of 4/12/2026 at approximately 11:20 PM, they asked to use the toilet. A Certified Nurse aide told them they were in charge of 20 residents and did not have time to toilet them, and said to them that they (Resident #52) should relieve themselves in the bed. Resident #52 further stated that no staff returned to their room until the 4/13/2026 day shift arrived and got them up just prior to the interview. They further stated they were unable to identify the Certified Nurse Aide because they did not wear a name tag and refused to identify themselves. During an interview on 04/13/2026 at 1:48 PM, Administrator #1 stated all residents were to be treated with dignity and respect; it was unacceptable for any staff member to refuse to toilet any resident and tell them to go in the bed. When an incident was brought to their attention, they would immediately educate that staff member and complete an inservice. 10 New York Code of Rules and Regulations 415.5(a)

Based on observation, record review, and interviews conducted during the survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for one (1) of two (2) medication carts (South Unit) and one (1) of one (1) (South Unit) medication room reviewed. Specifically, there were three (3) unopened insulin pens delivered 2 days prior that state keep refrigerated until opened. Two (2) opened insulin kwik pens with no open and or expiration dates. One (1) inhaler with no open and no expiration dates, One (1) inhaler with no expiration date. One (1) box of hard candy in bottom of the medication cart and the medication room narcotic lock box #2, inside lock was left open. Findings include: The Facility's Policy and Procedure titled Medication Administration revised 12/2019, documented Medications shall be administered in a safe and timely manner, and as prescribed. 8. The expiration date on the medication label must be checked prior to administration. When opening a multi-dose container, the date shall be recorded on the container. Refer to Pharmacy guidance for expiration of opened medications. The Facility's Policy and Procedure titled Medication Storage and labeling revised 1/21/2026, documented this facility will store Medications safely and securely and in a manner that maintains the integrity of the product in accordance with manufacturer's recommendations, current standards of practice and federal and state regulations. 4. Medications will be stored in an orderly, organized manner in a clean area. 7. medications (including ophthalmic, ear drops and house stock medications) may be used until the listed manufacturer expiration date unless otherwise specifically indicated or labeled. 8. Medication injection pens including insulin pens and cartridges are single patient use only and will be labeled and stored for resident individual use. 9. A multi-dose vial or injection pen that has been opened or accessed (e.g., needle-punctured) should be dated and discarded within 28 days unless the manufacturer specifies a different date for that opened vial or injection pen a. If a multi-dose vial has not been opened or accessed (e.g., needle-punctured), it should be discarded according to the manufacturer's expiration date. b. The manufacturer's expiration date refers to the date after which an unopened multi-dose vial should not be used. The beyond-use-date refers to the date after which an opened multi-dose vial should not be used. The beyond-use-date should not exceed the manufacturer's original expiration date. 10. Insulin storage requirements for vials, injection pens and cartridges will follow MIFU and include but is not limited to a. Do not freeze. (Frozen insulin should be discarded) b. Do not use insulin beyond the expiration date stamped on the vial, pen, or cartridge that is supplied from the drug manufacturer. c. Do not use insulin beyond the Discard On date listed on the auxiliary label. d. Do not expose insulin to direct heat or light. e. Unopened, not-in-use insulin should be stored in a refrigerator at a temperature of 36-46 F or as per MIFU. f. Opened, in-use insulin should be stored at room temperature below 86 F or as per MIFU. NYS Bureau of Narcotic Enforcement (BNE) regulations (10 NYCRR Part 80) require Schedule II, III, and IV substances must be in a stationary, locked double cabinet with separate keys for each, or equivalent secure storage. During an observation on 04/13/2026 at 10:15 AM, the South Unit medication cart contained one (1) Trelegy Ellipta inhaler dated 3/26/2026 with no expiration date; one (1) Ventolin inhaler with no open and or expiration date; one (1) fluticasone/salme 250 microgram opened 4/10 with no expiration date, and two (2) Lantus insulin pens with no open or expiration dates. The South unit cart also was noted to have unopened two (2) Lantus solar insulin pens and One (1) novolog insulin pen. During an interview on 04/13/2026 at 10:15 AM, Licensed Practical Nurse #1 was unable to verbalize expiration date of inhalers. Licensed Practical Nurse #1 stated the fluticasone was brought in from home by the resident's family and found in resident's room. Licensed Practical Nurse #1 put the fluticasone in the medication cart for safe keeping. They also stated the three unopened insulin pens were delivered over the weekend and they had not been able to put them in the refrigerator yet. During an observation on 04/13/2026 at 10:30 AM, the South Unit Medication Room Narcotic Lock Box #2's inside lock was left unlocked. During an interview on 04/13/2026 at 10:30 AM, Licensed Practical Nurse #1 stated the lock is broken as it sometimes catches and locks and there are times that it does not. This is not the first time this has happened to her, she states. Licensed Practical Nurse #1 stated when medication storage locks are broken, they call maintenance or put in a work order, for which she has not done yet. During an interview on 04/13/2026 at 12:14 PM, Director of Nursing #1 stated the medication is responsible for labeling medications upon opening. All insulins should be labeled when opened with date and time opened. Medications with shortened expiration dates after opening such as insulin, eye drops and inhalers are reviewed during new hire nurse orientation and with annual competencies. If a narcotic lock box is broken the medication nurse should notify the Director of Nursing. During an interview on 04/13/2026 at 1:59 PM, Administrator #1 stated new lock boxes were recently purchased or the medication rooms. The nursing staff are aware that narcotics are to be double locked at all times. A Narcotic Log Inservice covering process for signing out narcotics was conducted on 1/8/2026 and 1/9/026. Going forward a narcotic book audit will be conducted by the Director of Nursing in addition to 1:1 in-service on the floors. 10 New York Codes, Rules, and Regulations 415.18(d)

Based on observations, interviews, and record review during a survey, the facility failed to ensure licensed nursing staff, including nursing leadership, possessed the competencies and skill sets necessary to provide care and oversight for residents requiring specialized clinical services and safe medication practices. This included failure to ensure staff competency in respiratory/tracheostomy care for two of two (2) residents reviewed for respiratory care (Residents #7 and #87), and for one (1) resident reviewed related to a medication-related incident (Resident #87). The Director of Nursing failed to investigate a serious medication-related incident, failed to ensure physician notification of a narcotic discrepancy in accordance with facility policy, and failed to implement or maintain disciplinary action for unsafe nursing practice. This deficient practice had the potential to affect all residents requiring skilled nursing care. Findings Include: The facility policy titled Competencies, revised 01/18/2023, reviewed 12/2025, documented facility personnel shall be competent in job-specific duties and tasks. The policy documented department managers were responsible for staff training and competency validation. Competencies shall be completed on hire, annually, and upon change in duties or processes. The policy further documented competency validation shall be completed upon identification of performance concerns, staff shall receive additional training when deficits are identified, and competency validation and training shall be completed and documented. The facility policy titled Medication - Narcotic Management, last revised 04/2019, documented all narcotics shall be secured, accounted for, and discrepancies immediately reported to the Director of Nursing. The facility policy titled Notifications, last revised 04/2019, documented the facility shall notify the resident's physician immediately of significant changes in condition or incidents requiring physician intervention. The facility policy titled Accident - Incidents, reviewed 06/01/2024, documented the facility shall monitor, evaluate, and investigate all accidents, incidents, and adverse events. The policy documented incidents must be promptly reported to nursing supervision and evaluated. The nurse shall notify the resident's physician of the incident and any injuries. The supervisor/manager shall assess, document, and initiate investigation, including staff and witness statements, resident assessment, and determination of cause. The Director of Nursing shall review findings and ensure follow-up and appropriate actions. Documentation shall include physician notification, interventions, and corrective actions. The interdisciplinary team shall review incidents, determine root cause, and implement interventions and education. The facility policy titled Infection Prevention and Control Program, revised 01/21/2026, documented the facility shall maintain an infection prevention and control program to provide a safe and sanitary environment and prevent transmission of infections. The policy documented the facility shall implement systems to prevent, identify, report, investigate, and control infections, and staff shall follow accepted infection control practices. The policy further documented the program includes staff education and competency related to infection control practices. Resident #7: Resident #7 was admitted to the facility on [DATE] with a diagnosis of malignant neoplasm of the larynx (throat cancer), tracheostomy (surgical opening in neck for breathing), and human immunodeficiency virus (a communicable disease). The 01/28/2026 Minimum Data Set (an assessment tool) documented, the Resident was cognitively intact, required substantial to maximal assistance with activities of daily living, and received suctioning and tracheostomy care. The newly implemented care plan initiated on 04/09/2026 documented the need for an Ambu bag at bedside. On 04/08/2026 at 2:55 PM, the resident was observed in their room with a tracheostomy. A suction catheter was uncovered and lying on top of a suction canister containing cloudy fluid. No dates were present on tubing or equipment. On 04/13/2026 at 11:05 AM, the tracheostomy setup appeared in the same condition as previously observed. A deep suction catheter was uncovered and placed on top of a half-full suction canister containing cloudy fluid, with a used urinal directly below. A bottle of water connected to the tracheostomy collar was not dated. There was no Ambu bag present. During an interview on 04/10/2026 at 12:23 PM, Resident #7 stated tracheostomy care and suctioning were not performed, and staff were not skilled to perform it and don't offer. During an interview on 04/13/2026 at 11:05 AM, Licensed Practical Nurse #2 stated they personally had had performed tracheostomy care on 04/12/2026; however, supplies in the room appeared unchanged. The Licensed Practical Nurse #2 was unable to locate necessary supplies, could not describe full tracheostomy care, and stated they had required additional training to be competent in the proper care of a tracheostomy. Review of the April 2026 Treatment Administration Record documented physician orders for tracheostomy care every shift and as needed. Review identified inconsistent documentation of care across shifts, with multiple staff initials and variability in completion of ordered treatments. Further review identified documentation directing staff to encourage resident to allow staff or may self-clean, which was inconsistent with the resident's care needs and required skilled nursing interventions. Record review of Licensed Practical Nurse #2 competency records identified competencies for infection control, medication administration and blood glucose monitoring; however, there was no documented evidence of competency validation for tracheostomy care or respiratory equipment management. Resident #87: Resident #87 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of the head, face and neck (cancer in the head or neck), presence of an artificial laryngectomy tube (an artificial airway in the neck), and cirrhosis of the liver (liver disease). The 07/26/2025 Minimum Data Set (an assessment tool) documented the resident was cognitively intact, with no evidence of hallucinations, delusions, or behavioral symptoms. The 07/25/2025 care plan identified pain related to medical conditions, with interventions including monitoring pain levels, administering prescribed analgesics, and evaluating effectiveness. The care plan also identified respiratory needs related to the presence of an artificial airway, with interventions including monitoring respiratory status, observing for signs and symptoms of respiratory distress or changes in secretions, and providing suctioning as ordered. Review of the 07/26/2025 medication administration record documented the medication had been administered by Registered Nurse #2 at 4:00 PM. The resident and the pain scale had been reassessed and evaluated as effective. No incident was documented in the medical record. Review of an incident statement dated 08/5/2025 documented Registered Nurse #2 placed a crushed narcotic (oxycodone) in a medication cup in Resident #87's room and left the medication unattended. Upon return, the medication was no longer present. The nurse assumed the resident had taken the medication, confronted the resident, and the resident denied taking it. Review of the Medication Administration Record dated 07/25/2025 through 07/27/2025 documented oxycodone as administered by Registered Nurse #2. During an interview on 04/15/2026 at 10:51 AM, Medical Director #1 stated they were not notified of the narcotic discrepancy, and the medication should not have been documented as administered if the facts were unclear. They further stated all staff should have been competent in all areas offered by the facility. Regarding tracheostomy care there should be no nurse unable to perform the skills. During an interview on 04/15/2026 at 12:56 PM, the Director of Nursing acknowledged responsibility for oversight of clinical care and investigations; however, did not provide evidence that a complete investigation had been conducted or that required follow-up actions were implemented. During a telephone interview on 04/14/2026 at 2:40 PM law officer #1 stated they had deferred further action based on the statement by the Director of Nursing's assured them that the facility would conduct an internal investigation. There was no evidence an investigation was initiated or completed, including absence of staff interviews, fact-finding, determination of cause, or corrective actions. Further record review did not demonstrate evidence that the Director of Nursing notified the resident's physician of the missing narcotic medication or allegation the resident consumed the medication, in accordance with facility policy. Review of the comprehensive care plan identified the resident required airway management and monitoring; however, physician orders did not reflect airway management needs or emergency equipment. Review of the personnel file for the nurse involved did not demonstrate documentation of disciplinary action. There was no evidence of corrective action, counseling, or performance intervention. There was no evidence that performance concerns resulted in competency evaluation or retraining. The facility failed to ensure nursing staff competency in respiratory care, failed to ensure safe medication practices, and failed to ensure appropriate investigation, physician notification, and corrective action. The Director of Nursing failed to provide oversight and failed to address unsafe nursing practice, including failure to notify the physician of a narcotic discrepancy in accordance with facility policy. These failures demonstrated lack of competent nursing services. 10 New York Codes, Rules, and Regulations: 415.13(a)

Based on record review and interviews during a survey, the facility failed to ensure residents were free from abuse, neglect, misappropriation of resident property for four (4) (Resident #6, #33, # 85 and #87) of five (5) residents reviewed. Specifically, (a.) Resident #6 was abused when touched inappropriately by Resident #33, when Resident #33 had known inappropriate sexual behaviors. (b.) Resident #85 was neglected when rolled out of bed onto the floor during care provided by a single caregiver on 5/04/2025, when Resident #85 was care planned for a two-person caregiver for bed mobility. (c.) On 7/26/2025, Registered Nurse #2 accused Resident # 87 of consuming a crushed narcotic when the nurse left the room. Resident #87 denied taking it and felt humiliated and stated they were not given pain medication as prescribed. The nurse documented the medication was given. This resulted in mental anguish, with Resident #87 calling law enforcement. Facility was made aware but did not investigate the allegation of abuse or misappropriation of resident property (medication). (d.) Resident #87 had complex care requirements including tracheostomy /laryngectomy care that were unaddressed.The facility's Policy and Procedure titled Abuse reviewed 6/01/2024 documented the facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including but not limited to staff, family, friends and residents of the facility. The facility prohibits any exploitation of the mentally and physically disabled resident in the facility. The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property. Definitions: Neglect, Failure of the facility, its employees or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish or distress. Sexual Abuse, non-consensual sexual contact of any type with a resident and includes, but is not limited to, humiliation, harassment, coercion, or assault. 4. The Administrator and Director of Nursing are responsible for investigation and reporting. They are also ultimately responsible for the following as they relate to abuse, neglect, and/or misappropriation of property standards and procedures: a. Implementation b. ongoing monitoring c. Reporting d. Investigation 5. Incidents and allegations of abuse, neglect, misappropriation of property and exploitation will be reported to the Quality Assurance Performance Improvement (QAPI) Committee for tracking, trending, and corrective action. (a.)Resident #6 was admitted to the facility with diagnosis of End Stage Renal Disease (a permanent kidney failure requiring regular dialysis, a procedure that filters waste and toxins from the blood, or a kidney transplant to maintain life); Dementia unspecified (symptoms of cognitive decline such as memory loss and impaired thinking), and Anxiety Disorder (a mental health condition characterized by persistent, excessive, and uncontrollable worry about every day, routine things). The Minimum Data Set (an assessment tool) dated 11/20/2025, documented they could be understood, understand others, and was cognitively intact. Resident #33 was admitted to the facility with diagnosis of Major Depressive Disorder (a serious, common mental health disorder characterized by a persistent, intense, and long-lasting depressed mood or loss of interest in activities), Dementia Unspecified Moderate (symptoms of cognitive decline such as memory loss and impaired thinking), and Other Sexual Dysfunction. The Minimum Data Set (an assessment tool) dated 05/20/2025, documented they could be understood, understand others, and was cognitively intact. The Facility Investigation dated 8/9/2025 documented during an activity, Resident #6 extended a handshake greeting to Resident #33. Instead of handshake, Resident #33 reached and touched Resident #6 left breast. Resident #6 propelled backwards to remove themselves from the situation and came inside. Resident #6 verbalized distressed feelings related to the incident. The Comprehensive Care Plan for Resident #33 dated 7/2022, documented Resident with behaviors of touching themselves in public areas, staring at women, verbalization of sexual comments, inappropriate touching of staff and residents. Interventions: effective 8/25/2025, one on one (1:1) supervision when out of bed; effective 4/23/2024 Distract Resident with preferred activities such as Legos, Hot wheels, toys, music. Evaluate side effects of medications; RESOLVED 10/31/2024: Resident was on one to one (1:1) during 7 AM to 11 PM. 10/31/2024: Initiate psychology evaluation as needed. Review of Psychiatric Notes dated 8/28/2025 documented, psychiatric symptoms are not currently stabilized and Gradual Dose Reduction was Contraindicated. They were started on Olanzapine on 12/16/2024, but there had not been any significant change in their sexually inappropriate behavior; Olanzapine was increased to five (5) milligrams daily after the resident touched a female's breast. Assessment: Resident #33 denied making sexual remarks or demonstrating sexual behaviors. During an interview on 04/14/2026 at 11:47 AM, Regional Director of Nursing #1 stated Resident #33 had not had any sexual behaviors toward other residents until the August 2025 incident. (b.)Resident #85 was admitted to the facility with diagnosis of Morbid Obesity (a weight 80-100 pounds over ideal levels, posing severe health risks); Lymphedema (a chronic condition characterized by the buildup of protein-rich lymph fluid in body tissues, causing swelling, usually in the arms or legs); and General Anxiety Disorder (a mental health condition characterized by persistent, excessive, and uncontrollable worry about every day, routine things). The Minimum Data Set, dated [DATE], documented they could be understood, understand others, and was cognitively intact. Resident #85's Care Kardex (an electronic system that contains directions for providing resident-specific care) dated 5/01/2025 documented mobility roll left and right required two (2) staff assistance, and for both staff to provide hands-on care. The Facility's Incident and Accident report dated 5/04/2025, documented Resident #85 was observed lying on their left side on the side of the bed. Resident #85 had full range of motion in all four (4) extremities and was without injury. When a Certified Nurse Aide provided incontinence care without a second staff member, Resident #85 was turned onto their left side and slipped off the side of the bed onto the floor.Resident #85's Comprehensive Care Plan did not have a Care Plan reflecting falls on 5/04/2025. The Care Plan was canceled as of 1/16/2026, documenting the resident was at risk for falls and had an actual fall related to Deconditioning, Gait/balance problems, Immobility. During an interview on 04/14/2026 at 1:18 PM, Regional Director of Nursing #1 stated a checklist is completed whenever there is a fall; front-line staff notify a Registered Nurse for an assessment. The Registered Nurse would assess resident injury and skin integrity and then the provider is notified. Afterwards, an incident report is completed and reviewed during morning meeting and each incident report was investigated. During an interview on 04/14/2026 at 1:18 PM, Director of Nursing #1 stated they signed off on the fall progress noted dated 5/04/2025. The incident report was completed and there was no further investigation as they deemed there was no injury and non-reportable to the Department of Health. Director of Nursing #1 stated there were no statements collected.Record review from document supplied by Regional Director #1 revealed a generated Resident #85's Care Kardex for 5/2025, documenting Resident #85 was a two (2)-person caregiver for rolling left and rolling right. Director of Nursing #1 had no response as to why only one (1) care giver was present at time of incident, nor why the incident had no further investigation for care plan violation and was not reported to the Department of Health. (c.)Resident #87 was admitted to the facility with diagnoses of malignant neoplasm of the head, face and neck (cancer in the head or neck), presence of an artificial laryngectomy tube (an artificial airway in the neck), and cirrhosis of the liver (a liver disease). The Minimum Data Set, dated [DATE], documented they could be understood, understand others, and was cognitively intact. Record review dated 07/26/2025 documented Registered Nurse #2 placed a crushed narcotic (oxycodone) in a medication cup in resident #87's room and briefly left the area. Upon return, the medication was no longer present. The nurse assumed that the resident had taken the medication and confronted the resident with this accusation. Resident #87 denied taking the medication. Registered Nurse #2 then signed for the medication as having been administered. Registered Nurse #2 did not record any incident in the resident record. Following the incident, Resident #87 became visibly upset and distressed following the accusation, crying, and subsequently contacted law enforcement. Police responded to the facility on [DATE]; however, the matter was deferred to the facility for internal investigation, and no formal police report was completed. There was no documented evidence that the facility investigated the allegations of abuse or misappropriation of resident property (medication). Review of the Medication Administration Record dated 07/25/2025 through 07/27/2025 identified that oxycodone was documented as administered, with entries signed as given by Registered Nurse #2. During an interview on 04/15/2026 at 10:51 AM, Medical Director #1 stated they were not notified of the missing narcotic medication or the missed dose. They further stated Registered Nurse #2 should not have signed for it as given if the facts were unclear. They stated they would have administered another one-time dose as the story had lacked credibility. (d.)Review of Resident #87's comprehensive care plan dated 03/24/2026 through 03/26/2026 identified the resident had multiple high-risk clinical needs, including airway management related to a tracheotomy/artificial larynx, enteral nutrition, cancer-related pain, impaired communication, decreased mobility, and fall risk. Interventions included monitoring respiratory status, managing secretions, providing suctioning as needed, maintaining airway patency, administering tube feedings, managing pain, and assisting with activities of daily living. The care plan reflected the need for ongoing monitoring, staff assistance, and timely intervention across multiple disciplines. Review of Resident #87's physician orders on the Order Summary Report dated 04/09/2026, reflecting active orders as of 07/26/2025, identified the resident had a diagnosis indicating an altered airway (presence of artificial larynx/tracheotomy). However, there were no physician orders for tracheostomy or laryngectomy care, including suctioning, stoma care, humidification, or respiratory therapy involvement. Additionally, there were no orders for required bedside emergency airway supplies, such as a spare tube, obturator, suction equipment, or emergency airway instructions. Orders during this period were limited to general care, including medications, wound care, enteral feeding, and routine monitoring. Overall, record review identified a discrepancy between the resident's documented clinical condition and care plan needs, and the absence of corresponding physician orders to support airway management and emergency preparedness, as well as inconsistencies in medication administration documentation. 10 New York Codes, Rules, and Regulations 415.4 (b)(1)(i)

