Every finding on record at Waterview Heights Rehabilitation and Nursing Cente

Based on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free from accident hazards as possible for one of one resident reviewed (Resident #1). Specifically, the facility failed to identify and correct an unsafe third-floor resident room window which opened approximately 15 inches and failed to have a system to routinely inspect resident room windows for safety. Subsequently, on [DATE], the resident was able to exit the window and fell to their death. The findings include:Resident #1 had diagnoses including psychotic disorder (a mental health condition which can affect thoughts and behaviors), anxiety disorder (a condition which can cause excessive fear or worry, and diabetes mellitus (a condition which causes high blood sugar). The Minimum Data Set (a resident assessment tool) dated [DATE] included Resident #1 was cognitively intact.Review of the facility investigation revealed on [DATE], Resident #1 went through the window in resident room [ROOM NUMBER] and fell to the ground below. The pictures provided by the facility revealed the window opened approximately 15 inches; when opened, the top of the window was approximately five feet from the floor, and the operable portion of the window did not have a device to limit how far the window could open. Emergency personnel pronounced Resident #1 deceased at the facility. Following the incident on [DATE], maintenance staff purchased chains and installed them on resident room windows on the second and third floors of the South building to limit the windows from opening more than approximately six inches.During observations on [DATE] from 12:49 PM through 2:00 PM, resident room and dining room windows on the second and third floors of the South building had chains fastened to the operable part of the window and window frame with screws. The windows opened approximately four to six inches and had tight-fitting screens. A window in resident room [ROOM NUMBER] on the [NAME] second floor opened more than six inches and had a tight-fitting screen. Maintenance staff secured the window during the surveyor's observation.During an interview on [DATE] at 9:45 AM, the Director of Central Supply stated they were outside near the loading dock when they saw Resident #1 falling headfirst from the third-floor window. The Director of Central Supply stated they called the supervisor and emergency services and remained with Resident #1 until nursing staff arrived and began cardiopulmonary resuscitation (an emergency procedure used when a person's heart or breathing has stopped).During an interview on [DATE] at 10:18 AM, the Assistant Maintenance Director #1 stated the facility did not conduct window audits to ensure window safety devices were in place. Assistant Maintenance Director #1 stated maintenance staff purchased chains after the incident and installed them to prevent the second and third floor windows of the South building from opening more than approximately six inches.During follow-up interviews on [DATE] at 11:30 AM and 12:30 PM, the Assistant Maintenance Director #1 stated there had been no window audits during the prior three months. Assistant Maintenance Director #1 stated maintenance staff did not assess the windows in other areas of the facility as part of the initial corrective action.During an interview on [DATE] at 12:40 PM, the Administrator stated maintenance staff placed chains on the second and third floor windows of the South building. The Administrator stated all windows in the South building were the same type and windows in the other buildings were different. The Administrator stated maintenance staff were expected to assess all facility windows following the incident.Title 10 of the New York Codes, Rules and Regulations 415.29(a)(1)

Based on observations, interviews, and record review, the facility failed to implement an effective Infection Prevention and Control Program to identify, investigate, monitor, and analyze infections to prevent the development and transmission of communicable diseases and infections for one of nine residents reviewed (Resident #139). Specifically, the facility failed to identify and investigate Resident #139's recurrent urinary tract infections (an infection affecting any part of the urinary system) through its infection surveillance program and failed to ensure Enhanced Barrier Precautions (an infection prevention strategy requiring the use of gowns and gloves during high-contact resident care activities) were followed while providing care to Resident #139. As a result, Resident #139 was admitted to the hospital from [DATE] through 05/15/2026 with sepsis (the body's life-threatening response to infection) secondary to a catheter-associated urinary tract infection (an infection associated with the use of an indwelling urinary catheter) with pyelonephritis (a bacterial infection of the kidney).The findings include:The facility policy titled, Surveillance Program, reviewed January 2026, included the Infection Prevention and Control Program would provide a systematic method for collecting, consolidating, and analyzing infection data using multiple sources, including clinical records, microbiology reports, antibiotic reports, and staff reports. The Infection Preventionist would track infections, compare infection rates, perform root cause analyses for infections and outbreaks, identify performance improvement actions, and monitor infection trends through the Quality Assurance Performance Improvement process.The facility policy titled, Catheter Care Urinary, revised January 2026, included staff were to follow Standard Precautions (infection prevention practices used during the care of all residents) and wear gloves when handling urinary catheters (a tube inserted through the urethra into the bladder to drain urine) and urinary drainage systems.Review of the facility's Infection Surveillance Reports from 01/01/2026 through 05/31/2026 identified 43 urinary tract infections among residents, including 14 during January 2026, nine during February 2026, nine during March 2026, seven during April 2026, and four during May 2026. Review further identified documented Escherichia coli (a bacteria that can cause urinary tract infections) urinary tract infections during January, February, March, and April 2026.Review of the Infection Surveillance Reports did not include documented evidence urinary tract infections were routinely investigated, trended, analyzed, or a root cause analysis conducted despite the repeated occurrence of infections throughout the facility. Further review did not include documented evidence performance improvement activities were implemented to address recurrent urinary tract infections as required by facility policy.Resident #139 had diagnoses including obstructive uropathy (a blockage affecting the normal flow of urine), dementia (a disorder affecting memory, thinking, and reasoning), and a chronic indwelling urinary catheter. The Minimum Data Set (a resident assessment tool) dated 05/21/2026 included Resident #139 had severe cognitive impairment and an indwelling urinary catheter.Review of Resident #139's Comprehensive Care Plan, revised on 04/20/2026, included staff were to maintain Enhanced Barrier Precautions due to the presence of an indwelling urinary catheter, wear gowns and gloves during high-contact care activities, and provide the assistance of two staff members during transfers.Review of Resident #139's current Kardex (a care plan used by certified nursing assistants for resident care) on 06/16/2026 revealed the resident had an indwelling urinary catheter, required assistance with toileting and personal hygiene, and the assistance of two staff members during transfers. The Kardex did not include Enhanced Barrier Precautions.Review of Resident #139's medical record from 01/10/2026 through 06/17/2026 identified repeated physician evaluations, urinalyses (laboratory tests of urine), urine cultures (laboratory tests used to identify bacteria in urine), urinary catheter changes, and multiple courses of antibiotics (medications used to treat bacterial infections) for recurrent urinary tract infections.Review of an outpatient urology consultation dated 03/04/2026 revealed Resident #139 had grossly infected urine, perineal skin excoriation (skin breakdown caused by prolonged moisture or irritation), required improved daily perineal care, and began antibiotic treatment while urine culture results were pending.Review of a hospitalization summary dated 05/15/2026 documented Resident #139 was admitted to the hospital from [DATE] through 05/15/2026 with sepsis (the body's life-threatening response to infection) secondary to a catheter-associated urinary tract infection (an infection associated with the use of an indwelling urinary catheter) with pyelonephritis (a bacterial infection of the kidney). Resident #139 returned to the facility on [DATE] with physician orders to maintain Enhanced Barrier Precautions because of the indwelling urinary catheter.Review of nursing progress notes dated 01/10/2026 through 06/17/2026 documented repeated signs and symptoms consistent with urinary tract infection, including cloudy urine, amber-colored urine, increased agitation, positive urine culture results identifying Escherichia coli, repeated physician orders for urine testing, urinary catheter replacement, and continued evaluation for a suspected urinary tract infection following the Resident's return from the hospital. There was no documented evidence the facility investigated the cause of Resident #139's recurrent urinary tract infections or completed a root cause analysis following the hospitalization for catheter-associated urinary tract infection with sepsis despite requirements outlined in the facility's Infection Prevention and Control Program policy.During an observation on 06/17/2026 at 12:10 PM, Resident #139 was in bed requesting assistance to get up. Stool was on the Resident's brief, back, and bedsheets. Enhanced Barrier Precautions signage was posted outside the Resident's room, and gowns and gloves were available at a personal protective equipment station across the hallway. Certified Nursing Assistant #7 and Certified Nursing Assistant #8 provided transfer assistance, incontinence care, dressing assistance, and urinary catheter care while wearing gloves but not gowns. Certified Nursing Assistant #7 emptied the Resident's urinary drainage bag wearing gloves only. During the transfer, the urinary drainage bag and drainage tubing were observed resting on the floor while attached below the resident's wheelchair.During an interview on 06/17/2026 at 10:02 AM, the Infection Preventionist stated they were unaware Resident #139 had experienced recurrent urinary tract infections and had not followed the resident's infections because the electronic surveillance system identified only residents receiving antibiotics. The Infection Preventionist stated they had identified an increase in Escherichia coli urinary tract infections during the previous three months, but had not investigated the cause or provided education to staff.During an interview on 06/17/2026 at 10:24 AM, the Infection Preventionist stated infection surveillance reports were reviewed at the end of each month rather than in real time and routine monitoring focused primarily on gastrointestinal and respiratory infections instead of urinary tract infections. The Infection Preventionist acknowledged the surveillance process failed to identify Resident #139's suspected urinary tract infection during June 2026.During an interview on 06/17/2026 at 12:54 PM, Certified Nursing Assistant #7 stated Resident #139 was on Enhanced Barrier Precautions because of the indwelling urinary catheter. Certified Nursing Assistant #7 acknowledged a gown should have been worn while providing care and stated the urinary drainage bag and drainage tubing should not have touched the floor.During an interview on 06/17/2026 at 12:59 PM, Certified Nursing Assistant #8 stated they did not wear a gown because they did not realize Resident #139 had an indwelling urinary catheter until after entering the room. Certified Nursing Assistant #8 acknowledged a gown should have been worn while providing resident care.During an interview on 06/18/2026 at 1:29 PM, Licensed Practical Nurse Manager #1 stated staff were expected to wear gowns and gloves when providing high-contact care to residents on Enhanced Barrier Precautions. Licensed Practical Nurse Manager #1 stated urinary drainage bags and drainage tubing should not touch the floor because contact with the floor increased the risk of contamination of the urinary drainage system.During an additional interview on 06/22/2026 at 10:24 AM, the Infection Preventionist stated failure to follow Enhanced Barrier Precautions during resident care increased the risk for the transmission of infection.During an interview on 06/22/2026 at 12:12 PM, the Director of Nursing stated all resident infections should have been tracked in a timely manner and they were unaware urinary tract infections were not consistently monitored. The Director of Nursing stated Resident #139's recurrent urinary tract infections should have been identified and investigated to determine contributing factors and prevent recurrence. The Director of Nursing stated infection surveillance should include monitoring symptoms, laboratory results, identification of organisms, interventions, and follow-up from the onset of symptoms through completion of the investigation.During a telephone interview on 06/22/2026 at 1:06 PM, the Medical Director stated all infections, including urinary tract infections, should have been tracked regardless of whether antibiotics had been prescribed. The Medical Director stated recurrent urinary tract infections should have been investigated to identify trends and contributing factors. The Medical Director stated medical providers relied on the Infection Prevention and Control Program to identify infection trends requiring intervention.Title 10 New York Codes, Rules and Regulations 415.19(a)(1-3)

Based on observations, interviews, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain proper grooming and personal hygiene for four of seven residents reviewed (Residents #43, #51, #152, and #162). Specifically, Resident #51 was observed on multiple occasions to have long chin hair and Resident #162, who was dependent for toileting care, had a strong scent of urine and was not provided care for over 12 hours. Residents #43 and #152 were observed on multiple occasions with overgrown facial hair and long finger nails with dark debris under their nails. Additionally, the facility lacked documented evidence staff consistently offered, provided, or documented grooming services or refusals in accordance with residents' assessed needs and preferences.The findings include:The facility policy Resident Care with Activities of Daily Living, last reviewed January 2026, included residents on toileting programs would be offered toileting assistance every two to four hours and as needed and staff would document resident toilet use and support provided. Residents receiving personal skin care should have the date and time the procedure was performed recorded in the resident's medical record. If a resident refused treatment, the reason why and the intervention taken should be recorded in the resident's medical record. Fingernails were not to be trimmed unless otherwise instructed by the supervisor and supervisors were to be notified if the resident refused the procedure.1. Resident #162 had diagnosis including Alzheimer's disease (a progressive disease affecting memory and thinking), hypertension (high blood pressure) and coronary heart disease (narrowing of blood vessels reducing blood flow to the heart). The Minimum Data Set (a resident assessment tool) dated 03/13/2026 included that Resident #162 had severe cognitive impairment and was dependent (staff does all of the effort, resident does none to complete the activity) for toileting hygiene and supervision or touching assistance (staff provides verbal cues and/or touching assistance as resident completes the activity) for personal hygiene (includes combing hair, shaving, washing/drying face and hands).Review of Resident #162's Comprehensive Care Plan revealed an intervention dated 12/16/2024 to provide toileting assistance per the resident's needs and Therapy recommendations.Review of Resident #162's Kardex (care plan used by certified nursing assistants to guide daily care) as of 06/17/2026 included that the resident was dependent on one staff member assistance with toileting hygiene.Review of Resident #162's Toileting Hygiene documentation dated 06/14/2026 revealed incontinence care was documented at 12:52 AM and again at 2:07 PM.During an observation on 06/14/2026 at 11:56 AM, Resident #162 was sitting in the hallway wearing only a pajama top with no pants, their incontinence brief was visible, and they had strong odor of urine.During an interview on 06/14/2026 at 12:16 PM, Licensed Practical Nurse #2 stated that Resident #162 was incontinent of bladder and bowel (urine and stool), was totally dependent on staff for resident care, and had received morning care on the night shift at approximately 5:30 AM. Licensed Practical Nurse #2 stated Resident #162 was on Certified Nursing Assistant #5's assignment for the day.During an interview on 06/14/2026 at 12:20 PM, Certified Nursing Assistant #5 stated that they had not provided any care to Resident #162 during their shift (7:00AM- 03:00 PM day shift) and that they would toilet Resident #162 after lunch.During an interview on 06/17/2026 at 3:48 PM, Licensed Practical Nurse Manager #3 stated residents should be offered toileting or incontinence care every two to four hours and that if a resident got up on the night shift, they should be offered toileting hygiene again around 08:00 AM to ensure that they were not soiled. Additionally, Licensed Practical Nurse Manager #3 stated that residents should be fully dressed in common areas and have their hair combed.During an interview on 06/18/2026 at 2:30 PM, the Director of Nursing stated that dependent residents should be rounded on at minimum every two to four hours to ensure they were not sitting in waste and receive incontinence care.2. Resident #152 had diagnoses including bilateral absolute glaucoma (a severe eye condition causing complete vision loss in both eyes due to irreversible optic nerve damage), tremors, and paranoid schizophrenia (a mental health condition with hallucinations, delusions, and difficulty determining what is real). The Minimum Data Set, dated [DATE] included the resident was cognitively intact, required staff assistance with personal hygiene and had no rejection of care.Review of Resident #152's Comprehensive Care Plan, revised on 02/11/2026, revealed the resident had impaired visual function related to glaucoma, required assistance with self-care, and preferred weekly showers on Thursday day shift. Interventions included, but were not limited to, providing personal hygiene with the assistance of one staff member and leaving the resident in safe circumstances and redirecting later if resident refused care.Review of Resident #152's Kardex as of 06/19/2026 included providing personal hygiene with the assistance of one staff member and weekly showers on Thursday day shift.Review of an unnamed report for 06/2026 revealed completion of personal hygiene documented on 06/01/2026 through 06/11/2026 and 06/13/2026 to 06/16/2026, but did not differentiate what personal hygiene care was provided.Review of Interdisciplinary Progress Notes dated 06/01/2026 through 06/19/2026 revealed no documented evidence that Resident #152 had been offered or refused assistance with shaving or nail care.During an observation and interview on 06/15/2026 at 9:55 AM, Resident #152 had several days of beard growth and long finger nails with dark debris under the nails. Resident #152 stated they did not want a beard or long finger nails, and they were only able to see shadows (due to eye condition).During an observation and interview on 06/16/2026 at 2:15 PM, Resident #152 had several days of beard growth and long finger nails with brown debris under the nails. Resident #152 stated they wanted their facial hair trimmed and that someone washed them on 06/15/2026.During an interview on 06/22/2026 at 12:53 PM, Certified Nursing Assistant #9 stated a resident's care needs were determined by checking Point of Care (software used by certified nursing assistants to document care provided to residents), and a resident should not have long nails with dark debris under the nails. They would offer to shave or trim the nails of a resident if it was not completed on the resident's shower day, and they would reapproach if the resident refused. Certified Nursing Assistant #9 stated they would notify a nurse of any care refusals and document the refusals in Point of Care.During an interview on 06/22/2026 at 12:21 PM, Licensed Practical Nurse #7 stated a resident's care needs were determined by checking the Kardex, the chart or therapy notes. Licensed Practical Nurse #7 stated they would ask a resident if they wanted a shave or nail trim if it was not completed on the resident's shower day, and residents should not have long nails with dark debris under the nails. Licensed Practical Nurse #7 stated they would document completion of care or refusal of care in a progress note.During an interview on 06/22/2026 at 12:28 PM, Registered Nurse Manager #2 stated a resident's care needs were determined by checking the Kardex, the care plan, and the care card. Registered Nurse Manager #2 stated residents should be shaved and provided nail care on their shower day, and if the resident refused, the nurse or nurse manager should be notified. Additionally, the certified nursing assistants should document in the electronic medical record if the resident refused or if an alternative was given, and the nurses document in a progress note.During an interview on 06/22/2026 at 1:13 PM, the Director of Nursing stated residents should be offered to be shaved or have nails trim as needed, residents should be reapproached if care is refused, and refusals should be documented in Point of Care and a progress note.3. Resident #51 had diagnoses including encephalopathy (brain damage that can cause an altered mental state), failure to thrive, and chronic obstructive pulmonary disease (a condition that affects breathing). The Minimum Data Set, dated [DATE] included that the resident was severely cognitively impaired and required moderate assistance with personal hygiene care.Resident #51's Comprehensive Care Plan (initiated 06/10/2026) and Kardex (as of 06/17/2026) included that the resident required moderate assistance with personal hygiene.An Occupational Therapy note dated 06/04/2026 included that Resident #51 required minimal assistance with grooming activities.Review of Resident #51's Care Task records from 05/01/2026 to 06/18/2026 revealed documentation that the resident received showers weekly with no missed days, and daily documentation of personal hygiene with no missed days.During observations on 06/15/2026 at 9:57 AM, 06/16/2026 at 11:41 AM, and 06/17/2026 at 1:05 PM, Resident #51 was seen with approximately one-half inch long hairs on their chin.During an interview on 06/18/2026 at 12:44 PM, Certified Nursing Assistant #5 stated facial hair is addressed during residents' showers, and Resident #51 had never refused that kind of care.During an interview on 06/18/2026 at 12:44 PM, Licensed Practical Nurse #2 stated facial hair is taken care of when the staff sees it and on shower days, Resident #51 had rarely refused care, and they were unsure why the resident's facial hair was not addressed.During an interview on 06/18/2026 at 1:29 PM, Licensed Practical Nurse Manager #1 stated all residents are shaved on shower days unless they refuse.During an interview on 06/22/2026 at 12:12 PM, the Director of Nursing stated they expected staff to address facial hair on shower days and whenever the hair begins to grow back in.Title 10 New York Codes, Rules and Regulations 415.12(a)(3)

Based on observations, interviews, and record review, the facility failed to properly maintain the resident call system for two (North One and [NAME] One) of seven resident units. Specifically, a central station monitor for the nurse call system did not function properly and call lights above doors did not function as intended.The findings include:The facility policy Call Bell System Response, dated March 2026, included the nurses' call system will register a call from each resident's bedside, toilet and bathing facilities to the nurses' station. The call system should also register a visual signal at each resident's doorway. The Nursing Assistant assigned to resident will check for function of call bells on every shift and report any malfunctions immediately to a supervisor. In the event of a defective call bell, Engineering will be informed and a hand bell is to be provided to resident. As deemed necessary routine checks will be initiated to ensure resident's needs are met until the defective call light is repaired.During observations on 06/15/2026 from 10:28 AM to 10:34 AM, nurse call lights above the doors outside rooms [ROOM NUMBERS], and the shared bathroom for rooms 214/216 (North One) did not illuminate when activated from the bedside and bathroom call cords.During observations and interview on 06/15/2026 at 3:17 PM, the nurse call panel and monitor screen at the [NAME] One nurse station desk was covered with folders and papers. Unit Clerk #1 stated the nurse call system panel had not been working for a week and they want it fixed. Unit Clerk #1 stated they had found the call system panel unplugged and plugged it back in but it still did not work. Staff have to look down the halls because they do not get any information at the panel.During observations and interview on 06/15/2026 from 3:15 PM to 3:20 PM, the nurse call buttons at the bedside and in the bathroom were activated in resident room [ROOM NUMBER] (West One), and the lights above the door and in the corridor did not illuminate and the nurse call system monitor screen located at the nurses' station did not indicate the call light had been activated. The Director of Maintenance stated they were unaware of any issues with the nurse call system and had not received any emails or work orders but would have it addressed. The Director of Maintenance stated the console at the nurse station was unplugged and when it was plugged back in, it was working properly.Record review on 06/16/2026 at 3:03 PM revealed monthly maintenance logs, dated 04/23/2026 and 05/12/2026, included checks of the nurse call system on each unit and did not list any problems with lights not illuminating or registering at the panels.Title 10 New York Codes, Rules, and Regulations: 415.29(b)Title 10 New York Codes, Rules, and Regulations: 713-1.3(b), 713-2.22(g)

Based on record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice that met each resident's physical, mental, and psychosocial needs for six (6) of 21 residents (Residents #33, #42, #90, #179, #204, and #209) reviewed. Specifically,-Resident #209 returned from the emergency department on 10/01/2025 and there was no documented evidence the resident was assessed and their treatment in the emergency department was reviewed upon return, or the physician was made aware of their return. Subsequently, the resident was hospitalized on [DATE] for an untreated, worsening urinary tract infection. -Resident #42 returned from the hospital on [DATE] and was not started on an antibiotic per hospital discharge recommendations until 11/07/2025. Additionally, hospital recommendations for a basic metabolic panel (a lab that checks for fluid balance and metabolism) in one (1) week was not completed. Subsequently, the resident was re-hospitalized on [DATE] for gross hematuria (blood in the urine). -Resident #204 returned from the emergency department on 11/21/2025 with an after-visit summary recommending discontinuation of acetaminophen. The resident was administered three (3) doses of acetaminophen before the order was discontinued on 11/22/2025. -Resident #33 returned from the emergency department on 11/03/2025 and there was no documented evidence the resident had a follow up appointment scheduled with gastroenterology (digestive system specialist) as recommended. -Resident #90 returned from the emergency department on 11/22/2025. The 11/23/2025 Physician #12 progress note documented the plan included awaiting emergency department imaging results/after visit summary and follow recommendations once available and to continue routine medications unless contraindicated by emergency room evaluation. There was no documented evidence the resident's treatment in the emergency room was reviewed. -Resident #179 returned from the hospital on [DATE]. The hospital after-visit summary documented the antibiotic recommended to be given twice daily was last administered in the hospital the morning of 11/25/2025. Upon return to the facility, the resident did not receive the recommended antibiotic at bedtime on 11/25/2025 or in the morning on 11/26/2025. This resulted in actual harm to Resident #209 and the likelihood of serious injury, serious harm, serious impairment, or death that was Immediate Jeopardy and Substandard Quality of Care to resident's health and safety for all residents admitted or readmitted to the facility. Findings include: There was no documented evidence of facility policies related to readmission procedures. 1) Resident #209 had diagnoses including quadriplegia (paralysis of all four limbs), dysfunction of the bladder, benign prostatic hyperplasia (enlarged prostate causing trouble urinating) with lower urinary tract symptoms, and presence of urogenital implants (surgical medical devices to help the urinary system work properly). The 09/21/2025 Minimum Data Set (a resident assessment tool) documented the resident had severe cognitive impairment, was dependent for all activities of daily living, and had an indwelling urinary catheter. The 10/01/2025 Licensed Practical Nurse Unit Manager #14 progress note documented the resident's suprapubic catheter (a tube placed through an incision in the abdomen to drain urine) was leaking and they were advised by Physician Assistant #49 to send the resident to the hospital for possible replacement. The 10/01/2025 hospital emergency department notes by Physician #50 documented there was no drainage around the suprapubic tube, and it was draining. The catheter was irrigated and flushed without difficulty. There were no fevers and no white count on previous urines with alternating infection verses colonization. The urine was sent for culture (determines possible growth of bacteria) and was okay for continued outpatient follow up. The resident was discharged back to the facility the same day (10/01/2025). There was no documented evidence in the resident's medical record when they returned to the facility, or that a nursing assessment was completed upon return. There was no documented evidence the resident's emergency room treatment was reviewed, recommendations for medical management were reviewed or addressed, or the resident's attending physician was notified upon their return to the facility. There was no documented follow-up on the urine culture obtained in the emergency room. The hospital notes from the 10/01/2025 emergency room visit were printed on 10/08/2025 by former admission Coordinator #55 and included a prescription from hospital Physician Assistant #52 dated 10/03/2025 for amoxicillin-potassium clavulanate (antibiotic) tablet 875-125 milligrams every 12 hours for urinary tract infection for ten (10) days. There was no documented evidence the resident's physician was notified of the prescription for the antibiotic.The 10/07/2025 physician order documented the resident was to receive amoxicillin-potassium clavulanate tablet 875-125 milligrams every 12 hours for urinary tract infection for ten (10) days. The October 2025 Medication Administration Record did not document any administered doses of the 10/07/2025 prescribed antibiotic. The 10/08/2025 one (1) week after the emergency room visit) Physician #12 progress note documented an acute care visit for follow up for urinary tract infection. The resident went to the emergency room last week where a urinalysis and culture were obtained, and the resident was later discharged back to the facility. The facility received a call today the urine culture was positive (presence of bacteria indicating an infection). An antibiotic was ordered per emergency department recommendations. The 10/08/2025 at 3:02 PM Licensed Practical Nurse #13 progress note documented the resident was sent to the emergency room at their spouse's request. There was no documentation of signs or symptoms related to the transfer. The 10/08/2025 hospital Physician #51 progress note documented the resident presented to the emergency department for evaluation and treatment of abdominal pain. The resident was seen and evaluated in the emergency room last week and was diagnosed with a urinary tract infection and sent home with an order for antibiotics. The resident was not started on treatment as the order was not received by the nursing facility. The resident had increased abdominal pain and tenderness suggestive of a progressive worsening urinary tract infection. Overall, the resident seemed to be worsening since returning home (to the facility). The differential diagnoses were urinary tract infection, pyelonephritis (a serious bacterial infection of the kidney), and acute kidney injury. They attempted to call the facility but were unable to reach them to confirm their ability to fill a prescription. Given the difficulty getting this filled, they did not feel comfortable sending the resident back to the facility. During an interview on 12/10/2025 at 4:05 PM, Licensed Practical Nurse Unit Manager #14 stated the cart nurse (medication nurse) was responsible for documenting a resident's return. The cart nurse was also responsible for reviewing the after-visit summary and should note if there were any new orders. They stated as the Unit Manager, they were also responsible to follow up on any resident returns the following day. They documented in a note on 10/01/2025 that Resident #209 went to the hospital and should have followed up the next day, but they did not. During an interview on 12/11/2025 at 10:14 AM, Assistant Director of Nursing #15 stated the emergency room often did not send paperwork, and the admissions department was asked to print it. Usually there was no nurse-to-nurse report from the emergency department when a resident returned to the facility. They recalled Resident #209's family member telling them about an antibiotic the resident was supposed to have. If the family member had not brought it up, the facility would never have known about it. They called the pharmacy who informed them the emergency department had sent a prescription, but it was not filled because it was not sent from a facility authorized provider. They stated they told Physician #12 the antibiotic needed to be ordered. The nurse manager should have followed up on the paperwork and the emergency room visit. If a resident returned after hours, it was the nursing supervisor's responsibility. This happened another time as well, around the same time frame but they could not recall the other resident's name. The cart nurse or the supervisor should document a progress note upon resident's return. If a resident needed an antibiotic for any reason and did not get it, the infection would get worse. Antibiotics should be started within 24 hours. Resident #209's family member was upset and wanted the resident sent back to the hospital because the facility was not taking care of them, and they did not want the resident in the facility anymore. If there had been communication with the hospital, the facility would have known there was a urine culture pending and could have followed up about the need for an antibiotic. They stated the floor nurses were not knowledgeable about getting report and ensuring there was paperwork, but the nurse managers and supervisors should know. Nurse managers were supposed to review what residents went out to the hospital and what residents returned in morning report. During a telephone interview on 12/11/2025 at 11:34 AM, Physician #12 stated on 10/08/2025, Resident #209's family member informed the facility the resident was supposed to be on an antibiotic. If nursing had followed up sooner, they would have ordered the antibiotic, and the resident may not have had to go out to the hospital again. Unfortunately, without the antibiotic the resident's condition deteriorated, and they had to go back to the hospital.During a telephone interview on 12/11/2025 at 12:58 PM, Resident #209's family representative stated the resident had to be hospitalized on [DATE] with a worsening urinary tract infection because they were never administered an antibiotic. They spoke with Licensed Practical Nurse Unit Manager #14 who told them they spoke with the hospital and there was no mention of an antibiotic. During a telephone interview on 12/16/2025 at 1:56 PM, the Director of Nursing stated the emergency room return with Resident #209 fell through the cracks. If the resident returned without paperwork, the nurse should have contacted the hospital. It was the facility's responsibility to ensure resident needs were met and followed up on appropriately. They did not recall being made aware of the issue with Resident #209, or any other residents, or they would have followed up. 2) Resident #42 had diagnoses including urinary tract infection, hematuria (blood in urine), and acute kidney failure. The 10/20/2025 Minimum Data Set documented the resident was cognitively intact, required partial/moderate assistance with toileting hygiene, and had an indwelling urinary catheter. The 11/02/2025 Registered Nurse #8 nursing progress note documented the resident's urinary catheter had a substantial amount of blood throughout the tubing and in the bag. The on-call provider was notified and ordered the resident to be sent to the hospital. The 11/05/2025 hospital Physician #53 Discharge Summary documented the following for Primary Care Provider follow up: -Urology follow up for trial void in one (1) to two (2) weeks and for hematuria work up with cystoscopy (an exam of the inside of the bladder using a camera). -Outpatient follow-up for a large hiatal hernia (the top of the stomach bulges through the diaphragm). -Start amoxycillin (antibiotic) one (1) gram three (3) times a day to complete ten (10)-day course. -Basic metabolic panel lab test in one (1) week to monitor creatinine (a waste product from protein breakdown used to assess kidney function). The 11/05/2025 Registered Nurse #42 progress note documented the resident returned to the facility. There was no documented evidence of review or follow-up on the resident's emergency department treatment, or recommendations for medical management. The 11/06/2025 Physician #12 progress note documented the resident was seen for evaluation following recent hospitalization for hematuria. Recommendations included a urology follow-up appointment in one (1) to two (2) weeks and continue amoxycillin for enterococcus (type of bacteria) urinary tract infection. The gastrointestinal/abdominal exam was negative and did not indicate there was a large hiatal hernia. The 11/07/2025 physician orders documented amoxycillin 1000 milligrams three (3) times a day for urinary tract infection for ten (10) days and a complete blood count (measures the number and size of cells in the blood) and basic metabolic panel labs one (1) time only for renal (kidney) function evaluation.There was no documented evidence the 11/07/2025 complete blood count and Basic Metabolic Panel labs were completed or that a urology appointment was scheduled. The 11/14/2025 Change in Condition by Licensed Practical Nurse #37 documented the resident was sent to the emergency room for evaluation of hematuria. 3) Resident #204 had diagnoses including chronic kidney disease, adult failure to thrive (overall physical decline), and end stage heart failure. The 11/08/2025 Minimum Data Set documented the resident had moderate cognitive impairment, required supervision for most activities of daily living, and received a scheduled pain medication regimen. The 11/20/2025 Registered Nurse Supervisor #42 progress note documented the resident was assessed after an unwitnessed fall. The resident was sent to the emergency department for further evaluation. The 11/21/2025 hospital after visit summary medication list documented a large red stop-sign and directions to stop taking acetaminophen. The 11/21/2025 Licensed Practical Nurse #37 progress note documented the resident returned to the facility. There was no documented evidence the resident's emergency treatment was reviewed or recommendations for medical management were reviewed or addressed. There were no documented orders to discontinue acetaminophen. The November 2025 Medication Administration Record documented acetaminophen 500 milligrams, give to (2) tablets by mouth three (3) times a day for pain. The acetaminophen was documented as administered on 11/21/2025 at 7:00 PM, and 11/22/2025 at 9:00 AM and 2:00 PM. The acetaminophen was discontinued on 11/22/2025 at 5:12 PM. During an interview on 12/09/2025 at 11:35 AM, Licensed Practical Nurse #13 stated they let their nurse manager, or a supervisor know when a resident returned to the facility from the hospital, and they did not document if a resident returned to the facility. They stated they never reviewed the paperwork. It was the Nurse Manager's or Supervisor's, and the Medical Provider's responsibility to obtain and review hospital paperwork. During an interview on 12/10/2025 at 2:04 PM, the Admissions Director stated they alerted staff of a hospital return, printed the hospital paperwork, and uploaded it to the medical record. If it was only an emergency room visit, they were not involved unless they were asked to print something from the hospital record. During a telephone interview on 12/11/2025 at 11:34 AM, Physician #12 stated nursing should follow up on all emergency room visits and call the hospital to obtain the discharge paperwork if needed. It was important the facility knew what the hospital recommendations were to provide what was needed in the nursing home. When residents went out to the hospital or returned, it was discussed in morning meeting. If nursing did not report to them a resident returned from the hospital, they had no way of knowing. Residents who returned to the facility were typically seen by medical the next day. During an interview on 12/12/2025 at 10:59 AM, the Administrator stated the facility did not always receive paperwork from the hospital. The cart nurse or nurse manager was responsible to go through the paperwork, talk to the provider, put any new orders in, and complete an assessment. Each unit was responsible, and several people would have been doing parts of a hospital or emergency department return. Paperwork should be reviewed within 24 hours; they did not know the whole process, but it had to be team effort. There should have been a progress note written when residents returned to the facility. Leadership had a telegram text communication on their cellular phones and any movement of a resident in and out of the facility should be communicated there. They asked the nurses to request the emergency room paperwork, but they were not sure if there was a formal education with the nurses about the return process. They were not aware of hospital return issues for Residents #33, #42, #90, #179, and #204. The paperwork should have been reviewed and followed up on for patient care. Something was changed for a reason, antibiotics should not be missed, and there could be negative effects. Resident #209 got worse and had to be hospitalized . The nurses did not follow up and the provider did not follow up. Assistant Director of Nursing #15 or the Director of Nursing should have investigated how this happened and how this was missed. They expected the Director of Nursing to investigate the issue with Resident #209 after they were made aware on 10/08/2025, but they did not follow up with them. 10NYCRR415.23Immediate Jeopardy was identified, and the Administrator was notified on 12/12/2025 at 5:35 PM. Immediate Jeopardy was removed on 12/16/2025 at 3:38 PM prior to survey exit based on the following corrective actions taken:-A new process was started with residents returning from the hospital that included reviewing medications, and a new emergency department checklist was implemented. -Admissions staff uploaded emergency room visits the next business day. -The Assistant Director of Nursing educated staff on the evening shift on 12/12/2025. -The nursing supervisor educated the night shift on 12/12/2025 and the day shift on 12/13/2025. -The nursing supervisor on duty educated over the weekend and the Assistant Director of Nursing and the Director of Nursing followed up. -The nursing supervisor was made aware when the hospital was sending a resident back, and was responsible to ensure the checklist was filled out. -The nurse on west 1 (ambulance bay door) notified the nursing supervisor of a resident's arrival. -On 12/12/2025 at 7:20 PM, the facility's immediate plan was reviewed and accepted. -On 12/15/2025 it was identified the facility was not in compliance with one (1) of two (2) hospital readmissions from over the weekend.-The facility staff involved were re-educated on 12/15/2025 and verification of re-education was received.-Staff education was verified onsite during interviews on 12/16/2025. Multiple licensed nursing staff were interviewed. -Staff were able to report content of education.

