Every finding on record at West Lawrence Care Center. LLC

Based on observations, record review, and interviews conducted during the Recertification and Complaint Survey from 07/28/2025 to 08/04/2025, the facility did not ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was evident during review of Staffing, Residents' food preferences, Dignity, Home like Environment, Resident Assessment, and Abuse, 1.) The Administration did not ensure the facility was sufficiently staffed to meet the residents' needs, residents' assessments were accurate, and their dietary preferences met. In addition, the Administration did not monitor and enhance the quality of care and services as indicated by repetition of deficiencies that were cited on previous recertification surveys {F584 and F657} 2.) Nursing Services were not administered adequately to ensure that residents rights and preferences were provided to the residents, that home like environment were maintained, and that participation in care planning occurred. The findings are:The facility's policy titled Quality Assurance and Performance Improvement of [NAME], effective 1/1/22, last reviewed 02/25, documented that Quality assurance performance improvement principles will drive the decision making within the organization. Decisions will be made to promote excellence in quality of care, quality of life, resident choice, person directed care and resident transitions. 1. Refer to citation F577, F582, F584, F600, F609, F627, F675, F725, F813, and F921On 08/04/2025 at 4:09 PM, the Administrator was interviewed and stated they were not aware of any environmental issues, the residents' food preferences, nor that there were concerns about dietary preferences as there were never any complaints made about resident's food choices and preferences. The Administrator also stated they were aware that sufficient nursing staffing was an issue and nursing staff are given incentives to pick up other shifts, and that there was an oversight in not posting all surveys. The Administrator further stated they aware of a resident's discharge to the hospital but did not consider it an issue. monitored to prevent recurrence. The Administrator was interviewed for Quality Assurance and stated that meetings for Quality Assurance are held monthly, where several topics are discussed. 2. Refer to citation F550, F553, F584, F600, F641, F657, F692, F725On 08/04/2025 at 4:09 PM, the Director of Nursing was interviewed and stated they were unaware of the extent of the staffing issues but was aware that agency staff posed a challenge. The Director of Nursing also stated they were aware of the resident's rights as it pertains to F550, and F553, however was not aware that it impacted resident care and services. The Director of Nursing further stated they were aware of the inaccuracies of residents' assessments, but did not consider it egregious and this and the staffing issue were discussed in the Quality Assurance meetings. The Director of Nursing stated they were unaware of the issues identified in F584, F600, F657, and F675, indicating lack of oversight. The Director of Nursing also stated they have implemented a number of initiatives, and the Maintenance and Nursing team do rounds on the units, to address any areas that are in need of attention. 10 NYCRR 415.26

Based on interview, observation and record the facility did not ensure each resident received 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. Specifically, the facility policy and practices did not honor resident's food preferences and required all residents to consume Kosher meals. In addition, residents were permitted to consume outside food or meals prepared or brought in by family members unless prior arrangements were made with facility staff. When outside food was permitted, residents were not allowed to consume these foods in an area of the facility of their own choosing as this food could only be consumed in the Recreation area. Residents were only permitted to purchase outside food once weekly with their own funds. This resulting in residents experiencing dissatisfaction with their dining experiences and restricted access to individual resident food preferences for those without the means to pay for their own food.The findings are: The facility assessment updated 6/13/2025 documented [NAME] Care Center will provide food and nutrition choices to meet the personal preference of patients and [NAME] will take into account the personal preferences of patients and residents. The facility has a bed capacity of 215 beds. The census at the time of the survey was 158 residents. The undated Resident Handbook stated [NAME] Care Center is a strict kosher facility. No Non-Kosher food of any kind may be brought into the facility. Additionally, meat products and milk products may not be consumed at the same time. For further explanation of the kosher dietary laws speak with the Social Services Department. The Civil Rights Questionnaire dated 07/28/2025 documented a census of 158 residents 14 residents of Jewish religious affiliation. On 07/28/2025 on entrance into the facility at 9:00 AM there was a sign observed on the outer door and lobby door of the facility which stated No outside food is permitted in the facility at any time. Thank you for your corporation [NAME] Administration. On 07/28/2025 at 10:58 AM, Resident #153 was interviewed and stated their family cannot bring food for them to eat and they cannot eat the food in their room. Resident #153 also stated when their child does bring them food, and they have to take the food back home with them. On 07/31/2025 at 10:22 AM, Resident #47 stated they get food from outside on Friday such as pizza. Resident #47 also stated that they were told that they cannot have outside food and family and friends do not bring them food and if they do they must have it in the dining room as they cannot bring it to the unit. During an interview on 07/31/2025 at 10:26 AM, Resident #96 stated they have been in the facility a few months and they were informed it was a kosher facility prior to coming. Resident #96 also stated they once ordered outside food but cannot afford to do this all the time as they would have to pay for it with their own money. On 07/31/2025 at 12:30 PM, the Registered Dietitian #1 was interviewed and stated resident are allowed outside food in a room downstairs in the Recreation room eating foods. Registered Dietitian #1 also stated the facility has kosher food and residents are not supposed to have food on the unit. During an interview on 07/31/2025 at 01:17 PM, the Food Service Administrator stated the patient population of the facility is predominantly African American and Spanish patients. The Food Service Administrator also stated the residents/resident representatives are made aware that the facility is a kosher facility. The Food Service Administrator further stated residents can have outside food, but they have to make a reservation for the food usually with the Recreation, or Nurse supervisor and the resident would have to eat in the Recreation room with the visitor. The Food Service Administrator stated residents are allowed to have outside food every Friday and can order Chinese or Italian food or bacon cheeseburgers. On 08/01/2025 at 12:32 PM, Resident Representative #1 for Resident #153 was interviewed and stated that they have tried to bring food from home for Resident #153 to consume and they have had to take it back home with them because they were not allowed to provide or bring outside food to the resident without prior approval from the facility. On 08/01/2025 at 12:33 PM, Resident #153 was re-interviewed and stated they were not allowed to bring outside food into the facility or consume outside food in the facility. Resident #153 also stated they were informed about the outside food, but this is different because at other facilities they were able to bring food into the building. Resident #153 further stated once they got takeout food on a family visit, and they were allowed to consume the food outside the building as they don't allow outside food in here. Resident #153 stated their fiancé cooks home cooked meals for them and they are craving outside food. Resident #153 further stated their family brought them food and they thought the family room area or cafeteria would be available, but they were told they could not eat in there because no food other than kosher food was allowed in the facility. On 8/4/2025 at 11:15AM, Resident #90 was interviewed, and stated the food here is horrible and they do not like the food, and they cannot get the foods they want. Resident #90 further stated they were told the facility was kosher 3 years ago, and they would like to be able to buy their own food, but they have to suffer along with the facility rule. On 08/04/2025 at 11:21 AM, Resident #133 stated their family brings food from home, and they have to eat it in the Recreation room. On 08/04/2025 at 11:24 AM, Resident #84 was interviewed and stated the food here is terrible and they do not let you bring in any food. Resident #84 also stated they were informed the facility is kosher, but they do not like the food, and they are thinking about transferring someplace else because they cannot eat the food. Resident #84 further stated they want food they can eat, regular food, and they are not asking for too much from the facility. During an interview on 08/04/2025 at 12:43 PM, Resident #83 stated they were informed the facility was kosher 4 weeks ago and they eat the food because they are starving. Resident #83 also stated their family, and friends bring them food, but they have to eat it downstairs. On 08/04/2025 at 12:53 PM, Resident #26 was interviewed and stated they were not informed that the facility was kosher, and they are not allowed to get food from outside. Resident #26 also stated their family can bring them food, but they have to make an appointment/reservations to bring them the food. Resident #26 further stated they cannot have cheese on their burgers, and everyone is asking for cheese for their burgers. During an interview on 08/04/2025 at 1:46 PM, Recreation Aide #1 stated they monitor the recreation room for visitors up to 2 times a week when visitors bring outside food for residents. Recreation Aide #1 also stated they make sure that the room is set up, the suction machine is plugged in and if a resident has a choking emergency that there is someone close by. Recreation Aide #1 further stated residents are offered take out on Fridays and they can order Chinese food, pizza or food from the deli. Recreation Aide #1 stated family are able to bring their own personal food, and it has to be eaten in the recreation room. During an interview on 08/04/2025 at 1:20 PM, the Rabbi stated the building is strictly kosher and most kosher facilities allow no outside food, as no outside food is allowed where kosher foods are served. The Rabbi also stated there are times family/visitors can make arrangement for outside food, and non-kosher foods are not allowed in the resident dining room or resident rooms. The Rabbi also stated that there is a Friday program where residents are offered to buy takeout food which is eaten in the recreation room, and this has been in place to offer residents the opportunity to have food supervised with Recreation and Social Work involved. Resident#12 admitted to the facility with diagnoses that include Coronary Artery Disease, Hypertension, End Stage Renal Disease and Hemiparesis. The admission Minimum Data Set, dated [DATE] documented Resident #12's cognition as intact, very important to have snacks available between meals and have family or close friend involved in discussions about their care. On 07/29/2025 at 12:20 PM, Resident #12 was interviewed and stated they do not like the food and that they are not allowed to bring in any food. Resident #12 also stated 3 weeks ago their child brought some Jello cups for them, which were confiscated by the staff, and they were told it is a Kosher facility, and the Jello was not returned. Resident #12 further stated they are not Kosher, so they do not understand why they can't eat their own food. On 07/30/2025 at 11:00 AM, during the Resident Council meeting, Resident #26 stated that stated that their food is not allowed in the facility. Resident #26 also stated they are not kosher, and are not allowed to bring in food, so they cannot have their food when they want. On 07/30/2025 at 11:00 AM, during the Resident Council meeting, Resident #123 stated they can only order food on Fridays and that it is Chinese and Italian only. Resident #123 also stated they do not like the food here and only eat lunch and dinner when they can order the food on Fridays. On 08/01/2025 at 10:48 AM, Registered Nurse Supervisor #2 was interviewed and stated the residents are aware that food cannot be brought in from the outside, however, the residents can order food from any place that delivers, and it's facilitated by the Recreation department. Registered Nurse Supervisor #2 also stated food is ordered once a week by the Recreation department only, but if the family wants to bring in food, they must call the Social Worker ahead of time, and they will schedule a place on the 1st floor where it can be eaten in a designated area only. On 08/01/2025 at 10:54 AM, the Dietician was interviewed and stated if residents want food from outside, the facility can arrange to have the food eaten in a specific area and the cannot eat it in their room. The Dietician also stated that the facility can order for them from a few restaurants, however the residents must pay for their own food. On 08/01/2025 at 11:11 AM, the Activities Director who is also the Social Work Director was interviewed and stated the administration gives them items and menus that are available on Fridays, from which the residents can order food from. The Activities Director also stated residents are not allowed to order from the outside, and there no food can be delivered. The Activities Director further stated residents can have food brought in from outside, and families can bring the food, but they recommend appointments first, because it can only be eaten on the 1st floor, and they must ensure the availability of the families, for spacing in the dining room. The Social Worker Director stated that they only order the food for the residents on a Friday, because that is how the policy is written. On 08/04/25 at 4:00PM, the Administrator was interviewed and stated that the facility is a Kosher facility, and they have instituted a program whereby once a week, the residents could purchase food from the outside, through the Recreation department. The Administrator also stated that this a supervised program, and the policy is part of the admission agreement and in the accommodations, and that families and visitors can have the non-kosher food in the recreation and conference room, on the 1st floor. The Administrator further stated residents and families can make special requests if the residents are unable to leave their room whereby the facility will make sure that there is no food in the room besides the food brought in into the room, to maintain the kosher rule. The Administrator stated they are not aware that there were any issues with the rule. 10 NYCRR 415.12

Based on interview and review of the facility Daily Staffing Reports and Payroll Based Journal Staffing Data Report of Quarter 2 2025 (January 1 to March 31) which indicated Excessively Low Weekend Staffing and One Star Staffing Rating, it was determined that the facility did not ensure there was sufficient nursing staff on a 24-hour basis to provide nursing care to the residents. The findings include: The Facility assessment dated [DATE] documented there were 43 beds on each floor from 3rd to 6th floor. The Facility Assessment revealed the par level was 1 Registered Nurse for each floor on the Day shift from 7:00 AM-3:00 PM and 1 Registered Nurse for whole facility for Evening shift 3:00 PM-11:00 PM and Night shift 11:00 PM-7:00 AM. The Facility Assessment also documented there were 1.5 Licensed Practical Nurses on the 3rd, 4th, and 6th floor and 1 Licensed Practical Nurse on the 5th floor for Day shift, and 1 Licensed Practical Nurse on each floor for the Evening and Night shift. The Facility Assessment further documented each floor should have 4 Certified Nursing Assistants for the Day shift, 3 Certified Nursing Assistants for the Evening shift, and 2 Certified Nursing Assistants for the Night shift. The weekend Daily Staffing sheets from 01/04/2025 to 03/30/2025 provided by the facility revealed the following: 1 Registered Nurse for the whole facility during the Day shift instead of 1 Registered Nurse for each floor for day shift as the par level indicated. There was no 0.5 Licensed Practical Nurse working on Sunday 01/05/2025, Sunday 01/19/2025, Saturday 01/25/2025, Sunday 01/26/2025, Sunday 02/09/2025, Sunday 03/09/2025, Sunday 03/16/2025, and Sunday 03/23/2025. On Saturday 01/04/2025, Day shift, the 6th floor had 3 Certified Nursing Assistants which was below the par level of 4 Certified Nursing Assistants on each floor. On Sunday 01/05/2025, Evening shift, there was no Licensed Practical Nurse on the 5th floor, and 1 Certified Nursing Assistant on 5th and 6th floor which was below par level of 1 Licensed Practical Nurse per floor and 3 Certified Nursing Assistants on each floor.On Sunday 01/12/2025, Evening shift, there were 2 Certified Nursing Assistants on the 3rd floor and 1 Certified Nursing Assistant on the 4th, 5th, and 6th floor, which was below the par level of 3 Certified Nursing Assistant on each floor. On Sunday 01/19/2025, Night shift, there was 1 Certified Nursing Assistant on the 3rd, 4th, 5th, and 6th floor which was below the par level of 2 Certified Nursing Assistants for each floor. On Saturday 02/01/2025, Day shift, there were 3 Certified Nursing Assistants on the 5th floor, which was below the par level of 4 Certified Nursing Assistants for each floor. On Sunday 02/02/2025, Evening shift, there were 2 Certified Nursing Assistants on the 6th floor, which was below the par level of 3 Certified Nursing Assistants on each floor. On Sunday 02/09/2025, Evening shift, there 2 Certified Nursing Assistants on the 6th floor, which was below the par level of 3 Certified Nursing Assistants on each floor. On Sunday 02/09/2025, Night shift, there was 1 Certified Nursing Assistant on the 6th floor, which was below the par level of 2 Certified Nursing Assistants on each floor. On Saturday 02/15/2025, Evening shift, there were 2 Certified Nursing Assistants on the 6th floor, which was below the par level of 3 Certified Nursing Assistants on each floor.On Sunday 02/23/2025, Day shift, there were 3 Certified Nursing Assistants on the 5th floor, which was below the par level of 4 Certified Nursing Assistants for each floor. On Sunday 02/23/2025, Night shift, there was 1 Certified Nursing Assistant on the 3rd, 4th, and 5th floor which was below the par level of 2 Certified Nursing Assistants for each floor. On Sunday 03/02/2025, Day shift, there were 3 Certified Nursing Assistants on the 3rd floor, which was below the par level of 4 Certified Nursing Assistants for each floor. On Sunday 03/02/2025, Evening shift, there 2 Certified Nursing Assistants on the 4th floor, which was below the par level of 3 Certified Nursing Assistants on each floor. On Saturday 03/08/2025, Night shift, there was 1 Certified Nursing Assistant on the 4th floor, which was below the par level of 2 Certified Nursing Assistants for each floor. On Sunday 03/09/2025, Day shift, there were 3 Certified Nursing Assistants on the 4th and 5th floor, which was below the par level of 4 Certified Nursing Assistants for each floor. On Sunday 03/09/202, Night shift, there was 1 Certified Nursing Assistant on the 3rd floor which was below the par level of 2 Certified Nursing Assistants for each floor. On Sunday 03/23/2025, Day shift, there were 3 Certified Nursing Assistants on the 3rd floor, which was below the par level of 4 Certified Nursing Assistants for each floor. On Saturday 03/29/2025, Day shift, there were 3 Certified Nursing Assistants on the 6th floor, which was below the par level of 4 Certified Nursing Assistants for each floor. On Sunday 03/30/2025, Night shift, there was 1 Certified Nursing Assistant on the 3rd floor which was below the par level of 2 Certified Nursing Assistants for each floor. On 08/01/2025 at 10:03 AM, Certified Nursing Assistant #3 was interviewed and stated staffing was short most weekends when some staff called out. Certified Nursing Assistant #3 also stated the agency Certified Nursing Assistants called out on the weekends most of time. Certified Nursing Assistant #3 further stated there should be 4 Certified Nursing Assistants on the unit for day shift. Certified Nursing Assistant #3 stated when someone called out and no replacement was made, they had extra residents to take care of on their shift. Certified Nursing Assistant #3 also stated residents had to wait longer for care and stayed in bed instead of transferring out to the wheelchair when there was short staff. On 08/01/2025 at 1:39 PM, Certified Nursing Assistant #4 was interviewed and stated there were only 3 instead of 4 Certified Nursing Assistant working on the unit for the day shift if the facility was unable to find a replacement aide when someone called out. Certified Nursing Assistant #4 also stated residents had to wait longer time for care and stayed in bed when they were short in staffing. On 08/01/2025 at 1:48 PM, Certified Nursing Assistant #5 was interviewed and stated staffing was short for the weekends. Certified Nursing Assistant #5 also stated there were only 2 instead of 4 Certified Nursing Assistants sometimes for day shift when staff called out. Certified Nursing Assistant #5 stated they tried their best and were not able to bring all residents out of bed and residents had to wait a longer time for care when staffing was short.On 08/04/2025 at 11:04 AM, the Director of Nursing was interviewed and stated they were covering Staffing Coordinator since June 2025 and the newly hired Staffing Coordinator was in training. The Director of Nursing also stated they started working at the facility on 03/24/2025 and was not aware of the staffing shortage issue for the period 01/01/2025 to 03/31/2025. The Director of Nursing further stated the Registered Nurse Supervisor for the shift called the staff not scheduled to work for overtime when scheduled staff called out or did not report to work. The unit would be short of staff if the Registered Nurse Supervisor was not able to get replacement staff. The Director of Nursing stated they had orientation for Certified Nursing Assistant every week now to bring more staff in. The Director of Nursing also stated there should be 1 Registered Nurse for the Day shift for the whole facility but not for each floor. The Director of Nursing had no explanation why the facility assessment documented there should be one Registered Nurse for each floor during the Day shift. The Director of Nursing stated the 0.5 out of the 1.5 Licensed Practical Nurse on the 3rd, 4th, and 6th floor referred to a treatment nurse for wound care. The Director of Nursing was not able to explain why the treatment nurse added up to 1.5 Licensed Practical Nurse in the facility assessment. The Director of Nursing also stated the Registered Nurse had to cover the Licensed Practical Nurse for medication administration or wound care if they were short of Licensed Practical Nurses. The Director of Nursing further stated the Registered Nurse called them to report and then either the Assistant Director of Nursing or themselves would come to facility to cover the Registered Nurse role. On 08/04/2025 at 11:40 AM, the Administrator was interviewed and stated they were not aware of a staffing shortage issue for weekend and the Payroll Based Journal triggered for Excessively Low Weekend Staffing and One Star Staffing Rating for the Fiscal Year Quarter 2, 2025 (January 1 - March 31). The Administrator also stated there would be short staffing when someone called out and no replacement was made. 10 NYCRR 415.13(a)(1)(i-iii)