Based on observation, interview, and record review conducted during a survey, the facility failed to ensure residents were able to exercise the right to self-determination, including making choices regarding daily routines, meals, and living environment, for two (2) (Resident #9, Resident #47, and Resident #71) of three (3) residents reviewed for choices. Specifically, (a.) Resident #9 was not permitted to return to bed upon request and was not provided with meaningful meal choices; and (b.) Resident #47 was expected to have moved from their room without consent despite refusal. Findings include: Review of the facility policy titled Resident Rights, revised 05/28/2024, documented healthcare personnel shall treat all residents with kindness, respect, and dignity. The policy further documented residents have the right to self-determination; to exercise their rights without interference, coercion, discrimination, or reprisal; to participate in care planning and treatment; to choose an attending physician and participate in decision-making regarding their care; to voice grievances without fear of reprisal; and to make choices about aspects of their life in the facility. Review of the facility policy titled Room Change Policy, dated 05/2024, documented residents and/or their representatives were to be involved in room change decisions, informed of the reason for the move, and have their preferences considered. Review of the facility policy titled Quality of Life/Dignity, dated 05/28/2024, documented residents were to be treated with dignity and respect and have their choices honored to the extent possible. Resident #9 Resident #9 was admitted to the facility with diagnoses including end stage renal disease (kidney failure), chronic respiratory failure (lung disease), and adjustment disorder with mixed anxiety and depressed mood (a short-term, stress-related condition characterized by an unhealthy, emotional reaction to a stressful life event). The Minimum Data Set (an assessment tool) dated 10/13/2025, documented they could be understood, understood others, and was cognitively intact. During an observation and interview on 04/08/2026 at 1:54 PM, Resident #9 had requested to return to bed. Licensed Practical Nurse #1 stated the resident was not their patient. Additional staff also indicated the resident was not assigned to them when the resident requested assistance. Licensed Practical Nurse #1 stated the resident could not return to bed due to requiring a Hoyer lift. During an interview on 04/08/2026 at 3:22 PM, Director of Nursing #1 and Administrator #1 stated residents would have been able to return to bed whenever requested and there was no limitation related to Hoyer lift use. Resident #47Resident #47 was admitted to the facility with diagnoses including sepsis (a blood infection), major depressive disorder (a serious, common mental health condition characterized by persistent severe sadness, low energy, and loss of interest in activities), and malnutrition (poor nutrition). Review of the Minimum Data Set, dated [DATE], documented that the resident documented they could be understood, understood others, and was cognitively intact. During an interview on 04/09/2026 at 1:58 PM, Resident #47 stated they were told they needed to move out of their room and were not provided with a choice. The resident stated they had recently been moved and had been informed that lack of their signature or consent would not prevent the move, as the room was needed for another resident.Record review verified the resident had refused to sign the room change documentation. Record review did not include documentation the resident's refusal was honored or that the resident was provided with a meaningful opportunity to choose. During an interview on 04/09/2026 at 1:58 PM, Unit Secretary #1 stated Resident #47 would have to move to a new room. They stated that Resident #47 had refused to sign the room change consent form and therefore another staff member signed as a witness to the notification of room change. Unit Secretary #1 stated the move was required based on directive received via email from corporate requiring a (specific gender) bed be opened within the facility. Unit Secretary #1 stated the resident had no choice in the matter and would be moved regardless of their desire to stay in the room they were in. During a telephone interview on 04/09/2026 at 4:38 PM, Corporate Staff #1 stated room changes were managed at the facility level and residents retained the right to refuse a room change. If a resident had declined a room change, the facility would not be expected to force the move and should instead adjust admissions accordingly. Corporate Staff #1 stated to move a resident from their room against their consent would be a violation of their resident rights. They further stated there were very few legitimate reasons to move a resident out of their room and accommodating an outside admission would not meet the criteria for a room change. During an interview on 04/10/2026 at 12:02 PM, Director of Nursing #1 stated Resident #47's planned room change was to accommodate an outside admission and acknowledged the residents lack of consent. Director of Nursing #1 agreed there had been multiple room changes for accommodation reasons, however in several cases there was documented resident refusal to sign consent with a subsequent non-consenting move resulting. Director of Nursing #1 referred to paper copies of consent to move for one (1) resident. Record review revealed there was no evidence produced that paper copies of consent to move. During an interview on 04/10/2026 at 1:22 PM, an additional resident [number withheld for privacy] stated notification was given that a move was required to accommodate another resident and no choice was provided. The resident stated refusal to sign the agreement, but relocation occurred regardless, and the move was believed to be retaliatory following a prior disagreement. The resident stated law enforcement was contacted due to concerns belongings were being removed without permission. During an interview on 04/15/2026 at 10:17 AM, Registered Nurse #1 stated residents should not be moved without consent; however, acknowledged residents were moved often to accommodate admissions and staff followed direction regarding room changes. They acknowledged the lack of homelike feeling for residents when they move so often, and it can cause adjustment issues with the elderly. 10 New York Codes, Rules, and Regulations: 415.3(b)(1)

Based on observations, record review, and interviews during the survey, the facility did not ensure a safe, clean, comfortable, and homelike environment for two (2) (Resident #10, #41 and #58) of four (4) residents reviewed. Specifically, Resident #10 had a bedside commode with soiled tissue on the floor next to their bed and commode. There were landing strips at the bedside with copious dried brown material consistent with fecal material. Resident #58 was the roommate to Resident #10 and stated they were subject to soiled materials at the entrance of their room and often had to call for assistance for Resident #10 when they soil the floor. Findings include: The facility's Procedure titled Resident Room Cleaning documented a four-step process: 1. Knock and announce yourself. 2. Clean Bathroom. 3. Clean sink and vanity 4. Clean Room f) Check all corners and edges for trash and debris stuck in corners and edges. g) Also use putty scraper to pick up anything stuck to the floor. h) Dust all horizontal and vertical surfaces i) Dust mop around behind all furniture j) damp mop floor with Neutral Cleaner including hallway outside room to next room k) Spray Air Freshener in air and on privacy curtains. Resident #10 was admitted to the facility with diagnoses of fracture of the upper end of one (1) of the humerus bones (a break in the top part of the left arm bone near the shoulder joint, often resulting from falls or trauma), dementia (a group of conditions that cause a progressive decline in cognitive abilities), and anxiety (mental health condition characterized by excessive fear or anxiety that interferes with daily activities). The Minimum Data Set (an assessment tool) dated 3/18/2026, documented the resident had moderate cognitive impairments, could be understood, and could understand others. Resident #58 was admitted to the facility with diagnosis of Diabetes Mellitus (a chronic metabolic disorder characterized by consistently high blood sugar levels resulting from inadequate insulin production or the body's inability to use insulin effectively), Osteoarthritis (chronic, degenerative joint disease, often called wear-and-tear arthritis), and Non-Alzheimer's Dementia (a general term for cognitive decline, with Alzheimer's being the most common, Non-Alzheimer's Dementia differ from Alzheimer's by causing earlier behavioral, motor, or language changes rather than just memory loss). The Minimum Data Set, dated [DATE], documented the resident had moderate cognitive impairments, could be understood, and could understand others. During an observation on 4/07/2026 at 2:24 PM, Resident #10 was noted to have a bedside commode and landing strips on floor, parallel to bed on the left side. The landing strips were caked with brown material consistent with feces, and other stains that were unidentifiable. There were also several soiled tissues on the floor that appeared to have been meant to be in the garbage bin but instead landed on the floor. During an interview on 4/07/2026 at 2:24 PM, Resident #58 stated their roommate, Resident #10, often used the commode then throws soiled tissues on the floor. They also stated there were times Resident #10 attempted to self-toilet but instead defecated on the floor. Resident #58 stated they call for help but it took hours before anyone comes to help. During an observation on 04/08/2026 10:32 AM, Resident #10 was self-toileting themselves on the bedside commode, in an open area, no curtains drawn, attempting to wipe themselves. They threw tissue onto the floor instead of garbage bin. During an interview on 04/08/2026 at 10:38 AM, Housekeeper #1 stated they were a floater housekeeper. They were assigned to Resident #10's room last week and today. They had not yet cleaned Resident #10's room. They were not assigned to the room the previous day and would notify maintenance to change the landing strips. Housekeeper #1 stated when they cleaned the rooms, they start at over-bed table, sweep, mop and clean bathroom with disinfectant, and that nursing picks up any bulk. They further stated they would disinfect the bedside commode. During an interview on 04/08/2026 at 10:33 AM, Maintenance Director #1 stated it was the responsibility of the housekeeping staff to notify maintenance of stained, soiled or damaged landing strips. They further stated Maintenance would first attempt to clean the strips. If the strips were unable to be cleaned they will be replaced. Maintenance Director #1 stated Resident #10 had behaviors of eating chocolate cookies daily and the brown stains on the landing strips were caked up cookies, not feces. 10 New York Codes, Rules, and Regulations 415.29(j)(1)

Based on observation, interview, and record review conducted during a survey, the facility failed to maintain records in accordance with accepted professional standards and practices, as accurately documented and completed for two (2) (Resident #'s 65 and 84) of 23 residents reviewed. Specifically, (a.) for Resident #65, there was no documentation in the electronic medical record that a verbal order was received from the Medical Provider to schedule the resident's pain medication and no documentation that the nurses administered the resident's pain medication after the order was changed on 4/14/2026; and (b.) for Resident #84 there was missing documentation in the Certified Nurse Aide tasks record that care was provided to the resident. Additionally, the narcotic book shift count for the south unit was signed in advance. The findings include: The facility policy titled Charting and Documentation- CNA dated 3/2020, documented all services provided to the resident, or any changes in the resident's medical or mental condition shall be documented in the resident's medical record. Certified Nursing Assistants may make entries in the resident's medical chart of all care rendered to the residents. Certified Nurse Aides were encouraged to document care as close to completion of task as possible, but if not, must be documented by the end of their shift. The facility policy titled Medication-Narcotic Management last reviewed 4/2019, documented narcotics and schedule II medications would be counted with two (2) professional nurses at the beginning and end of each shift. Documentation that a count was completed and accurate would be completed at the beginning and end of each shift. Resident #65 Resident #65 was admitted to the facility following a left total knee replacement with diagnoses of chronic pain syndrome (a persistent condition where pain lasts for more than 3-6 months), Dorsalgia (chronic or acute pain in the back, specifically targeting the thoracic (mid-back) region, but often encompassing the neck and shoulder area), and chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe). The Minimum Data Set (an assessment tool) dated 4/01/2026, documented the resident was cognitively intact, could be understood, and could understand others. During an interview on 4/15/2026 at 9:00 AM, Resident #65 stated they were supposed to get their pain med at 7:00 AM. They stated they got it at 7:00 PM on 4/14/2026 and 1:00 AM on 4/15/2026. When they spoke to the Licensed Practical Nurse, they were informed that the medication was not signed for the Medical Provider and that they were administered the medication at 6:00 AM. They stated their pain was at a 7. They stated they did not understand why they got the medication last night, but not this morning. Resident #65 stated they spoke with Director of Nursing #1 and Licensed Practical Nurse #2 about what happened over the weekend with it taking over 2 hours to receive their pain medication and they agreed that the pain medication would be scheduled, but it was not implemented. A physician order dated 4/14/2026 at 4:01 PM, documented hydrocodone-acetaminophen tablet 7.5 325 milligram, give 1 tablet by mouth every 6 hours for pain for 14 days. The order was not signed and there was no documented evidence that the Medical Provider provided a verbal order for the medication. Resident #65's Medication Administration Record for April 2026, did not reflect that Resident #65 received their scheduled hydrocodone-acetaminophen on the evening of 4/14/2026 into the morning of 4/15/2026. During an interview on 4/15/2026 at 10:05 AM, Registered Nurse #1 stated they were present when Director of Nursing #1 talked with the Medical Provider about scheduling the pain medication for Resident #65, but the Medical Provider did not sign the order. They confirmed that there was no documentation in the electronic medical record that Nurse Practitioner #1 gave a verbal order to schedule the pain medication. Registered Nurse #1 stated the nurses that worked the evening and night shifts gave the resident the medication but could not sign off for it in the electronic medical record because the order was not signed for. They stated the nurses did document it in the narcotic book. They stated the nurses were going to come in and put in progress notes that the medication was given, since they had not done so. Registered Nurse #1 stated the nurses should have called the on call Registered Nurse or the Medical Provider. During an interview on 4/15/2026 at 10:42 AM, Director of Nursing #1 stated they called Nurse Practitioner #1 with Registered Nurse #1 and Regional Director of Nursing #1 present and received the order to schedule Resident #65's pain medication. They stated the order was entered and transcribed by Registered Nurse #1. They stated the order was updated to reflect a new order and the Medical Provider did not sign it. They stated 2 nurses made the same error and the nurses should have reached out to the Medical Provider. Resident #84 Resident #84 was admitted to the facility with diagnoses of Rhabdomyolysis (a serious, potentially life-threatening medical condition involving the rapid breakdown of damaged skeletal muscle, Atherosclerotic heart disease (a chronic condition caused by plaque buildup that narrows and hardens arteries, limiting oxygen-rich blood flow to the heart), and chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breath). The Minimum Date Set (an assessment tool) dated 3/02/2026, documented the resident was cognitively intact, could be understood and could understand others. A complaint received by the New York State Department of Health on 3/04/2026, documented Resident #84 was left stuck in their wheelchair all day, staff would not assist them to the bathroom or with care. It further documented that Resident #84 was told they could not walk, but staff were not present to check if they needed assistance. Resident #84's Comprehensive Care Plan for Self-Care and Mobility dated 2/25/2026, documented the resident required assistance with self-care and mobility related to immobility. The goal was Resident #84's self-care and mobility status would improve through next review. Some interventions included: the resident required partial assist of 1 staff for toilet transfers; supervision or verbal cues or touching assist of 1 staff for toileting hygiene; and supervision or verbal cues or touching assist of 1 for sit to stand. A review of the Documentation Survey Report for February 2025 (Certified Nurse Aides task record) for Resident #84, documented an intervention/task titled Care Provided. Each day and shift recorded if care was provided. Care included tasks such as toileting hygiene, toilet transfer, dressing, and bathing. During the month of February 2026, there was no documentation to support that care was provided to Resident #84 on 2/26/2026 day shift (7:00 AM to 3:00 PM), 2/27/2026 evening shift (3:00 PM to 11:00 PM), and 2/28/2026 night shift (11:00 PM to 7:00 AM). During an interview with Registered Nurse #1, they stated from their view in the electronic medical record it appeared to be missed documentation. They stated if they had to guess, the Certified Nurse Aides did not have time to document. They further stated they often hound the Certified Nurse Aides to get their charting done and it was discussed at their monthly staffing meetings. During an interview on 4/14/2026 at 12:55 PM, Director of Nursing #1 was shown Resident #84 Certified Nurse Aide documentation for February 2026. They stated the care was done, it was just not documented. During an observation on 4/13/2026 at 10:15 AM, the south unit narcotic book shift count for 4/13/2026 7:00 AM to 3:00 PM shift was signed for change of shift 3:00 PM to 11:00 PM in advance by Licensed Practical Nurse #1. During an interview on 4/13/2026 at 10:15 AM, Licensed Practical Nurse #1 stated they signed it ahead of time, so they would not forget to sign it when they left. During an interview on 4/13/2026 at 3:09 PM, Director of Nursing #1 stated their narcotic log in-service was conducted on 1/08/2026 and 1/09/2026 and they reviewed the process for signing for narcotics. Director of Nursing #1 further stated they would audit narcotic books now and do one-to-one In-services on the floor. 10 New York Codes, Rules, and Regulations 415.22(a)(1-4) No Notes