Based on observations, record review, and interviews conducted during the survey, the facility failed to ensure adequate supervision to prevent accidents for three (3) of seven (7) residents (Resident #34, #44, and #100) reviewed. Specifically:-Resident #100 who was cognitively impaired and wore a wander alert device, left the faciity on [DATE] undetected, and attempted to enter staff vehicles in the parking lot. The resident was not provided 30-minute checks as ordered following the incident. The elopement was not reported to the New York State Department of Health as required. Additionally, the resident was observed attempting to exit through stairwell doors without their wander alert device alarming; and staff were observed silencing the wander alert alarm without checking the area for residents. -Resident #34 was at risk for falls, had an unwitnessed fall on 11/13/2025 resulting in a scalp laceration and neurological checks were not completed following the fall. Additionally, the resident was observed not wearing non-skid socks as care planned. -Resident #44 was at risk for falls, had multiple falls (09/16/2025, 09/18/2025, 11/24/2025, and 12/08/2025), was not provided fall interventions as care planned, interventions were not reviewed or revised following recurrent falls, neurological checks were not completed as ordered, and the falls were not thoroughly investigated to determine a root cause. This resulted in Immediate Jeopardy and Substandard Quality of Care to Resident #100 and placed all 28 residents identified as at risk for elopement, at risk for the likelihood of serious harm, serious injury, serious impairment, or death. Findings include:ELOPEMENT The facility policy Elopements revised 01/2025, documented staff was to investigate and report all cases of missing residents. A resident who left the premises or a safe area without the facility's knowledge and supervision was considered an elopement. When the individual returned to the facility, the Director of Nursing or charge nurse were to examine the resident for injuries, notify the attending physician and the resident's responsible party, complete and file a report of Incident/accident and document the event in the resident's medical record. Resident #100 had diagnoses including dementia with psychotic disturbance and Parkinson's disease (a progressive neurological disorder). The 10/03/2025 Minimum Data Set (a resident assessment tool) documented the resident had severely impaired cognition, fluctuating disorganized thinking and inattention, had no behaviors, and required supervision for mobility. The 11/03/2025 Comprehensive Care Plan documented the resident was at risk for elopement related to a change in their environment and cognitive impairment. Interventions included to check placement of the wander alert device each shift, provide the wander alert device number and location, and check the wander alert bracelet every shift. The 10/18/2025 Elopement Risk Assessment documented the resident was at risk for elopement and had one (1) or more elopement attempts. The 10/18/2025 Incident report, signed off by the Director of Nursing on 11/26/2025, documented:- on 10/18/2025 at 12:26 PM, the unit was notified Resident #100 was observed outside by Certified Nurse Aide/Concierge #9. The resident was attempting to open car doors. - the resident was redirected back inside by Certified Nurse Aide/Concierge #9 and the Supervisor, Director of Nursing, and Nurse Practitioner were notified.- Resident #100 was last seen at 12:15 PM wandering around the unit. - there were no findings on the head-to-toe assessment, the placement and function of the wander alert device was checked and found to be functioning, and the Resident #100 was placed on one-hour checks.- Maintenance checked the function of all doors and elevators with no issues found. There was no documented evidence of a review of the resident's care plan to ensure interventions were in place and appropriate, no documented evidence of a summary of the incident and no documented evidence of a report to the New York State Department of Health. The 10/18/2025 Physician Assistant #61 progress note documented they spoke with Registered Nurse #8 who informed them that Resident #100 was found outside of the facility. The resident was last seen approximately ten (10) minutes before being found outside, near the building. They were unsure how the resident left the building. Resident #100 was without injuries. They ordered the resident be placed on 30-minute checks, continue the wander alert device and ensure the device was functioning properly, obtain a urinary analysis related to a urinary tract infection and labs, and obtain a psychiatric consult to evaluate for medication adjustments. The October 2025 Treatment Administration Record documented Resident #100 was placed on 30-minute checks on 10/18/2025 during the 7:00 AM - 3:00 PM shift and the order was discontinued on 10/18/2025 at 1:59 PM. One-hour checks were initiated at 2:00 PM on 10/18/2025. There was no documented evidence of a physician order for discontinuing 30-minute checks or initiating one-hour checks. The 10/13/2025 and 11/06/2025 Wanderguard Door Inspection documented all alarms were working properly. There was no documented evidence of door checks on 10/18/2025. Resident #100 was observed on:-12/04/2025 9:47 AM wandering around the hallway and stopping in front of other residents that were sitting in the hallway. At 10:27 AM, wandering up and down the hallway. At 11:41 AM, attempting to follow a staff member through the stairwell to the right of the elevator and the wander alarm went off. -12/08/2025 from 11:50 AM to 12:26 PM, wandering the hallway. -12/09/2025 at 10:59 AM quickly following Registered Nurse #8 and a licensed practical nurse toward the E2 stairwell. The resident grabbed the door right before it shut and attempted to follow Registered Nurse #8 through the door. Registered Nurse #8 directed Resident #100 to let go of the door and then shut the door. The wander alert system did not alarm when the resident went to the door. At 11:02 AM, the resident had a wander alert device on their ankle. At 11:14 AM, the resident walked back toward the E2 stairwell and was redirected towards the dining room by a staff member. During an observation and interview on 12/08/2025 at 11:16 AM in the E stairwell, Registered Nurse Unit Manager #38 stated the door alarmed if the door stayed open too long and a code had to be put in to exit. If the door was open too long the code had to be put in to silence the door or it could be silenced at the nursing station desk. During an observation on 12/08/2025 at 3:05 PM, the E stairwell door was tested, there was an approximate three (3) second delay when the door was opened and the alarm sounded. The alarm was silenced with no staff checking the doorway to see why the alarm was triggered. There was no camera in the area for monitoring. At 3:19 PM, the door to the outside was set off and silenced with no staff checking to see why the alarm was triggered. An unidentified staff member was observed at the nursing station turning off the door alarm without checking the stairwell. During an observation on 12/09/2025 at 11:05 AM, the wander alert system was tested with a wander alert device obtained from Licensed Practical Nurse Unit Manager #37. The wander alert device sounded appropriately at the elevator. At 11:06 AM, the wander alert device did not audibly alarm at the F2 door to the stairwell but did signal light blink. The door relocked immediately when the code was entered on the wander alert box at the door. At 11:09 AM, an exit was attempted by the surveyor at the E2 door to the stairwell with the wander alert device. There was no signal light flashing, the door did not lock when the code was put in, and exit was successful without the wander alert device alarm triggering. During an interview on 12/09/2025 at 11:55 AM, Maintenance Worker #57 stated they completed the wandering alert device door checks. They checked all the doors except the first floor. The wander alert devices did not lock the doors, they only locked the elevators. Once the doors open from the delayed egress (when the exit door locks and it cannot be immediately opened until after several seconds), the wander alert alarm went off. The door checks were done monthly and if something was not working properly, they alerted the Director of Environmental Services. The wander alert alarm was turned off by entering the door code. During an observation and interview on 12/09/2025 at 1:39 PM with the Director of Environmental Services and Maintenance Worker #57, the wander alert system was not working at the E2 door to the stairwell. The Director of Environmental Services stated the sensitivity was not strong enough and needed to be adjusted and it may have weakened due to residents wandering near the door. Maintenance Work #57 stated they only tested the delayed egress when they did their door check and was confused on how to test the wander alert system. During an interview on 12/09/2025 at 12:05 PM, Certified Nurse Aide #59 stated all three (3) doors and the elevator on the [NAME] 2 unit had wander alert device alarms. The door wander alert device alarms were supposed to alarm when a resident went near the door or beeped if a resident tried to push on the door. If a resident was exit-seeking, the resident should be redirected, the nurse alerted, and staff should attempt to keep an eye on the resident. They believed when Resident #100 eloped on 10/18/2025, they were let out or they went behind someone as they could not leave through the unit door without a code. They stated they thought maintenance was fixing the doors that day because the resident's wander alert alarm did not go off. Resident #100 had their wander alert device on their ankle, and it was functioning. During an interview on 12/09/2025 at 12:21 PM, Registered Nurse #8 stated the doors in the dining room had wander alert alarms that were supposed to sound when residents with wander alert devices went near them. They stated on 10/18/2025, Resident #100 was found by staff outside in the back by the loading docks. When they went to get the resident, the resident was already coming up the stairwell from the back door with a staff member. The resident was gone for approximately ten (10) minutes. They did not know how the resident got outside as they had their wander alert device on, and it was functioning. Registered Nurse #8 said, they believed something was going on with the doors and codes to the doors, they were just open, and the resident went down the E stairwell. They were informed after the incident there were issues the night before with the wander alert system as it kept beeping. When maintenance checked the system after Resident #100 was back on the unit, they said everything was working. During a phone interview on 12/09/2025 at 12:44 PM, Certified Nurse Aide/Concierge #9 stated on 10/18/2025, Resident #100 was outside in the parking lot when they were coming back from lunch. They saw Resident #100 trying to get into cars. When they called the resident's name they went over to the loading dock. They asked the resident to come inside, and the resident followed them in. Registered Nurse #8 met the Certified Nurse Aide/Concierge on the stairs after they called them on the supervisor phone. During an interview on 12/09/2025 at 12:50 PM, Licensed Practical Nurse Unit Manager #37 stated wander alert devices were checked for placement every shift and function twice a day. The function was checked by walking the resident to the elevator or by the box in the supervisor's office that sounded off if it was functioning. All staff had the codes to the wander alert device keypads and could turn off the alarms. Nursing should only shut off the alarms after they made sure no residents had gone out the doors or got on the elevator. The only wander guard alarm that sounded was at the elevator because the doors were coded. They were unsure how Resident #100 got outside, but the resident was placed on safety checks after the elopement. If the door to the E stairwell door did not shut all the way, it would engage the alarm, but they were unsure how long it took. During an interview on 12/09/2025 at 1:06 PM, the Director of Nursing stated if there was an elopement, staff notified the supervisor. They and the Administrator were also notified. The situation would be investigated. They should make sure the resident was safe, inform the physician and responsible party, and report the incident to the Department of Health within two (2) hours. Staff had been educated on elopement risk, there were evaluations to identify residents as elopement risk which were included in the resident's chart. The facility also had wander alert devices for residents who had tendencies to wander and possibility to elope. The wander alert devices were checked every shift, but they were unsure how often the alarms at the doors and the elevator were checked. On 10/18/2025, Resident #100 was noted by the dock outside. It was not considered an elopement even though the resident had gotten off their unit with a wander alert device. The report they originally received documented the resident was standing on the loading dock and was seen by a staff member walking towards the dock. When they received the staff statements, they found out the resident was outside alone trying to get into cars. The elopement was not reported to the New York State Department of Health. They were new to the facility at the time and had followed up on reporting protocol and they were past the two (2)-hour reporting timeline, so it was not reported. They informed the Administrator the resident was outside unattended, but they were not provided any direction on reporting the incident. They were unsure how the resident got outside as their wander alert device was working. During an interview on 12/09/2025 at 1:37 PM, the Administrator stated staff were educated upon hire and annually regarding elopements. There was an elopement binder at the front desk. Resident #100 eloped in October 2025. They were informed the wander alert system was not functioning correctly and the resident was found outside. However, when maintenance came in to check the system, everything was working correctly. They were informed maintenance had to reset the system, but it was functioning correctly. They believed Resident #100 got out via the E stairwell. All the doors on the second and third floor were supposed to have a wander alert alarm on them if a resident with a wander alert device got near them. If the door did not alarm, the staff were to immediately call maintenance. All staff were able to shut off the wander alert alarms at the doors and elevators. Regular door alarms should not be turned off at the nursing station without checking to see who went out the door. It was important to have a functioning wander alert system to prevent a resident from eloping. Resident #100's elopement was not reported to the New York State Department of Health as it was past the reporting deadline by the time they found out about the incident. They were not made aware the resident was unattended in the parking lot until the following Monday (10/20/2025) and they should have been made aware of the elopement right away. During a phone interview on 12/09/2025 at 4:19 PM, the Medical Director stated they were unsure if they were notified of Resident #100's elopement from the facility in October 2025. It was not a situation that necessarily needed to be escalated to the Medical Director, but a physician should be notified. Facility wander alert systems were not under their control, but they expected the devices in the facility were properly functioning and safety measures were in place. If an on-call provider ordered 30-minute checks of a resident, the facility should follow through on the order. During a phone interview on 12/09/2025 at 5:03 PM, Physician #12 stated if a resident eloped, they expected the resident to be placed on one-to-one monitoring. The resident should be assessed by a registered nurse and the assessment communicated to the medical team. They were made aware Resident #100 was found outside the facility. If 30-minute checks were ordered by a provider, staff should not change them to one (1) hour checks without another medical order. FALLS The facility policy Fall Prevention Program revised 01/2025, documented residents must be assessed in a timely manner for potential causes of a fall and the environmental issues addressed promptly. After a first fall, the team reviewed the resident's gait, balance, and current medications. Based on the assessment, the interdisciplinary team would identify interventions to prevent subsequent falls. The interdisciplinary team, with physician's guidance, were to follow up on any fall with an associated injury and monitor as delayed complications could occur. If the interventions were successful in preventing falls, the staff continued with the current approaches or determined if they are still needed if the problem had resolved. If a resident continued to fall, the staff and the physician were to re-evaluate the situation and current interventions. 1) Resident #34 had diagnoses including repeated falls and unsteadiness on feet. The 10/17/2025 Minimum Data Set documented the resident was cognitively intact, had no behaviors, required supervision to touching assistance for transfers and ambulation, and had two (2) or more falls without injury.The 04/16/2025 Comprehensive Care plan documented the resident was at risk for falls related to weakness, deconditioning, restlessness, and history of recurrent falls. Interventions included to ensure resident was wearing appropriate footwear for movement, and non-slip socks while out of bed. The undated Kardex (care instructions) documented for safety, the resident was to wear non-slip socks while out of bed. A 09/04/2025 physician order documented neuro checks per facility protocol for 72 hours post-fall every shift for three (3) days. The 11/13/2025 Incident Report completed by Licensed Practical Nurse #14 documented Resident #34 was found in their room on the floor with a small amount of blood coming from the right side of their scalp. The incident was unwitnessed, and injuries were observed at the time of the incident. The resident had an abrasion to the top of the scalp. The incident report documented there were no predisposing physiological or situational factors documented. The 11/13/2025 Medical Provider #24 note documented the Resident #34 was seen for an unwitnessed fall. The unit nurse found the resident at their bed side with blood oozing from the right side of their head. It was suspected the resident hit their head on the nightstand next to the bed. The resident had a laceration to the right side of their head measuring approximately 1.5 centimeters by 0.3 centimeters with shallow depth. No other injuries were noted. The resident had a history of repeated falls. The orders were to monitor for delayed signs or symptoms; fall precautions: non-skid shoes/footwear, call bell within reach, bed at the lowest position, floor mats on both sides of the bed, and remove nightstand from the bedside; to monitor vitals for at least 72 hours; and neurological checks for at least 72 hours post fall. There was no documented evidence neurological checks were completed as ordered. Resident #34 was observed out of bed without non-skid socks on:-12/04/2025 at 11:20 AM;-12/05/2025 at 10:51 AM sitting in their recliner. At 11:13 AM, while Certified Nurse Aide #62 and an unidentified certified nurse aide assisted the resident up from bed to their chair; -12/08/2025 at 12:07 PM, propelling themself in their wheelchair. During an interview on 12/08/2025 at 1:57 PM, Certified Nurse Aide #62 stated they should check the care plan every day to ensure no changes were made. If non-skid socks were on the resident's care plan, staff should ensure they were on. The night shift got Resident #34 up for safety reasons as the resident was a fall risk, and the night shift was responsible for getting them dressed. When they assisted the resident with transferring, they were not paying attention and did not check to see if the resident had non-skid footwear on. During an interview on 12/15/2025 at 4:23 PM, Licensed Practical Nurse #13 stated nursing staff should check the care card every shift. Resident #34 had fall precautions in place and should have non-slip socks on as they tried to get up and was unstable. The resident needed the non-skid socks to prevent falls. Neurological checks were documented in the computer and on paper. Neurological checks were documented for 72 hours and were supposed to be completed for unwitnessed falls. During an interview on 12/16/2025 at 12:16 PM, Licensed Practical Nurse Manager #14 stated if there was an unwitnessed fall, they should start neurological checks. On 11/13/2025, Resident #34 hit their head and the medical provider's note from the incident documented there should have been neurological checks. Neurological checks were documented on paper and then given to the Assistant Director of Nursing or Director of Nursing to put with the investigation. Resident #34 should wear non-skid socks as they were at risk for falls, and it is on their care plan. During a phone interview on 12/18/2025 at 10:14 AM, the Assistant Director of Nursing #15 stated the certified nurse aides should review care plans daily. All falls were investigated if they were unwitnessed. Neurological checks were initiated immediately after an unwitnessed fall. Typically, a registered nurse would start the neurological checks and instruct the licensed practical nurse on what forms to complete. Neurological checks were documented on the neurological check sheet and placed in the 24-hour binder. The nursing staff were responsible to ensure the neurological checks were completed as ordered. The 24-hour binder was monitored by the nurse manager. When they reviewed unwitnessed fall accident and incident reports they also reviewed to see if neurological checks were completed. Resident #34 was high risk for falls and staff should follow the fall interventions on the care plan and Kardex. The resident was care planned for non-skid socks and should have them on. The 11/13/2025 fall incident report was started by Licensed Practical Nurse Manager #14. Medical Provider #24 recommended neurological checks to be completed, and they should have been completed. They were unaware neurological checks were not completed, and they did not recall reviewing the accident/incident report for the fall on 11/13/2025. During a telephone interview on 12/18/2025 at 3:39 PM, Physician #12 stated the facility protocol was to do neurological checks every shift after a fall. Resident #34 has a lot of falls. A registered nurse should assess the resident, call the medical provider and then they were to follow fall protocol and start neurological checks. During a phone interview on 12/19/2025 at 9:17 AM, the Director of Nursing stated neurological checks were completed for head strikes or unwitnessed falls. The registered nurse would do the initial neurological check and then the cart nurse (medication nurse) assigned would continue the neurological checks. These were completed for 72 hours. Neurological checks were documented on a paper form and placed in the 24-hour report book on the unit. The nurse on the unit and the unit manager were responsible for ensuring neurological checks were completed. The purpose of a neurological check was to ensure there were no cognitive or mental status changes. Neurological checks were facility protocol. With a head strike, they expected neurological checks to be completed. During a phone interview on 12/19/2025 at 11:20 AM, Medical Provider #24 stated Resident #34 had a history of frequent falls and was seen by them on 11/13/2025 for a fall. Neurological checks should have been completed, and they were not aware they were not completed. All falls should have neurological checks completed for 72 hours and it was nursing's responsibility to complete them each shift.2) Resident #44 had diagnoses including dementia, glaucoma (eye condition that damages the optic nerve), and a history of falling. The 10/05/2025 Minimum Data Set (a tool to assess resident) documented the resident had severe cognitive impairment, required supervision for transfers/ ambulation, had one (1) fall with no injury, and two (2) or more falls with minor injury. The Comprehensive Care Plan initiated 05/06/2024 and revised 10/03/2025 documented the resident was at risk for falls and had actual falls related to history of falls, poor bed mobility, impaired cognition, and poor safety awareness. Interventions included items were kept within reach, ensure appropriate footwear, bilateral floor mats, and initiate an investigation to identify the cause of falls. The 09/16/2025 at 6:00 PM fall incident completed by Registered Nurse #42 documented an unwitnessed fall. Resident #44 was found on the floor sitting on their left side next to the dresser. Neurological checks were within normal limits, the resident had a laceration to their right eyebrow and was sent to the emergency room for evaluation. There were no predisposing environmental or situational factors documented. There was no documented evidence of staff statements, neurological checks, or determination if the resident's care planned interventions for falls were in place. The 09/16/2025 fall risk evaluation by Licensed Practical Nurse Unit Manager #43 documented Resident #44 had multiple falls in the past six (6) months and was at moderate risk for falls. The 09/18/2025 at 2:05 AM fall incident completed by Licensed Practical Nurse #44 documented Resident #44 had an unwitnessed fall and was observed on the floor with no injury. Neurological checks were completed on 09/18/2025 at the time of the incident. There was no documented evidence to determine if the resident's care planned interventions for falls were in place. The 09/18/2025 72-hour neurological check sheet documented neurological checks were completed at 3:00 AM and 3:15 AM, with resident refusals documented until from 3:30 AM - 7:00 AM. There was no documented evidence of additional neurological check sheets after 7:00 AM on 09/18/2025. The 11/24/2025 at 4:15 PM fall incident completed by Licensed Practical Nurse #4 documented an unwitnessed fall with no injury. The resident was found in the bathroom on the floor without injury. Predisposing physiological, situational, and environmental factors were documented as other without an explanation. There were no statements, no documented neurological checks, and no documented evidence to determine if the resident's care planned interventions for falls were in place. The 12/08/2025 at 2:55 AM fall incident completed by Licensed Practical Nurse #44 documented an unwitnessed fall with no injury. Resident #44 was heard falling by staff at the nursing station and was observed on the floor in their room. Predisposing environmental factors included incontinence and behavior; predisposing physiological factors included gait imbalance and incontinence; and predisposing situational factors included ambulating without assistance. There were no statements to determine the last time Resident #44 was toileted, no documented neurological checks, and no documentation to determine if the resident's care planned interventions for falls were in place. There was no documented evidence the care plan was reviewed or revised post incident. Resident #44 was observed at the following times:-On 12/02/2025 at 3:38 PM, lying in bed. They stated they had a lot of falls and their back hurt. There were no fall mats on the floor next to the bed as care planned. -On 12/04/2025 at 10:47 AM, 1:11 PM, and 1:47 PM, sleeping in bed with a bed sheet over their head. The bed was at hip height (versus in low position) and there were no fall mats on the floor as care planned. -On 12/05/2025 at 9:54 AM, sleeping in bed with a bed sheet over their head. There were no fall mats on the floor next to the bed. At 11:26 AM in bed yelling they could not find their shoes and they needed to go to the bathroom. There were no fall mats on the floor next to the bed as care planned. -On 12/08/2025 at 3:14 PM, sleeping in bed with no fall mats on the floor next to the bed as care planned. -On 12/09/2025 at 11:56 AM, in bed watching television. The bed was at hip height and there were no fall mats on the floor next to the bed as care planned. -On 12/10/2025 at 12:00 PM, sleeping in bed with a bed sheet over their head. The bed was at hip height and there were no fall mats on the floor next to the bed as care planned. During an interview on 12/09/2025 at 12:04 PM, Certified Nurse Aide #45 stated fall interventions were located on the Kardex (care instructions), and they were expected to follow the Kardex. They were not aware of any falls for Resident #44, and they did not have any fall interventions. During an interview on 12/09/2025 at 12:29 PM, Licensed Practical Nurse #4 stated a resident with a history of falls should have the bed in the lowest position and fall mats. Resident #44 had falls, they got up on their own, so they tried to do frequent checks on the resident. During an interview on 12/10/2025 at 1:10 PM, Licensed Practical Nurse Unit Manager #43 stated interventions for fall prevention were in the care plan and they expected them to be followed. After a fall, they initiated the fall risk management screen but the supervisor or the Assistant Director of Nursing were responsible to complete the investigation and update the care plan. Resident #44 had three (3) or four (4) falls, maybe more. They did not know how to access the fall care plan to see the interventions that were in place but stated they knew the resident did not have fall mats because the resident could trip on them. During a telephone interview on 12/16/2025 at 1:36 PM, the Director of Nursing stated Assistant Director of Nursing #15 was responsible for risk management including falls. After the investigation was completed, it was given to them. They then signed off on the investigation and the Administrator closed them out. The facility was working on falls and attempting to ensure all falls were investigated and that care plans were being reviewed and revised for effective interventions. During an interview on 12/16/2025 at 2:58 PM, Assistant Director of Nursing #15 stated they were responsible for all accident/incident reports for the facility and ensuring there were thorough and complete investigations. There should be statements from all staff. Falls were discussed in morning meeting. If neurological checks were indicated, that was part of the packet. The process of the investigation would show if there was a break in the care plan. They relied on the unit managers to alert them if interventions were not effective. Most fall investigations were not completed, and they had to follow up. In reviewing Resident #44's care plan, it was not being reviewed or revised with each fall. The investigations for Resident #44 were not done and they were not sure how they missed them. During an interview on 12/22/2025 at 11:00 AM, the Administrator stated they were teaching staff how to complete a proper investigation which included witness statements, a documented registered nurse assessment, and to review/revise interventions. Falls were discussed in morning meeting and the care plan was reviewed to ensure there were no care plan violations. There were no complete and thorough investigations for Resident #44. The Director of Nursing was ultimately responsible, had support, was not asking for help, and was not completing investigations timely. 10 NYCRR 415.12(h)(1)(2)Immediate Jeopardy was issued to the Administrator for F-689 Elopement on 12/09/2025 at 6:00 PM. The Immediate Jeopardy was lifted on 12/11/2025. The following steps were taken to lift the Immediate Jeopardy:-As of 12/09/2025 at 7:49 PM, the facility's immediate plan was reviewed and accepted. -As of 12/11/2025 at 1:15 pm 100% of all staff currently working had been educated on elopement and wander alert malfunction. -85% of all staff had been educated on elopement and wander alert malfunction.-The remaining staff would be educated prior to the start of their next shift. -Staff education was verified onsite during interviews on 12/11/2025. Multiple staff including nursing, maintenance

Based on observations, record review, and interviews conducted during the survey, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care resulting from the cumulative effect of noncompliance cited for F684 Quality of Care, F677 Activities of Daily Living, F689 Accident Hazards, F865 Quality Assurance and Performance, and for 242 of 242 residents residing in the facility. This noncompliance was found to be widespread and created an environment reflecting pervasive disregard for one (1) or more residents' well-being and quality of life, which caused or was likely to cause serious injury, harm, impairment or death that was Immediate Jeopardy and Substandard Quality of Care. Findings include:F684 - Quality of CareWhen Resident's #33, #42, #90, #179, #204, and #209 returned from a hospital or emergency department visit, nursing did not assess the residents, the physician was not made aware, and hospital recommendations for medical management were not reviewed or addressed. The facility's failure to have a process in place when a resident returned from the hospital or emergency department to follow up and review the residents' treatment, order/stop necessary medications or diagnostic testing, and/or schedule follow up visits, placed all residents returning from the hospital at risk for serious harm, serious injury, serious impairment, or death. This resulted in actual harm to Resident #209 that was Immediate Jeopardy and Substandard Quality of Care to resident health and safety for all residents returning from the hospital or emergency department. F677 - Activities of Daily Living Care Provided for Dependent ResidentsResident #132 was not assisted with showering, incontinence care, personal hygiene, and getting out of bed as planned. This resulted in psychosocial harm to Resident #132 that was not Immediate Jeopardy and was Substandard Quality of Care. F689 - Free of Accident Hazards/Supervision/DevicesResidents #34, #44, and #100 were not provided supervision to prevent accidents. Resident #100 eloped from the facility undetected; Resident #34 was at risk for falls, was not wearing their no skid socks as care planned and did not have neurological checks completed following a fall; and Resident #44 was at risk for falls, was not provided fall interventions as planned, interventions were not reviewed or revised following recurrent falls, neurological checks were not completed as ordered, and their falls were not thoroughly investigated. F 865 QAPI Program The facility did not implement and maintain the approved plans of correction from the Extended Recertification Survey dated 05/09/2025 for Resident Rights/Exercise of Rights (F550), Safe/Clean/Comfortable/Homelike Environment (F584), Quality of Life (F675) ADL Care Provided for Dependent Residents (F677), Quality of Care (F684), Treatment/Services to Prevent/Heal Pressure Ulcers (F686), Free of Accident Hazards/Supervision/Devices (F689), Dialysis (F698) Label/Store Drugs and Biologicals (F761), Nutritive Value/Appear, Palatable/Prefer Temp (F804) and Food Procurement, Store/Prepare/Serve- Sanitary (F812), Administration (F835) QAPI Program/Plan, Disclosure/Good Faith Attempt (F865) and Infection Control (F880) 10 NYCRR 415.5

Based on observations, interviews, and record review conducted during the survey, the facility failed to ensure the interdisciplinary team determined a resident's ability to self-administer medications was clinically appropriate for one (1) of one (1) resident (Resident #147) reviewed. Specifically, Resident #147 had expired and/or discontinued medications and used insulin needles in their room.Findings include: The facility policy Self- Administration of Medications dated 01/2025, documented residents had the right to self-administer medications if the interdisciplinary team determined that it is clinically appropriate for the resident to do so. Self-administered medications must be stored in a safe and secure place, which is not accessible by another resident. If safe storage is not possible in the resident's room, the medications of the resident permitted to self-administer would be stored on a central medication cart or in the medication room. Nursing would transfer the unopened medication to the resident when the resident requested them. Resident #147 had diagnoses including diabetes, depression, and high blood pressure. The 12/02/2025 Minimum Data Set (a resident assessment tool) documented the resident was cognitively intact and required set up or clean up assistance with most activities of daily living.The 06/12/2023 physician order documented the resident may self-administer the following medication: by mouth medications, insulin and check own blood glucose levels. There was no documented evidence the resident was assessed for their ability to safely self-administer medications. The Comprehensive Care Plan initiated on 02/10/2023 and revised on 07/11/2025 documented the resident had poor adherence to care regimen and medications. Interventions included assess ability to understand and adhere to therapeutic regimen. The Comprehensive Care Plan initiated 10/03/2023 and revised 08/21/2025 documented the resident required assistance with self-care related to confusion and limited range of motion. There was no documented evidence the resident was care planned to self-administer medications or check blood glucose levels. The following medications were ordered for Resident #147:-On 03/27/2025, Trulicity (diabetes medication) subcutaneous solution pen-injector 3 milligrams/0.5 milliliter inject 0.5 milliliters subcutaneously one (1) time a day every Tuesday for diabetes, may self-administer.-On 07/31/2025, insulin aspart (rapid acting insulin) Injection solution 100 unit/milliliter, inject 60 units subcutaneously two (2) times a day for diabetes. Hold for blood glucose less than 120.-On 07/31/2025, insulin aspart injection solution 100 unit/milliliter, inject 74 units subcutaneously in the morning for diabetes starting on 08/01/2025. Hold for blood glucose less than 120. -On 10/07/025, insulin degludec (long-acting insulin) subcutaneous solution- pen injector 100 unit/milliliter, inject 50 units at bedtime for diabetes. Hold for blood sugar less than 100. -On 08/20/2025, pen needles 5/16 (insulin needle) inject one (1) pen needle subcutaneously before meals for diabetes. The following medication were discontinued for Resident #147:-discontinued on 06/13/2023 selegiline hydrochloride (used for depression) 5 milligram tablets-discontinued on 06/13/2025 losartan (antihypertensive) 100 mg. During an observation on 12/02/2025 at 4:12 PM, in a cabinet in the resident's bathroom (the resident had a private room) there was a sharps container, a 30 day blister pack of selegiline 5 milligram tablets with a refill date of 01/2024, and a 30 day blister pack of losartan 100 milligrams labeled with refill dates of 02/03/2025 and 03/02/2025. On the resident's bedside table there was an insulin pen 100 units in a bag, and six (6) used insulin needles in a fabric bag. During an observation on 12/05/2025 at 10:55 AM, Resident #147 was sleeping in their bed, and the fabric bag with capped needles was hanging from the over-the-bed tray table. During an observation on 12/08/2025 at 12:35 PM, there were four (4) used insulin needles capped in a fabric bag attached to the over-the-bed tray table, Resident #147 was lying in their bed. During an interview and observation on 12/15/2025 at 4:08 PM, Resident #147 stated the needles in the felt bag on the over-the-bed table with the caps on them were used. They stated the nursing staff would bring them a sharps container and they put them in the container. The sharps container and the expired medications remained in the cabinet. During an interview on 12/15/2025 at 4:23 PM, Licensed Practical Nurse #13 stated Resident #147 had an order to self-administer medications and had been self-administering since they were admitted . They thought Resident #147 was assessed by medical and nursing. They stated they administered Resident #147 their ordered narcotic, but Resident #147 did their own blood glucose checks and administered their own insulin. They stated they documented Resident #147's reported blood glucose. Resident #147 had blister packs of medications and was supposed to keep their medication in the drawer. Resident #147 had their own sharps container and let nursing staff know when they needed a new container. Discontinued medications should be removed from the resident's room immediately and they were not aware of any discontinued medications in the resident's room. During an interview on 12/16/2025 at 11:29 PM, Licensed Practical Nurse Unit Manager #14 stated they had a self-administration assessment for Resident #147, and this should be re-done quarterly. They were not sure who completed the assessment, but it would be documented in the resident chart. Resident #147 had been able to self-administer their medications since they were admitted to the facility. Nursing staff brings the medication to the resident room and Resident #147 keeps them at the bedside. Resident #147 should not have expired or discontinued medications at the bedside. If a medication was discontinued, nursing staff should remove it from the bedside. Resident #147 should not be keeping needles in the pouch. They should be put in the sharp's container. They were not aware of the expired or discontinued medication or needles in the pouch. During a telephone interview on 12/18/2025 at 10:14 AM, the Assistant Director of Nursing #15 stated they provided education to ensure the resident took their medications and knew what the medications were. A resident should have an assessment completed for self-administration of medications completed quarterly. They were not aware Resident #147 did not have an assessment for self-administration of medications. If a medication was discontinued or changed, it should be removed from the resident's room, Staff should ensure there are no expired medications or discontinued medications in the room. Staff should also check to ensure the resident was taking their medications. Needles should be placed in the sharp's container, and nursing staff should be assisting the resident with disposal of the needles. Resident's #147's losartan was discontinued on 03/06/2025. Assessment for self- administration should be completed to ensure the resident was safe to take the medication and to ensure the resident had the correct medications in their room. 10 NYCRR 415.3 (f)(1)(vi)

Based on observations, record review, and interviews the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for one (1) of seven (7) residents (Resident #132) reviewed. Specifically, Resident #132 was not assisted with showering, incontinence care, removal of facial hair, and getting out of bed as planned. Additionally, staff documented care was completed when it was not. The lack of regular and consistent care resulted in psychosocial harm to Resident #132 that was not Immediate Jeopardy. Findings include: The facility policy Resident Care with Activities of Daily Living (ADLs) reviewed 01/2025, documented residents were accurately assisted with support for basic activities of daily living. The resident's care plan was reviewed to assess for any special needs of the resident. The date and time care was provided was documented in the resident's activities of daily living and/or in the resident's medical record. Any refusals were reported to the supervisor. The facility policy Resident Rights reviewed 01/2025, documented all residents were treated with kindness, respect, and dignity. Residents had the right to a dignified existence, were free from abuse and neglect, and had the right to self-determination. Resident #132 had diagnoses including multiple sclerosis (a progressive central nervous system disease), cerebral palsy (a condition affecting movement), and depression. The 11/07/2025 Minimum Data Set (a resident assessment tool) documented the resident was cognitively intact, was dependent for all activities of daily living, and did not reject care. The Comprehensive Care Plan documented:-On 07/18/2024 and revised 10/17/2025 the resident was at risk for functional decline in self-care related to multiple sclerosis. Interventions included dependent for transfers, toileting, dressing, personal hygiene, and showering/bathing. The resident was dependent on two (2) for mechanical lift for shower transfer and a shower bed for safety. -On 07/18/2024 and revised 11/13/2025 the resident used psychotropic medication related to depression, insomnia, and bipolar disorder. Interventions did not include person-centered care. -On 08/01/2024 and revised 07/17/2025, the resident was incontinent of bowel and bladder related to multiple sclerosis. Interventions included check every two (2) hours and assist with toileting as needed. Brief check and change every 3-4 hours and as needed. -On 08/03/2024 and revised 11/05/2025, the resident was at risk for being a victim related to dependence on others for activities of daily living. Interventions included activities of daily living assistance was provided as needed. There was no documented evidence on the November 2025 Certified Nurse Aide Flow Sheet Resident #132 received a shower. The documentation for showers was coded as not applicable-not attempted. The resident Kardex (care instructions) active as of 12/09/2025 did not indicate a scheduled shower day for the resident. Their incontinence brief was to be changed every three (3) to four (4) hours and as needed. The resident was dependent on two (2) for transfer from bed to chair and shower transfer. The shower bed was recommended for safety. They were dependent on one (1) for personal hygiene. During an observation and interview on 12/02/2025 at 12:08 PM, Resident #132 was lying in their bed in a hospital gown. Their hair was down to their shoulders and greasy. They had facial hair resembling a full beard and mustache that was approximately two (2) inches long. They stated they preferred short hair, and their family member was going to cut their hair for them, but it was problematic because they had to be up in the chair when they visited for them to be able do it. Staff knew the resident wanted a shave, but the resident stopped asking because it was not getting done. They always kept themselves clean shaven, but they could no longer use their arms and had to rely on staff to do it. They did not even know what day their shower day was. They stated their hair was greasy and they felt the grease was building up in their ears. They had to request care; it was not just offered to them. They stated the staff did not listen to their needs. It made them feel like they were not important enough to worry about.The 12/02/2025 Certified Nurse Aide #45 flow sheet documented they changed the resident's incontinence brief at 11:48 AM (scheduled for 8:00 AM) and 11:49 AM (scheduled for 12:00 PM); transferred them into the tub/shower and provided personal hygiene that included shaving at 11:51 AM; and transferred them to their Geri chair at 11:52 AM.The 12/03/2025 Certified Nurse Aide #59 flow sheet documented they changed the resident's incontinence brief at 1:21 PM (scheduled for 8:00 AM) and 1:22 PM (scheduled for 12:00 PM); gave them a shower at 1:23 PM; provided personal hygiene that included shaving at 1:26 PM; transferred them into the tub/shower at 1:27 PM; and transferred them to their Geri chair at 1:37 PM. During an observation and interview on 12/04/025 at 9:12 AM, Resident #132 was lying in bed in a hospital gown. They stated they asked the staff daily to get up in the chair, but they were lucky to get up once a week. They told Resident Assistant #66 they wanted to get out of bed at 7:30 AM but they just answered the call bells, and they could not actually do anything, and would have to tell the certified nurse aides or nurses. Certified Nurse Aide #64 gave them a shower and a shave yesterday. That was the first shower they received since they moved to this unit on 11/04/2025. At 2:00 PM, they were lying in bed in a hospital gown. The 12/04/2025 Certified Nurse Aide Flow sheet documented Licensed Practical Nurse #4 changed the resident's incontinence brief at 8:00 AM and 12:00 PM; transferred them into the tub/shower and their Geri chair at 2:59 PM. At 2:59 PM they provided personal hygiene care that included shaving.During an observation and interview on 12/05/2025 at 10:02 AM, Resident #132 was lying in bed in a hospital gown. They stated Licensed Practical Nurse Unit Manager #43 told them they would make sure they got up in the chair today. They wanted to get up every day, but stated the facility did not have enough staff to get them up every day. At 11:37 AM, Resident #132 was up in their Geri chair (a chair that provides more support than a regular wheelchair) wearing clothing. At 11:42 AM, Licensed Practical Nurse Unit Manager #43 approached the resident and said Oh you are up in the chair and not in a gown. You look good.The 12/05/2025 Certified Nurse Aide #63 flow sheet documented they changed the resident's continence brief at 2:52 PM (scheduled for 8:00 AM) and 2:53 PM (scheduled for 12:00 PM); provided personal hygiene that included shaving at 2:58 PM; transferred them into the tub/ shower and their Geri chair at 2:59 PM. The 12/06/2025 Certified Nurse Aide #63 flow sheet documented they changed the resident's incontinence brief at 2:13 PM (scheduled for 8:00 AM). There was no other activity of daily living care documented on the day shift (7:00 AM-3:00 PM). The 12/07/2025 Certified Nurse Aide #64 flow sheet documented they changed the resident's incontinence brief twice at 2:39 PM (scheduled for 8:00 AM and 12:00 PM); provided personal hygiene that included shaving at 2:41 PM; and transferred them into the tub/shower and their Geri chair at 2:42 PM. On 12/08/2025 during a continuous observation and interview starting at 10:37 AM, Resident #132 was lying in bed in a hospital gown. They stated they were waiting for their incontinence brief to be changed and had asked at 7:00 AM when Resident Assistant #66 answered their call bell, and said they would tell the certified nurse aides, but they were cleaning up from breakfast right now. They had facial hair approximately a quarter of an inch long. At 1:25 PM, the call light was on. At 1:27 PM, Resident Assistant #66 answered the call light, left the room, and returned to the dining room where lunch was taking place. At 2:03 PM, the Resident #132 stated they were still waiting for their incontinence brief to be changed, and it was last changed at 6:00 AM this morning. At 2:06 PM, Certified Nurse Aide #65 entered the room. At 3:07 PM, the resident was lying in bed in a hospital gown and their facial hair was approximately a quarter of an inch long. They stated staff had finally changed their incontinence brief. The 12/08/2025 Certified Nurse Aide #68 flow sheet documented they changed the resident's incontinence brief at 6:04 AM (scheduled for 4:00 AM). Certified Nurse Aide #65 documented they changed the resident's incontinence brief at 2:21 PM (scheduled for 8:00 AM) and 2:22 PM (scheduled for 12:00 PM); provided personal hygiene that included shaving; transferred them into the tub/shower at 2:25 PM; and transferred them into their Geri chair at 2:26 PM. During an interview on 12/08/2025 at 2:06 PM, Resident Assistant #66 stated they assisted the residents with simple tasks like filling a water pitcher, making their bed, or answering their call bells. If a resident needed an incontinence brief changed, they had to tell the certified nurse aides. When they answered Resident #132's call light, Resident #132 told them they needed to be changed. They stated they waited until lunch was over to tell someone, but they could not recall who they told. During an interview on 12/08/2025 at 3:49 PM, Certified Nurse Aide #64 stated care was documented in the electronic record and if a resident was provided with care more than once on their shift it was documented that way. Shower days were on the paper assignment sheet. They tried to shave residents on their shower days or if they looked scruffy, they asked the resident. Shaving was supposed to be offered daily. Residents should be offered to get up before breakfast but if they did not want to, they would try again after breakfast. Residents were toileted everyone (1) to two (2) hours, and if they said they were wet or needed to be changed. The number of times a resident's incontinence brief was changed on a shift was documented. Documenting a task as completed meant it was done. Residents should receive the care as indicated and people should be treated how you would want to be treated. Resident #132 could not get in the shower because they could not control their body. The other day they went to find the shower bed so they could shower the resident. They had seen it before on other units, so they knew it existed, and they found it in the basement. The resident had only had bed baths prior to that. Certified Nurse Aide #64 stated Resident #132 was very appreciative and said it made them feel good. It had been a while since the resident was shaved and they needed it. The resident had never refused care from them. The 12/09/2025 Certified Nurse Aide #45 flow sheet documented they changed the resident's incontinence brief at 11:40 AM (scheduled for 8:00 AM) and 11:41 AM (scheduled for 12:00 PM); provided personal hygiene that included shaving at 11:42 AM; transferred them into the tub/shower at 11:43 AM, transferred them into their Geri chair at 11:44 AM. During a follow up interview on 12/09/2025 at 11:47 AM, Resident #132 was lying in bed in a hospital gown. They stated they could not do things for themself and felt the staff were not there to help them. When they did care for them, they made negative comments. The facility was unable to provide care sufficient for their needs. It did not make them feel good and they felt like they were abandoned. They never refused care and when they asked for help, they were given excuses such as staff was busy, they would get to it in a minute, or it was a shift change. If they put the call bell on now, they would be told it was mealtime. During an interview on 12/09/2025 at 12:04 PM, Certified Nurse Aide #45 stated the charting included incontinence brief changes and how many times. If there was only one (1) documentation, it meant they were only changed once in eight (8) hours. They asked their residents daily if they wanted to be shaved. Residents should get out of bed every day but when there were only two (2) certified nurse aides like today, there was not enough time. Resident #132 required total care and a mechanical lift to get out of bed. They did not ask them to get out of bed, especially on days there were only two (2) certified nurse aides. The resident's hair was greasy last week on Tuesday, but the resident stated they only wanted incontinence care that day. They were told the resident could be difficult. Documentation was supposed to be accurate and if something was not done it should not be documented as done. During an interview on 12/09/2025 at 12:29 PM, Licensed Practical Nurse #4 stated personal care such as bathing, toileting, and getting residents out of bed was expected to be done daily and was the responsibility of the certified nurse aides and the nurses. If a task could not be completed, it should be reported to them. The care plan/Kardex was the guideline for the resident's care. If they provided activity of daily living care, they documented it. Documentation needed to be accurate. Resident #132 was clean shaven when they arrived on the unit, and they knew Certified Nurse Aide #64 shaved and showered them last week. The resident was typically in bed, but they knew they requested to get up. During an interview on 12/10/2025 at 12:48 PM, Certified Nurse Aide #65 stated care was supposed to be documented after it was completed but it got busy, so they often completed it at the end of their shift. Shaving was done if the resident needed it, and they offered it daily. On days when there were only two (2) certified nurse aides, the nurse would have to watch the floor to get a resident requiring a mechanical lift out of bed. Showers were completed once a week per the assignment sheet. Residents were toileted every two (2) to three (3) hours and documented with each occurrence. If they were toileted three (3) times, it was documented three (3) times. Resident #132 was dependent for all care and did not refuse care. During an interview on 12/10/2025 at 1:10 PM, Licensed Practical Nurse Unit Manager #43 stated residents should be provided with daily care that makes them presentable. Incontinence care should be every two (2) hours. Residents should get out of bed daily. The Kardex should be followed for resident safety. Ultimately, they were responsible for appropriate care being provided. If a resident was dependent for care and was not getting the care they needed, they could feel left out or forgotten about. Resident #132 required total care, was new to the unit and had just received their first shower since arriving on the unit. The resident came to their unit because they were upset with the care on their previous unit. They thought the resident had been out of bed every day except for 12/02/2025 because they were short staffed that day, and they were assigned a medication cart. If there were only two (2) certified nurse aides, it was hard to care for 40 people. They tried to help but they were often on a cart and could not help as much. Resident #132 was happy to have been showered, shaved and up in the chair the other day. During a telephone interview on 12/11/2025 at 1:58 PM, Physician #12 stated if resident was not physically able to complete activities of daily living, staff should be helping. If a resident was dependent on staff and was not receiving appropriate assistance, they could feel horrible. Resident #132 was dependent and could not do anything for themselves. Resident #132 was cognitively intact and could feel frustrated, depressed, or they might even have an outburst. During a telephone interview on 12/16/2025 at 1:56 PM, the Director of Nursing stated it was important residents received the care needed and everyone was responsible. If residents were not getting the assistance they needed or asked for, they would lose trust, feel like they could not depend on us, and it was just poor customer service. 10NYCRR 415.12(a)(3)

Based on record review, observations, and interviews the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure ulcers and wound care for one (1) of six (6) residents (Resident #10) reviewed. Specifically, Resident #10 had a leg immobilizer that was not removed for skin checks that resulted in an unstageable pressure ulcer. This resulted in actual harm to Resident #10 that was not Immediate Jeopardy.Findings included:The facility policy Prevention of Pressure Ulcers/Injuries, revised 01/2025 documented comprehensive skin assessment were done on admission and included areas of impaired circulation due to pressure from positioning or medical devices and skin would be checked daily during care. Support surfaces were selected as appropriate based on the resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors.The facility policy Wound Care revised 01/2025 documented gloves were worn to remove old dressings, removed and hands washed and dried before putting on new gloves; sterile tongue blades and applicators were used to remove ointments and creams from containers; and reusable supplies, such as scissors, were wiped with alcohol.Resident #10 had diagnoses including a fracture of the left lower leg, peripheral vascular disease (narrowing or blockage of blood vessels leading to reduced blood flow), and diabetes. The 09/18/2025 Minimum Data Set (a resident assessment tool) documented the resident had intact cognition, was dependent for transfers and bed mobility, and was at high risk for developing pressure ulcers.The Comprehensive Care Plan revised 10/16/2025 documented the resident had alteration in skin integrity related to an actual pressure ulcer related to a fracture of left lower leg and an unstageable wound of the left ankle. Interventions included heel protectors and a chair pressure relieving device.Immobilizer The 09/16/2025 physician order documented the left knee immobilizer was to be removed every evening shift for skin integrity assessment and hygiene.The 09/30/2025 Orthopedic Report of Consultation documented the left leg fracture was treated with a knee immobilizer for 6-8 weeks and non-weight bearing at all times.The 10/09/2025 weekly skin monitor documented the resident's skin was intact.The 10/16/2025 Initial Wound Evaluation and Management Summary documented the immobilizer caused friction/pressure to the back of the left ankle resulting in a pressure wound with necrosis (dead tissue).The 10/16/2025 Physician #24 progress note documented the resident had an appointment with the orthopedic surgeon for the left leg fracture. A wound was seen on the back of the left ankle, most likely caused by the immobilizer. The resident had refused removal of the immobilizer for skin checks on multiple occasions.There was no documented evidence of refusals by Resident #10 for immobilizer removal on the October 2025 treatment administration record.The October 2025 treatment administrator record documented Resident #10's immobilizer was removed daily, and skin checks were completed.During an interview on 12/09/2025 at 10:17 AM, Licensed Practical Nurse #19 stated Resident #10 would not allow staff to remove their immobilizer and that should be reflected in the treatment administrator record. They did not see that the resident had gone back to orthopedics. They did not know if the secretary had scheduled the appointment, but they should have been seen by orthopedics.During an interview on 12/16/2025 at 9:18 AM, Registered Nurse #58 stated there was an order to remove a splint or immobilizer to check for any skin breakdown or irritation for Resident #10. If checks were not performed, it needed to be documented. The resident refused a lot because they feared it being touched. They signed for removal of the immobilizer on 10/14/2025 but did not think they had removed it because if they did, they would have seen the wound. The refusals should had been documented.During an interview on 12/16/2025 at 9:56 AM, Licensed Practical Nurse #39 stated they did not recall doing a skin check or removing the immobilizer for Resident #10. Licensed Practical Nurse #39 reviewed the treatment administration record and confirmed they signed for removal of the immobilizer. If a resident refused treatment, it was reflected in the administration record as a refusal and the nurse supervisor would have been notified.During an interview on 12/16/2025 at 12:25 PM, Resident #10 stated no one removed their brace. When they first returned with the long leg immobilizer, they were very protective of the leg and refused to let anyone remove the brace. They had never broken a bone before and were afraid. They now allowed removals with the short immobilizer, but no one had removed it.During an interview on 12/18/2025 at 11:48, Physician #24 stated immobilizers could cause pressure ulcers if they were located over a boney prominence, but most were designed not to cause pressure. A resident who wore an immobilizer, who was having their skin checked daily, would have their pressure ulcer identified early. Pressure ulcers did not happen over a few minutes. If an immobilizer was to be removed with daily skin checks for Resident #10, they would expect that it was being done.During an interview on 12/19/2025 at 2:30 PM, Physician #40 stated pressure ulcers may be caused by splints and immobilizers if they did not fit properly. Everyone who applied it had to ensure that it was done properly and was the right size. Immobilizers removed daily to check skin could prevent pressure ulcers. Resident #10's wound was caused by the metal bar on their immobilizer rubbing while in bed. They expected that if skin checks happened daily, an abnormality would have been found before the resident developed a pressure ulcer.10NYCRR 415.12(c)(1)

Based on observations and interviews the facility failed to ensure residents maintained acceptable parameters of nutritional status for one (1) of one (1) Resident (Resident #34) reviewed. Specifically, Resident #34 who had a history of abnormal weight loss and dysphagia (difficulty swallowing) had significant weight loss and weekly weights were not obtained per the registered dietitian's recommendations. This resulted in harm to Resident #34 that was not Immediate Jeopardy. Findings include:The facility policy Nutritional Assessment, revised 01/2025 documented the dietitian would complete a nutritional assessment for changes in condition that placed a resident at risk for impaired nutrition. A care plan would be developed to minimize the resident's risks for nutritional complications.The facility policy Weight Assessment and Interventions, revised 01/2025 documented nursing staff measured resident weights on admission, the day after admission, then weekly for two (2) weeks. Any weight change of 5% or more since the last weight assessment would be retaken the next day for confirmation. If the weight was verified, nursing immediately notified the dietitian in writing. Assessment information would be analyzed by the multidisciplinary team.Resident #34 had diagnoses including abnormal weight loss, dysphagia (difficulty swallowing) and altered mental status. The 10/17/2025 Minimum Data Set (a resident assessment tool) documented the resident was cognitively intact, weighed 129 pounds, had 5% or more weight loss in the last month or 10% or more in the last six months, and was not on a prescribed weight loss program. The 04/16/2025 Comprehensive Care Plan documented Resident #34 was at risk for malnutrition and/or had a nutritional problem related to cognitive impairment, dysphagia, need for mechanically altered diet, and significant weight changes. Interventions included monthly weights and weights as needed. The 04/24/2025 physician order documented the resident would be weighed on admission, the next day, and weekly for four (4) weeks. If no weight concerns were noted, weights would be measured monthly. Resident's #34 weight record documented the following weights: -04/16/2025, 158 pounds, with reweight 04/17/2025 160.4 pounds,-05/09/2025, 148 pounds (7.7% loss in three weeks),-07/08/2025, 145.2 pounds (9.5% loss in three months),-08/05/2025, 133.6 pounds (8% in one month)-10/16/2025, 128.8 pounds -11/05/2025, 123.6 pounds (16.5% loss in six months). The 10/16/2025 Registered Dietitian #7 progress note documented an unplanned weight loss of 5.8% in one (1) month and 19.4% in six (6) months with a request for weekly weights for four (4) weeks. There was no documented evidence of a physician order for weekly weights, no documented weekly weights, and no documented evidence the Comprehensive Care Plan was updated to include weekly weights. During a telephone interview on 12/15/2025 at 2:03 PM, Registered Dietitian #7 stated weights were obtained by the seventh of each month and they reviewed the weights for any significant weight changes of 5% in one (1) month, 7.5% in three (3) months, or 10% in six (6) months. They sent a list of weekly and missing weights to the unit nursing manager, and reminders of weekly weights to the unit nursing manager, the Assistant Director of Nursing, the Director of Nursing, and the Administrator. They also notified the medical staff of significant weight changes. During an interview on 12/16/2025 at 11:29 AM, Licensed Practical Nurse Unit Manager #14 stated the registered dietitian sent out electronic mail to alert them of weight changes or needed weights. Weekly weights required a physician order, and either they or the registered dietitian entered the order into the electronic medical record. The licensed practical nurse should document the weights as ordered by the physician. Resident #34 did not have documented weekly weights. They were unaware of any weight refusals by Resident #34. During a telephone interview on 12/18/2025 at 10:14 AM, Assistant Director of Nursing #15 stated the registered dietitian notified them and the unit manager of residents who needed weekly weights. The registered dietitian was provided the weights, entered them into the electronic medical record, and electronically mailed them for reweights. If the registered dietitian wanted weekly weights, they electronically mailed them and the provider, and either the physician or nursing placed the order. Resident #34 had weight loss and if the registered dietitian requested weekly weights they should have been obtained. During a follow-up telephone interview on 12/18/2025 at 12:08 PM, Registered Dietitian #7 stated nursing sent the weights to them by electronic mail or entered them into the electronic medical record. They reviewed the weights and notified the unit nursing manager, Assistant Director of Nursing, and Director of Nursing of needed reweights. If a resident refused weights nursing documented that in the medical record. They notified the unit nursing manager, medical staff, Assistant Director of Nursing, and Director of Nursing of recommended weekly weights. They requested weekly weights for Resident #34, and they were not obtained. During an interview on 12/19/2025 at 9:17 AM, the Director of Nursing stated the registered dietitian did not work onsite but sent electronic mail about weight loss and residents who were on weekly weights. The unit nursing manager should ensure the weights were obtained. If a resident refused a weight, it was documented in the medical record. 10NYCRR 415.12(i)1