Based on observation, record review and interviews conducted during a Recertification survey, the facility did not ensure that they had a policy regarding the use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. Specifically, the facility policy did not ensure that facility staff were able to assist residents in accessing and consuming food brought from outside, and did not permit storage of food brought in by family or visitors. Based on observation, record review and interviews conducted during a Recertification survey, the facility did not ensure that they had a policy regarding the use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. Specifically, the facility policy did not ensure that facility staff were able to assist residents in accessing and consuming food brought from outside, and did not permit storage of food brought in by family or visitors. The finding is: The facility policy and procedure dated 01/2025 titled Use and Storage of Food and Beverage Items Brought to the Facility stated as a Kosher Certified Facility it is the policy of [NAME] Care Center to ensure food and beverages prepared in accordance to and to the highest possible levels of both Jewish religious dietary laws and food safety standards. No food or drink may be brought and stored into the facility by family members and or visitors without prior consent of the Administration. Residents and/or representatives will be educated on the policy and procedure related to food and beverage items brought into the facility upon admission, and as needed during resident and family council meetings. Employees including contractual staff will be educated on the policy and procedure upon hire and annually. Specially prepared or alternative food (other than Kosher food) or food required by a therapeutic or modified diet prescribed by a physician will be discussed with the interdisciplinary team and Administration prior to implementation. Family members or visitors should inform and discuss with the Social Workers/Designated Representative of their desire to bring food and beverages prepared from outside. Family members or visitors with food items approved by administration must consume the food items in the recreation office/designated area. Any food prepared outside the facility can only use or be served with utensils brought from outside the facility. Nursing staff will monitor resident rooms, unit pantry and refrigeration units for food and beverages not prepared by the facility for disposal. Any unlabeled and undated foods and beverages must be immediately discarded. The facility assessment updated 6/13/2025 documented [NAME] Care Center will provide food and nutrition choices to meet the personal preference of patients and [NAME] will take into account the personal preferences of patients and residents. The facility has a bed capacity of 215 beds. The census at the time of the survey was 158 residents. The undated Resident Handbook stated [NAME] Care Center is a strict kosher facility. No Non-Kosher food of any kind may be brought into the facility. Additionally, meat products and milk products may not be consumed at the same time. For further explanation of the kosher dietary laws speak with the Social Services Department. The Civil Rights Questionnaire dated 07/28/2025 documented a census of 158 residents 14 residents of Jewish religious affiliation. On 07/28/2025 on entrance into the facility at 9:00 AM there was a sign observed on the outer door and lobby door of the facility which stated No outside food is permitted in the facility at any time. Thank you for your corporation [NAME] Administration. On 07/28/2025 at 10:58 AM, Resident #153 was interviewed and stated their family cannot bring food for them to eat and they cannot eat the food in their room. Resident #153 also stated when their child does bring them food, and they have to take the food back home with them. On 07/31/2025 at 10:17 AM, the [NAME] was interviewed and stated since working here they have not been allowed to bring in outside food. The [NAME] also stated only kosher food is allowed in the kitchen, there are a meat and a dairy side of the kitchen so there is no mixing of food. On 07/31/2025 at 10:22 AM, Resident #47 stated they get food from outside on Friday such as pizza. Resident #47 also stated that they were told that they cannot have outside food and family and friends do not bring them food and if they do they must have it in the dining room as they cannot bring it to the unit. During an interview on 07/31/2025 at 10:26 AM, Resident #96 stated they have been in the facility a few months and they were informed it was a kosher facility prior to coming. Resident #96 also stated they once ordered outside food but cannot afford to do this all the time as they would have to pay for it with their own money. On 07/31/2025 at 12:30 PM, the Registered Dietitian #1 was interviewed and stated resident are allowed outside food in a room downstairs in the Recreation room eating foods. Registered Dietitian #1 also stated the facility has kosher food and residents are not supposed to have food on the unit. During an interview on 07/31/2025 at 01:17 PM, the Food Service Administrator stated the patient population of the facility is predominantly African American and Spanish patients. The Food Service Administrator also stated the residents/resident representatives are made aware that the facility is a kosher facility. The Food Service Administrator further stated residents can have outside food, but they have to make a reservation for the food usually with the Recreation, or Nurse supervisor and the resident would have to eat in the Recreation room with the visitor. The Food Service Administrator stated residents are allowed to have outside food every Friday and can order Chinese or Italian food or bacon cheeseburgers. On 08/01/2025 at 12:32 PM, Resident Representative #1 for Resident #153 was interviewed and stated that they have tried to bring food from home for Resident #153 to consume and they have had to take it back home with them because they were not allowed to provide or bring outside food to the resident without prior approval from the facility. On 08/01/2025 at 12:33 PM, Resident #153 was re-interviewed and stated they were not allowed to bring outside food into the facility or consume outside food in the facility. Resident #153 also stated they were informed about the outside food, but this is different because at other facilities they were able to bring food into the building. Resident #153 further stated once they got takeout food on a family visit, and they were allowed to consume the food outside the building as they don't allow outside food in here. Resident #153 stated their fiancé cooks home cooked meals for them and they are craving outside food. Resident #153 further stated their family brought them food and they thought the family room area or cafeteria would be available, but they were told they could not eat in there because no food other than kosher food was allowed in the facility. On 8/4/2025 at 11:15AM, Resident #90 was interviewed, and stated the food here is horrible and they do not like the food, and they cannot get the foods they want. Resident #90 further stated they were told the facility was kosher 3 years ago, and they would like to be able to buy their own food, but they have to suffer along with the facility rule. On 08/04/2025 at 11:21 AM, Resident #133 stated their family brings food from home, and they have to eat it in the Recreation room. On 08/04/2025 at 11:24 AM, Resident #84 was interviewed and stated the food here is terrible and they do not let you bring in any food. Resident #84 also stated they were informed the facility is kosher, but they do not like the food, and they are thinking about transferring someplace else because they cannot eat the food. Resident #84 further stated they want food they can eat, regular food, and they are not asking for too much from the facility. During an interview on 08/04/2025 at 12:43 PM, Resident #83 stated they were informed the facility was kosher 4 weeks ago and they eat the food because they are starving. Resident #83 also stated their family, and friends bring them food, but they have to eat it downstairs. On 08/04/2025 at 12:53 PM, Resident #26 was interviewed and stated they were not informed that the facility was kosher, and they are not allowed to get food from outside. Resident #26 also stated their family can bring them food, but they have to make an appointment/reservations to bring them the food. Resident #26 further stated they cannot have cheese on their burgers, and everyone is asking for cheese for their burgers. During an interview on 08/04/2025 at 1:46 PM, Recreation Aide #1 stated they monitor the recreation room for visitors up to 2 times a week when visitors bring outside food for residents. Recreation Aide #1 also stated they make sure that the room is set up, the suction machine is plugged in and if a resident has a choking emergency that there is someone close by. Recreation Aide #1 further stated residents are offered take out on Fridays and they can order Chinese food, pizza or food from the deli. Recreation Aide #1 stated family are able to bring their own personal food, and it has to be eaten in the recreation room. During an interview on 08/04/2025 at 1:20 PM, the Rabbi stated the building is strictly kosher and most kosher facilities allow no outside food, as no outside food is allowed where kosher foods are served. The Rabbi also stated there are times family/visitors can make arrangement for outside food, and non-kosher foods are not allowed in the resident dining room or resident rooms. The Rabbi also stated that there is a Friday program where residents are offered to buy takeout food which is eaten in the recreation room, and this has been in place to offer residents the opportunity to have food supervised with Recreation and Social Work involved. Resident#12 admitted to the facility with diagnoses that include Coronary Artery Disease, Hypertension, End Stage Renal Disease and Hemiparesis. The admission Minimum Data Set, dated [DATE] documented Resident #12's cognition as intact, very important to have snacks available between meals and have family or close friend involved in discussions about their care. On 07/29/2025 at 12:20 PM, Resident #12 was interviewed and stated they do not like the food and that they are not allowed to bring in any food. Resident #12 also stated 3 weeks ago their child brought some Jello cups for them, which were confiscated by one of the Staff, and they were told it is a Kosher facility, and the Jello was not returned. Resident #12 further stated they are not Kosher, so they don't understand why they can't eat their own food. On 07/30/2025 at 11:00AM, during the Resident Council meeting, Resident #26 stated that stated that their food is not allowed in the facility. Resident #26 also stated they are not kosher, and are not allowed to bring in food, so they cannot have their food when they want. On 07/30/2025 at 11:00AM, during the Resident Council meeting, Resident #123 stated they can only order food on Fridays and that it is Chinese and Italian only. Resident #123 also stated they do not like the food here and only eat lunch and dinner when they can order the food on Fridays. On 08/01/2025 at 10:48 AM, Registered Nurse Supervisor#2 was interviewed and stated the residents are aware that food cannot be brought in from the outside, however, the residents can order food from any place that delivers, and it's facilitated by the Recreation department. Registered Nurse Supervisor#2 also stated food is ordered once a week by the Recreation department only, but if the family wants to bring in food, they must call the Social Worker ahead of time, and they will schedule a place on the 1st floor where it can be eaten in a designated area only. On 08/01/2025 at 10:54 AM, the Registered Dietician was interviewed and stated if residents want food from outside, the facility can arrange to have the food eaten in a specific area and the cannot eat it in their room. The Dietician also stated that the facility can order for them from a few restaurants, however the residents have to pay for the meal. On 08/01/2025 at 11:11 AM, the Activities Director who is also the Social Work Director was interviewed and stated the administration gives menus from which the residents can order food from on Fridays. The Activities Director also stated residents are not allowed to order from the outside, and no food can be delivered to the facility. The Activities Director further stated residents can have food brought in from outside, and if families bring food they recommend appointments first, because it can only be eaten on the 1st floor, and they must ensure there is adequate spacing in the dining area. The Activities Director stated that they can only order food for the residents on a Friday, because that is how the policy is written. On 08/04/25 at 4:00 PM, the Administrator was interviewed and stated that the facility is a Kosher facility, and no outside food is allowed in the facility, so they have instituted a program whereby once a week, residents can purchase food from outside, through the Recreation department. The Administrator also stated that this a supervised program, and the policy is part of the admission agreement and is posted in signs, and families and visitors can have the non-kosher food in the recreation and conference room, on the 1st floor. The Administrator further stated residents and families can make special requests if the residents are unable to leave their room whereby the facility will make sure that there is no food in the room besides the food brought in into the room, as to maintain the kosher rule no outside food is allowed on resident units. The Administrator stated they are not aware that there were any issues with the rule. 10 NYCRR 415.14(h)