Based on observations, interviews, and record review during a survey, the facility failed to ensure respiratory care services were provided in accordance with professional standards for 2 of 2 residents (Resident #87 and #7) with a tracheostomy (surgical opening in the neck necessary for breathing). The facility failed to support a clean environment or the maintenance of the availability of required tracheostomy supplies. The facility failed to ensure the availability of an Ambu bag (rescue breathing device) at the bedside for residents with a tracheostomy. The facility had not ensured staff consistently performed, documented, and demonstrated competent tracheostomy care in accordance with facility policy. This deficient practice had the potential to result in ineffective airway management, increased risk for infection, and compromised respiratory status. This failure had the potential to affect the resident's ability to receive timely emergency airway support. Findings include: The facility policy titled Tracheostomy Care, revised 12/02/2024, documented, tracheostomy care was to be provided in accordance with standards of practice to maintain airway patency, prevent respiratory infection, and maintain skin integrity. Care was to be performed by competent licensed staff based on assessed needs. Staff were responsible for maintaining a clean environment; ensure required supplies and equipment, including suction equipment, oxygen source, and essential airway devices (Ambu bag) at the bedside, were available and functional; perform routine and as-needed tracheostomy care and suctioning; monitor for respiratory distress; utilize appropriate personal protective equipment; and document care provided in the clinical record. Resident #7 was admitted to the facility on [DATE] with a diagnoses of malignant neoplasm of the larynx (throat cancer), tracheostomy (surgical opening in neck for breathing), and human immunodeficiency virus (a communicable disease). The 01/28/2026 Minimum Data Set (an assessment tool) documented, the Resident was cognitively intact, required substantial to maximal assistance with activities of daily living, and received suctioning and tracheostomy care. The care plan initiated on 04/09/2026 documented the need for an Ambu bag at bedside. During an observation on 04/08/2026 at 2:55 PM, Resident #7 reported staff had not performed tracheostomy care. A suction catheter was observed uncovered, cloudy liquid was present in the canaster, and tubing lacked date identification. During an observation on 04/10/2026 at 12:23 PM, Resident #7 stated they did not receive tracheostomy care and had not been suctioned despite having felt the need. The resident stated they felt the staff were not skilled to perform the care. Review of the 04/10/2026 Treatment Administration Record documented the care had been completed. During tracheostomy care observation and interview 04/13/2026 at 11:05 AM, Licensed Practical Nurse #2 Unit Manager entered the resident's room. The tracheostomy care setup appeared untouched. A deep suction catheter was observed uncovered and placed on top of the half full cloudy suction canister, with a used urinal located directly below. A bottle of water connected to the trach collar was present without a date. The resident stated staff did not know how to perform tracheostomy care and reported limited access to staff able to perform suctioning. The Licensed Practical Nurse was unable to locate necessary tracheostomy supplies in the room and was unaware of available supply sources. The Licensed Practical Nurse asked the resident where the supplies were and the resident responded by writing on the white board a message that indicated that they had not had the correct supplies in months. The Licensed Practical Nurse stated they had thought they had come in. They further described prior tracheostomy care as simply wiping the stoma opening. They had been unable to clearly describe the complete tracheostomy care procedures and admitted they and most of the other nurses needed to refresh their tracheostomy skills. Licensed Practical Nurse stated the resident could perform their own tracheostomy care to which the resident responded they were not comfortable doing their own care. An attempt to contact the Respiratory Therapist with the contact email provided by the facility was not returned. During an observation and interview on 04/13/2026 at 11:34 AM, Licensed Practical Nurse #4 was unable to identify the presence of an Ambu bag in the resident's room. They indicated where it should have been located; however, no Ambu bag was present in the room. The resident stated an Ambu bag had never been available at the bedside. Licensed Practical Nurse #4 stated the lack of the Ambu bag was unknown and they would replace it promptly. During an interview on 04/09/2026 at 10:00 AM, the Director of Nursing stated tracheostomy supplies should be maintained in a clean area and staff should be trained in proper care techniques. The Director of Nurses documented in a secure file transfer that Resident #7 and their family member provided their own tracheostomy supplies and maintained the resident had adequate correct supplies in their room. During an interview on 04/15/2026 at 10:13 AM Registered Nurse #1 stated that the resident should have had clean and covered supplies and that tracheostomy care consists of more than just cleaning a site. If a nurse was simply cleaning the site it would not be considered complete and should not have been signed for. Ambu bag should be at bedside if not they would have to get the code cart from a distance away down the hall which was not safe. Registered Nurse #1stated that this is a most important crucial measure and would be imperative in the case of a freshly post-operative tracheotomy. During an interview on 04/15/2026 at 11:18 AM Medical Director stated the staff should be dating and changing the respiratory equipment for a tracheostomy resident per protocol to prevent infection. Care should be provided daily and if there were any staff lacking the skills to perform tracheostomy care they should receive training prior to working with the resident. All policies should be followed and the lack of an Ambu bag at bedside was not competent practice. Resident #87 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of the head, face and neck (cancer in the head or neck), presence of an artificial laryngectomy tube (an artificial airway in the neck), and cirrhosis of the liver (liver disease). The 07/26/2025 Minimum Data Set (an assessment tool) documented the resident was cognitively intact, with no evidence of hallucinations, delusions, or behavioral symptoms. The 07/25/2025 care plan identified pain related to medical conditions, with interventions including monitoring pain levels, administering prescribed analgesics, and evaluating effectiveness. The care plan also identified respiratory needs related to the presence of an artificial airway, with interventions including monitoring respiratory status, observing for signs and symptoms of respiratory distress or changes in secretions, and providing suctioning as ordered. During an interview on 04/08/2026 at 3:11 PM, the resident's health care proxy expressed Resident #87s concerns regarding staff competency to manage the resident's laryngectomy tube, including suctioning and airway care. The health care proxy reported that the resident did not have the ability to independently manage care and expressed concerns regarding the facility's ability to meet the resident's respiratory needs. The health care proxy further reported being unable to recall whether emergency airway equipment, including an Ambu bag, was present at the bedside. During a telephone interview on 04/09/2026 at 4:38 PM, Corporate Registered Nurse #1, reported determinations regarding a facility's ability to meet a resident's clinical needs were made by the facility's nursing and clinical staff and not by corporate staff. If a facility accepted a resident with a tracheostomy or similar airway needs, the decision reflected the facility's determination that it had the capacity and competency to provide the required level of care. During an interview on 04/15/2026 at 11:18 AM Medical Director reported tracheostomy care was assumed to be provided by the facility and should have been delivered with appropriate care. The Medical Director reported the facility would not accept a resident with a tracheostomy at the time of the interview and stated concerns regarding the facility's ability to provide such care. The Medical Director further reported the identified lack of ability to provide appropriate tracheostomy care should have been thoroughly investigated. During an interview on 04/15/2026 at 12:56 PM, the Director of Nursing reported the facility was able to provide tracheostomy care. They reported unawareness of why the resident stated there were no supplies in the room and indicated supplies were available. They had been unaware that an Ambu bag was not present at the bedside and stated this should not have occurred. They further stated that the resident was able to have performed their own care. The Licensed Practical Nurse should not have touched a soiled cannula with bare hands and that respiratory care items should have been appropriately dated. 10 New York Codes, Rules, and Regulations: 415.12(c)

Based on observation, interview, and record review conducted during a survey, the facility failed to ensure residents could safely self-administer medication when clinically appropriate for two (2) (Resident #'s 19 and 71) of two (2) residents reviewed for medication administration. Specifically, (a.) Resident #19 had medications in their room, but the resident was not assessed for their ability to self-administer medication, and there was no documentation from the physician or in the resident's care plan that they could self-administer medications; and (b.) Resident #71 had medications in their room that were not ordered by a physician and they reported taking/using the medications. Findings include: The facility policy titled Medication-Self Administration last revised 7/2019, documented residents may request to keep medications at bedside for self-administration in accordance with resident rights. Under procedures, it was documented that (1.) staff and practitioner would assess each resident's mental and physical abilities to determine whether self-administering medications was clinically appropriate for the resident upon request; (2.) general evaluation of decision-making capacity would be conducted and the nurse would perform a more specific skill assessment; (3.) if a resident was determined to be unsafe self-administering medications, nursing staff may determine that the resident could self-administer medications with assistance from the nurse, by storing the medication in the med-cart and observing the resident self-administer their medications at the correct time; (4.) self-administered medication were to be stored in a safe and secure place, which was not accessible by other residents; (5.) staff should identify and give to the charge nurse any medications found at the bedside that were not authorized for self-administration, for return to the family or responsible party; (6.) the staff and the practitioner would periodically reevaluate a resident's ability to continue to self-administer medications. Resident #19 Resident #19 was admitted to the facility with diagnoses of paroxysmal atrial fibrillation (a condition characterized by rapid, irregular heartbeats that start and stop abruptly), hypertension (high blood pressure), and depression (a mental health condition characterized by persistent sadness, loss of interest, and other symptoms that significantly impair daily life). The Minimum Data Set (an assessment tool) dated 1/20/2026, documented the resident was cognitively intact, could be understood, and could understand others. During an observation on 4/08/2026 at 3:38 PM, a medication cup was observed at Resident #19's bedside with cream/crushed medication inside. A review of Resident #19's medical record did not include documentation that the resident was assessed for their ability to self-administer their medications. A review of Resident #19's medical record did not include documentation from the resident's physician that the resident could self-administer their medications. A review of Resident #19's care plan did not include documentation the resident could self-administer their medications. Resident #71 Resident #71 was admitted to the facility with diagnoses of end stage renal disease (a condition where the kidneys can no longer effectively filter waste and excess fluid from the blood), Sequelae of Guillain-Barre syndrome (long-term or permanent residual health issues arising from peripheral nerve damage, lasting beyond the acute phase of the disease), and congestive heart failure (a weakened heart condition that causes fluid buildup in feet, arms, lungs, and other organs). The Minimum Data Set, dated [DATE], documented the resident was cognitively intact, could be understood, and could understand others. During an observation on 4/08/2026 at 3:25 PM, collagen peptides, alpha lipoic acid (antioxidant), and aspercreme (pain reliever) were observed at Resident #71's bedside and/or in their window. During an interview on 4/08/2026 at 3:25 PM, Resident #71 stated they took collagen peptides and alpha lipoic acid to help with wound healing. They stated it was brought in by their family. Resident #71's Medication Administration Record for April 2026 did not include orders for collagen peptides, alpha lipoic acid, or aspercreme During an interview on 4/09/2026 at 12:00 PM, Director of Nursing #1 stated there were no residents in the facility who self-administered their medications. During an interview on 4/09/2026 at 12:02 PM, Administrator #1 stated there were no residents at the facility that self-administered their medications. If a resident chose to self-administer their medications, they would have to demonstrate that they could do it on their own, utilize a locked box in order to store medications properly, and be assessed by the interdisciplinary team to determine if the resident was an appropriate candidate. They stated if a resident was determined to be a good candidate for self-administering their medication, they would have a conversation with the medical provider and the resident. Administrator #1 stated Resident #71 showed a desire to self-administer their medications but decided not to since medications would need to be locked up. They stated it was discussed at Resident #71's care plan meeting that vitamins, antifungal powders, and over the counter medications needed medical provider orders. 10 New York Codes, Rules, and Regulations: 415.3(f)(1)(vi)

Based on record review and interviews during a survey, the facility did not ensure that all alleged violations involving neglect were reported within 24 hours after the allegation was made for one (1) (Resident #85) of five (5) residents reviewed for abuse. Specifically, Resident #85 was neglected when rolled out of bed onto the floor during care provided by a single caregiver on 5/04/2025; Resident #85 was care planned for a two-person caregiver for bed mobility. The incident was not reported to the New York State Department of Health. Findings Include: Cross reference to F-600The Facility's Policy and Procedure Titled Accident-Incidents reviewed 6/01/2024, documented: 12. Director of Nursing and Administrator are responsible to review Incident / Investigation and Conclusion to determine if incident requires reporting to outside agencies such as Department of Health, Office of Inspector General, CMS, etcetera. Evaluation: 13. All incidents and Accidents will be evaluated when applicable by the interdisciplinary team. 14. The team will review the investigation and continue if necessary, discuss and determine from the investigation the root causes, make recommendations for additional intervention, education and conclude the investigation. 14.1 The team will write an interdisciplinary team note discussing above. Resident #85 was admitted to the facility with diagnosis of Morbid Obesity (a weight 80-100 pounds over ideal levels, posing severe health risks); Lymphedema (a chronic condition characterized by the buildup of protein-rich lymph fluid in body tissues, causing swelling, usually in the arms or legs); and General Anxiety Disorder (a mental health condition characterized by persistent, excessive, and uncontrollable worry about every day, routine things). The Minimum Data Set, dated [DATE], documented they could be understood, understand others, and was cognitively intact. Resident #85's Care Kardex (an electronic system that contains directions for providing resident-specific care) dated 5/01/2025 documented mobility roll left and right required two (2) staff assistance, and for both staff to provide hands-on care. The Facility's Incident and Accident report dated 5/04/2025, documented Resident #85 was observed lying on their left side on the side of the bed. Resident #85 had full range of motion in all four (4) extremities and was without injury. When a Certified Nurse Aide provided incontinence care without a second staff member, Resident #85 was turned onto their left side and slipped off the side of the bed onto the floor.Record review revealed no documented evidence that the incident was reported to the New York State Department of Health. During an interview on 04/14/2026 at 1:18 PM, Director of Nursing #1 stated it was deemed non-reportable to the Department of Health. 10 New York Codes, Rules, and Regulations 415.4(b)(2)

Based on observation, interview, and record review during a survey, the facility failed to ensure food brought into the facility from outside sources was stored, labeled, and maintained in accordance with professional standards of practice to prevent contamination and foodborne illness, for two (2) of two (2) residents reviewed (Resident #2 and Resident # 86). Specifically, Perishable food items (milk, mayonnaise and lettuce) were observed stored in a resident's window were unrefrigerated and not maintained at a safe temperature and were not managed in accordance with facility policy. Findings Include: The facility policy titled Food - From Outside, revised 07/12/20, documented all perishable foods must have been refrigerated, labeled, and discarded within 48 hours, and that foods left without temperature control for more than 2 hours were to have been discarded. Nursing staff were responsible for having monitored resident rooms for spoilage, contamination, and safety Resident #2 Resident #2 was admitted to the facility with diagnoses which included diabetes mellitus (high blood sugar); major depressive disorder (feeling very sad for a long time); exocrine pancreatic insufficiency (body could not properly digest food). The 03/31/2026 Minimum Data Set (an assessment tool) documented the resident was understood and able to understand; was cognitively intact; required minimal assistance with activities of daily living; required moderate assistance with ambulation. The 10/07/2025 care plan documented the resident had nutritional problems related to diabetes mellitus and was on a therapeutic diet; goals included maintaining adequate intake; maintaining blood glucose levels within an acceptable range; interventions included providing counseling regarding nutritional needs; evaluating eating habits and food preferences. During an observation and interview on 04/09/2026 at 2:45 PM, a jar of mayonnaise, two cartons of milk, and a head of lettuce stored on the windowsill of Resident #2s room. The Resident stated they had used the cool air as a refrigerator. Resident #2 stated their family members brought food into the facility to provide additional food options. Staff did not provide further options or guidance regarding storage. During an observation on 04/10/2026 at 2:05 PM, continued presence of mayonnaise, two cartons of milk and lettuce on the windowsill of Resident #2. The outdoor temperature recorded during the day ranged between 67 degrees Fahrenheit and 70 degrees Fahrenheit. Resident #86 Resident #86 was admitted to the facility on [DATE] with diagnoses which included infection of right knee prosthesis with methicillin-susceptible Staphylococcus aureus (MSSA) (infection in the knee replacement caused by bacteria); primary adrenal cortical insufficiency (body does not make enough stress hormones); atrial fibrillation (irregular heartbeat). The 04/02/2025 care plan documented the resident had a central line (PICC line) (a long tube placed in a vein to give medicine or fluids) with a goal to remain free from complications; the resident received outside food from visitors with a goal to prevent adverse effects from consumption; interventions included education to visitors on safe food handling temperatures, therapeutic diet and consistency needs, food safety handout mailed to the resident's family. The care plan documented limited physical mobility with a goal to increase mobility; interventions included fall prevention measures. The care plan documented a nutritional problem related to malnutrition (not getting enough nutrition) with a goal to maintain adequate nutrition without significant weight changes; interventions included review of meal consumption; reporting significant weight changes. During a record review of a complaint received to the Department of Health, on 04/09/2026 at 9:33 AM, documentation revealed Resident #86 was diagnosed with Salmonella (food poisoning from bacteria) during the facility stay. emergency room documentation indicated the illness was related to food consumption and identified as foodborne illness. Resident #86 was discharged from the facility at the time of the survey. Review of the facility 04/2025 and 05/2025 Infection Prevention and Control Monthly Reports and associated line lists revealed no documented evidence of foodborne illness identified, tracked, or trended. Review of the 04/2026 food temperature logs revealed temperatures were routinely monitored and maintained at appropriate levels; however, there was no documentation of monitoring or oversight of perishable food stored in resident rooms. During an interview on 04/09/2026 at 10:00 AM, the Dietary Manager #1 stated outside food should be labeled, dated, and stored properly; however, acknowledged staff did not consistently monitor or enforce storage requirements. During an interview on 04/15/2026 at 10:00 AM, the Director of Nursing stated there should not have been any food in resident rooms that were not stored at the proper temperature. They would be checking all rooms to ensure the facility complied. Foodborne illness is a serious risk especially if the policy was not followed. During an interview on 04/15/2026 at 12:26 PM, Infection Control Nurse #1 stated it was not acceptable for a resident to have stored unrefrigerated perishable items in their room. There would have been an opportunity for bacteria growth resulting in a foodborne illness. The Infection Control Nurse further stated they only recently had been made aware of this, and the food had been removed. During an interview on 04/15/2026 at 11:20 AM, the Medical Director stated all food in the facility should have been stored at the proper temperature and under proper conditions; it was unacceptable for perishable food to be stored in resident rooms, especially on warm days, as it could become a source of foodborne illness. During an interview on 04/15/2026 at 1:39 PM, the Administrator stated it was inappropriate for residents to have perishable items stored in their room and not refrigerated; staff should have brought the concern to administration, and administration would have addressed it. 10 New York Codes, Rules, and Regulations 415.19 No Notes