Based on observations, record review, and interviews during the survey, the facility failed to provide specific services outside the facility when they did not employ a qualified professional to furnish the specific service for one (1) of four (4) residents (Resident #17) reviewed. Specifically, Resident #17 was not provided with neurology follow up appoints as recommended. This resulted in harm to Resident #17 that was not Immediate Jeopardy. Findings include: The facility policy, Consultations, last reviewed 01/2025 documented the facility was responsible to provide residents with specific services that were not provided by in-house medical providers. The facility was to facilitate the services in a timely manner to ensure the resident did not suffer ill effects from the delayed service. Resident #17 had diagnoses including sciatica (pain caused by compression of the sciatic nerve) and liver disease. The 09/06/2025 Minimum Data Set assessment documented the resident had intact cognition, was independent with most activities of daily living, received scheduled pain medications, and had constant pain that affected sleep.The 09/23/2025 Physician #24 progress note documented Resident #17 complained of pins and needles to both lower extremities and a neurology follow up was recommended for ongoing headaches and neuropathic pain. There was no documented evidence a neurology appointment was scheduled for Resident #17. The 11/07/2025 Physician #24 progress note documented the resident was seen for pain despite gabapentin being started. The resident had intractable headaches and neuropathic pain in both legs and was still waiting for a neurology appointment. There was no documented evidence a neurology appointment was scheduled for Resident #17.The 12/01/2025 Nurse Practitioner #25 progress note documented the resident was seen for worsening headaches and was requested a neurology appointment. On 12/01/2025 a physician order was placed for a neurology referral for worsening headaches. The order was signed off as completed by Licensed Practical Nurse #19.During an interview on 12/02/2025 at 1:10 PM, Resident #17 stated they were supposed to see a neurologist but did not have an appointment. On 12/11/2025 at 11:49 AM, Resident #17 was observed wearing sunglasses. The resident stated they wore them when they had a headache. During an interview on 12/09/2025 at 10:17 AM, Licensed Practical Nurse #19 stated they were notified last week Resident #17 need a neurology consult. There was a neurology consult order dated 12/01/2025 but was not done at the time as Unit Clerk #27, who scheduled the appointments, was not working.During an interview on 12/15/2025 at 3:34 PM, Assistant Director of Nursing #21 stated outside appointments for residents should be made as soon as possible. If the secretary was having a difficult time making an appointment they were to call the provider for possible assistance. If Resident #17 had a recommendation, then they should have had an appointment scheduled. During an interview on 12/18/2025 at 11:48 AM, Physician #24 stated the unit secretaries scheduled outside appointments. Physician #24 would put in an order and verbally tell the secretary an appointment needed to be scheduled. They entered an order and verbally told the secretaries about consults that needed to be scheduled. They would expect to be notified if there was a delay in scheduling an outside appointment. 10NYCRR 415.26(e)

Based on observations and interviews during the survey, the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for one (1) of one (1) main kitchen. Specifically, the main kitchen was in disrepair, including cracked and uneven flooring, worn grout, damaged door thresholds, corroded plumbing, and broken shelving; personal items were stored with clean food service equipment; and food storage practices did not support the prevention of potential cross-contamination. Findings include:The facility policy Food Storage, last reviewed 01/2025, documented food was to be stored in a manner that prevented contamination and cross-contamination, including storing raw animal foods on lower shelves and protecting food items during storage.The facility policy Food Safety, last reviewed 01/2025, documented kitchen environments and food service operations were to be maintained in a sanitary condition to prevent biological and physical food safety hazards, and unsanitary surfaces, equipment, or storage practices could contribute to food contamination.The facility policy Food & Nutrition Services Responsibilities, last reviewed 01/2025, documented kitchen and food storage areas were to be maintained in a clean, sanitary, and safe condition, and dietary leadership was responsible for ensuring compliance with food safety and sanitation standards.The facility policy Hours of Operation, last reviewed 01/2025, documented the kitchen was to be cleaned daily, including food preparation and service areas, to maintain sanitary conditions.The following observations were made in the main kitchen on 12/02/2025 at 10:30 AM:-kitchen flooring had cracked, missing, and uneven tiles throughout the kitchen.-flooring surfaces had worn grout, peeling areas, and exposed subflooring.-debris was noted throughout the kitchen floor, embedded within cracked and recessed grout lines.-damaged and deteriorated door thresholds.-accumulated debris and residue beneath kitchen equipment.-soil and grime were present along wall edges, in corners, beneath equipment, and around storage areas.-plumbing beneath sinks and dishwashing equipment had visible corrosion and buildup.-damaged shelving in the dry storage area.-personal items stored on shelving with clean food service equipment.-frozen meat was stored on a shelf in the freezer directly above uncovered pizza shells. Internal dietary and kitchen audits conducted on 12/03/2025, 12/08/2025, and 12/15/2025, completed by Employee #23 documented overall passing scores and compliance with routine food safety practices, including food temperatures, labeling, equipment cleanliness, and staff hygiene. The internal audits identified no concerns related to the physical condition, cleanliness, or repair of the kitchen environment. There were no identified food storage practice issues that would contribute to cross-contamination. During an interview on 12/11/2025 at 1:13 PM, the Director of Food Service stated environmental and maintenance staff were responsible for deep cleaning and physical repairs in the kitchen. Work orders were submitted when issues were identified; however, no current work orders were submitted for environmental conditions in the kitchen. Kitchen staff swept and mopped floors daily after breakfast, lunch, and dinner. They stated floors accumulated dirt rapidly due to heavy traffic. Deep scrubbing and floor repairs were not completed routinely and poor repair of some floor surfaces made effective cleaning difficult. There was a dedicated floor technician previously employed; however, that position was currently vacant. Maintenance and environmental services were responsible for floor repair and corrosion on dishwasher piping. Some flooring issues, including areas near the tray line, were previously addressed but later recurred. Corrosion on the dishwasher piping existed prior to their employment, and no specific work order was submitted for that condition. They stated standard practice was to store frozen meats in a separate freezer section from pizza shells and vegetables. Storing meat above an unsealed box of pizza shells was not consistent with their storage process and could cause for cross contamination.During a telephone interview on 12/16/2025 at 1:04 PM, the Director of Maintenance and Environmental Services stated they were responsible for oversight of maintenance in the kitchen areas, including floors, walls, fixtures, equipment, and surfaces. Kitchen staff were responsible for routine cleaning of the kitchen. Environmental and maintenance issues were reported through work orders. They relied on staff notification to identify kitchen issues that needed to be addressed. They were not aware of any issues that needed to be repaired, and no recent work orders were received from the kitchen staff. They stated while there was significant corrosion built up on the dishwasher pipes; they did not leak. During a telephone interview on 12/15/2025 at 2:59 PM, the Administrator stated kitchen staff were responsible for routine cleaning of the kitchen, including floors and food preparation areas. Weekly kitchen audits focused on outdated food, refrigerator and freezer temperatures, and cleanliness of high-use equipment such as slicers and can openers. Flooring integrity and plumbing conditions were not a primary focus of these audits. They stated the kitchen flooring had areas of wear, and a deep cleaning was planned. Recent turnover in floor care staff had a negative effect on regular cleaning, and a replacement floor technician was hired. When issues were identified, maintenance work orders should be submitted. Maintenance would log the requests, assign staff, and document when the work order was completed. Repairs related to deteriorated flooring, corroded plumbing, or other structural kitchen issues were initiated by the Director of Food Services. They stated the condition of the kitchen floors and disrepair did not stand out as a particular concern or focus of their kitchen audits. 10 NYCRR 415.14(h)

Based on observations, record review, and interviews, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, administration failed to ensure residents received appropriate quality of care by allowing the following deficient practices to exist, placing residents at risk for serious injury, serious harm, serious impairment, or death: F689 Free of Accident Hazards and F684 Quality of Care. Administration failed to ensure policies and procedures were properly identified, communicated, and consistently implemented and were not aware of the extent of the deficient practices cited. Additionally, administration failed to ensure resident safety and attain the highest practicable physical, mental and psychosocial well-being leading to several deficient practices in the areas of: F677 Activities of Daily Living Care Provided for Dependent Residents, F686 Treatment and Services to Prevent/Heal Pressure Ulcers, F675 Quality of Life, and F880 Infection Prevention and Control.Findings include:The facility job description Administrator documented the administrator provided overall direction for all activities related to administration, personnel, office management, and safety for the facility. The administrator was responsible for the development and training in all areas, as well as working closely with all members of the management team to ensure that responsibilities were effectively discharged . Essential functions included, but not limited to, the provision of quality health care and daily living services for residents in conformance with state and federal laws, as well as promoted respect for the individuals and protection of their basic rights. A safe, sanitary, and pleasant environment was maintained for all residents. They made certain that all residents received proper assessment of needs, care planning, and treatment in a manner that promoted dignity, self-esteem, and quality of life of the individual and all care was properly documented. Deficient Practice Information:Resident's Free from Accident, Refer to the citation text under F689. The facility failed to ensure adequate supervision to prevent accidents for three (3) of seven (7) residents reviewed. Quality of Care. Refer to the citation text under F684. The facility failed to ensure residents received treatment and care in accordance with professional standards of practice that met each resident's physical, mental, and psychosocial needs for six (6) of 21 residents reviewed. Activities of Daily Living Care Provided for Dependent Residents. Refer to the citation text under F677. The facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for one (1) of seven (7) residents reviewed. Treatment and Services to Prevent/ Heal Pressure Ulcers. Refer to the citation text under F686. The facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure ulcers for two (2) of six (6) residents reviewed. Quality of Life. Refer to the citation text under F675. The facility failed to ensure residents were provided with an environment that supported and enhanced each resident's quality of life for all 242 residents residing in the facility.Infection Prevention and Control. Refer to the citation text under F880. The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five (5) of five (5) residents reviewed. During an interview on 12/09/2025 at 1:37 PM, the Administrator stated staff were educated upon hire and annually regarding elopements. There was an elopement binder at the front desk. Resident #100 eloped in October 2025. They were informed the wander alert system was not functioning correctly and the resident was found outside. However, when maintenance came in to check the system, everything was working correctly. They were informed maintenance had to reset the system, but it was functioning correctly. They believed the resident got out via the E stairwell. All the doors on the second and third floor were supposed to have a wander alert alarm on them if a resident with a wander alert device got near the doors. If the door did not alarm, the staff were to immediately call maintenance. All staff were able to shut off the wander alert alarms at the doors and elevators. Regular door alarms should not be turned off at the nursing station without checking to see who went out the door. It was important to have a functioning wander alert system to prevent a resident from eloping. Resident #100's elopement was not reported to the New York State Department of Health as it was past the reporting deadline by the time they found out about the incident. They were not made aware the resident was unattended in the parking lot until the following Monday (10/20/2025) and they should have been made aware of the elopement right away. During an interview on 12/12/2025 at 10:59 AM, the Administrator stated the facility did not always receive paperwork from the hospital. The cart nurse or nurse manager was responsible to go through the paperwork, talk to the provider, put any new orders in, and complete an assessment. Each unit was responsible, and several people would have been doing parts of a hospital or emergency department return. Paperwork should be reviewed within 24 hours; they did not know the whole process, but it had to be team effort. There should have been a progress note written when residents returned to the facility. Leadership had a telegram text communication on their cellular phones and any movement of a resident in and out of the facility should be communicated there. They asked the nurses to request the emergency room paperwork, but they were not sure if there was a formal education with the nurses about the return process. They were not aware of hospital return issues for Residents #33, #42, #90, #179, and #204. The paperwork should have been reviewed and followed up on for patient care. If something was changed for a resident, there was a reason for it; antibiotics should not be missed, because there could be negative effects. Resident #209 got worse and had to be hospitalized . The nurses and the provider did not follow up. Assistant Director of Nursing #15 or the Director of Nursing should have investigated how this happened and how this was missed. They expected the Director of Nursing to investigate the issue with Resident #209 after they were made aware on 10/08/2025, but they did not follow up with them.During an interview on 12/22/2025 at 11:00 AM, the Administrator stated they were teaching staff how to complete a proper investigation which included witness statements, a documented registered nurse assessment, and to review/revise interventions. Falls were discussed in morning meeting and the care plan was reviewed to ensure there were no care plan violations. There were no complete and thorough investigations for Resident #44. The Director of Nursing was ultimately responsible, had support, was not asking for help, and was not completing investigations timely. 10NYCRR 483.70(i)

Based on observations, interviews, and record review conducted during the survey, the facility failed to ensure a Quality Assurance and Performance Improvement (QAPI) program that put forth good faith attempts to develop, implement, and maintain an appropriate plan of action to address identified issues that impacted resident safety or ensured corrective actions were set around safety, quality, rights, choice and respect. Specifically, the facility did not implement and maintain the approved plans of correction from the Extended Recertification Survey dated 05/09/2025 for Resident Rights/Exercise of Rights (F550), Safe/Clean/Comfortable/Homelike Environment (F584), Quality of Life (F675) ADL Care Provided for Dependent Residents (F677), Quality of Care (F684), Treatment/Services to Prevent/Heal Pressure Ulcers (F686), Free of Accident Hazards/Supervision/Devices (F689), Dialysis (F698), Nutritive Value/Appear, Palatable/Prefer Temp (F804) and Food Procurement, Store/Prepare/Serve- Sanitary (F812), Administration (F835) QAPI Program/Plan, Disclosure/Good Faith Attempt (F865) and Infection Control (F880). The findings include: The undated facility Quality Assurance and Performance Improvement (QAPI) Plan included the Healthcare System's mission, which is to provide exceptional clinical care coupled with a luxury experience for their residents and their loved ones. The purpose included an evaluation of the residents' experience of services approach to improve the delivery of care provided to residents. The design and scope of the Quality Assurance and Performance Improvement Plan will be integrated and coordinated among all direct or indirect services provided to their residents. They will monitor effectiveness of resident care including identification of trends in performance will be monitor, evaluated, and assessed from improvement in the areas of nursing services, food and nutrition services, infection control, physician services, housekeeping and laundry, pharmaceutical services and rehabilitation services. The Administrator will ensure a leadership role and encourage input from facility staff, Residents as well as their families and or representatives. Resident Rights/Exercise of Rights (F550)The facility did not ensure residents had the right to a dignified existence in a manner and an environment that promoted the maintenance or enhancement of quality of life for two (2) residents reviewed. Safe/Clean/Comfortable/Homelike Environment (F584)The facility did not ensure residents resided in a safe, clean, sanitary, and homelike environment. Quality of Life (F675)The facility did not provide an environment which supported and enhanced each resident's quality of life. This noncompliance resulted in Immediate Jeopardy. ADL Care Provided for Dependent Residents (F677)The facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for one (1) resident reviewed. This resulted in psychosocial harm to Resident #132 that was not Immediate Jeopardy. Quality of Care (F684)The facility failed to ensure residents received treatment and care in accordance with professional standards of practice that met each resident's physical, mental, and psychosocial needs for six (6) residents reviewed. This resulted in Immediate Jeopardy. Treatment/Services to Prevent/Heal Pressure Ulcers (F686)The facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure ulcers for two (2) residents reviewed. Free of Accident Hazards/Supervision/Devices (F689)The facility failed to ensure adequate supervision to prevent accidents for three (3) residents reviewed related to Elopement and Falls. This resulted in Immediate Jeopardy. Dialysis (F698) The facility did not ensure that residents who required dialysis services (a process that filters the blood when the kidneys do not work properly) received such services consistent with professional standards of practice for one (1) resident reviewed. Nutritive Value/ Appear Palatable/Prefer Temp (F804)The facility failed to ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature. Food Procurement, Store/Prepare/Serve- Sanitary (F812)The facility did not ensure the kitchen environment and food storage practices were maintained in a manner that supported safe and sanitary food service operations. Administration (F835)The facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Infection Control (F880) The facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five (5) residents reviewed. During an interview on 12/22/2025 at 12:00 PM, the Administrator stated the Quality Assurance and Performance Improvement committee meets monthly and has been focusing on their high risk, high volume, problem prone areas. The Administrator stated they and the Quality Assurance & Performance Improvement committee looks at every general opportunity to improve where they think they can do better. They have audits, staff, resident and family feedback to learn about continued areas of concerns. They currently have performance improvement plans for Dignity, Environment, Professional Standards, weekly audits for activities of daily living (ADL), pressure ulcers/wounds, accidents, food services and medication storage and infection control. They were not aware of identified concerns regarding Quality of Care with regards to hospitalizations and emergency room visits and nursing documentation. 10 NYCRR 415.27(a-c)

Based on observations, record review, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for six (6) of six (6) residents (Residents #10, #188, #192, #77, #217 and #17) reviewed and five (5) of ten (10) staff (Certified Nurse Aides #62 and #91, Registered Nurse Manager #38, and Licensed Practical Nurses #35 and #71) reviewed for influenza vaccination.Specifically:-Resident #10 had an unstageable pressure ulcer to the left ankle and was on enhanced barrier precautions. Licensed Practical Nurse #39 was observed performing wound care using inappropriate infection control practices including lack of proper hand hygiene and glove use, insufficient personal protective equipment and use of unclean scissors.- Residents #188 and #192 tested positive for COVID-19 and did not have transmission-based precaution (droplet precautions) signage posted outside their rooms and staff were observed not wearing appropriate personal protective equipment into the designated rooms.- Resident #77 was on transmission-based precautions (enhanced barrier precautions) and did not have signage posted outside their room.- Resident #217 was on transmission-based precautions (enhanced barrier precautions) and staff was observed performing care without appropriate personal protective equipment.- Resident #17 was on transmission-based precautions (droplet precautions) and staff was observed not wearing appropriate personal protective equipment into the room.- Multiple staff members (Certified Nurse Aides #62 and #91; Registered Nurse Manager #38; and Licensed Practical Nurses #35 and #71) were unvaccinated for influenza and were observed in resident areas not wearing a mask or wearing a mask improperly.Findings include: The facility policy Influenza Vaccine reviewed 01/2025, documented between October 1st and March 31st each year, the influenza vaccine would be offered to employees, unless the vaccine was medically contraindicated, or the employee had already been immunized. For those who received the vaccine, the date of vaccination, lot number, expiration date, and site of vaccination would be documented in the employee's medical record. If an employee refused the vaccine for reasons other than medical contraindications, that would be documented on the employees informed consent for influenza vaccine. Administration of the influenza vaccine would be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination.The facility policy Enhanced Barrier Precautions reviewed 01/2025, documented enhanced barrier precautions required the use of a gown and gloves for high contact resident care activities; signage would be posted outside of the resident room; hand hygiene should be performed; a new gown and gloves should be put on before caring for a different resident. High contact activities included: dressing, bathing/showering, transferring that required hands on assistance, changing linens, changing briefs, assisting with toileting, device care or use, and wound care.The facility policy Droplet Precautions reviewed 01/2025, documented droplet precautions were used for resident's known or suspected to be infected by microorganisms transmitted directly from the respiratory tract of the susceptible mucosal surfaces of another resident. A physician's order was required for the initiation of transmission-based precautions. As soon as precautions were implemented, Stop Report to Nurse signage would be placed on the resident's door and remain in place until precautions had been discontinued.The facility policy Wound Care revised 01/2025, documented to use disposable cloth to establish a clean field on the resident's overbed table; wash and dry hands; put on gloves; remove dressing; pull glove over dressing and discard; wash and dry hands; put on gloves; apply treatment as indicated; wipe reusable supplies with alcohol; wash and dry hands.1) Resident #10 had diagnoses including a fracture of left lower leg, peripheral vascular disease (poor circulation), and diabetes. The 09/18/2025 Minimum Data Set (a resident assessment tool) documented the resident had intact cognition and was dependent for transfers and bed mobility.The Comprehensive Care Plan documented:-10/16/2025 the resident had an actual unstageable wound of the left ankle. The goal was the wound would not show any signs of infection.-12/02/2025 resident was on enhanced barrier precautions. Interventions included staff would wear gloves and gown and hand hygiene.The 10/16/2025 physician order documented to cleanse the back of the left ankle with wound cleanser, pat dry, and apply Alginate Honey-Impregnated gauze (type of topical dressing that absorbs the wound drainage), cover with abdominal pad and wrap with Kerlix daily and as needed.During a wound care observation on 12/16/2025 at 9:56 AM, Resident #10's door had a droplet/contact precaution sign and an enhanced barrier precaution sign on the wall outside the door. Licensed Practical Nurse #39 entered the resident's room with a surgical mask and gloves on. They used scissors to cut off the old dressing, placed the scissors on the table next to clean supplies; sprayed wound cleanser on the wound; used gauze to cleanse the wound; and used gloved fingers to remove dressing that was stuck to the wound bed. Without changing gloves, Licensed Practical Nurse #39 dispensed antiseptic gel onto their gloved finger, applied the gel to the wound bed, cut a piece of alginate using the same unclean scissors; applied the alginate to the wound bed, covered the area with an abdominal pad then wrapped the leg with gauze.During an interview on 12/16/2025 at 10:11 AM, Licensed Practical Nurse #39 stated they should have removed their gloves after they removed the old dressing, washed their hands, and then put on clean gloves. The gloves and scissors were contaminated after removing the old dressing. They should have changed gloves prior to dressing the wound and should not have used the same scissors from dirty to clean. They stated should have worn full personal protective equipment.During an interview on 12/16/2025 at 2:10 PM, Assistant Director of Nursing/Infection Control Nurse #21 stated they expected hand hygiene to be performed prior to starting a dressing change, in between glove changes, and after a dressing was completed. The wound could become contaminated if dirty gloves were worn to apply a new dressing.During an interview on 12/18/2025 at 11:48 AM, Physician #24 stated an infected pressure ulcer on a resident with comorbidities such as diabetes and vascular disease had a higher risk of infection.2) Resident #77 had diagnoses including kidney disease and diabetes. The 09/13/2025 Minimum Data Set documented the resident had severely impaired cognition and received dialysis (a process that filters the blood).The Comprehensive Care Plan, revised 08/05/2024, documented the resident required hemodialysis related to end stage renal disease. Interventions included maintain enhanced barrier precautions every shift and monitor for signs and symptoms of infection to the access site. The 11/05/2024 physician order documented maintain enhanced barrier precautions every shift.Resident #77 had no transmission-based precaution signage posted outside their room at the following times: on 12/04/2025 at 10:34 AM, 12/08/2025 at 12:10 PM, 12/09/2025 at 9:05 AM, 12/10/2025 at 1:07 PM, and 12/11/2025 at 12:03 PM.During an interview on 12/09/2025 at 11:38 AM, Certified Nurse Aide #1 stated they were assigned to care for Resident #77 that day and most of last week during the day shift. They stated the resident was not on transmission-based precautions so they would just wear gloves when caring for them. If they were on transmission-based precautions, there would be a sign posted outside their room to alert them. The sign would also tell them what personal protective equipment was needed to go into the room. They thought the nurse manager was responsible for putting residents on transmission-based precautions, and no one ever told them Resident #77 was on precautions.During an observation and interview on 12/11/2025 at 12:03 PM, Registered Nurse #58 was standing at the medication cart outside of Resident #77's room. They stated Resident #77 was not on transmission-based precautions and if they were, there would have been a sign posted outside their room. There was an order for enhanced barrier precautions, but they thought it could have been wrong because it was from 2024.During an interview on 12/15/2025 at 1:58 PM, Licensed Practical Nurse Manager #33 stated Resident #77 was on enhanced barrier precautions because they had a dialysis catheter. They were just made aware the resident did not have signage posted so they hung a sign and placed a bin full of personal protective equipment outside their room. They stated staff should have known the resident was on enhanced barrier precautions because they had an order, and it was on their care plan. Staff should wear appropriate personal protective equipment when caring for the resident.Employee Masks and Influenza Vaccines The following observations were made of improper wearing of surgical masks or lack of surgical masks:-On 12/04/2025 at 10:13 AM, Certified Nurse Aide #62 was obtaining resident weights while wearing a surgical mask that did not cover their nose.-On 12/04/2025 at 10:14 AM, Certified Nurse Aide #91 walked through the resident unit wearing a surgical mask positioned below their nose.-On 12/04/2025 at 10:20 AM, Certified Nurse Aide #91 brought a resident into a room. The certified nurse aide was wearing a surgical mask positioned below the nose. At 12:57 PM, Certified Nurse Aide #91 leaned over a resident to shave them while wearing a surgical mask covering their mouth only. At 1:05 PM, Certified Nurse Aide #91 exited the room and walked to the nurses' station wearing the mask below the nose. At 1:06 PM, Certified Nurse Aide #91 stated they needed to wear a mask due to not receiving the influenza vaccination.-On 12/05/2025 at 9:25 AM, Registered Nurse Manager #38 was seated at the nursing station wearing a surgical mask positioned under their chin.-On 12/08/2025 at 12:24 PM, Licensed Practical Nurse #35 was seated at the nursing station wearing a surgical mask below their chin. At 12:35 PM, Licensed Practical Nurse #35 walked down the hallway with a medication cart while wearing a surgical mask positioned below their nose.-On 12/09/2025 at 8:40 AM, Licensed Practical Nurse #71 was observed at a medication cart putting on a mask after entering the unit. They stated they had not received the influenza vaccination. Staff vaccination records documented:-Certified Nurse Aide #62 received an influenza vaccine on 12/04/2025 at an undocumented time.-Certified Nurse Aide #91 received their influenza vaccine on 12/11/2025 (after the observations of improper face mask use).-Registered Nurse Manager #38 declined the influenza vaccine on 12/01/2025.-Licensed Practical Nurse #35 did not have documentation of influenza vaccination or declination.-Licensed Practical Nurse #71 declined the influenza vaccine on 12/12/2025.During an interview on 12/05/2025, the Administrator stated staff who had not received the influenza vaccine were required to wear a mask at all times in the facility and masks were required to be worn correctly, covering the nose and mouth.During a telephone interview on 12/16/2025 at 10:00 AM, Assistant Director of Nursing/Infection Control Nurse #21 stated their responsibility included oversight of the facility's infection prevention and control program, staff education on hand hygiene, appropriate personal protective equipment uses, and correct donning and doffing procedures, in collaboration with nurse managers and the facility educator. They stated nursing staff could initiate Enhanced Barrier Precautions when clinical criteria were present and they were responsible for notifying the provider and obtaining required physician orders. The precaution status was expected to be reflected in the medical record, provider orders, daily census, and assignment sheets. Signage and personal protective equipment bins were expected to be placed immediately upon initiation of precautions. Nurse managers were responsible during business hours and supervisors were responsible during evenings and weekends. Staff were expected to don required personal protective equipment prior to entering rooms on precautions and were not to exit isolation or COVID-positive rooms wearing personal protective equipment. Hand hygiene was required before and after glove use, between tasks, and upon exiting resident rooms. Staff who had not received the influenza vaccine were required to wear masks during flu season, masks were required to be worn correctly covering the nose and mouth, and enforcement was the responsibility of managers and supervisors through routine rounding.10 NYCRR S415.19

Based on observations, record review, and interviews, the facility failed to maintain an effective pest control program so that the facility was free of pests for one (1) of one (1) main kitchen reviewed. Specifically, there was evidence of roaches in the main kitchen. Findings Include:The facility policy Pest Control, reviewed 03/2026, documented the facility would implement a continuing and effective pest control prevention and monitoring program to maintain the facility as pest and rodent free as possible.The third-party vendor pest control customer service reports documented the following:-On 02/12/2026, a liquid preventive and a dust bait were applied by the dishwasher area and joining wall bathroom and a recommendation was made for an after-hour escalation treatment.-On 02/16/2026, a treatment for German roaches was applied in the kitchen; moderate activity was seen with heavy activity noted underneath the garbage disposal by the dishwasher; the area where the hole in the wall was, had been the focus problem. Recommendations included floor fans to keep the area as dry as possible after the kitchen closed and to completely empty and remove all garbage from the kitchen at closing time.-On 02/24/2026, the food disposal in the kitchen where the main roach concerns were, was still being used even though it was broken. During follow-up night jobs, if the pest control technician finds the disposal to continue to be in use, guarantee for services will be withheld due to a constant source being provided to the roaches.The following observations of roaches in the main kitchen were made on 03/02/2026 at 12:40 PM:-The women's bathroom had over 25 dead roaches on the floor and three (3) crawling roaches. -One (1) dead roach on the floor near the microwave and cases of thickened juices. -Several roaches on the floor, wall and ceiling inside the dish room. One roach was observed dropping from the ceiling. During an interview on 03/03/2026 at 1:10 PM, Assistant Food Service Director #23 stated maintenance had to replace the garbage disposal pipe. Maintenance said the exterminator asked to keep the hole open, so it was being left open. They never had fans on the floor. They stated maintenance came in at night to re-grout the floor and they were unsure if they were using fans. During an interview on 03/05/2026 at 8:52 AM, the Director of Maintenance stated the kitchen had leaks in the wall pipes and food was going into the wall. The exterminators recommended letting the area dry out. The area had been treated. At nighttime, after the dishes were done, a fan was set out by dietary staff to dry the area. During an interview on 03/05/2026 at 5:02 PM, the Administrator stated maintenance oversaw pest control and should follow vendor recommendations including putting fans in the kitchen after hours. 10 New York Codes, Rules and Regulations 415.29(j)(5)

Based on observations, record review, and interviews the facility did not ensure residents had the right to a dignified existence in a manner and an environment that promoted the maintenance or enhancement of quality of life for two (2) of five (5) residents (Residents #8 and #5) and for 5 of eight (8) resident rooms (201B, 202A, 202B, 209 and 324B) reviewed. Specifically, Residents #8 and #5 were observed on multiple occasions being transported in their padded reclining wheelchair facing backwards on multiple occasions and rooms 201B, 202A, 202B, 209 and 324B were not clean, sanitary and homelike. Findings include:The facility policy, Quality of Life-Dignity, last reviewed 01/2023, documented each resident should be cared for in a manner that promoted and enhanced quality of life, dignity, respect, and individuality. Staff should keep the resident informed and oriented to their environment. Procedures should be explained before being performed and residents would be told in advance if they were going to be taken out of their usual or familiar surroundings. 1)Resident #8 had diagnoses including Alzheimer's disease. The 09/25/2025 Minimum Data Set (a resident assessment tool) documented the resident had severely impaired cognition, did not use a wheelchair, did not walk, and was dependent for transfers. The Comprehensive Care Plan revised 09/27/2025 documented Resident #8 was at risk for functional decline in mobility and self-care related to weakness and cognition. Interventions included the resident was dependent with wheeling 50 and 150 feet and engage, encourage, and regularly assess the resident's ability to use appropriate assistive devices. Resident #8 was observed:-On 12/04/2025 at 1:10 PM, seated in their padded reclining wheelchair. Resident Assistant #84 transported resident down the hallway towards the dining room while the resident was facing backwards. -On 12/05/2025 at 10:12 AM, seated in their padded reclining wheelchair. Certified Nurse Aide #26 transported the resident out of their room and down the hallway while the resident was facing backwards. 2)Resident #5 had diagnoses including schizophrenia (serious mental health disorder) and bipolar disorder (mental health disorder causing extreme mood swings). The 09/16/2025 Minimum Data Set documented the resident had severely impaired cognition, was dependent for all activities of daily living, and did not use a wheelchair or walk. The Comprehensive Care Plan revised 08/01/2024 documented Resident #5 required assistance with self-care and mobility related to confusion and limited mobility. Interventions included dependence with wheeling 50 and 150 feet and encouragement to fully participate with each interaction. Resident #5 was observed: -On 12/02/2025 at 1:30 PM, seated in their padded reclining wheelchair. Licensed Practical Nurse Manager #19 transported the resident into the dining room while the resident was facing backwards. -On 12/04/2025 at 1:12 PM, seated in their padded reclining wheelchair. Certified Nurse Aide #26 transported the resident from the hallway and into the dining room while the resident was facing backwards. -on 12/05/2025 at 10:12 AM, seated in their padded reclining wheelchair at a table in the dining room. Certified Nurse Aide #90 walked up from behind the resident without saying anything and transported them through the dining room while the resident was facing backwards. -On 12/09/2025 at 9:11 AM, seated in their padded reclining wheelchair. Certified Nurse Aide #60 transported the resident down the hallway while the resident was facing backwards. During an interview on 12/05/2025 at 10:12 AM, Certified Nurse Aide #90 stated residents in wheelchairs should be alerted before they were moved. They stated they should have pushed Resident #5 facing forward so they could see where they were going. Pushing the resident forward also decreased the risk of bumping them into walls. During an interview on 12/05/2025 at 1:28 PM, Licensed Practical Nurse Manager #19 stated staff were expected to notify the resident before moving them in their chair, the residents were supposed to be facing forward, and always going in the direction staff walked. During an interview on 12/15/2025 at 3:34 PM, Assistant Director of Nursing #21 stated staff were expected to approach a resident from the front, explain the plan, and ask their permission before moving their chair. Residents should not be transported backwards because it could scare the resident or cause an accident or injury. The resident should always be able to see where they were going. 3) On 12/02/2025, the following observations were made:At 12:01 PM - room [ROOM NUMBER] had an odor consistent with feces. The mattress had a dark brown stain measuring approximately two (2) feet by one (1) foot.At 12:33 PM - the resident in room [ROOM NUMBER] A was sleeping on a mattress without sheets. A fly was on the resident's leg. There were empty beverage containers and a partially full cup on the bedside table. Multiple boxes were stored along the wall across from the bed.At 12:34 PM - room [ROOM NUMBER] B was unoccupied. The bed was stripped and the exposed mattress and had a strong urine odor.At 1:00 PM - room [ROOM NUMBER]B room had a strong urine odor. Furniture surfaces had scuff marks and chipped areas. A sheet was tied to the curtain rod and used as a window covering. The bed sheet was torn.At 3:38 PM - room [ROOM NUMBER] B had a soiled privacy curtain.During an interview on 12/11/2025 at 2:00 PM, Assistant Director of Nursing #21 stated staff were responsible to maintain the rooms in a clean and organized condition.During a telephone Interview on 12/16/2025 at 1:04 PM the Director of Maintenance and Environmental Services stated their responsibility was to oversee maintenance and housekeeping services throughout resident care areas, dining areas, common areas, and support spaces. Environmental issues were identified primarily through staff reports. There was no formal inspection schedule or routine environmental audit process. They had no pending work orders or escalated environmental concerns they identified as urgent at the time of interview. 10NYCRR 415(a)

Based on observations, record review, and interviews the facility failed to ensure residents resided in a safe, clean, sanitary, and homelike environment for eight (8) resident rooms (rooms 102 A, 105, 116, 201 B, 202 A, 202 B, 209, and 324 B) and four (4) of six (6) resident units (North 1, [NAME] 1, South 1, and South 2) reviewed.Findings include: The facility policy Resident Rights revised 01/2025, documented residents were entitled to a safe, clean, comfortable, and homelike living environment.The facility policy Floors last reviewed 01/23/2025, documented floors were cleaned daily.The facility policy Linen Handling and Transport reviewed 01/2025, documented soiled linens were removed promptly, and clean linens were maintained free from contamination.The facility policy Cleaning and Disinfection of Resident-Care Items and Equipment reviewed 01/2025, documented resident-care items and equipment were cleaned, disinfected, and stored appropriately.On 12/02/2025, the following observations were made:At 12:01 PM - room [ROOM NUMBER] had an odor consistent with feces. The mattress had a dark brown stain measuring approximately two (2) feet by one (1) foot.At 12:33 PM - the resident in room [ROOM NUMBER] A was sleeping on a mattress without sheets. A fly was on the resident's leg. There were empty beverage containers and a partially full cup on the bedside table. Multiple boxes were stored along the wall across from the bed.At 12:34 PM - room [ROOM NUMBER] B was unoccupied. The bed was stripped and the exposed mattress and had a strong urine odor.At 1:00 PM - room [ROOM NUMBER]B room had a strong urine odor. Furniture surfaces had scuff marks and chipped areas. A sheet was tied to the curtain rod and used as a window covering. The bed sheet was torn.At 3:38 PM - room [ROOM NUMBER] B had a soiled privacy curtain.On 12/03/2025, the following observations were made: At 11:09 AM - North 1 Hallway: A posted activity calendar reflected the month of November.At 11:21 AM - [NAME] 1 Hallway: A posted activity calendar reflected the month of October.At 2:27 PM - The South 1 medication room sink area was heavily soiled, had visible residue and debris within the basin and on surrounding surfaces.At 3:00PM - North 1 unit, the vinyl tile flooring had significant wear, discoloration, and staining. Several tiles were mismatched in color and appearance. Cracked tiles, chipped edges, and visible separations between tiles were present, some areas appeared uneven or recessed. Darkened seams and gaps were visible, particularly near door thresholds and along the base of walls and door frames, paint was worn and chipped, with underlying material exposed in several locations. The lower portions of walls had scuffing and deterioration near the floor level. Transitions between rooms were uneven, with visible breaks where flooring materials met. Black anti-slip strips affixed to the floor near a doorway and the surrounding floor surface in the area showed additional wear and discoloration. A door was marked with a black marker that indicated the room was the North 1 dirty utility room.During an observation on 12/09/2025 at 9:36 AM, the South 2 labeled Clean Utility Room had a used hairbrush with hair debris and a cloth garment stored on a treatment cart. An intravenous solution was stored on a shelf in the room with an empty soda can tucked beside it. Cardboard boxes were stored directly on the floor. Cabinets and shelving had visible dirt and residue. A winter coat was rolled into a ball and stored on clean sheets on the shelf. Outside the room across the hallway there was a wooden door labeled S2 handwritten in black marker. During an observation on 12/09/2025 at 10:44 AM, resident room [ROOM NUMBER] had a disposable soiled incontinence brief on the floor in plain view from the hallway. During an observation on 12/09/2025 at 10:45 AM, in resident room [ROOM NUMBER], the wall behind the bed had missing paint, scuff marks, scratches, and discoloration near the electrical outlet. An activity calendar was posted on the wall with a single piece of tape, the edges were folded in, and the copy was dark and not legible. During an observation on 12/09/2025 at 10:56 AM, the South 2 dining area ice machine had rust and corrosion on the metal piping beneath the ice machine. Peeling paint and residue were present on pipes. The floor beneath the plumbing was stained. A plumbing connection was wrapped with paper towels. The top surface of the ice machine contained medication packaging, caps, personal drink containers, and visible residue.During an observation on 12/11/2025 at 10:09 AM, the South 1 dining area ice machine had a flexible tubing attached to the piping and secured with plastic ties. An open funnel-style drain emptied directly into a plastic-lined trash receptacle positioned below the pipe. The interior of the receptacle contained dark liquid debris. The surrounding floor tiles showed discoloration, staining, and accumulated dirt, particularly along grout lines. The area had staining, moisture exposure and rotted peeling baseboard.During an interview on 12/03/2025 at 3:30PM Licensed Practical Nurse #18, stated the South 1 medication room sink condition did not meet expected standards of cleanliness. The sink and surrounding area were cleaned after the initial inspection because they were disgustingDuring an interview on 12/11/2025 at 9:57AM, Licensed Practical Nurse Manager #19 described the clean utility room as a place where clean items for residents would be stored, including linen, shampoo, soaps, catheters, dressings, and lotions. There should not be any personal items in the clean utility room, and all items should be maintained in a clean manner. There should not be any staff articles mixed, nor should there be empty soda cans in any area of supplies.During an interview on 12/11/2025 at 2:00 PM, Assistant Director of Nursing #21 stated clean utility rooms were intended for the storage of clean items used for resident care. They should be clearly identified and protected from contamination. The room contained items including intravenous fluids and clean linens and other necessities for resident care. They stated the clean utility areas were expected to be restricted to appropriate supplies only, with food, beverages and personal item prohibited. Staff were responsible to maintain the rooms in a clean and organized condition.During a telephone Interview on 12/16/2025 at 1:04 PM the Director of Maintenance and Environmental Services stated their responsibility was to oversee maintenance and housekeeping services throughout resident care areas, dining areas, common areas, and support spaces. Environmental issues were identified primarily through staff reports. There was no formal inspection schedule or routine environmental audit process. They stated minor floor damage was not considered significant unless it worsened or was reported. Dining area sinks and clean utility rooms relied on staff notification for corrective action. Ice machines were serviced approximately every six (6) months. Handwritten room signage was acknowledged as not homelike but functional. They had no pending work orders or escalated environmental concerns they identified as urgent at the time of interview.10 NYCRR 415.29(j)(1)

