Every finding on record at Yonkers Gardens Center for Nursing and Rehab

Based on observations and interviews conducted during the recertification survey from 2/5/2026 to 2/12/2026, the facility did not ensure that food was stored, prepared and distributed in accordance with professional standards for food safety practice. The facility also did not maintain essential kitchen equipment in a clean and sanitary condition. Specifically, observations revealed expired food items stored in the walk-in refrigerator. An opened and uncovered box of frozen vegetables was observed in the walk-in freezer. Sandwiches and cold cuts prepared for distribution were wrapped in plastic but lacked proper labeling. The glass doors of the countertop hot box food warmers were observed to be covered with large brown and black accumulations of burned grease. During tray line observation, the cook was not wearing a beard covering. A Food Service Worker was observed using unlabeled bottles of grape jelly in food preparation. The faucets at the pot wash sink were observed to be dripping despite being turned off. The floor area adjacent to the hot box warmers was observed to be slippery. The findings include:The facility policy and procedure, Food Storage-Perishable reviewed on 11/2004, documented all food stored in the refrigeration units will be in covered containers or otherwise suitably protected.The facility policy and procedure, Labeling and Dating reviewed on 03/2010, documented all bulk pre-packaged prepared items, i.e. mayonnaise, salad dressing, barbecue sauce, will be marked with an open date and discarded per the manufacturer's expiration date.During an initial tour of the kitchen on 2/5/2026 at 09:48 AM conducted with the Clinical Nutrition Manager, the following observations were made:In the walk-in refrigerator, three (3) 10-pounds plastic containers of sour cream with an expiration date of 1/19/2026 were observed. A half-gallon container of unsweetened Almond Breeze with an expiration date of 1/24/2026 was also present. Additionally, sandwiches and cold cuts prepared for distribution were wrapped in plastic but lacked appropriate labeling.Observation of the walk-in freezer revealed an opened and uncovered box of diced butternut squash. A bag of Tyson breaded white chicken patties was observed outside of its original box and without an expiration date.During observations on 2/5/2026 at 10:16 AM, on 2/11/2026 at 11:56AM and on 2/11/2026 at 3:12 PM the faucets at the pot wash sink were observed dripping despite being turned off. The glass doors of the countertop hot box food warmers were covered with large brown and black accumulations of burned grease. The floor area adjacent to the hot box warmers was slippery.During observation on 2/5/2026 at 10:17AM Food Service Worker #26 was using unlabeled bottles of grape jelly in food preparation.During an interview on 2/5/2026 at 10:18AM Food Service Worker #26 stated that once a grape jelly bottle becomes empty, they remove the original product label, wash the bottle, and refill it with regular grape jelly.During an interview on 2/5/2026 at 10:20AM Clinical Nutrition Manager stated that employees were not permitted to use unlabeled bottles or refill containers with different products for food preparation. The Clinical Nutrition Manager stated the unlabeled bottles would be discarded.During tray line observation on 2/5/2026 at 10:35AM [NAME] #8 was not wearing a beard covering.During an interview on 2/5/2026 at 10:36AM [NAME] #8 stated they were supposed to wear beard covering but forgot to put it on.During an interview on 2/11/2025 at 3:35PM, the Food Service Director stated that in their absence, kitchen supervisors and the [NAME] President of Operations checked stored products for expiration dates on a daily basis. The Food Service Director stated that when present in the facility, they conduct daily in-services regarding storage, food preparation, and monitoring of expiration dates. The Food Service Director stated they were not aware that unlabeled bottles were being reused. The Food Service Director stated that the kitchen was to be cleaned after each food preparation and that verbal work orders were submitted to the maintenance department for any malfunctioning equipment, including leaking faucets.10NYCRR 415.14 (h)