Number of residents sampled: 4Number of residents cited: 2 Based on record review and interview conducted during the Recertification and Complaint Survey (759831), the facility did not ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegations were made, to the State Survey Agency. This was evident for 2 (Resident #51 & Resident #104) of 4 resident reviewed for Abuse out of 34 total sampled residents. Specifically, the facility's incident report documented that on 11/11/2024 at 10:00 AM, Resident #51 hit Resident #104 with the leg rest of Resident #51's wheelchair, accusing them of stealing underwear. The Administrator was first made aware of the incident on 11/11/2024 at 10:45 AM, and the facility did not report the abuse allegation to the New York State Department of Health until 11/11/2025 at 02:52 PM.The findings are:The facility's policy titled Resident Abuse, Neglect, & Exploitation, effective 03/13, last reviewed 01/2025 stated the Administration/Director of Nursing is responsible to report immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in seriously bodily injury, to the Administrator of the facility and to other officials in accordance with State law through established procedure.Resident #51 was admitted to the facility with diagnoses that include Non-Alzheimer's Dementia, Anxiety Disorder, and Schizophrenia.The Annual Minimum Data Set assessment dated [DATE] documented Resident #51 had severely impaired cognition, and had no behavioral symptoms directed towards others.Resident #104 was admitted to the facility with diagnoses that include End Stage Renal Disease and Depression.The Annual Minimum Data Set assessment dated [DATE] documented Resident #51 had short and long-term memory impairment and had no behavioral symptoms directed towards others.A Nurse's note dated 11/11/24 documented the New York City Police Department was notified of the altercation, 2 officers reported to facility from precinct and Resident #51 to be transferred to the hospital for psychiatric evaluation and departed the facility at 3:35 PM.The facility's report titled Occurrence Report, dated 11/11/24 at 10:00 AM, documented Resident #51 accused Resident #104 of stealing underwear. Resident #51 used the leg rest of the wheelchair to hit Resident #104 on their leg. Both residents were evaluated and denied any injuries. An emergency code was called, and the residents were separated. Both residents were evaluated and there were no visible injuries. Resident #51 was transferred to the hospital for evaluation. The Nursing Home Facility Incident Report documented that the incident occurred on Monday, 11/11/2024 at 10:00 AM, the Administrator was first made aware of the incident on Monday, 11/11/2024 at 10:45 AM, and the Director of Nursing reported the altercation to the New York State Department of Health on Monday 11/11/2024 at 14:52.On 08/04/2025 at 4:09 PM, the Administrator was interviewed and stated that they were made aware when the resident-to-resident interaction occurred. The Administrator also stated that the Director of Nursing that reported the altercation no longer works with the facility, but that they do not recall if the regulations state that all resident-to-resident interactions are to be reported within 2 hours. 10 NYCRR 415.4(b)(2)

Based on observation and interview the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This was observed in the 1st Floor visitor bathroom Specifically, from 07/28/2025, to 07/30/2025 the visitor and staff female bathroom located on 1st floor was observed with large, rusted area on the bottom of the bathroom barrier, a missing tile creating a hole at back of the toilet, the light fixture was uncovered, and there was mis-matched paint on the walls.The findings include but are not limited to:The facility's policy and procedure titled Maintenance/Housekeeping dated last revised 12/2024 documented the during regular inspection staff will survey, check and inspect all common areas, mechanical spaces and resident rooms. The policy further documented the resident rooms are inspected for cleanliness, odors and general good housekeeping. On 07/29/2025 at 11:18 AM, and 07/30/2025 at 09:00 AM, the visitor female bathroom was observed with a large, rusted area noted on the bottom on the left side of the toilet barrier. There was a missing tile with an open area to the back of the toilet on the left side. In addition, the light fixture was uncovered and there was mis-matched paint on the walls.On 08/04/2025 at 11:30 AM, the Maintenance Director was interviewed and stated they are responsible for making rounds and fixing anything that needs to be fixed around the building. The Maintenance Director also stated the staff reports any concerns to be fixed and they will respond and send one of the workers to fix the areas. The Maintenance Director further stated they were not aware of the large, rusted area and the missing tile in the female restroom on the first floor and this was not reported to the Maintenance Director. On 08/04/2025 at 4:09 PM the Administrator was interviewed and stated they were not made aware of any environmental issues and the Maintenance Director does not report small issues to Administrator. 10 NYCRR 415.29

Number of residents sampled: 5Number of residents cited: 1Based on observation, record review, and interviews during the Recertification survey, the facility did not ensure that a therapeutic diet was provided when there is a nutritional problem, and the health care provider orders a therapeutic diet. This was evident for 1 (Resident #83) of 5 residents reviewed for Nutrition out of a total of 34 sampled residents. Specifically, Resident #83, who had a Physician's order for pureed food and honey thickened liquid, was observed eating leftover chopped beans and drinking apple juice from the tray of another resident prescribed a chopped diet and thin liquids. The findings are: The facility's policy titled Aspiration Precautions last revised 08/2025 stated the facility ensures that all residents are assessed for risk factors for aspiration, implement, educate and monitor resident and Interdisciplinary team members on interventions and precautions to prevent the occurrence of aspiration. Constant supervision with intake is needed. The facility's policy titled Dysphagia Clinical Protocol last revised 08/2025 stated the physician will order an altered consistency diet when it is clinically appropriate to manage significant risks of aspiration in individuals for whom other alternatives are unavailable, not feasible, or have not worked. Resident #83 had diagnoses which included Malnutrition, Gastroesophageal Reflux Disease, and Altered Mental Status. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #83 had impaired cognition, required supervision assistance for eating, and is on a mechanically altered diet. A Nursing progress note dated 05/24/2025 documented Resident #83 was noted trying to take food from another resident's left over and must be monitored closely at mealtime. A Social work progress note dated 05/27/2025 documented that Resident #83 has a behavior of taking food off other residents' trays. Interdisciplinary team to monitor resident and provide support to resident. A Nursing progress note dated 06/04/2025 documented Resident #83 was observed taking non-pureed food items from another resident. Resident #83 was redirected by staff and was reinforced that sharing food is not permitted. Resident was informed of the risk of aspiration if they are not compliant with diet. Resident #83 was placed to dine at separate table to minimize episode of the mentioned behavior. Staff will continue to monitor resident closely and offer redirection. The sixth-floor dining room seating chart displayed that Resident #83 was to be seated with two other residents who are also prescribed a pureed diet. A Care Plan with focus Choking/Aspiration was initiated on 3/25/2019 and last updated on 07/27/2025 with facility interventions that included to provide diet as ordered: regular diet, puree consistency, honey thickened liquids and supervise/assist resident to eat slowly. A Care Pan with focus Nutrition/Hydration Status as evidenced by Resident #83 noted with behaviors including attempting to steal food from resident's tray was initiated on 03/22/2019 and last revised on 05/12/2025. The facility interventions included to monitor for signs of choking/aspiration. A Care Plan with focus Activities of Daily living all task was initiated on 03/22/2019 with facility interventions that included supervision assistance for eating, one-person physical assist for support and pureed food with honey thickened liquid/choking. Resident on Aspiration precautions. A note included to seat resident as per seating chart and supervise during meals. A Physician's Order renewed on 07/16/2025 documented the following dietary orders: regular with pureed consistency and honey thickened liquids. May have bread, soft sandwiches, and cake. A Speech Therapy Quarterly assessment dated [DATE] documented that Resident #83 is to be on pureed solids and honey liquids with instructions to maintain aspiration precautions. On 07/28/2025 at 12:21 PM, Resident #83 was observed moving the left-over tray of Resident #39 closer to them. Resident #39 was not present at the table as they had finished eating and left the table earlier. Resident #39's meal ticket documented that Resident #39 was on a chopped diet with chopped hamburger and beans. The State Surveyor asked Resident #83 if this was their tray to which they responded yes and proceeded to place a couple of pieces of the chopped beans into their mouth and take a sip of apple juice from the left-over tray of Resident #39. Certified Nursing Assistant #8 and Licensed Practical Nurse #3 were seated at the table next to Resident #83 feeding other residents. Certified Nursing Assistant #8 then notified Licensed Practical Nurse #3 and informed Resident #83 that it was not their tray and moved the tray back to where it was originally on the same table. The tray was not removed from the table and contained a few pieces of beans and an unopened coffee creamer which was still accessible to Resident #83. On 07/30/2025 at 2:41 PM, Licensed Practical Nurse #3 was interviewed and stated Resident #83 is on a pureed diet with thickened liquids. Normally Resident #83 is seated with other residents who are all on pureed diets. Licensed Practical Nurse #3 also stated 07/28/2025 was the first time Resident #83 was seated with Resident #39, and Resident #83 has attempted in the past to take food from the trays of other residents. Licensed Practical Nurse #3 further stated that it was an unfortunate situation as they were feeding another resident and had their back turned to Resident #83, and it was brought to their attention by Certified Nursing Assistant #8. By the time the staff realized, Resident #83 had already eaten a few pieces of Resident #39's leftover food. Licensed Practical Nurse #3 stated while Resident #83 is alert, they also have impaired cognition, and staff must remind them often to refrain from eating food off the tray of other residents. Licensed Practical Nurse #3 also stated Resident #83 must be supervised closely to make sure they are safe when eating and do not harm themselves as they may take food off other residents and also has a habit of slipping away. Licensed Practical Nurse #3 further stated Resident #83 is at risk for aspiration and choking if they consume the food of other residents, in addition, to the spread of germs and infections. On 08/01/2025 at 10:11 AM, the Registered Dietician was interviewed and stated Resident #83 is on a regular diet with puree consistency and honey thickened liquids. As of January 30, 2024, Resident #83 is on aspiration precautions and cannot handle any other consistency of foods aside from pureed. If Resident #83 does consume other consistencies of food, they have a possibility of choking. The Registered Dietician also stated to limit episodes, it is important to ensure there are staff to monitor Resident #83 consistently, as Resident #83 does have altered mental status and behavioral issues and is unable to make decision on their own and can-do things that can be unsafe. It is important there is staff to monitor them. On 08/01/2025 at 2:40 PM, Certified Nursing Assistant #8 was interviewed and stated they witnessed Resident #83 taking the tray of another resident at which time they informed the Licensed Practical Nurse #3. Certified Nursing Assistant #8 further stated that to their knowledge, Resident #83 did not have a history of taking food of other residents and there are seating charts for all residents that are seated in the dining room. On 08/01/2025 at 2:44 PM, Registered Nurse Supervisor #3 was interviewed and stated they were made aware of the incident by Certified Nurse Assistant #8 and Licensed Practical Nurse #3 when they came into the dining room. Registered Nurse Supervisor #3 stated Resident #83 is currently on a puree consistency diet, and it can be an issue if Resident #83 consumes the food of other residents as it is an aspiration risk, choking risk, allergy issue, and infection control issue. Registered Nurse Supervisor #83 further stated while there are progress notes documenting Resident #83 has taken food off other residents, this was the first time the behavior was reported to them. On 08/04/2025 at 10:53 AM, Speech Therapist #1 was interviewed and stated they do screenings quarterly and evaluated Resident #83 on May 8th, 2025, with recommendations to continue with the current diet. Speech Therapist #1 also stated Resident #83 has a history of dysphagia, difficulty chewing and swallowing food safely, and also has a history of taking foods where it is accessible. Speech Therapist #1 further stated there is a risk of aspiration if Resident #83 consumes the food off other resident's trays because Resident #83 is on a pureed diet with honey thickened liquids which is the safest for them at this time. On 08/04/2025 at 1:52 PM, the Director of Nursing Services was interviewed and stated that there are residents that do attempt to take food off other residents, particularly, if they are confused and on an altered diet. The Director of Nursing Services also stated if a resident on a specific diet consumes food of other resident, it is a risk of aspiration, cross contamination and risk for safety. Staff are responsible to supervise residents and report appropriately. The Director of Nursing Services further stated that residents should be monitored closely. 10 NYCRR 415.12(i)(2)

Based on observations, record review, and interviews during the Recertification and Complaint (759832) survey conducted from 7/28/2025 to 8/02/2025, the facility did not ensure that they permitted each resident to remain in the facility, and did not transfer or discharge the resident from the facility unless the transfer or discharge was necessary for the resident's welfare and the resident's needs cannot be met in the facility. This was evident for 1 (Resident #151) out of 5 reviewed for Choices out of a sample of 34 residents. Specifically, Resident #151 was not permitted to return to the facility after they went out on pass and returned late and was instead transferred to the hospital. In addition, the facility failed to provide any documentation regarding Against Medical Advice status or a discharge notice provided to the resident prior to hospital transfer. The findings included:The facility policy Out on Pass with Responsible Party/Leave of Absence reviewed 7/10/2024 documented to enable residents to safely enjoy and spend quality time outside the confines of the facility, [NAME] Center to grant temporary leave form the facility (Out on Pass/Leave of Absence). This temporary leave is granted upon request by either resident or family/responsible party after assessment by the Interdisciplinary Team. A resident leaving the facility other than going for scheduled or approved medical purposes is considered as Out on Pass/Leave of Absence. Out on Pass maybe in the form of a day pass (before midnight) or overnight pass (after midnight). Residents who go Out on Pass with Responsible Party must return prior to midnight. Failure to return by midnight will be considered a voluntary Against Medical Advice and be discharged from our facility. If resident wishes to be readmitted resident must go to the Hospital and obtain a Patient Review Instrument for admission. The interdisciplinary team may also specify the number of hours a resident may go Out On Pass with Responsible Party based on their specific medical status, care needs, diet order and medication/treatment regimen. The facility policy and procedure Discharge Planning dated 01/2025 stated the facility will transfer or discharge resident only when such transfer or discharge is made in recognition of the resident's right to receive considerate and respectful care, to receive necessary care and services, and to participate in the development of the comprehensive care plan and in recognition of the residents rights of other resident in the facility. The policy also stated the facility will transfer or discharge a resident only when the interdisciplinary team, in consultation with the resident or the resident designated representative determines that: transfer or discharge necessary for the residents welfare and the residents needs cannot be met after reasonable attempts at accommodation in the facility.Resident # 151 was admitted to the facility with diagnoses that included Anxiety disorder, Osteoarthritis of knee, and Pain. The Quarterly Minimum Data Set assessment dated [DATE] and 07/09/2025 documented Resident #151 had intact cognition, required supervision or touching assistance with eating and participated in assessment and goal setting.The Annual Minimum Data Set assessment dated [DATE] documented in Section F Preferences for Customary Routines and Activities that it was very important to do their favorite activities and things with groups of people. The Physicians order initiated on 6/3/2022, last renewed on 7/16/2025 documented Resident #151 can go out on pass with a responsible party. The Nursing Progress notes dated 11/1/2024 documented at 10:17 PM, Resident went out of pass during 3 PM -11 PM shift for daughter's wedding. Resident did not return as of 10:15 PM, 3 PM-11 PM shift endorse to 11 PM-7 PM shift to follow up on return, The Nursing progress note dated 11/1/2024 at 11:56 PM, documented at 11:49 PM, Resident did not return from out on pass, call placed to emergency contact #4 that picked resident up message left with reminder that resident must be back in the facility prior to 12 AM. The Nursing progress note dated 11/2/2024 at 12:09 AM, documented 11:56 PM another call placed to emergency contact #4 was unanswered. Reminder message left that resident must be back prior to 12 AM for acceptance back to the facility. Attempt made to call emergency contact #1 was unsuccessful, Social Worker informed. The Nursing progress note written by Registered Nurse #5 on 11/2/2024 at 1:09 AM documented at 12:35AM call received from front desk the resident arrives outside the facility and wants to speak with writer. Resident noted sitting in wheelchair in entry area alone without responsible party. When asked for responsible party that he returned with the resident stated she is gone, she is incapacitated car noted reversing form driveway. Resident #151 was reeducated that Out On Pass protocol is that return must be done prior to 12 AM and if not, is considered as a voluntary Against Medical Advice so the responsible returning party would need to resume responsibility. Resident #151 was notably upset, the former Director of Nursing and Director Social Worker were notified. The Director of Social Work stated that resident has to return with party, or if left alone 911 has to be called. The Director Social Worker is able to speak with resident. Documented at 12:43 - 911 called to pick resident up and at 12:48 PM- 911 arrives resident picked up and taken to hospital. There was no documented evidence Resident #151 was permitted to return to the facility and appropriately assessed for any ill effects from being away from the facility longer than expected when they returned later than agreed upon after a therapeutic leave. In addition, there was no evidence in the medical record that Resident #151 was evaluated by their Physician, and the information for the basis of the transfer was documented. The Nursing progress note dated 11/4/2024 at 2:41 PM documented Resident #151 was readmitted at 1:47 PM from the hospital in stable condition, alert and oriented, able to make needs known. Resident went Out on Pass and signed Against Medical Advice to hospital. Resident refused readmission assessment. Medical Doctor aware of readmission and medication reconciled. Monitoring continues.The Medical progress note dated 11/5/2024 at 6:11 PM, documented Resident #151 was readmitted on [DATE] after hospitalized on [DATE] as was denied entry to skilled nursing facility due to late arrival and missing reentry curfew and required reevaluation. After medical optimization and hemodynamically stable, Resident discharged from the hospital and has been readmitted to our facility. Hospital records reviewed, medication reconciliation and no altered mental status. There was no documented evidence provided regarding the Out on Pass notice provided to Resident #151 on 11/02/2024 or the Against Medical Advice form that Resident #151 signed prior to being transferred to the hospital after returning 30 minutes late from pass. During an interview on 07/28/2025 at 11:51 AM, Resident #151 stated they got back after midnight, and they were locked out of the building, and they were sent to hospital for the weekend due to violating curfew. Resident #151 also stated that there was no set return time documented on the paperwork. Resident #151 further stated that in November 2024 it was cold outside, and they were taken to the hospital. Resident #151 stated they did not want to go to the hospital, but they were told they had to go.During an interview on 7/31/2025 at 3:17 PM, Emergency Contact #1 for Resident #151 stated they were not called and notified Resident #151 was sent to the hospital. Emergency Contact #1 also stated they ordered an Uber to take Resident #151 back to the facility and they arrived at the facility at 12:30 AM. During an interview on 08/01/2025 at 10:30 AM, the Director of Social Work stated Resident #151 was late returning from pass. The Director of Social Work also stated when residents return from pass after midnight they are sent to the hospital and have to go to the hospital and get a Patient Review Instrument completed in order to be readmitted to the facility. During an interview on 08/01/2025 at 11:01 AM, Registered Nurse #5 stated when a resident goes out on pass an Out on Pass form is completed which has the contact information for the designated person and residents have to be back in the facility before midnight. Registered Nurse #5 also stated the Nursing Supervisor, or unit nurse will contact the resident or designated representative 1 hour before 12 AM to let them know they have to be back before midnight. Registered Nurse #5 further stated Resident #151 attended their child's wedding and needed to be back before 12 AM, so they contacted Resident #151 and their designated representative, and no one answered the call. They also tried unsuccessfully to reach all the other emergency contacts and informed the Social worker and the Director of Nursing when they were unable to do so. Registered Nurse #5 stated they were notified by the facility receptionist by phone that Resident #151 was downstairs on 11/02/2024 and they met Resident #151 at the doors and Resident #151 explained that they did not hear the phone. Registered Nurse #5 stated the Social Worker and Director of Nursing were contacted by phone and informed Resident #151 they had to go to the hospital, and Resident #151 was sent to the hospital. During an interview on 08/01/2025 at 11:22 AM, the Director of Nursing there may be reasons for a resident's late arrival back to the facility, such as traffic accident and patients are educated individually. The Director of Nursing also stated when a resident arrives after midnight circumstance of late arrival is reviewed on a case by case basis, and sometimes if a resident arrives after midnight they are transferred to hospital as Against Medical Advice. During an interview on 8/4/2025 at 2:11 PM, the Administrator stated when Resident came back late from pass the Director of Nursing directed the nursing supervisor to send the resident to the hospital.10 NYCRR 415.3(i)(1)(iii)