Based on observation, interview, and record review conducted during a survey, the facility failed to ensure ongoing provision of programs to support each resident and their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial wellbeing for two (2) (Resident #'s 6 and 9) of two (2) residents reviewed. Specifically, (a.) Resident #6 was nearing end of life and was not provided with any stimulation or one-to-one interaction or visits; and (b.) Resident #9 stated they felt like a prisoner and were not provided with time outdoors per their preference. Additionally, perfume sampling was included on the activity's agenda on 4/14/2026 and could have caused adverse reactions for some residents. Findings Include: The facility policy titled Pain-Management revised 4/28/2025, documented the facility would recognize and manage a resident's pain in accordance with the resident's goals and preferences, current standards of practice and State and Federal Guidelines to promote and/or maintain the resident's highest practicable mental, physical, and psychosocial well-being. Resident's self-report of pain and non-verbal signs of pain would be evaluated using the follow scales including but not limited to: (a.) cognitively intact resident would be evaluated per self-report and numerical pain scale of one to ten; and (b.) resident with cognitive impairment, or who is non-verbal would be evaluated per self-report (if able) and/or pain assessment in advanced dementia (PAINAD) pain scale or [NAME] pain scale. Pharmacologic and non-phrenological interventions may be used to manage a resident's pain. The nursing staff would evaluate the resident for pain upon admission to the facility, quarterly, as clinically indicated, and/or with an onset of new pain or worsening of existing pain. The evaluation would include but was not limited to: (a.) identification of the underlying cause; (b.) characteristics of pain such as location, intensity, frequency, pattern, and severity; (c.) situation or interventions that may impact on the resident's pain; and (d.) impact of pain in resident activities of daily living, sleeping, appetite, and mood. Based on the interdisciplinary team's evaluation, a resident centered plan of care would be developed and updated as clinically indicated and include: (a.) resident preferences, goals and acceptable levels of pain; (b.) treatment of pain including, pharmacologic as well as non-pharmacologic interventions; and (c.) side effects, adverse consequences, and effectiveness of pain interventions. Prior to administration of as needed pain medication the nurse would evaluate for and document in the clinical record: (a.) location of pain; (b.) pain level prior to medication; (c.) pain scale used; (d.) non-pharmaclogical interventions; (e.) pharmaclogical interventions; and (f.) effectiveness of non-pharmaclogical and pharmaclogical interventions. Resident #10 Resident #10 was admitted to the facility with diagnoses of fracture of the upper end of the left humerus (a break in the top part of the left arm bone near the shoulder joint, often resulting from falls or trauma), dementia (a group of conditions that cause a progressive decline in cognitive abilities), and anxiety (mental health condition characterized by excessive fear or anxiety that interferes with daily activities)). The Minimum Data Set (an assessment tool) dated 3/18/2026, documented the resident had moderate cognitive impairments, could be understood, and could understand others. During an observation on 4/07/2026, Resident #10 complained of pain and their left hand was noted to be swollen. During an observation on 4/08/2026 at 10:45 AM, Resident #10 complained of pain and asked what time they could get their pain medication. There was noted swelling to their left hand. This was reported to Licensed Practical Nurse #2 and Director of Nursing #1. A nursing progress note dated 4/08/2026 at 1:00 PM, documented spoke with Medical Director #1 about pain in Resident #65's hands. Medical Director reviewed current medications and ordered Diclofenac Sodium External Gel 1 %. A physician order dated 4/08/2026, documented Diclofenac Sodium External Gel 1 % (Diclofenac Sodium (Topical)) apply to both hands topically every 8 hours as needed for pain apply a small amount. During an observation on 4/10/2026 at 1:41 PM, Resident #10 was observed in their room and the swelling in their hand had decreased significantly. During an interview on 4/10/2026 at 1:41 PM, Resident #10 stated their left stand still hurt, but not the way it used to. They stated if they kept doing what they were doing, it would get even better. During an interview on 4/08/2026, Licensed Practical Nurse #2 stated if a resident was complaining of pain they would do an assessment, collect data and send information to the Medical Provider. They stated Resident #10 had a standing morphine order. Licensed Practical Nurse #2 stated they completed a pain scale every shift, not prior to administering pain medications. They stated Resident #10 had been complaining of pain as long as they could remember. They stated there have not been any other interventions for Resident #10, just the morphine, they stated there was no Medical Provider in the building at the time, so they would place the concern in the Medical Provider book and message the Medical Provider. During an interview 4/08/2026 11:11 AM, Director of Nursing #1 stated if pain medication was routine, they did not ask the resident for a pain level. They only did for as needed pain medications. If a resident continued to complain of pain. Director of Nursing #1 stated they would assess and follow up with interventions. Resident #47 Resident #47 was admitted to the facility with diagnoses of rheumatoid arthritis (a chronic, autoimmune inflammatory disorder where the immune system mistakenly attacks the join lining causing painful swelling, stiffness, and potential bone erosion or deformity), fibromyalgia (a condition that causes widespread musculoskeletal pain, fatigue, and sleep disturbance), and age-related osteoporosis (a progressive disease where bone remodeling becomes imbalanced-bone breakdown exceeds formation leading to low bone mass, structural deterioration, and brittle bones). The Minimum Data Set (an assessment tool) dated 3/24/2026, documented the resident was cognately intact, could be understood, and could understand others. During an interview on 4/08/2026 at 12:31 PM, Resident #47 stated their pain was not in control when they could not take their medication and for some reason no matter how hard they tried they could not get their pain med between the hours of 3:00 PM and 11:00 PM. The resident reported on 3/04/2026 the entire day they were unable to obtain their narcotic pain medication. They stated there was no explanation as to why it was not available and their pain was not adequately controlled on that day. During an interview on 4/10/2026 at 10:07 AM, Resident #47 stated they got their pain medication the previous night, but there were so many times that they did not. They stated the medications were signed for, but they swore they did not get them. They stated they asked for pain medication on 04/05/2026 but no one ever responded. During an interview on 4/13/2026 at10:02 AM, Resident #47 stated over the weekend when they asked for their pain medication, they got no response for hours. They stated when they finally did get their medications the nurse questioned have you been missing something. Resident #47's Comprehensive Care Plan for Comfort dated 3/30/2026, documented the resident had a decrease in comfort related to arthritis, fibromyalgia, immobility, and peripheral vascular disease. The goal was: resident would achieve pain goal of tolerable pain while at rest through next review date. Interventions included: administer medications as ordered, evaluate the effectiveness of pain interventions as needed/review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition, psychiatry consult as needed, psychology consult as needed. A physician order dated 3/26/2026 at 10:42 AM, documented hydrocodone-acetaminophen oral tablet 5-325 milligram, give 1 tablet my mouth every 8 hours as needed for pain for 14 days. Order was discontinued on 4/03/2026 at 3:53 PM. A physician order dated 3/26/2026 at 3:53 PM, documented hydrocodone-acetaminophen oral tablet 5-325 milligram, give 1 tablet my mouth every 8 hours as needed for pain for 14 days. Resident #47's Medication Administration Record for April 2026, documented the Resident did not receive their hydrocodone-acetaminophen on 4/03/2026. They received acetaminophen table 325 milligrams as needed for pain. It further documented that a pain evaluation was not completed on 4/05/2026 for Resident #47 and the resident did not receive any pain medication. A pain interview assessment dated [DATE], documented Resident #47 frequently had pain. Pain occasionally effected their sleep, therapy activities, and day-to-day activities. Pain intensity through a numeric rating scale was 7. During an interview on 4/13/2026 at10:04 AM, Nurse Practitioner #1 stated they were on vacation for 2 weeks, but there was a Medical Director that signed for renewals when they were not there. They stated Resident #47 should not have gone an entire day without receiving pain medication because the order was not renewed. They stated the resident needed to have pain control and a lapse in reordering was on the facility. During an interview on 04/13/2026 at 11:00 AM, Director of Nursing #1 stated as needed medication had not been given during the evening shift of 04/05/2026 and stated the resident must not have requested it. Resident #65 Resident #65 was admitted to the facility following a left total knee replacement with diagnoses of chronic pain syndrome (a persistent condition where pain last for more than 3-6 months), Dorsalgia (chronic or acute pain in the back, specifically targeting the thoracic (mid-back) region, but often encompassing the neck and shoulder area), and chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe). The Minimum Data Set (an assessment tool) dated 4/01/2026, documented the resident was cognitively intact, could be understood, and could understand others. During an interview on 4/08/2026 at 3:09 PM, Resident #65 stated they were at the facility for therapy following a total knee replacement. They stated they had pain medications as needed. They stated when they asked for their pain medication it took the staff upward of an hour to get them. They stated the other night they wanted a pain med and the Certified Nurse Aide could not find the nurse for over an hour. Resident #65 further stated that ice packs were limited and they only had 1 ice pace since they were admitted . They stated ortho provided them with ice packs when they had their staples removed on that day. During an interview on 4/14/2026 at 9:38 AM, Resident #65 stated on Sunday 4/12/2026, they asked for their pain meds and it took 2 and half hours to get them. They stated their pain was at a 7 or 8. During an interview on 4/15/2026 at 9:00 AM, Resident #65 stated they were supposed to get their pain med at 7:00 AM. They stated they got it at 7:00 PM and 1:00 AM. When they spoke to the Licensed Practical Nurse, they were informed that the medication was not signed for the Medical Provider and that they were administered the medication at 6:00 AM. They stated their pain was at a 7. They stated they did not understand why they got the medication last night, but not this morning. When asked about the grievance, Resident #65 stated they spoke with Director of Nursing #1 and Licensed Practical Nurse #2 about what happened over the weekend and they agreed that the pain medication would be scheduled, but it was not implemented. Resident #65's Comprehensive Care Plan for Comfort dated 3/25/2026, documented alteration in comfort related to arthritis and left knee replacement. Goals included: resident is able to verbalize pain and request pain medication as needed through next review, resident will achieve pain goal of tolerable pain while at rest through next review date, and residents pain goal is to have tolerable level from pain during movement through the review date. Interventions included: administer medications as ordered, evaluate effectiveness of pain medications as needed, monitor for evidence of exacerbation of trauma, monitor for signs and symptoms of pain with each interaction, report to nurse resident complaints of pain or requests for pain treatment, reposition frequently, resident is able to verbalize pain and request pain medications as needed. A physician order dated 3/26/2026 at 2:45 PM, documented hydrocodone-acetaminophen tablet 7.5 325 milligram, give 1 tablet by mouth every 6 hours as needed for pain for 14 days. Order was discontinued on 4/06/2026 at 10:52 AM. A physician order dated 4/06/2026 at 10:52 AM, documented hydrocodone-acetaminophen tablet 7.5 325 milligram, give 1 tablet by mouth every 6 hours as needed for pain for 14 days. Order was discontinued on 4/14/2026 at 4:01 PM. A physician order dated 4/14/2026 at 4:01 PM, documented hydrocodone-acetaminophen tablet 7.5 325 milligram, give 1 tablet by mouth every 6 hours for pain for 14 days. The order was not signed and there was no documented evidence that the Medical Provider provided a verbal order for the medication. Resident #65's Medication Administration Record for April 2026, documented the resident only received their hydrocodone-acetaminophen 1 time on 4/06/2026 for a pain level of 8 after they had received it 3 times a day the days prior. It further documented on Sunday 4/12/2026, they received a dose of hydrocodone-acetaminophen at 4:55 AM and not again until 1:17 PM. The Medication Administration Record did not reflect that Resident #65 received their scheduled hydrocodone-acetaminophen on the evening of 4/14/2026 into the morning of 4/15/2026. During an interview on 4/14/2026 at 10:42 AM, Certified Nurse Aide #2 stated they would tell the nurse if a resident indicated that they were in pain. They stated sometimes the nurse would go in right away to check on the resident, but if they did not, they would follow up with the nurse to make sure they checked on the resident. During an interview on 4/14/2026 at 10:46 AM, Registered Nurse #1 stated they had talked with Resident #65 extensively about their pain medications. They stated they could not speak to why some of the nurses were not bringing them in a timely manner. They stated they told Resident #65 to ring the bell more frequently if they felt it was taking too long or if the message had gotten lost. They had also told Resident #65 to bring it to their attention. Registered Nurse #1 stated they had talked to the nurses about going in to see the resident when the pain medications were available again. They stated Resident #65 kept saying their pain meds were due, but then they would remind the resident that it was not due, it was available. They further stated typically the Medical Provider would not schedule pain medications like the one that Resident #65 was receiving. During an interview on 4/14/2026 at12:14 PM, Director of Nursing #1 stated they completed every shift pain assessment. They stated some residents assumed that the nurses were going to give the resident a pain medication rather than asking for it. They stated they do have other pain medications available if medication was not due, such as Tylenol or they could offer non-pharmalogical options for pain relief. Director of Nursing #1 stated some residents did not understand how as needed medications worked. They stated they were not aware of Resident #65's concerns, but that there was an active grievance for the resident that they had not gotten to look at yet. During an interview on 4/14/2026 at 1:47 PM, Social Worker #1 stated they met with Resident #65 yesterday 4/13/2026. They stated the resident did not file a grievance because they already had. They stated part of the grievance was that it was taking up to 2 hours to get their pain meds and they had given the grievance to Director of Nursing #1. During an interview on 4/15/2026 at 10:05 AM, Registered Nurse #1 stated they were present when Director of Nursing #1 talked with the Medical Provider about scheduling the pain medications for Resident #65, but the Medical Provider did not sign the order. They stated the nurses that worked the evening/night shift gave the resident the medication but were not able to sign off for in the electronic medical record. They stated the nurses did document it in the narcotic book. They stated the nurses were going to put in progress notes that the medication was given. Registered Nurse #1 stated the narcotic book indicated that the medication was taken at 6:00 AM for Resident #65, so they were not sure why the resident stated that they had not received it. They further stated they would speak with the Medical Provider about getting a one-time order for the pain medication, but needed to talk with the nurse to make sure the resident actually got the dose. During an interview on 4/15/2026 at 10:51 AM, Medical Director #1 stated they often received calls to renew narcotic orders. They stated they signed orders in real time, almost 100% of the time, but with narcotics, even with a signed order it would sometimes lapse, and they would need to change the order. Medical Director #1 stated they reviewed medications each and every visit. They stated pain management was a case-by-case basis. They stated the Nurse Practitioner would check the resident's history and use of opioids. If a resident was post-surgery, they were more likely to treat short term with pain meds that were provided from the hospital. They were always looking at gradual dose reduction. When questioned about arthritic pain that was treated with morphine, they stated morphine was used for very high-level pain scale. They preferred to use a low dose of tramadol or oxycodone rather than anti-inflammatory medication in this population. 10 New York Codes Rules and Regulations 415.12

Based on interview and record review conducted during the survey, the facility did not ensure the facility-wide assessment was updated to determine what resources were necessary to ensure residents were able to maintain or attain their highest practicable physical, functional, mental, and psychosocial well-being and meet current professional standards of practice. Specifically, the Facility assessment dated [DATE], documented under Special Treatment and Conditions, the number/average or range of residents were zero (0). The facility actually had one (1) active (#7) and one (1) discharged (#87) tracheostomy resident at the time of review. Findings include: The Facility assessment dated [DATE] documented Part 2:Services and Care We Offer Based on our Residents' Needs: Other special care needs - Dialysis, hospice, ostomy care, tracheostomy care, bariatric care, palliative care, end of life care. Facility assessment dated [DATE], documented under Special Treatment and Conditions, the number/average or range of residents were zero (0). Resident #7 was admitted to the facility with diagnosis of Malignant Neoplasm of Larynx (cancer of voice box) status post Laryngectomy with tracheotomy (removal of larynx/voice box with a surgical procedure that creates an opening in the neck allowing direct airflow to the lungs, bypassing the mouth and nose); Chronic Obstructive Pulmonary Disease (a condition involving constriction of the airways and difficulty or discomfort in breathing). The Minimum Data Set (an assessment tool) dated 01/28/2026, documented they could be understood, understand others, and was cognitively intact. Resident #7's Comprehensive Care Plan dated 10/21/2025 documented resident is at risk for/has an alteration in respiratory system related to Chronic stable laryngectomy patient, Ambu bag (a hand-held, self-inflating device used to provide positive pressure ventilation to patients who are not breathing or breathing inadequately) and suction setup at bedside. Intervention created on 4/7/2026 documented provide tracheotomy stoma care daily and as needed using aseptic technique.as resident tolerates, and respect wishes to self-administer cleansing and apply HME (A Heat and Moisture Exchanger; a passive humidification device used in tracheostomy care that sits on top of the tracheostomy tube. and use an air compressor / Licensed Vocational Nurse (LVN) set up for humidified therapy. During an observation on 4/13/2026 at 11:00 AM, there was no Ambu bag at resident #7's bedside. In addition, Licensed Practical Nurse # 2 was observed attempting to provide tracheotomy care, but required direction from the resident in how to perform care. Resident #87 was admitted to the facility with diagnoses of malignant neoplasm of the head, face and neck (cancer in the head or neck), presence of an artificial laryngectomy tube ( an artificial airway in the neck), and cirrhosis of the liver (a liver disease). The Minimum Data Set (an assessment tool) dated 07/26/2025, documented they could be understood, understand others, and was cognitively intact. Review of Resident #87's comprehensive care plan dated 03/24/2026 through 03/26/2026 identified the resident had multiple high-risk clinical needs, including airway management related to a tracheotomy/artificial larynx, enteral nutrition, cancer-related pain, impaired communication, decreased mobility, and fall risk. Interventions included monitoring respiratory status, managing secretions, providing suctioning as needed, maintaining airway patency, administering tube feedings, managing pain, and assisting with activities of daily living. The care plan reflected the need for ongoing monitoring, staff assistance, and timely intervention across multiple disciplines. Review of Resident #87's physician orders on the Order Summary Report dated 04/09/2026, reflecting active orders as of 07/26/2025, identified the resident had a diagnosis indicating an altered airway (presence of artificial larynx/tracheotomy). However, there were no physician orders for tracheostomy or laryngectomy care, including suctioning, stoma care, humidification, or respiratory therapy involvement. Additionally, there were no orders for required bedside emergency airway supplies, such as a spare tube, obturator, suction equipment, or emergency airway instructions. Orders during this period were limited to general care, including medications, wound care, enteral feeding, and routine monitoring. Overall, the record review identified a discrepancy between the resident's documented clinical condition and care plan needs, and the absence of corresponding physician orders to support airway management and emergency preparedness, as well as inconsistencies in medication administration documentation. During an interview on 4/15/2026 at 10:51 AM, Medical Director #1 stated, they would not accept any resident without staff having appropriate training to care for each resident, and if they were unable to obtain the necessary supplies for that resident. The Facility Assessment is updated to reflect staffing needs. During an interview on 04/15/2026 at 1:31 PM, The Facility Assessment is updated annually and as needed. It was brought to the attention of the Administrator that the Facility assessment dated [DATE] documented zero (0) tracheostomy residents. The census includes one (1) active resident and one (1) discharged , resident. 10 New York Code of Rules and Regulations 415.26

Based on observation, record review and interviews conducted during a survey, the facility did not ensure residents were free from significant medication errors for one (1) (Resident #9) of seven (7) residents reviewed, for a total of twenty-five (25) observations. Specifically, Resident #22 had a medication dose discrepancy for an anti-seizure medication that was not addressed for twenty-one (21) days after the order was changed. Findings include: The Facility's Policy and Procedure titled Medication Administration revised 12/2019, documented Medications shall be administered in a safe and timely manner, and as prescribed. PROCEDURE: The individual administering the medication must check the label THREE (3) times to verify the right medication, right dosage, right time and right method (route) of administration before giving the medication. Resident #9 was admitted to the facility with diagnosis of Hemiplegia (severe or complete paralysis on one vertical side of the body, affecting the arm, leg, and sometimes the face), Hemiparesis (weakness, numbness, or reduced movement on one side of the body), following Cerebral Infarction (stroke i.e.: when blood flow to part of the brain is suddenly cut off), and Major Depressive Disorder (a serious mental health condition characterized by a persistent low mood, loss of interest in activities, and low energy). The Minimum Data Set (an assessment tool) dated 10/20/2025, documented they could be understood, understand others, and was cognitively intact. The Physician's Order dated 3/19/2026 documented give Depakote Tablet Delayed Release 125 milligrams; Give 3 tablet by mouth three times a day for Major Depressive Disorder. The Medication Administration Record documented start date of 3/31/2026 at 13:56PM. During an observation on 4/9/2026 at 9:00 AM, Registered Nurse #4 poured Depakote Tablet Delayed Release 125 milligrams (3 tablets) to administer to resident #9. The medication blister pack instructions read: Depakote Tablet Delayed Release 125 milligrams; Give three (3) tablets by mouth two (2) times a day. The physician order read give three (3) tablets, three (3) times a day. When pointed out the discrepancy between the physician order and blister pack order, Registered Nurse #4 stated they were told to follow what is in the computerized medication administration record. They then called Licensed Practical Nurse#2 , who is also the Unit manager, to gain clarify. Licensed Practical Nurse#2 reiterated they were also told to follow what is in the computerized Medication Administration Records. Licensed Practical Nurse#2 was unable to ascertain which was the correct physician order. During an interview on 4/9/2026 at 10:00AM, Director of Nursing #1 was also unable to ascertain which order was the correct order. However, they stated that when there is an order change the facility continues to use the old medication blister pack. When the old order blister pack is completed, they will place the new order with pharmacy services. During an interview on 4/9/2026 at 10:00AM, Administrator #1 located the order change that was initiated on 3/19/2026 to increase Depakote Tablet Delayed Release 125 milligrams (give 3 tablets) from two (2) times per day to three (3) times per day. They stated the order change should have been sent to pharmacy and either they would send a new blister pack of medication or further instructions. During an interview on 4/15/2026 at 10:51 AM, Medical Director #1 stated with any medication discrepancy, it is the responsibility of the medication nurse to notify the medical director or nurse practitioner on call or on site for clarification. Orders must be signed in real time by the ordering provider. The nurse entering the order must ensure the provider signs off on the order so that the mediation can be administered. 10 New York Codes, Rules, and Regulations 415.12(m)(2)