Based on observation, interview, and record review conducted during the recertification survey from 02/05/2026 to 02/12/2026, the facility did not ensure the resident's right to a safe, clean, comfortable and homelike environment on (2) two of (5) five resident floors (floors 3 and 4). Specifically,1) resident room/s on floor 3 had bathroom fixtures in disrepair, bedroom furniture, doors/walls with stains/scratches, and a soiled stained mechanical lift, and 2) resident room/s on floor 4 had a clock hanging off the wall, a damaged radiator, patched and mismatched wall paint, stained and warped ceiling tiles, dried rust-colored stains on walls/radiators, and a resident hall bathroom on floor 4 had a soiled and stained privacy curtain. The findings include:The policy titled Homelike Environment dated 11/30/2025 documented the facility will provide housekeeping and maintenance services as necessary to maintain a sanitary environment. During observation from 02/05/2026 at 10:08 AM to 02/11/2026 at 3:05 PM the bathroom in room [ROOM NUMBER] had missing wall tiles behind the toilet, and the toilet seat was peeling and cracked. In room [ROOM NUMBER] the dresser had broken and missing drawers, a closet door with a detached loose doorknob was hanging off the track, the wall and door had dried food stains. A mechanical lift on floor 3 had dried brown streaks and dust and grime on the bottom metal base.During observation from 02/05/2026 at 10:34 AM to 02/10/2026 at 11:54 AM in room [ROOM NUMBER], a clock was hanging off the wall from a wire, the top right portion of the radiator was damaged/missing and the wall adjacent to the radiator had large white patches that did not match the wall color. The privacy curtain in the resident hall restroom had brown stains on floor. In room [ROOM NUMBER] the ceiling tiles were warped/stained, the ceiling down to and including the radiator had large streaks of rusty brown dried stains running from the ceiling down to the room's radiator was also covered with rusty brown dried stains.During interview on 02/10/2026 at 11:35 AM, the Director of Maintenance stated their department's job responsibilities included painting, plastering, repairing any broken items and furniture throughout the facility, and repairing ceiling tiles. The Maintenance Department received work order requests and tracked the work they did through a facility-wide computer application available for any staff member to report repair needs. The Director of Maintenance stated they performed daily rounds on each unit and spot-checked residents' rooms to see if there were any repair needs that had not been reported. They stated there has been a significant improvement to the facility's environment since they began working for the facility 6 months ago. After observing the floor 3 and 4 environmental concerns, the Director of Maintenance stated none of these issues were reported to them by staff on the units and they missed these issues on their previous rounds.During interview on 02/10/2026 at 3:47 PM, the Director of Housekeeping stated they ensure cleanliness of resident rooms by making visual rounds on each unit multiple times throughout the day and ensuring their staff were performing their duties and had enough supplies. The Director of Housekeeping stated the facility staff called them or their staff directly when housekeeping was needed to address soiled areas or items. Each unit had a schedule of terminal cleaning for resident rooms where all items were cleaned, including the beds. During interview on 02/12/2026 at 8:20 AM, Housekeeper #25 stated they were assigned to floor 3 on the day shift and their responsibilities included cleaning resident rooms, furniture, bathrooms, and floors. They stated floor 3 was challenging because it was the dementia unit. Housekeeper #25 stated they were not responsible for cleaning the doors or walls of the residents' rooms or hallways. They stated an evening housekeeper was previously assigned to clean the unit hallways and doors and to clean mechanical lifts, wheelchairs, and other resident equipment, but that position was eliminated in 10/2025. Housekeeper #25 stated those duties have not been assigned to any other staff.During interview on 02/12/2026 at 10:51 AM, floor 3 and 4 Nursing Supervisor and Registered Nurse #3 stated they performed rounds daily on each unit and reported any environmental concerns to the Maintenance Department using the facility's computer program and called the Director of Maintenance directly to report urgent repair needs. They stated all nursing staff on the unit were responsible for communicating with the housekeeping staff when resident areas needed to be cleaned. The Housekeeping staff were also responsible for cleaning resident equipment10 NYCRR 415.5(h)(2)

Based on observations, interviews, and record review conducted during the recertification survey from 02/05/2026 to 02/12/2026, the facility did not ensure residents unable to carry out activities of daily living received necessary services to maintain good grooming and personal hygiene for three (3) of six (6) residents (Resident #11, #7, and #78) reviewed for activities of daily living. Specifically, 1) Resident #11 was not provided with staff assistance to perform facial hair grooming, 2) Resident #7 was not provided with staff assistance to take showers, and 3) Resident #78 was not provided with staff assistance to shower or groom their facial hair.The findings are:The facility policy and procedure, Activities of Daily Living Total Care last reviewed on 12/2025, documented all caregivers, nurses, and staff involved in the direct care of residents or patients who require assistance with activities of daily living, including but not limited to assist with oral care, hair care, shaving, nail care, and other grooming activities. 