Number of residents sampled: 6Number of residents cited: 1Based on record review and staff interviews conducted during a Recertification and Complaint (759838) survey, the facility did not ensure that each resident is free from abuse, neglect, and corporal punishment of any type by anyone. This was evident for 1 (Resident #13) out 6 residents reviewed for Abuse. Specifically, Resident #13 was bit on their right arm by Certified Nursing Assistant #2 while being assisted with Activities of Daily Living on 03/23/2025. The findings include: The facility's policy and procedure titled Resident Abuse, Neglect, & Exploitation with effective date 3/2013 and last review date 1/2025 stated the facility is to ensure all residents are free from abuse, neglect, misappropriate of resident property, and exploitation. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The policy also stated the responsible person for Abuse Prohibition is the Director of Nursing. The policy further stated all prospective employees will be screened prior to employment to rule out any history of abuse, neglect or mistreatment or resident. All employees would be trained on abuse prevention policy. All incidents will be investigated. The facility will report all incident or violations where abuse, neglect, mistreatment of misappropriation of property suspected to New York State Department of Health according to protocol.Resident #13 had diagnoses including Hemiplegia, Vascular dementia, and Aphasia. The Annual Minimum Data Set assessment dated [DATE] documented Resident #13 had severely impaired cognition, had no behavior symptoms, no rejection of care and was dependent on staff for Activities of Daily Living. The Nursing note dated 3/23/2025 documented that Resident #13 stated they had been bitten by Certified Nursing Assistant #2. The Nursing note also documented Certified Nursing Assistant #2 admitted biting Resident #13 with a towel placed over Resident #13's right arm. The Nursing note further documented redness, and a bite mark was observed on Resident #13's right arm.The Employee Statement by Certified Nursing Assistant #2 documented they placed a towel over Resident #13's right arm and bit Resident #13's right arm through the towel.The Facility Investigation Report dated 3/28/2025 documented there was reasonable cause to believe that abuse, neglect, or mistreatment occurred. The facility investigation report documented Resident #13 reported Certified Nursing Assistant #2 bit them. Certified Nursing Assistant #1 who was assigned to Resident #13 stated they asked Certified Nursing Assistant #2 for assistance as Resident #13 required 2-person assistance. Certified Nursing Assistant #1 witnessed a conversation between Resident #13 and Certified Nursing Assistant #2, in which Certified Nursing Assistant #2 told Resident #13 that if you bite me, I will bite you back. Certified Nursing Assistant #1 stated Resident #13 had tendencies to attempt to bite staff and could be resistive and combative during care at times. The facility investigation report documented Certified Nursing Assistant #1 observed Certified Nursing Assistant #2 place a towel on Resident #13's right arm as part of care. Certified Nursing Assistant #1 removed the towel after care and noticed redness and impressions on Resident #13's right arm. Certified Nursing Assistant #1 immediately reported the finding to the nurse on the unit. Certified Nursing Assistant #1 stated they did not witness Certified Nursing Assistant #2 biting Resident #13. The facility investigation report documented Certified Nursing Assistant #2 stated Resident #13 bit their right arm and that why they bit Resident #13 back. It also documented Certified Nursing Assistant #2 stated the placed their mouth over a towel on Resident #13's right arm and bit Resident #13. Licensed Practical Nurse #1 checked on Resident #13 and noticed redness on Resident #13's right arm after receiving report from Certified Nursing Assistant #1. Registered Nurse #1 assessed Resident #13 and interviewed all parties involved. The facility investigation report documented Certified Nursing Assistant #2 acknowledged biting Resident #13. It also documented 911 was called and police officers came and then left without arresting anyone. It further documented Certified Nursing Assistant #2 was suspended pending the outcome of the investigation.The Criminal History Record Check Termination Notice (Form 105) documented Certified Nursing Assistant #2 was terminated from the Criminal History Record Check Program on 3/25/2025. On 07/30/2025 at 10:05 AM, Certified Nursing Assistant #2 was interviewed and stated Resident #13 tried to bite them during care and they told Resident #13 that they would bite back if Resident #13 did so. Certified Nursing Assistant #2 admitted they placed a piece of towel on Resident #13's right arm and put their mouth on the towel. Certified Nursing Assistant #2 stated they just played with Resident #13 and did not bite Resident #13. On 07/30/2025 at 9:29 AM, Certified Nursing Assistant #1 was interviewed and stated Resident #13 had intact skin and no redness on skin before care. Certified Nursing Assistant #1 also stated only themself, Certified Nursing Assistant #2 and Resident #13 were in the room at the time. Certified Nursing Assistant #1 stated they observed Resident #13's right arm was covered by a piece of towel during care and the towel was not there before care. Certified Nursing Assistant #1 further stated they removed the towel after care and observed redness and teeth mark on Resident #13's right lower arm closed to elbow. Certified Nursing Assistant #1 stated they reported the finding immediately to the Licensed Practical Nurse #1. On 07/30/2025 at 9:36 AM, Licensed Practical Nurse #1 was interviewed and stated they went to see Resident #13 after receiving the report from Certified Nursing Assistant #1 about redness on Resident #13's right arm. Licensed Practical Nurse #1 also stated they observed Resident #13 had redness on the right arm close to elbow. Licensed Practical Nurse #1 further stated Resident #13 kept saying they were bitten. On 07/31/2025 at 8:56 AM, Registered Nurse #1 was interviewed and stated they assessed Resident #13 after receiving the report from Licensed Practical Nurse #1. Registered Nurse #1 also stated they found Resident #13 had redness in the shape of teeth bite on the right arm. Registered Nurse #1 further stated they had the two involved Certified Nursing Assistants, #1 and #2, stand in front of Resident #13 for Resident #13 to identify the abuser. Registered Nurse #1 also stated Resident #13 pointed at Certified Nursing Assistant #2 and stated they bit Resident #13. Registered Nurse #1 further stated Certified Nursing Assistant #2 was dismissed immediately, and they reported the incident to Director of Nursing immediately afterward. On 08/01/2025 at 8:49 AM, the Director of Nursing was interviewed and stated the facility started an investigation after receiving report of the incident. The staff involved were interviewed, and Certified Nursing Assistant #2 admitted they placed a towel on Resident #13's right arm and bit Resident #13. The Director of Nursing stated they determined that abuse did happen and terminated Certified Nursing Assistant #2. The Director of Nursing also stated all staff received training on abuse during orientation. 10 NYCRR 415.4(b)(1)(i)

Number of residents sampled:3Number of residents cited:1Based on interviews and record review conducted during the Recertification survey, the facility did not ensure a resident, or their designated representative was provided appropriate notification at the termination of Medicare Part A benefits. This was evident for 1 (Resident #27) of 3 residents reviewed for Beneficiary Notification out of 34 total sampled residents. Specifically, the Notice of Medicare Non-Coverage was not mailed out to Resident #27's designated representative on the same day telephone notification was made. The findings are: The facility policy titled Beneficiary Notice last revised 08/2025 documented that the facility must notify the resident and or legal representative of Medicaid/Medicare Coverage/Liability in such a manner to acknowledge and respect resident rights. The Notice of Medicare Non-coverage is given by the facility to all Medicare beneficiaries at least two days before the end of Medicare covered part A stay or when all of Part B therapies are ending. The Notice of Medicare Non-Coverage informs the beneficiary of the right to an expedited review by a quality improvement organization. Resident #27 was discharged from skilled rehabilitation services on 04/04/2025 and remained in the facility. The Notice of Medicare Non-coverage form documented a note written by the Minimum Data Set Coordinator on 04/02/2025 which stated that the Minimum Data Set Coordinator spoke with the sibling of Resident #27 and explained that rehabilitation service will end on 04/04/2025. Resident #27's sibling verbalized understanding of the contents of the notification. There was no documentation a copy of the Notice of Medicare Non-Coverage had been mailed to Resident #27's representative. On 08/04/2025 at 10:04 AM, the Minimum Data Set Coordinator was interviewed and stated that they had spoken to the sibling of Resident #27 who verbalized understanding of the contents of the Notice of Medicare Non-coverage, and they would not be appealing the decision. The Minimum Data Set Coordinator further stated that the procedure is that the Notice of Medicare Non-Coverage is to be mailed out 2 days before the ending of services, so that residents or their representatives have the time to appeal the decision. The Notice of Medicare Non-Coverage for Resident #27 should have been mailed out on the same day that telephone contact was made. The Minimum Data Set Coordinator further stated they were unable to mail out the Notice of Medicare Non-Ccoverage, so they had called one of the staff in the facility to mail it out on their behalf. It was confirmed by the Director of Social Work via email that it was mailed out via certified mail. The Minimum Data Set Coordinator further stated that the facility could not find the receipt to confirm it was sent out the same day telephone notification was made. On 08/04/2025 at 1:58 PM, the Director of Social Work was interviewed and stated that they occasionally help mail out the Notice of Medicare Non-coverage form if asked to do so by the Minimum Data Set Coordinator. The Director of Social Work stated that they mailed out the Notice of Medicare Non-coverage via certified mail to the family member of Resident #27 and had received a receipt but could not locate the receipt. The Director of Social Work further stated that they are aware it is important for the Notice of Medicare Non-Coverage to be sent out so that residents are aware they have the right to appeal. On 08/04/2025 at 1:52 PM, the Director of Nursing Services was interviewed and stated that Notice of Medicare Non-coverage should be mailed out the same day as telephone notification. The Director of Nursing services further stated that it is a matter of resident's rights, and they are unsure as to what happened in this scenario. 10 NYCRR 415.3 (g)(2)(ii)

Number of residents sampled: 3Number of residents cited: 1 Based on record review and interviews conducted during the Recertification survey from 07/28/2025 to 08/04/2025, the facility did not ensure Comprehensive Care Plans were reviewed based on changing goals, preferences and needs of the resident and in response to current interventions. This was evident for 1 (Resident #90) out of 3 residents investigated for Activities of Daily Living out of a total investigative sample of 34 residents. Specifically, Resident #90 was observed on multiple occasions with strong odor of urine on their person and in their room, and there was no evidence that the Comprehensive Care Plan was revised to include interventions to address Resident #90's ongoing behavior of refusal of care. The findings are:The facility policy and procedure policy titled Comprehensive Care Planning last reviewed 01/2025 stated the Comprehensive Care Plan must describe the following including the services that are to be furnished to attain or maintain the resident's highest practical physical, mental and psychosocial well-being. The facility policy and procedure policy titled Activities of Daily Living Protocol stated the plan of care will be reviewed by all responsible disciplines for consistency in delivery of care as well as ensuring that the plan of care accurately reflects the resident's current status. Resident #90 had diagnoses which included Osteoarthritis, Diabetes, and Bipolar Disorder.The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #90's cognition as moderately impaired with a Brief Interview for Mental Status score of 12. The Minimum Data Set 3.0 further documented Resident #90 required supervision for eating, dependent care for toileting and showers, and supervision with touch assistance for personal hygiene, and was frequently incontinent of bladder and always incontinent of bowel.On 07/28/2025 at 09:45 AM, a strong urine odor was observed outside Resident #90's room during Initial Pool observations. The room appeared clean, there was no debris observed on the floor and the bed was made with clean linens. Resident #90 was not in room at this time.On 07/29/2025 from 9:28 AM to 9:44 AM, there was a strong urine odor detected in the hallway outside Resident #90's room. Resident #90 was observed sitting in a wheelchair in the room and stated that the strong odor of urine is coming from themself. Resident #90 also stated the housekeeper does clean their room, but the urine smell is still strong, especially on the mattress. Resident #90 further stated this does not make them feel good about themself, and they refuse showers because they are scared they will fall. On 07/30/2025 at 9:21 AM, Resident #90 observed sitting in wheelchair in their room completing word puzzles. A strong urine odor continued to emanate from the room and could be detected in the hallway outside of the room. Resident #90's clothing appeared clean and was changed from the previous day, their hair was well groomed, but the strong urine odor persisted. On 07/31/2025 at 12:14 PM, Resident #90 observed sitting in the wheelchair at nurses' station and a strong urine odor was detected. Registered Nurse #1 who sitting at the nurse's station stated they will change the cushion on Resident #90's wheelchair.The Comprehensive Care Plan titled Activity of daily Living Tasks functional decline; status post hospitalization requires extensive assistance with Activity of Daily Living dated created 8/21/2020 and last evaluation note 6/20/2025, did not contain personalized interventions to address Resident #90's ongoing strong urine odor in their room and on their person, and instead documented the level of assistance Resident #90 required for Activities of Daily Living Care. The Comprehensive Care Plan titled Behavior Symptoms: Resists Care/ Noncompliance Psychiatric disorder, Noncompliance with daily care needs, Noncompliance with medication, Noncompliance with ambulation and transfer status removes clothes, incontinent brief, throws food all over on the floor. Stays naked in bed. Refuses medications at time. Urinates on floor and bed, refuses to allow room to be cleaned at times, refuses showers created 8/27/2020 and last evaluation note dated 6/11/2025 did not contain personalized interventions to address Resident #90's ongoing strong urine odor in their room and on their person. A Nursing progress note dated 03/28/2025 at 01:38 pm, Resident #90 refused care on shiftA Nursing progress note dated 04/01/2025 at 02:14 pm documented Late entry 3/31/25 resident refused care at 2 pm. A Nursing progress note dated 6/5/2025 documented Resident #90 refused incontinence briefs change despite encouragement and educational counseling.On 08/04/2025 at 1:08 PM, Registered Nurse Supervisor #1 stated they are responsible for initiating and updating care plans. Registered Nurse Supervisor #1 also stated they try to encourage Resident #90 in different ways and tried to be creative on how to have Resident #90 comply with care. Registered Nurse Supervisor #1 further stated the care plans interventions for Activities of Daily comes from the Certified Nursing Accountability record. Registered Nurse Supervisor #1 stated they can add interventions to address the resident's education on personal hygiene, risk for infection, and the importance of keeping the environment clean. Registered Nurse Supervisor #1 also stated they did have a note on 6/28/2024 when they educated Resident #90 on compliance with personal hygiene to help prevent infection. Registered Nurse Supervisor #1 stated they could personalize Resident #90's care plan to include all the interventions the team is doing to have Resident #90 comply with care, and in keeping the environment clean On 08/04/2025 at 4:09 PM, The Director of Nursing was interviewed and stated care plans should be person-centered, and staff should assess and look at the idiosyncrasies of each resident, and care plan based on their individual needs. The Director of Nursing also stated this is done for all residents, and this is a huge initiative, to personalize all care plans. 10 NYCRR 415.11(c)(2) (i-iii)