Based on observations, record review, and interviews conducted during the survey, the facility failed to ensure residents were provided ongoing programs to support each resident in their choice of activities for three (3) of five (5) residents (Residents #9, #104, and #184) and on three (3) of seven (7) units (South 3, North 1 and [NAME] 1) reviewed. Specifically, Residents #9 and #104 were not invited or assisted to meaningful activities that included their interests and preferences; Resident #184 did not have a plan for meaningful activities that included their interests or preferences; there were no unit specific activities conducted on the South 3 unit from 12/02/2025 - 12/11/2025; the posted activity calendar on North 1 reflected the month of November; and the activity calendar on [NAME] 1 reflected the month of October.Findings include: The facility policy Activity Programs last reviewed 01/2025, documented activity programs were designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. Activities were offered based on the comprehensive resident-centered assessment and the preferences of each resident. The activities program was ongoing and included facility-organized group activities, independent individual activities and assisted individual activities. Residents were encouraged to participate in scheduled activities. The December 2025 Activity Calendar documented the following activities:-On 12/01/2025 at 10:30 AM bible study; at 2:00 PM floor games; at 3:30 PM German Singer; and at 5:30 PM coffee hour. -On 12/02/2025 at 10:30 AM yoga; at 2:00 PM Xmas craft; at 3:30 PM coffee hour; and at 4:30 PM 1:1 visits. -On 12/03/2025 at 10:30 AM paper snowflakes; at 2:00 PM chit chat; at 3:30 PM bingo; at 4:00 PM music with Troy; and at 5:00 PM movie night. -On 12/04/2025 at 10:30 AM socials; at 2:00 PM uno; at 3:30 PM board games; and at 4:30 PM noodle ball. -On 12/05/2025 at 10:30 AM church; at 2:00 PM guess who; at 3:30 PM gingerbread house; and at 4:30 PM Xmas coloring. -On 12/06/2025 at 10:30 AM daily news; at 2:00 PM activity carts; and at 3:00 PM room visits. -On 12/07/2025 at 10:30 AM book club; at 2:00 PM heads up; and at 3:30 PM broom ball. -On 12/08/2025 at 10:30 AM bible study; at 2:00 PM [NAME] H; at 3:30 PM Res. choice; and at 4:30 PM coffee hour. -On 12/09/2025 at 10:30 AM Xmas songs; at 2:00 PM [NAME] L; at 3:30 PM karaoke; and at 4:30 PM bowling. -On 12/10/2025 at 10:30 AM floor visits; at 2:00 PM Xmas craft; at 3:30 PM games; and at 4:30 PM movie night. -On 12/11/2025 at 10:30 AM 1:1's; at 2:00 PM [NAME] B; at 3:30 PM crafts; at 4:30 PM table games; and at 5:30 PM broomball. 1) Resident #9 had diagnoses including dementia, depression, and anxiety. The 05/19/2025 Minimum Data Set (a resident assessment tool) documented the resident had severe cognitive impairment; it was very important to have books, newspapers, and magazines to read, listen to music they liked, and do their favorite activities; it was somewhat important to be around animals such as pets, do things with groups of people, and participate in religious services or practices. The Comprehensive Care Plan initiated 05/19/2025 documented the resident was a new admission to the facility and needed time to adjust to their routine. Resident #9 attended/participated in activity programs of interest/choice. They chose to engage in independent activity pursuits such as television, walking on the unit, socializing with other residents, 1:1 visits with staff, and outside time. Interventions included encourage the pursuit of individual activities, provide with equipment/supplies as needed; invite and escort to activities, special events, and parties of choice/interest; provide with appropriate cognitive/sensory activities; provide a monthly calendar/daily schedule of activity programs; provide with personal 1:1 bedside visits; and provide with reminders and encouragement as needed. The unsigned 11/03/2025 Recreation Quarterly Assessment documented the resident actively participated in small groups, large groups, and 1:1 activities. The resident preferred on and off unit programs, their own room, and outside settings with positive response. The resident required reminders and transport assistance. Resident #9 was observed pacing the hallways without staff interaction on 12/02/2025 at 11:03 AM, 11:36 AM, 12:31 PM; 12/04/2025 at 9:00 AM: 12/05/2025 at 9:46 AM, 11:04 AM, and 1:21 PM; and 12/08/2025 at 10:57 AM, 11:40 AM, 12:26 PM, and 1:58 PM. Resident #9 was not observed engaged in any activities. During an observation on 12/08/2025 at 2:13 PM, a musician was playing holiday songs on their guitar and singing in the main lobby. Resident #9 was not present. At 3:02 PM, the musical activity continued in the main lobby and Resident #9 was not present. At 3:13 PM, Resident #9 was pacing the South 3 unit without any interaction with staff or other residents. 2) Resident #104 had diagnoses including dementia, adult failure to thrive (overall decline), and wandering. The 09/19/2025 Minimum Data Set documented the resident had severe cognitive impairment; it was very important to listen to music they liked, keep up with the news, and do their favorite activities; it was somewhat important to have books, newspapers, and magazines to read, be around animals such as pets, do things with groups of people, go outside to get fresh air when the weather was good, and participate in religious services or practices. The Comprehensive Care Plan initiated 10/15/2025 documented the resident was a new admission to the facility and needed time to adjust to their routine. They attended/participated in activity programs of interest/choice. The resident chose to engage in independent activity pursuits such as visiting with their spouse, outings, reading, television, Spanish programs and some group activities like music, live entertainment, and socializing with other residents and staff. Interventions included to encourage the pursuit of individual activities and provide with equipment/supplies as needed; invite and escort to activities, special events, and parties of choice/interest; provide with appropriate cognitive/sensory activities; provide with a monthly calendar/daily schedule of activity programs; provide with personal 1:1 bedside visits; and provide with reminders and encouragement as needed. The unsigned 09/16/2025 Recreation Assessment documented Resident #104 was interviewed for daily and activity preferences. It was very important to the resident to do their favorite activities. The resident's interests included Bingo, books/magazines, cards, fresh air, movies, music, pet visits, spiritual/religious, and television/radio. The resident preferred small groups, large groups, and 1:1 settings. The resident had positive response to group programs. Resident #104 was observed at the following times:-On 12/02/2025 at 11:03 AM, 11:36 AM, 12:01 PM, and 12:27 PM pacing the hallway without any interaction with staff or other residents. At 1:13 PM eating in the dining room seated by themselves in the corner facing a wall without any interaction with staff or other residents. -On 12/05/2025 at 9:49 AM, 10:37 AM, 11:05 AM, 11:22 AM, and 1:20 PM pacing the hallway without any interaction with staff or other residents. -On 12/08/2025 at 11:16 AM, 11:33 AM, 12:30 PM, 1:20 PM, and 3:05 PM pacing the hallway without any interaction with staff or other residents. During an interview on 12/05/2025 at 9:50 AM, Resident #104 stated they liked to dance and liked music including polka and fast dance. During a follow up interview on 12/08/2025 at 12:51 PM, Resident #104 stated they liked music and used to play the guitar and the bongos. They stated there were no music activities at the facility. During an observation on 12/08/2025 at 2:13 PM, there was a musician playing holiday songs on their guitar and singing in the main lobby. Resident #104 was not present. At 3:02 PM the musical activity continued in the main lobby and Resident #104 was not present. At 3:05 PM, Resident #104 was standing in the hallway on South 3 unit and immediately approached and talked with the surveyor as they got off the elevator. 3) Resident #184 had diagnoses including dementia, depression, and anxiety. The 05/15/2025 Minimum Data Set documented the resident had moderate cognitive impairment; it was somewhat important to have books, newspapers, and magazines to read, listen to music they liked, be around animals such as pets, do their favorite activities, go outside to get fresh air when the weather was good, and participate in religious services or practices. There was no documented evidence of a person-centered comprehensive care plan that included the resident's activities preferences. The unsigned 08/06/2025 Recreation Assessment documented Resident #184 was interviewed for daily and activity preferences. It was somewhat important to the resident to do their favorite activities. The resident's interests included Bingo, current events/history, fresh air, movies, music, pet visits, spiritual/religious, and television/radio. The resident preferred self-directed/independent, small groups, large groups, and 1:1 settings. The resident had positive response to group activities. There was no documented evidence Resident #184 had a quarterly recreation assessment.Resident #184 was observed at the following times:-On 12/02/2025 at 12:06 PM, sitting in their wheelchair in the hallway without any interaction with staff or other residents. -On 12/04/2025 at 9:10 AM and 9:44 AM sitting in their wheelchair in the hallway without any interaction with staff or other residents. At 10:06 AM, sleeping in their wheelchair in the hallway. At 10:23 AM sitting in their wheelchair in the hallway without any interaction with staff or other residents. At 11:06 AM sleeping in their wheelchair in the hallway. -On 12/08/2025 at 10:59 AM, and 12:30 PM, sitting in their wheelchair in the hallway without any interaction with staff or other residents. During an observation on 12/08/2025 at 2:13 PM, there was a musician playing holiday songs on their guitar and singing in the main lobby. Resident #184 was not present. At 3:02 PM the musical activity continued in the main lobby and Resident #184 was not present. At 3:07 PM, Resident #184 was sitting in their wheelchair in the hallway without any interaction with staff or other residents. During an interview on 12/09/2025 at 12:04 PM, Certified Nurse Aide #45 stated they had not seen any activities on the South 3 unit. If there were large group activities it was announced over the loudspeaker. During an interview on 12/09/2025 at 12:29 PM, Licensed Practical Nurse #4 stated there were not currently any unit activities because there was COVID in the building. During an interview on 12/10/2025 at 12:48 PM, Certified Nurse Aide #65 stated activities were held down on the first floor and not on the unit. During an interview on 12/10/2025 at 1:10 PM, Licensed Practical Nurse Unit Manager #43 stated they had an activities aide assigned to the unit, but they did not know their name. There were not usually unit activities, but they saw them once come up and color with the residents. Activities were important for quality of life, to maintain normalcy, and so residents did not just sit in front of walls. During an observation and interview on 12/12/2025 at 11:38 AM, Activity Aide #70 was coloring in the South 3 dining room. There were residents present and coloring, but Activity Aide #70 did not engage with the residents. Activity Aide #70 stated activities were based on the calendar and unit activities were held every other day. They invited residents to the large group activities downstairs. If a resident could get themselves downstairs, they could come, otherwise, they just tried to talk with the residents on the unit. The residents needed things to do that kept them from being lonely. It was important residents attended activities to feel at home and make them comfortable. They stated the residents on the South 3 unit were not all there so there were not many things they could do, but they could do crafts. They were new so they were still getting to know the residents. They had not done any unit specific activities on South 3 the past couple of weeks because the residents were not really involved so they hung out on another unit with another activity aide. During an interview on 12/15/2025 at 11:52 AM, Activities Aide #6 stated they were covering for the Director of Activities because they were currently out. They were making sure activities were completed on the unit but were also assigned their own unit to complete activities. They stated it was hard to do both. There were a lot of group activities at the facility but because there currently was COVID in the building, they were focusing on unit specific activities. At least once a day there should be an activity on the unit. As activity aides, they just knew which activities were unit activities and which were large group activities. Even if the activity aide was not doing an activity at that time, it was expected they were on the unit engaging with the residents. They stated Certified Nurse Aide #64 told them on 12/12/2025 unit activities were not occurring on South 3. When they approached Activity Aide #70 about this, Activity Aide #70 stated they were told they should not be on the unit because there was COVID. They felt Activities Aide #70 was afraid because they were new. Activities made the residents feel at home and they were still human and a part of the world. During an interview on 12/15/2025 at 12:56 PM, the Director of Social Work stated it was the resident's right to attend activities. It should be a part of their everyday life and brought them joy, happiness, hope, and a meaningful purpose.During an interview on 12/16/2025 at 12:18 PM, the Director of Activities stated they were responsible for activities care plans upon admission. The care plans were then reviewed with each care plan meeting to reassess and update preferences. Not everyone came down for large group activities but there were smaller unit activities as well. They usually only went to the floors if someone was off, otherwise they relied on their staff to report any changes. They knew Resident #184 well and did not know why they did not have an activity care plan. Their assessment was late, they had a computer problem that they were not seeing the schedule of when the assessments were due. Resident #104 was due for an assessment. They were not aware of any issues with activities on South 3 and Activities Aide #70 was new. They stated they relied on Licensed Practical Nurse Unit Manager #43 to tell them if there were any issues, and they had not. There were supposed to be activities on the South 3 unit at 10:30 AM. If there was a large music activity at 2:00 PM activities staff were supposed to be on the unit at 1:30 PM getting the residents downstairs. There was a coffee/social hour at 3:15 PM and then another activity on the floor at night. There should be unit specific activities, so residents stayed active and socialized. Resident #9 was hard because they just walked but the activities aide should attempt to converse with them. Resident #104 liked music and enjoyed activities much more now than when they first came to the facility. Resident #184 like to play cards and attend music and religious activities. Each resident was supposed to be invited to each activity every day. 10NYCRR 415.5(f)(1)

Based on observations, interviews, and record review conducted during the Extended Recertification Survey from 03/09/2025 to 05/09/2025, the facility failed to provide an environment which supported and enhanced each resident's quality of life, which was the result of the cumulative effect of noncompliance cited for abuse/neglect, incontinence care, quality of care, pressure ulcers, accident hazards, sufficient staffing, significant medication errors, and infection prevention and control. This noncompliance was found to be pervasive and created an environment reflecting a complete disregard of one or more residents' well-being and quality of life, which has caused or is likely to cause serious harm that is Immediate Jeopardy, related to one or more residents' self-worth, self-esteem, and well-being. On 05/09/2025 the survey team identified and declared Immediate Jeopardy and the facility Administrator was notified at 2:03 PM. The findings include: For additional information see Centers for Medicare/Medicaid Services Form 2567: F689 - Free of Accident Hazards/Supervision/Devices Specifically, for Residents #4, #11, #83, #461, and #508 the facility failed to ensure that residents received adequate supervision during meals to prevent accidents for residents that were on aspiration precautions. Additionally, Resident #461 was observed with the incorrect liquid consistency as ordered by the provider (to prevent choking). This resulted in Immediate Jeopardy. F725 - Sufficient Nursing Staff The facility failed to ensure sufficient nursing staff to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for residents in the facility. Specifically, there was insufficient staff to meet all resident needs including showers, assistance with eating, toileting, personal hygiene, and receiving medications as ordered by the medical team due to lack of licensed nurses and certified nursing assistants. This resulted in Immediate Jeopardy. F760 - Residents are Free from Significant Medication Errors Specifically, for Residents #3, #32, #111, and #459 the facility failed to ensure that residents were free of significant medication errors. Specifically, there was no documented evidence the residents received multiple significant medications over the course of several days including but not limited to insulin, antihypertensives (used to treat high blood pressure), antiplatelets (used to prevent blood platelets from forming clots), antidepressants, antipsychotics, antibiotics, antirejection medication (used for kidney transplants) and a medication used to treat kidney disease in dialysis patients. Additionally, review of full-house Medication Administration Audit Reports revealed no documented evidence that 193 residents from 02/13/2025 to 02/17/2025 and 213 residents from 03/21/2025 to 03/30/2025 had received multiple medications on multiple days which was verified by staff interviews and record review. This resulted in Immediate Jeopardy F880 - Infection Prevention and Control The facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and help prevent the development and transmission of communicable diseases and infections for three (3) (Residents #82, #148, and #459) of 10 residents reviewed and one (1) of one (1) facility potable water systems (the collection, treatment, storage, and distribution of safe drinking water). Specifically, Issue one (1) includes: The facility failed to 1) provide further testing for Legionnaires' disease for residents diagnosed with pneumonia, 2) to ensure short-term water disinfection control measures were implemented for the potable water system after receipt of samples testing positive for Legionella, and 3) to report potable water system samples exceeding greater than 30% positivity for Legionella to the New York State Department of Health, which resulted in the likelihood of serious injury, serious harm, serious impairment or death to all 214 residents in the facility. This resulted in Immediate Jeopardy F600 - Free from Abuse and Neglect For 13 (Residents #3, #4, #11, #32, #62, #83, #111, #148, #158, #178, #459, #461, #508) of 13 residents reviewed, the facility failed to ensure that residents were free from neglect when it failed to provide the required structures and processes in order to meet the needs of one or more residents. Specifically, the facility failed to ensure sufficient nursing staff to provide nursing services to meet the residents' needs including showers, assistance with eating, toileting, personal hygiene, skin care, application of devices to prevent loss of range of motion, receiving medications as ordered by the medical team and supervision of residents on aspiration precautions to prevent choking. For Resident #178, who was observed on several occasions not wearing recommended hand splints resulting in lost range of motion to their hands, which resulted in actual harm, that was not immediate jeopardy. For Resident #158 who was observed incontinent for extended periods of time, it can be determined that a reasonable person in the residents' position would have experienced serious psychosocial harm (such as anger, embarrassment, humiliation, anxiety), that was not immediate jeopardy. Additionally, Resident #158 was identified by staff to have skin breakdown to their buttocks and there was no documented evidence that a medical provider was notified, or treatments initiated until three days later, which resulted in actual harm, that was not immediate jeopardy. F684 - Quality of Care Specifically, Resident #178 was observed on several occasions not wearing specially made hand splints as recommended by Occupational Therapy to maintain range of motion resulting in lost range of motion to their hands. This resulted in actual harm to Resident #178 that was not immediate jeopardy. F686 - Treatment/Services to Prevent/Heal Pressure Ulcers Specifically, Resident #158 was identified by staff to have skin breakdown to their buttocks on 03/14/2025. There was no documented evidence that a medical provider was notified, or treatments initiated until three days later and the resident had two (2) new stage two (2) pressure ulcers. This resulted in actual harm to Resident #158 that was not immediate jeopardy. 10 NYCRR 415.5

Based on observations, interviews and record review conducted during the Extended Recertification Survey and complaint investigations (NY00372404, NY00372850, NY00364319, & NY00372698) from 03/09/2025 to 05/09/2025, the facility failed to ensure sufficient nursing staff to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for residents in the facility (Units South One, South 2, South 3, North One, North Two, [NAME] One and [NAME] Two). Specifically, there was insufficient staff to meet all resident needs including showers, assistance with eating, toileting, personal hygiene, and receiving medications as ordered by the medical team due to lack of licensed nurses and certified nursing assistants. On 04/23/2025 the survey team identified and declared Immediate Jeopardy. The facility's failure to provide adequate staff to provide activities of daily living care, adequate supervision to those on aspiration precautions, and administer medications results in the likelihood for serious injury, serious harm, serious impairment or death for all residents in the facility. The facility Administrator was notified at 4:40 PM. This is evidenced by, but not limited to the following: The facility policy Minimum Staffing dated January 2025, documented the facility would provide adequate staffing to meet the care and services for the resident population. Minimum staffing needs were identified for implementation in crisis situations, such as weather-related emergencies and staff illness outbreaks to ensure quality care of residents. The Staffing Associate would work collaboratively with the Director of Nursing, the Administrator and the evening and night supervisors to maintain appropriate staffing levels for their respective shifts by scheduling existing staff, per-diem staff, use of voluntary overtime, agency coverage and mandatory overtime to maintain daily staffing hours equal to 3.5 hours of care per resident per day, with at least 2.2 hours provided by a certified aide, and at least 1.1 hours by a licensed practical nurse or registered nurse. In the event the minimum could not be achieved there would be at least 1 nurse per 40 residents on day and evening shifts to deliver the appropriate care as needed and at least 1 nurse per 80 residents on the night shift. For additional information see Centers for Medicare/Medicaid Services Form 2567, reference F689 (Free of Accident Hazards/Supervision/Devices): For additional information see Centers for Medicare/Medicaid Services Form 2567, reference: F565 - Resident/Family Group Response: Review of facility Grievances/Complaints revealed filed grievances regarding care concerns including the lack of showers, not being assisted out of bed, and lack of staffing. Additionally, review of Resident Council Meeting Minutes revealed residents reported multiple care concerns including, but not limited to, not receiving showers regularly, call lights not answered timely, and medications not being administered due to lack of staffing. F677 - Activities of Daily Living Care for Dependent Residents: Several residents reported no showers for several weeks and were observed with unwashed hair, uncut nails and/or unshaven due to lack of staffing. F689 - Free of Accident Hazards/Supervision/Devices The facility failed to ensure that residents received adequate supervision during meals to prevent accidents for multiple residents that were on aspiration precautions. F760 - Residents are Free from Significant Medication Errors: Review of full-house Medication Administration Audit Reports revealed no documented evidence that 193 residents had received multiple medications on multiple days from 02/13/2025 to 02/17/2025 and 213 residents from 03/21/2025 to 03/30/2025 which was verified by facility staff interviews and record review. The Facility assessment dated [DATE], documented the facility was licensed for 229 beds with an average daily census of 215. The Facility Assessment referred to the emergency staffing policy for their emergency staffing plan. Nursing, nutrition services, and housekeeping staff would be evaluated at the beginning of each shift and adjusted as needed to meet the care needs and acuity of the resident population. There should be 3 Registered Nurses, 17 Licensed Practical Nurses, and 22 Certified Nursing Assistants per day. Based on the Payroll Based Journal Staffing Data report (facility reported staff worked by job title for a specific period) the facility had excessively low weekend staffing with a one-star staffing rating for fiscal year first quarter (October 1 - December 31, 2024). During the entrance conference on 03/09/2025 at 11:39 AM, the Administrator stated the facility census was 214 residents. Observations and interviews on 03/09/2025 on the South One Unit with a census of 38 included: -At 10:23 AM, Licensed Practical Nurse #12 stated they were the only nurse on the Unit with one Certified Nursing Assistant. -At 12:06 PM, Resident #111 stated there was no nursing staff the weekend of Valentine's Day (02/14/2025 through 02/16/2025) and sometimes there was just one (1) nurse and one (1) Certified Nursing Assistant. Resident #111 stated weekends were the worst and recently had to wait over 24 hours before the Certified Nursing Assistant, who was the only one on the unit, helped them get cleaned up when they had the stomach flu and soiled their bed. Observations and interviews on 03/09/2025 on South Two Unit included: -At 9:58 AM, the unit had strong, foul odors of urine. Licensed Practical Nurse #2 stated there was one (1) nurse and one (1) Certified Nursing Assistant for 37 residents. Certified Nursing Assistant #17 stated that they had been a Certified Nursing Assistant for less than a year and it was only their 3rd or 4th day working at the facility. -At 12:52 PM, Resident #158 was wearing sweatpants that were wet throughout the groin area almost down to the knees with a foul odor of urine. At 1:27 PM, 2:27 PM, and 4:20 PM, Resident #158's sweatpants remained unchanged. -At 3:41 PM, a visitor came into the hall to request help for Resident #148, who had been incontinent. In an immediate observation, Resident #148 had a large amount of stool on their bottom, hip, hands, fingernails and their bed linens. The visitor stated that it had been weeks since Resident #148 had a shower, and that sometimes it took an hour and a half to find staff to help. -At 4:51 PM Licensed Practical Nurse Unit Manager #1 stated that they were supposed to have two (2) Certified Nursing Assistants but there were only the two (2) nurses (licensed) on the unit who were trying to round and give care to every resident. Observations and interviews on 03/09/2025 on South Three Unit with a census of 39 included: -At 10:06 AM, there was one (1) Licensed Practical Nurse, one (1) Certified Nursing Assistant and one (1) Certified Nursing Assistant on light duty (no lifting). -At 10:31 AM, Resident #71 stated the facility was short staffed all the time, most of the time there was only one (1) nurse for the whole floor and sometimes no nurse. Resident #71 stated sometimes they did not receive their medications or are not assisted with their meals. During an interview on 03/10/2025 at 11:39 AM, Resident #100 stated sometimes they have to wait up to three (3) hours for help and once staff had not come in all night (to provide care). Weekends were the worst. Observations and interviews on North One and North Two Units with a census of 39 included: -On 03/09/2025 at 10:00 AM, Licensed Practical Nurse #10 said they were the only nurse till 8:30 AM which happened a lot and no Certified Nursing Assistants. Review of nurse punches revealed a Certified Nursing Assistant punched in at 10:15 AM. (There were no Certified Nurse Assistants from 7:00AM - 10:15AM). -On 03/10/2025 at 8:11 AM, Resident #110 stated staffing was bad every day and once they laid in stool for over five (5) hours. In an observation and interview on 03/09/2025 at 10:40 AM , there was 1 Licensed Practical Nurse and 1 Certified Nursing Assistant for 31 residents on the [NAME] Two Unit. Registered Nurse Supervisor #3 stated they were assisting with passing medications on the unit in addition to being the Nursing Supervisor for the entire building. Review of the Daily Nursing Staff Punches revealed nursing staff clocked in and out at sporadic times during the shifts and included but is not limited to, the following: On 02/14/2025 with a facility census of 223 residents, -The day shift (7:00 AM to 3:00 PM) had 7 Certified Nursing Assistants (1:32 ratio) and 7 Licensed Nurses (1:32 ratio) who punched in at 8:00 AM. -The evening shift (3:00 PM to 11:00 PM) had 4 Certified Nursing Assistants (1:56 ratio) and 6 Licensed Nurses (Licensed Practical Nurse and/or Registered Nurse) (1:37 ratio) at 5:00 PM. On 02/15/2025 with a census of 221 staffing included: -The day shift had 7 Licensed Nurses (1:32 ratio) at 9:00 AM -The evening shift had 7 Licensed Nurses (1:32 ratio) at 6:00 PM. -The night shift had 5 Certified Nursing Assistants (1:44 ratio) and 6 Licensed Nurses (1:37 ratio). On 02/16/2025 with a census of 220 staffing included: -The day shift had 5 Certified Nursing Assistants (1:44 ratio) and 3 Licensed Practical Nurses (1:73 ratio). The Director of Nursing came in at 11:54 AM. -The evening shift had 4 Licensed Practical Nurses and the Director of Nursing (1:44 ratio) and 8 Certified Nursing Assistants (1:28 ratio). -The night shift had 3 Certified Nursing Assistants (1:73 ratio) and 4 Licensed Nurses (1:44 ratio). On 02/17/2025 with an average daily census of 215 (actual staffing not available) staffing included: -The day shift had 7 Certified Nursing Assistants (1:31 ratio). -The night shift had 3 licensed nurses (1: 54 ratio). On 03/02/2025 with an average resident census of 215 the staffing included: -During the day and evening shifts there were 4 Licensed Practical Nurse (1: 54 ratio). -During the night shift, there were 2 Certified Nursing Assistants (1:108 ratio). -A Registered Nurse punched in for six (6) hours (versus the minimum of eight (8) consecutive hours per the regulation) for the entire day. During an interview on 03/10/2025 at 9:40 AM, Licensed Practical Nurse #2 stated that they did not have enough staff on 03/09/2025 day shift and that was the reason why residents were left wet for hours. During an interview on 03/13/2025 at 11:12 AM, Certified Nursing Assistant #4 stated they recalled working the weekend of 02/14/2025, and that they were the only Certified Nursing Assistant on the unit with one (1) nurse and approximately 40 residents. Certified Nursing Assistant #4 stated not much resident care was completed besides feeding the residents and each resident was changed or taken to the bathroom once. Residents who required two (2) staff and a mechanical lift for transfers did not get out of their bed. They said the nurse could not help them with resident care as they were trying to pass all the medications, and it was impossible to get to everyone. During an interview on 03/13/2025 at 11:13 AM, the Certified Nursing Assistant Staffing Coordinator stated that the facility was budgeted for four (4) Certified Nursing Assistants and two (2) nurses a shift for days and evenings, and two (2) Certified Nursing Assistants and one (1) nurse for night shift for each of the six (6) units. They were told for minimal staffing included two (2) Certified Nursing Assistants and one (1) nurse per unit. They said when at critical staffing levels residents could not get out of bed especially if they required two assist and showering residents would not happen unless a resident was covered in stool. The Certified Nursing Assistant Staff Coordinator stated staff complain daily about not having enough staff on the units to care for the residents. Residents and family members have complained there was not enough staff and their complaints were valid. The Certified Nursing Assistant Staffing Coordinator stated on 02/14/2025, the facility was at critical staffing levels, so the Director of Nursing worked on a unit and therapy staff stayed over to help pass meal trays and assist residents. There were times the facility had only six (6) to seven (7) staff total in the building for the night shift. During an interview on 03/13/2025 at 11:51 AM, Certified Nursing Assistant #5 stated they often worked by themselves with one (1) nurse on a unit (40 bed unit). They said when it was just them and a nurse it was impossible to get to all the residents and they would have to pick who needed the most care. For a resident who required two (2) staff assist they would have to care for them on their own. During an interview on 03/13/2025 at 12:00 PM, the Director of Nursing stated their minimum staffing level was one (1) licensed nurse and one (1) Certified Nursing Assistant for 40 residents, but they would then try to infuse other resources including therapy staff. The Director of Nursing stated one (1) nurse passing medications to 40 residents would need help to finish. They said on the weekend of 02/14/2025 through 02/16/2025 they were aware of numerous staff calling in sick as it was Valentine's Day weekend and there was a snowstorm. The facility offered bonuses to staff to come in, and they and the Assistant Directors of Nursing came in and helped wherever they could. The Director of Nursing said more than 20 residents did not receive their medications because there was not enough nursing staff to give them. The Director of Nursing stated that they were aware of the concerns regarding one (1) nurse for 40 residents, but it is within our guidelines. In an telephone interview on 03/13/2025 at 6:04 PM, a family member stated that they were upset that the hospital wanted to transfer Resident #459 back to the facility and they felt the facility did not have the staff to take care of the resident who needed a lot of assistance with care and required special medications for an organ transplant and a nephrostomy tube (tube inserted directly into the kidney through the skin to drain urine). Recently the resident had been left sitting in stool and they could not find any staff to help. During an interview on 03/16/2025 at 6:05 AM, Licensed Practical Nurse #14 stated that there were night shifts where there were only one (1) to three (3) nurses in the entire building. Sometimes it was just them and one (1) Certified Nursing Assistant, and they could not get to all of the residents for care. They have begged the facility for help. During an interview on 03/20/2025 at 10:03 AM Licensed Practical Nurse Unit Manager #1 stated they did not have time to do their job as they were always administering medications. During an interview on 03/21/2025 at 12:48 PM, the Medical Director stated that it was a well-known issue that residents did not receive their medications timely or at all and that it was likely due to lack of staffing. The Medical Director stated if residents did not get their hypertensive medications they could and have a heart attack, have a stroke, kidney damage or death. Without pain medication a resident could be in extreme pain, be agitated or have a stroke. Without their antiseizure medication residents could have a seizure and die. If a resident did not get their antirejection medication for day it could lead to rejection of the kidney. In a follow up interview on 03/21/2025 at 2:50 PM and at 6:31 PM, the Director of Nursing stated one (1) Certified Nursing Assistant for 40 resident was a lot, and if staff could not get to all the residents for care, they should say something. They are working on the staffing challenges and trying to hire more staff. During an interview on 03/21/2025 at 6:31 PM, the Administrator stated they were aware of issues with nurse staffing and have hired more agency nursing staff and an in-house recruiter. In a follow up interview on 03/31/2025 at 3:28 PM, the Director of Nursing stated they have worked on the medication carts to ensure medications were passed but this does impact their Director of Nursing duties. After reviewing nursing staff punches (hours worked) the Director of Nursing stated that the punches were not always accurate. Agency staff are supposed to know how to punch in and out but it was difficult to prove how many staff were in the building during a shift. The Director of Nursing stated low nurse staffing numbers could be why so many residents did not receive their medications. On 04/25/2025 at 12:05 PM the survey team declared that the IJ was removed based on the following corrective actions taken by the facility: -The Facility Assessment, dated 04/14/2025, included that staffing would be evaluated and adjusted as needed at the beginning of each shift to meet needs and acuity of the resident population, and was updated to reflect the temporary closing of a resident unit (which housed 19 residents) to help meet the facility's staffing needs. -Review of the Daily Census Report, dated 04/25/2025, revealed the North Two (2) unit (23 beds total) was empty. The unit closure was also confirmed when observed on-site. -The facility policy and procedure, Staffing Minimum, dated January 2025 included details for minimum and emergency staffing and if staffing levels fell below minimum, the Director of Nursing and Administrator would be contacted for direction. -Review of training records revealed 29 staff signatures including department heads, ancillary staff, and nursing supervisors had received education related to the facility's emergency staffing plan. An attestation, signed by the Administrator and dated 04/25/25, included 100% of all facility departments heads, nursing supervisors and ancillary staff would receive education prior to the start of their next scheduled shift. -Interviews with the staffing coordinator, nursing supervisors, nurse managers and the Minimum Data Set Coordinator verified receipt of the above education. -A New Hire Report from 04/01/2025 to 04/24/2025, included 27 new hires: 15 certified nursing assistants, 10 licensed practical nurses, 1 licensed practical nurse unit manager, 1 registered nurse admissions nurse. -The facility provided three staffing agency agreements signed between February 2025 and April 2025. -Interview with the Administrator revealed the facility had events planned to increase staff morale and retention and were set to begin in early May 2025. -Resident census and staffing numbers (certified nursing assistants, licensed nurses) for each residential unit were verified while on-site and deemed appropriate to meet the care needs of the current resident population. 10 NYCRR 415.13 (a)(1)(i-iii) 47641

Based on observations, interviews, and record review conducted during the Extended Recertification Survey and complaint investigations (NY00372404, NY00372850, NY00371489, and NY00372698) from 03/09/2025 to 05/09/2025, for four (4) (Residents #3, #32, #111, #459) of nine (9) residents reviewed, the facility failed to ensure that residents were free of significant medication errors. Specifically, there was no documented evidence that the residents received multiple significant medications over the course of several days including but not limited to insulin, antihypertensives (used to treat high blood pressure), antiplatelets (used to prevent blood platelets from forming clots), antidepressants, antipsychotics, antibiotics, antirejection medication (used for kidney transplants) and a medication used to treat kidney disease in dialysis patients. Additionally, review of full-house Medication Administration Audit Reports revealed no documented evidence that 193 residents had received multiple medications on multiple days from 02/13/2025 to 02/17/2025 and 213 residents from 03/21/2025 to 03/30/2025 which was verified by staff interviews and record review. These issues resulted in the likelihood of serious injury, serious harm, or death for all the residents in the facility (census 207) that was Immediate Jeopardy and substandard quality of care. The findings include: Review of the facility policy Administering Medications, dated January 2025, included medications must be administered in accordance with the orders, including required timeframe, and must be administered within one (1) hour of their prescribed time. The individual administering the medication will record in the resident's medical record the date and time the medication was administered and the signature and title of the person administering the drug. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document same in the eMAR (electronic Medication Administration Record) for that drug and dose. The person withholding, receiving the refusal, or administering medication at a different time will notify the attending/covering physician. 1. Resident #459 was a recent readmission with diagnoses including chronic kidney disease, history of a kidney transplant, and recent pyelonephritis (kidney infection). The Minimum Data Set (a resident assessment tool) dated 02/03/2025 documented the resident had severe impairment of cognitive function. Physician orders dated 01/27/2025 included prednisone once daily for organ transplant/prevent rejection, nifedipine extended release daily for high blood pressure and cyclosporine modified once daily for hydronephrosis (enlarged kidney) of a kidney transplant and pyelonephritis. Review of the January 2025 Medication Administration Record revealed the prednisone, nifedipine extended release, and cyclosporine modified had not been administered for the entire day due to other/see nurses note. In a medication administration note dated 01/28/2025 Licensed Practical Nurse Manager #3 documented the prednisone, nifedipine extended release, and cyclosporine were not administered as they had not arrived from the pharmacy. There was no documented evidence the physician was notified that the medications had not been administered. Review of the February 2025 Medication Administration Record revealed the cyclosporine modified was documented as not administered on 02/03/2025 due to the resident being out of the facility. There was no documented evidence in the resident's medical record that the resident was out of the facility on 02/03/2025. Resident #459 was transferred to the hospital on 02/10/2025. In a nursing progress note dated 03/06/2025 Licensed Practical Nurse #2 documented Resident #459 returned from the hospital at 1:45 PM. Physician orders dated 03/06/2025 following readmission from the hospital included cyclosporine modified twice daily for kidney transplant. In a Medication Administration Note dated 03/06/2025 at 9:51 PM Licensed Practical Nurse #2 documented cyclosporine modified was not administered as the medication was not in. There was no documented evidence the physician was notified of the missed dose. In a telephone interview on 03/13/2025 at 6:04 PM Resident #459's family stated that they found out that Resident #459 (who had been readmitted to the hospital on 03/11/2025) had not been receiving their medications consistently because sometimes there were not enough nurses to administer them including their daily antirejection medication that they needed because the resident had a kidney transplant. Physician orders dated 03/14/2025 following readmission from the hospital included cyclosporine twice daily for kidney transplant. Review of the Medication Administration Record dated 03/14/2025 (evening shift) and 03/15/2025 (day shift) revealed the cyclosporine had been documented as not administered due to the order had not been placed in the electronic medical record yet. During an interview on 03/20/2025 at 11:53 AM Physician #2 stated Resident #459 should not miss any medications and that sometimes there is not a provider in house, but the nurses should know how to put all the orders in the electronic medical record. Review of a hospital After Visit Summary (discharge orders) dated 03/21/2025 following readmission to the facility revealed orders for cyclosporine to be given twice daily. Physician orders following readmitted d 03/21/2025 included cyclosporine modified three (3) times a day signed by Physician #2 . Review of the March 2025 Medication Administration Record revealed the cyclosporine modified was administered three (3) times daily from 03/22/2025 to 03/31/2025. During an interview on 03/31/2025 at 10:02 AM Licensed Practical Nurse Manager #1 stated when a resident returned from the hospital, nursing reviews the hospital After Visit Summary and puts the orders in the computer which the providers then review and sign off on them. Licensed Practical Nurse Manager #1 stated the cyclosporine being given three times a day was probably due to a typo when the orders were originally put in, that they had most likely been very busy and got called away from the desk. During an interview on 03/31/2025 at 10:14 AM Nurse Practitioner #1 stated that when a resident gets admitted from the hospital the nurses should input the orders into the computer based on the After Visit Summary and then the provider verifies the orders and signs them. Nurse Practitioner #1 stated that the cyclosporine should not have been given three times daily as the After Visit Summary and the discharge summary both documented cyclosporine to be given twice daily and that receiving the medication three times daily could cause hypertension, leukopenia (low white blood cells), or toxicity along with other adverse effects. Nurse Practitioner #1 did not know why the order was put in incorrectly and stated that the providers should be double checking the orders with the After Visit Summary as that would be part of the process for verifying them. During an interview on 03/31/2025 at 3:28 PM the Director of Nursing stated that when a resident gets admitted from a hospital the nurse putting in the orders should have compared the After Visit Summary to what they put in the computer then a provider should compare the orders prior to signing off on them. The Director of Nursing stated they did not know how the cyclosporine got ordered and administered to Resident #459 incorrectly. 2.Resident #32 had diagnoses including End Stage Renal Disease requiring hemodialysis (treatment that removes waste products from the blood when the kidneys fail to), bipolar disorder (mental health condition), diabetes mellitus, and high blood pressure. The Minimum Data Set, dated dated dated [DATE], documented the resident was cognitively intact and took high risk medications such as an antipsychotic, antianxiety, antidepressant, and antiplatelet. Review of physician orders dated 01/17/2025 revealed venlafaxine twice daily for depression, quetiapine daily for bipolar disorder, metoprolol twice daily and hydralazine three times daily for high blood pressure, Plavix daily for coronary artery disease, insulin glargine daily for diabetes mellitus, hydroxyzine twice daily for itching and anxiety, and sevelamer daily with meals for kidney disease. In a medical progress note dated 02/17/2025 Physician #1 documented that Resident #32 missed several medications on 02/15/2025. In a nursing progress note dated 02/17/2025 the Director of Nursing documented that Resident #32 did not receive medications on 02/16/2025. Review of Resident #32's February 2025 Medication Administration Record revealed no documented evidence that the following medications had been administered (as indicated by a blank box) and included but not limited to: a. On 02/15/2025 during the evening shift: sevelamer, hydroxyzine, venlafaxine, quetiapine, metoprolol and hydralazine. b. On 02/16/2025 during the day shift: sevelamer (8:00 AM and 12:00 PM doses), hydroxyzine, venlafaxine, metoprolol, hydralazine (8:00 AM and 2:00 PM doses), insulin glargine, and Plavix. 3.Resident #111 had diagnoses including diabetes mellitus, bipolar disorder, and high blood pressure. The Minimum Data Set, dated dated dated [DATE], included the resident was cognitively intact and took high risk medications such as insulin, antipsychotic, antidepressant, and anticonvulsant. Current Physician orders reviewed on 03/12/2025 included insulin lispro routine dose and sliding scale before meals for diabetes, insulin glargine daily for diabetes, venlafaxine daily for depression, aripiprazole daily for bipolar disorder with depression, and lisinopril daily for high blood pressure. Review of Resident #111's February 2025 Medication Administration Record revealed no documented evidence that the following medications had been administered (as indicated by a blank box) and included but not limited to: a. On 02/15/2025 during the day shift: insulin glargine b. On 02/16/2025 during the day shift: insulin lispro (7:30 AM and 11:30 AM doses), venlafaxine, aripiprazole, and lisinopril Review of interdisciplinary progress notes from 02/15/2025 to 02/20/2025 did not include any documentation as to why the medications had not been administered or if the medical team had been notified. During an interview on 03/09/2025 at 12:07 PM, Resident #111 stated there had been little to no staff on the weekend of February 15th. They were diabetic, had gone more than 12 hours without receiving their insulin and were supposed to have blood glucose levels checked and receive insulin three (3) times daily before each meal. 4.Resident #3 had diagnoses including urinary tract infection, multiple sclerosis (a debilitating disease of the nervous system), and depression. The Minimum Data Set, dated dated dated [DATE], included the resident was cognitively intact. Review of physician orders dated 02/14/2025 revealed cephalexin (antibiotic) three (3) times daily for 14 days for a urinary tract infection, baclofen three (3) times daily for muscle spasms and escitalopram daily for depression. In a nursing progress note dated 02/16/2025 the Director of Nursing documented that on 02/15/2025 and 02/16/2025 Resident #3 did not receive some of their medications. Review of Resident #3's February 2025 Medication Administration Record revealed no documented evidence that the following medications had been administered (as indicated by a blank box) and included but not limited to: a. On 02/14/2025 during the evening shift: cephalexin (2:00 PM and 7:00 PM doses) b. On 02/15/2025 during the evening shift: cephalexin and baclofen (5:00 PM and 9:00 PM doses). c. On 02/16/2025 during the day shift: cephalexin (9:00 AM and 2:00 PM), baclofen and escitalopram. Additionally, review of a full-house Medication Administration Audit Report revealed no documented evidence that 193 residents had received multiple medications on multiple days from 02/13/2025 to 02/17/2025. During an interview on 03/13/2025 at 11:38 AM the Medical Director stated they were unaware that medications had not been administered to several residents and would expect there were enough nurses scheduled in the facility, so all medications were administered. In a follow up interview on 03/21/2025 at 12:48 PM, the Medical Director stated they were made aware that some residents did not receive medications on time or at all, likely due to lack of staffing. The Medical Director stated all medications prescribed by a provider would be considered significant, a resident not receiving medications was unacceptable and it was never okay for a skilled nursing facility resident to not get their medications. The Medical Director stated missing an antirejection medication for a kidney transplant would set the resident up for rejection of that kidney, even if it was an old transplant and the resident would need lifelong immunosuppressant medication. During an interview on 03/21/2025 at 6:30 PM, the Administrator stated they and the Quality Assurance Committee were aware that many residents did not have significant medications administered . They stated the Director of Nursing should be checking medication administration reports every shift. In a follow up visit on 03/31/2025, review of the March 2025 Medication Administration Audit Report revealed no documented evidence that 213 residents had received multiple medications on multiple days from 03/21/2025 to 03/30/2025 which was verified by staff interviews and record review. During an interview on 03/31/2025 at 1:20 PM the Administrator stated when a resident gets admitted from the hospital the physician should be comparing the orders to the hospital discharge summary. The Administrator said there should be no reason why any residents were missing medications within the last 10 days as they have had at least one (1) nurse on every floor during every shift. During an interview on 03/31/2025 at 3:28 PM the Director of Nursing stated the goal was to audit the Medication Administration Reports after every shift but when the nursing supervisor is on a medication cart, we have to take people at their word that they are doing it. The Director of Nursing stated when they review the weekend audits on Monday morning, I do not know why I see whole floors that did not get their medications when we had nurses assigned. On 04/01/2025 the survey team identified and declared Immediate Jeopardy. The facility Administrator was notified at 11:19 AM. On 04/01/2025 at 5:30 PM the survey team declared Immediate Jeopardy was removed based on the following corrective actions taken by the facility: -The medical team was notified of all residents who had medication errors (missed medications) since 03/21/2025, medical assessments were in process and daily vital signs were initiated and will be ongoing for the next 48 hours. -100% of all onsite day and evening shift licensed nursing staff education was completed and included: the facility's policies Administering Medications and Adverse Consequences and Medication Errors, the missed medication daily review process and proper communication of staffing emergencies related to coverage. - Interviews with 14 licensed nurses onsite (100%) were completed to verify the above education including the evening nurse supervisor. An attestation that 100% of all facility licensed nurses including agency nurses would be educated prior to their next shift. - A daily facility wide Medication Administration Audit Report for every shift for any missed or omitted medications will be conducted by the Nursing Supervisor or the Director of Nursing (or designee). Review of the audit report for past 24 hours was done by survey team and no additional significant medication errors identified. -Interviews with facility Administrator, Director of Nursing and Corporate Director of Nursing were completed regarding a root cause analysis of significant medication errors as related to staffing issues and plans initiated to prevent ongoing issues including closing one resident unit down as soon as possible and increased agency presence in the facility as needed (verified with current staff onsite). 10 NYCRR 415.12(m)(2)