Based on interview and record review conducted during a survey, the facility failed to ensure that Comprehensive Care Plans were reviewed and/or revised to reflect the resident's current condition for one (1) (Resident #85) of six (6) reviewed for accidents. Specifically, for Resident #85, there was no documented evidence that the Comprehensive Care Plan was reviewed and/or revised after a fall that occurred on 5/04/2026. Findings include: The facility policy titled Care Plans- Comprehensive last reviewed 8/02/2024, documented a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs was developed and implemented for each resident. It documented that assessments of residents were ongoing and care plans were revised as information about the residents and the residents' conditions changed. The interdisciplinary team reviewed and updated the care plan when there was a significant change in the residents' condition and when the desired outcome was not met. The facility policy titled Fall Management and Prevention last revised 1/2023, documented the interdisciplinary team identified and implemented appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. The staff would review and revise interdisciplinary care plan when a change was identified, after an event. Resident #85 was admitted to the facility with diagnoses of end stage renal disease (a condition where the kidneys can no longer effectively filter waste and excess fluid from the blood), type 2 diabetes (an endocrine dysfunction causing unregulated blood glucose levels), and chronic respiratory failure (a condition where the lungs cannot adequately exchange oxygen and carbon dioxide). The Minimum Data Set (an assessment tool) dated 10/13/2026, documented the resident was cognitively intact, could be understood, and could understand others, An Initial Event assessment dated [DATE] at 8:16 PM, documented Resident #85 was turned on their left side on the side of the bed when they slipped off the side of the bed onto the floor, while the Certified Nurse Aide was providing incontinence care. The resident did not hit their head. Interventions initiated to decrease risk for falls included: (a.) occupational therapy evaluation and treatment as indicated, physical therapy evaluation and treatment as indicated, non-skid socks, and bed in lowest position. Resident #85's Comprehensive Care Plan for Falls, documented the resident was at risk for falls/has had an actual fall related to deconditioning, gait/balance problems, and immobility. There was no documented evidence that Resident #85's Comprehensive Care Plan was reviewed and/or revised after a fall that occurred on 5/04/2026. During an interview on 4/14/2026 at 1:18 PM, Director of Nursing #1 stated when a resident was found on the floor an incident and accident report was completed with statements. Incident and accident reports were brought to morning meeting and discussed with the interdisciplinary team and closed out by the interdisciplinary team. They stated the care plan was updated once agreed upon interventions were put into place. 10 New York Codes, Rules, and Regulations: 415.11(c)(2)(i-iii)

Based on record review and staff interviews conducted during a survey, the facility failed to ensure that a resident's discharge was appropriate based on the resident's clinical status at the time of discharge (because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility) for one (1) (Resident #83) of three (3) residents reviewed. Specifically, Resident #83 had diagnoses including chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make It difficult to breathe) and was discharged to home despite waiting on results of a lab test: coronavirus disease (COVID)/influenza (flu) swab taken days prior to discharge. The facility did not obtain or review results of diagnostic testing (COVID/Flu) ordered prior to discharge. The facility did not ensure a physician evaluation confirmed clinical stability for discharge after cough syrup and COVID/Flu test were ordered. The resident was admitted to the hospital two (2) days after discharge with a diagnosis of influenza. Findings include: The facility policy titled Discharge-Transfer/Discharge Process effective 4/28/2026, documented the facility would coordinate a safe transfer or discharge for residents leaving the facility. When a resident was transferred or discharged from the facility, pertinent information regarding the transfer/discharge would be documented in the clinical record, including the discharge/transfer destination, reason for discharge/transfer, and summary of the resident's current medical status. If a resident was being discharged to the community, the resident and/or their representative would be provided with written interdisciplinary discharge instructions that summarize their medical, physical, and psychosocial condition at the time of discharge. Resident #83Resident #83 was admitted to the facility with diagnoses of type two (2) diabetes (an endocrine system dysfunction causing unregulated blood glucose levels), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make It difficult to breathe), and pulmonary hypertension (a serious, chronic disease characterized by high blood pressure in the arteries of the lungs, causing the right side of the heart to work too hard). The Minimum Data Set (an assessment tool) dated 12/29/2025, documented the resident was cognitively intact, could be understood, and could understand others. A complaint made to the Department of Health on 01/29/2026 at 3:15 PM documented the Resident #83 was scheduled to be discharged from the facility on 1/09/2026 following completion of their rehabilitation stay at the facility. Complainant #1 stated as 1/09/2026 approached, Resident #83 became increasingly ill, incapacitated, and was in no condition to be sent home. They stated the facility packed the resident into an ambulette and sent them home vomiting, which resulted in a near immediate hospitalization. Complainant #1 stated they had attempted to stop or postpone the discharge until Resident #83 was even somewhat less ill, but the facility did not listen. During an interview on 04/13/2026 at 9:03 AM, Complainant #1 stated Resident #83 was so sick when they were sent home, and should not have sent the resident home like that. They stated that once the resident was home, their cough did not get better. They stated Resident #83 was sent home on a Friday and the next day Complainant #1 had the resident sent back to the hospital, where they tested positive for influenza. Complainant #1 stated the facility had told them the resident tested negative for influenza, but they did not believe the facility tested the resident. They stated Resident #83 was very sick and weak.A physician treatment encounter note dated 12/31/2026 at 12:00 AM documented Resident #83 was clinically stable to discharge home with family. A transfer/discharge notice dated 1/09/2026 completed for Resident #83, documented the resident's health had improved sufficiently so the resident no longer needed the services provided by the facility as evidenced by successful completion of sub-acute rehabilitation. It was documented that the resident would not sign the notice and Administrator #1 was a witness to this. Complainant #1 was informed verbally about the notice on 1/06/2026. A physician order was initiated on 1/06/2026 at 5:16 PM for Guaifenesin Liquid 100 milligram/5 milliliters, give 10 milliliters by mouth every four (4) hours as needed for cough. Review of Resident #83's Medication Administration Record for January 2026, documented the resident was administered the cough medicine on 1/07/2026 at 11:35 AM and 1/08/2026 at 4:35 PM. A Medication Administration Note dated 1/07/2026 at 1:13 PM documented Guaifenesin Liquid 100 milligram/5 milliliters, give 10 milliliters by mouth every four (4) hours as needed for cough. It further documented as needed administration was ineffective. A Medication Administration Note dated 1/08/2026 at 5:49 PM, documented Guaifenesin liquid 100 milligram/5 milliliters, give 10 milliliters by mouth every four (4) hours as needed for cough. It further documented as needed administration was effective. A physician order dated 1/07/2026 at 4:45 PM, documented coronavirus disease (COVID)/influenza (flu) swab, one time only for check for one (1) day. Review of Resident #83's Medication Administration Record for January 2026, documented the covid, flu swab was completed on 1/07/2026 at 4:47 PM by Registered Nurse #1. There was no documented evidence as to why cough syrup and a COVID/Flu swab were ordered for Resident #83 prior to discharge. There was also no documentation that results were obtained from Resident #83's COVID/flu swab. There was no documented evidence that a medical provider saw Resident #83 after their treatment encounter on 12/31/2026 after cough medicine and a COVID/Flu swab were ordered to determine the resident's clinical status prior to discharge. Hospital Record for Resident #83, with encounter date of 1/10/2026, documented the resident was admitted from the emergency department on 1/11/2026. It documented that the chief complaint was shortness of breath/weakness. The assessment/plan documented Resident #83 was a [AGE] year old (gender) with past medical history of congestive heart failure, chronic kidney disease, type two (2) diabetes, pulmonary hypertension, hypoxic respiratory failure who presented in the emergency room for evaluation of one (1) week of history of malaise, weakness, cough, and shortness of breath. A chest x-ray showed pulmonary congestion, viral panel was positive for influenza, and a blood test used to diagnose and assess the severity of congestive heat failure was elevated. Presentation was consistent with acute on chronic heart failure exacerbation (sudden, dangerous worsening of symptoms like shortness of breath, fatigue, and swelling due to rapid fluid accumulation) in the setting of viral pneumonia (a lung infection caused by viruses that cause respiratory inflammation, often resulting in fever, dry cough, headache and fatigue). During an interview on 4/10/2026 at 11:02 AM, Administrator #1 stated they were covering social work responsibilities from September 2025 to February 2026 when the new social worker was hired. They stated Resident #83 was sent home with their discharge instructions and they called the resident throughout the day because Complainant #1 was not there. They stated when they spoke with the resident after discharge, the resident was anxious, but was not in respiratory distress and had everything they needed which included a concentrator, food, and appropriate services. They stated Complainant #1 did meet the resident at the home and set up their oxygen. Administrator #1 stated Resident #83 had no acute signs or symptoms of respiratory distress at the time of discharge. They stated per Complainant #1 request, they checked the resident for COVID/Flu and probably ordered cough syrup. They stated given the resident's anxiety, they completed the tests to appease Complainant #1. Administrator #1 further stated they would not have sent Resident #83 home if the resident was sick or had a change in condition. During an interview on 4/13/2026 at 12:32 PM, Registered Nurse #1 stated Resident #83 had a cough and congestion one (1) or two (2) weeks prior to discharge. They stated Complainant #1 had requested a coronavirus disease (COVID)/influenza (flu) test, but by the time the resident was getting ready for discharge, the resident was feeling better. They stated Resident #83 had some anxieties about going home. Registered Nurse #1 stated they never received the results of the COVID/flu swab. They stated the resident was weaned down to their baseline oxygen saturations. They stated Resident #83 suffered from anxiety and would often say that they could not breathe. Registered Nurse #1 stated they were putting a lot of orders in for cough medicine around that time for other residents on the unit. They stated the resident was feeling better and excited to be discharged to home. During an interview on 4/14/2026 at 10:03 AM, Rehabilitation Manager #1 stated around the time of discharge, Resident #83 said they were not feeling well and the facility was testing them for coronavirus disease (COVID)/influenza (flu). During an interview on 4/14/2026 at 10:52 AM, Registered Nurse #1 stated the facility had a rapid coronavirus test, but not a rapid influenza test. Tests results would typically come back the same day if processed at the hospital, or it would take four (4) or five (5) if the hospital sent it to an outside lab. Registered Nurse #1 stated Resident #83 was having symptoms so they got the respiratory panel for coronavirus, influenza, and respiratory syncytial virus (RSV, a common virus that usually causes mild, cold-like symptoms, but can lead to severe lung infections, especially in infants, older adults, and those with weakened immune systems), but the resident's symptoms were starting to resolve. They stated they did not remember doing the test and they were uncertain if it was sent out. They stated because the resident was no longer showing symptoms, it was no longer indicated when questioned about the results of the test. During an interview on 4/14/2026 at 12:19 PM, Director of Nursing #1 stated when Resident #83 was about to be discharge, their family member wanted the resident to be tested for coronavirus disease (COVID)/influenza (flu). They stated on the day of discharge the resident was tearful, but grateful and had no respiratory symptoms. Director of Nursing #1 stated they were not aware that Resident #83 received cough medicine the days prior to discharge. They stated if a coronavirus disease (COVID)/influenza (flu)swab was completed it should have been sent out. They stated the order would have been cancelled if it were not completed. They stated they could not assume that the test was not sent to the lab, but test results could not be found. During an interview on 4/15/2026 at 1:59 PM, Administrator #1 stated the hospital had started shipping respiratory panels to outside labs, which had a four (4) day turn around. They would not have gotten the results prior to discharge and the resident had no symptoms. They stated they saw that the resident went to the hospital and was diagnosed with the influenza after discharge.During an interview on 4/15/2026 at 11:33 AM, Medical Director #1 stated influenza was more severe than COVID. They stated they did not just complete coronavirus disease (COVID)/influenza (flu) swabs; it was usually based on symptoms. When discussing Resident #83, Medical Director #1 stated it sounded like there was more to their situation than what was indicated. They stated they would expect documentation for rationale for a COVID/flu swab to be completed and for cough medicine ordered. They stated discharge planning continued up until the resident went home.10 New York Codes, Rules, and Regulations: 483.21(c)(1)

Based on observation, interview, and record review during a survey, the facility failed to ensure necessary services were provided to maintain good nutrition and activities of daily living for 1 (one) of 4 (four) residents reviewed for activities of daily living care (Resident #41). Specifically, For Resident #41, the facility failed to provide appropriate assistance and cueing during meals as this resident required support when eating. Findings include: Review of the facility policy titled Activities of Daily Living Care and Support, revised 11/6/2025 documented Activities of Daily Living care and support are to be provided in accordance with the resident's assessed needs, personal preferences, and individualized plan of care, including assistance with hygiene, mobility, toileting, and dining. The policy further documented the interdisciplinary team would have monitored the resident's ability to perform Activities of Daily Living and revise the plan of care as indicated, and the amount of assistance provided would have been documented in the clinical record. Resident #41 was admitted to the facility with a diagnosis of Traumatic Subdural Hemorrhage (bleeding on the brain), Hypertension and malnutrition (poor nutrition). The Minimum Data Set (an assessment tool) dated 3/30/2026, documented Resident #41 had a severe cognitive impairment. It further documented the resident always understood was able to be understand others; required assistance with meal preparation only. The 03/23/26 care plan documented the resident had a nutrition problem and was malnourished with 7% weight loss in 1 month. The plan was to continue their diet as ordered; monitor weights; offer snacks; evaluate intake and preferences; review meal/fluid intake; Report significant weight changes to physician. Record review of the certified nurse aide documentation intake records from admission [DATE]-[DATE] revealed poor, inconsistent intake with frequent minimal consumption and refusals and no consistent adequate intake pattern. Record review of the certified nurse aide documentation from 04/01/2026-04/13/2026 revealed frequent low or refused intake with inconsistent consumption overall, poor oral intake and a lack of sustained or adequate nutritional and fluid intake. Record Review of Resident# 41's weight since admission documented on 03/23/2026, the resident weighed 137.2 pounds. On 04/10/2026, the resident weighed 134.6 pounds. On 04/15/2026, the resident weighed 132.1 pounds. During this time, Resident #42 demonstrated a 5.1-pound weight loss. During an observation on 04/08/2026 at 12:25 PM, Resident #41 was in the dining area with a meal present. The resident did not initiate eating; no encouragement was provided. Staff were observed at a distance and did not engage the resident to promote intake. During an observation on 04/10/2026 at 1:05 PM, Resident #41 was in their room with a meal tray containing a hotdog and vegetables. No food had been consumed. The resident remained seated in front of the tray without initiating eating and did not demonstrate the ability to independently begin the meal. The resident remained alone in the room. Following constant observation, no staff had entered the room to provide cueing, encouragement, or assistance with eating. At 1:46 PM, a Certified Nurse Aid entered the room, removed the uneaten meal tray and remarked about the uneaten food and left the room. During an observation on 04/13/2026 at 12:59 PM, Resident #41 was in their room with a meal tray delivered. All food items remained covered. The resident demonstrated difficulty initiating the task of eating, as evidenced by attempting to open containers and holding items without successfully accessing the food. The resident placed a covered bowl into a plastic bag containing bread, turned toward the bed, adjusted the linens, and lay down without consuming the meal. During an observation on 04/13/2026 at 1:23 PM, a Certified Nurse Aide # 1 entered the resident's room, stated, You not going to eat? and removed the meal tray without helping, cueing, or encouragement provided to assist the resident with consuming the meal. During an observation on 04/14/2026 at 8:45 AM, Resident #41 was standing in their room with a breakfast meal consisting of eggs, juice, cereal, and a cut muffin. The resident manipulated food items on the plate and initiated drinking fluids but did not consume solid food. During an observation on 04/14/2026 at 9:25 AM, Certified Nurse Aide #2 subsequently entered Resident #41's room, asked if the resident was finished, and removed the tray. The meal remained uneaten. During an observation on 04/15/2026 at 8:25 AM, Resident #41 had an early breakfast tray delivered to their room due to an outside appointment. The resident was ready for their appointment and had been walking around the facility in their coat. They had not been in their room during the time the tray was delivered, and the tray remained uneaten when they left the facility. During an interview on 04/08/2026 at 9:57 AM, the resident's family member #2 stated they had discussed concerns with Nurse Practitioner #1 regarding the resident's weight loss and inability to feed themselves independently. They stated the resident required direction and encouragement for daily functioning and did not initiate tasks independently. They further stated the resident had required encouragement to eat and expressed concerns that staff had not consistently provided supervision or assistance, particularly during meals. They expressed concern regarding the resident's anxiety, unmet toileting needs, and lack of staff engagement. They stated they would be discussing this at the care plan meeting later that day. Family member #2 described a concern regarding Resident # 41s ability to toilet themselves independently. They described the resident occasionally soiling the bed and, in an effort, to conceal the mess they would make the bed over the soiled sheets. The family described situations where the resident flushed their incontinent briefs down the toilet causing the toilet to overflow. During an interview on 04/15/2026 at 9:08 AM, Occupational Therapist #1 stated they had evaluated Resident #41on 03/24/2026 and identified the resident as independent with some cognitive impairment. Their recommendation was for supervision with Activities of Daily Living. They had not been aware the resident was not consuming meals and stated they would expect to be notified for further evaluation and treatment if the resident was not able to carry out the skill of eating. Staff should report if a resident was unable to eat or toilet independently and indicated that if the resident had been flushing incontinence briefs, that would suggest a need for increased assistance. During an interview on 04/15/2026 at 9:32 AM, Licensed Practical Nurse #3 stated the resident was independent sometimes, reported the resident would eat at times, and stated they were not aware of the resident not eating. They reported the resident was independent with toileting themselves. During an interview on 04/15/2026 at 9:36 AM, Certified Nurse Aide #1 stated the resident just does not eat. Certified Nurse Aide #2 said the resident did not do well in the dining room, so they changed their eating location to their room, but they still did not eat their meals. During an interview on 04/15/2026 at 9:38 AM, Registered Nurse #1 stated the resident was to have their meal prepared. If the resident was not eating meals the staff should let them know. Staff should be preparing the meal by opening the lids and encouraging consumption. During an interview on 04/15/2026 at 10:51 AM, Registered Dietitian #1 stated they were aware of the consistent decline in the Resident #41's weight. They stated on 04/14/2026, they added nutritional supplements to the resident's meal tray. They were aware of the resident's low intake; however, they had not been aware of the lack of assistance or encouragement with the resident's meals 10 New York Codes, Rules, and Regulations: 415.12(c)

Based on observation, record review, and interviews conducted during a survey, the facility did not ensure that its medication error rate did not exceed 5 percent for two (2) (Resident #9 and #22) of seven (7) residents observed during medication administration with 25 observations. This resulted in a medication error rate of 24 percent. Findings include: The Facility's Policy and Procedure titled Medication Administration revised 12/2019, documented Medications shall be administered in a safe and timely manner, and as prescribed. PROCEDURE: The individual administering the medication must check the label THREE (3) times to verify the right medication, right dosage, right time and right method (route) of administration before giving the medication. Resident #9 was admitted to the facility with diagnosis of Hemiplegia (severe or complete paralysis on one vertical side of the body, affecting the arm, leg, and sometimes the face), Hemiparesis (weakness, numbness, or reduced movement on one side of the body), following Cerebral Infarction (stroke i.e.: when blood flow to part of the brain is suddenly cut off), and Major Depressive Disorder (a serious mental health condition characterized by a persistent low mood, loss of interest in activities, and low energy). The Minimum Data Set (an assessment tool) dated 10/20/2025, documented they could be understood, understand others, and was cognitively intact. The Physician's Order dated 3/19/2026 documented give Depakote Tablet Delayed Release 125 milligrams; Give 3 tablet by mouth three times a day for Major Depressive Disorder. The Medication Administration Record documented start date of 3/31/2026 at 13:56PM. During an observation on 4/9/2026 at 9:00 AM, Registered Nurse #4 poured Depakote Tablet Delayed Release 125 milligrams (3 tablets) to administer to resident #9. The medication blister pack instructions read: Depakote Tablet Delayed Release 125 milligrams; Give three (3) tablets by mouth two (2) times a day. The physician order read give three (3) tablets, three (3) times a day. When pointed out the discrepancy between the physician order and blister pack order, Registered Nurse #4 stated they were told to follow what is in the computerized medication administration record. They then called Licensed Practical Nurse#2, who is also the Unit manager, to gain clarify. Licensed Practical Nurse#2 reiterated they were also told to follow what is in the computerized Medication Administration Records. Licensed Practical Nurse#2 was unable to ascertain which was the correct physician order. During an interview on 4/9/2026 at 10:00AM, Director of Nursing #1 was also unable to ascertain which order was the correct order. However, they stated that when there is an order change the facility continues to use the old medication blister pack. When the old order blister pack is completed, they will place the new order with pharmacy services. During an interview on 4/9/2026 at 10:00AM, Administrator #1 located the order change that was initiated on 3/19/2026 to increase Depakote Tablet Delayed Release 125 milligrams (give 3 tablets) from two (2) times per day to three (3) times per day. They stated the order change should have been sent to pharmacy and either they would send a new blister pack of medication or further instructions. Resident #22 was admitted to the facility with diagnosis of Alzheimer's Disease (a progressive, irreversible neurological disorder that destroys brain cells, causing cognitive decline, memory loss, and behavioral change); , osteoporosis (a common bone disease characterized by weak, brittle bones with reduced mass and density); and status post hip fracture (broken hip). The Minimum Data Set (an assessment tool) dated 2/32026, documented they could be understood, understand others, and was cognitively intact. The April 2026 Medication Administration Record for Resident #22 documented give Tylenol 325 milligrams two (2) tablets twice daily; Ferrous Sulfate 325 milligrams one (1) tablet daily; Vitamin D 5000unit / 125 micrograms, give five (5) tablets daily; Memantine 5 milligrams, one (1) tablet twice daily. Special instructions: Crush Medication. During an interview on 4/9/2026at 8:45 AM, Licensed Practical Nurse #5 was asked how the medication is administered to resident #22. Licensed Practical Nurse #5 stated they crush resident #22 pills because that is what was written in the special instructions. When asked to see the physician order to crush medications, Licensed Practical Nurse #5 stated they were unable to find the actual physician order,but acknowledged that there should be an order from either physician or nurse practitioner. During an interview on 4/9/2026 at 10:00AM, Director of Nursing #1 stated that all crushed medications require a physician order. When Director of Nursing #1 was asked to show surveyor the physician order, they were unable to locate the crush medication orders for resident #22 and entered the order during the interview. During an interview on 4/15/2026 at 10:51 AM, Medical Director #1 stated with any medication discrepancy, it is the responsibility of the medication nurse to notify the medical director or nurse practitioner on call or on site for clarification. Orders must be signed in real time by the ordering provider. The nurse entering the order must ensure the provider signs off on the order so that the mediation can be administered. 10 New York Codes, Rules, and Regulations 415.12 (m)(1)