Based on observation, record review, and interviews conducted during the recertification survey from 07/28/2025 to 08/04/2025, the facility did not ensure a resident's right to receive services with reasonable accommodation of their needs and preferences. This was evident for 1 (Resident #151) of 31 total sampled residents. Specifically, Resident #31 was observed in their and they were not able to wash their hands in their bathroom sink without leaning forward and risk falling out of their wheelchair, their bathroom mirror was not on positioned appropriately for grooming, the cabinet in their room was at a height to allow them to access items in the cabinet, and the bottom drawers in their cabinet were difficult to access making it difficult for Resident #151 to access their clothing. The findings are:Resident #151 was admitted to the facility with diagnoses that included Anxiety disorder, Osteoarthritis of knee, and Pain. The Quarterly Minimum Data Set assessments dated 03/31/2025 and 07/09/2025 documented Resident #151 had intact cognition, required supervision or touching assistance with eating and participated in assessment and goal setting.The Quarterly Minimum Data Set assessment dated [DATE] and 07/09/2025 documented Resident #151 had intact cognition, required supervision or touching assistance with eating, dependent assistance with toilet transfer, partial/moderate assistance with upper and lower body dressing, and participated in assessment and goal setting. The assessments also documented Resident #151 used a wheelchair for mobility and was frequently incontinent of bowel and always continent of urine. The Annual Minimum Data Set assessment dated [DATE] in Section F Preferences for Customary Routines and Activities documented it was very important for Resident #151 to choose what clothes to wear and to take care of their personal belongings or things.On 08/01/2025 at 1:18 PM, Resident #151 was observed in the bathroom in their room. There was a tilted tilt mirror in the bathroom and Resident #151 was observed extending their body forward while seated in the wheelchair to be able to wash their hands properly as there was limited room at the sink to allow Resident #151 full access to the sink. On 08/04/2025 at 11:57AM, Resident #151's room was observed with the Director of Maintenance. Resident #151 was observed to be unable to reach the sink and had to lean forward in their wheelchair in order to reach the faucet handles, the toilet roll holder, and the bathroom cabinet. Upon observing this, the Director of Maintenance stated they needed to find Resident #151 another room to meet their needs, and they would have to see if they are any open rooms so their move can be coordinate with nursing. During an interview on 08/01/2025 at 1:20 PM, Resident #151 stated the mirror is not low enough for them to see their face when they are shaving, and they require assistance to get on and off the toilet in this room. Resident #151 also stated they cannot use the closet because of the way the door opens, and in order to take clothes out of their closet they have to bend forward in their wheelchair which makes them uncomfortable as they have fallen out of the wheelchair like this before. Resident #151 further stated that it is difficult to access the closet drawers for the same reason, so they hang their clothing outside of the closet. Resident #151 stated they cannot reach the bathroom dresser shelf when in the wheelchair and the toilet paper dispenser when seated on the toilet.During an interview on 08/04/2025 at 12:00 PM, the Director of Maintenance stated Resident#151's room was renovated and set up by an outside company. he Director of Maintenance also stated the company installed the fixtures in the bathroom and they do not check the installation. The Director of Maintenance further stated all rooms are designed the same and if a resident is in a wheelchair, they should be able to reach items in their room comfortably. 10 NYCRR 415.5(e)(1)

Number of residents sampled:2Number of residents cited:1 Based on record review and interview conducted during the Recertification survey, the facility did not ensure that, to the extent practicable, the resident participated in the development, review, and revision of the comprehensive care plan. This was evident for 1 (Resident #34) of 2 residents reviewed for Care Planning, out of 34 sampled residents. Specifically, Resident #34's care plan meeting had not been scheduled nor held since their admission on [DATE]. The findings are:The facility's policy titled Comprehensive Care Planning, effective 01/2014, last updated 01/25 documented that every effort will be made to schedule care plan meetings at the best time of the day for the resident and family. The facility will assist residents to participate, e.g., helping residents, and families, legal surrogates or representatives understand the assessment and care planning process; when feasible, holding care planning meetings at the time of day when a resident is functioning best; planning enough time for information exchange and decision making; encouraging a resident's advocate to attend (e.g. family member, friend) if desired by a resident.Resident #34 was admitted to the facility with diagnoses that include Diabetes Mellitus, Pneumonia, and Malnutrition.The admission Minimum Data Set, dated [DATE] documented Resident #34 gad intact cognition, no behaviors, and participated in assessment and goal setting. On 07/29/2025 at 11:10 AM, Resident #34 was interviewed and stated they do not recall if they were invited or attended a care plan meeting. The Care Plan Meeting Schedule log dated 1/07/2025 to 7/31/2025 was reviewed and revealed Resident #34's care plan meeting had not been scheduled.There was no documented evidence in Resident #34's medical records that a care plan meeting was scheduled, and Resident #34 had been invited to attend a care plan meeting. On 08/04/2025 at 1:37 PM, the Social Worker Director was interviewed and stated residents are notified via sheets (invitation) and on the morning of the care plan meeting, the Registered Nurse Supervisor reminds the residents and asks if they want to attend or not. The Social Worker Director also stated the Minimum Data Set Coordinator schedules the care plan meeting. The schedule is on the calendar in the Electronic Medical Record, and the Social Worker Director will check to see if the care plan is scheduled. The Social Worker Director further stated based on the calendar that they were reviewing, there was no scheduled care plan meeting for Resident #34, and there should have been a care plan meeting for Resident #34. On 08/04/2025 at 1:58 PM, the Minimum Data Set Coordinator was interviewed and stated they are responsible for scheduling the care plan meeting. The Minimum Data Set Coordinator also stated when the Minimum Data Set is due, the care plan meeting is scheduled within the next 7 days, on either a Tuesday or a Thursday. The admission Minimum Data Set Coordinator further stated the Minimum Data Set assessment for Resident #34 was completed on 06/22/2025, and they usually do the scheduled care plan meetings on Excel, but this meeting probably did not go over to Electronic Medical Record, so the care plan meeting was missed.10 NYCRR 415.3(f)(1)(v)

Number of residents sampled: 3Number of residents cited: 1Based on observations, record review, and interviews conducted during the Recertification Survey the facility did not ensure that the residents were treated with respect and dignity and cared for in a manner and in an environment that promotes maintenance or enhancement of resident quality of life. This was evident for 1 (Resident #90) of 3 residents reviewed for Activities of Daily Living out of an investigative sample of 34 residents. Specifically, Resident #90 with a history of refusing care was observed on multiple occasions having a strong urine odor on their person while in common areas and in their room shared with other residents.The findings are:The facility policy and procedure titled Quality of Life- Dignity dated last revised in August 2025, documented that the facility's policy is to ensure each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individually.Resident #90 had diagnoses which included Osteoarthritis, Diabetes, and Bipolar Disorder.The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #90's cognition as moderately impaired with a Brief Interview for Mental Status score of 12. The Minimum Data Set 3.0 further documented Resident #90 required supervision for eating, dependent care for toileting and showers, and supervision with touch assistance for personal hygiene, and was frequently incontinent of bladder and always incontinent of bowel.On 07/28/2025 at 09:45 AM, a strong urine odor was observed outside Resident #90's room during Initial Pool observations. The room appeared clean, there was no debris observed on the floor and the bed was made with clean linens. Resident #90 was not in room at this time.On 07/29/2025 at 9:28 AM and 07/29/2025 at 9:44 AM, there was a strong urine odor detected in the hallway outside Resident #90's room. Resident #90 was observed sitting in a wheelchair in the room and stated that the strong odor of urine is coming from themself. Resident #90 also stated the housekeeper does clean their room, but the urine smell is still strong, especially on the mattress. Resident #90 further stated this does not make them feel good about themself, and they refuse showers because they are scared they will fall. On 07/30/2025 at 9:21 AM, Resident #90 observed sitting in wheelchair in their room completing word puzzles. A strong urine odor continued to emanate from the room and could be detected in the hallway outside of the room. Resident #90's clothing appeared clean and was changed from the previous day, their hair was well groomed, but the strong urine odor persisted. On 07/31/2025 at 12:14 PM, Resident #90 was observed sitting in the wheelchair at nurses' station and a strong urine odor was detected. Registered Nurse #1 who was sitting at the nurse's station stated they will change the cushion on Resident #90's wheelchair.On 08/04/2025 at 10:19 AM, Resident #90's room was observed with an uncovered mattress and persisting urine odor. A Nursing progress note dated 03/28/2025 at 01:38 pm, Resident #90 refused care on shift. A Nursing progress note dated 04/01/2025 at 02:14 pm documented Late entry 3/31/25 resident refused care at 2 pm. A Nursing progress note dated 6/5/2025 documented Resident #90 refused incontinence briefs change despite encouragement and educational counseling.A Nursing progress dated 07/11/2025 at 06:21 am documented Resident #90 refused all care and was verbally aggressive to Certified Nursing Assistant and urinated on floor.Multiple Psychiatric consults dated 01/06/2025 to 06/11/2025 contained no documented evidence Resident #90 behaviors regarding personal hygiene including and their environment addressed. Multiple Psychology progress notes dated 02/24/2025 to 07/26/2025 contained no documented evidence Resident #90 behaviors regarding personal hygiene including and their environment addressed. On 07/20/2025 at 02:23 PM, Certified Nursing Assistant #7 was interviewed and stated they are currently assigned to provide care for Resident #90 during July 2025. Certified Nursing Assistant #7 also stated Resident #90 requires extensive assistance of two persons for toileting, showers and personal hygiene. Certified Nursing Assistant #7 further stated Resident #90 refuses to change incontinence briefs on the night shift, will often remove the incontinence brief and urinate on the floor and on the bed, and will only agree to change the incontinence brief when it is fully saturated with urine. Certified Nursing Assistant #7 stated they are aware of the strong urine odor which comes from Resident #90's bed because the bed usually has a plastic covering, but the covering is gone so the urine gets through to the mattress and soaks the bed causing the strong urine odor. The urine odor has also seeped into the cushion on the wheelchair. Certified Nursing Assistant #7 also stated they were not aware of the mattress or the cushion in the wheelchair being changed, and they report to the nurse daily that Resident #90 refuses care. On 07/31/2025 at 11:31 AM, Licensed Practical Nurse #2 was interviewed and stated Resident #90 is alert and oriented, and resistive to care. Licensed Practical Nurse #2 also stated Resident #90 refuses incontinence care and needs to be approaches multiple times and given a lot of encouragement from staff to change incontinent briefs and take showers. Licensed Practical Nurse #2 acknowledged there was a strong urine odor detected when approaching Resident #90's room, however the housekeeper cleans the room every day and the odor persists.On 07/31/2025 at 11:09 AM, Housekeeper #1 was interviewed and stated they were aware Resident #90 has behaviors of urinating on the floor and at times in the hallway. The Housekeeper #1 also stated when Resident #90 calls staff to be changed and staff do not respond right away they will get upset, remove the incontinence brief, urinate on the floor in the room, and take the incontinence to the nurse's station. and the urine will get all over the floor in the hallways. Housekeeper #1 stated they constantly clean Resident #90's room but there is no change in the smell of urine in the room. #328. On 07/31/2025 at 11:40 AM, Registered Nurse Supervisor #1 was interviewed and stated Resident #90 has known behaviors of refusing care, refusing to be changed, removing incontinence brief, and placing it on the floor. Registered Nurse Supervisor #1 also stated they have used multiple approaches including educating on personal hygiene and infection control, and reapproaching Resident #90. Registered Nurse Supervisor #1 further stated Resident #90 frequently refuses showers and fabricate stories at times, and the Interdisciplinary team has discussed Resident #90's behaviors. Registered Nurse Supervisor #1 stated every couple of months the mattress, floor mats and wheelchair cushions are changed, but they were unable to provide the date this last occurred. On 08/01/2025 at 8:59 AM, the Director of Nursing Services was interviewed and stated Resident #90 has a long-standing psychiatric history, is resistive to care, and refuses medications at times. The Director of Nursing Services also stated Resident #90 has poor hygiene overall, and the team meets with Resident #90 on a regular basis to discuss their personal hygiene and the odor in their room [ROOM NUMBER]. The Director of Nursing Services stated Resident #90 tries to be independent, but with their mental illness and impaired judgement, they need assistance. The Director of Nursing Services also stated they were not personally aware of the strong urine odor on Resident #90 person or in their room and was made aware of it on 7/30/2025 when informed by Registered Nurse Supervisor #1.On 08/01/2025 at 10:54 AM, the Director of Social Work was interviewed and stated Resident #90 has a history of refusing care, refusing showers, and removing their incontinence brief. The Director of Social Work also stated Resident #90 attends care planning meetings, and they have had one on one discussions with them for the past year regarding personal hygiene and Resident #90 will agree to improve and the next day go back to their behavior. The Director of Social Work further stated Resident #90's mattress is changed every 2- 3-week mattress and was last changed four days ago. On 08/04/2025 at 8:37 AM, the Housekeeping Director was interviewed and stated they were aware of the issues with the urine odor in Resident #90's room and the plan in place is to clean the room every day and as needed and to change the mattress as needed. The Housekeeping Director also stated despite cleaning the room daily the odor remains. The Housekeeping Director further stated they know it is not acceptable for the room to have a persisting urine odor, but they continue to clean daily. The Housekeeping Director added that Resident #90's mattress was last changed a few weeks ago but was unable to give a specific date when this occurred.10 NYCRR 415.5(a)