Based on observations, interviews, and record reviews conducted during an Extended Recertification Survey from [DATE] to [DATE], the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and help prevent the development and transmission of communicable diseases and infections for three (3) (Residents #82, #148, and #459) of 10 residents reviewed and one (1) of one (1) facility potable water systems (the collection, treatment, storage, and distribution of safe drinking water). Specifically, Issue one (1) includes: The facility failed to 1) provide further testing for Legionnaires' disease for residents diagnosed with pneumonia, 2) to ensure short-term water disinfection control measures were implemented for the potable water system after receipt of samples testing positive for Legionella, and 3) to report potable water system samples exceeding greater than 30% positivity for Legionella to the New York State Department of Health, which resulted in the likelihood of serious injury, serious harm, serious impairment or death to all 214 residents in the facility. Issue two (2) includes: Residents #82 was on enhanced barrier precautions (interventions designed to reduce transmission of multidrug-resistant organisms) and staff did not wear appropriate personal protective equipment (equipment worn to minimize exposure to potential hazards, such as a facemask, gloves and/or gown) and did not perform hand hygiene or change soiled gloves following incontinence care and before touching environmental objects. Additionally, the resident's indwelling catheter drainage bag was observed on the floor without a barrier. For Resident #148, staff did not change gloves or perform hand hygiene following incontinence care and before touching environmental objects. Resident #459 had a nephrostomy tube (a tube placed directly into the kidney through the skin to drain urine), was not on enhanced barrier precautions as ordered, and staff were observed providing hands-on care without appropriate personal protective equipment. The findings include: Issue one (1): Review of the facility policy Legionella Water Management Program, dated [DATE], included the following: a. The water management team will consist of at least the following personnel: the infection preventionist, the administrator, the medical director or designee, the director of maintenance, and the director of environmental services. b. The water management program includes the following elements: specific measures used to control the introduction and/or spread of Legionella (e.g., temperature, disinfectants), the control limits or parameters that are acceptable and monitored, a system to monitor control limits and the effectiveness of control measures, a plan for when control limits are not met and/or control measures are not effective, and documentation of the program c. The Water Management Program will be reviewed at least once a year, or sooner in cases including, but not limited to, if the control limits are not consistently met. Review of the facility policy Legionella Surveillance Detection, dated [DATE], included the following: a. The facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. Legionnaires' disease will be included as part of our infection surveillance activities. b. As part of the Infection Prevention and Control Program, all cases of pneumonia that are diagnosed in residents more than 48 hours after admission will be investigated for possible Legionnaires' disease. c. If pneumonia or Legionnaires' disease is suspected, the nurse will notify the physician or practitioner immediately. d. Diagnosis of Legionnaires' disease is based on a culture of lower respiratory secretions and urinary antigen testing obtained at the same time. Review of the facility policy Legionella Management Plan Potable Water System, dated [DATE], included disinfection and response procedures to be used when Legionella counts exceed 30% positive and specified that results are reported promptly to program team members to make determinations of effective remediation strategies using New York State guidelines via appendix 4-B of that document. Percentage of positive Legionella test sites greater than 30% includes the following responses: a. Immediately institute short-term control measures in accordance with the direction of a qualified professional and notify the department. b. The water system shall be re-sampled no sooner than seven (7) days and no later than four (4) weeks after disinfection to determine the efficacy of the treatment. c. Retreat and retest. If retest is greater than or equal to 30% positive, repeat short-term control measures. Review of the facility policy Surveillance for Infections, dated [DATE], included the Infection Preventionist would conduct ongoing surveillance for healthcare-associated infections and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and interventions. The Infection Preventionist and the attending physician would determine if laboratory tests were indicated and if special precautions were warranted. Additionally, the Infection Preventionist would determine if the infection was reportable and would gather and interpret surveillance data. Record review and interview on [DATE] at 1:55 PM included the following: a. 10 Legionella water samples for the domestic water supply were submitted to a lab on [DATE]. Results received on [DATE] included 7 of the 10 (70%) samples were positive for Legionella and were obtained from South Three, room [ROOM NUMBER]-bathroom sink; South Two, room [ROOM NUMBER]-bathroom sink; North Two, room [ROOM NUMBER]-bathroom sink; North Unit shower; [NAME] One, room [ROOM NUMBER]-bathroom sink; Main Hall sink; and South One, room [ROOM NUMBER]-bathroom sink. b. 10 Legionella water samples for the domestic water supply were submitted to a lab on [DATE]. The [DATE] results included 5 of the 10 (50%) samples were positive for Legionella and obtained from South Three shower room; South Two room [ROOM NUMBER]-bathroom sink; Main Hallway sink; South Three room [ROOM NUMBER]-bathroom sink; and North Two room [ROOM NUMBER]-bathroom sink. Follow-up sampling was not performed until [DATE] (43 days later). In an immediate interview, the Director of Maintenance stated sample results were not reported to the New York State Department of Health. Review of records provided by the Administrator on [DATE] at 9:50 AM included a list of seven (7) residents who were diagnosed with pneumonia ranging from [DATE] to [DATE]. Additional record review revealed three (3) of the seven (7) residents had expired and had resided on North One, South Three, and [NAME] One. During an interview on [DATE] at 2:10 PM, the Administrator stated there were no Legionnaires' disease testing results for the seven (7) residents diagnosed with pneumonia. During an interview and record review on [DATE] at 10:08 AM, the Director of Maintenance stated after receipt of the positive Legionella results in [DATE] and [DATE], the vendor came in and did a high chlorine flush of the water system. Record review of service reports revealed the vendor was at the facility [DATE], [DATE], [DATE], and [DATE] for routine monthly service. The service report dated [DATE] included the dosing pump controls were not responsive, and a new pump would be installed. The service report dated [DATE] included pump controls were unresponsive. The service report dated [DATE] included the replacement of the chlorine pump as interface was not working. The vendor service reports did not document if short term control measures were implemented after greater than 30% of the water samples came back positive for Legionella on [DATE] and [DATE]. During a phone interview on [DATE] at 12:35 PM, the Medical Director stated they were not aware water samples at the facility were positive for Legionella; they would be concerned for the residents and should have been notified. During an interview on [DATE] at 12:48 PM, the Director of Maintenance stated they told the Administrator about the positive Legionella results, and they were taking care of it. The Director of Maintenance stated they did a high chlorine flush of the system each time and sanitized all the shower heads. There was no documented evidence that a chlorine flush of the domestic water system or other short-term control measures had been performed. During an interview on [DATE] at 2:14 PM, the Director of Nursing stated they had not been notified that the facility's water system had tested positive for Legionella. They stated the Director of Maintenance was responsible to collect the water samples and should have informed them of the positive results. The Director of Nursing stated it would have been important for them to be notified to ensure the medical provider was updated and urine and culture tests were completed on any resident testing positive for pneumonia. During an interview on [DATE] at 3:00 PM, the Regional Director of Nursing stated there was no corporate Infection Preventionist to manage the facility's infection control program. On [DATE] the survey team identified Immediate Jeopardy Past Non-Compliance. Based on the following corrective actions it was determined through interviews and record review the facility implemented corrective actions to correct the non-compliance effective [DATE]. A follow up onsite review on [DATE] included the following: -The Legionella policies and water management plans were reviewed, no revisions required, and the facility is currently compliant with their policies and the regulation. -The supplemental disinfection system is currently functioning properly. -The prior exceedances were reported to NYSDOH on [DATE]. -The round of samples taken [DATE] had a20% positivity rate, requiring no further action on the part of the facility. -Two residents recently diagnosed with pneumonia tested negative for Legionnaires' disease. -The facility is monitoring all residents diagnosed with pneumonia for possible Legionnaires' disease. -Director of Maintenance stated they flush the water system monthly, sanitize the shower heads monthly, and monitor the chlorine residual daily as part of routine preventative maintenance procedures. -The facility provided documentation that on [DATE], Administration provided education regarding Legionella Testing Procedures due to positive water testing. Signature sheet of those present included, but were not limited to: Administrator, Director of Nursing, Assistant Director of Nursing, Medical Director, Director of Maintenance, Assistant Director of Environmental Services, and multiple Registered Nurses and Unit managers. There is no Plan of Correction required for Issue one (1) of the F880 Issue two (2) The facility policy Barrier Enhanced Precautions, dated [DATE], included enhanced barrier precautions expands the use of personal protective equipment and designates the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug resistant organisms to staff hands and clothing. High contact resident care activities include, but are not limited to, transferring residents, changing linens, changing briefs, assisting with toileting, care of medical devices, and wound care for chronic wounds. Hand hygiene should be performed, and a new gown and gloves should be put on before caring for a different resident. The facility policy Standard Precautions dated [DATE] included hands shall be washed after direct contact with bodily fluids. Gloves should be worn when anticipated direct contact with bodily fluids and changed as necessary during care to prevent cross-contamination from one body site to another and to remove gloves after use, before touching non-contaminated items and environmental surfaces and wash hands immediately to avoid transfer of microorganisms to other residents or environments. 1.Resident #82 had diagnoses including bladder dysfunction, benign prostatic hyperplasia (enlargement of the prostate) and chronic kidney disease. The Minimum Data Set (a resident assessment tool) dated [DATE] included the resident had moderately impaired cognition. Resident #82's Comprehensive Care Plan dated [DATE] and current Certified Nursing Assistant Kardex (care plan) both included the resident had a suprapubic catheter (a tube inserted directly into the bladder through the abdomen to drain urine into a bag) and was incontinent of bowel. Interventions included to provide catheter care every shift and as needed, maintain the urine collection bag below the level of the bladder, maintain enhanced barrier precautions, and that the resident was dependent on staff for toileting hygiene. Current physician orders dated [DATE] included to maintain enhanced barrier precautions. During an observation on [DATE] at 3:11 PM, an enhanced barrier precaution sign was posted outside of Resident #82's room and included personal protective equipment (gown and gloves) were required for high-contact resident care activities. Personal protective equipment was available outside the room. During observations on [DATE] at 3:31 PM, [DATE] at 12:39 PM, [DATE] at 1:52 PM, [DATE] at 12:13 PM, and [DATE] at 1:46 PM, Resident #82 was lying in bed with their urine collection bag and catheter tubing lying directly on the floor next to the bed or under the bed without a barrier. During an observation on [DATE] at 1:54 PM, Certified Nursing Assistant #14 washed their hands, put on gloves but no gown, and placed the urinary catheter bag on the bed. They then provided care to Resident #82, who was incontinent of stool. They removed the soiled incontinence brief and pad and placed them on the floor with no barrier. Without changing gloves or washing their hands, Certified Nursing Assistant #14 applied a clean brief, then touched clean linens, the bed control, the bedside table, and the closet door, and emptied the urinary catheter bag. During an interview on [DATE] at 2:19 PM, Certified Nursing Assistant #14 stated they did not change gloves or wash their hands after providing incontinence care but should have before they touched other objects in the resident's room. Certified Nursing Assistant #14 looked at the enhanced barrier precaution sign posted outside Resident #82's room and stated they did not see it and should have also worn a gown and mask while providing care. During an interview on [DATE] at 3:07 PM, Licensed Practical Nurse Manager #4 stated Resident #82 was on enhanced barrier precautions because they had a suprapubic catheter and staff should wear gloves, gown and a mask when providing care and emptying their catheter bag to prevent the spread of infections. Licensed Practical Nurse Manager #4 stated staff should also change their gloves and wash their hands after incontinence care and before touching other objects in the room to prevent contamination, and catheter bags should always be placed below the level of the bladder and never directly on the floor. 2.Resident #459 had diagnosis including dementia, encephalopathy (impaired brain function), history of a kidney transplant and immunodeficiency (decreased ability of the body to fight infections). The Minimum Data Set, dated dated dated [DATE] included the resident had severe impairment of cognitive function. Review of Resident #459's Comprehensive Care Plan, dated [DATE], revealed Resident #459 had a nephrostomy tube. Interventions included to monitor intake and output per protocol. The care plan did not include that the resident was on enhanced barrier precautions. Physician orders dated [DATE] included to flush Resident #459's nephrostomy tube daily and maintain Enhanced Barrier Precautions, due to a nephrostomy tube. During an observation on [DATE] at 11:24 AM, Certified Nursing Assistant #2 and Licensed Practical Nurse Manager #3 were providing care to Resident #459 while wearing gloves but no gowns. Certified Nursing Assistant #2 emptied the resident's urine bag. There was no enhanced barrier precaution sign or personal protective equipment outside the resident's room. During an interview on [DATE] at 10:45 AM, Certified Nursing Assistant #2 stated they did not wear a gown while providing care to Resident #459 but should have because the resident should have been on enhanced barrier precautions. 3.Resident #148 had diagnoses including dementia, failure to thrive and ataxia (lack of muscle coordination, making it difficult to walk). The Minimum Data Set, dated dated dated [DATE] documented the resident had severely impaired cognition. Review of Resident #148's current Comprehensive Care Plan, last revised [DATE], included the resident was incontinent of bowel and bladder and dependent on staff for toileting hygiene. Interventions included to check the resident for incontinence and change them every three (3) to four (4) hours and as needed and provide perineal care after each incontinent episode. During an observation on [DATE] at 3:41 PM, Licensed Practical Nurse #2 was wearing gloves while they provided incontinence care to Resident #148 and applied cream to the buttocks. Licensed Practical Nurse #2 did not change their soiled gloves or wash their hands after changing the resident's soiled brief and before touching clean linens and multiple objects in the resident's room. During an interview on [DATE] at 11:07 AM, Licensed Practical Nurse #2 stated they should have changed their gloves and washed their hands following incontinence care, to avoid contamination of other objects. During interviews on [DATE] at 2:14 PM and 2:50 PM, the Director of Nursing stated that staff should wear the appropriate personal protective equipment while providing resident care. Residents with indwelling medical devices should be on enhanced barrier precautions, and staff should wear gowns, gloves, and masks during care to reduce the spread of infection. The Director of Nursing said staff should change their gloves and wash their hands following incontinence care and before touching clean linens or objects in the room, to prevent contamination. They said soiled linens should not be placed directly on the floor due to infection control concerns, and catheter bags should always be kept below the level of the bladder and not directly on the floor, due to risk for infection. The Director of Nursing stated Resident #459 should have had an enhanced barrier precautions sign on their door and personal protective equipment available outside the room. Since the facility did not have an infection preventionist, the nurses, managers, or certified nursing assistants should put the cart and signage outside the resident's room. 10NYCRR: Section 415.19, 10NYCRR: Part 4, Subparts?,d+[DATE].4(a)(3), ,d+[DATE].7(b) 50512

Based on observations, interviews, and record review conducted during an Extended Recertification Survey from 03/09/2025 to 05/09/2025, the facility failed to ensure that the residents' environment remained as free of accident hazards as possible, and that each resident received adequate supervision and assistive devices to prevent accidents for five (5) (Residents #4, #11, #83, #461 and #508) of five (5) residents reviewed for accidents and five (5) (West One, [NAME] Two, North First Floor, North Two, and South Three) of seven (7) resident areas observed for accident hazards. Specifically, the facility failed to ensure the residents, who were on aspiration precautions (precautionary steps taken by the facility to prevent inhalation of food or drink into the lungs due to swallowing difficulties), received adequate supervision and/or assistance during meals. Additionally, Resident #461 was observed with the incorrect liquid consistency as ordered by the provider (to prevent choking). This resulted in a pattern of no actual harm that was Immediate Jeopardy and Substandard Quality of Care with the likelihood of serious harm, serious impairment, serious injury, or death to 33 residents identified at risk for aspiration precautions when eating. In addition, the heating surfaces of radiators in multiple residents' rooms exceeded 125 degrees Fahrenheit, creating a potential burn risk from accidental contact, as they were accessible to residents, including residents with wandering behavior. Findings include: Issue one (1) The facility's policy Aspiration Precautions, revised February 2022, documented that residents on aspiration precautions must be fed within the direct supervision of licensed personnel. The facility's policy Liquid Consistency, dated July 2021, documented that all meal and liquid preparations will be done in the kitchen. 1.Resident #461 had diagnoses that included gastro-esophageal reflux (a digestive disease of the stomach) and dysphagia (difficulty swallowing). The Minimum Data Set (a resident assessment tool) dated 03/04/2025 documented the resident had moderate impairment of cognitive function, had coughing and/or choking issues during meals or swallowing medications, and required supervision, touching assistance or cueing when eating. Physician orders dated 03/06/2025 documented a regular pureed texture diet with honey (thickened) consistency liquids, and aspiration precautions. The Comprehensive Care Plan and the Certified Nursing Assistant Kardex (care plan) both dated 03/06/2025 documented Resident #461 required supervision or touching assist while eating and was on aspiration precautions with small bites and no straws for all intakes and all meals. During observations and interviews on 03/12/2025 at 9:22 AM, Resident #461 was in bed eating breakfast. The head of the bed was elevated, but the resident had become slouched down while eating. There were no facility staff in sight of the resident. Resident #461's breakfast tray contained a packet of thickened coffee that was unopened. The resident was drinking hot water from a coffee cup that was not thickened and was coughing. Resident #461 stated that the coffee tasted terrible and, damn, I keep coughing. The resident then drank some milk and again started coughing, and staff were immediately notified. In an immediate interview, Licensed Practical Nurse #1 stated the liquid in the coffee cup was not thickened and added the packet of coffee thickener to the hot water. Licensed Practical Nurse #1 stated that they were from an agency and did not know any of the residents on the unit. During an interview on 03/12/2025 at 9:43 AM, Licensed Practical Nurse Manager #2 on [NAME] Two Unit stated they did not know how many residents on the unit were on aspiration precautions and would have to check with the therapy department to know what level of assistance Resident #461 required for meals. Licensed Practical Nurse Manager #2 stated they were not sure why no one was monitoring Resident #461 during their meal or why no one added the thickened coffee packet to the liquid. During an interview on 03/12/2025 at 11:43 AM, Food Service Director #1 stated regular consistency coffee and hot chocolate are sent to the residents with a packet of thickener and nursing staff were responsible to thicken it for the resident. 2. Resident #11 had diagnoses that included pneumonia, dementia, and dysphagia. The Minimum Data Set, dated dated dated [DATE] documented the resident had moderate impairment of cognitive function and required supervision or touching assist for eating. The current Certified Nursing Assistant Kardex reviewed on 03/12/2025 documented Resident #11 was on aspiration precautions, required supervision while eating, and to maintain an upright posture during meals and for 30-60 minutes after. In a medical progress note dated 12/16/2024, Nurse Practitioner #1 documented that Resident #11 had noted coughing and emesis (vomiting), was at high risk for aspiration, and would start on antibiotics for presumed aspiration pneumonia (respiratory infection caused by inhalation of food or drink into the lungs). A hospital discharge summary dated 12/20/2024 documented that Resident #11 was admitted to the hospital on 12/16/2024 due to respiratory distress and diagnosed with pneumonia most likely due to aspiration. Physician orders dated 02/27/2025 included aspiration precautions and a dysphagia mechanically altered Level 2 textured diet (a diet for individuals with difficulty swallowing requiring foods to be moist, soft-textured, and easily formed into a bolus). During observation of lunch on 03/11/2025 at 1:51 PM, Resident #11 was lying in bed, not sitting upright, with the bed elevated at approximately 45 degrees. Their lunch tray was on the bedside table and positioned over their abdomen. Resident #11 removed the cover from the lunch tray and began eating independently. There was no facility staff in the resident's room or in sight of the resident. In continuous observations between 1:51 PM to 2:18 PM, no staff were observed going into Resident #11's room. During an observation on 03/11/2025 at 2:18 PM, a staff member entered Resident #11's room to remove the lunch tray and told Resident #11 that they needed to sit up straight, but left without assisting the resident with positioning. During an observation on 03/12/2025 at 9:58 AM, a staff member entered Resident #11's room and delivered coffee and a bowl of oatmeal. Resident #11 was lying in bed and leaning to the right. The staff member left the room without repositioning the resident for eating. During an interview and observation on 03/12/2025 at 10:12 AM, Certified Nursing Assistant #2 stated Resident #11 was on a pureed diet, due to swallowing issues. They said supervision consisted of walking back and forth down the hallway, peeking in on the residents to see if they needed assistance, and that any resident on aspiration precautions should go to the dining room to be fed. They stated Resident #11 was on aspiration precautions but sometimes refused to get out of bed and should have a staff member present in their room for meals, but they did not always have enough staff. In an immediate observation, Resident #11 remained in bed with the head of bed elevated at approximately 45 degrees and the resident was leaning to the right, eating oatmeal. There was no staff in the room. Certified Nursing Assistant #2 stated someone should be in with the resident while they eat but they did not have enough staff on the unit that day. 3.Resident #4 had diagnoses that included dementia, right hemiplegia (paralysis on one side of the body) and dysphagia. The Minimum Data Set, dated dated dated [DATE] documented the resident had severe impairment of cognitive function. No swallowing disorders were documented. Current Physician orders dated 06/28/2024 documented orders for a regular pureed diet with nectar thickened liquids, and aspiration precaution. Review of Resident #4's Certified Nursing Assistant Kardex revealed the resident required supervision or touching assist with eating, was on aspiration precautions, and to keep the head of bed upright at 90 degrees during meals. Cues for slow pacing included half-teaspoon bites and alternating drinks every one to three bites. If coughing, cue the resident to take deep breaths to allow cough to clear. During an observation on 03/12/2025 at 9:32 AM, Resident #4's breakfast tray was delivered to their room and Certified Nursing Assistant #3 raised the head of the bed to approximately 70 degrees, with the resident positioned on their left side and the bedside table placed over the bed. Certified Nursing Assistant #3 set up the breakfast tray and left the room. Resident #4 fed themselves hot cereal and large gulps of apple juice from the original container. There were no staff in the room or in sight of the resident the entire time the resident was feeding themselves. During an observation and interview on 03/12/2025 at 9:53 AM, Certified Nursing Assistant #1 stated it was normal for Resident #4 to eat breakfast in bed and they were unsure if the resident was on aspiration precautions or not and would have to look it up. After review of Resident #4's electronic medical record they said the resident was on aspiration precautions and should be in a common area for meals so they could be supervised. In an immediate observation, Certified Nurse Aide #1 stated the resident should be on their back and positioned up higher in bed. During an interview on 03/14/2025 at 1:09 PM Licensed Practical Nurse #3 stated the resident was on aspiration precautions and staff should follow Speech Language Pathology recommendations on the care plan including sitting upright and monitor for coughing or signs of choking. 4. Resident #83 had diagnoses that included dysphagia, pneumonia, and anoxic brain injury (loss of oxygen to the brain resulting in mental status changes). The Minimum Data Set, dated dated dated [DATE] documented the resident had severe impairment of cognitive function. Current physician orders dated as revised 08/07/2024 documented Resident #83 required a mechanically altered dysphagia diet and was on aspiration precautions. Review of Resident #83's current Certified Nursing Assistant Kardex on 03/11/2025 revealed the resident was dependent on staff for eating, on a ground diet, on aspiration precautions, and should remain upright for meals and 30-60 minutes after. During observations on 03/12/2025 at 9:47 AM, Resident #83 was in bed with the head elevated approximately 45 degrees and their breakfast tray on the bedside table and not within reach. There were no staff in the resident's room and the resident's call bell was on the floor. A container of orange juice was on the bedside table and was within reach of the resident, who picked it up and began drinking independently. No staff were observed in sight of the resident. During observations and interviews on 03/12/2025 at 10:16 AM, Certified Nursing Assistant #1 said Resident #83 was dependent with meals, which required them (staff) to do everything for the resident and was on aspiration precautions. They said Resident #83 did not want their breakfast when asked earlier. 5. Resident #508 had diagnoses including a subdural hemorrhage (collection of blood between the brain and the inner layer of the skull) and dysphagia. The Minimum Data Set, dated dated dated [DATE] documented the resident was cognitively intact and had issues with coughing or choking during meals or when swallowing pills. Physician orders dated 02/25/2025 included a dysphagia mechanically altered level 2 textured diet, honey (thickened) consistency and aspiration precautions. The Comprehensive Care Plan dated 02/14/2025 documented Resident #508 was on aspiration precautions for all meals, a pureed diet with honey-thick liquids, encourage small bites, slow pacing, and a liquid rinse with swallowing. During an observation on 03/14/2025 at 12:59 PM, Resident #508 was in their room eating lunch independently. There were no staff in sight. The resident was drinking juice. Half a bowl of carrots and half a sandwich had been consumed. The meal ticket included Resident #508 was on aspiration precautions. During an interview on 03/12/2025 at 9:45 AM, Speech Therapist #1 stated when a resident requires supervision while eating or touching assistance, staff need to be in the vicinity of the resident. Residents on aspiration precautions have a higher risk of aspirating on thin liquids and if residents were eating in their room, staff should be in there also. During an interview on 03/12/2025 at 11:28 AM, the Director of Nursing stated aspiration precautions are to protect residents that have difficulty with swallowing so they do not choke and they should have staff in the room (to supervise). The thickened liquids should be prepared by the kitchen and dietary staff. During an interview on 03/13/25 at 11:38 AM, the Medical Director stated residents on aspiration precautions should have therapy recommendations followed and be supervised. The risks include choking, aspiration and death. On 03/12/2025, the survey team identified and declared Immediate Jeopardy and the facility Administrator was notified at 5:00 PM. On 03/18/2025 at 4:05 PM, the survey team declared Immediate Jeopardy was removed effective 03/17/2025 at 2:00 PM, based on the following corrective actions taken by the facility: 1. Review of the 33 residents identified to be on aspiration precautions, medical records, physician orders and care plans. 2. 100% of nursing, dietary and therapy staff, unit clerks, and resident assistants were educated on aspiration precautions, checking meal tickets against tray contents, how to properly supervise and assist residents on aspiration precautions, and the correct procedure for feeding and recognizing signs of aspiration. Post-tests were completed and reviewed. Interviews with several staff members on multiple units revealed appropriate knowledge of aspiration precautions. 3. The Director of Dietary (or designee) was observed reviewing meal tickets during tray preparation, and licensed staff were observed verifying the meal tickets against meal trays for accuracy prior to passing. 4. Review of lunch trays on several units revealed the correct food item consistencies, and interviews with staff revealed appropriate knowledge of the process. 4. Unit binders containing lists of residents on aspiration precautions and guidance on diet consistencies were reviewed. 5. Kitchen/dietary staff were observed preparing thickened liquids before meal trays left the kitchen. 6. The facility's Aspiration policy was reviewed. 7. Trays of residents on aspiration precautions were observed arriving separate from other trays (per the facility's removal plan) and a text-blast informing staff of the new process was sent to 100% of nursing and dietary staff. Interviews with several staff members on multiple units verified appropriate knowledge of the new process. 8. Observations of staff supervising and assisting residents on aspiration precautions with meals. Issue two (2) The heating surfaces of radiators in multiple residents' rooms exceeded 125 degrees Fahrenheit, creating a potential burn risk from accidental contact, and were accessible to residents, including residents with known wandering behaviors. On 03/09/2025 at 11:47 AM, the surveyor verified that the 'Extech Instruments' model 39272 digital thermometer was accurate using the ice-point method and read 32.6 degrees Fahrenheit in a cup of ice water. Observations on 03/09/2025 at 11:55 AM on the South Three Unit in room [ROOM NUMBER] included the surface of the metal grate cover on the top of the heating unit was hot to the touch. When measured by the surveyor using an 'Extech Instrument' model 39272 digital thermometer, the temperature of the metal grate cover was 135.5 degrees Fahrenheit. The resident bed closest to the window was two (2) feet directly adjacent to this heating surface. Observations on 03/09/2025 at 12:10 PM in the [NAME] Two Unit dining room included the surfaces of the metal grate covers for three (3) heaters were 155.7 degrees Fahrenheit, 139 degrees Fahrenheit and 126.7 degrees Fahrenheit, using an 'Extech Instruments' model 39272 digital thermometer. The heaters were four (4) feet long by four inches wide and located approximately three to four (4) feet from adjacent tables with two (2) residents ambulating nearby. During an interview on 03/09/2025 at 3:37 PM, the Director of Maintenance stated that the heat for the [NAME] Two dining room was turned down and the steam heating throughout the facility is a difficult system. Observations on 03/10/2025 at 10:38 AM in the North Two Unit sunporch/resident lounge included the surface of the radiator cover was 149.3 degrees Fahrenheit using an 'Extech Instruments' model 39272 digital thermometer. The radiator was just above the floor level and Resident #149 was sitting in a chair approximately four feet from the radiator. Observations on 03/10/2025 at 12:32 PM in the [NAME] One Unit lounge at the end of the hall near Stairwell G1 included the surface of the two radiator covers were found to be 149.5 to 157.8 degrees Fahrenheit using an 'Extech Instruments' model 39272 digital thermometer. Observations on 03/10/2025 at 12:40 PM in the [NAME] Two Unit dining room included the surface of the heater was 157.8 degrees Fahrenheit using an 'Extech Instruments' model 39272 digital thermometer. There were two (2) residents in wheelchairs and another resident ambulating in the area nearby. Observations on 03/10/2025 at 12:40 PM in the [NAME] Two Unit dining room across from room [ROOM NUMBER] included the surface of the floor level heater was 153.5 degrees Fahrenheit, as measured using an 'Extech Instruments' model 39272 digital thermometer. Resident #140 was ambulating using the handrail directly in front of this heating surface at the time. During an interview on 03/10/2025 at 3:20 PM, the Director of Maintenance stated that they check the surface temperatures of the heaters but do not keep records and were not aware of any issues. During an interview on 03/10/2025 at 4:17 PM, the Administrator stated that after review of all incident and accident reports, there have not been any burns identified. Observations on 03/12/2025 at 8:46 AM on the North One Unit outside the activities room included the radiator cover was between 137.8 to 148.3 degrees Fahrenheit using a [NAME] digital infrared thermometer. Observations on 03/12/2025 from 9:12 AM to 9:18 AM in the [NAME] Two (2) Unit hallways included the radiator covers, using a [NAME] digital infrared thermometer, measured 127.6 to 144.1 degrees Fahrenheit near the nurse's station, resident rooms #204, #206, #212, #214, #216, and near the storage room. Each heating unit was just above floor level and approximately seven feet long by one foot high. Three (3) residents were seated outside room [ROOM NUMBER] near the radiators. During an interview on 03/18/2025 at 9:33 AM, Licensed Practical Nurse #10 stated most of the residents on [NAME] Two had wandering behaviors and wore wander guard bracelets (allows the residents to move around the unit independently). 10NYCRR: 415.12(h)(1), 415.29(a)(1), 10NYCRR: 713-1.3(h)(1) 38878 47641 50512 .

Based on observations, interviews, and record review conducted during an Extended Recertification Survey from 03/09/2025 to 05/09/2025, for 13 (Residents #3, #4, #11, #32, #62, #83, #111, #148, #158, #178, #459, #461, #508) of 13 residents reviewed, the facility failed to ensure that residents were free from neglect when it failed to provide the required structures and processes in order to meet the needs of one or more residents. Specifically, the facility failed to ensure sufficient nursing staff to provide nursing services to meet the residents' needs including showers, assistance with eating, toileting, personal hygiene, skin care, application of devices to prevent loss of range of motion, receiving medications as ordered by the medical team and supervision of residents on aspiration precautions to prevent choking. For Resident #178, who was observed on several occasions not wearing recommended hand splints resulting in lost range of motion to their hands, which resulted in actual harm, that was not immediate jeopardy. For Resident #158 who was observed incontinent for extended periods of time, it can be determined that a reasonable person in the residents' position would have experienced serious psychosocial harm (such as anger, embarrassment, humiliation, anxiety), that was not immediate jeopardy. Additionally, Resident #158 was identified by staff to have skin breakdown to their buttocks and there was no documented evidence that a medical provider was notified, or treatments initiated until three days later, which resulted in actual harm, that was not immediate jeopardy. The findings include: Review of the facility policy Abuse Clinical Protocol dated January 2025 revealed the physician and staff would help to identify risk factors for abuse in the facility to include, but not limited to, deficiencies in the physical environment, problems related to adequate staffing, and staff burnout that might affect how the residents were being cared for. Along with other staff and management, the physician would help to identify situations that might constitute neglect to include, but not limited to, inadequate prevention or care of pressure ulcers and recurrent failure to provide incontinence care. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. The medical director will advise facility management and staff about systems to ensure that basic medical, functional, and psychosocial needs are being met and that potentially preventable or treatable conditions affecting function and quality of life are addressed appropriately. For additional information see Centers for Medicare/Medicaid Services Form 2567: F677 - Activities of Daily Living Care for Dependent Residents Specifically, Residents #62 and #148 reported no showers for several weeks and were observed with unwashed hair, Resident #178 had no documented showers for several weeks, was observed with unwashed hair, long uncut nails and was unshaven over multiple days, and Resident #158 was observed incontinent for extended periods of time. Resident #158 had diagnoses including failure to thrive, dementia and diabetes. The Minimum Data Set (a resident assessment tool) dated 03/01/2025 included the resident had severe impairment of cognitive function. The undated Comprehensive Care Plan reviewed on 03/18/2025 documented the resident was incontinent of urine and stool and required staff to check for incontinence and change as needed every three (3) to four (4) hours. During an observation on 03/09/2025 at 12:52 PM Resident #158 was incontinent of urine soaking through to their sweatpants in the groin area almost down to the knees with a strong odor of urine. When observed at 2:27 PM and again at 4:20 PM the residents' pants remained soiled with a strong odor of urine. During an observation and interview on 03/17/2025 at 10:14 AM Resident #158 was in bed. Their incontinence brief was half off and heavily soiled with a strong odor of urine. The linens were soiled with wet yellow and brown stains. Staff were notified, entered the room and Certified Nursing Assistant #8 stated that they could not remember when the resident had last received incontinence care but was sometime last night as they only had two aides on the unit (census of 38). In a follow-up interview at 11:56 AM Certified Nursing Assistant #8 stated they were unaware the resident had been so soiled, but the resident required two staff for cares due to being combative. During an interview on 03/21/2025 at 2:50 PM the Director of Nursing stated they would be very concerned if a resident were to go all day without incontinence care (Resident #158). The Director of Nursing stated staffing has been very challenging. F684 - Quality of Care Specifically, Resident #178 was observed on several occasions not wearing specially made hand splints as recommended by Occupational Therapy to maintain range of motion resulting in lost range of motion to their hands. F686 - Treatment/Services to Prevent/Heal Pressure Ulcers Specifically, Resident #158 was identified by staff to have skin breakdown to their buttocks on 03/14/2025. There was no documented evidence that a medical provider was notified, or treatments initiated until three days later and the resident had two (2) new stage two (2) pressure ulcers. F689 - Free of Accident Hazards/Supervision/Devices Specifically, for Residents #4, #11, #83, #461, and #508 the facility failed to ensure that residents received adequate supervision during meals to prevent accidents for residents that were on aspiration precautions. Additionally, Resident #461 was observed with the incorrect liquid consistency as ordered by the provider (to prevent choking). F760 - Residents are Free from Significant Medication Errors Specifically, for Residents #3, #32, #111, and #459 the facility failed to ensure that residents were free of significant medication errors. Specifically, there was no documented evidence the residents received multiple significant medications over the course of several days including but not limited to insulin, antihypertensives (used to treat high blood pressure), antiplatelets (used to prevent blood platelets from forming clots), antidepressants, antipsychotics, antibiotics, antirejection medication (used for kidney transplants) and a medication used to treat kidney disease in dialysis patients. Additionally, review of full-house Medication Administration Audit Reports revealed no documented evidence that 193 residents from 02/13/2025 to 02/17/2025 and 213 residents from 03/21/2025 to 03/30/2025 had received multiple medications on multiple days which was verified by staff interviews and record review. F725 - Sufficient Nursing Staff The facility failed to ensure sufficient nursing staff to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for residents in the facility. Specifically, there was insufficient staff to meet all resident needs including showers, assistance with eating, toileting, personal hygiene, and receiving medications as ordered by the medical team due to lack of licensed nurses and certified nursing assistants. During an interview on 03/10/2025 at 9:40 AM Licensed Practical Nurse #2 stated that they did not have enough staff on 03/09/2025 day shift and that was the reason why residents were left wet for hours. During an interview on 03/13/2025 at 11:12 AM, Certified Nursing Assistant #4 stated they recalled working the weekend of 02/14/2025, and that they were the only Certified Nursing Assistant on the unit with one (1) nurse and approximately 40 residents. Certified Nursing Assistant #4 stated not much resident care was completed besides feeding the residents and each resident got changed or taken to the bathroom once. Residents who required two staff and a mechanical lift for transfers did not get out of their bed. They said the nurse could not help them with resident care as they were trying to pass all the medications, and it was impossible to get to everyone. During an interview on 03/13/2025 at 11:13 AM, the Certified Nursing Assistant Staffing Coordinator stated that the facility was budgeted for four (4) Certified Nursing Assistants and two (2) nurses a shift for days and evenings, and two (2) Certified Nursing Assistants and one (1) nurse for night shift for each of the six (6) units. They were told minimal staffing included two (2) Certified Nursing Assistants and one (1) nurse per unit. They said when staffing was at critical levels residents could not get out of bed especially if they required two assist and showers did not happen unless a resident was covered in stool. The Certified Nursing Assistant Staffing Coordinator stated staff complain daily about not having enough staff on the units to care for the residents. Residents and family members have complained there was not enough staff and their complaints were valid. At times the facility has had only six (6) to seven (7) staff total in the building for the night shift. During an interview on 03/13/2025 at 11:51 AM, Certified Nursing Assistant #5 stated they often worked by themselves with one (1) nurse on a unit (40 bed unit). They said when it was just them and a nurse it was impossible to get to all residents and they would have to pick who needed the most care. For a resident who required two (2) staff assist they would have to care for them on their own. During an interview on 03/13/2025 at 12:00 PM, the Director of Nursing stated their minimum staffing level was one (1) licensed nurse and one (1) certified nursing assistant for 40 residents, but they would then try to infuse other resources including therapy staff. The Director of Nursing stated one nurse passing medications to 40 residents would need help to finish. They said on the weekend of 02/14/2025 through 02/16/2025 they were aware of numerous staff calling in and more than 20 residents did not receive their medications because there was not enough nursing staff to give them. The Director of Nursing stated that they were aware of the concerns regarding one (1) nurse for 40 residents, but it was within their (the facility's) guidelines. During an interview on 03/16/2025 at 6:05 AM, Licensed Practical Nurse #14 stated that there were night shifts where there were only one (1) to three (3) nurses in the entire building and they could not get to all of the residents for care. They have begged the facility for help. During an interview on 03/21/2025 at 12:48 PM, the Medical Director stated that it was a well-known issue that residents did not receive their medications timely or at all and that it was likely due to lack of staffing. During interviews on 03/21/2025 at 2:50 PM and 6:31 PM, the Director of Nursing stated one (1) Certified Nursing Assistant for 40 resident was a lot, and if staff could not get to all the residents for care, they should say something. They are working on the staffing challenges and trying to hire more staff. During an interview on 03/21/2025 at 6:31 PM, the Administrator stated they were aware of issues with nurse staffing and have hired more agency nursing staff and an in-house recruiter. During an interview on 03/31/2025 at 3:28 PM, the Director of Nursing stated they have worked on the medication carts to ensure medications were passed but this does impact their Director of Nursing duties. The Director of Nursing stated low nurse staffing numbers could be why so many residents did not receive their medications. During an interview on 04/23/2025 at 10:03 AM, Licensed Practical Nurse #10 stated they worked on 04/20/2025 day shift and there was only one nurse and one aide on the unit. They stated there were 22 residents on the unit who all required the assistance of two staff for activities of daily living and four (4) residents who required supervision during meals due to aspiration precautions. Licensed Practical Nurse #10 stated the staffing scenario happens often and because they have to assist the aide with resident care, they often complete their medication passes late, including blood sugars and insulin administration. During an interview on 04/23/2025 at 10:10 AM, Certified Nursing Assistant #9 stated the residents on the North One Unit needed the assistance of two (2) staff for most of their care. At mealtimes there were a lot of trays to be passed, and some residents needed supervision due to aspiration precautions. Certified Nursing Assistant #9 stated when there was only one (1) aide on the unit, the only residents able to get out of bed were those with appointments and they do their best to ensure all residents are dressed and dry. They stated a lot of things do not get done with only one (1) aide and one (1) nurse, but we do the best we can. During observations on 04/24/2025 at 9:00 AM and 11:48 AM on the South Two Unit (resident census was 40) there was one (1) registered nurse, one (1) licensed practical nurse, and one (1) certified nursing assistant on the unit. During an interview on 04/24/2025 at 11:52 AM, Certified Nursing Assistant #19 stated the South Two Unit was supposed to get another certified nursing assistant to help but no one else had arrived. Certified Nursing Assistant #19 stated they passed breakfast meal trays on their own and the majority of the residents on the back hall (approximately 16 residents) and all residents that required the assistance of two staff had not received any care. During an interview on 04/24/2025 at 12:18 PM, the Administrator stated they were not aware until significantly later in the morning that all scheduled staff had not arrived on the South Two Unit. While the facility strives for higher, their minimum staffing for 40 residents is one (1) nurse and one (1) aide. 10 NYCRR 415.4 (b)(1)(i)

Based on observations, interviews and record review conducted during an Extended Recertification Survey and complaint investigation (NY00372698) from 03/09/2025 to 05/09/2025, the facility failed to ensure that all residents received treatment and care in accordance with professional standards of practice for 2 (Residents #178 and #459) of 41 residents reviewed. Specifically, Resident #178 was observed on several occasions not wearing custom-made hand splints as recommended by Occupational Therapy to maintain range of motion, resulting in lost range of motion to their hands. Resident #459 did not have orders for care of their nephrostomy tube (tube inserted directly into the kidney through the skin to drain urine) for an extended period of time. This resulted in actual harm to Resident #178 that was not immediate jeopardy. The findings include: 1. Resident #178 had diagnoses including rheumatoid arthritis, spinal stenosis and a history of repeated falls. The Minimum Data Set (a resident assessment tool) dated 02/28/2025 included the resident had moderate impairment of cognitive function and was dependent on staff for all activities of daily living. In an Occupational Therapy progress note dated 12/04/2024, Occupational Therapist #1 documented they educated and trained Certified Nursing Assistant #2, Registered Nurse Unit Manager #2 and Licensed Practical Nurse #2 on how to apply and remove the resting hand splints for Resident #178, with instructions to apply daily to both hands and remain on for six hours. Occupational Therapist #1 documented Resident #459 had improved range of motion at that time. In an Occupational Therapy progress note dated 12/20/2024, Occupational Therapist #1 documented they educated and trained Certified Nursing Assistant #2 and Certified Nursing Assistant #13 on how to apply and remove the resident's hand splints. Review of the Occupational Therapy Discharge Summary dated 12/26/2024 revealed discharge recommendations for splints, caregivers were trained and will provide assistance to the resident to wear the splints six hours a day or as tolerated. Occupational Therapist #1 documented the resident had made good progress with the splints, with an increase in hand range of motion while on therapy. Review of Resident #178's current Comprehensive Care Plan, Certified Nursing Assistant Kardex (care plan), and Treatment Administration Records reviewed on 03/12/2025 revealed no documentation that the hand splints had been recommended or provided since discharge from therapy. Review of Resident #178's current physician orders on 03/12/2025 did not include use of daily hand splints. During an observation and interview on 03/09/2025 at 4:24 PM, Resident #178 had contractures (condition where the muscles, tendons and tissues harden causing pain and deformity) of both hands. There were no splints on either hand. Resident #178 stated at this time that they were able to open the right hand slightly, but they could not open their left hand at all. When asked if they wore splints, Resident #178 answered that they needed their nails cut. During observations on 03/12/2025 at 9:22 AM and 03/14/2025 at 10:59 AM Resident #178 had no splints on either hand. During an interview on 03/19/2025 at 10:45 AM, Certified Nursing Assistant #2 stated if a resident required hand splints, it would be in the Kardex. Certified Nursing Assistant #2 said they have seen splints in Resident #178's room but they are not usually assigned to that hall. During an interview on 03/20/2025 at 2:17 PM, Occupational Therapist #1 stated Resident #178 had contractures, and they made the resident special hand splints that were meant to prevent the hands from curling in, for passive range of motion and to prevent further contractures. Occupational Therapist #1 stated they taught the staff how to apply and remove the hand splints, how long the resident should wear them, and that the resident had built up tolerance to wear them for up to six hours a day. Occupational Therapist #1 stated the Nurse Managers are supposed to put orders in and put the information in the resident's care plans. Occupational Therapist #1 stated they re-evaluated Resident #178 the day before (03/19/2025) and the resident had a decline in range of motion from when the resident was discharged from therapy in December 2024 and had regressed back to where they were when first admitted to the facility. During an interview on 03/21/2025 at 12:48 PM, the Medical Director stated the whole point of a skilled nursing facility is to rehabilitate residents, and with a loss of range of motion to Resident #178's hands, the rehabilitation progress is now gone. The Medical Director stated it sounded like a communication issue which resulted in harm to the resident. During an interview on 03/21/2025 at 2:50 PM the Director of Nursing stated when therapy makes a recommendation, they should communicate with the Registered Nurses to put an order in and add the information to the resident's care plan. The Director of Nursing stated they did not know why there were no orders for the hand splints in the resident's care plans. The facility policy Assistive Devices and Equipment, reviewed January 2025, documented the facility provides, maintains, trains and supervises the use of assistive devices and equipment for residents. Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the residents' plan of care. 2. Resident #459 was a recent readmission with diagnoses including chronic kidney disease, history of a kidney transplant, recent pyelonephritis (kidney infection) requiring placement of a nephrostomy tube. The Minimum Data Set, dated dated dated [DATE] documented the resident had severe impairment of cognitive function. Facility admission orders did not include any orders for the care or monitoring of the nephrostomy tube. Review of Resident #459's Treatment Administration Record dated 01/27/2025 to 02/10/2025 did not include any documentation related to any care or flushing of their nephrostomy tube. Current Physician orders dated 03/07/2025 following readmission from the hospital documented a nephrostomy tube dressing change every other day and as needed, to cleanse site with sterile saline, pat dry and cover with border gauze dressing and for a Registered Nurse to flush the nephrostomy tube daily with 5 milliliters of normal saline. During an observation on 03/09/2025 at 10:22 AM the Surveyor found Resident #459 lying on the floor. Their nephrostomy tube was coming out of the right side of their abdomen and stretched to a urine collection bag hanging on the side of the bed. There was no dressing over the nephrostomy insertion site and the tubing was not secured to the resident's body. In a nursing progress note dated 03/11/2025, Licensed Practical Nurse Manager #1 documented the resident was transferred to the hospital due to a dislodged nephrostomy tube. During a telephone interview on 03/13/2025 at 6:04 PM, a family member stated that the hospital staff had told them that the nephrostomy tube should have been flushed when the resident first arrived at the facility. The family member stated the kidney transplant was many years ago. During an observation of care on 03/17/2025 at 11:24 AM there was no dressing on the resident's nephrostomy insertion site and the tubing was not secured to the resident's body. The facility was unable to provide documentation that any nephrostomy care was added to Resident #459's care plan or treatment record or had been ordered by a physician during their initial admission to the facility. During an interview on 03/20/2025 at 11:32 AM Physician #2 stated that Resident #459 did not have any orders for care of their nephrostomy tube during their first admission at the facility but there should have been orders to change the dressing every other day and to flush the tubing daily. When asked if failure to change the dressing and flush the tube daily could have led to the nephrostomy tube infection, Physician #2 stated they could not say for sure. During a telephone interview on 03/21/2025 at 12:48 PM The Medical Director stated the nephrostomy tube should have been secured to the resident's abdomen or it should have been secured with sutures. The Medical Director stated that hospital transfers are usually done by the physician assistant, and facility staff should verify if a resident's nephrostomy tube needed to be flushed, which would depend on if it was just changed or if there was tissue in the tubing that needed to be flushed out. The Medical Director stated these were things that the facility should know when accepting a resident. During an interview on 03/21/2025 at 2:50 PM, The Director of Nursing stated not all nephrostomy tubes require flushing, but there should have been a conversation regarding the expectations for the management of the nephrostomy tube when the report was given. When Resident #459 was admitted , there were no directions on what to do with the nephrostomy tube and the admitting nurse should have asked the provider for orders for care of the tube, including flushing and dressing changes to prevent infection. The facility policy Care of Nephrostomy Tube, reviewed January 2025, documented that during assessments, the staff should check placement of the nephrostomy tubing, monitor for kinks and integrity of the tape, and ensure the drainage bag is below the level of the kidneys. Physician's orders were needed to change the dressing and/or for irrigation (flushing of the nephrostomy tube). Additionally, staff should report any signs of infection, reduced urine output, or inability to irrigate the tube to a physician. 10 NYCRR 415.12