1) Resident #11 was admitted to the facility with diagnoses including non-Alzheimer's dementia, schizophrenia and depression. The Minimum Data Set (resident assessment) dated 12/14/2025 documented Resident #11 had moderately impaired cognition and needed partial assistance from staff with personal hygiene, and substantial assistance with toileting hygiene and shower/bathe self. The Comprehensive Care Plan for Activities of Daily Living, last updated on 12/22/2023, documented Resident #11 required partial assistance of one person with personal hygiene. During observations and interviews on 02/05/2026 at 1:41 PM and on 02/06/2026 at 10:06 AM , Resident #11 was ambulating in the hallway with long, unshaven facial hair. During an interview, the resident stated that one specific staff member shaved their face, however the resident was unable to recall when their face was last shaved. The resident stated that they preferred to be clean-shaven and stated that they were waiting for that staff member to provide shaving assistance. During interview on 02/11/2026 at 12:16 PM Certified Nurse Aide #6 stated that they were assigned to provide care for Resident #11 approximately two to three times per week, which included assistance with personal hygiene. Certified Nurse Aide #6 stated that each time they assisted the resident, they assess grooming needs, including facial hair that may require shaving, as the resident was unable to shave safely and independently. Certified Nurse Aide #6 stated that grooming activities, including shaving, fall within their responsibilities. Certified Nurse Aide #6 stated that the last time they were assigned to Resident #11 was on 02/06/2026, and on that date they were busy with providing showers to other residents and were unable to shave the resident. Certified Nurse Aide #6 stated that the resident's facial hair was currently too long to be shaved with a razor and would need to be trimmed with a shaving machine or scissors prior to shaving. Certified Nurse Aide #6 stated that they could not remember when the resident was last shaved. Certified Nurse Aide #6 stated that today, they offered to shave the resident, but the resident refused. Certified Nurse Aide #6 stated that when a resident refused care, they reported the refusal to the nurse. During an interview on 02/11/2026 at 12:36 PM, Registered Nurse #7 stated that certified nurse aides were responsible for grooming activities, including facial hair that required shaving. Registered Nurse #7 stated that they had not received report from Certified Nurse Aide #6 regarding Resident #11 refusing care. 2) Resident # 7 had diagnoses including hypertension, hepatitis and major depressive disorder. The Minimum Data Set (an assessment tool) dated 01/15/2026 documented that Resident # 7 had slightly impaired cognition and was dependent on staff for oral hygiene, toileting and shower/bathe self. The comprehensive care plan for Occupational Therapy, last updated 01/06/2026 documented that the resident was dependent on staff for hygiene/grooming, bathing tasks and transfers. The comprehensive care plan for Activities of Daily Living, last updated on 01/10/2026 documented that the resident was dependent on staff daily in meeting activity of daily living needs. During an interview and observation on 02/05/2026 at 11:00 AM, Resident #7 stated they had not had a bath or a shower for a very long time. They stated that they only received a bed bath, and they wanted to wash their hair. During this observation, the resident's appearance was consistent with her statement as her hair appeared to be unwashed. During an interview on 02/11/2025 at 12:06 PM, Certified Nursing Aide # 13 stated that the resident had not received a shower since their admission. They stated that every time they offered the resident a shower, they refused. During an interview on 02/12/2026 at 9:35 AM Registered Nurse # 3 Unit Manager stated that they could not recall any report of the resident not getting a shower. Additionally, they stated that the charge nurse should have documented if the resident refused a shower. A record review of the Certified Nursing Aide accountability record for January 2026 and the month of February 2026 did not document that the resident ever refused a shower. 3) Resident #78 had diagnoses of dementia and hydrocephalus. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #78 was severely cognitively impaired, did not exhibit any rejection of care, had bilateral functional limitation in range of motion to upper and lower extremities, totally dependent on staff for transfers in and out of bed, shower transfers, bathing, and personal hygiene. No mobility devices were used with Resident #78 within the assessment period. The Comprehensive Care Plan related to skin impairment initiated 06/02/2022 and last revised on 08/22/2025 documented Resident #78 had fragile skin and decreased mobility. Interventions to ensure Resident #78's skin remained intact included moisturizing the skin daily and getting out of bed daily. The Comprehensive Care Plan related to activities of daily living created 06/07/2022 and last revised 02/02/2026 documented Resident #78 required a left-hand roll. There was no documented evidence that care planning interventions were developed and implemented to address Resident #78's dependence upon staff to perform personal hygiene, transfer, and bathing activities. The Certified Nurse Aide Instructions documented Resident #78 required two people and mechanical lift to be transferred out of bed to a recliner and was dependent on staff to perform personal hygiene, bathing, and shower transfers. On 02/05/2026 at 10:25 AM and 02/06/2026 at 11:57 AM, Resident #78 was observed in a hospital gown in bed with unkempt greasy hair and a full scraggly beard. On 02/06/2026 at 12:14 PM, a telephone interview was conducted with the Resident #78's Designated Representative and they stated Resident #78 should be transferred out of bed daily, showered in the shower room twice weekly as scheduled, and clean shaven. The Designated Representative stated they were unable to travel to the facility but attended a care planning meeting and expected staff to provide Resident #78 with activity of daily living assistance whether they were able to visit or not. On 02/09/2026 at 11:02 AM, 12:34 PM, and 1:00 PM, Resident #78 was observed in bed in hospital gown with a full scruffy beard. On 02/11/2026 at 11:38 AM, Certified Nurse Aide #6 was interviewed and stated they were assigned to Resident #78 who required the total assistance of two staff to perform bathing, transfers in and out of bed, and personal hygiene. Certified Nurse Aide #6 stated Resident #78 had severe cognitive impairments, was calm and cooperative during care, and did not refuse care. Resident #78 was scheduled to come out of bed for a shower today but Certified Nurse Aide #6 stated the resident received a bed bath this morning instead. Resident #78's hair continued to look disheveled and greasy because Certified Nurse Aide #6 stated they slightly wet Resident #78's head and then dried the resident's hair with another towel. Certified Nurse Aide #6 stated they did not get Resident #78 totally wet because the water was cold, they didn't want the resident to be uncomfortable. Certified Nurse Aide #6 stated the 3rd Floor did not have a shower stretcher to accommodate Resident #78's positioning needs while showering. On 02/12/2026 at 10:51 AM, 3rd Floor Nursing Supervisor, Registered Nurse #3, was interviewed and stated the charge nurse on the unit was responsible for overseeing the Certified Nurse Aides and the care provided to residents. Registered Nurse #3 stated they and the Director of Nursing were responsible for overseeing the charge nurses. Registered Nurse #3 stated they did not audit chart documentation, and the Director of Nursing would run a report or check to ensure nursing documentation accurately depicted the services provided to the residents. Registered Nurse #3 stated they were not aware of Resident #78's out of bed schedule; however, Resident #78 should be clean shaven and Registered Nurse #3 stated they have not seen the resident with full facial hair. Registered Nurse #3 stated Resident #78 should be transferred out of bed for showers and every floor had a shower stretcher available. Registered Nurse #3 stated new shower stretchers were just purchased for the whole facility and none of the 3rd Floor staff reported there was any issue with providing Resident #78 with a shower. Resident #78 would be receiving a new recliner because this was the second time the previous recliner broke. On 02/12/2026 at 1:24 PM, the Director of Nursing was interviewed and stated they were made aware there were some concerns with residents receiving assistance with their activities of daily living. The Director of Nursing stated the charge nurses on the unit supervised the aides and the nursing supervisors supervised the aides and the charge nurses. Certified Nurse Aides were expected to document the assistance they provided a resident and which tasks they performed with the resident. 10 NYCRR 415.12(a)(3)

Based on observation and interview conducted during the 02/05/2026 to 02/12/2026 Recertification Survey the facility did not ensure appropriate storage of medications in accordance with currently accepted professional standards of practice for one (1) of 10 medication carts and two (2) of six (6) medication rooms. Specifically, one (1) medication cart on the 6th floor was observed unlocked and unattended, and one (1) medication room on the 5th floor was observed unlocked/unattended and contained methadone for Resident #119 and #156 that was stored in the same locked cabinet with other narcotics.The findings include:The 12/2025 policy titled methadone use documented the facility will maintain the use of methadone for pain or management of addiction in accordance with state and federal regulations. When methadone is prescribed