Based on observations and interviews conducted during the Recertification survey, the facility did not ensure that that the notice of the availability of the most recent New York State Department of Health survey report and plan of correction, was posted in areas that are prominent and readily accessible to the public. Specifically, there were no prominent postings of notices of availability throughout the facility. In addition, members of the Resident Council were unable to identify locations where signs or postings documented the availability and location of the survey results.The findings are:The facility's policy titled Posting of Survey Findings, Effective Date: 3/2013, last reviewed 8/2025, documented that a copy of the most recent standard survey, including any subsequent extended surveys, follow-up revisits reports, etc., along with state approved plans of correction of noted deficiencies, is maintained in a 3-ring binder located in an area frequented by most residents, such as the main lobby or resident activity room. The policy also documented copies of previous survey reports and state approved plans of correction are available upon request to the public, residents or their legal representatives (sponsors), designated ombudsman representative, and staff members. Requests for past survey results should be made in writing, signed and dated, and presented to the Administrator, or his/her designee, during normal business hours.On 07/28/2025 at 10:00AM, the Survey results binder was observed in the lobby, on the wall, opposite the receptionist's desk. On 07/30/2025 at 11:30 AM, the Survey results binder was observed in the lobby, on the wall, opposite the receptionist's desk. The binder contained only the results of the last Recertification survey, 07/14/23. There were no complaint surveys in the binder.On 07/30/2025 at 11:00 AM, a Resident Council meeting was held. Seven Residents were in attendance and Resident #26 and Resident #123 stated they had not seen a sign or posting indicating the location of the New York State Department of Health survey results.From 07/28/2025 to 08/01/2025 multiple observations were made on the units and revealed that there were no notices of availability and location of the survey results posted throughout the facility lobby. On 08/01/2025 at 11:21 AM, the Administrative Assistant was interviewed and stated they are responsible for posting the survey results and the binder is located in the lobby. The Administrative Assistant also stated that they were not aware that that the notice of the location of the survey results is supposed to be on all the units and that the survey binder should also contain all recertification and complaint surveys for the past 3 years. The Administrative Assistant further stated they just thought they had to update the binder. On 08/04/25 at 4:00 PM, the Administrator was interviewed and stated that they were aware that the survey binder should include all surveys for the past 3 years and that it was an oversight that the survey binder was not updated. The Administrator also stated that they were not aware that the notices for location of the survey binder should have been posted on the units and on the 1st floor. 10 NYCRR 415.3 (d)(1)(v)

Number of residents sampled: 5Number of residents cited: 2Based on record review and interview conducted during the Recertification survey, the facility did not ensure the Minimum Data Set 3.0 assessments accurately reflected resident's status. This was evident for 1 (Resident #89) of 1 resident reviewed for Dental and 1 (Resident #34) of 4 residents reviewed for Accidents out of 34 total sampled residents. Specifically, 1). The Minimum Data Set Assessment did not reflect Resident #89's dental status as edentulous, and 2). The admission Minimum Data Set assessment did not reflect Resident #34 had a fall prior to admission. The findings are: The undated facility policy and procedure titled Minimum Data Set (MDS 3.0) stated the Minimum Data Set (MDS 3.0) is a federal mandated specific instrument to be used for conduction of a comprehensive assessment of all nursing home residents, initially and periodically. The policy further stated the purpose is to conduct consistent and periodic review of residents consistent with accepted standards. 1.Resident #89 had diagnoses which included Hypertension, Seizures, and Dementia. The admission Minimum Data Set 3.0 assessment dated [DATE] documented Resident #89 was cognitively intact. Section L 0200 Dental of the admission Minimum Data Set documented none of the above present indicating Resident #89 had no dental issues. On 07/29/2025 at 11:59 AM, Resident #89 was observed lying in bed. Resident #89 stated they have no teeth and would like to have dentures. The Dental consult for Resident #89 dated 2/18/2025 documented on evaluation Resident #89 is completely edentulous. No abnormalities noted. The Dental consult dated 5/23/2025 for Resident #89 documented on oral exam patient is completely edentulous. No abnormalities noted. The Dental Care Plan for Resident #89 created 2/10/2025 and last reviewed 5/14/2025 documented oral dental status as edentulous. The admission Minimum Data Set 3.0 assessment did not accurately document Resident #89's dental status as edentulous. On 08/04/2025 at 10:25 AM, Resident #89 was re-interviewed and stated they were admitted to the facility with no teeth. On 08/04/2025 at 10:04 AM, the Minimum Data Set Coordinator was interviewed via telephone and stated they were responsible for completing the Minimum Data set 3.0 assessments for the facility. The Minimum Data Set Coordinator stated when completing the Minimum Data Set, they will open the resident's medical record, and review nurse's notes, medical notes, any uploaded documents like consults, the Medication Administration Record, Treatment Administration Record and speaks to staff. The Minimum Data Set Coordinator also stated they will speak to whoever is able to give information for the residents. The Minimum Data Set Coordinator further stated they completed Section L, Dental, in the Minimum Data Set assessment and Resident #89 does not have any dental problems. The Minimum Data Set Coordinator stated if Resident #89's Dental consult stated they are edentulous, this should be coded on the Minimum Data Set assessment. The Minimum Data Coordinator stated they only work remotely and had not physically seen Resident #89 as they only review the chart when completing the assessment. On 08/04/2025 at 10:41 AM, the Minimum Data Set Consultant was interviewed via telephone and stated they are responsible for overseeing the Minimum Data Set Department ensuring that the schedules are followed for completing and submitting Minimum Data Sets 3.0 timely. The Minimum Data Set Consultant also stated the person who signs off in section Z100 is the person responsible for the accuracy of the Minimum Data Set, and by signing Section Z100 the person is attesting that the Minimum Data Set is correct. The Minimum Data Set Consultant added they are not responsible for the accuracy of the Minimum Data Set assessment. 2. Resident #34 was admitted to the facility with diagnoses that include Diabetes Mellitus, Pneumonia, and Malnutrition. The admission Minimum Data Set assessment dated [DATE] documented Resident #34 had intact cognition, no behaviors, no impairments, needed supervision for eating, moderate assistance for bed mobility, and maximal assistance for chair and toilet transfer. The Minimum Data Set assessment also documented Resident #34 did not have a fall any time in the last 2-6 months prior to admission/entry or reentry. The Comprehensive Care Plan titled Cognition, created on 6/18/2025 included a goal of resident will maintain current level of cognitive status. Interventions include to monitor for changes or decline in cognitive status. The Inpatient Discharge summary dated [DATE] documented Resident #34 was admitted to the hospital on [DATE], presented for ground level fall with level of consciousness. On 08/04/2025 at 10:16 AM, the Minimum Data Set Coordinator was interviewed and stated that they are responsible for entering the information for the Minimum Data Set, dated [DATE], Section J1700, B, which indicated if there were any falls in the last 2-6 months, prior to entry. The Minimum Data Set Coordinator also stated they reviewed Resident #34's medical record, including the hospital discharge summary, however they guess that they missed Resident #34 had a fall, as it was documented on the summary, and it should have been coded as such on the Minimum Data Set assessment. On 08/04/2025 at 4:09 PM, the Director of Nursing was interviewed and stated that they oversee the Minimum Data Set Coordinator and there has been nothing too egregious prior to this omission with Resident #34. The Director of Nursing also stated the facility does audits of assessments and checks for accuracy. The Director of Nursing further stated the staff who fills out the specific sections in the Minimum Data Set are responsible for the accuracy of those sections. 10 NYCRR 415.11 (b)

Based on observation, record review, and interviews during an abbreviated survey, (NY00325381), the facility did not ensure the resident's right to be treated with respect and dignity including the right to be free from physical or chemical restraints imposed for the purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. This was evident for one (1) out of three (3) residents sampled (Resident #1). Specifically, on 10/04/2023, Registered Nurse Supervisor #1 documented received a call from License Practical Nurse #1 at approximately 8:20 AM. License Practical Nurse #1 and Certified Nursing Assistant #1 stated Resident #1's left arm was tied to the siderail of the bed with a sock. Registered Nurse Supervisor #1 interviewed Resident #1 and Resident #1 stated they were tied up all night and was experiencing pain. There were no signs of bruised or injuries and an x-ray was ordered. The findings are: The facility's Policy and Procedure titled Resident Abuse, Neglect and Exploitation revised 04/2023, documented the facility ensures all residents are free from abuse, neglect, misappropriation of resident property and exploitation. This also includes the right to be free from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. The facility's Policy and Procedure titled, Physical Restraints revised 10/2024, documented the facility recognizes and respects the right of their residents to be free from physical and chemical restraints unless its use is medically indicated and permitted under applicable laws, guidelines, and standards. Resident #1 was admitted to the facility with diagnoses including Hypertension (high blood pressure), Hyperlipidemia (a condition characterized by abnormally high levels of fats in the blood), Age related muscle weakness with severe contractures to digits on the left hand. The Minimum Data Set (an assessment tool), dated 09/13/2023, documented Resident #1 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) score of 12 associated with moderately impaired cognition. The facility's investigation dated 10/16/2023, documented on 10/04/2023 at approximately 8:15 AM, Certified Nursing Assistant #1 observed Resident #1's left arm tied with a sock to the siderail of the bed. They removed the sock immediately and reported it to License Practical Nurse # 1. Resident #1 was interviewed by the Social Worker #1, and they reported their arm was tied with a sock to the side rail all night. The facility's investigation revealed Certified Nursing Assistant #3 was assigned to Resident #1 on the 11:00 PM -7:00 AM shift, and the surveillance video showed they did not provide any activity of daily living care to Resident #1. On 10/04/2023 at approximately 12:00 PM, Certified Nursing Assistant #4 reported to the Director of Nursing that Certified Nursing Assistant #2 called the facility at approximately 9:00 AM requesting that Certified Nursing Assistant #4 untie Resident #1's hand from the siderail. The Facility's investigation concluded restraints were used. The x-ray results dated 10/04/2023 documented no obvious fracture or dislocation. Employee Statement of Occurrence (no date specified) by Certified Nursing Assistant #3 documented at 11:00 PM, when monitoring residents, (no date was provided) Resident #1. Was okay. Certified Nursing Assistant #3 did not notice anything unusual. Resident #1 appeared to be clean and dry and did not need to be changed. Employee Statement of Occurrence dated 10/04/2023, by Registered Nurse Supervisor #1 documented they received a call from License Practical Nurse #1 at approximately 8:20 AM, License Practical Nurse #1 and Certified Nursing Assistant #1 stated that they observed Resident #1's left arm tied to the bed rail with a sock. Registered Nurse Supervisor #1 interviewed Resident #1 and Resident #1 stated they were tied up all night and was experiencing pain. Physical assessment done and no bruises were noted, and an x-ray was ordered. Untitled statement dated 10/04/2023 by Certified Nursing Assistant #2 documented they did not restrain Resident #1 on 10/03/2023. Untiled statement dated 10/05/2023, by Receptionist documented on 10/04/2023 at approximately 8:45 AM, Certified Nursing Assistant #2 called the facility asking to speak to Certified Nursing Assistant #4. Statement further documented Certified Nursing Assistant #2's tone sound urgent. Employee Statement of Occurrence dated 10/12/2023, by Certified Nursing Assistant #1 documented on 10/04/2023 at 8:30 AM, Certified Nursing Assistant #1 observed Resident #1 soaked with urine and their left hand was tied to the siderail of the bed. During an interview on 12/31/2024 at 11:17 am, Resident #1 stated the staff does not disrespect them and that they have never tied their wrist. Several attempts made to interview Certified Nursing Assistant #1 but was unsuccessful, letter sent on 01/13/25. Several attempts made to interview Certified Nursing Assistant #3 but was unsuccessful, letter sent on 01/13/25. During a telephone interview on 01/13/2025 at 1:31 PM, License Practical Nurse #1 stated Certified Nursing Assistant #1 reported to them on 10/04/2023 (can't recall the time) that Resident #1's left arm was observed tied to the bedrail with a sock. Certified Nursing Assistant #1 had removed the sock, and they did not observe any bruises to Resident #1's skin. License Practical Nurse #1 stated they reported it to their supervisor immediately. During a telephone interview on 01/13/2025 at 1:50 PM, Certified Nursing Assistant #4 stated they were sitting at the nurse's station when they answered a call on the facility's phone. Certified Nursing Assistant #4 stated it was approximately 9:00 AM and Certified Nursing Assistant #2 asked them if they can check on Resident #1. Certified Nursing Assistant #4 stated Certified Nursing Assistant #2 stated they tied Resident #1's hand. Certified Nursing Assistant #4 stated they did not witness Resident #1's hand tied, and they reported to their supervisor what Certified Nursing Assistant #2 told them. During a telephone interview on 01/21/2025 at 10:45 AM, Certified Nursing Assistant #2 stated they were assigned to Resident #1 on the 3:00 PM-11:00 PM shift 10/03/2023. They denied restraining Resident #1. Certified Nursing Assistant #2 stated they went back to Resident #1's room at 10:00 PM to check to see if Resident #1's incontinent brief was dry. They stated they pulled the sheet and Resident #1's incontinent brief was dry, and they did not observe anything on Resident #1. They stated they did not call or speak to anyone at the facility on 10/04/2023. During a telephone interview on 01/28/2025 at 11:36 AM, Social Worker stated Registered Nurse Supervisor #1 informed them on 10/04/2023 (can't recall the time) that Resident #1's wrist was tied with a sock to the bedrail. Social Worker stated they met with Resident #1 (on the same day, can't recall the time) and Resident #1 stated their hand was tied to the siderail with a sock all night and they were experiencing pain. Social Worker also stated Resident #1 stated they weren't changed all night. During a telephone interview on 01/28/2025 at 11:50 AM, Director of Nursing stated they concluded Certified Nursing Assistant #2 restrained Resident #1 because Certified Nursing Assistant #2 was the last known staff that cared for Resident #1. Certified Nursing Assistant #3 was assigned to Resident #1 on the 11:00 PM-7:00 AM shift and admitted to not providing care to Resident #1. Director of Nursing stated Certified Nursing Assistant #2 called the facility on 10/04/2023 and spoke to Certified Nursing Assistant #4. They reviewed the surveillance video and observed Certified Nursing Assistant #4 rushing to Resident #1's room after speaking on the phone. During a telephone interview on 01/28/2025 at 2:44 PM, the Administrator stated they were away and received a call from the facility informing them of the incident in October 2023 (can't recall date or time). They stated Certified Nursing Assistant #2 was removed from the schedule immediately and was later terminated. 10 NYCRR 415.4(a) (2-7)

Based on observation, record review, and interviews during an abbreviated survey (NY00325381), the facility did not ensure that a resident who is unable to carry out activities of daily living received the necessary services to maintain good personal hygiene. This was evident for one (1) out of three (3) residents sampled (Resident #1) Specifically, on 10/03/2023 during the 11:00 PM-7:00 AM shift, Certified Nursing Assistant #3 stated they did not provide personal care to Resident #1 because they forgot and falsely documented care was provided. The surveillance video was reviewed and confirmed that Certified Nursing Assistant #3 did not provide any activity of daily living care to Resident #1. On 10/04/2023 at 8:30 AM, Resident #1 was observed saturated with urine. Certified Nursing Assistant #3 was terminated. The findings are: The facility's Policy and Procedure titled Resident Abuse, Neglect and Exploitation revised 04/2023, documented the facility ensures all residents are free from abuse, neglect, misappropriation of resident property and exploitation. The facility's Policy and Procedure titled Activities of Daily Living Protocol revised 01/2023, documented the facility will implement measures to assess the resident's ability to perform activity of daily living and based on the assessment, implement treatment and services for resident's needs to maintain, improve and prevent decline. Resident #1 was admitted to the facility with diagnoses including Hypertension (high blood pressure), Hyperlipidemia (a condition characterized by abnormally high levels of fats in the blood), and Age related muscle weakness. The Minimum Data Set (an assessment tool), dated 09/13/2023, documented Resident #1 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) score of 12 associated with moderately impaired cognition. The Comprehensive Care Plan titled: Activity of Daily Living Tasks dated 08/07/2023, documented interventions to provide incontinent care. Resident Nursing Instructions dated 07/19/2022, documented Resident #1 was incontinent of bowel and bladder, and they required dependent assistance by staff for incontinent care every shift. The facility's investigation dated 10/16/2023, documented at approximately 8:15 AM on 10/04/2023, Certified Nursing Assistant #1 observed Resident #1 saturated with urine when they went to provide personal care. Initially, Certified Nursing Assistant #3 provided the facility with a statement documenting that they did resident monitoring and Resident #1 did not require changing. The Director of Nursing interviewed Certified Nursing Assistant #3 who was assigned to Resident #1 during the 11:00 PM-7:00 AM shift, and they stated they did not render care to Resident #1 because they forgot. The surveillance video was reviewed and confirmed that Certified Nursing Assistant #3 did not provide any activity of daily living care to Resident #1. Certified Nursing Assistant #3 was terminated on 10/04/2023, for confirmed patient neglect and mistreatment as well as falsification of documentation. Employee Statement of Occurrence (no date specified) by Certified Nursing Assistant #3, documented Certified Nursing Assistant #3 did resident monitoring at 11:00 PM (no date provided) and checked on Resident #1. Resident #1 stated they were okay. Certified Nursing Assistant #3 did not notice anything unusual. Resident #1 appeared to be clean and dry, and they did not need to be changed. Employee Statement of Occurrence dated 10/12/2023 by Certified Nursing Assistant #1 documented on 10/04/2023 at 8:30 am, Certified Nursing Assistant #1 observed Resident #1 soaked with urine. During an interview on 12/31/2024 at 11:17 am, Resident #1 stated the staff does not disrespect them. Several attempts made to interview Certified Nursing Assistant #1 but was unsuccessful, letter was sent on 01/13/2025. Several attempts made to interview Certified Nursing Assistant #3 but was unsuccessful, letter was sent on 01/13/2025. During a telephone interview on 01/28/2025 at 11:36 AM, Social Worker stated Resident #1 reported to them that they weren't changed all night. During a telephone interview on 01/28/2025 at 11:50 AM, Director of Nursing stated Certified Nursing Assistant #3 was assigned to Resident #1 on the 11:00 PM-7:00 AM shift and admitted to not providing care to Resident #1. During a telephone interview on 01/28/2025 at 2:44 PM, the Administrator stated they were away and received a call from the facility informing them of the incident in October 2023 (can't recall date or time). 10 NYCRR 415.12(a)(3).