Based on observation, interviews and record review conducted during the Extended Recertification Survey and complaint investigation (NY00372404) from 03/09/2025 to 05/09/2025, the facility did not ensure that a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for one (1) (Resident #158) of six (6) residents reviewed. Specifically, Resident #158 was identified by staff to have skin breakdown to their buttocks on 03/14/2025. There was no documented evidence that a medical provider was notified, or treatments initiated, until three days later. This resulted in actual harm to Resident #158 that was not Immediate Jeopardy. The finding includes: The facility policy Prevention of Pressure Ulcers/Injuries dated January 2025, documented for staff to inspect the skin on a daily basis when performing or assisting with personal care or activities of daily living. Identify any signs of developing pressure injuries; inspect pressure points (sacrum, heels, buttocks etc.); wash the skin after any episodes of incontinence; reposition resident as indicated on care plan; evaluate, report and document potential changes in the skin. Resident #158 had diagnoses that included encephalopathy (impaired brain function), diabetes (high blood sugar levels), and dementia. The Minimum Data Set (a resident assessment tool) dated 03/01/2025 documented Resident #158 had severe cognitive impairment, was incontinent of bowel and bladder, was at risk for the development of pressure ulcers, and had no current pressure ulcers. The current comprehensive care plan, last revised 09/30/2024, documented Resident #158 was at risk for pressure ulcers related to incontinence. Interventions included to minimize extended exposure of skin to moisture by providing frequent incontinence care and prompt removal of wet/damp clothing or sheets as needed, and to monitor, document and report changes in skin status to a medical provider. During observations on 03/09/2025 at 12:52 PM, Resident #158 was wearing sweatpants that were wet throughout the groin area almost down to the knees with a foul odor of urine. At 1:27 PM, 2:27 PM, and 4:20 PM, Resident #158's sweatpants remained unchanged. During an observation on 03/17/2025 at 10:14 AM, Resident #158 was in bed with their incontinence brief visible and partially pulled down from the hip. The sheet under the resident was wet, with yellow/brown discoloration and a strong odor of urine was present. During an observation and interview on 03/17/2025 at 10:51 AM, Certified Nursing Assistant #2 and Certified Nursing Assistant #8 were providing incontinence care to Resident #158, who was slightly rolled on their side. The resident's incontinence brief was heavily saturated with urine and the resident had an open area on the left buttock that was an approximately 1.5 centimeters circle. In an immediate interview, Certified Nursing Assistant #2 stated that the open area was seen on 03/14/2025 when they were assisting another Certified Nursing Assistant with care. Review of the March 2025 Medication and Treatment Administration Records revealed no documentation that any treatments for the skin impairment had been initiated until 03/17/2025. Review of a Weekly Skin assessment dated [DATE] and signed by the Director of Nursing revealed no documentation of any skin impairment to Resident #158's buttock area. Review of Resident #158's interdisciplinary progress notes and the 03/14/2025 to 03/17/2025 24-hour nurse report sheets at 11:17 AM revealed no documentation of any skin impairment to Resident #158's buttock area. In a medical progress note dated 03/17/2025 at 2:57 PM, Nurse Practitioner #1 documented they were asked to see Resident #158 for an open area on their buttocks. Nurse Practitioner #1 documented the resident had two (2) stage two (2) pressure ulcers, one to their coccyx (at the base of the spine) and one to their ischium (lower back of the hip bone). During an interview on 03/17/2025 at 11:56 AM, Certified Nursing Assistant #8 stated they last cared for Resident #158 on Friday night to day (03/14/2025) and had noticed a reddened area to the resident's buttock but could not remember if the area was opened. Certified Nursing Assistant #8 stated they did tell the nurse about the reddened area but were unable to recall which nurse because they were new to the facility. During an interview on 03/17/2025 at 1:12 PM, Licensed Practical Nurse #5 stated they saw Resident #158 had some skin breakdown on their left buttock earlier that same day (03/17/2025) and there was no treatment ordered for it, but they would contact their supervisor. Licensed Practical Nurse #5 stated they had not been made aware prior to 03/17/2025 that Resident #158 had any skin breakdown. During an interview on 03/17/2025 at 1:53 PM, Certified Nursing Assistant #2 said they were assisting with care for Resident #158 on Friday morning (03/14/2025) with Certified Nursing Assistant #16, who told them that there was an open area on the resident's bottom and to go notify the nurse, which they did. During a phone interview on 03/19/2025 at 10:54 AM, Certified Nursing Assistant #16 stated they had provided care to Resident #158 on 03/14/2025 and the resident did have several open areas on their buttocks that were red and bleeding. Certified Nursing Assistant #16 stated they had notified Licensed Practical Nurse #2, who gave them a cream to apply to the resident's buttocks. Several attempts to contact and interview Licensed Practical Nurse #2 were unsuccessful. During an interview on 03/20/2025 at 3:19 PM, Licensed Practical Nurse Manager #1 stated they had worked on 03/14/2025 and had not been made aware that Resident #158 had any open areas on their sacrum/buttocks area. Licensed Practical Nurse Manager #1 said staff should have informed them of any new open wounds. During an interview on 03/21/22025 at 2:48 PM, the Director of Nursing stated if skin breakdown was identified by staff, they should notify the nurse assigned to the resident and the assigned nurse should let the nurse manager know. The Director of Nursing was not aware of the breakdown. 10 NYCRR 415.12 (c)(2)

Based on observations, interviews, and record reviews conducted during the extended Recertification Survey from 07/08/2024 to 09/17/2024, the facility did not ensure that all drugs and biologicals in the facility were properly stored in accordance with State and Federal Laws for eight (West Two Long Hall, South One Short Hall, North One Unit, North Two Unit, South Two Long Hall, South Two Short Hall, South Three Short Hall and South Three Long Hall) of nine medication carts and three (South One, North One, and [NAME] One) of four medication rooms reviewed. Specifically, medication carts contained expired medications, medications with no resident identifiers on them, open food for staff use, a medication with no pharmacy or manufacturer label, opened insulin pens that were in use and undated, and medications stored in containers with the wrong resident identifiers. Medication rooms contained expired medications and controlled medications that were not secured with two locks. Additionally, facility staff members did not follow the facilities medication storage policy or procedure. These issues resulted in the likelihood of serious injury, harm, and death for all the residents in the facility (census 216) that was Immediate Jeopardy. The findings are: The facility policy Storage of Medications, dated January 2024, documented that drugs and biologicals shall be stored in the packaging, containers, or other dispensing systems in which they are received, the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals, medications must be stored separately from food, and all controlled substances will be stored in a double locked cabinet affixed to the wall in the medication room. 1. During an observation and interview on 07/11/2024 at 5:32 PM, the South Three Long Hall medication cart had an Admelog (fast-acting) insulin pen stored in a toothpaste container labeled with a resident name on it that was different than the label on the insulin pen. A plastic container labeled with a resident's name had three bottles of eye drops; two (Refresh tears and brimonidine) bottles that were not labeled with any information and one (latanoprost) bottle with different resident identifiers than were on the container's label. One plastic container label with a resident's name had one bottle of latanoprost eye drops that was not labeled with any resident identifiers. During an immediate interview, Licensed Practical Nurse #4 stated medications should be stored in the pharmacy packaging with resident information on them. 2. During an observation and interview on 07/12/2024 at 11:24 AM, the [NAME] One medication room held two narcotic cupboards. One cupboard's second (outer) door was open leaving multiple narcotic medications not secured or secured under a single lock (versus two). During an immediate interview, Licensed Practical Nurse #5 stated the narcotic cupboards should have both doors closed and locked. They forgot to lock it after taking medication from the cupboard. 3. During an observation and interview on 07/11/2024 at 1:48 PM, the [NAME] Two Long Hall medication cart had one vial of lispro (rapid-acting) insulin had no open or expiration date and a bottle of vitamin D3 in use that had an expiration date of June 2023. During and immediate interview, Licensed Practical Nurse #2 stated there should be no expired medications in the medication cart and insulin should be labeled with the open and expiration date. 4. During an observation and interview on 07/11/2024 at 4:14 PM, the South One Short Hall medication cart contained one small bag of Smart Food popcorn and one small bag of Doritos tortilla chips, opened in a drawer. During an immediate interview, Licensed Practical Nurse #3 stated staff food should never be stored in the medication cart. 5. During an observation and interview on 07/11/2024 at 4:47 PM, the North One Unit, the medication cart contained a bottle of ibuprofen (pain reliever) that was opened and in use; there was no expiration date on the medication. Three bottles of medications were expired including melatonin (a sleep aid) with an expiration date of April 2024, acidophilus (a probiotic) with an expiration date of June 2024, and magnesium with an expiration date November 2023. The North One medication room contained a bottle of medication that was not labeled with any pharmacy or manufacturer label and had no resident identifiers. During an immediate interview, Registered Nurse #1 stated they should never use any medication from a bottle without a pharmacy or manufacturer's label. During an interview on 07/15/2024 at 10:05 AM, the Director of Nursing stated that all medications (including over the counter and prescribed, resident specific medications) should be labeled, have an expiration date on them, and resident specific information. All insulin pens should be labeled with open and expiration dates, and no food should be stored in the medication carts. The Director of Nursing said that all controlled medications (narcotic medications) should be kept in the controlled substance cabinet with both doors locked. 6. Additional observations and interviews conducted on 08/01/2024 revealed the following: a. At 9:53 AM, the South Three Long Hall medication cart had one bottle of aspirin with an expiration date of December 2022 and one vial of Lantus (long-acting) insulin in use with no open or expiration dates. The vial of insulin was not labeled with any resident identifiers and was stored in a plastic bag with a resident's handwritten name. b. At 10:29 AM, the South Three Short Hall medication cart had a staff member's Starbucks drink stored on top of the cart and an open cup of applesauce was on top of the cart with no open date. One vial of lispro insulin and one vial of Admelog insulin, both vials in use with no open or expiration dates, and no resident identifiers on the vials. One Lantus insulin pen was loose and stored in the cart (not stored in a bag or other container) and not labeled with open or expiration dates. The medication cart had approximately 24 loose, unlabeled medications in the bottom of the drawers. One drawer had a liquid spill of an unidentified substance that covered the bottom of the drawer and five of 10 medication bottles stored in the drawer. During an immediate interview, Licensed Practical Nurse #15 stated there should never be any loose pills in the cart or medication spills in the medication cart. All medications should be labeled with resident identifiers and stored in the pharmacy packaging. Insulin and eye drops should be labeled with the open and expiration dates. c. At 10:58 AM, the South Two Long Hall medication cart had a vial of lispro insulin stored in a plastic bag with a resident's handwritten name and date. The date handwritten on the bag was illegible and the insulin vial was in use and not labeled with open or expiration dates. d. At 11:06 AM, the South Two Short Hall medication cart had a basaglar (long-acting) insulin pen stored in a plastic bag labeled with resident identifiers and dated 07/26/2024 (did not indicate if this was the open or expiration date). The insulin pen was in use and was not labeled with any resident identifiers, an open or expiration date. e. At 11:17 AM, the North Two medication cart had a budesonide and Formoterol (used to treat chronic respiratory disease) inhaler stored in the drawer with no bag or box and was not labeled with any resident identifiers. An insulin glargine pen with one resident's identifiers, was not labeled with an open or expiration date, and was stored in a clear plastic bag labeled with another resident's identifiers. On 08/02/2024, Immediate Jeopardy was declared. The facility administrator was notified at 5:14 PM. On 08/04/2024 at 2:00 PM, Immediate Jeopardy was removed based on the following corrective actions taken by the facility: a. 100% of the licensed nursing staff working at the time of removal had received education on the proper labeling of all medications with the date they were opened, discarding all medications with an expired medication date, improper labeling of medications manually, careful administration of medication using a blister pack, and the proper way to dispose of unused loose medications in both the medication cart and the medication rooms. b. Interviews completed with multiple licensed nursing staff on seven of seven units revealed appropriate knowledge on the proper labeling of all medications with the date they were opened, discarding all medications with an expired medication date, improper labeling of medications manually, careful administration of medication using a blister pack, and the proper way to dispose of unused loose medications in both the medication cart and the medication rooms. c. Approximately 61% of the licensed nurses were educated on appropriate proper labeling of all medications with the date they were opened, discarding all medications with an expired medication date, improper labeling of medications manually, careful administration of medication using a blister pack, and the proper way to dispose of unused loose medications in both the medication cart and the medication rooms. d. The corrective action included a plan to educate all staff (including licensed, certified, and non-medical staff) and agency staff, staff on vacation and/or leave prior to the start of their next shift and would be tracked by the administrative team to ensure 100% compliance. e. Observations on seven of seven resident units which included six medication carts and three medication rooms, revealed no concerns with proper labeling and storage of medications. 10 NYCRR 415.18(d)(e)(1-4)

Based on observations, interviews, and record review conducted during the extended Recertification Survey from 07/08/2024 to 09/17/2024, it was determined that the facility and governing body failed to assure that the resident received appropriate quality of care by allowing the following deficient practices to exist putting the resident at risk for harm and serious injury: F550, F600, F677, F686, F760, F761, and F837. Specifically, there was inconsistent communication with the facility Administrator to ensure management of the facility and regulatory compliance. Multiple deficiencies were identified during the Recertification Survey and extended survey, including but not limited to, Immediate Jeopardy, Harm, Substandard Quality of Care, and multiple repeat deficiencies. This resulted in the likelihood of serious injury, serious harm, or death for all the residents in the facility (census 205) that was Immediate Jeopardy. This is evidenced by, but not limited to, the following: For additional information see Centers for Medicare/Medicaid Services Form 2567, refer to F550 (Resident Rights/Exercise of Rights): During observations in the unit dining room for breakfast and/or lunch on 07/10/2024 at 1:16 PM, 07/11/2024 at 9:31 AM, and 07/11/2024 at 1:25 PM, the majority of residents (up to 22 on one observation) in the dining room were served meals on paper plates and were using plastic utensils. During an interview on 07/11/2024 at 1:38 PM, Certified Nursing Assistant #5 stated the facility had been using plastic utensils during meals for several weeks. During an interview on 07/12/2024 at 9:34 AM, the Diet Technician stated the facility's current number of plates and utensils were not enough, so they were using plastic utensils and paper plates. During interviews on 07/12/2024 at 11:27 AM and 07/15/2024 at 8:44 AM, the Director of Food Service stated the facility did not have enough stock for all residents and the last two units that meals were delivered to had to use paper plates and plastic utensils. The Director of Food Service stated the Assistant Director of Dietary did the ordering for the dining supplies, but the corporate controller could change or decrease the amount ordered. During an interview on 07/15/2024 at 7:49 PM with the Administrator, Assistant Administrator, Regional Administrator (governing body representative) and Regional Clinical Director (governing body representative), the Regional Administrator stated they were not aware of on-going concerns since the last plan of correction was cleared and audits had been stopped. For additional information see Centers for Medicare/Medicaid Services Form 2567, refer to F565 (Resident/Family Group and Response): During a special Resident's Council meeting held on 07/10/2024 at 11:30 AM with the state surveyor and six residents (from different units), residents reported call lights do not get answered in a timely manner especially on weekends, medications were not given on time, there was a lack of linens, and residents were not receiving assistance with activities of daily living including bathing and showering. Residents also reported the facility did not act promptly upon their concerns and there was no follow-up from facility staff regarding their complaints/grievances. A review of the Resident Council meeting minutes for January 2024, March 2024, April 2024, May 2024, and June 2024 revealed the residents reported care concerns including but not limited to, not receiving showers regularly, nails not being trimmed and cleaned, call lights not being answered timely, bed linens not being changed, a lack of linens, and medications not being administered timely. Each of the meeting minutes included an old business section which included the concerns from last month had been discussed and residents stated they were not seeing any improvement in those areas. The meeting minutes did not include any follow-up done by staff regarding their concerns. During an interview on 07/15/2024 at 7:49 PM with the Administrator, Assistant Administrator, Regional Administrator and Regional Clinical Director, the Regional Administrator stated they were not aware of concerns related to the follow-up of grievance brought by the Resident Council. The Regional Administrator stated all grievances should be placed on a grievance form and monitored weekly, but it appeared as though this was not being done. The Regional Administrator stated it had been determined the previous facility Administrator was not following up on resident grievances. For additional information see Centers for Medicare/Medicaid Services Form 2567, refer to F584 (Safe/Clean/Comfortable/Homelike Environment): During an interview on 07/08/2024 at 12:18 PM, Unit Secretary #1 stated there were no washcloths or towels available on the unit to care for the residents and the supervisor had been notified. During an observation and interview on 07/09/2024 at 10:42 AM on the South 1 Unit, Resident #140 was lying in bed. There were no sheets in place. During an interview on 07/10/2024 at 11:36 AM, Certified Nursing Assistant #12 stated there was not an adequate supply of linen to care for the residents and they did not feel they could adequately do their job without having the necessary supplies. During an observation on 07/11/202424 at 10:24 AM on the South 2 Unit, Resident #92 was asleep in their bed that had no sheets on the mattress. The linen cart contained no sheets or blankets. During an interview on 07/12/2024 at 2:20 PM with the Administrator and the Regional Administrator, the Regional Administrator stated staff should be using washcloths and towels for bathing and showering residents. The Regional Administrator stated they were not aware resident care had been delayed due to the limited availability of washcloths and towels. The Regional Administrator stated there had been a lot of money spent on linen, there was a par system (inventory control system to determine the levels of linen the facility should have to meet resident care needs) in place to track the linen supply, and washcloths should be available. During an interview on 07/15/2024 at 9:12 AM, the Laundry Supervisor stated there was no par system in place for linens and there were currently only 15 washcloths to send to two, 40 bed units. For additional information see Centers for Medicare/Medicaid Services Form 2567, refer to F600 (Free from Abuse and Neglect): The facility did not ensure the residents' right to be free from abuse, mistreatment, or neglect. Specifically, Resident #70 reported ongoing abuse from their roommate that staff were aware of and for Residents #92, #134, #177 and #182, the facility did not implement interventions to protect the residents from sexual abuse. For Resident #106, the facility did not ensure the resident received incontinence care in a timely manner and they were left soiled for several hours on multiple occasions. For Resident #140, the facility did not ensure the resident received clean linen and they were observed sleeping on a bare mattress. For additional information see Centers for Medicare/Medicaid Services Form 2567, refer to F725 (Sufficient Nurse Staff): The facility did not ensure sufficient staffing to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for residents in the facility. Specifically, there were several observations of residents who were incontinent and had not received timely assistance with care, and several residents had not received significant medications on 07/04/2024, 07/05/2024, and 07/29/2024 due to no nurse being available to administer the medications. During an interview on 07/15/2024 at 7:49 PM with the Administrator, Assistant Administrator, Regional Administrator and Regional Clinical Director, the Regional Administrator stated leadership had not been notified of the staffing issues on 07/4/2024 and 07/5/2024 (causing many residents to not get significant medications). The Regional Clinical Director stated several changes had been made which included posting open shifts, making schedule changes to accommodate staff, meetings held before the weekend to ensure there was enough staff, holding staff accountable for call-offs, and holding weekly general orientations to prevent delays in new staff starting. On 09/17/2024, the survey team identified and declared Immediate Jeopardy. The facility Regional Administrator and Assistant Administrator were notified at 5:20 PM. On 09/17/2024 at 7:13 PM the survey team declared that the IJ was removed based on the following corrective actions taken by the facility: -Review of weekly recruitment audits of all new incoming and outgoing staff and the recent hiring of a recruitment officer. -Education of the Assistant Administrator (Acting) and the current Administrator (prior to return from leave) regarding the role and duties of the Administration team, communication with governing body, involvement with QAPI team on an ongoing basis. Includes review of daily emails between current (new) Administrator and the Corporate Administrator involving current census, staffing issues, resident incidents requiring follow up, hospitalization s, discharges and/or deaths. -Invoices for linen purchases (07/09/2024, 07/16/2024, 07/17/2024, 08/01/2024, 08/23/2024, 09/10/2024, 09/13/2024) and education to administration team regarding inventory controls -Two additional contracts with agencies for Registered and Licensed Nurses -Review of a revised Grievance process by the Administration team including the Grievance binder with all recent resident grievances, follow ups and outcomes. -Updated Quality Assurance and Performance Improvement Plan Policy with goals and interventions. -Updated Facility Assessment. 10 NYCRR 415.26(b)(3)(1)

Based on interviews, observations, and record reviews conducted during the extended Recertification Survey and complaint investigation (#NY00341657) from 07/08/2024 to 09/17/2024, the facility failed to ensure residents right to be free from abuse, mistreatment, or neglect for seven (Residents #70, #92, #106, #134, #140, #177, and #182) of eight residents reviewed for abuse. Specifically, for Residents #92, #134, #177, and #182, the facility did not implement interventions to protect the residents from sexual abuse. For Resident #70 who had reported to several staff members, ongoing abuse from their roommate, the facility failed to investigate the allegations. For Resident #106, the facility did not ensure incontinence care was received in a timely manner when the resident was left soiled for several hours on multiple occasions. For Resident #140, the facility did not ensure clean bed linens were supplied and the resident was observed sleeping on a bare mattress. These issues resulted in the likelihood of serious injury, serious harm, or death for all of the residents in the facility (census 213), which resulted in Immediate Jeopardy. This is evidenced by the following: The facility's policy Abuse Prohibition Protocol, Types of Abuse, Response/ Reporting, dated January 2021, includes it is the facility policy that every resident has the right to be free from abuse, mistreatment, neglect, and misappropriation of property. All personnel must attempt to immediately stop the abuse, then promptly report any incident or suspected incident of resident abuse. 1. Resident #92 had diagnoses which included dementia, visual hallucinations, and anxiety. The Minimum Data Set Resident Assessment, dated 03/12/2024, documented the resident had severely impaired cognition. Review of the current Comprehensive Care Plan did not include Resident #92 had a history of sexual-related behaviors or person-centered interventions to address the behaviors. The current Kardex (care plan used by Certified Nursing Assistants to guide care) included to provide the resident with a safe and secure, clutter free environment. Resident #177 had diagnoses which included dementia, diabetes, and adult failure to thrive. The Minimum Data Set Resident Assessment, dated 06/28/2024, included the resident had severely impaired cognition and no verbal or physical behaviors directed toward others. Resident #177's current Comprehensive Care Plan did not include the resident had a history of sexual-related behaviors. Review of an undated Facility Investigation revealed on 05/07/2024 at 5:30 PM, Resident #92 entered the room of two residents (Resident #166 and #177). Resident #92 removed their clothes and climbed into Resident #166's bed (near the door) and made a sexual advance towards Resident #166. Resident #166 got off the bed, alerted nursing staff and Resident #92 was removed from the room. Resident #92 was redressed by nursing staff and was escorted to the dining room. At approximately 6:45 PM, Resident #166 alerted staff that Resident #92 and Resident #177 were in the room, engaging in sexual behaviors. Upon entry, Certified Nursing Assistant #5 observed Resident #92 standing without pants on and Resident #177 was touching Resident #92's private area. Staff immediately removed Resident #92 from the room and Registered Nurse Supervisor #5 was made aware. The facility investigation included Residents #92 and #177 were considered non-consenting adults due to their impaired cognitive status, poor judgement and insight, and the inability to understand the consequences of their actions. Resident #177 was subsequently moved to a different unit. During an interview on 07/12/2023 at approximately 1:00 PM, Resident #92 said they got along with some residents and never had issues with any residents. During an interview on 07/15/2024 at 9:55 AM, Certified Nursing Assistant #5 said if a resident had a history of certain behaviors, such as behaviors that were sexual in nature, the information should be in the resident's chart. If a resident required supervision, the information should be listed on the Kardex. Certified Nursing Assistant #5 said on 5/7/2024 Resident #166 notified them Resident #92 was in their room. Certified Nursing Assistant #5 said they removed Resident #92, walked the resident to their room and got the resident dressed. Certified Nursing Assistant #5 said Resident #166 later alerted them Resident #92 was in the room with Resident #177. When Certified Nursing Assistant #5 walked into the room, Resident #177's hand was touching Resident #92's private area They said after the incident with Resident #166, no one told them to stay with Resident #92. During an interview on 07/15/2024 at 3:14 PM, Licensed Practical Nurse Manager #2 said Resident #177 was moved from another unit due to a previous incident (sexual behavior in nature). Licensed Practical Nurse Manager #2 said a history of resident-to-resident sexual behaviors should be included on the resident's care plan. During an interview on 07/15/2024 at 4:23 PM, Assistant Director of Nursing #1 said they would expect to see a history of resident-to-resident sexual behaviors included on a resident's care plan. Assistant Director of Nursing #1 was familiar with the incident involving Resident #92 and Resident #177 and said after Resident #92's sexual behaviors were directed at Resident #166; staff should have been watching the resident (in an effort to prevent further incidences). During an interview on 08/06/2024 at 1:06 PM, Certified Nursing Assistant #5 said after learning Resident #92 had a history of inappropriate behaviors they kept an eye on the resident. Certified Nursing Assistant #5 said even on days the resident was not on their assignment, they would still monitor them because the resident had a history of wandering into other resident rooms. 2. Resident #134 had diagnoses which included dementia with agitation, delirium, and diabetes. The Minimum Data Set Resident Assessment, dated 12/06/2023, documented the resident had severely impaired cognition and no history of behaviors directed toward others. Review of the current Comprehensive Care Plan and Kardex revealed that Resident #134 was at risk for being a victim due to inability to understand their surroundings. Neither care plan included a history of any inappropriate behavior directed towards other residents. Resident #182 had diagnoses including dementia, anxiety, and depression. The Minimum Data Set Resident Assessment, dated of 04/30/2024, included the resident had severely impaired cognition. Review of the current Comprehensive Care Plan and Kardex did not include any behaviors directed toward other residents or staff. During an observation on 07/08/2024 at 8:59 AM, Resident #134 was walking up and down the hallway behind Resident #182. While standing at the nurse's station, Resident #134 placed their arm around Resident #182 and began kissing them repeatedly on the cheek. Resident #182 was making whimpering noises and walked away. At 9:07AM, Resident #182 was in front of the nurse's station when Resident #134 placed their hand on Resident #182's lower back and attempted to kiss them on the cheek. Resident #182 put their hand up, said stop, and walked away. During an interview on 07/12/2024 at 9:50 AM, Certified Nursing Assistant #7 stated Resident #134 wanders all day long and does have behaviors directed towards multiple residents (including Resident #182) which included touching them in passing, kissing, and hugging them. Certified Nursing Assistant #7 stated they try to intervene if they observe the interactions, but they had not told anyone because they felt the interactions were innocent in nature. During an interview on 07/15/2024 at 8:45AM, the Assistant Administrator stated staff should separate the two residents, report these interactions to the Nurse Manager, who should initiate an investigation and report it to administration. During an interview on 07/15/2024 at 10:25AM, Assistant Director of Nursing #1 stated Resident #134 does have behaviors, but they had not seen or been told that Resident #134 touched or kissed other residents. They stated staff should have reported these interactions so the behaviors could be care planned for with interventions. The Director of Nursing joined the interview and stated Resident #134 had rubbed their back and kissed their cheek, but they did not feel there was any malice to these interactions with staff or residents. 3. Resident #106 had diagnoses that included a stage 4 (full thickness tissue damage) healing pressure ulcer (bed sore), depression, and hemiplegia (paralysis on one side of the body). The Minimum Data Set Resident Assessment, dated 05/03/2024. revealed the resident was cognitively intact, did not exhibit behaviors or rejection of care, required assistance with transfers and toileting hygiene, and was always incontinent of bladder and bowel. Review of the current Comprehensive Care Plan and the current Kardex revealed Resident #106 required assistance with activities of daily of living, had bladder and bowel incontinence, and was at risk for impaired skin integrity. Interventions included, but were not limited to, check for needed assist with toileting every two hours and/or check and change incontinence brief as needed every three to four hours; provide peri-care (private areas) after each incontinent episode; keep skin clean and dry with prompt removal of wet or damp clothing or sheets, and encourage the resident to use their call bell for assistance. During observations and interview on 07/08/2024 at 10: 30 AM, Resident #106 was sitting upright in bed. There was the odor of urine with yellow and brown stains on the incontinence pad underneath the resident. Resident #106 stated they were soaked, had already eaten breakfast and had not been changed out of their wet incontinence brief since the previous night at bedtime. They said they put their call bell on for assistance and a nurse responded that the Certified Nursing Assistants were working their way down the hall. At 11:54 AM, Resident #106 remained in bed and stated they still had not been assisted with incontinence care. The room continued to have an odor of urine and the incontinence pad had not been changed. During an observation and interview on 07/11/2024 at 9:11 AM and again at 10:56 AM, Resident #106 remained in bed and stated they were again soaked and had not been changed since the previous night at bedtime. The incontinence pad placed underneath the resident was stained yellow extending from their incontinence brief and smelled of urine. Resident #106 stated they had not received care on 07/08/2024 until after they had eaten their lunch. During an interview on 07/11/2024 at 1:30 PM, Resident #106 stated they have requested repeatedly that they get changed prior to breakfast and lunch, but it is not being done and it makes them feel terrible (like a piece of crap), like they were not worthy of being given any service. During an interview on 07/11/2024 at 1:40 PM, Licensed Practical Nurse #3 stated there was often no linens available, and residents and family members were often upset when staff could not assist with care before breakfast. The laundry staff were only available on day shift and had to wash linen from the previous day before delivering it to the unit which was sometimes during the late morning or afternoon. Licensed Practical Nurse #3 stated when the cart was delivered there were usually only six washcloths for 40 residents and staff had to cut up towels to use as washcloths or were expected to use disposable wipes, which were not good for washing residents. During an interview on 07/12/2024 at 1:34 PM, Registered Nurse Manager #1 stated they had not received any complaints from residents about not receiving assistance with incontinence care from night shift until late morning. They said sometimes staffing was not good, and the facility was working on the issue. Registered Nurse Manager #1 stated they try to assist as much as possible and sometimes the linen cart does not get delivered to the unit until after breakfast which also affects care. During an interview on 07/12/2024 at 1:45 PM, Certified Nursing Assistant #13 stated the unit was understaffed most of the time and they feel unable to get everything done timely, including nail care, incontinence care, passing meal trays, and documentation. Certified Nursing Assistant #13 stated most times staff were unable to provide morning care until after breakfast due to not having linens, which often did not arrive until 10:30 AM or later and then not enough linen was provided, such as six towels and six incontinence pads for 40 residents. 4. Resident #70 had diagnoses that included hemiplegia (paralysis on one side of the body), end stage renal disease (kidney failure) requiring dialysis, and respiratory failure with dependence on supplemental oxygen. The Minimum Data Set Resident Assessment, dated 06/03/2024, documented the resident was cognitively intact. Review of the current Comprehensive Care Plan revealed that Resident #70 was at risk for adjustment issues related to the resident's recent placement in a nursing home, with staff interventions to provide the resident emotional support and allow opportunities for the resident to express themselves. The resident was also taking psychotropic medication to treat depression. During an interview on 07/08/2024 at 9:41 AM, Resident #70 said they were frustrated with their roommate (Resident #88) who was rude, mean, yelled at them, shouted curse words at them, and blasted their television purposely so that Resident #70 could not hear their own television. The resident said they had reported these behaviors to staff on countless occasions, and the staff would talk with the roommate, but the behaviors continued. During an interview on 07/10/2024 at 4:30 PM, Social Worker #2 and the Director of Social Work both said the unit staff had not made them aware Resident #70 was having problems with their roommate. Social Worker #2 said they would have talked with nursing and admissions to move the resident had they known. During an interview on 07/10/2024 at 4:59 PM, Certified Nursing Assistant #9 said Resident #70 reported the abuse to them, and they had reported the resident's concerns to Licensed Practical Nurse Manager #2, Licensed Practical Nurse #11, and Registered Nurse Supervisor #2. Certified Nursing Assistant #9 said the resident had asked to be moved to a different room. Certified Nursing Assistant #9 said after Resident #88 had sprayed Resident #70 with air freshener, they had brought Resident #70 into the hall to separate them from their roommate. Certified Nursing Assistant #9 then removed the air freshener from Resident #88 and notified Licensed Practical Nurse Manager #2. During an interview on 07/10/2024 at 5:08 PM, the Director of Nursing said the allegations of abuse had not been brought to their attention and that it should have been immediately. During an interview on 07/12/2024 at 9:56 AM, Licensed Practical Nurse Manager #2 said Resident #70's roommate (Resident #88) had four roommates in the last year who all asked to be moved away from them. Licensed Practical Nurse Manager #2 said they knew Resident #88 was being mean and rude to Resident #70 and these occurrences were often related to Resident #70 being incontinent, which was a trigger for Resident #88 based on statements they had made to Resident #70 in the past. Licensed Practical Nurse Manager #2 said they did not report Resident #70's concerns to Social Worker #2, the Director of Nursing, or the Administrator because they did not consider it abuse. 5. Resident #140 had diagnoses which included schizophrenia, major depressive disorder, and cerebral infarction (stroke). The Minimum Data Set Resident Assessment, dated 6/30/2024, documented the resident was cognitively intact, and had no history of behaviors. During an observation and interview on 07/09/2024 at 10:42 AM on the South 1 Unit, Resident #140 was lying in bed. There were no sheets in place and the resident was wrapped in what appeared to be a personal fleece blanket. When interviewed, Resident #140 stated staff were too busy to put sheets on their bed the previous night and no one had come to offer assistance yet. On 08/02/2024, the New York State Department of Health survey team identified and declared Immediate Jeopardy. The facility administrator was notified at 5:10 PM. On 08/04/2024 at 2:00 PM, the New York State Department of Health survey team declared the Immediate Jeopardy was removed based on the following corrective actions taken by the facility: -100% of staff working at the time of removal had received education on abuse, neglect, mistreatment and proper reporting and notifications. - Interviews completed with multiple staff, including licensed nursing staff, direct care staff and environmental services staff on seven of seven resident care units, revealed appropriate knowledge of abuse, neglect, mistreatment, and proper reporting and notifications. -Approximately 41% of all non-licensed staff were educated regarding abuse, neglect, mistreatment, and proper reporting and notifications. -Approximately 61% of all licensed nursing staff were educated regarding abuse, neglect, mistreatment, and proper reporting and notifications. -The corrective action included a plan to educate all staff (including licensed, certified, and non-medical staff), agency staff, and staff on vacation and/or leave prior to the start of their next shift and would be tracked by the administrative team to ensure 100% compliance. 10 NYCRR 415.4 (b)(1)(i)

Based on observations, interviews, and record review conducted during the extended Recertification Survey from 07/08/2024 to 09/17/2024, the facility failed to ensure the resident received the necessary care, treatment, and services, consistent with professional standards of practice, to promote healing, prevent new pressure ulcers from developing, and/or prevent existing pressure ulcers from worsening for one (Resident #106) of five residents reviewed. Specifically, the facility did not ensure that wound treatments recommended by the Wound Care Physician were accurately and timely transcribed and implemented, that wound treatments were provided as ordered, and Resident #106 was observed on several occasions with lack of incontinence care. These issues resulted in the potential likelihood of serious injury for all the residents in the facility (census 216) that was Immediate Jeopardy. Review of the facility policy, Prevention of Pressure Ulcers/Injuries, dated January 2024, included to keep skin clean and free of exposure to urine and fecal matter, and to wash the skin after any episode of incontinence. Review of the facility policy, Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated January 2024, included the physician would authorize pertinent orders related to wound treatments, including wound cleansing, and debridement (the removal of dead or infected skin tissue) approaches, dressings, and the application of topical agents if indicated for the type of skin alteration. During resident visits, the physician would evaluate and document the progress of wound healing, especially for residents with complicated, extensive, or non-healing wounds. Resident #106 had diagnoses that included a stage 4 (full thickness tissue damage) pressure ulcer (bed sore), depression, and hemiplegia (paralysis on one side of the body). The Minimum Data Set Resident Assessment, dated 05/03/2024, revealed the resident was cognitively intact, was always incontinent of bladder and bowel, required assistance with toileting hygiene, had a Stage 4 pressure ulcer and moisture associated skin damage (inflammation or skin breakdown caused by prolonged exposure to a source of moisture such as urine or stool), and received pressure ulcer care. Review of the current Comprehensive Care Plan documented Resident #106 had a stage 4 pressure ulcer to the sacrum (area of skin at base of spine) and was incontinent of urine and bowel. Interventions included, but were not limited to, apply treatment creams and dressings per physician's orders and to check and change incontinence briefs every three to four hours and as needed. Review of a Wound Assessment and Plan note, dated 02/26/2024, the Wound Care Physician documented wound healing had stalled and ordered a wound treatment that included to cleanse with normal saline, apply collagen particles (powder-like wound treatment to promote healing) to wound bed, loosely pack with alginate AG (type of wound dressing with antibacterial properties) and cover with ABD pad (highly absorbent wound dressing) every day and as needed. Review of medical orders did not include evidence the Wound Care Physician's orders had been transcribed into the electronic medical record until 03/05/2024. Review of a Wound Assessment and Plan note, dated 03/11/2024, the Wound Care Physician documented wound healing had declined related to critical contamination and ordered a wound treatment that included to cleanse with normal saline, apply collagen particles to wound bed, loosely pack with alginate AG and cover with ABD pad every day and as needed. Review of medical orders did not include evidence the Wound Care Physician's orders had been transcribed into the electronic medical record. Review of a Wound Assessment and Plan note, dated 03/18/2024, revealed the Wound Care Physician's treatment orders made on 03/11/2024 were never implemented. Review of the Treatment Administration Record from 03/11/2024 to 03/20/2024 revealed Resident #106 continued to receive skin barrier film to the skin surrounding the wound for six days (despite the Wound Care Physician's treatment order changes on 03/11/2024). In a Wound Assessment and Plan note, dated 04/15/2024, the Wound Care Physician documented wound healing had declined related to peri care and the skin surrounding the wound was macerated (skin that has softened and broken down due to prolonged exposure to moisture). Treatment orders included to cleanse the wound with normal saline, apply skin barrier film to skin surrounding wound, loosely pack with iodoform (a sterile dressing that is used to treat draining or infected wounds) gauze and cover with ABD pad every day and as needed. Review of medical orders did not include evidence the Wound Care Physician's orders had been transcribed into the electronic medical record. Review of Wound Assessment and Plan notes, dated 04/22/2024, 04/29/2024 and 05/06/2024, revealed treatment orders to cleanse with normal saline, loosely pack with iodoform gauze and cover with ABD pad daily and as needed. Review of medical orders did not include evidence the Wound Care Physician's orders had been transcribed into the electronic medical record. In a Wound Assessment and Plan note, dated 05/13/2024, the Wound Care Physician documented wound healing had declined related to dermatitis and included treatment orders to cleanse with sterile water, apply triamcinolone/ nystatin (Mycolog II cream) (a steroid cream used to treat fungal infections) to the skin surrounding the wound, loosely pack with iodoform gauze and cover with ABD pad daily and as needed. Review of the Treatment Administration Record from 04/15/2024 to 05/15/2024 revealed Resident #106 received wound treatments that included collagen particles (despite the Wound Care Physician's treatment order changes on 04/15/2024). Review of a Provider Progress Note, dated 06/19/2024, Nurse Practitioner #1 revealed the resident was seen to review a wound culture of the sacral wound obtained on 6/3/2024 and reports of green drainage from and redness surrounding the wound. The wound culture was positive for Staphylococcus Aureus (bacteria that causes skin infections) and Nurse Practitioner #1 ordered Bactrim (antibiotic medication used to treat infections) to be administered for seven days. Review of Wound Assessment and Plan notes, dated 07/01/2024, 07/08/2024, 07/15/2024, and 07/22/2024, revealed wound treatment orders that included to cleanse with sterile water, apply Miconazole 2% cream (an antifungal cream used to treat skin infections) to the skin surrounding the wound, loosely pack with iodoform gauze and cover with a non-adherent super absorbent dressing daily and as needed. Review of medical orders did not include evidence the Wound Care Physician's orders had been transcribed into the electronic medical record. Review of the Treatment Administration Record from 07/01/2024 to 07/27/2024 revealed Resident #106 received Mycolog II cream to the skin surrounding the wound for 26 days (despite the Wound Care Physician's treatment order changes on 07/01/2024). Review of Treatment Administration Records from January 2024 through July 2024 revealed missing documentation (blank boxes) for 21 out of 218 total opportunities for wound care. During observations and interview on 07/08/2024 at 10:24 AM, Resident #106 was sitting upright in bed. There was the odor of urine and yellow and brown stains on the incontinence pad underneath the resident. Resident #106 stated they were soaked and had not been changed out of their wet incontinence brief since the previous night at bedtime. At 11:54 AM, Resident #106 remained in bed and stated they still had not been assisted with incontinence care. The room continued to have an odor of urine and the incontinence pad had not been changed. Additionally, an Enhanced Barrier Precautions (an infection control strategy) sign was observed on the door outside the resident's room. Instructions on the sign included, but were not limited to, everyone must clean their hands before entering and when leaving the room, staff must wear a gown and gloves for high contact resident care activities that included transferring, providing hygiene, changing briefs, or assisting with toileting, and wound care (any skin opening requiring a dressing). During an observation and interview on 07/11/2024 at 9:11 AM, Resident #106 remained in bed and stated they were soaked and had not been changed since the previous night at bedtime. The incontinence pad placed underneath the resident was stained yellow extending from the incontinence brief and smelled of urine. Additionally, the resident stated they had not received care on 07/08/2024 until after they had eaten their lunch. During an observation and interview on 07/11/2024 at 1:40 PM, Licensed Practical Nurse #3 entered Resident #106's room to provide wound care, at which time Resident #106 reported to the nurse that they were wet (incontinent of urine). Licensed Practical Nurse #3 proceeded to perform wound care to Resident #106's sacral pressure ulcer. Licensed Practical Nurse #3 was not wearing a gown during the procedure and did not change their gloves or perform hand hygiene after removing the old dressing (containing wound drainage), cleaning the wound, and before applying the new dressing (which included the application of collagen particles that had not been ordered by the Wound Care Physician since 04/15/2024). During an interview, Licensed Practical Nurse #3 stated they had not changed gloves or performed hand hygiene during and immediately following wound care but should have. During an interview on 07/15/2024 at 3:14 PM, Licensed Practical Nurse Manger #2 said a blank box on the Medication Administration Record or Treatment Administration Record would indicate the something was not given (or done). During an interview on 08/05/2024 at 1:22 PM, the Wound Care Physician explained their role involved the assessment of residents' wounds, prescribing wound treatments, evaluating if ordered treatments were still appropriate, performing minor procedures, and ordering labs or tests if necessary. The Wound Care Physician said they are in the facility one day a week (to assess residents wounds) and the Wound (and Infection Control) Nurse was responsible for reviewing the Wound Care Physician's notes to update the wound treatment orders into the electronic medical record. The Wound Care Physician stated there were times they evaluated Resident #106's wound and the surrounding skin was deteriorating, which the resident attributed to not being provided incontinence care. The Wound Care Physician stated they frequently observed residents being heavily soiled (incontinent of urine or stool) when they would assess them during wound rounds. During an interview on 08/06/2024 at 11:04 AM, the Wound and Infection Control Nurse said they perform wound rounds on Mondays with the Wound Care Physician and would review their visit notes the following day (if available). The Wound and Infection Control Nurse stated they would change the wound treatment orders in the electronic medical record based on what the Wound Care Physician wrote in their notes. The Wound and Infection Control Nurse said they started in their role in May 2024, and they were told that prior to their arrival, the Director of Nursing and Assistant Director of Nursing #1 were transcribing the wound treatment orders into the electronic medical record. The Wound and Infection Control Nurse could not speak to why the correct wound treatments orders were not entered into the electronic medical record as indicated by the Wound Care Providers' notes dated 02/26/2024, 03/11/2024, 04/15/2024, 04/22/2024, 04/29/2024, and 05/06/2024. Upon reviewing the Wound Assessment and Plan note dated 7/1/2024 and current medical orders, the Wound and Infection Control Nurse said the Wound Care Physician included a treatment order for Miconazole cream, but the current order was for triamcinolone/nystatin (Mycolog II cream). They were not sure how the error occurred, but it was possible they got the creams mixed up. During an interview on 08/06/2024 at 12:24 PM, Assistant Director of Nursing #2 said they would expect the nurses to perform wound treatments as ordered by the provider. Assistant Director of Nursing #2 said they would expect the nurse transcribing the wound treatment orders into the electronic medical record to review the Wound Care Provider's notes to ensure accuracy. During an interview on 08/07/2024 at 9:11 AM, the Wound Care Physician stated they had been informed by nursing staff about inconsistencies between the Wound Care Physician's visit notes and the treatment orders entered into the electronic medical record. The Wound Care Physician said there was a time when the facility did not have a wound nurse and they did not know who was transcribing the treatment orders into the electronic health record. The Wound Care Physician said that orders not being transcribed into the electronic medical record timely, dressings not being changed (as ordered) and the resident not being assisted with incontinence care frequently and timely could all have an impact on the resident's (lack of) wound healing. The Director of Nursing did not return calls made on 08/07/2024 and 08/08/2024 requesting an interview. On 08/22/2024, the New York State Department of Health survey team identified and declared Immediate Jeopardy. The facility administrator was notified at 12:00 PM. On 08/22/2024 at 6:00 PM, the survey team declared that the IJ was removed based on the following corrective actions taken by the facility: 1. 100% of licensed staff working on the day and evening shifts at the time of removal had received education on the following: a. Appropriate Personal Protective Equipment and hand hygiene for wound care (including incontinence care). b. Appropriate weekly, post admission/readmission skin assessments on all residents. c. Accurately transcribing and implementing Physician orders, including hospital discharge instructions and wound care medical consultants, for wound care treatments and ensuring treatment orders match Physician orders and consultant recommendations (unless otherwise indicated). Additionally notifying the medical team for unclear orders or no orders for existing skin issues. d. Accurate and timely documentation of wound care. e. Care Plan interventions for all existing skin issues. 2. Interviews completed with licensed staff on all six facility resident units to verify content of education completed and understanding of. 3. Review of a facility wide audit conducted for all residents consisting of head-to-toe skin assessments to ensure all skin issues addressed with medical and orders were correctly transcribed and implemented. 4. Medical record review of sample group of residents with current wounds/skin issues to ensure all Physician orders and consultant recommendations matched the treatment administration records to verify the correct treatments were being provided. 5. The correction action included a plan to educate all licensed staff, agency staff and any staff on vacation/leave prior to next working shift and tracked by Administration team to ensure 100% compliance. 10 NYCRR 415.12 (c)(1)