for narcotic addiction only methadone must be stored separately from other controlled medications in a double locked cabinet designated for that purpose.During observation on 02/05/2026 at 11:15 AM the 5th floor medication room was unlocked. The cabinets over the sink were unlocked and contained medications. During interview on 02/05/2026 at 11:19 AM Registered Nurse Supervisor #17 stated the medication room should have been locked. They stated they did not know why the room would be unlocked. During interview on 02/05/2026 at 12:23 PM Licensed Practical Nurse #15 stated they were aware the medication room should have been locked. During observation and interview on 02/05/2026 at 4:28 PM the medication cart on the 6th floor was in the hall, unlocked and not within the line of sight when Registered Nurse #2 stepped away to enter the medication room. Registered Nurse #2 stated the medication cart should have been locked when they stepped away to get something from the medication room. During observation of the 5th floor medication room on 02/10/2026 at 1:20 PM methadone (a long-acting medication used to treat drug addiction) for Resident #119 and #156 was stored in a double locked cabinet with other narcotics.During interview on 02/11/2026 at 10:00 AM the Director of Nursing stated medication rooms and medication carts should always be locked. They stated there were two (2) locked cabinets in medication rooms. They stated methadone was supposed to be stored separately from other narcotics. They stated they were unaware the staff were storing methadone with other narcotics. During interview on 02/11/2026 at 12:00 PM the Pharmacy Consultant stated the medication rooms should always be locked. They stated methadone should be stored separately from the other narcotics.During interview on 02/12/2026 at 11:09 AM the Medical Director stated staff needed to abide by the rules when storing methadone.10 NYCRR 418.18(e) (1-4)

Based on observation, and interview during recertification survey from 02/05/2026 to 02/12/2026, facility personnel did not ensure linens were handled and stored in a manner to prevent the spread of infection. Specifically, linens and towels were exposed and stored on top of hampers in resident rooms, and dirty linens were on the floor in the 4th and 5th floor shower rooms. The findings include: The policy titled Handling of Linens dated 11/2025 documented the facility will ensure that all linens are handled, stored, processed and transported to prevent the spread of infection. Staff will handle all used linen as potentially contaminated and will bag linen at the point of use. During observation on 02/06/2026 at 9:59 AM clean linens, and towels were stored on top of resident hampers in rooms [ROOM NUMBERS].During observation on 02/09/2026 10:49 AM clean linens were stored on top of the resident hamper in room [ROOM NUMBER].During observation on 02/09/2026 at 10:52 AM dirty linens were in a pile on the floor of the fourth-floor shower room.During observation on 02/09/2026 10:59 AM linens and resident clothing were stored on top of the resident hamper in rooms [ROOM NUMBERS].During observation on 02/09/26 11:02 AM dirty linens, gloves, and socks were on the floor of the fifth-floor shower room.During observation on 02/09/2026 at 11:12 AM a pillow and linens were stored on top of the resident hamper in room [ROOM NUMBER]. Towels were stored on top of the resident hamper in room [ROOM NUMBER]. Gowns were stored on top of the resident hamper in room [ROOM NUMBER].During interview 02/09/2026 at 11:35 AM Registered Nurse Unit Manager # 10 stated Certified Nurse Aides were responsible for bringing linen/s into resident rooms. They stated they were not aware that linen was stored on top of resident hampers. They stated Certified Nurse Aides were responsible for putting dirty linens into the laundry.During interview on 02/09/2026 at 11:46 AM Certified Nurse Aide # 10 stated they were trained on proper storage of linens. They stated linens should be stored in the clean utility room and/or the cart in the hall. They stated they left linens on the laundry bin or a chair in resident room/s.During interview on 02/09/2026 at 3:47 PM the Infection Preventionist stated proper handling of linen was a part of environmental in-service. They stated clean linen was to be stored in carts on units. They stated dirty linen should be bagged/placed in the laundry chute. They stated they did not know why linen was being stored elsewhere.10 NYCRR415.19