Based on observation, interviews, and record review conducted during an abbreviated survey (NY00311350), the facility did not ensure that an alleged violation of physical abuse was reported immediately, but not later than 2 hours if the alleged violation involves abuse or results in serious bodily injury, no later than 24 hours if the alleged violation involves neglect, exploitation, mistreatment, or misappropriation of resident property; and does not result in serious bodily injury. Additionally, the facility failed to report an alleged violation of abuse within 24 hours to local law enforcement. This was evident for 1 out of 5 residents (Resident #1) sampled for abuse. Specifically, 1) On 02/20/23, Resident #1 reported to Licensed Practical Nurse (LPN) #1 that they threw water on Certified Nursing Assistant (CNA) #1 and that CNA #1 in turn threw water on Resident #1. LPN #1 did not immediately report the incident to Registered Nurse Supervisor (RNS) #1 who was on duty at the time. LPN #1 reported the allegation of abuse on 02/21/23 to the Director of Nursing (DON). 2) The DON became aware of the allegation of abuse on 02/21/23 and reported it to New York State Department of Health (NYS DOH) on 02/23/23. Additionally, the facility did not report the allegation of abuse to local law enforcement. The findings are: The Policy and Procedure titled Resident Abuse, Neglect, and Exploitation states that an employee observing or suspecting or being told of another employee physically abusing a resident must report the incident immediately to their department head or supervisor. Commence onsite investigation upon completion of the initial verbal/written report and review with Administration. Report immediately, but not later than 2 hours after the allegation is made. Report no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and to other officials in accordance with State law through established procedure. Resident #1 was admitted to the facility with diagnoses including Major Depressive Disorder and Colostomy Status. The Minimum Date Set (MDS) dated [DATE] documented that Resident #1 had intact cognition. Resident #1 required total assist of two people with toilet use. A Risk Management Summary of Investigation dated 02/24/23 documented that Resident #1 reported on 02/21/23 that on 02/20/23, CNA #1 woke them up stating that CNA #1 was going to empty their urine bag. It is documented that CNA #1 accused Resident #1 of emptying the bag and Resident #1 denied emptying the bag. CNA #1 called Resident #1 a f-----g liar and Resident #1 asked CNA #1 to leave their room. Resident #1 reported that CNA #1 continued to argue and was walking towards Resident #1 in a threatening manner (as if they were going to fight Resident #1) and Resident #1 threw a cup of water on CNA #1 to force CNA #1 to back up. CNA #1 in turn went to the bathroom and fill a cup with water and threw it on Resident #1. It is documented that CNA #1 was interviewed and stated that they felt Resident #1 threw a cup of liquid, what CNA #1 felt was urine, on them and they in turn threw water on Resident #1. Resident #1 was assessed with no injury. The facility concluded that there is caused to believe that an alleged resident abuse, crime, mistreatment, or neglect had occur. The Director of Nursing (DON), who is no longer employed in the facility, provided a written statement dated 02/21/23 stating that they interviewed CNA #1 about the allegation of Resident #1 and CNA #1 stated, I 'm not going to lie, I went in the bathroom, got water and threw it back on Resident #1. During an interview on 07/03/23 at 12:27pm, LPN #1 said that they heard noise coming from Resident #1's room on 02/20/23 and they proceeded to see what was going on. LPN #1 stated that they observed CNA #1 coming out of Resident #1's room with their uniform wet. LPN #1 said that CNA #1 reported that Resident #1 threw a cup of tea on them. LPN #1 stated that Resident #1 reported that they threw a cup of tea on CNA #1 and that CNA #1 in turn threw a cup of water on them. LPN #1 explained that Resident #1 had already changed their tee-shirt, but they observed Resident #1's wet tee-shirt laying on Resident #1's bed. LPN #1 stated that they removed CNA #1 from Resident #1's assignment and asked another CNA to change Resident #1's sheet that was soiled with feces. LPN #1 said that they did not report the incident to Registered Nurse Supervisor (RNS) #1 who was on duty at the time. LPN #1 said that they left the facility at the end of their shift without reporting the incident to anyone. LPN #1 said they reported the incident the following morning on 02/21/23 to the Director of Nursing (DON). LPN #1 stated that they heard Resident #1 and CNA #1 arguing back and forth but did not hear what was being said. LPN #1 was unable to recall the time. During an interview on 07/03/23 at 1:45pm, the Assistant Director of Nursing (ADON) stated that Resident #1 reported to the Social Worker (SW) on 02/21/23 that CNA #1 was abusive to them. The ADON said that they were present when the Director of Nursing (DON) interviewed CNA #1. The ADON stated that CNA #1 said that they threw a cup of water back on Resident #1. During subsequent interview on 07/26/23 at 3:07pm, the ADON said that the facility did not report the allegation of abuse local law enforcement because Resident #1 did not want to file a police report. During an interview on 07/25/2023 at 1:42pm, the Administrator stated that the DON no longer working in the facility. The Administrator stated that the DON should have called in the report immediately after DON interview the Resident. The Administrator stated that I don't know why the DON did not. The Administrator stated that the policy is to report the incident based on DOH's regulation. 10 NYCRR 415.4(b)(1)(i)

Based on observation, interviews, and record review conducted during an abbreviated survey (NY00311350), the facility did not ensure that a resident was free from physical abuse. This was evident for 1 out of 5 residents (Resident #1) sampled for abuse. Specifically, on 02/20/23, Resident #1 reported to Licensed Practical Nurse (LPN) #1 that Certified Nursing Assistant (CNA) #1 was verbally abusive and that they threw a cup of tea on CNA #1 who in turn threw a cup of water on Resident #1. Resident #1 also reported the abuse allegation to the Social Worker on 02/21/23. Resident #1 was assessed on 02/21/23 with no injury. The Policy and Procedure titled Resident Abuse, Neglect, and Exploitation states that all residents are treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment, and care for personal needs. To ensure that residents are free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restrain not required to treat the resident's symptoms. The findings are: Resident #1 was admitted to the facility with diagnoses including Major Depressive Disorder and Colostomy Status. The Minimum Date Set (MDS) dated [DATE] documented that Resident #1 had intact cognition. Resident #1 required total assist of two people with toilet use. A Risk Management Summary of Investigation dated 02/24/23 documented that Resident #1 reported on 02/21/23 that on 02/20/23, CNA #1 woke them up stating that CNA #1 was going to empty their urine bag. It is documented that CNA #1 accused Resident #1 of emptying the bag and Resident #1 denied emptying the bag. CNA #1 called Resident #1 a f-----g liar and Resident #1 asked CNA #1 to leave their room. Resident #1 reported that CNA #1 continued to argue and was walking towards Resident #1 in a threatening manner (as if they were going to fight Resident #1) and Resident #1 threw a cup of water on CNA #1 to force CNA #1 to back up. CNA #1 in turn went to the bathroom and fill a cup with water and threw it on Resident #1. It is documented that CNA #1 was interviewed and stated that they felt Resident #1 threw a cup of liquid, what CNA #1 felt was urine, on them and they in turn threw water on Resident #1. Resident #1 was assessed with no injury. The facility concluded that there is caused to believe that an alleged resident abuse, crime, mistreatment, or neglect had occur. A Nursing Progress Note dated 02/20/23 at 8:16pm documented that Resident #1 was observed with inappropriate behavior while CNA #1 was giving care. Resident #1 screamed, yelled, and threw a cup of tea on CNA #1's uniform. CNA #1 reported to writer that when they were talking to Resident #1, Resident #1 refused to slow down. Resident #1 no longer resides in the facility. However, Resident #1 provided the facility with a statement, typed, and signed by Resident #1), dated 02/22/23. It is documented that Resident #1 reported that on 02/20/23, CNA #1 woke them up stating that CNA #1 wanted to empty the urine bag. It is documented that CNA #1 accused Resident #1 of emptying the bag because the bag was not full, and Resident #1 denied emptying the bag. It is documented that CNA #1 called Resident #1 a liar and Resident #1 asked CNA #1 several times to leave their room and CNA #1 did not comply and called Resident #1 a f-----g liar. It is documented that Resident #1 told CNA to leave their mother f-----g room and CNA #1 started to approach Resident #1's bed like they were going to fight Resident #1. It is documented that Resident #1 threw water on CNA #1 because Resident #1 was not going to lay there and be abused. It is documented that CNA #1 went into the bathroom and filled a cup of water and threw it on Resident #1. CNA #1 refused to be interviewed. However, CNA #1 provided the facility with a written statement dated 02/20/23. It is documented that CNA #1 went to Resident #1's room to perform evening care. It is documented that CNA #1 asked Resident #1 about their colostomy bag and Resident #1 started to curse at CNA #1. It is documented that Resident #1 was abusive, insulting, demanding, and told CNA #1 to get out of their room and that Resident #1 was going to get CNA #1 fired. It is documented that before CNA #1 was able to leave Resident #1's room, Resident #1 picked up a cup and a urinal with feces and threw it in CNA #1's face and body. CNA #1 stated that they ran to the bathroom and washed off. It is documented that as they were exiting the bathroom, Resident #1 started throwing other things at CNA #1. CNA #1 also wrote that they went back to Resident #1's room and asked Resident #1 why did Resident #1 why did Resident #1 do that and Resident #1 started yelling, cursing, and became aggressive and abusive. The Director of Nursing (DON), who is no longer employed in the facility, provided a written statement dated 02/21/23 stating that they interviewed CNA #1 about the allegation of Resident #1 and CNA #1 stated, I 'm not going to lie, I went in the bathroom and got water threw it back on Resident #1. It is documented that CNA #1 also verbalized that Resident #1 removes and plays with their colostomy. During an interview on 07/03/23 at 12:27pm, LPN #1 said that they heard noise coming from Resident #1's room on 02/20/23 and they proceeded to see what was going on. LPN #1 stated that they observed CNA #1 coming out of Resident #1's room with their uniform wet. LPN #1 said that CNA #1 reported that Resident #1 threw a cup of tea on them. LPN #1 stated that Resident #1 reported that they threw a cup of tea on CNA #1 and that CNA #1 in turn threw a cup of water on them. LPN #1 explained that Resident #1 had already changed their tee-shirt, but they observed Resident #1's wet tee-shirt laying on Resident #1's bed. LPN #1 stated that they removed CNA #1 from Resident #1's assignment and asked another CNA to change Resident #1's sheet that was soiled with feces. LPN #1 said that they did not report the incident to Registered Nurse Supervisor (RNS) #1 who was on duty at the time. LPN #1 said that they left the facility at the end of their shift without reporting the incident to anyone. LPN #1 said they reported the incident the following morning on 02/21/23 to the Director of Nursing (DON). LPN #1 stated that they heard Resident #1 and CNA #1 arguing back and forth but did not hear what was being said. LPN #1 was unable to recall the time. During an interview on 07/03/23 at 1:45pm, the Assistant Director of Nursing (ADON) stated that Resident #1 reported to the Social Worker (SW) on 02/21/23 that CNA #1 was abusive to them. The ADON stated that Resident #1 reported that they asked CNA #1 to change their sheet and CNA #1 refused. The ADON said that Resident #1 reported that they asked CNA #1 to leave their room and CNA #1 refused to leave so they threw a cup of tea on CNA #1. The ADON said that Resident #1 expressed that CNA #1 in turn threw water on Resident #1. The ADON stated that they were present when the Director of Nursing (DON) interviewed CNA #1 and CNA #1 said that they threw back a cup of water on Resident #1. During an interview on 07/05/23 at 11:30am, the SW stated that on 02/21/23, Resident #1 reported to them that CNA #1 was inappropriate with them. The SW said that Resident #1 said that they asked CNA #1 to change their sheet and CNA #1 said that they are not going to change the sheet because Resident #1 played with the colostomy bag causing it to leak. The SW stated that Resident #1 also reported that CNA #1 told Resident #1 that they deserve to lay in s--t. 10 NYCRR 415.4(b)(1)(i)