Based on observations, interviews, and record reviews conducted during the extended Recertification Survey and complaint investigation (#NY00343730) from 07/08/2024 to 09/17/2024, for 32 (Residents #4, #17, #19, #33, #36, #40, #42, #44, #56, #59, #60, #68, #80, #83, #84, #85, #90, #104, #107, #114, #116, #117, #133, #140, #164, #167, #168, #179, #190, #358, #359, and #614) of 46 residents reviewed, the facility failed to ensure the residents were free from significant medication errors. Specifically, Resident #359 was not administered their anti-anxiety and respiratory medications (not available) and was sent to the hospital the following day. Residents #33, #60, #68, and #140, did not receive significant medications that included insulin, anticoagulant (a blood thinner that prevents or reduces the clotting of blood), anti-seizure medication, and anti-hypertensive (medication for high blood pressure) on 07/04/2024 and 07/05/2024 as prescribed due to nurse staffing concerns. Resident #83, who was prescribed an antibiotic for seven days received an extra dose of the medication without a physician's order. Resident #80 did not receive their insulin, anti-hypertensive, diuretic (water pill), or their pain medication prior to leaving the facility for an outing on 07/08/2024. Resident #164 received medications that included a muscle relaxant, anti-seizure, and anti-hypertensive approximately three hours after the scheduled administration time which the resident stated affected their ability to move. Additionally, Residents #4, #17, #19, #33, #36, #40, #42, #44, #56, #59, #60, #68, #84, #85, #90, #104, #107, #114, #116, #117, #133, #140, #167, #168, #179, #190, #358, and #614 on South 1 unit did not receive any of their scheduled medications during the evening shift (3:00pm - 11:00pm) on 07/29/2024 because there was no nurse on the unit. These issues resulted in the likelihood of serious injury, serious harm, or death for all the residents in the facility (census 205) that was Immediate Jeopardy and substandard quality of care. This is evidenced by, but not limited to, the following: The facility policy Administering Medications, dated January 2024, included medications must be administered in accordance with the orders, including any required timeframe. If a drug was withheld, refused, or given at a time other than the scheduled time, the individual administering the medication should document in the electronic medication administration record for the drug and dose. The person withholding, receiving the refusal, or administering the medication at a different time would notify the attending or covering provider. 1. Resident #359 had diagnoses that included emphysema (lung condition causing shortness of breath and reduces the amount of oxygen in the blood), chronic obstructive pulmonary disease (disease that prevents airflow to the lungs), and anxiety. Review of a Nursing Admission Note, dated 07/08/2024, revealed that Resident #359 was cognitively intact. Review of the current Comprehensive Care Plan revealed Resident #359 received psychotropic medications for anxiety and depression and treatments for an alteration in respiratory status. Interventions included, but were not limited to, administration of treatments and medications per physician orders. Review of Resident #359's physician orders, dated 07/08/2024, included alprazolam (anti-anxiety medication) every 12 hours as needed for anxiety, arformoterol tartrate inhaler (for chronic obstructive pulmonary disease to decrease shortness of breath) twice daily, budesonide inhaler (prevent asthma attacks) twice daily, and oxygen at three liters per minute continuous via nasal cannula. During an interview on 07/11/2024 at 1:04 PM, a visitor stated on the day Resident #359 was admitted to the facility, they had not received their medications including their anti-anxiety or respiratory medications and were told by facility staff the medications had not been delivered by the pharmacy. The visitor stated Resident #359 called them (that evening) and told them they had not received any of their medications. The visitor stated the next morning (day after admission) they received a call from facility staff informing them the resident's oxygen level was low, they were given 12 liters of oxygen, and transferred back to the hospital. Review of the July 2024 Medication Administration Record revealed Resident #359 did not receive the arformoterol tartrate and budesonide inhalers on 07/08/2024 and their alprazolam on 07/08/2024 or in the morning on 07/09/2024. All missing medications were coded as not available. Review of a nursing progress note dated 07/08/2024 at 11:37 PM, Licensed Practical Nurse Manager #2 documented the arformoterol tartrate and budesonide were not administered because they were not received from the pharmacy. There was no documented evidence the medical provider was notified that the medications were not available. Review of a nursing progress note dated 07/09/2024 at 9:49 AM, Assistant Director of Nursing #1 documented Resident #359 was transferred to the hospital due to increased anxiety and complaints of shortness of breath. During an observation and interview on 07/12/2024 at 1:10 PM, Resident #359 was on three liters of oxygen via nasal cannula and said when they were first admitted to the facility, they did not have any of their medications and they requested to be sent to the hospital. During an interview on 07/15/2024 at 3:14 PM, Licensed Practical Nurse Manager #2 stated when a new resident was admitted to the facility, the medication orders were entered into the electronic medical record and if entered after 11:00 AM, they would not receive the medications until 10:00 PM. Licensed Practical Nurse Manager #2 said if a medication was not available, staff should call the pharmacy to see when they would receive it, and if an administrator were in the building, they would authorize an immediate delivery. Licensed Practical Nurse Manager #2 said the nurse should also notify the provider that the medication was not available. Licensed Practical Nurse Manager #2 said on 07/08/2024 the medications did not arrive at 10:00 PM. Licensed Practical Nurse Manager #2 said they thought alprazolam was kept in the emergency box, but they did not have access to it due to no nursing supervisor in the building at the time and the arformoterol tartrate and budesonide would not have been in the emergency box. Licensed Practical Nurse Manager #2 said they did not notify the medical provider. During an interview on 07/15/2024 at 4:23 PM, Assistant Director of Nursing #1 stated if a medication was due to be given but was not available, the nurse should call the pharmacy to get an immediate delivery and notify the Physician, but this did not occur. They said they were not aware a nursing supervisor had not been in the building on 07/08/2024 but there should have been someone in the facility at the time that had access to the emergency box. 2. Resident #60 had diagnoses that included diabetes, atrial fibrillation (irregular and often rapid heart rate), a stroke, and congestive heart failure. The Minimum Data Set Resident Assessment, dated 05/31/2024, revealed the resident was cognitively intact and received an anticoagulant (to prevent blood clots and strokes) medication and insulin. Current Physician orders for Resident #60 included apixaban (an anticoagulant) twice daily for atrial fibrillation and Lantus (a long-acting insulin used to control blood sugar) once daily at bedtime for diabetes. During an interview on 07/08/2024 at 1:25 PM, Resident #60 stated there was no nurse on the unit this past weekend to give medications and they had not received their insulin. Review of the July 2024 Medication Administration Record revealed apixaban (scheduled for 6:00 PM) and Lantus insulin (scheduled for 9:00 PM) were documented as not administered on 07/04/2024 and 07/05/2024. Review of interdisciplinary progress notes, dated 07/04/2024 to 07/12/2024, did not include any documented evidence that a provider had been notified of the missed medications. During an interview on 07/12/2024 at 1:25 PM, Licensed Practical Nurse #12 stated Resident #60 had reported not receiving insulin on two days the previous week, but they had not been concerned because their blood sugar readings were within normal limits. Licensed Practical Nurse #12 reported Resident #60's concerns to Registered Nurse Manager #1. During an interview on 07/12/2024 at 1:34 PM, Registered Nurse Manager #1 stated the Director of Social Work had reported Resident #60 had not received any medications on a couple of days the previous week, but Registered Nurse Manager #1 was not sure what was done to address the missed medications. 3. Resident #33 had diagnoses including epilepsy (a chronic neurological condition that causes recurrent seizures in the brain), heart disease, and mild intellectual disabilities. The Minimum Data Set Resident Assessment, dated 05/01/2024, revealed the resident had moderately impaired cognition and was on an anticoagulant medication. Current Physician orders included apixaban twice daily for atrial fibrillation, hydralazine (a medication used to treat hypertension) once daily at bedtime and divalproex sodium (a medication used to treat epilepsy/seizures) once daily at bedtime. Review of the July 2024 Medication Administration Record revealed apixaban and divalproex sodium (scheduled for 6:00 PM) and hydralazine (for 9:00 PM) were documented as not administered on 07/04/2024 and 07/05/2024. Review of interdisciplinary progress notes, dated 07/04/2024 to 07/12/2024, did not include any documented evidence that a provider had been notified of the missed medications. During an interview on 07/12/2024 at 1:25 PM, Licensed Practical Nurse #12 stated they thought some residents on the South 1 Unit had not received their medications on 07/04/2024 and 07/05/2024 but was unsure of the reason why. During an interview on 07/12/2024 at 1:34 PM, Registered Nurse Manager #1 stated they were aware some residents on the South 1 Unit missed medications the previous week. Registered Nurse Manager #1 stated the nursing supervisor had called them to report being short nurses, but they were out of town and unable to help. Registered Nurse Manager #1 stated blanks in the Medication Administration Record usually meant the medication was not given. If not given, the medical provider should be notified, and the notification documented. During an interview on 07/12/2024 at 1:55 PM, Licensed Practical Nurse #3 stated they were the only nurse on South 1 from 3:00 PM to 7:00 PM on 07/04/2024, and 07/05/2024 with one Certified Nursing Assistant with them and they were responsible for administering medications for all residents on the unit (40) and assisting with passing meal trays, feeding residents, and incontinence care (making it difficult to get everything done). Licensed Practical Nurse #3 stated the medication keys were given to Registered Nurse Supervisor #3 on 07/04/2024 and to Licensed Practical Nurse #13 on 07/05/2024 at 7:00 PM. Review of staffing schedules on 07/04/2024 revealed there were three nurses in the facility from 7:00 PM- 9:00 PM and two nurses from 9:00 PM -11:00 PM for 206 residents. Registered Nurse Supervisor #3 did not return calls made on 07/15/2024 and 07/16/2024 requesting an interview. During an interview on 07/15/2024 at 4:26 PM, Nurse Practitioner #1 stated they would consider antipsychotics, psychotropics, blood pressure, anticoagulants, and seizure medications as significant medications and would expect to be notified if any of those medications were missed. Nurse Practitioner #1 stated the missed medications included anti-seizure and anticoagulant medications that required medical follow-up with the residents. Residents who missed anti-seizure medications required lab work to ensure their levels remained therapeutic and additional monitoring for symptoms and vital signs for residents who missed anticoagulants. Nurse Practitioner #1 stated they were made aware recently that medications had not been given to several residents for entire shifts due to not having nurses available to administer them. During an interview on 07/15/2024 at 7:49 PM with the Administrator, Assistant Administrator, Regional Administrator and Regional Clinical Director, the Regional Administrator stated the Quality Assurance Committee was aware of concerns related to missed medications and they were not sure what happened. The Regional Administrator stated leadership had not been notified and was not aware of staffing concerns on 07/04/2024 and 07/05/2024. 4. During an interview on 08/01/2024 at 2:11 PM, Licensed Practical Nurse Manager #2 said residents on the South 1 unit did not receive their evening medications on 07/29/2024 because there was no nurse on the unit. Licensed Practical Nurse Manager #2 said residents' finger sticks (blood glucose levels) were also not checked (as ordered) because there was no nurse on the unit. During a follow-up interview at 2:51 PM, Licensed Practical Nurse Manager #2 showed the Electronic Medication Administration Record for the evening shift on 07/29/2024 and 32 residents with medications scheduled to be given were highlighted red, indicating they had not been given medications during the shift. Review of the Medication Administration Audit Report for the South 1 unit residents from 07/24/2024 through 07/30/2024 revealed 28 residents were not administered their significant medications as scheduled during the evening shift on 07/29/2024. Medications included but were not limited to antiseizure medications, insulins, anticoagulants (blood thinners), antibiotics, blood pressure medications, analgesics (medications for pain), antipsychotics (medications that treat psychosis-related conditions and symptoms), anti-depressants and medications for Parkinson's. During an interview on 08/05/2024 at 1:27 PM, the Staffing Coordinator said on 07/29/2024, the Director of Nursing stayed during the evening shift to supervise the Licensed Practical Nurse Supervisor (Licensed Practical Nurse #13). The Staffing Coordinator said Licensed Practical Nurse #17 was assigned to South 1 during the evening shift on 07/29/2024. Review of the Actual Nursing Staffing sheets for 07/29/2024 revealed Licensed Practical Nurse #17 was assigned to South 1 unit from 3:00 PM to 11:00 PM (evening shift). However, review of the Nursing Staff Daily Punches report dated 07/29/2024 revealed Licensed Practical Nurse #17 did not punch in or out, indicating they did not work, and the Director of Nursing was in the facility for the duration of the evening shift (until 11:56 PM). During a follow-up interview on 08/05/2024 at 4:14 PM, the Staffing Coordinator said they had given the wrong information, and that Licensed Practical Nurse Supervisor #1 came in at 11:10 PM on 07/29/2024 to work the night shift. The Staffing Coordinator said if the punch report showed blanks (punch in and punch out), it meant the staff member did not work. The Staffing Coordinator said they made the Director of Nursing aware by 3:30 PM on 07/29/2024 that Licensed Practical Nurse #17 was not in the facility. The Staffing Coordinator said on 07/29/2024, their scheduling duties were done by 3:00 PM because they had to work as a Certified Nursing Assistant on the [NAME] 1 unit. During an interview on 08/08/2024 at 11:14 AM, Physician #1 said if it was identified that residents were not administered medications, the medical providers would be notified during morning meetings (with facility leadership). Physician #1 stated they did not recall being made aware of South 1 residents not being administered medications during the evening shift on 07/29/2024. Physician #1 said they had heard that nurses would stay past the end of their shift to administer medications (due to no nurses available to relieve them). During an interview on 08/08/2024 at 11:57 AM, Nurse Practitioner #1 said the nurses in the facility would contact the on-call medical providers during off shifts (typically after 4:30 PM). Nurse Practitioner #1 said during morning report, facility leadership would print and review the list of medications that were missed (not administered) and the nurse managers would be notified. Nurse Practitioner #1 stated they were not in the building on 07/30/2024 and did not recall being notified medications were not given to residents on South 1 during the evening shift on 07/29/2024. Nurse Practitioner #1 said they had heard of instances, usually once a week, in which medications were missed (not administered) and it was usually due to not having a nurse. During an interview on 08/08/2024 at 2:18 PM, Medical Director #1 stated they had been the facility's Medical Director up until 08/03/2024. Medical Director #1 said all medications could be significant, with anti-seizure, blood thinners and insulin especially important because they require closer monitoring and evaluation to prevent adverse reactions. Medical Director #1 stated they would expect to be notified if residents were not receiving their medications and they did not recall being notified residents on an entire unit were not administered medications. Medical Director #1 said if a medication could not be given, they would expect the nursing supervisor to be made aware and if needed, the issue be escalated to the nurse practitioner or the on-call medical provider, so they could tell the nurses what to do about the missed medications. Medical Director #1 stated the concern was never brought to the Quality Assurance and Performance Improvement Committee or facility leadership meetings. The Director of Nursing did not return calls made on 08/07/2024 and 08/08/2024 requesting an interview. On 09/17/2024 the survey team identified and declared Immediate Jeopardy. The facility Regional Administrator and the Assistant Administrator were notified at 5:20 PM. On 09/17/2024 at 7:13 PM the survey team declared that the IJ was removed based on the following corrective actions taken by the facility: -Immediate education regarding the medication administration policy and the medication error policy to include the medication error form, the medication error severity assessment tool, the missed medication daily review process to ensure compliance, and proper communication of staffing emergencies related to coverage was completed with all licensed nursing staff currently in the facility with an attestation that all 59 of the facility's licensed nursing staff will be educated prior to their next shift. - a facility wide audit, with a lookback period of 30 days, to identify any residents with any missed or omitted medications and medical team notification of any missed medications. -Interviews with licensed nursing staff on each resident unit to verify education completed and post test results related to medication errors, appropriate notifications (medical team, nursing supervisors) and documentation, missing medication reports, significant medication errors on severity and outcomes, and pharmacy process for missing medications. 10 NYCRR 415.12(m)(2)

Based on observations, interviews, and record review conducted during the extended Recertification Survey and complaint investigation (#NY00343916) from 07/08/2024 to 09/17/2024, for five (Resident #55, #92 #106, #140, and Resident #457) of seven residents reviewed, the facility did not ensure that the residents were treated in a respectful and dignified manner. Specifically, Resident #55 was observed in the dining room wearing only a t-shirt and an incontinence brief. Resident #92 was observed to be asleep in their bed and the bed was bare, with no sheets in place. Resident #106 was observed laying on a urine soiled incontinence pad. Resident #140 was observed lying on a mattress without sheets. Resident #457 was observed lying on wet linens over an extended period of time. Additionally, there were multiple observations of residents using paper plates and plastic utensils for meals. This was evidenced by the following: Review of the facility policy, Quality of Life-Dignity, dated January 2024, documented each resident shall be treated with respect and dignity at all times, and shall be assisted to dress in their own clothes. Review of the facility policy, Resident Care with Activities of Daily Living, dated January 2024, documented the facility would provide resident(s) with adequate toileting to maintain the maximum level of toileting and continence. Review of the facility policy, Resident Rights, dated January 2024, documented federal and state laws guaranteed certain basic rights to all residents in the facility which included (but not limited to) equal access to quality care. Review of the facility policy, Dining Atmosphere, dated January 2024, documented dishware and flatware used for meals should be non-disposable. Review of Resident Council (an organized group of residents who meet regularly to discuss and address concerns about their rights, quality of care and quality of life) meeting minutes from April 2024 through June 2024 included (but not limited to) concerns about a linen shortage, the use of blankets in the place of incontinence pads, bed linens not being changed, and staff cutting up linens to use as wash cloths. Each month, documentation included that past concerns were addressed, but the residents had not seen improvement. 1. Resident #457 had diagnoses of respiratory failure, requirement of supplemental oxygen, and diabetes. A Nursing Admission Note, dated 07/02/2024, included the resident was cognitively intact, was incontinent of bladder, wore an incontinence brief, and had requested the use of a bedside commode. Review of the current Comprehensive Care Plan and Kardex (care plan used by Certified Nursing Assistants to guide care) revealed Resident #457 was incontinent of urine and stool, required supervision or touch assist for toilet transfers, used a bedside commode, and required incontinence briefs with checks and changes every three to four hours, or as needed. During an interview on 07/08/2024 at 9:41 AM, Resident #457 said they were not able to use the bathroom in their four-person room because the toilet was too low for them, and they used a commode (currently placed at the head of their bed). Resident #457 stated they are not provided proper care in that some days they only got assistance and/or changed (incontinence care) once a day. During an observation on 07/09/2024 at 10:30 AM, Resident #457 was in bed. The bed linens were visibly wet from their left thigh to their upper right shoulder and the room smelled of urine. Resident #457 said staff had delivered their breakfast tray earlier and knew the sheet was wet as it was visible over their shoulder. During an observation and interview on 07/10/2024 at 12:56 PM, Resident #457 was sitting on the side of their bed and stated that they could not use the bathroom toilet because they had arthritis, and it was too low for them. Resident #457 said they could not use the commode independently and when they called for assistance, staff did not come so they had to urinate in their brief. During an observation and interview on 07/10/2024 at 2:18 PM, Resident #457's bathroom had two toilets, both with the seats at about knee height (approximately one and a half to two feet in height). Certified Nursing Assistant #8 stated currently none of the four residents in the room used the bathroom because they were all dependent on staff for toileting. During an interview on 07/15/2024 at 11:00 AM, Certified Nursing Assistant #6 said if a resident was continent of urine, they would wait for the resident to call for assistance to use the bathroom or commode. If a resident was incontinent, incontinence care was provided after morning care and incontinence rounds were supposed to be done every two hours, which was hard to complete when the unit was short staffed. Certified Nursing Assistant #6 said they thought Resident #457 did know when they needed to use the bathroom and had only seen the resident use the commode for bowel movements. Certified Nursing Assistant #6 said residents should not have to void (urine or stool) in their brief if they were continent. During an interview on 07/15/2024 at 11:33 AM, Licensed Practical Nurse #5 said nursing staff should provide residents assistance with toileting either when the resident's call light was on or during rounding. Licensed Practical Nurse #5 said if a resident was continent, they should get up (to go to the bathroom). Licensed Practical Nurse #5 said Resident #457 was continent of urine and could get up but did not. Resident #457 preferred to have their soiled brief changed or to use the commode. Licensed Practical Nurse #5 said when they asked Resident #457 why they did not get up to go to the bathroom, the resident said it was due to their oxygen, so longer oxygen tubing had been offered (not observed in the resident's room at the time). During an interview on 07/15/2024 at 3:14 PM, Licensed Practical Nurse Manager #2 said Resident #457 received incontinence care because they were non-weight bearing and therapy was using the commode with the resident. Licensed Practical Nurse Manager #2 said a resident should not have to sit in urine or stool during meals as it was undignified. 2. Resident #55 had diagnoses including vascular dementia, anxiety disorder, and obsessive-compulsive disorder (a disease where a person experiences uncontrollable and recurring thoughts and/or engaged in repetitive behaviors). The Minimum Data Set Resident Assessment, dated 05/17/2024, documented that Resident #55 was dependent on staff for toileting and hygiene and needed assistance with lower body dressing. Review of Resident #55's current Kardex documented that Resident #55 needed to be toileted before meals. During an observation on 07/10/2024 at 4:55 PM, Resident #55 was in the dining room in a wheelchair wearing only a shirt and an incontinence brief. Resident #55 did not have any shoes or pants on and was uncovered from the waist down. Four residents and one staff member were also in the dining room. During an interview on 07/10/2024 at 5:00 PM, Certified Nursing Assistant #10 stated residents should be dressed and presentable when out of their room and if they saw a resident who was not dressed appropriately, they would remove them from the common area and get them dressed. During an interview on 07/10/2024 at 5:10 PM, Licensed Practical Nurse #6 stated a resident should not be in a common area in just a shirt and brief. They stated that Resident #55 was known to take their clothes off and staff should re-dress the resident or at least cover them up for their privacy. 3. Resident #106 had diagnoses that included a stage 4 (full thickness tissue damage) healing pressure ulcer (bed sore), depression, and hemiplegia (paralysis on one side of the body). The Minimum Data Set Resident Assessment, dated 05/02/2024, documented that Resident #106 was cognitively intact, did not exhibit behaviors or rejection of care, required assistance with transfers and toileting hygiene, and was always incontinent of bladder and bowel. Review of the current Comprehensive Care Plan and the current Kardex revealed Resident #106 required assistance with activities of daily living, had bladder and bowel incontinence, and was at risk for impaired skin integrity. Interventions included, but were not limited to, check for needed assist with toileting every two hours and/or check and change incontinence brief as needed every three to four hours. Provide peri-care (private areas) after each incontinent episode and keep skin clean and dry with prompt removal of wet or damp clothing or sheets. During observations and interview on 07/08/2024 at 10:24 AM, Resident #106 was sitting upright in bed. There was an odor of urine and yellow and brown stains on the incontinence pad underneath the resident. Resident #106 stated they were soaked, had already eaten breakfast and had not been changed out of their wet incontinence brief since the previous night at bedtime. They said they put their call bell on for assistance and a nurse responded that the Certified Nursing Assistants were working their way down the hall. At 11:54 AM, Resident #106 remained in bed and stated they still had not been assisted with incontinence care. The room continued to have an odor of urine and the incontinence pad had not been changed. During an observation and interview on 07/11/2024 at 9:11 AM and again at 10:56 AM, Resident #106 remained in bed and stated they were again soaked and had not been changed since the previous night at bedtime. The incontinence pad placed underneath the resident was stained yellow extending from the incontinence brief and smelled of urine. Resident #106 stated they had not received care on 07/08/2024 until after they had eaten their lunch. During an interview on 07/11/2024 at 1:30 PM, Resident #106 stated they have requested repeatedly that they get changed prior to breakfast and lunch, but it is not being done and it makes them feel terrible (like a piece of crap), like they are not worthy of being given any service. 4. Resident #92 was admitted with diagnoses that included dementia, visual hallucinations, and anxiety. The Minimum Data Set Resident Assessment, dated 06/05/2024, documented Resident #92 was severely cognitively impaired. During an observation on 07/11/2024 at 10:24 AM on the South 2 Unit, Resident #92 was asleep in their bed. The bed was bare, with no sheets in place. The linen cart on the unit had no pillowcases, fitted sheets, flat sheets, or blankets. During an interview on 07/11/2024 at 1:40 PM, Licensed Practical Nurse #3 stated that often there was no linen available, and residents and family members would get upset when staff could not assist with care before breakfast. The laundry staff were only available on day shift and had to wash linen from the previous day before delivering it to the units which was sometimes during the late morning or afternoon. Licensed Practical Nurse #3 stated when the cart was delivered, there was usually only six washcloths for 40 residents, and staff had to cut up towels to use as washcloths or use disposable dry wipes. 5. Resident #140 had diagnoses that included cerebral infarction (stroke), malignant neoplasm of breast (breast cancer), and type 2 diabetes mellitus. The Minimum Data Set Resident Assessment, dated 05/30/2024, documented Resident #140 was cognitively intact. During an observation and interview on 07/09/2024 at 10:42 AM on the South 1 Unit, Resident #140 was lying in bed. There were no sheets in place and the resident was wrapped in what appeared to be a personal fleece blanket. When interviewed Resident #140 stated staff were too busy to put sheets on their bed the previous night and no one had come to offer assistance yet that morning. During an interview on 07/10/2024 at 11:36 AM, Certified Nursing Assistant #12 stated there was not an adequate supply of linen to care for the residents. When linen was delivered to the unit, there were usually six towels and five washcloths for 40 residents. Certified Nursing Assistant #12 stated they often had to improvise when giving residents care, including cutting a bath sheet to make washcloths. 6. During observations at breakfast and/or lunch on 07/10/2024 at 1:16 PM, 07/11/2024 at 9:31 AM, and 07/11/2024 at 1:25 PM in the dining room, the majority of residents (up to 22 on one observation) in the dining room were served meals on paper plates and were using plastic utensils. During an interview on 07/11/2024 at 1:38 PM, Certified Nursing Assistant #5 stated the facility had been using plastic utensils for meals for a couple of weeks. During an interview on 07/12/2024 at 8:41 AM, the Assistant Director of Rehabilitation stated that a resident using plastic utensils could result in spillage of food and dropping the plastic utensils while eating. During an interview on 07/12/2024 at 9:34 AM, the Diet Technician stated the facility's current number of plates and utensils was not enough, and the facility was using plastic utensils and paper plates to replace what was missing. During an interview on 07/12/2024 at 11:27 AM and again on 07/15/2024 at 8:44 AM, the Director of Food Service stated the facility did not have enough dishware in stock for all resident's meals and the last two units delivered to had to use paper plates and plastic utensils for meals. The Director of Food Service stated the Assistant Director of Food Service did the ordering for the dining supplies, but the corporate office could change or decrease the amount ordered. During an interview on 07/11/2024 at 2:02 PM and again on 07/15/2024 at 8:50 AM, the Assistant Director of Food Service stated they order supplies the facility needed, but the corporate office controlled the amount ordered. During an interview on 07/15/2024 at 9:55 AM, the Administrator stated the facility should not be using plastic utensils and paper plates for meals because it was a dignity issue. The Administrator said the best solution would be to obtain the adequate amount of dining products. During an interview on 07/15/2024 at 10:00 AM, the Regional Administrator stated the facility should have a par (inventory control system in place to determine the levels of non-disposable dishware, glassware, and utensils the facility should have to meet resident care needs) level for dining products that the kitchen staff should be monitoring. The Regional Administrator said ordering should be done weekly to maintain the par level. 10 NYCRR 415.5

Based on observations, interviews, and record review conducted during the extended Recertification Survey from 07/08/2024 to 09/17/2024, for six (South 1, South 2, South 3, North 1, North 2, and [NAME] 2) of seven resident units, the facility did not ensure sufficient staffing to provide nursing services to attain or maintain the highest practical physical, mental, and psychosocial well-being for residents in the facility. Specifically, there were several observations of residents who were incontinent and had not received timely assistance with care, and several residents had not received significant medications on 07/04/2024, 07/05/2024, and 07/29/2024 due to no nurse being available to administer the medications. This resulted in actual psychosocial harm to Resident #106 that was not immediate jeopardy. The findings included but not limited to the following: For additional information see Centers for Medicare/Medicaid Services Form 2567: F677 Activities of Daily Care Provided for Dependent Residents; F760 Residents Are Free of Significant Medication Errors. Review of the Facility Assessment, dated 06/21/2024, revealed the facility was licensed for 228 beds with an average daily census of 180 residents. Resident care and services included, but were not limited to, assistance with activities of daily living, incontinence prevention and care, and medication administration. The staffing plan included that nursing staff was evaluated at the beginning of each shift and adjusted as needed to meet the care needs and acuity of the resident population. The facility's Full Time Equivalents (measurement that compares the amount of time worked by each employee to that of a full-time employee) were as follows: Registered Nurses: Three full-time and three per diem (employees who work when the need arises); Licensed Practical Nurses: 28 full-time and 17 per diem; Certified Nursing Assistants 32 full-time, 22 part-time and 22 per diem. Review of the facility policy Emergency Nurse Staffing Plan, dated January 2023, revealed the Staffing Coordinator would discuss with the Director of Nursing staffing levels daily and in the event of critically low staffing, the Mandation Policy would be strictly followed. The Staffing Coordinator was expected to follow daily staffing practices which included, but were not limited to, evaluating nurse staffing, and adjusting at least every eight hours and more if needed based on patient census and acuity level (the level of care that was required), and confirming the number of staff on duty was sufficient to ensure nursing care needs of each resident was met. During the entrance conference on 07/08/2024 at 8:56 AM with the Administrator, Assistant Administrator and Director of Nursing, the Director of Nursing stated the facility census was 213 residents. 1. Observations and interviews on the South 3 Unit (40 residents) included: a. On 07/08/2024 at 8:52 AM, Licensed Practical Nurse #14 stated there were two Licensed Practical Nurses and one certified Nursing Assistant on the unit for day shift. The resident census was 40. b. On 07/08/2024 at 10:01 AM, Certified Nursing Assistant #12 was passing a breakfast tray to a resident room who was incontinent of bowel and on a soiled sheet. Certified Nursing Assistant #12 asked Licensed Practical Nurse #14 for assistance due to the resident requiring the assist of two staff for care. Licensed Practical Nurse #14 stated that assisting the aide with the resident's care would cause them to be late passing medications and it was often difficult to get their medication administration done when the staffing was short. c. On 07/08/2024 at 11:12 AM, Resident #116 was in bed and the incontinence pad underneath the resident was soiled and had a large brown stain that extended toward their mid-back and there was an odor of urine. d. On 07/15/2024 at 8:42 AM, Certified Nursing Assistant #11 stated they were the only aide on the unit that shift and was not sure if additional staff were coming. They stated they would not be able to assist all residents with morning care, turning and positioning and feeding. e. On 07/15/2024 at 12:51 PM, Assistant Director of Nursing #2 stated they were not aware that South 3 only had one Certified Nursing Assistant on the unit on 07/08/2024, and the unit should have more than one aide on the day and evening shift. 2. Observations and interviews on the North 2 Unit included: a. On 07/08/2024 at 9:24 AM, Resident #456 stated there was no aide on the overnight shift and they did not receive assistance with incontinence care until 4:00 AM. b. On 07/08/2024 at 9:55 AM Resident #69 was lying in bed with no clothes on. There was a brown substance on their right heel, left hip, on the fitted sheet, and on the hospital gown that was underneath the resident's bottom. The call bell was on the floor and not within reach. When interviewed Licensed Practical Nurse #5 stated the North 1 and North 2 Units had a total of 36 residents and there was two Licensed Practical Nurses and three Certified Nursing Assistants (one was a new hire in training). c. On 07/08/2024 at 10:12 AM, Resident #122 was observed with long facial hair on their chin and upper lip and unwashed, greasy hair. Resident #122 said their hair was last washed a few weeks ago, was sometimes itchy, and that they were waiting for a haircut. d. On 07/08/2024 at 10:21 AM, Resident #199 said they had received their medications late the previous night because there was only one nurse on the unit. e. On 07/09/2024 at 10:30 AM, Resident #457 was in bed. The bed linens were visibly wet from their left thigh to their upper right shoulder and the room smelled of urine. Resident #457 said staff had delivered their breakfast tray earlier and knew the sheets were wet as it was visible over their shoulder. f. On 07/10/2024 at 12:56 PM, Resident #457 was sitting on the side of their bed and stated they cannot use the commode independently, but when they call for assistance, staff do not come so they urinate in their brief. 3. Observations and interview on the South 2 Unit (40 beds) included: a. On 07/08/2024 at 9:04 AM, Licensed Practical Nurse Manager #1 stated there was one other Licensed Practical Nurse (beside themselves) who was assigned to medications and two Certified Nursing Assistants for 37 residents. b. On 07/08/2024 at 11:17 AM, Resident #98 was in a wheelchair partially in the bathroom with their pants on the floor. There was stool on the floor near their bed and on the bed sheets. There were no staff in sight. 4. Observations and interview on South 1 Unit (40 residents) included: a. On 07/08/2024 at 10:24 AM, Resident #106 was in bed. There was the odor of urine and yellow and brown stains on the incontinence pad underneath the resident. Resident #106 stated they were soaked, had already eaten breakfast and had not been changed out of their wet incontinence brief since the previous night at bedtime. They had put their call bell on for assistance and a nurse responded that Certified Nursing Assistants were working their way down the hall. At 11:54 AM, Resident #106 was in bed and stated they still had not been assisted with incontinence care. The room continued to have an odor of urine and the incontinence pad did not appear to have been changed. During an interview on 07/11/2024 at 1:30 PM, Resident #106 stated they have requested repeatedly that they get changed prior to breakfast and lunch, but it is not being done and it makes them feel terrible (like a piece of crap), like they were not worthy of being given any service. b. On 07/08/2024 at 1:25 PM, Resident #60 stated there was no nurse on the unit this past weekend to give medications and they had not received their insulin. Review of Resident #60's July 2024 Medication Administration Record revealed apixaban (scheduled for 6:00 PM) and Lantus insulin (scheduled for 9:00 PM) were documented as not administered on 07/04/2024 and 07/05/2024. c. On 07/09/2024 at 10:42 AM, Resident #140 was lying in bed. There were no sheets in place and the resident was wrapped in what appeared to be a personal fleece blanket. When interviewed, Resident #140 stated that staff were too busy to put sheets on their bed the previous night and no one had come to offer assistance yet this morning. d. On 07/12/2024 at 1:34 PM, Registered Nurse Manager #1 stated they were aware that some residents on the unit missed medications the previous week as the nursing supervisor had called them to report being short of nurses. e. On 07/12/2024 at 1:55 PM, Licensed Practical Nurse #3 stated they had worked as the only nurse on the unit for the evening shift on 07/03/2024, 07/04/2024, and 07/05/2024. On 07/04/2024 there was one Certified Nursing Assistant scheduled with them and they were responsible for administering medications for all residents on the unit and assisting with passing meal trays, feeding residents, and incontinence care (making it difficult to get everything done). 5. Observations and interview on [NAME] 2 Unit (31 residents) included: a. On 07/08/2024 at 10:26 AM, Resident #182's fingernails were approximately one-half inch long on both hands and some nails had sharp jagged edges. b. On 07/12/2024 at 1:34 PM, Resident #134's fingernails were approximately one-half inch long with debris underneath. Review of the daily punches (staff signed in to work) for Licensed Nursing Staff on 07/04/2024, evening shift revealed there was one Registered Nurse (3:00 PM to 9:00 PM), two Registered Nurse Supervisors (3:00 PM to 11:00 PM), and one Licensed Practical Nurse (3:00 PM to 7:00 PM). The resident census was approximately 206 residents. The nurse to resident ratio from 9:00 PM to 11:00 PM was one nurse to approximately 103 residents. Review of the actual staffing sheets for 07/07/2024 revealed one Licensed Practical Nurse and one Registered Nurse Supervisor in the facility for night shift for 206 residents resulting in a nurse to resident ratio of one nurse to 103 residents. Additionally, there was one Certified Nursing Assistant assigned to both North 1 and North 2 during the 07/07/2024 night shift for 36 residents. Review of the Certified Nurse Aide Staffing sheet for 07/08/2024 revealed there were 12 Certified Nursing Assistants during the day shift for 213 residents or one aide per 18 residents. During an interview on 07/10/2024 at 1:35 PM, a family member stated the facility never had enough help and that there were several residents who required assistance with feeding but not enough staff to assist them all, so they tried to be at the facility daily to ensure their family member got fed. During an interview on 07/11/2024 at 12:18 PM, a second family member stated they had witnessed residents lying in stool for extended periods of time and not being changed timely and that the facility was short staffed on the weekends, sometimes with only two staff members on the unit (40 residents). The family member stated they had to wash the resident they were visiting that day. During an interview on 07/15/2024 at 2:58 PM, the Staffing Coordinator stated that on each unit there should be a minimum of three Certified Nursing Assistants and two Licensed Practical Nurses on the day and evening shift, and two Certified Nursing Assistants and one Licensed Practical Nurse on the night shift. When the staffing is under the minimum, all staff are contacted to attempt to fill the open shift and if unable to fill the shift other certified and/or licensed staff in the building will assist as needed. During an interview on 07/15/2024 at 4:26 PM, Nurse Practitioner #1 stated they were made aware about a week prior that medications had not been given for entire shifts due to not having a nurse available to administer the medications. During an interview on 07/15/2024 at 7:49 PM with the Administrator, Assistant Administrator, Regional Administrator and Regional Clinical Director, the Regional Administrator stated leadership had not been notified of the staffing concerns on 07/04/2024 and 07/05/2024. The Regional Administrator stated there was a recruiter specifically assigned to the facility and they felt there had been a lot of staff hired. The Regional Clinical Director stated several changes had been made which included posting open shifts, making schedule changes to accommodate staff, meetings held before the weekend to ensure there was enough staff, holding staff accountable for call-offs, and holding weekly general orientations to prevent delays in new staff starting. 6. During an interview on 08/01/2024 at 2:11 PM, Licensed Practical Nurse Manager #2 said residents on the South 1 unit did not receive their evening medications on 07/29/2024 because there was no nurse on the unit. Licensed Practical Nurse Manager #2 said residents' finger sticks (blood glucose levels) were also not checked (as ordered) because there was no nurse on the unit. During a follow-up interview at 2:51 PM, Licensed Practical Nurse Manager #2 showed the Electronic Medication Administration Record for the evening shift on 07/29/2024 and 32 residents with medications scheduled to be given were highlighted red, indicating that they had not been given medications during the shift. Review of the Medication Administration Audit Report for the South 1 unit residents from 07/24/2024 through 07/30/2024 revealed 28 residents were not administered their significant medications as scheduled during the evening shift on 07/29/2024. Medications included but were not limited to antiseizure medications, insulins, anticoagulants (blood thinners), antibiotics, blood pressure medications, analgesics (medications for pain), antipsychotics (medications that treat psychosis-related conditions and symptoms), antidepressants and medications for Parkinson's. Review of the actual staffing sheets for 07/29/2024 revealed Licensed Practical Nurse #17 was assigned to South 1 unit from 3:00 PM to 11:00 PM (evening shift). However, review of the daily punches report, dated 07/29/2024, revealed Licensed Practical Nurse #17 did not punch in or out, indicating they did not work, and the Director of Nursing was in the facility for the duration of the evening shift (until 11:56 PM). During an interview on 08/08/2024 at 11:57 AM, Nurse Practitioner #1 stated they were not in the building on 07/30/2024 and did not recall being notified that medications were not given to residents on South 1 during the evening shift on 07/29/2024. Nurse Practitioner #1 said they had heard of instances, usually once a week, in which medications were missed (not administered) and it was usually due to not having a nurse. During an interview on 08/08/1024 at 2:18 PM, Medical Director #1 stated they had been the facility's Medical Director up until 08/03/2024. Medical Director #1 stated they would expect to be notified if residents were not receiving their medications and they did not recall being notified that residents on an entire unit were not administered medications. The Director of Nursing did not return calls made on 08/07/2024 and 08/08/2024 requesting an interview. 10 NYCRR 415.13(a)(1)(i-iii)