Based on observation, interview, and record review conducted during the recertification survey from 02/05/2026 to 02/12/2026, the facility did not ensure a safe, functional, sanitary, and comfortable environment for residents, staff and the public. Specifically, 1) the designated smoking area had a substantial amount of cigarette butts and ice and snow covering on the ground, and 2) elevator #1 had damaged wall paneling and air vent grates. The findings includeThe policy titled Homelike Environment dated 11/30/2025 documented the facility will maintain outdoor areas for the safety and access of residents and visitors to ensure grounds, walkways, and entrances are free of tobacco-related waste. During observation on 02/05/2026 at 1:49 PM and 02/06/2026 at 10:00 AM, the designated outdoor smoking area had a large accumulation of snow and ice bordering a narrow-shoveled path from the door of the facility to a group of benches to the left. There were more than 50 cigarette butts littering the ground and mixed in with the ice and snow.During observation on 02/05/2026 at 12:25 PM, elevator #1 had 2 damaged metal air vent grates at the base of the right wall exposed sharp protruding metal prongs. The right wall paneling had a large section broken off at the lower left-hand corner.During interview on 02/10/2026 at 11:35 AM, the Director of Maintenance stated their department's job responsibilities included painting, plastering, repairing any broken items and furniture throughout the facility, repairing ceiling tiles and maintaining safe temperatures in the facility. The Maintenance Department received work order requests and tracked the work they did through a facility-wide computer application available for any staff member to report repair needs. The Director of Maintenance stated they performed daily rounds on each resident unit and did not mention the outdoor patio as part of their responsibility. After observing the damage to elevator 1, the Director of Maintenance stated the elevator was functioning and the air vents were working even though there was damage to the metal grate covers. There were no current plans to repair the wall paneling and metal grates in the elevator.During interview on 02/10/2026 at 3:47 PM, the Director of Housekeeping stated the Maintenance Department was responsible for clearing snow and ice from the outdoor designated smoking area. Housekeeping staff were responsible for sweeping up the cigarette butts in the area but there was no set cleaning schedule in place. The Director of Housekeeping observed the cigarette butts littering the ground of the smoke area and stated there should not be cigarette butts on the floor. They stated they needed to set up a better system for their staff to keep the area clean. The Director of Housekeeping stated they performed daily rounds on the resident units but rarely went to check the cleanliness of the outdoor smoking area.10 NYCRR 415.29

Based on observations, interviews, and record review conducted during the recertification and abbreviated surveys (#2669870), from 02/05/2026-02/12/2026 the facility did not ensure an effective pest control program was maintained for 3 (three) of 5 (five) residential floors (4th, 5th, and 6th floor) in the facility. Specifically, a roach was observed in room [ROOM NUMBER], residents and staff voiced complaints regarding roaches and mice, and the pest control company logs for the past 6 (six) months documented the ongoing presence of roaches on the resident units.Findings include:During an interview on 02/05/2026 at 9:56 AM, Resident #209 stated when they were in the bathroom they saw cockroaches on the floor. During an interview on 02/05/2026 at 10:14 AM, Resident #92 stated there were a lot of mice and roaches. They stated they told the housekeeper and the housekeeper said they could not do anything about it.During an observation on 02/06/2026 at 9:59 AM, there was a pest trap, with dead bugs stuck on, in room [ROOM NUMBER] under the heating unit. During an interview on 02/06/2026 at 10:18 AM, Resident #16 stated they had seen roaches in their bathroom. On 02/06/2026 at 11:06 AM, Resident Council Meeting was held with 16 residents in attendance. Four (Resident #66, #93, #115, and #110) stated they reported issues with roaches and rats during the resident council meetings and pest control efforts were ineffective. During an observation on 02/10/2026 at 12:39 PM, there was a roach on the floor under a resident overbed table in room [ROOM NUMBER].A review of the facility Pest Control Log from September 2025 to February 2026 documented pest concerns related to roach and mice infestation. The Pest Control Log documented the roach infestation was ongoing. The Pest Control Logs documented on, 09/07/2025, 10/08/2025, 10/10/2025, 10/17/2025, 10/31/2025, 11/03/2025, 11/04/2025, 11/13/2025, 11/14/2025, 12/08/2025, 12/13/2025, 12/26/2025, 1/14/2026, 1/19/2026, 1/23/2026, roaches and bugs were observed on the unit. During an interview on 02/12/2026 at 9:51 AM the Administrator stated they were aware of the issues regarding roaches and mice being seen on the units. They stated In December of 2025 they increased the pest control to 2 visits per week. They stated they had not discussed the pest problem as part of the Quality Assurance Performance Improvement program.During a phone interview on 02/12/2026 11:20 AM Office Manager at the pest control company stated they had an active contract with the facility, did site visits and recently increased visits to twice a week. They were aware of pest sightings and changed chemicals to increase effectiveness. They were aware that the facility continued to have roaches and mice.During an interview on 02/12/2026 at 11:53 AM, Certified Nurse Aide #22 stated the unit had an ongoing problem with roaches, they thought the pest control company came about once a month, they had not noticed any improvement.During an interview on 02/12/2026 at 11:56 AM, Certified Nurse Aide #21 stated they had seen roaches in residents' rooms and told management. 415.29(j)(5)