Based on observation, interview, and record review conducted during a survey, the facility failed to ensure ongoing provision of programs to support each resident and their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial wellbeing for two (2) (Resident #'s 6 and 9) of two (2) residents reviewed. Specifically, (a.) Resident #6 was nearing end of life and was not provided with any stimulation or one-to-one interaction or visits; and (b.) Resident #9 stated they felt like a prisoner and were not provided with time outdoors per their preference. Additionally, perfume sampling was included on the activities agenda on 4/14/2026 and could have caused adverse reactions for some residents. Findings Include: The facility policy titled Activity Program last reviewed 5/2019, documented the facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities designed to meet the interests of and support the physical, mental, and psychosocial wellbeing of each resident. Individualized and group activities were provided that: (a.) reflected the schedules, choices and rights of the residents; (b.) were offered at hours convenient to the resident; (c.) reflected the cultural and religious interests, hobbies, life experiences, and personal preferences of the residents; and (d.) appealed to men and woman as well as those of various age groups residing in the facility. Resident #6 Resident #6 was admitted to the facility with diagnoses of end stage renal disease (a condition where the kidneys can no longer effectively filter waste and excess fluid from the blood), hypertension (high blood pressure), and dementia (a group of conditions that cause a progressive decline in cognitive abilities). The Minimum Data Set (an assessment tool) dated 4/01/2026, documented the resident was severely cognately impaired, could be understood, and could understand others. During an observation made on 4/08/2026 at 11:51 AM, Resident #6 was observed in their room, no activities were present, and they had no staff interactions throughout the morning. During an observation on 4/10/2026 at 1:44 PM, Resident #6 was observed in bed, their skin was dusky ash appearance, they were lethargic, had dry mucosa, and periods of apnea. Resident #6 responded to questions and attempted to have a conversation. There were no activities present in the resident's room. During an interview on 4/10/2026 at 2:12 PM, Director of Activities #1 stated clergy went to see Resident #6, but since family was present, they did not see them. Director of Activities #1 stated they normally provided one-to-one visits with the resident. There was no documented evidence that one-to-one visits were provided to Resident #6. Resident #9 Resident #9 was admitted to the facility with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (a neurological condition causing paralysis or weakness on the left side of the body, stemming from right brain damage), dementia, and depression (a mental health condition characterized by persistent sadness, loss of interest, and other symptoms that significantly impair daily life). The Minimum Data Set, dated [DATE], documented the resident was cognitively intact, could be understood and could understand others. During an interview on 4/08/2026 at 1:56 PM, Resident #9 stated they felt like a prisoner. They stated they have resided at the facility for 6 years and only went outside for medical appointments. Resident #9 stated they would like to go outside and sit in the sun. During an interview on 4/08/2026 at 2:30 PM, Director of Activities #1stated Resident #9 refused to come out of their room, but they provided activities to the resident in their room. When asked for the log of one-to-one visits provided to Resident #9, Director of Activities #1 was unable to produce any documentation. Director of Activities #1 stated Resident #9 had not been outdoors, but they would offer to take the resident outside going forward. They stated Resident #9's family member took them outside. There was no documented evidence that one-to-one visits were provided to Resident #9. During an observation on 4/14/2026 at 10:15 AM, the activity scheduled was sample of perfumes and history. Nursing staff brought concerns regarding perfume sampling and the reaction it could cause to some residents to the activity department and advised them not to sample perfumes. The activity was altered. During an interview on 4/14/2026 at 11:48 AM, Regional Director of Nursing #1 stated they did not believe that the activities calendar was reviewed before it was implemented. They stated an activity to sample perfume was not recommended as perfumes could create health hazards. During an interview on 4/15/2026 at 10:54 AM, Medical Director #1 stated that perfume sampling was not an appropriate activity in a skilled nursing facility setting. 10 New York Codes, Rules, and Regulations 415.5(f)(1)h

Based on record review and interviews during an abbreviated survey (Case # NY00331618), the facility failed to ensure residents were free from neglect. Specifically, Certified Nurse Aide #1 did not follow Resident #3's care plan which included that the resident required physical assistance from two nursing staff to safely complete bed mobility. On 1/15/2024, Certified Nurse Aide #1 attempted to roll the resident while they were in bed without assistance from another nursing staff member. Subsequently, the resident fell on to the floor and sustained fractures to both of their legs. This resulted in actual harm that was not immediate jeopardy for Resident #3. This is evidenced by: The Policy and Procedure titled Abuse, last revised December 2022, documented the facility prohibited the mistreatment, neglect, abuse of residents/patients, and misappropriation of resident/patient property by anyone including but not limited to staff, family, friends, and residents of the facility. The facility prohibited any exploitation of the mentally and physically disabled resident in the facility. The facility had designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property. Resident #3 was admitted to the facility with diagnoses of hemiplegia and hemiparesis (muscle weakness or paralysis) affecting left non-dominant side, conversion disorder with seizures or convulsions (a medical condition where the body muscles contract and relax rapidly resulting in uncontrolled shaking) and spastic hemiplegic cerebral palsy (a neurological condition that can present as issues with muscle tone, posture and/or a movement disorder). The Minimum Data Set (an assessment tool) dated 1/12/2024, documented the resident could be understood and could understand others with intact cognition for decisions of daily living. The Activities of Daily Living Care Plan, initiated 9/20/2019, documented Resident #3 was dependent on physical assistance from two or more staff to perform transfers, bed mobility (rolling from their left to right side), bathing, toileting, and dressing. The resident was documented as unable to use their own strength for any part of bed mobility. Two or more staff were required to use their own strength to lift or hold the resident's body, arms, and legs during the entire activity. The Facility Investigation dated 1/16/2024 documented Resident #3 required the assistance of two nursing staff to roll the resident in bed from side to side. Upon investigation, it was identified that on 1/15/2024 at approximately 6:45 PM, Certified Nurse Aide #1 failed to follow Resident #3's care plan while attempting to roll the resident in bed without the assistance of another staff. While attempting to roll the resident, the resident's left leg began to slide off the bed then the resident's whole body slid to the floor. Resident #3 was assessed by Registered Nurse #2 following the incident and documented the resident had no pain or discomfort at the time. According to the facility's investigation report, Resident #3 reported pain the following morning on 1/16/2024 at approximately 5:30 AM and was assessed by Registered Nurse Unit Manager #1; the physician was notified, and the resident was transferred to the hospital for further evaluation. Hospital records were obtained which revealed the resident had sustained fractures in both legs. An Investigation Statement dated 1/15/2024 documented that Certified Nurse Aide #1 acknowledged they were aware Resident #3's care plan included the resident required two staff to perform care, however, they thought they were capable of providing the care by themself. A Radiology Report dated 1/16/2024 documented Resident #3 had a non-displaced fracture of the fibular head (a broken calf bone where the pieces remain aligned and do not move far enough out of place to create a gap) (top of a bone in the lower leg) of their right leg and a femoral diaphyseal (fracture (a break in the thigh bone near its center) and non-displaced fracture of posterior aspect medical distal femoral condyle (base of the femur behind the knee) of their left leg. During an interview on 5/20/2024 at 11:30 AM, Resident #3 stated Certified Nurse Aide #1 attempted to turn them by themself. They stated they told Certified Nurse Aide #1 they were not positioned correctly in order to be turned. They stated they noticed their left leg was completely off the bed and then all of sudden they were on the floor. They stated they were frustrated with Certified Nurse Aide #1 because they warned them this would happen. They broke both their legs during the fall and required surgery. They stated both legs had since healed, and they felt safe at the facility. They stated the facility had made sure there were two staff providing their care when they returned from the hospital following the incident. During an interview on 5/31/2024 at 1:10 PM, Director of Nursing #1 stated Certified Nurse Aide #1 had received education and completed a return demonstration of how to access resident care plans prior to the incident. They stated the facility was sufficiently staffed when Certified Nurse Aide #1 attempted to provide care to Resident #3 without assistance and they elected to try to do the care on their own. They stated Resident #3 was immediately assessed after they fell on to the floor and initially, the resident reported to be without pain. They stated the on-call physician was notified at the time of the fall and no orders were given to transport the resident to the hospital at that time. They stated the resident was lifted to their bed with a mechanical lift and monitored. They stated the following morning, the resident reported having pain and the on-call physician was notified and gave the order for the resident to be transported to the hospital. They contacted the hospital to follow-up on the resident's condition and were notified the resident had sustained fractures. They stated that facility-wide education was conducted to ensure that all staff could identify how to check the resident's care plan and which residents required the assistance of two staff in order to complete care. 10 New York Codes, Rules, and Regulations 415.4(b) Based on the following corrective actions taken as of 1/16/2024, 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: Certified Nurse Aide #1 was immediately suspended and subsequently terminated following the facility investigation. A Nursing In-service titled Comprehensive Care Plan and Kardex Usage was conducted on 1/16/2024 for nursing and therapy staff which included a hand-out, discussion and return demonstration. The in-service was signed off as completed by nursing and therapy staff across all shifts. The facility ran a report of all residents in the building who required the assistance of two staff to perform bed mobility and conducted an audit to ensure staff could identify which residents required two-person assistance. 95% of facility staff were educated on abuse, neglect and mistreatment related to neglect of care.

Based on observation, interviews, and record review during an abbreviated survey (Case #NY00310764), the facility failed to ensure each resident received adequate supervision to prevent accidents. Specifically, on 2/12/2023, the facility failed to provide Resident #1, who was cognitively impaired, with adequate supervision to prevent an elopement. Subsequently, Resident #1 was able to exit the building through the front door, which was alarmed, and exited the facility for approximately two hours. Did not discover the resident was missing until the resident's Power of Attorney called the facility to alert them that the resident was at their previous house. Review of resident's address on google maps revealed the resident house was approximately 5.2 miles North of the facility. The facility did not follow their process for elopement when the front door alarm was sounded, and an unknown staff member reset the alarm. The facility staff did not initiate a headcount when the wanderguard alarm sounded. This resulted in no actual harm with the likelihood for more than minimal harm that is Immediate Jeopardy and substandard quality of care to resident health and safety. Resident #1 Resident #1 was admitted to the facility with diagnoses of left leg fracture, left arm fracture, and dementia. The Minimum Data Set (MDS- an assessment tool) dated 2/8/2023, documented the resident could be understood and could understand others with a with moderately intact cognition for decisions of daily living. The Clinical Operations Policy for elopement, dated 2/2020, documented facility would implement prevention strategies for residents at risk for elopement. Implementation of the wander bracelet or other electronic alert systems, transfer to a more suitable or more secured facility, and notify the physician for changes in behavior, such as increasing insistence or attempts to leave. Staff working with the residents who were at risk for elopement would take into consideration to alert other staff members when the resident left unattended or away from a secured unit. Facility's Policy for Elopement- Missing Residents dated 1/2020, documented should an employee discover that a resident was missing from the facility, they should announce on the overhead paging system: Code Grey (3 times), the unit or area involved, the room number of the missing resident, and the time the resident was determined to be missing. The staff members assigned to the unit where the resident resides verify that the resident had not signed out and then staff notify the administration. If the search of the facility were unsuccessful, the charge person were supposed to coordinate a search of the outside of the facility, the premises, and surrounding areas. The policy did not include documentation of staff responding to the alarm when the alarm goes off. The Comprehensive Care Plan (CCP) dated 2/6/202023 for (actual/potential) risk for elopement related to cognitive impairment fluctuating and the desire to leave the facility unattended. Interventions included to identify triggers for the resident's desire to leave, initiate psychology evaluations as needed, and wander guard to the left ankle. The CCP for Activities of Daily Living dated 12/2/2022, documented resident required assistance related to altered weight bearing status, dementia, limited mobility, and limited Range of Motion (ROM). The interventions included to encourage the resident to participate to the fullest extent possible with each interaction, encourage the resident to use the bell to call for assistance, monitor for changes in status, notify interdisciplinary team as needed, and Therapy per orders. A Registered Nurse (RN) Assessment Note dated 2/3/2023 at 10:43 PM, written by RN #4 documented Resident #1 had asked the nurse if they had scissors. The nurse asked the resident how they could help them, and they insisted on not telling the nurse what the scissors were to be used for. Resident #1 finally told the nurse that they wanted to cut the wander guard off their ankle. A Social Services Note dated 2/6/2023 at 8:40 AM, written by the Director of Social Work (DSW) documented the Social Worker (SW) #1 met with Resident #1 due to increased exit seeking behaviors. Resident #1 told the SW that they wanted to go home. The DSW explained to the resident that the barrier to their discharge back to the community was their weightbearing status. A Behavior Note dated 2/6/2023 at 3:58 PM, written by RN #4 documented the resident was displaying exit seeking behaviors, increased anxiety about going home, and expressed the desire to return home. RN #4 saw the resident passing the nurses station with their quad cane. Resident #1 went up to the door exiting the facility and tried to open the door but was not successful. The resident had a wander guard on their right ankle. A General Documentation Note dated 2/6/2023 at 7:39 PM, written by the DSW documented the resident had increased exit seeking behaviors. They were asked to meet with the resident because they were found to be exit seeking around 3:49 PM. Resident #1 and RN #4 were observed sitting in the lobby and resident appeared to be quite anxious/distressed. Resident #1 reported they wanted to leave the building, stating I want to go home. They also stated they had a house not too far from the facility and they would walk there. A General Documentation Note dated 2/6/2023 at 10:56 PM, written by RN #2, documented Resident #1 was exit seeking. They were ambulating without their cane or wheelchair, slightly agitated and was redirected. A General Documentation Note dated 2/9/2023 at 8:00 PM, written by Licensed Practical Nurse (LPN) #3, documented the resident made multiple attempts to leave the building, left the floor without their walker, wheelchair, and or cane. Resident #1 stated they were going home. Resident #1 was redirected and brought back to their room. The Accident/Incident (A/I) Statement Form written by LPN #3 on 2/12/2023 at 3:15 PM, documented RN #1 asked them about the whereabouts of Resident #1 due to a phone call from their Power of Attorney (POA) wondering who signed Resident #1 out. LPN #3 documented the resident had not been signed out to their knowledge and the resident was not in their room. The resident was last seen by Certified Nurse Aide (CNA) #9 at 1:30 PM during the pick-up of the resident's lunch tray. The front door alarm was activated at approximately 2:15 PM. They walked to the front lobby to check, but someone had already turned it off. The staff member that reset the alarm was not determined and the reason for the front door alarming was not determined. During an observation of the wanderguard system with the Nursing Home Administrator (NHA) present on 2/27/2023 at 4:00 PM. The wanderguard locked the doors so the wanderguard residents could not get out if they pushed to open the doors. If a resident with a wanderguard tried to exit behind someone with the door already open, the alarm would sound a higher pitched siren. The 15-second emergency egress would override the wanderguard system. During an interview on 2/24/2023 at 11:49 AM, the NHA stated that they did not know how the resident got the wander guard off or how they got out of the building. The facility does not have a camera system, so they were unable to determine how it happened. The NHA stated that they felt the elopement was planned by Resident #1 because they knew there was no staff coverage at the door after 2:00 PM that day, and had been verbalizing that they wanted to leave the facility. During an interview on 2/27/23 at 11:56 AM, Receptionist (RCP) #1 stated they were aware that wanderguards were used to alert staff when a resident attempted to leave the facility. Residents with wanderguards had a specific code connected to the alarm system. When a wanderguard activates an alarm, they were supposed to alert staff and attempt to locate the resident. RCP #1 stated all nurses had the code to deactivate the alarm system. When staff failed to locate a resident, they were expected to notify the Administrator and law enforcement immediately. During an interview on 2/27/23 at 12:27 PM, CNA #4 stated they were aware Resident #1 had a wander guard. Resident #1 was alert and oriented and required limited assistance. Prior to 2/12/23, Resident #1 attempted to leave the facility on numerous occasions. During an interview on 2/27/23 at 12:45 PM, LPN #2 stated Resident #1 had a wanderguard around their left ankle. Normally when a resident with a wander guard attempts to leave the facility entrance, the alarm would be activated. The policy required staff to notify the Director of Nursing (DON) or the ADM when a resident cannot be located. LPN #2 stated staff failed to investigate the cause of the alarm as required by policy. They stated staff were not aware Resident #1 had eloped until the resident's POA called the facility. Resident #1 was exit seeking and attempted to leave the facility on numerous occasions. The resident followed them multiple times when they went out on smoke breaks and wanted to leave the facility. On 2/12/2023, the POA received a call from the tenant that currently resided in the resident's home notifying them that Resident #1 was at the Resident #1's house did not know how they got there. Staff were not aware that the resident had left the facility until approximately 3:45 PM when they called to determine who signed the resident out. The resident was not cleared to leave the facility due to their non-weightbearing status. Resident #1 told the POA that they left the facility through the front door, walked down the highway and hitch-hiked (travel by getting free ride in passing vehicles) home. During an interview on 2/27/23 at 2:15 PM, LPN #1 stated they worked on 2/12/23 the morning shift, when they attempted to exit the facility at approximately 3:10 PM, they noticed the alarm did not grant permission to exit the building. LPN #4 assisted with the alarm door and discovered the door was not closed (The door did not close as the magnetic locks were released when the alarm was set off). LPN #1 stated the alarm showed a code associated with a resident's wanderguard but did not know what that code was or what it meant until the in-service training was conducted after the elopement. They stated they were never given the code to override the alarm once the alarm was activated. The weather on 2/12/23 was cold and approximately 27 degrees Fahrenheit. During an interview on 2/28/2023 at 12:30 PM, the resident's tenant stated that Resident #1 showed up at their home sometime after 2:00 PM but was unable to give a precise time. The tenant stated Resident #1 arrived wearing a sweater, leggings, and crocs. The tenant stated they cleaned the resident up because they were covered in mud and dirt as if they had fallen. The tenant then called the POA to tell them that the resident was at their home. The resident was at their home for about 2 hours before the facility staff arrived. During an interview on 3/1/23 at 9:30 AM, the Director of Maintenance (DM) said the wanderguard was designed to lock the doors when the residents were within six feet of the entrance. The DM stated there was no reason to believe the alarm system failed. They checked the alarm system and did not identify any faults. The door was designed to open when you pushed the door open for fifteen seconds. When an alarm door sounds, the wanderguard code attached to the resident was revealed on the system panel. On 2/12/23, they were notified by the Administrator that Resident #1 had eloped. They arrived at the facility at approximately 4:30 PM and completed a wanderguard check. All doors were working appropriately and did not find any indication that the alarm system had malfunctioned. During a subsequent interview on 3/2/23 at 1:04 PM, LPN #3 stated when an alarm sounds, it showed up on the alarm panel at the nurse's station. The alarm panels direct staff to the exact location which caused the alarm to trigger. LPN #3 stated staff would look and search to verify the cause and code number of the alarm. A Code Grey was called when a resident could not be located. Staff were directed to never switch off alarm until the resident had been located and if the resident cannot be located, staff would call the Administrator and law enforcement immediately. LPN #3 stated when Resident #1 eloped on 2/12/23, it was expected that staff would investigate the cause of the alarm before shutting the alarm off and only nurses had the code to override or turn off the alarm. During an interview on 3/2/23 at 1:14 PM, LPN #4 stated staff should never override the alarm before they investigate the cause of the alarm. LPN #4 stated when an alarm was activated, staff should locate the cause of the alarm and locate all the residents in the building. LPN #4 stated in the event that a resident was missing, staff should contact the ADM and law enforcement immediately. Staff were to perform a head count when the entrance alarm sounded, but the staff did not follow the process. During an interview on 3/2/23 at 3:37 PM, RN #1 stated that on 2/12/23 they worked from 3:00 P.M. until 11:00 P.M. and was the charge nurse for the entire facility. A wander guard alarm has a clear and distinct sound and was different from the alarm system. On 2/12/23 at approximately 3:10 PM, they received a call from the resident's Power of Attorney. The POA asked who had signed the resident out of the facility. They did not hear the alarm sound but immediately called Code Grey and did a parameter search. RN#1 stated they would have expected staff to investigate the cause of the alarm immediately. There was no staff monitoring the front desk at the time. The resident had dementia and was exit seeking. LPN #4 picked up the resident from their former residence. The resident had mud on their clothes and an abrasion on their hand and cheek that was consistent with a fall. Based on the following corrective actions, the facility corrected the noncompliance as of 2/15/2023. The facility reached past noncompliance by taking sufficient corrective actions prior to the abbreviated survey to both remove the immediate jeopardy and fully correct the noncompliance before survey staff entered the Nursing Home (NH) on 2/20/2023. The facility's corrective actions included the following effective 2/15/23: 96% of staff have been reeducated on the procedure of the wanderguard system and the elopement policy. The staff were educated on the process for responding to the wanderguard system during an in-service conducted in February of 2023. The education material describes the alarm process and the different beeps for tones to indicate loitering and the main wanderguard alarm. The education also stated that when the alarm sounds, the first person to respond should not silence the alarm. They were to search the immediate area and check the elopement binder to identify which resident triggered the alarm and locate the resident. The alarm was not to be silenced until all residents are accounted for. A headcount was also necessary to ensure no other residents have left the building because the magnetic locks will not be in effect while the alarm was sounding. 10 NYCRR 415.12(h)(2)