Based on observation, record review and staff interviews, during the recertification and extended survey, it was determined that the Administrator failed to ensure that the facility operated in a manner that enabled it to effectively use its resources to maintain the highest practical well being and safety of each resident. Specifically, 1) the Administrator failed to identify the potential for entrapment risk with side rails (bed systems and components, as outlined in a New York State Department of Health Dear Administrator Letter (DAL) dated 6/19/15 NH15-05 (Zone 1)), despite having prior knowledge of these recommendations. This was evident for one of five residents reviewed for Accidents in a Stage Two Sample of 42 Residents. Additionally, 2) the Administrator did not ensure that all Accident/Incidents (A/I) were thoroughly investigated and that a Fracture related to an unwitnessed fall for Resident #110 was reported to the New York State Department of Health (NYSDOH) for one of five residents reviewed for Accidents. Additionally the Administrator signed that he reviewed the A/I report for Resident #110, however, the Administrator did not ensure that the agency (contract) Licensed Practical Nurse (LPN) received a counseling/education following the occurrence with Resident #110. The LPN worked for 26 shifts after the incident. This resulted in Immediate Jeopardy and Substandard Quality Care for Resident # 63. The findings of deficient practice are cited in F 323 K- Accidents and Supervision, and F 520 F - Quality Assurance Committee. The Finding are: 1) A nurses note dated 11/27/15 on the 7:00 AM -3:00 PM shift documented that Resident # 63 was observed with her neck entrapped through the side rail on her bed. The Registered Nurse (RN) released the residents head and no further documentation of the incident was made on the 24 hour report. An A/I report was never generated and nursing administration was never apprised. On 6/22/16 at 10:50 AM the Administrator was interviewed. The Administrator stated that he had never been made aware of the incident on 11/27/15 when Resident # 63 was observed with her neck through the side rail. The Administrator stated that he was aware for the past six or seven years of the danger of entrapment associated with side rail use. The Administrator further stated that he recalled discussions with the life safety consultants at that time regarding the recommended gap size of no greater than 4 and 3/4 inch space within the rail. He stated that all side rails should have been removed at that time and that unauthorized placement of side rails should never have been initiated. The Administrator further stated that he does receive and read all DALs. As to the specific DAL dated 6/19/15 NH 15 -05 Titled Entitled Entrapment risk with bed systems and components he was unable to recall receiving, but he was aware of the recommended gap size of no greater than 4 and 3/4 inch space within the rail to prevent entrapment. The Administrator did not recall if there was a policy specific to the dimensions of the side rails, but acknowledged that there should have been and that he would have been responsible to ensure compliance. The Administrator stated that the Director of Maintenance would have been aware of the recommended measurements of 4 and 3/4 inch but that the other two maintenance workers would not be. The Administrator further stated that he does make rounds but was not aware until yesterday 6/21/16 that any resident was actually using side rails. The Administrator further stated that the building will be under going major renovation and that 215 electric beds will be purchased with side rails of no greater than 4 and 3/4 inch space within the rail to prevent entrapment. Additionally, the Administrator stated that the Director of Nursing Services (DNS) would not be aware of the recommended 4 and 3/4 inch space within the rail of the side rails. The administrator did state that nursing was responsible for the authorization of side rails and that maintenance was responsible to install the rails. The Administrator was asked to provide any Quality Assurance (QA) that had been conducted on the use of side rails since July of 2015, any consultant notes regarding side rails and any maintenance logs with regards to side rail use. The Administrator was unable to provide any pertinent documentation. An interview was held with the Maintenance Director on 6/22/16 at 10:30 AM. The Director stated that he has worked in the facility for eleven years and has never been informed either in writing or verbally that the side rail needed to be a certain size between the rail rungs to prevent the residents from becoming trapped. Additionally, the Director stated that he had never received notification from any unit that there was a problem with side rails. 2) On 6/23/16 at 12:20 PM the Administrator was interviewed regarding Resident #110, who had sustained an in house [MEDICAL CONDITION]. Record review revealed that Resident #110 told a nurse that he fell and was put back to bed by a woman. It was reported that the nurse did not believe the resident and therefore did not tell the supervisor or physician. Therefore, resident was not assessed for several hours. The resident was subsequently sent out to the hospital and was diagnosed as having a [MEDICAL CONDITION]. The Administrator stated that he does sign off on all A/Is but he was not aware that Resident # 110 had sustained a [MEDICAL CONDITION]. The Administrator further stated that he was not aware that statements were not obtained, the A/I investigation was not complete and that it was never determined how the resident had actually fallen or who put him back to bed. Additionally, the Licensed Practical Nurse (LPN) assigned to Resident # 110 on 9/22/15 never completed a written statement or reported the incident to the RN Supervisor despite the resident complaining of pain. The administrator further stated that the LPN should not have been permitted to continue working in the facility for twenty six tours without having received a counseling/education regarding her handling of the situation. On 6/27/16 the Immediate Jeopardy was removed after monitoring confirmed the facility had implemented a plan to remove the immediacy. The determination to remove the Immediate Jeopardy was based on the facility's Policy and Procedure revision to include an interdisipinary team approach for side rail assessment, education of staff regarding the revised Policy and Procedure, and removal of the siderails which exceeded the FDA recommended 4 3/4 inch space within the rail space. On 6/27/16 the outside consultant conducted an additional audit of all resident beds to validate that all unneeded side rails had been removed. 415.26

Based on observations, record review and staff interviews during the recertification and extended survey, the facility failed to ensure that the resident environment remained as free of accident hazards as possible; and that each resident received adequate supervision and assistive devices to prevent accidents. This was evident for six residents reviewed for Accident/Incidents (A/I) in a total stage two sample of 42. Specifically, 1a) On 11/27/15, Resident #63's head/neck was entrapped within a side rail that was attached to the resident's bed. 1b) On 6/22/2016 at 8:00 AM the facility identified that four of thirteen residents still had side rails attached to their beds measuring 7 and 3/4 inches within the rail space. This measurement exceeded the FDA recommended space within the rail of 4 3/4 inches. (Residents #71, #21, #29, and #165.) This resulted in Immediate Jeopardy and Substandard Quality of Care for Resident #63, #71, #21, #29 and #165. The findings include but are not limited to: 1a) Resident #63 has [DIAGNOSES REDACTED]. Resident #63 was observed on 6/15/16 at 1:30 PM. The resident was seated in her bed watching television, with bilateral 3/4 padded side rails up. An air mattress was observed on the resident's bed. The side rails were observed to be flush with the bed with the rail pads in place. The resident responded to a greeting and appeared pleasantly confused. Subsequent observations were made 6/16/16 at 9:50 AM, and on 6/17/16 during wound care between 10:30 AM and 11:05 AM. On 6/17/16 at 10:30 AM Resident #63 was agitated and verbally aggressive to staff. The resident initially refused wound care, but after a given time and a change of staff the resident was compliant with the treatment and it was completed. Following the treatment administration the resident was positioned in bed with bilateral 3/4 padded side rails up. The Minimum Data Set (MDS) Assessment Significant Change dated 11/4/15 documented that Resident #63 could understand and could usually be understood. The resident had long and short term memory problems with moderate impairment for decision making. The resident required extensive assist of one staff for bed mobility. The MDS did not indicate that Resident #63 utilized side rails. The Quarterly MDS assessment dated [DATE] documented that Resident #63 could understand and could usually be understood. The resident had long and short term memory problems with moderate impairment for decision making. The resident was totally dependent on two staff members for bed mobility. The MDS did not indicate that Resident #63 utilized side rails. A Nursing Progress Note (NPN) dated 11/27/15 documented on the 7 AM - 3 PM shift, by the Registered Nurse, that: Resident observed with her neck through the side rail. Assisted by removing resident, no visible injury noted. Side rail pads applied every shift. Family notified. Will continue to monitor and maintain safety. On 6/21/16 at 1:00 PM the Registered Nurse (RN) MDS/Risk Manager stated that there was no A/I for the incident that occurred on 11/27/15 for Resident #63. Additionally, the RN stated that there would not be a Comprehensive Care Plan for the use of side rails for Resident #63. On 6/21/2016 at 2:15 PM the DNS was interviewed. The DNS stated that the RN Supervisor that had assisted with removing Resident #63's head from the side rail should have reported the incident to the DNS. The DNS stated that the RN should have notified the physician and that the RN should have initiated an Accident /Incident report immediately. The DNS also stated that statements should have been obtained from the staff on the 7 AM to 3 PM shift and that the incident should have been placed on the 24 hour report so that monitoring could be continued throughout the shifts. The DNS stated that a care plan should have been developed/updated for the incident with the side rail. The DNS further stated that the RN had only worked in the facility a few months and resigned shortly after the incident had occurred. The resident's Primary Care Physician was interviewed on 6/21/16 at 2:30 PM. The physician stated she was very familiar with Resident #63 and could not recall being contacted regarding the resident's head being entrapped in the side rail. The Physician stated that she would expect the nursing staff to contact her or the physician on call if there were any concern of injury for a resident. The physician stated that the resident utilizes side rails for the special mattress that is on her bed. During a subsequent interview with the DNS and the RN MDS/Risk Manager on 6/21/2016 at 2:45 PM, the RNs stated that they had not been aware of the incident with Resident #63's head being entrapped in the side rail back in November 2015, until it was brought to their attention during this survey. The 24 hour Nursing Report dated 11/27/15 was reviewed. There was no documentation on the report for Resident #63. An Interim Physician order [REDACTED]. The Physician Monthly Orders reviewed from 11/2015 through 6/7/2016 documented an order for [REDACTED]. On 6/21/16 at 2:45 PM an observation of Resident #63's bed was made with the RN nurse manager/Supervisor. The resident was positioned in bed watching television. The resident's padded side rails were raised. The padding was noted to be flush with the bed but the Velcro used to secure the pads to the rails was not fastened on either side leaving a gap between the padding and rail. The 3/4 side rails measured approximately 4 feet long, the space between the rungs within the side rail measured 7 and 3/4 inches. The side rail padding measured approximately 3 feet, leaving exposed space at the foot of the rail on the left side of the bed and at the top of the rail on the right side of the bed. The padding on the left side of the bed ended at approximately the resident's shoulder. If the bed were to be placed in a flat position, the resident's head would be accessible to the open area of the rail. The Recommendations presented in a document Guidance for Industry and FDA (Food and Drug Administration) Staff, Titled Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, issued on March 10, 2006 and presented in a Dear Administrator Letter from the New York State Department of Health to the New York State Nursing Home Administrators on June 19, 2015 documented that recommendations for Zone 1 (the area within the rail) of a (bedside) rail should not exceed 4 3/4 inches. Review of the current Comprehensive Care Plans (CCP) for Resident #63 revealed that there was no CCP developed for the use of side rails. Review of the Nursing Assessments revealed that there was no side rail assessment. An interview was conducted with the RN Nurse Manager/Supervisor for Unit 3 on 6/21/16 at 11:30 AM. The RN stated that she was the Wound Care Coordinator when Resident #63's incident with the side rail occurred. The RN stated that the resident utilizes side rails due to the low air pressure reducing mattress that is on the resident's bed. The Certified Nursing Assistant (CNA #1) was interviewed on 06/22/2016 AM between 9:45 - 10:00 AM. The CNA stated that she recalled working 11/27/15 on the 7:00 AM -3:00 PM shift. The CNA stated she was familiar with Resident #63 and had worked with her but was not assigned to her that day. CNA #1 stated that she makes rounds on the unit when she comes on in the morning (to see all the residents) at some point after lunch and before she leaves for the day. CNA #1 stated that on 11/27/15 she had made rounds after lunch (between 1:30-2:30) and saw Resident #63 positioned in bed with her right side facing the window. The CNA stated that she observed the resident's head to be stuck in the side rail and that she immediately called for the Nursing Supervisor and the resident's CNA. CNA #1 stated that she remained with the resident until the nurse and CNA (#2) arrived. CNA #1 stated that the Supervisor, CNA #2 and she carefully removed the resident's head back through the bars. The nurse checked the resident, and told the CNA the resident did not have an injury. CNA #1 stated that Resident #63 said she was fine, and the resident appeared to be her normal self. CNA #1 stated that she told the RN Supervisor that the resident needed to have pads on her side rails, which were obtained right away. CNA #1 stated that since that incident the resident has had side rail pads attached to the side rails and that the pads have Velcro straps to secure them to the railing. Interviews were conducted on 06/22/2016 at 2:10 PM with the Director of Physical Therapy (PT) and the Physical Therapist who had worked with Resident #63 in the past. The PT staff stated that the resident is evaluated quarterly due to the resident's medical condition/contractures. The Director of PT stated that Resident #63 was discharged from PT on 11/5/15 and was again re-evaluated in February 2016. The PT Director stated that she was not aware of the incident that occurred with Resident #63 when her head became entrapped in the side rail. The Director of PT stated that she had not received a request to evaluate side rail use for Resident #63. The Physical Therapist who had worked with Resident #63 stated that he was not aware that an incident involving Resident #63 head being entrapped in the side rail had occurred. The PT stated he had not been asked to do a side rail assessment for Resident #63. A 3rd interview was conducted with the RN Nurse Manager/Supervisor of the 3rd floor on 06/23/2016 at 9:55 AM. The RN stated that she was responsible for the Minimum Data Set (MDS) Assessments on the 3rd floor since she became manager in March 2016. The RN stated she had completed Resident #63's May MDS Assessment. The RN stated that the Side Rail section was not checked because the rails were not being used as a restraint. The RN stated that the resident had side rails for the use of a low pressure air mattress for the treatment of [REDACTED]. The RN stated that currently side rail use should be documented on the Activities of Daily Living care plan under the bed mobility section. The RN stated that she was aware that the side rail for Resident #63 was not documented on the Comprehensive Care Plan and that she would update it. The RN stated that currently there is no formal assessment tool for the use of side rails. The RN stated that all residents with low air pressure reducing mattresses have rails applied so they do not roll out of the bed. A telephone interview was conducted with the Medical Director on 06/23/2016 at 11:50 AM. The Medical Director stated that he could not recall being notified of an incident involving side rail entrapment for Resident #63. The MD stated that he would remember if he had been told that a resident had their head stuck between bed rails. The MD stated that the resident primary care physician or he should have been notified. The MD also stated that an assessment of the resident should have been completed. The Medical Director stated that if a resident requires side rails, the physician should be notified and a discussion should occur to determine either the use of or the discontinuation of side rails. The Facility Policy and Procedure titled Accident/Incidents (Resident related) dated 7/12 documented that it is the facility's policy to maintain the safety of all residents, in as much as possible. Documentation under the section Accident Hazard included: Defective or improperly latched side rails, between rails and mattress, between side rail and the bed frame or spaces between side rails and the head or foot board of the bed that can entrap limbs, neck or thorax, and can cause injury or death. 1b) Resident #71 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was sometimes understood and could sometimes understand and had severely impaired cognitive skills for daily decision making with no long and short term memory problems. The MDS also documented that the resident was totally dependent on two or more staff for bed mobility. An observation of Resident #71's room and bed was held on 6/22/16 at 9:05 AM, which revealed that the resident had bilateral side rails on the bed measuring 4 feet long and the distance between the slats/rungs of the side rail was 7 and 3/4 inches. The resident's entire Comprehensive Care Plan was reviewed on 6/21/16 at 4:25 PM and revealed no documented evidence that the resident had two side rails up when in bed. The MDS Coordinator/Risk Manager Registered Nurse (RN) was interviewed on 6/23/16 on 11:05 AM and stated that all residents with side rails should have had their side rails documented on the Activities of Daily Living (ADL) CCP as they use them to help in bed mobility. The RN also stated that it was the responsibility of the Nurse Managers to put this information on the ADL CCP, but the Nurse Manager had not done so. 1c) Resident # 21 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that the Resident's Cognitive Skills for Daily Decision making is severely impaired with short and long term memory problems. The MDS documented that Resident #21 required limited assistance of one staff for bed mobility and extensive assistance of two staff for transfer. Additionally, the MDS documented that the resident does not use bed rails. An observation of Resident #21's room and bed was held on 6/22/16 at 9:00 AM, which revealed that the resident had bilateral side rails on the bed measuring 4 feet long and the distance between the slats/rungs of the side rail was 7 and 3/4 inches, which exceeded the FDA recommendations of 4 3/4 inches. The Licensed Practical Nurse (LPN) was interviewed on 6/22/16 at 9:15 AM. the LPN stated that she was familiar with the resident. The resident was capable of moving around in the bed and was unaware of bed boundaries. An interview was held with the Charge Nurse Registered Nurse (RN) on 6/23/16 at 9:30 AM. The RN stated that there should have been a care plan for the use of side rails. On 6/22/16 at 10:50 AM the Administrator was interviewed. The Administrator stated that he had never been made aware of the incident on 11/27/15 when Resident # 63 was observed with her neck through the side rail. The Administrator stated that he was aware for the past six or seven years of the danger of entrapment associated with side rail use. The Administrator further stated that he recalled discussions with the life safety consultants at that time regarding the recommended gap size of no greater than 4 and 3/4 inch space within the rail. He stated that all side rails should have been removed at that time and that unauthorized placement of side rails should never have been initiated. The Administrator stated that the Director of Nursing Services (DNS) would not be aware of the recommended 4 and 3/4 inch space within the rail of the side rails. The administrator did state that nursing was responsible for the authorization of side rails and that maintenance was responsible to install the rails. On 6/27/16 the Immediate Jeopardy was removed after monitoring confirmed the facility had implemented a plan to remove the immediacy. The determination to remove the Immediate Jeopardy was based on the facility's Policy and Procedure revision to include an interdisipinary team approach for side rail assessment, education of staff regarding the revised Policy and Procedure, and removal of the siderails which exceeded the FDA recommended 4 3/4 inch space within the rail space. On 6/27/16 the outside consultant conducted an additional audit of all resident beds to validate that all unneeded side rails had been removed. 415.12(h)(1)(2)