Based on observation and interview during a recertification survey from 02/05/2026 through 02/12/2026, the facility did not ensure dignity was maintained for one (1) of four (4) residents (Residents #181) reviewed for dignity. Specifically, the phlebotomist drew blood from Resident #181 in the dining room area where residents were waiting for lunch. The findings include:Resident # 181 was admitted with diagnoses that included but not limited to cerebral infarction, epilepsy and hypertension.Resident Rights policy last reviewed May 2025 documented for any procedure that involves direct resident care, provide for the resident's privacy.The 12/15/2025 Minimum Data Set admission assessment documented Resident #181 was cognitively impaired, no behavior.During an observation on 02/06/2026 at 12:49PM, in the dining room where residents were waiting for lunch, a phlebotomist was observed with their tray of supplies in front of Resident # 181. The phlebotomist was observed removing the resident's left sweater sleeve and drew blood from Resident #181's left arm. The phlebotomist walked to another table in the dining room and placed their tray of supplies in front of another resident. Registered Nurse Unit Manager #19 arrived at the dining room and spoke to the phlebotomist and told them to leave the dining room. When interviewed, Registered Nurse Unit Manager #19 stated the phlebotomist should have asked staff to take Resident #181 to the room and draw the blood in Resident #181's room. 10 NYCRR 415.3.(c)(1)(i)

Based on observations, record reviews and interviews during the recertification survey from 2/5/2026 to 2/12/2026 the facility did not promote and facilitate resident self determination through support of the resident's choices for one (1) of five (5) residents (Resident #7) reviewed for Choices. Specifically, Resident # 7 was not allowed to choose their bedtime. Findings include:Resident # 7 had diagnoses including hypertension, hepatitis and major depressive disorder. The admission Minimum Data Set (an assessment tool) dated 5/27/2025 documented that resident # 7 had intact cognition and it was somewhat important to the resident to be able to choose their bedtime.The comprehensive care plan for Behavior Disturbance last updated 01/10/2026 documented to give the resident as many choices as possible about care and activities.During an interview on 02/10/2026 at 12:32 PM, the resident stated that the staff tell them when they have to go to bed. They stated that they did not like to go to bed early and it was their preference to stay up later. Additionally, they stated that they did not feel free in the facility and they were not given choices.During an interview on 02/11/20926 at 12:06 PM, Certified Nursing Aide # 13 stated that the next shift of aides got mad when residents were still up. They stated that if it was close to shift change, they would tell the residents they had to go to bed now. They stated that if the resident was able to get themself in bed they could stay up, but if they were unable to get themself to bed then they must go into bed.During an interview on 02/12/2026 at 9:35 AM Registered Nurse # 3 Unit Manager stated that the resident must be in bed by the change of shift because they were on hourly monitoring for a fall risk. Additionally, they stated that the resident had to go to bed early because they were non-ambulatory.415.5(b)(1-3)

Based on observation, interview, and record review conducted during the recertification survey from 02/05/2026 to 02/12/2026, the facility did not ensure quarterly statements of the resident's financial record were made available for (1) one of (2) two residents (Resident #78) reviewed for Personal Funds. Specifically, there was no evidence quarterly statements of Resident #78's personal funds account was provided to the resident's Designated Representative. The findings include:Resident #78 had diagnoses of dementia and hydrocephalus.The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #78 had severe cognitive impairment and their family participated in the assessment. On 02/06/2026 at 12:14 PM, a telephone interview was conducted with Resident #78's Designated Representative and they stated they used to receive quarterly statements of Resident #78's personal funds account activity until approximately 18 months ago. The Designated Representative stated they called the facility's business office multiple times and had to request copies of Resident #78's personal funds account statements. The Designated