Based on observation, record review, and interviews during an abbreviated survey (Case #NY 302), the facility did not ensure the resident has the right to be free from physical abuse for 1 (Resident #1) of 3 residents reviewed for abuse. Specifically, the facility did not ensure that Certified Nursing Assistant #1 (CNA) did not enter Resident #1's room after Resident #1 and their resident representative had stated to the Registered Nurse Manager (RNM) during a meeting on 9/2/2022 that they did not want CNA #1 near or providing care to them. On 9/15/2022, CNA #1 entered Resident #1's room, a verbal altercation occurred between CNA #1 and Resident #1, and CNA #1 physically assaulted Resident #1 by pushing their hands forcefully into both of the resident's eyes. Subsequently, Resident #1 required care in the emergency room and was diagnosed with a corneal abrasion (a scrape on the clear part in the front of the eye) to their right eye. This resulted in actual harm that was not immediate jeopardy. This was evidenced by: Resident #1: Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- an assessment tool) dated 9/13/2022, documented the resident was cognitively intact, could be understood, and could understand others. The MDS dated [DATE], documented the resident had highly impaired vision. The Policy and Procedure last revised in February 2019 titled Abuse, documented the facility prohibits the mistreatment, neglect, and abuse of residents by anyone including staff. During an observation of Resident #1 on 9/16/2022 at 10:21 AM, the resident was wearing sunglasses removed them for the observation of the resident's eyes by the surveyor and then put them back on. The resident had three small scratches below their left lower eye lid and one above their left eye. There was a small purple/red bruise within the inner corner of their right eye near the bridge of their nose. The sclera (the white part of the eye) of their right eye was reddened. The Accident and Incident Report dated 9/15/2022 at 9:30 PM, documented there was a staff witness of physical abuse to Resident #1 by CNA #1. The witness reported CNA #1 entered Resident #1's room, shut the door, and proceeded to smush Resident #1's face with their hand, pushing the resident's head back in response to the resident having called CNA #1 a bad name. 911 was called to report elder abuse and was subsequently arrested on elder abuse charges. The untimed facility Investigation Form dated 9/15/2022, documented CNA #1 was witnessed by another staff member of physically pushing Resident #1's face with their hand. CNA #1 was terminated due to the substantiated physical abuse Resident #1. CNA #1 was arrested by the law enforcement agency that responded to the facility on [DATE]. The emergency room note dated 9/16/2022 at 12:29 PM, documented the resident reported they had been assaulted by the aide at the nursing home and complained of right eye pain. The physical examination documented the resident had diffuse facial tenderness to light touch. A stain placed in the eyes showed a 3.0 millimeter (mm) in length by 1.0 mm in width corneal abrasion in the right eye. CT scans were done of the facial bones and head and showed no evidence of facial bone fracture or acute intracranial (within the skull) abnormalities. The resident was prescribed [MEDICATION(S)] (an antibiotic) ointment to the right eye to treat the corneal abrasion and follow-up with primary care on 9/17/2022 and ophthalmology in 1-3 days. During an observation of Resident #1's injuries on 9/19/2022 at 8:38 AM, the resident had three small scratches below their left lower eye lid and one above their left eye. The resident's bruising on the inner corner of their right eye remained the same size and appearance as it was when observed on 9/16/2022. The resident's sclera was reddened in the resident's right eye, and they had ointment in and around their right eye. A Comprehensive Care Plan (CCP) dated 9/16/2022, documented Resident #1 was at risk for neglect and abuse. The resident has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a recent episode of an abuse-related event. It documented to assess the resident for signs of abuse/neglect, investigate all allegations of abuse and neglect promptly, Psychiatry consult, provide emotional support and ensure the resident is free from abuse. A CCP dated 9/16/2022, documented Resident #1 was at risk for alteration in mood related to abuse-related episode. It documented to monitor the resident's mood and report changes to the charge nurse, offer reassurance as needed, and Psychiatry consult as needed. A CCP dated 9/17/2022, documented Resident #1 was at risk for infection related to corneal abrasion. It documented to refer the resident to the ophthalmologist (eye doctor) for any worsening of symptoms. A Wound Documentation note dated 9/15/2022 at 10:00 PM, documented an Registered Nurse (RN) assessment was completed. Resident #1 had an abrasion under their right eye that measured 0.5 centimeters (cm) in length by 0.6 cm in width. The left eye abrasion measured 0.2 cm in length by 0.2 cm in width. A Nursing Clinical Evaluation Note dated 9/15/2022 at 10:00 PM, documented Resident #1 was assessed over video with the Director of Nursing at 9:30 PM. It documented there was a small scratch of the left side above Resident #1's eye and 2 small scratches under the eye. On the right inner corner of the resident's right eye was a purple/red area that measured 0.5cm in length by 0.6 cm in width. The Medical Doctor (MD) and resident's representative were notified. The September 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An RN Assessment Note dated 9/16/2022 at 9:15 AM, documented Resident #1 was wearing their sunglasses and refused to let the RN remove them. A Social Work Note dated 9/16/2022 at 9:30 AM, documented Resident #1 was seen by the Social Worker (SW) regarding the incident that occurred on 9/15/2022 with CNA #1. The SW documented the resident stated they were not scared; they just did not want to see CNA #1 again. An Acute Visit Note dated 9/16/2022 at 10:18 AM, documented Resident #1 was examined by the Physician Assistant (PA). The resident stated that last night (9/15/2022) she hit my eyes. There were visible abrasions under both eyes, right more noticeable. The resident had tenderness upon palpation (touch) under both eyes, right greater than left and their nose. The pain was ongoing and difficult for the resident to describe. The PA ordered x-rays of facial/nasal bones, the orbit (eye socket), and jaw. They ordered Tylenol for pain. The PA asked Psychology to see the resident. An untimed Medical Provider order dated 9/16/2022, documented to administer Tylenol Extra Strength 500 milligrams (mg) 4 times a day for pain. The Discharge Patient Sheet provided on 9/16/2022 at 11:47 PM, documented the resident received a scratch or scrape (abrasion) to their cornea. It documented the cornea was a sensitive area, very painful when injured, and a scrape on the cornea could cause sensitivity to light. An untimed Medical Provider order dated 9/16/2022, documented to instill [MEDICATION(S)] (an antibiotic) ointment 0.50 inch in right eye every 4 hours (6 times a day) for corneal abrasion starting on 9/17/2022 at 12:00 AM, until 9/20/2022 at 12:00 AM. An untimed Medical Provider order dated 9/16/2022, documented to monitor the resident's behaviors such as mood changes, signs of depression, withdrawal, and anxiety and document once every shift. A Social Service Documentation Note dated 9/17/2022 at 8:25 AM, documented Resident #1 stated their right eye was sore. A Tele-Health physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . It documented the resident told them they were assaulted by a Certified Nurse Assistant (CNA) a few days ago and explained the incident to the NP. The resident reported CNA #1 brought their meal tray into their room and placed it at the bedside. The resident is blind and needed help to set up their tray. The CNA did not help. When the CNA re-entered to room to get the tray, the resident stated they told the CNA the next time they threw the tray, they would throw it right back at them. Then CNA #1 slapped Resident #1 across both eyes. It documented the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Social Service Documentation note dated 9/17/2022 at 11:38 AM, documented Resident #1 reported a poor night's sleep the night before; they did not fall asleep until almost 5:00 AM. The resident stated they asked the nurse for their anxiety medication. The resident stated they just wanted to move on from the incident and forget about it. A Social Service Documentation note dated 9/19/2022 at 8:35 AM, documented the SW met with Resident #1 at 7:50 AM regarding the 9/15/2022 incident. The resident reported they were tired because they did not fall asleep until 1:30 AM. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The MD documented their left lower eyelid was mildly reddened and irritated with some swelling around the eye. There was mild conjunctival irritation, possibly from trauma. The MD ordered the [MEDICATION(S)] ointment to include the left eye as well as the right eye and complete 5 days of treatment. A Psychology Progress Note dated 9/19/2022 at 2:26 PM, documented Resident #1 had a long history of abuse, including a traumatic childhood and an abusive marriage. They were bullied at school and did not graduate from high school. Resident #1 had requested to be seen as they were the victim of physical abuse on 9/15/2022 at the hands of a CNA. The resident presented with anxiety and stress following the assault. It documented the resident had an anxious affect (the immediate expression of emotion), inability to relax, restless, was biting their lip, rocking, felt on edge, and the felt the need to be on guard. The resident reported poor sleep, impaired concentration, and fatigue. There was some withdrawal. An untimed Medical Provider order dated 9/19/2022, documented to schedule an ophthalmology follow-up on right corneal abrasion (per emergency room visit). During an interview on 9/16/2022 at 10:21 AM, Resident #1 stated CNA #1 came into their room and threw their dinner tray on the table in their room. The resident stated they did not say anything to CNA #1 about it. When CNA #1 returned to their room to pick up the tray, Resident #1 stated, you throw that tray at me again, I'll pick it up and throw it right back at you. Resident #1 stated when they said that to CNA #1, the CNA got right in their face and was yelling, but the resident stated they could not understand what the CNA was saying. Then CNA #1 started to walk out of the room, and Resident #1 stated they called the CNA a [OBSCENITY] . Resident #1 stated CNA #1 returned, got right into the resident's face, and yelled at them, you're not deaf, but you are blind. Resident #1 stated that was when CNA #1 hit them in both eyes. The resident stated the CNA hit them so hard it pushed their wheelchair backward into their bedside stand. Resident #1 stated they had moderate to severe hearing loss and was legally blind. Resident #1 stated their right eye was in a lot of pain. The resident rated it was 8-9 on the numeric pain scale of 0-10 (0- no pain, 10- severe pain). They stated it was a sore, burning pain. The resident denied pain in their left eye. The resident stated every time they had an encounter with CNA #1, they were rude. Resident #1 stated prior to the 9/15/2022 incident, they, and their resident representative (RA) had a meeting at the facility regarding CNA #1. The resident stated neither they nor their RA wanted CNA #1 anywhere near the resident. CNA #1 was not supposed to be anywhere near her but would still come in the room to care for their roommate and would deliver trays. The resident stated they were nervous to be around CNA #1, but not fearful. Resident #1 stated that now, if they saw CNA #1, they would probably have a panic attack. They had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 stated CNA #1 had been arrested. During an interview on 9/16/2022 at 1:16 PM, CNA #2 stated they were in the room when the incident occurred last evening (9/15/2022) at about 7:45 PM. CNA #2 stated CNA #1 came to them and stated Resident #1 was wet and acting up. CNA #2 told CNA #1 they would go to Resident #1's room as soon as they had finished with the resident they were transferring with a mechanical lift. CNA #1 waited in the room with them and then followed CNA #2 to Resident #1's room when they had finished transferring the resident. CNA #2 stated they let Resident #1 know they were there and asked the resident what was wrong because they appeared upset. Resident #1 was telling CNA #2 how CNA #1 had slammed their tray down, it upset the resident, and words had passed between them. CNA #2 told CNA #1 to get out of the room because they were not supposed to be in there and the resident was telling CNA #2 what had happened. CNA #2 stated CNA #1 was not allowed to take care of Resident #1 so they switched out a resident so CNA #1 would not be going into the room. CNA #1 stood in the doorway and did not leave when CNA #2 told them to leave. CNA #2 stated the 2nd time they told CNA #1 to leave, they started to leave and stated CNA #1 told the resident they were blind so they wouldn't know if they (CNA #1) slammed down the tray. CNA #2 had left the room, but heard the resident say I'm not so blind that I couldn't get out of this chair and kick your ass. After they passed those words, and CNA #2 was past the door threshold, CNA #2 stated they told the resident CNA #1 was leaving the room and the resident stated good, she's nothing but a little [OBSCENITY] . CNA #2 stated that CNA #1 heard the resident say that, turned around, and came back into the room. CNA #1 closed the door behind them and asked the resident what they called them and if they called them a [OBSCENITY] . That was when CNA #1 grabbed the resident's wheelchair and slammed it back into a little dresser the resident had in their room. CNA #2 stated CNA #1 used both hands, and using their fingertips pushed them real hard into the resident's eyes. It was so hard that it raised the front wheels of the resident's wheelchair off the ground. It looked like the resident could have tipped over backward. CNA #2 stated soon as they tried to open the room door, CNA #1 kept trying to corroborate a story about the incident, but CNA #2 told them they had to report it. When they left the resident's room, they closed the door behind them. CNA #2 stated they tried to find a nurse and went room to room but could not find one. CNA #2 stated they provided care to about 3 more residents as CNA #1 stood by them. CNA #2 stated CNA #1 followed them everywhere they went, even into resident rooms. CNA #2 stated finally found a CNA (CNA #3) and told them they needed the nurse, that CNA #1 had just hit a resident. CNA #2 stated CNA #3 went to the nurse manager on another unit to tell them. CNA #2 stated they went to Resident #1's room to stay with them to keep them safe. At that point, CNA #1 had disappeared. CNA #2 stated they did not know where they went. The Nurse Manager stated they wanted CNA #2 to write a statement. CNA #2 stated first, they spoke with the DON. Then, while CNA #2 was writing their statement, the DON told the Nurse Manager that CNA #1 needed to be removed from the building, so they went to find CNA #1. Then the Sheriff Deputies arrived. During an interview on 9/16/2022 at 2:13 PM, CNA #3 stated they were working last evening (9/15/2022). They stated CNA #2 reported the incident that involved Resident #1, and they were very upset. CNA #3 stated CNA #1 kept following CNA #2 like they wanted to keep them in their sight so CNA #2 would not tell anyone, but the Supervisor was told about the incident when CNA #1 went to answer the doorbell (there was no receptionist on the evening shift). CNA #3 stated CNA #1 wanted to speak with them about the incident, and CNA #1 exited the facility. CNA #3 stated they went back to the unit to tell CNA #2 that the supervisor wanted to speak with them. CNA #3 stated at that time, the Supervisor came and told CNA #1 they could not re-enter the facility. CNA #3 stated the police arrived about 8:00- 8:15 PM. CNA #3 stated CNA #1 was not allowed to provide care to the resident, so they were the resident's CNA yesterday (9/15/2022) on 7 AM-3 PM and 3 PM-11 PM shifts. CNA #3 stated CNA #2 shadowed them in the morning and evening because it was their first day of work at the facility. During an interview on 9/16/2022 at 2:34 PM, Registered Nurse Manager (RNM) #1 stated on 9/2/2022, they had a meeting with Resident #1 and their representative. The resident and their representative were adamant they did not want CNA #1 near them or providing care to them. RNM #1 stated the resident told them they didn't like CNA #1; they were rude and rushed with care. RNM #1 stated they told CNA #1 they were not to go into the resident's room for any reason. They stated they told staff that CNA #1 was not allowed to care for the resident, and they would need to exchange one of the residents on their assignment with CNA #1 so they would not have Resident #1 on their assignment. During an interview on 9/19/2022 at 1:03 PM, the Physician's Assistant (PA) stated they saw the resident because they heard there had been a trauma. The PA stated the resident was alert and oriented and was in no apparent distress. On palpation (using hands to examine) there was orbital (eye) pain and some small abrasions under the eyes. The PA stated they ordered x-rays and the resident went to the hospital. The PA confirmed the resident had a corneal abrasion and the resident was to see an ophthalmologist as ordered by the emergency room . During an interview on 9/20/2022 at 3:25 PM, the Medical Director stated when the event occurred, they were notified as soon as the facility was aware of the incident. The Medical Director stated they had not seen the resident and they would not be making rounds for resident care. They were managing the administrative care of the residents, would be reviewing and updating P&P and doing case studies with a team to improve resident care and outcomes. The Medical Director stated the primary care group of medical providers would be providing all direct resident care. During a subsequent interview on 9/22/2022 at 10:41 PM, CNA #3 stated they spoke with CNA #1 on 9/15/2022 following the incident because they were friends and they wanted to ask them if they really did it. CNA #1 admitted they had pushed on the resident's eyes with both hands. CNA #3 stated they had seen Resident #1's face following the incident and thought the scratches may have occurred from CNA #1's fingernails. 10 NYCRR 415.4(b)(1)(i)