Based on observations, interviews, and record review conducted during the extended Recertification Survey and complaint investigations (#s NY00339393, NY00343730, and NY00343916) from 07/08/2024 to 09/17/2024, for ten (Residents #69, #98, #106, #116, #122, #134, #140, #182, #456, and #457) of 13 residents reviewed, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #69 was lying in bed with no clothes on, there was a brown substance observed on their body, as well as, on the fitted sheet and the hospital gown that was underneath the resident's bottom. Resident #98 was in a wheelchair partially in the bathroom with their pants on the floor. There was stool on the floor near their bed and on the bed sheets with no staff in sight. Resident #106 was observed on several occasions with lack of incontinent care. Resident #116 was in bed and the incontinent pad underneath the resident was soiled and had a large brown stain that extended toward their mid-back with an odor of urine. Residents' #134 and #182 did not receive nail care over the course of several days. Resident #456 stated there was no aide on the overnight shift and they did not receive assistance with incontinence care until 4:00 AM. Resident #457 was observed lying in bed on wet linens and stated they required assistance with toileting, but staff did not come when they called for assistance, so they urinated in their brief. Resident #140 was observed sleeping in a bed that had no sheets in place and the resident was wrapped in what appeared to be a personal fleece blanket. Resident #122 was observed on several occasions with unwashed hair and long unshaven facial hair. This resulted in actual harm to Resident #106. This is evidenced by but not limited to the following: 1. Resident #106 had diagnoses that included a stage 4 (full thickness tissue damage) healing pressure ulcer (bed sore), depression, and hemiplegia (paralysis on one side of the body). The Minimum Data Set Resident Assessment, dated 05/02/2024, revealed the resident was cognitively intact, did not exhibit behaviors or rejection of care, required assistance with transfers and toileting hygiene, and was always incontinent of bladder and bowel. Review of the current Comprehensive Care Plan and the current Kardex (care plan used by Certified Nursing Assistants to guide care) revealed that Resident #106 required assistance with activities of daily of living, had bladder and bowel incontinence, and was at risk for impaired skin integrity. Interventions included, but were not limited to, check for needed assist with toileting every two hours and/or check and change incontinence brief as needed every three to four hours. Provide peri-care (private areas) after each incontinent episode and keep skin clean and dry with prompt removal of wet or damp clothing or sheets. During observations and interview on 07/08/2024 at 10:24 AM, Resident #106 was sitting upright in bed. There was the odor of urine and yellow and brown stains on the incontinence pad underneath the resident. Resident #106 stated they were soaked, had already eaten breakfast and had not been changed out of their wet incontinence brief since the previous night at bedtime. They said they put their call bell on for assistance and a nurse responded that the Certified Nursing Assistants were working their way down the hall. At 11:54 AM, Resident #106 remained in bed and stated they still had not been assisted with incontinence care. The room continued to have an odor of urine and the incontinence pad had not been changed. During an observation and interview on 07/11/2024 at 9:11 AM and again at 10:56 AM, Resident #106 remained in bed and stated they were again soaked and had not been changed since the previous night at bedtime. The incontinence pad placed underneath the resident was stained yellow extending from the incontinence brief and smelled of urine. Resident #106 stated they had not received care on 07/08/2024 until after they had eaten their lunch. During an interview on 07/11/2024 at 1:30 PM, Resident #106 stated they have requested repeatedly that they get changed prior to breakfast and lunch, but it is not being done and it makes them feel terrible (like a piece of crap), like they are not worthy of being given any service. During an interview on 07/12/2024 at 1:34 PM, Registered Nurse Manager #1 stated they had not received any complaints from residents about not receiving assistance with incontinence care from night shift until late morning. They said sometimes staffing was not good, and the facility was working on the issue, that they try to assist as much as possible and sometimes the linen cart does not get delivered to the unit until after breakfast which also affects care. During an interview on 07/12/2024 at 1:45 PM, Certified Nursing Assistant #13 stated the unit was understaffed most of the time and they feel unable to get everything done timely, including nail care, incontinence care, passing meal trays, and documentation. Certified Nursing Assistant #13 stated most times staff were unable to provide morning care until after breakfast due to no linen which often did not arrive until 10:30 AM or later and then not enough linen was provided, such as six towels and six incontinence pads for 40 residents. 2.Resident #69 had diagnoses that included cerebral infarction (stroke), muscle weakness, and adult failure to thrive. The Minimum Data Set Resident Assessment, dated 06/30/2024, revealed the resident had severe cognitive impairment and required assistance from staff for personal hygiene, dressing and bathing. Review of the current Comprehensive Care Plan revealed that Resident #69 required assistance with activities of daily of living and was incontinent of bladder and bowel. Interventions included, but were not limited to, check for needed assistance with toileting every two hours and/or check and change incontinence brief as needed every three to four hours. Provide peri-care after each incontinent episode. Review of the current Kardex revealed that Resident #69 could not be transferred to the toilet due to a medical condition or safety concern, used a high back chair, and were dependent on staff for toileting hygiene in bed. During an observation on 07/08/2024 at 9:55 AM, Resident #69 was lying in bed with no clothes on. There was a brown substance on their right heel, left hip, on the fitted sheet, and on the hospital gown that was underneath the resident's bottom. The resident's call bell was on the floor and not within reach. During an observation on 07/10/2024 at 12:40 PM, Resident #69 was in bed eating independently, the resident's sweatpants were on the bed next to the resident, and they were asking for someone to put their pants on them. At approximately 12:45 pm, Resident Assistant #2 (unit helper that does not provide direct resident care) entered the room, Resident #69 asked for assistance with their pants and Resident Assistant #2 stated they would assist them after lunch. During an observation and interview on 07/10/2024 at 2:18 PM, Resident #69 was observed in bed wearing their sweatpants, there was a brown pudding like substance on their shirt. Certified Nursing Assistant #8 stated they did not put the resident's pants on, and they were not sure who did. Certified Nursing Assistant #8 stated they usually did not put Resident #69's pants on until after meals due to the resident urinating. 3. Resident #116 had diagnoses including a history of subdural hemorrhage (pool of blood covering the brain), muscle weakness, and type 2 diabetes mellitus. The Minimum Data Set Resident Assessment, dated 05/24/2024, revealed the resident had severe cognitive impairment and was dependent on staff for personal hygiene and bathing. Review of the current Comprehensive Care Plan revealed Resident #116 required assistance with activities of daily of living and was incontinent of bladder and bowel. Interventions included, but were not limited to, check for needed assistance with toileting every two hours and/or check and change incontinence brief as needed every three to four hours. Provide peri-care after each incontinent episode. Review of the current Kardex revealed Resident #116 could not be transferred to the toilet due to a medical condition or safety concern and was dependent on staff for toileting hygiene in bed. During an observation on 07/08/2024 at 11:12 AM, Resident #116 was in bed and the incontinence pad underneath the resident was soiled with a large brown stain that extended toward their mid-back and there was an odor of urine in the room. During an interview on 07/15/2024 at 8:42 AM, Certified Nursing Assistant #11 stated they were the only aide on the unit that shift and was not sure if additional staff were coming. They stated they would not be able to assist all residents with morning care, turning and positioning, and feeding. During an interview on 07/15/2024 at 12:51 PM, Assistant Director of Nursing #2 stated they were not aware that South 3 (a 40-bed unit) only had one Certified Nursing Assistant on the unit on 07/08/2024, and the unit should have more than one aide on the day and evening shift. 4.Resident #98 had diagnoses that included dementia, muscle weakness and difficulty walking. The Minimum Data Set Resident Assessment, dated 04/08/2024, revealed the resident had moderately impaired cognition and required staff assistance for personal hygiene, toileting, and bathing. Review of the current Comprehensive Care Plan and the current Kardex revealed that Resident #98 required assistance with activities of daily of living and was incontinent of bladder and bowel. Interventions included, but were not limited to, check for needed assistance with toileting every two hours and/or check and change incontinence brief as needed every three to four hours. Provide peri-care after each incontinent episode. During an observation on 07/08/2024 at 11:17 AM, Resident #98 was in a wheelchair partially in the bathroom with their pants on the floor. There was stool on the floor near their bed and on the bed sheets, and there were no staff in sight. 5. Resident #457 had diagnoses including respiratory failure with supplemental oxygen and diabetes. A Nursing Admission Note, dated 07/02/2024, documented that Resident #457 was cognitively intact, incontinent of bladder, wore an incontinence brief, and had requested use of a bedside commode. Review of the Comprehensive Care Plan and Kardex revealed Resident #457 was incontinent of urine and stool, required supervision or touch assist for toilet transfers using a walker, used a bedside commode, and required incontinence briefs with checks and changes every three to four hours, or as needed. During an interview on 07/08/2024 at 9:41 AM, Resident #457 said they were not able to use the bathroom in their four-person room because the toilet was too low for them, and they used a commode (currently placed at the head of their bed). Resident #457 stated they are not provided proper care in that on some days they only got assistance and/or changed (incontinence care) once a day. During an observation on 07/09/2024 at 10:30 AM, Resident #457 was in bed. The bed linens were visibly wet from their left thigh to their upper right shoulder and the room smelled of urine. Resident #457 said staff had delivered their breakfast tray earlier and knew the sheet was wet as it was visible over their shoulder. During an observation and interview on 07/10/2024 at 12:56 PM, Resident #457 was sitting on the side of their bed and stated they could not use the bathroom toilet because they had arthritis, and it was too low for them. Resident #457 said they could not use the commode independently and when they called for assistance, staff did not come so they had to urinate in their brief. During an observation and interview on 07/10/2024 at 2:18 PM, Resident #457's bathroom had two toilets, both with the seats at about knee height (approximately one and a half to two feet in height). Certified Nursing Assistant #8 stated currently none of the four residents in the room used the bathroom because they were all dependent on staff for toileting. During an interview on 07/15/2024 at 11:00 AM, Certified Nursing Assistant #6 said if a resident was continent of urine, they would wait for the resident to call for assistance to use the bathroom or commode. If a resident was incontinent, incontinence care was provided after morning care and incontinence rounds were supposed to be done every two hours, which was hard to complete when the unit was short staffed. Certified Nursing Assistant #6 said they thought Resident #457 did know when they needed to use the bathroom and had only seen the resident use the commode for bowel movements. Certified Nursing Assistant #6 said residents should not have to void (urine or stool) in their brief if they were continent. During an interview on 07/15/2024 at 11:33 AM, Licensed Practical Nurse #5 said nursing staff should provide residents assistance with toileting either when the resident's call light was on or during rounding. Licensed Practical Nurse #5 said if a resident was continent, they should get up (to go to the bathroom). Licensed Practical Nurse #5 said Resident #457 was continent of urine and could get up but did not. Resident #457 preferred to have their soiled brief changed or to use the commode. Licensed Practical Nurse #5 said when they asked Resident #457 why they did not get up to go to the bathroom, the resident said it was due to their oxygen, so longer oxygen tubing had been offered (not observed in the resident's room at the time). During an interview on 07/15/2024 at 3:14 PM, Licensed Practical Nurse Manager #2 said Resident #457 received incontinence care because they were non-weight bearing and therapy was using the commode with the resident. Licensed Practical Nurse Manager #2 said a resident should not have to sit in urine or stool during meals as it was undignified. 6. Resident #182 had diagnoses including dementia, anxiety, and depression. The Minimum Data Set Resident Assessment, dated 04/30/2024, documented the resident had severely impaired cognition, required assistance with personal hygiene and had not refused care. Review of the current Comprehensive Care Plan and Kardex revealed Resident #182 required assistance with personal hygiene. During an observation on 07/08/2024 at 10:26 AM, Resident #182's fingernails were approximately one-half inch long on both hands and some nails had sharp, jagged edges. During an observation on 07/09/2024 at 9:31 AM, Resident #182's fingernails remained uncut, and several had sharp jagged edges. During an observation on 07/12/2024 at 10:50 AM, Resident #182 was dressed and walking in the hallway. Their nails remained long, broken, and had brown debris under them. When interviewed at that time, Certified Nursing Assistant #7 stated Resident #182's fingernails needed to be cut and although the resident was not on their assignment, they would cut them. During an interview on 07/15/2024 at 7:49 PM with the Administrator, Assistant Administrator, Regional Administrator and Regional Clinical Director, the Assistant Administrator stated the Quality Assurance Committee was aware of concerns related to assistance with activities of daily living and resident care audits were on-going. 10 NYCRR 415.12(a)(3)

Based on observation, interviews, and record review conducted during an Extended Recertification Survey and complaint investigation (complaint #NY00316457) [DATE] to [DATE], the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 10 of 184 residents reviewed for Quality of Care. Specifically, the facility failed to initiate Cardiopulmonary Resuscitation (CPR) to 1 (Resident #579) of 1 resident reviewed who had orders for Full Code (provide CPR) upon recognition of cardiopulmonary arrest (absence of pulse and breathing). The facility did not have a system in place to accurately identify a resident's choice to have advanced directives followed for 7 of 184 residents reviewed. Subsequently, Residents #20, 40, 44, 46, 69, 102 and 133 had Medical Orders for Life-Sustaining Treatment (MOLST) identifying their code status wishes as Do Not Resuscitate (DNR-do not initiate CPR) but had physician orders for Full Code status. Additionally, the facility failed to ensure a system was in place to monitor resident's bowel status and to initiate the bowel protocol as ordered and did not ensure all necessary staff had sufficient access to the facility electronic medical record (EMR) to document resident's Bowel Movements (BM) for 2 (Residents #140 and #116) of 7 residents reviewed for bowel management. Subsequently, Resident #140 was admitted to the hospital with a small bowel obstruction with a large stool blockage in the colon. This resulted in actual harm for Resident #579 and Resident #140 with the likelihood for serious harm for Residents #20, 40, 44, 46, 69, 102 and 133 that is Immediate Jeopardy and Substandard Quality of Care. The findings include but not limited to the following: Finding # 1: Resident #579 was admitted to the facility several months ago with diagnoses that included acute metabolic encephalopathy (disease of the brain that alters brain function or structure), and a stroke and was readmitted recently after a hospitalization for a gastrointestinal tube disfunction and replacement. The Minimum Data Set (MDS- a resident assessment tool) dated [DATE] documented that the resident was severely impaired cognitively. The facility policy Emergency Procedure - Cardiopulmonary Resuscitation, review date [DATE], included: - If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR (unless it is known that a DNR order exists or obvious signs of irreversible death). - If a resident's DNR status is unclear, CPR should be initiated until it was determined that there is a DNR or a physician's order to not administer CPR. A hospital discharge summary dated [DATE] 10:06 a.m. documented Resident #579's code status as Full Code. Review of Resident #579's EMR revealed no MOLST form. Physician orders dated [DATE] and again on [DATE] documented that Resident #579 code status was Full Code. In a Resident Progress Note dated [DATE] at 6:06 a.m., Licensed Practical Nurse (LPN) #5 documented that staff provided care (incontinence care and to administer a tube feeding) to the resident at 12:30 a.m.-1:00 a.m. On 2:00 a.m. rounds, the resident was found unresponsive in their room, the Registered Nurse Supervisor (RNS) #1 was notified, and Resident #579 expired at 2:00 a.m. In a Resident Progress Note dated [DATE] at 6:38 a.m., RNS #1 documented that Resident #579 was found non-responsive, they were notified (time not noted), and an assessment completed. The resident was cold to the touch, cyanotic (blue or purplish discoloration of the skin), mottling (patchy discoloration of the skin) was beginning on the back of the resident's body and no heartbeat was heard for 60 seconds. The resident was pronounced (deceased ) at 2:40 a.m. Review of the Event Summary signed (but not dated) by the Director of Nursing (DON) revealed that on [DATE] at 2:38 a.m., RNS #1 was called to Resident #579's room after the resident was found unresponsive and not breathing by a Certified Nursing Assistant (CNA). RNS #1 performed an assessment and determined due to their observations CPR should not be initiated, and Resident #579 was pronounced deceased at 2:40 a.m. The facility investigation identified that upon review of the documentation, RNS #1 had pronounced the resident at 2:40 a.m., but LPN #5 had documented that the resident expired at 2:00 a.m. RNS #1 documented that LPN #5 had stated that they thought the resident must have expired at 2:00 a.m. based on their observations (of the resident). The facility investigation included that LPN #5 could not locate the binder which contained the resident's MOLST forms so proceeded to check the EMR which included Full Code orders. The facility's conclusion included that the resident was a Full Code, but when RNS #1 arrived and based on their assessment, they determined performing CPR would be medically futile. The follow up included that LPN #5 and all staff would need to be educated regarding the facility CPR policy. During an interview on [DATE] at approximately 10:00 a.m., LPN #5 stated that between 1:00 a.m. to 1:30 a.m., CNA #15 checked on Resident #579 and informed LPN#5 that the resident was not breathing. LPN #5 stated that they went to the resident's room and found the resident with their eyes wide open, pale, cold to the touch and they checked for a pulse for approximately 30 seconds. LPN #5 stated that they did not know the resident's code status, and they did not start CPR because they did not want to get in trouble for ignoring the code status. LPN #5 stated that they went to call the supervisor while two CNAs stayed with the resident. LPN #5 stated that they were preparing to start CPR while waiting for RNS #1, and that it took between two to three minutes for RNS #1 to get to the unit. LPN #5 stated that when RNS #1 arrived, they were advised that Resident #579 was a full code. During an interview on [DATE] at 3:15 p.m., Nurse Practitioner (NP) #1 stated that if staff were to find a resident who was a Full Code unresponsive, CPR should be started. If their code status was unknown nursing staff should check vital signs and notify the supervisor, who could check the code status. NP#1 stated they would expect the nurse to check the resident's code status prior to starting CPR. During an interview on [DATE] at 6:40 a.m., RNS #1 stated that the CNAs had gone in to see Resident #579 and realized that the resident had passed. RNS #1 stated that LPN #5 had called them and had looked in the computer instead of the MOLST binder for the resident's code status. RNS #1 stated that it was LPN #5's first time with this situation and that LPN #5 did not call a Code Blue (medical emergency such as cardiac or respiratory arrest) and did not call 911 as they should have. RNS #1 stated that it took them no more than two minutes to reach the unit and found Resident #579 cool with their lips and fingertips cyanotic, mottling and no heartbeat for 60 seconds using a stethoscope. RNS #1 stated that they were told of the resident's code status as they were walking in the room but that they did not start CPR as there was blood pooling at the back of the resident's legs and that they determined that the resident had been gone for more than 15 minutes and that it was not possible to bring the resident back. During an interview on [DATE] at 12:36 p.m., LPN #8 stated if a resident was found unresponsive, they would obtain vital signs, check the resident's MOLST and call the RN to assess. LPN #8 stated if they were unable to find the MOLST, then the resident is considered a full code and they would do everything they could to revive the resident such as call 911 and do CPR until they determine their code status. LPN #8 stated that the only person who can determine not to start CPR is the RN. Resident #69 had diagnoses that included pneumonia, diabetes, and dysphagia (difficulty swallowing). The MDS assessment dated [DATE], revealed that the resident was cognitively intact. The MOLST form dated as signed by NP#1 on [DATE], documented the Resident #69's code status was DNR. Review of current active physician orders revealed Resident #69's code status was Full Code. Resident #133 had diagnoses that included Alzheimer's dementia and anxiety disorder. The MDS assessment dated [DATE], documented the resident had severely impaired cognition. The MOLST form, initially signed on [DATE] and last reviewed on [DATE], documented Resident #133 code status was DNR. Review of active physician orders, dated [DATE], revealed Resident #133's code status was Full Code. In a History and Physical medical note, dated [DATE], the physician documented under History that Resident #133's code status was Full Code but under Advanced Care Planning the physician documented that the resident's MOLST form was reviewed, and the resident's code status was DNR. In a subsequent medical progress note dated [DATE], the physician documented the resident's code status as Full Code and confirmed that the patient's Advanced Care Plan was documented in the medical record. During an interview on [DATE] at 9:54 a.m., LPN #3 stated that MOLST forms were supposed to be reviewed every 60 days with medical visits but had not been done in a while due to COVID-19 and changes with providers and ownership. Previously, the Unit Managers were provided a list of residents whose MOLST forms would be pulled and provided to the doctor to sign when doing visits. LPN #3 stated that they would expect staff to identify a resident's code status by the MOLST form or reviewing the orders in the EMR. LPN #3 stated that in the past, there were audits on Advanced Directives that checked to ensure the MOLST matched the order, and that they were not sure how often the audits were done. When requested, the facility could not provide any audits. During an interview on [DATE] at 9:31 a.m., the Director of Social Work (DSW) stated that upon admission, Social Work (SW) reviews advance directive wishes with either the resident or their representative (depending on resident's capacity). The DSW stated that a resident is a Full Code if the resident cannot decide and if the representative does not respond. The DSW stated that the MOLST forms are scanned into every resident's EMR and placed in the binder on the resident's unit. Nursing is then responsible for checking that the MOLST form corresponds with the physician order and is also responsible for changing the code status orders if appropriate. During an interview on [DATE] at 9:39 a.m., the DON stated that SW is responsible for reviewing the resident's advance directives on admission, and that the medical provider should review and sign the resident's advance directives upon admission, readmission, and every 60 days. The DON stated that nursing is responsible for checking the accuracy between the MOLST and the physician orders for code status. The DON stated that they thought that SW was doing MOLST audits to check the accuracy between the MOLST, physician orders and the EMR but was unsure of how often the audits were conducted but it has been a struggle since we (new management) took over. The DON stated that if a resident was found unresponsive and not breathing, a Code Blue should be called, and the MOLST form checked. The DON stated that if the resident was a Full Code, CPR is to be started and continued until EMS arrives. During an interview on [DATE] at 10:10 a.m., NP #1 stated that they do not enter the code status in the EMR, but that they verify it and that it is reviewed every 60 days. During an interview on [DATE] at 10:09 a.m., the Medical Director stated that if nursing staff were to find a resident unresponsive, they would expect staff to call a code and call 911. The Medical Director stated that if a resident's code status was unknown, CPR should be started right away and not wait to find out the resident's code status and you can stop CPR if the resident's code status is identified as DNR. The Medical Director stated staff should know where residents' code status information is located and stated they were unaware of any discrepancies in resident's code status. During an interview on [DATE] at 1:58 p.m., LPN #16 stated that on admission, the admission nurse would enter a code status order based on what was listed on the resident's After Visit Summary (AVS) from the hospital. LPN #16 stated that it is the responsibility of the NP or SW to discuss a resident's advance directive wishes and complete and sign a MOLST form. LPN #16 stated that the order should be updated if different from the MOLST. LPN #16 stated that they are not sure how the discrepancy between Resident #69's MOLST form, and code status order occurred, and that there must have been a break in communication. Immediate Jeopardy (IJ) was identified and declared on [DATE] and the facility Administrator was notified at 3:39 p.m. On [DATE] at 7:41 p.m., the survey team declared that the IJ was removed based on the following corrective actions taken by the facility: - Completed immediate re-education/training regarding advance directives and Basic Life Support for all licensed nursing staff. The re-education included the location of all advance directive information of each resident. Any licensed staff noted to be on vacation, sick leave, or any other leave of absence would be educated prior to working another shift. All licensed nursing staff including agency nurses, onboarded on or after [DATE] would receive education and training regarding the same upon hire. - A facility-wide code status audit was conducted to ensure all orders and MOLST forms were correct and accurate. Finding #2: Resident #140 had diagnoses including constipation, hypothyroidism (low levels of thyroid hormone potentially slowing the body's metabolism), and dementia. The MDS assessment dated [DATE] documented the resident had severe cognitive impairment and was always incontinent of bowel. The facility policy Bowel Protocol, review date [DATE], included: - As part of the initial assessment, the staff and physician will help identify individuals with previously identified lower gastrointestinal tract conditions and symptoms. This should include a review of gastrointestinal problems during any recent hospitalization s. - Staff will initiate the Bowel Protocol as directed by the Medical Director for Milk of Magnesia (laxative) 30 milliliters (ml) (or for renal residents- lactulose 30 ml) for no bowel movement (BM) x 3 days, followed by Dulcolax (laxative) suppository 10 milligrams (mg) and if no results Fleet enema. MD notification is required during the protocol implementation. - The physician will adjust interventions based on identification of causes, resident responses to treatment, and other relevant factors. Physician Orders for Resident #140 dated [DATE] documented Dulcolax tablet 5 mg, give 10 mg (2 tablets) once a day and Dulcolax suppository 10 mg, administer rectally once a day as needed for constipation. Resident #140's [DATE] BM Report documented that Resident #140 had a BM on [DATE]. The next documented BM was dated [DATE]. Review of the Medication Administration Record (MAR) dated [DATE] - [DATE] revealed no documented bowel protocol medications had been administered from [DATE] through [DATE]. Resident #140 was admitted to the hospital on [DATE] with a diagnosis of a small bowel obstruction with a large stool blockage in the colon. The hospital Discharge Summary dated [DATE] included diagnoses of small bowel obstruction, large stool burden (large amount of stool), and dementia with a recommendation to monitor for daily bowel movements and administer Dulcolax suppository/tap water enema if no bowel movements noted in ,d+[DATE] days. Physician Orders dated [DATE] documented Dulcolax tablet 10 mg once a day as needed and Dulcolax suppository 10 mg, administer rectally once a day as needed for constipation. In a Resident Progress Note dated [DATE], NP #1 documented to continue monitoring daily bowel movements to make sure the patient receives Dulcolax suppository/tap water enema if no BM noted in ,d+[DATE] days. In a Resident Progress Note dated [DATE] identified as a late entry note at 2:30 p.m., LPN #3 documented that Resident #140 had a BM during the night. The BM Report dated [DATE] - [DATE] documented no BM after [DATE]. Review of the MAR dated [DATE] - [DATE] revealed no documented bowel protocol medications had been administered from [DATE] through [DATE]. During an interview on [DATE] at 6:31 a.m., LPN #4 (agency nurse) stated they had not been educated son the facility's bowel management protocol, but they would rely on previous training that if no BM in 3 days to initiate a bowel protocol. LPN #4 stated they were not educated on where to locate residents' BM records. During an interview on [DATE] at 6:36 a.m., Certified Nurse Assistant (CNA) #7 stated BMs are recorded in each resident's EMR, but they were unable to access the EMR. CNA #7 stated Resident #140 had not had any BMs on their night shift. During an observation and interview on [DATE] at 6:52 a.m., the DON assessed Resident #140 (after surveyor identified lack of documentation for BMs) and stated the resident's bowel sounds were diminished in all four quadrants and the abdomen was distended. The DON stated that the bowel protocol should be initiated when a resident has not had a BM in 3 days, and the medical team notified. The DON stated they would expect nursing to be monitoring Resident #140's bowel status closely as a bowel obstruction is a serious condition. In a follow up interview at 7:17 a.m., the DON stated Resident #140 had no documented BM since [DATE], that the bowel protocol had not been initiated and they would consider the lack of documenting BMs a system failure with the potential for harm for Resident #140 secondary to their history of small bowel obstruction and the medical team was notified. During an interview on [DATE] at 9:06 a.m., NP #1 stated they expected nursing to monitor and document residents for daily BMs and to monitor for possible abdominal obstruction. NP#1 stated they were not notified that Resident #140's BMs were not being monitored daily and had no documented BMs since [DATE]. NP#1 stated staff caring for residents should have access to document in the facility's EMR or to utilize an alternate back up documentation system and that this could be harmful to Resident #140. During an interview on [DATE] at 1:37 p.m., CNA #8 stated they had provided care for Resident #140 on [DATE] and assisted the resident to the toilet. CNA #8 stated there was an odor of a BM, but they did not see one because the resident flushed the toilet but that they did report this to the resident's assigned CNA. Review of the resident's EMR at this time revealed no BM had been documented for [DATE]. During an interview on [DATE] at 1:54 p.m., the Registered Nurse/Regional Clinical Director stated if a resident had no BM in 72 hours staff should implement the bowel protocol per policy. Additionally, they stated they were aware of staff being locked out of the EMR and was unable to provide verification that all staff currently had access. During an interview on [DATE] at 2:49 p.m., LPN #6 Clinical Coordinator stated they started generating resident bowel reports from the EMR ,d+[DATE] weeks ago, found missing documentation for several resident's bowel movements and that staff had reported an inability to document due to no EMR access. LPN #6 Clinical Coordinator stated they then started emailing (Information Technology) to get them access and informed the Nurse Managers. During an interview on [DATE] at 10:09 a.m., the Medical Director stated nursing staff should have been monitoring BMs and bowel sounds every shift for Resident #140 and if no BMs reported for 2 days, the bowel protocol should have been initiated and medical notified. IJ was identified, and the facility Administrator was notified on [DATE] at 5:18 p.m. On [DATE] at 1:47 p.m., the survey team declared that the IJ was removed based on the following corrective actions taken by the facility: - 90% of licensed nurses were educated on bowel protocol. - 90% of nursing staff were educated regarding BM logs and documentation requirements. - EMR access was obtained for all nursing staff and education regarding back up paper documentation provided. - Every unit had at least one operational kiosk and one operational desktop computer for nursing documentation and an Activity of Daily Living binder including BM logs. 10 NYCRR 415.12

Based on interviews and record review conducted during an Abbreviated Survey (complaint #NY00283953) completed on 1/21/22, the facility failed to protect residents' rights to be free from sexual abuse for one (Resident #1) of three residents reviewed for abuse. Specifically, Resident #1, who had severe cognitive impairment, was sexually assaulted by Housekeeper (HK #1). It was determined that Resident #1's likelihood to experience actual psychosocial and physical harm (which is not an Immediate Jeopardy) using the reasonable person concept (referenced in the Centers for Medicare and Medicaid Services Psychosocial Outcome Severity Guide) occurred because of the alleged assault. This is evidenced by the following: Review of the facility policy Abuse, Neglect, and Exploitation Prohibition, Training, Investigation, and Reporting Policy dated as reviewed 9/29/21, documented that it was the policy of the facility to ensure there are procedures and systems in place to prohibit and prevent abuse, neglect, exploitation, mistreatment, crime, involuntary isolation or seclusion, serious bodily injury, injuries of unknown source, and/or misappropriation of personal property by staff or fiduciaries, which includes compliance with all applicable laws and regulations including, but not limited to, the Elder Justice Act. Resident #1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, frontal lobe deficits (damage to brain function) and anxiety disorder. The Minimum Date Set Assessment, dated 5/19/21, documented that the resident had severe impairment of cognitive function with a BIMS (Brief Interview for Mental Status) score of 5/15. The current Comprehensive Care Plan (CCP) for cognitive loss/dementia, documented that Resident #1 had impaired cognition due to Alzheimer 's disease and had short-term and long-term memory deficits. The CCP for communication documented that the resident did not speak in the dominant language of the facility and spoke Spanish. A Report of Resident Incident/Accident, dated 9/29/21, included a witness statement by the Social Worker (SW) that at approximately 7:00 a.m., the SW was walking past Resident #1's room and noted their privacy curtain partially pulled so they entered the room to check on the resident. As the SW rounded the curtain, the SW saw Resident #1 standing next to the nightstand with their pants and brief down and HK #1 up against them from behind with their right hand in front of Resident #1 making thrusting motions. The SW immediately asked, What are you doing? and yelled at HK #1 to get away from the resident. HK #1 was then seen fumbling with the front of their pants and backed away from the resident saying, I'm sorry, I'm sorry. HK #1 was then sent out into the hallway where they were monitored by staff. Review of a written statement (obtained by the facility) from Certified Nursing Assistant (CNA) #1, dated 9/29/21, revealed that at approximately 7:10 a.m., they were requested to assist Resident #1 with language translation. CNA #1 entered the resident's room and asked (in Spanish) what had happened. Resident#1 was crying. CNA #1 sat with the resident and asked if Resident #1 was okay, to which Resident #1 did not answer. CNA #1 asked if someone touched them and the resident answered, yes. When asked where they had been touched, Resident #1 pointed to their pelvic area. Leaving Resident #1 with CNA #2 while CNA #1 reported back to facility staff, CNA #1 then told the resident and CNA #2 not to use the bathroom or remove any clothing as requested by facility staff. Upon returning to the room, CNA #1 saw the resident motioning pulling their pants down and stating me quita los pantalones. CNA #1 translated that as meaning they pulled my pants down. Resident #1 repeated this twice. When asked more questions Resident #1 shut down and would not answer any further. CNA #1's witness statement included that the resident cried the entire time CNA #1 was with them. A nursing progress note, dated 9/29/21, documented that the nurse was called to Resident #1's room at 7:00 a.m., to find the SW, who explained that a Housekeeper had allegedly sexually assaulted the resident. A full head to toe assessment was completed on the resident who was visibly upset and crying. There were no visible injuries or bruises noted. A Spanish speaking CNA (CNA #1) asked Resident #1 if they had been touched and the resident nodded yes. Resident #1 was asked if they were penetrated to which Resident #1 would not answer. A call was placed to 911 services requesting an ambulance and the police. At approximately 7:45 a.m., Resident #1 was taken to the hospital via ambulance. In a Supporting Deposition obtained by the Rochester City Police Department, dated 9/29/21, the SW documented that they were doing their rounds on South 2 and walked by the [Resident room number] and saw the curtain was partially pulled. The SW found this odd and entered the room to make sure the resident was ok. The SW documented that when they entered the room the resident was standing against the nightstand with their pants down around their knees. HK #1 was standing behind the resident. HK #1 had their right hand around the resident and was pressed up against them. HK #1was thrusting their hips up into the resident. HK #1 was still wearing their pants. The SW documented that they yelled What are you doing?! HK #1 stopped and began fiddling with the front of their pants. The SW documented they could not see exactly what HK #1 was doing. HK #1 backed away, began to laugh and began apologizing, saying, I'm sorry. The SW escorted HK #1 out to wait for police. In a Supporting Deposition obtained by the Rochester City Police Department, dated 9/29/21, CNA #1 documented they started their shift on 9/29/21 at 7:00 a.m. and was asked by SW to check in on the resident because they also spoke Spanish. CNA #1 documented that the resident was very upset and was crying. CNA #1 asked everyone to step out so they could speak with the resident. CNA #1 documented that they asked the resident if they were ok, the resident responded with silence. When asked if the resident was in pain, the resident responded Yes. CNA #1 documented that they asked the resident if someone had touched them, and the resident responded yes. When asked had someone touched them, the resident made a circular motion in the area of their pelvis. The resident was crying the whole time and was still very upset. CNA #1 documented they stepped out of the room after telling the resident not to use the bathroom or remove their clothing. CNA #1 documented that they returned a short time later as staff was having trouble keeping the resident calm. CNA #1 documented that the resident told them in Spanish He pulled my pants down twice. A hospital summary of care report, dated 9/29/21, documented that Resident #1 was seen due to being the victim of an alleged sexual assault and a rape kit was completed. The report indicated there was no obvious trauma on examination. In an interview on 9/30/21 at 11:45 a.m., the Administrator stated HK#1 had been employed by the facility since October 2017, The Administrator stated they were not aware of any concerns or issues from residents or staff regarding HK#1 and that there was nothing in their personnel file. When interviewed on 1/21/22 at 11:45a.m., the Director of Nursing stated that further interviews with residents and staff were not completed due to the Deputy Attorney General's office directing the facility to cease all investigations. When interviewed on 1/21/22 at 12:10 p.m., the Director of Environmental Services (DES) stated that they had never had any concerns with HK#1 and had not received any complaints from any facility staff regarding the HK#1's behavior. The DES stated that housekeeping staff are trained to never put hands on residents including that they are not even allowed to push residents in their wheelchairs. 415.4 (b)(1)(i)

Based on observations, resident and staff interviews, and record reviews, it was determined that for six (Residents #6, #67, #71, #87, #112, and #132) of six residents reviewed for accidents, the facility failed to ensure that the residents' environment remained as free of accident hazards as possible. Specifically, chunks of cracked, chipped, and flaking concrete debris had fallen to the ground from the facility's roof line (three story building) and from window ledges at the second floor level onto the courtyard/patio grounds area used routinely by residents without supervison. The facility failed to have a system in place to ensure that the exterior of the building was maintained to provide a safe environment in resident accessible areas. THIS IS A REPEAT DEFICIENCY FROM THE RECERTIFICATION SURVEY OF 4/4/11. This resulted in no actual harm with potential for serious harm that is IMMEDIATE JEOPARDY TO RESIDENT HEALTH AND SAFETY and is SUBSTANDARD QUALITY OF CARE. This is evidenced by, but not limited to, the following: Observations made on 1/31/12 from 3:30 p.m. to 3:40 p.m. revealed visible deterioration of concrete along the exterior surfaces of the east side of the building, where the enclosed courtyard/patio is located. There were two chunks of concrete that measured approximately 4 inches x 4 inches x 1 inch and 3 inches x 1/2 inch thick lying on the patio surface adjacent to the canopy/awning. During an observation that began on 2/1/12 at 1:30 p.m., Resident #67, seated in a wheelchair, independently and without supervision wheeled out of the building into the courtyard/patio area. The door to the courtyard was unlocked. Two Sanitarian surveyors entered the courtyard behind the resident. At this time, the Sanitarians observed the following: a. The concrete windowsill located approximately 15 feet above the awning/canopy area was cracked and worn. Sections of the concrete windowsill were missing. b. A sitting bench, labeled, "In memory of the Bus Driver," was located in the northeast corner of the patio. About 15 feet directly positioned over the sitting bench, the window sill of a second story window was cracked. A concrete piece of windowsill that measured approximately 3 x 8 feet x 8 inches was very loose and ready to fall. c. There were several chunks of concrete debris lying on the patio grounds near the emergency walking path for the South 1 dining room. The surfaces of the concrete pillars and roof ledge located directly above this area of egress showed evidence of cracked, flaking, and loose concrete pieces that measured approximately 10 x 10 inches and 3 feet x 10 inches. There were several pieces of concrete scattered about the patio grounds. Broken sections were visible on the concrete exterior wall located approximately 20 feet above the patio floor. Small pieces of concrete were sitting on surfaces of a table and chairs used by residents. d. Doors marked with illuminated exit signs direct occupants to use the activity courtyard patio/exit discharge pathways in the event of an emergency. e. Concrete was scattered on the patio walkway near the first floor North conference room exit. The concrete roof overhang located approximately 20 feet above this exit, just outside Room #208 (North 2), was cracked and flaking. The section measured approximately 3 x 10 inches. Resident and staff interviews conducted on 2/1/12 are as follows: a. At 2:15 p.m., the Director of Nursing (DON) stated that residents are not directly supervised while in the courtyard. b. At 2:16 p.m. in the Social Work office overlooking the courtyard, the Social Worker stated that Resident #6, who is wheelchair dependent, goes into the courtyard daily regardless of the weather. Resident #87, who is wheelchair dependent, visits the courtyard two or more times per week, weather permitting; Resident #71, one to two times per day; and Resident #112, one time per day. c. At 4:20 p.m., Resident #67 stated that she had been in the courtyard that week including that day and had not wheeled over or seen any falling debris. She reported that Residents #112 and #132 also go to the courtyard. d. At 4:23 p.m., Resident #71 stated that he goes to the courtyard and walks around or sits out there. e. At 4:26 p.m., Resident #112 stated that she goes to the courtyard unassisted and had been out there that week. f. At 4:36 p.m., the Administrator reported that he did not know there was concrete falling away from the exterior building walls surrounding the courtyard/patio that is regularly used by residents. He did know that there were similar issues in the front of the building. The Administrator reported that the facility did not have a procedure in place to ensure the exterior surfaces of the building were maintained to ensure resident safety. g. At 4:43 p.m., while in the courtyard, Resident #132 stated that he walks around in the courtyard and sits in the chairs and sometimes on the bench when the weather is nice. At that time, Resident #132 said he has never been told by staff that he should not go into this area except when the weather is really bad. During an observation made on 2/2/12 at 9:30 a.m., maintenance staff removed chipped concrete along the window ledges and roof line located in the activity courtyard via a ladder. An approximately 15 x 5-inch x 1-inch thick section of concrete was easily removed by hand and dropped to the ground. Other pieces were also easily removed by hand in the northeast corner of the patio. By 11:00 a.m. that day, loose concrete had been removed from upper levels of the courtyard from the awning, eastward. The narrow area of the courtyard between South 1 dining room and the Social Work office had loose concrete remaining at the top of the second floor level. In an interview on 2/2/12 at 10:12 a.m., the former Maintenance Director said he was not aware of the conditions of the concrete on the exterior surfaces of the building surrounding the courtyard/patio area. He stated that there had been no preventative maintenance program in place to address the conditions of external building surfaces. In an interview that day at 11:39 a.m., the Administrator confirmed that issues related to loose concrete on the exterior surfaces of the building had been addressed two years ago and had not been identified as a concern to be followed by the facility's Quality Improvement program. On 2/3/12 the facility alleged they had made appropriate interventions to ensure that the exterior building surfaces were as free of accident hazards as possible. The following interventions serve as the facility's allegation of compliance to remove the Immediate Jeopardy situation. On 2/1/12 the following interventions were implemented: a. At approximately 4:30 p.m. the facility implemented policies and procedures which would safeguard the residents from falling debris in the courtyard. b. The former smoking area was taped off with yellow caution tape. c. A large stop sign with mesh netting was placed against the doorway to alert staff, residents, and visitors that this area was off limits. d. The Administrator, Assistant Director of Nursing, and In-Service Coordinator met with the evening supervisor to establish facility approach. e. It was determined that the Supervisor would do one hour checks of the courtyard to ensure residents were not in the courtyard. f. An audit tool was developed to document the one hour checks of the courtyard. g. The Supervisor in-serviced all evening staff regarding the temporary closure of the courtyard. h. A sign was placed on the alarm panel at the North Nursing Station stating, "If this alarms, contact the Supervisor immediately." This alarm is wired to the door exiting the courtyard. i. The night supervisor inserviced all night staff regarding the temporatry closure of the courtyard. j. At approximately 6:00 p.m., the Administrator spoke with five residents who frequently use the courtyard and advised them not to use the area until further notice. The following interventions were put in place on 2/2/12: a. On the morning of 2/2/12, the courtyard audit tool documenting hourly checks, completed by the evening and night supervisors, were reviewed by the surveyors. b. At 9:30 a.m. that day, the maintenance crew used a hammer to strip away all loose particles. c. The surveyor and Administrator walked around and identified other areas with potential problems, and these areas were also corrected. d. Once all the loose concrete was knocked off the window sills, all pieces were picked up and disposed of properly. e. By 2:00 p.m. all areas that had material at risk for falling was stripped away to eliminate any immediate concern. f. At 3:00 p.m. visual inspection was completed by the Administrator and the surveyor. Upon completion of the remedial work, the Administrator and the Director of Maintenance evaluated the areas and found all areas safe for resident use. g. The Administrator will select a contractor in the spring to repair the affected areas. The facility has revised and implemented policies and procedures to incorporate tours of the exterior of the building. h. This tour will include a visual inspection of the exterior windowsills and ledges for loose concrete including the courtyard and will be included in monthly safety tours. The results of these tours will be presented at the monthly safety meetings. (10 NYCRR 415.12(h)(1))

Based on observations, resident and staff interviews, and record reviews, it was determined that for one of three residents reviewed for pressure sores, the facility did not thoroughly assess and implement preventative measures in a timely manner to ensure that resident's skin integrity was maintained and/or that healing was promoted. Specifically, qualified staff did not complete skin assessments in a timely manner, and preventative skin care measures were not implemented until after pressure sores developed. This affected Residents #213 and resulted in actual harm that is not Immediate Jeopardy, and is evidenced by the following: The facility's policy for skin care guidelines, dated February 2010, directs that all residents will have a full body skin assessment and risk factors identified on admission using the Braden scale. Appropriate nursing intervention will be applied as established by the skin care standards. Residents identified to be at risk will be noted on the care plan and interventions noted on the Certified Nursing Assistant (CNA) assignment sheet (care sheet). Proper positioning, transferring, and turning techniques will be used at least every two hours in an effort to prevent or decrease injury to skin for residents who are bed bound, bed to chair and chair bound. Guidelines for residents who are identified at high risk for pressure ulcers includes the following: elevate heels off the bed surface; use a pillow between the knees; if bed bound, reposition every two hours; if chair bound, reposition hourly; use skin protecting ointments and/or creams to protect skin exposed to urine or stool. Resident #213 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a physician's note, dated 9/13/11, revealed that the resident had leg [MEDICAL CONDITION] and a lack of sensation in the lower extremities. The Comprehensive Care Plan, dated 9/15/11, and the Certified Nursing Assistant (CNA) Resident Specific Assignment Sheet (care sheet) both show that the resident needs total assistance for cares related to Activities of Daily Living due to [MEDICAL CONDITION]. The care sheet also includes that the resident is to wear sneakers when not in bed. According to the Monthly Weight Record, the resident weighed 172 pounds on 11/10/11. Review of the Minimum Data Set (MDS) Assessment, dated 11/12/11, revealed that the resident is cognitively intact, totally dependent upon staff for dressing, and has no open wounds or skin issues on the feet. In a progress note, dated 11/15/11, the physician documented that the resident did not have leg [MEDICAL CONDITION]. In a progress note, dated 12/8/11, the Physician Assistant (PA) documented the presence of an unstageable pressure sore, quarter sized, located on the posterior aspect of the right foot, and an unstageable pressure sore, dime sized, located on the medial aspect of the surrounding skin. The PA's plan included an Allevyn heel cup treatment daily and to keep the resident's shoes off as much as possible. Review of the Monthly Weight Record, dated 12/13/11, revealed that the resident's weight was recorded at 186 pounds, a 14-pound weight gain in since 11/10/11. In a progress note, dated 12/16/11, the PA noted that the resident's right heel area had opened and is draining. The PA wrote that that the resident has worn a sneaker 12 hours a day. The PA's plan now changed to an [MEDICATION NAME] treatment covered with a heel cup and the use of an open back shoe on the right foot. The PA noted that this plan was discussed with the resident and the nurse. The physician progress notes [REDACTED]. The Wound Care Flow Sheet, dated 12/21/11, has an entry for a left heel unstageable pressure sore receiving a [MEDICATION NAME] dressing. A PA progress note, dated 1/10/12 documented the resident's 14-pound weight gain, identified the presence of [MEDICAL CONDITION], and initiated a plan to add diuretic medication to treat the [MEDICAL CONDITION]. A PA progress note, dated 1/23/12, records the presence of a new pressure sore on the left heel and open areas on the right heel caused by foot wear. During an interview on 2/6/12 at 3:48 p.m., the Licensed Practical Nurse (LPN) reported that the resident had been wearing ill fitting sneakers, and when the sneakers were checked for rubbing and friction, it was determined that the right Achilles (back of lower leg just above heel) was rubbing against the back of the sneaker and had caused blistering. This blistering resulted in open areas on her feet. The resident was told not to wear sneakers at all. Interviews conducted on 2/7/12 are as follows: a. At 3:35 p.m. the Registered Nurse (RN) Nurse Manager (NM) said the resident had been squeezing her feet into the sneakers, and nursing believed this was the cause of the pressure sores on the resident's feet. b. At 1:01 p.m. the resident said her shoes became very tight from the fluid in her feet, and she got blisters on her feet. She said she wore her sneakers because no one told her not to wear the sneakers until the blisters broke. Interviews conducted on 2/7/12 are as follows: a. At 8:33 a.m. the only regular CNA working on the unit stated that she took care of the resident for about two weeks when she was first admitted . The CNA said the resident wore her sneakers every day and did not have any problems with her feet. The last time she took care of the resident, she was not wearing sneakers. The CNA also stated that if she noticed that a resident's shoes did not fit correctly, she would let the Social Worker know so the resident could get new shoes. b. At 9:36 a.m. the float CNA stated that she follows the CNA care sheet, and if it says to put sneakers on, as long as the resident wants them on, she puts them on. When asked what she would do if the shoes were too tight, the CNA stated she would tell the NM. (10 NYCRR 415.12(c)(1))