Based on medical record review and interviews during an abbreviated survey (Case #NY 480) the facility did not ensure that the resident's environment remained free from accident hazards. Specifically, for one (Resident #1) of three residents reviewed, the facility did not ensure that staff were trained on securing the three-point retractable seatbelt when transporting residents in the facility van. The van was transporting a resident not secured with the three-point retractable seatbelt, the van stopped abruptly and the resident exited the wheelchair, and landed on the floor approximately 90 inches from the wheelchair. The resident was transported to the hospital and pronounced dead on arrival. This is evidenced by the following: Resident #1: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was noted to be alert and oriented during the nursing admission assessment. Review of the facility form titled Investigation Summary (undated) documented on [DATE], at approximately 4:00 pm, the resident was being transported back from a doctor's appointment. A car pulled out in front of the facility van, and the van driver stepped on the brakes. The van stopped abruptly and the resident fell forward out of his chair. He was transported to the hospital in [MEDICAL CONDITION] and pronounced deceased at 4:26 pm. Review of the County Sheriff's investigation dated [DATE] (supplemental #2), documented that the manner of death was accidental, immediate cause was severe bilateral rib and sternal fractures due to [MEDICATION NAME] force trauma. The sheriff documented that the coroner described the injuries to the resident caused a flail chest (a life-threatening medical condition that occurs when a segment of the rib cage breaks due to trauma and becomes detached from the rest of the chest wall), leading to the inability to breath. Review of the certificate of death dated [DATE], documented the immediate cause of death was severe bilateral rib and sternal fractures due to [MEDICATION NAME] force trauma. Observation of the transport van on [DATE] at approximately 2:00 pm, revealed two three-point retractable seatbelts on the back wall of the van and two additional three-point retractable seatbelts in the middle of the van. The facility did not have evidence that education regarding the safety of transporting residents was provided to transport staff. Interview with the County Sheriff Investigator on [DATE] at 9:30 am who stated that the three-point retractable seatbelt would have fit around the resident in the wheelchair, and he was able to demonstrate this. Interview with the DON (Director of Nursing) on [DATE] at 11:00 am, who stated the facility did not have a policy or a procedure for transferring residents in the facility van. When asked how the facility assesses the competency of the transport staff, the DON stated that they did not have a procedure at that time. Interview with the driver of the van on [DATE] at 1:00 pm, the driver stated he started helping with transports of residents a little over a year ago. At that time the previous driver demonstrated to him how to operate the lift and attach the locks to the wheelchairs. He stated that it then became a full time position. He stated he often will transport residents alone, without the assistance of a transport aide. The driver stated he received training regarding the application of the three-point retractable seatbelt on [DATE]. Interview with the transport aide (TA) on [DATE] at 2:50 pm, the TA stated she assisted the resident with the transport on [DATE] to the physician's office. The TA stated when the position started in 2002, a demonstration was completed on how to hook the chair to the floor and apply the seatbelt. The TA stated an attempt to apply the three-point retractable seatbelt occurred on the way to the appointment and on the return, but the three-point retractable seatbelt wouldn't go around the resident. The TA stated she did not report that to anyone. The TA stated other residents had been transported without use of the seatbelt. When asked if that information was reported, the TA stated it had not been reported. 483.25(d)(1)(2)

Based on observation, medical record review and staff interview the facility did not ensure that a resident received adequate supervision and assistance to prevent accidents for 3 (#s 6, 26 and 73) of 16 residents reviewed during the standard recertification survey. Specifically, a resident (#6) was found with oxygen tubing wrapped around her neck, asking the nurse to "help her die", and no additional supervision or assistance was provided to this resident. In addition, 2 residents ( #s 26 and 73) with known wandering behaviors were not adequately supervised and continued to wander into other residents' rooms (NY# 808). This resulted in actual harm for Resident #73 who wandered into another resident's room and was struck by that resident with a reacher causing injuries including a laceration that required stiches. This is evidenced by: Resident #73 The resident was admitted on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident was severely cognitively impaired. The nurses' notes documented the following incidents: 7/30/11: After dinner at 6:30 PM, the resident was seen pushing and kicking at another resident's chair. The resident was redirected and went back to do it again. When the nurse moved her away from the other resident a fourth time, she became angry and verbally abusive toward the nurse. Shortly afterward, this resident was wandering into other resident rooms and refusing to leave, becoming angry with the residents in the room. Ativan was given to calm the resident. 8/17/11 11:00 PM: The resident was in a verbal and kicking argument at the end of the south hall. The resident was easily redirected. 9/11/11: The resident had several altercations with another resident this shift. This resident was easily redirected. 9/27/11 11:00 PM: Ativan was given for increasing agitation and starting physical altercations with other residents. 9/29/11 11:00 PM: The resident started altercations with several residents uninvited. 10/8/11 11:00 PM: The resident did not do well with the Vera lift and was screaming, pinching and refusing to hold on. The resident required the assist of three for safety. Ativan was administered at 10:15 PM when agitation escalated until she was pounding on a resident's door yelling. 10/18/11 12:18 am: The resident had a verbal altercation with another resident this shift. The residents were found yelling at each other and no physical altercation was noted. Staff separated the residents without difficulty and this resident continued to propel self around unit. 10/31/11 10:00 PM: This resident was hit on the arm by another resident. She then grabbed the other resident's left arm causing two small skin tears. 11/23/11 7:00 am: The resident was self propelling in her wheelchair, continuously redirected out of other residents' rooms. 11/25/11 7:00 am: The resident was self propelling in her wheelchair and staff continuously tried to redirect resident out of other residents' rooms. 12/12/11 9:30 PM: The resident was found in another resident's room. There was a small lump on the top of her head, her left index finger was bruised and swollen and her right wrist had bruising on it. The resident's upper lip was cut and swollen and the right side of her nose had a small cut from her glasses . Ice was applied, the resident's family and physician were notified, and the resident was sent to the emergency room via ambulance. 12/12/11 10:10 PM: The Director of Nursing (DON) was notified of the above incident. 12/13/11: The resident returned to the facility at 1:10am. Ecchymotic areas were noted on the resident's right hand (1st and 2nd knuckle), swelling to the right medial wrist, range of motion (ROM) was within normal limits. The resident's left hand (first finger) and left posterior forearm were ecchymotic, a nickle sized ecchymotic area was noted on the resident's left biceps. The resident's right side of her nose had two small abrasions, her right upper lip was swollen and there were five sutures in place with steristrips over the site. The top of the resident's head (near the part in her hair line) had a small bump and a red line approximately 2 centimeters long. The comprehensive care plan (CCP) for cognitive loss/ dementia printed on 7/21/11, documented the resident was alert and oriented to person only. She became more restless and agitated as the night progressed. She had a history of [REDACTED]. Goals were to have cognitive function remain in a consistent state over the course of each day. Approaches included: maintain quiet environment, constant cueing and reminders, engage in activities, note changes in functioning level and report to physician (MD). The behavior CCP first printed on 7/21/11 documented the resident had a history of [REDACTED]. She was constantly getting up without assistance. The resident had also been combative with care: pinching, hitting and digging her nails into staff. The CCP documented that attempts to reorient have been unsuccessful. Goals included: episodes of physically abusive behavior will decrease through 90 days and the resident will allow staff to provide cares on a daily basis for 90 days. Approaches included to document behaviors in the nurses' notes, administer medications as ordered, redirect negative behavior, engage in activities, psychological evaluation as needed and anticipate the residents' needs. The care plan did not document any resident specific interventions. On 10/10/11 a note documented that the resident had one episode this month of arguing and yelling at a resident. The psychosocial well being CCP documented the resident had been admitted to the facility from an adult home. It documented the resident had behaviors at the adult home such as wandering , restlessness and agitation. The resident had been combative with care and was receiving antipsychotic and antianxiety medications. The resident had expressed feelings of being tired, difficulty concentrating and little interest in doing things. The goal documented the resident would accept her routine of daily living through 90 days. Approaches included: Psychologist consult as needed, administer medications as ordered, note any side effects of medications and report to MD, 1:1 visits from social worker, encourage family support, allow to express feelings and frustrations, and encourage resident. The CCP entitled "Resident Abuser/ Victim" initiated 10/31/11 identified the resident was physically abusive (pinching and hitting), wandering into peers' rooms, and attempting to touch others. The CCP documented this was related to dementia and agitation. Goals included: the resident will be free from abusive interactions with peers- no hitting or pinching through the next 30 days, resident will not be harmed within the next 30 days, and resident will engage in purposeful activity to redirect or ease state of agitation/ anxiety through 90 days. Team interventions included: determine cause of abusive behavior/ altercation event, separate victim from the abuser, encourage activities and provide reassurance and emotional support. A psychological diagnostic interview dated 11/7/11 documented the resident was seen due to a negative interaction with another resident, in which she was the victim. During the assessment the resident was noted to have impaired attention, concentration and memory. She denied any interpersonal conflicts and appeared to have no memory of the negative interaction. She was oriented to self but not to place or time. The summation of the report documented that the resident's level of cognitive impairment precludes her involvement in and ability to benefit from psychotherapy. She appeared to have no memory of the negative interaction, and there was no evidence of any emotional distress related to the event. During an interview via telephone on 12/15/11 at 10:45 am, a certified nurses aide (CNA) indicated she worked per diem. The CNA stated that the resident usually does not sleep and the staff need to keep a close eye on her because she wanders everywhere. The CNA stated the resident has always wandered around the unit into other residents' rooms. During an interview on 12/15/11 at 8:15 am, a CNA (who routinely works the 11-7 shift) stated the resident is someone who is usually up all night, wandering and talking to staff. The CNA stated that the resident does wander into other residents' rooms. The CNA stated there is always someone available on the 11-7 shift to be with the resident. The CNA stated that the resident is known to have more concerns on the 3:00pm-11:00pm shift. During an interview on 12/15/11 at 8:45 am the registered nurse manager (RNM) stated that during the day shift the resident was often very sleepy. The RNM stated she was not aware of the incidents in the nurses' notes until the surveyor pointed them out. She stated the MDS coordinator completes care plans. She stated that she expected behavioral issues to be communicated and addressed in a more proactive manner. During an interview on 12/15/11 at 11:45 am the facility social worker (SW) stated the resident was admitted from an adult home, as she had increasing wandering behaviors along with decreasing cognitive abilities. The SW stated she was not aware of all the incidents noted in the nurses' notes. She stated she currently does not do specific care plans and she would only become involved with an incident if she witnessed it, or if staff asked for her assistance. During an interview on 12/15/11 at 2:10 pm the Director of nursing (DON) stated she was not aware of all of the resident's behaviors documented in the nurses' notes. The DON stated that she believes the CNAs and nurses are becoming used to the resident's behaviors and are not considering them out of the ordinary. The DON stated this was a concern. During an interview on 12/15/11 at 2:30 pm the physician (MD), after reviewing her notes in the chart, stated she had first become aware of the resident's behaviors in August and she had adjusted the resident's psychotropic medication. The MD stated she does not expect to be notified of every incident, but would expect to be told if behaviors were a pattern. Resident #26 The facility did not provide adequate supervision after the resident was noted to have frequent episodes of wandering into other residents' rooms. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. This same MDS documented the resident wandered on a daily basis. The nurses' notes dated 9/11/11 at 11:00pm documented the resident had altercations with other residents and was not easily redirected. Nurses' notes dated 9/28/11, 9/30/11, 10/1/11, 10/2/11, 10/3/11 and 10/31/11 all documented the resident was wandering into other residents' rooms. The Comprehensive Care Plan (CCP) entitled "Psychosocial Well-Being" printed on 10/11/11 and most recently updated 12/18/11 documented the resident had a tendency to wander throughout the facility and into other residents' rooms. Approaches on the CCP documented administer medications per MD order, note any side effects and notify MD, encourage verbalization of feelings, encourage family support engage in activities and psychological consult as needed. There was no documented resident specific interventions to address the resident wandering into other residents' rooms. The CCP entitled "Mood State" documented (under evaluation notes) 10/20/11 resident wandered the halls attempting to enter different rooms. She was difficult to redirect, but then was able to self propel in another direction. There was no documented resident specific interventions to address the resident wandering into other residents' rooms. During interview on 12/20/11 at 10:15am the RNUM stated the resident should have a care plan addressing the fact she could become an aggressor or potential victim due to wandering into other residents' rooms. The RNUM stated she was still learning the requirements for long term care and, based on a previous conversation with another surveyor, she now understood this resident should have specific interventions addressing her wandering into other residents' rooms. Resident #6 The facility did not provide adequate supervision after the resident was noted to have oxygen tubing wrapped around her neck, and was asking the nurse to "help her die". The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed the resident usually understands and is understood, and had severely impaired cognitive skills for daily decision making. The same MDS documented (under the mood section) that the responsible staff or provider was informed there was a potential for resident self harm. The nurse's note dated 7/31/11 at 11:00pm and written by an licensed practical nurse (LPN), documented the resident was reaching out from the chair and grabbing at passing residents and staff. After the resident was put to bed, she was found with the oxygen tubing wrapped around her neck saying "help me die". There was no additional documentation in the nurses' notes regarding this incident. There was no documented evidence the social worker was aware of this incident. There was no documented evidence the physician was aware of this incident. During an interview on 12/19/11 at 10:35am the LPN who documented the above note stated the facility's policy is to call the supervisor when a resident expresses a desire to kill themselves. The LPN stated the supervisor would take over and usually the resident would be placed on 15 minute checks, and staff would talk to the resident. When asked about the above note, the LPN stated she did remember the incident on 7/31/11, however the oxygen tubing was not wrapped tightly, and it did not seem like an active suicide attempt. The LPN stated she did not feel it was anything to be concerned about, and if she was concerned, she would have notified the supervisor. When asked by the surveyor how she made that determination, the LPN stated she just based it on her observation. During an interview on 12/20/11 at 10:15am the Registered Nurse Unit Manager (RNUM) stated she was unaware of the above incident. The RNUM stated had she been notified of the above incident she would have filled out an accident and investigation form, notified the supervisor, and had the resident assessed by the psychologist or sent the resident to the emergency room . The RNUM stated she would have expected the LPN that documented the above nurse's note would have notified the supervisor immediately about this incident. 10 NYCRR 415.12(h)(1)(2)

Based on observation, record review and staff interview, the facility did not ensure that a resident who enters a facility without a pressure sore did not develop a pressure sore for 1 (#142) of 7 residents reviewed during the standard recertification survey. Specifically, a resident identified at high risk for development of pressure ulcers was not provided effective intervention of off loading to prevent a right heel ulcer from developing. The facility policy for pressure sore prevention does not identify specific interventions for residents at high risk. Additionally, the residents left heel was not off loaded at the time of survey. The development of an unstageable pressure sore resulted in actual harm. The findings are: Resident # 142 The resident was admitted on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set, dated dated dated ((MDS) dated [DATE] assessed the resident as severely cognitively impaired. The MDS also assessed the resident as requiring extensive assist with one person for bed mobility. Review of the comprehensive care plan (CCP) documented a care plan for pressure ulcers printed on 6/17/10. The resident was identified as being at risk for break down with factors including having diabetes, and relying on staff for mobility and assist with activities of daily living (ADL). Interventions included providing meaningful position changes every 2-4 hours, and providing a pressure relieving mattress. On 9/23/10 handwritten in on the CCP was documented that the residents right heel was examined by the wound team. The heel had an area of necrotic discoloration and small amount of frank bloody drainage. It was to be off loaded in bed with heel protection. It was also noted as placed in the MD log for 9/24/10. The CCP for ADL function documented that the resident had dementia, and a history of a fall with a [MEDICAL CONDITION] hip on 2008. It documented that the resident relied on staff for mobility and ADL's. It also noted that the resident chooses to be non ambulatory, due to painful lower extremities, with weight bearing activities. The care card (tool that CNA's use to identify resident specific care needs), had typewritten that updates of the card had occurred on 4/1/10, 7/10, and 9/16/10. Typewritten in for bed mobility the resident was an extensive assist of one. Handwritten in under miscellaneous on 9/23/10 the care card documented to offload heel when in bed, also to use a heel protector. Review of the Quarterly/ PRN (as needed) pressure ulcer risk assessment documented that a score of 8 or higher was high risk and prevention protocol must be initiated immediately and documented on the care plan. On 6/12/10 the residents score was an 11, on 9/1/10 the score was also 11. The risk factors identified were that the resident was non ambulatory, and had a [DIAGNOSES REDACTED]. Review of the nurses notes documented on 9/20/10 that a CNA called the registered nurse (RN) to the residents room. The resident was noted to have a quarter size area on his right heel, with dark necrotic tissue and dry skin edges that were sloughing. The resident denied tenderness. Lotion was applied to the right foot, and a protective dressing to the right heel. The plan noted that the resident would be added to wound rounds, and for the physician to evaluate on 9/21/10. On 9/23/10 the resident was noted to have been seen by the wound team. The right heel was noted to have necrotic discolored tissue showing skin sloughing with a small draining area. Drainage included a small amount of frank blood. This was noted to be placed in "MD activity log" (a book of information for the physician to review) for 9/24/10. The right heel was to be offload while in bed and heel protector in place when in bed. A nurses note on 9/24/10 documented that the resident had been seen by the physician, and a dry sterile dressing (DSD) was to continue along with the off loading of the right heel. Also the resident was to be followed by the wound team. Review of the wound tracking record documented that the wound was discovered on 9/20/10 and a protective dressing to the right heel two times a day was initiated. The wound team assessed it on 9/23/10 and documented that the right heel presented with necrotic tissue with a small amount of drainage. Also documented on 9/23/10 was that the resident was to be seen by the physician and heel was to be off loaded in bed. Review of the physicians orders documented on 9/24/10 and order for a dry protective dressing (DPD) and off loading of the right heel. Review of the facility's policy titled "Pressure Ulcer, Care and Prevention of dated 3/7/06, documented various types of equipment to be utilized for residents. The policy did not specify for whom and at what time these measures should be used. The facility policy titled "Pressure ulcer risk assessment", dated 3/17/05, identified that "licensed nurses" had basic responsibility in assessing residents risk. The policy documented that is a resident scored an 8 or more on the assessment, they were to be considered high risk. A nursing prevention protocol was to be initiated immediately. The policy did not describe what the protocol was. Observation of the dressing change on 2/4/10 at 10:30 am revealed a pressure ulcer on the residents right heel. Upon completion of the dressing change it was noted that the nurse replaced the pressure relieving boot, but the pressure sore was resting on the boot, not over the space which allows the heel to float. The resident stated that the sore hurts when he stands on his right foot. Interview with a CNA (#1 ) on 2/4/11 at 2:40 pm, the CNA stated that she had taken care of the resident for the last few weeks. The CNA stated she had taken care of the resident prior to the development of the heel ulcer. She stated that the resident did not have anything specific in place for heel protection prior to the heel ulcer development. She stated she would not automatically float heels. unless the care card stated to. Interview with CNA #3 on 2/4/11 at 2:50 pm she stated that she had last taken care of the resident a couple of months ago.. The CNA stated that if the resident had specific interventions for heels it would have been noted on the residents care card. She then stated the date on the care card would indicate the date the intervention started. Interview with Registered Nurse Manager(RNM) on 2/4/11 at 11:25 am and again on 2/4/11 at 3:00 pm the RNM confirmed that prior to the development of the heel sore, no specific interventions to protect the heels were in place. She confirmed that the off loading and heel protector started on 9/24/10 as the care card documented. Interview with physician on 2/7/11 at 9:25 am the physician indicated that the facility would not automatically initiate anything specific for heel protection, that it would be a resident specific decision. When asked if the residents diabetes and history of [MEDICAL CONDITION] would increase risk, the MD stated in retrospect yes it would. The MD stated that she was aware that prevention of pressure sores was an issue in the facility. She stated she had recently spoken to the Director of Nursing (DON) who was already aware of this need. During an interview with the DON and Staff Education RN on 2/7/11 at 11:30 am they stated they would not necessarily have placed any specific interventions to prevent the heels from breaking down. They confirmed that nothing specific was in place prior to the development of the heel sores. During the interview the DON and Staff Education RN confirmed that the residents mattress was a pressure reducing, not pressure relieving mattress. The DON stated that the facility had identified prevention of pressure sores as an area in need of improvement. 10NYCRR 415.12(c)(1)