Representative expressed their concern to the facility's business office, but the facility has not changed their accounting practices. The Resident Account Statement as of 02/10/2026 documented Resident #78 had their funds managed by the facility since 08/10/2023. There was no documented evidence Resident #78's personal funds statements were made available to the residents' Designated Representative quarterly. On 02/12/2026 at 12:16 PM and 1:55 PM, the Medicaid Coordinator was interviewed and stated they were responsible for providing quarterly account statements to cognitively intact residents in the facility. The facility's corporate business office, located off-site, was responsible for sending quarterly statements to the designated representatives of residents with cognitive impairments. The Medicaid Coordinator stated they contacted their corporate business office and were unable to provide any documented evidence Resident #78's quarterly account statements were provided to the Designated Representative.10 NYCRR 415.26(h)(5)(ii)(a-c)

Based on observation, record review and interview conducted during the recertification and abbreviated (2584489) survey from 02/05/2026 to 02/12/2026, the facility did not ensure that alleged violations involving abuse, mistreatment, or neglect were thoroughly investigated for one (1) of five (5) residents. (Resident #140) reviewed for abuse. Specifically, for Resident #140 there was no documented evidence the facility conducted a complete and thorough investigation, including statements, after Resident #140's family member reported the resident was beaten in the shower by certified nurse aides. The findings include: The facility policy and procedure on Abuse Prevention, revised 12/2025, were documented to provide a proactive and systematic approach to protecting residents' rights from harm related to abuse, neglect, or misappropriation of property. The facility protected residents' rights to be free from physical abuse and ensured that residents were not subjected to abuse by anyone, including but not limited to facility staff, residents, consultants or volunteers, and visitors. Reporting of abuse incidents, investigations, and facility response were directed to the New York State Department of Health.Resident #140 was admitted with diagnoses including diabetes mellitus, depression, and epilepsy.The annual Minimum Data Set (an assessment tool) dated 05/09/2025 documented that the resident had moderately impaired cognition and no behavioral issues. Resident # 140 required partial/moderate assistance for showering. Resident #140's comprehensive Care Plan for risk of potential verbal, physical, or sexual abuse, neglect, or mistreatment was initiated on 07/27/2024 and last updated on 08/29/2025, with goals that the resident would not experience any form of abuse or neglect.Register Nurse #3's progress note dated 08/06/2025 at 10:32 AM, documented around 10:09 AM the resident was in the hallway asking for help and unable to put his pantson. This was not their baseline; they were pale with altered mental status and stated they had a seizure. The resident's oxygen saturation was 66% on room air. They were administered oxygen and transferred to the hospital.A nursing progress note dated 08/06/2025 at 11:57 PM documented the resident was admitted to the hospital with a diagnosis of pulmonary emboli (blockage of lung artery from blood clot).The Facility Reported Incident submission to the New York State Department of Health (State Agency) dated 08/07/2025 at 7:48 PM, documented that Resident #140's family came to the facility on [DATE] at 6:40 PM and alleged that the facility's certified nurse aides punched the resident in the head, face, arms, and legs on 08/06/2025 in the morning. The family member stated that the certified nurse aide let the resident fall to the floor and forced the resident to take a cold shower; this was told to the family member by the resident. The resident was in the hospital on [DATE] being treated for a pulmonary embolism. Prior to the hospital transfer, the resident was seen in the hallway asking for help to put their pants on and was observed to be pale and not at their baseline. There was no report of physical abuse as alleged by the family. In addition, the resident did not have any bruises or injuries observed at the time of transfer to the hospital. So far, there is no substantial evidence to support the allegation. The resident's statement related to their condition could not be obtained.A description of the facility's investigation findings documented on 08/07/2025 that no staff or individuals witnessed the incident and that there were no staff by the name Raji in the facility or on the resident's unit. The Director of Nursing documented that statements were obtained from staff who worked the floor on 08/06/2025 on the day shift. Prior to the resident's transfer, the resident did not report any incident as claimed by Resident #140's family.The Nursing Home Investigative Report submitted to the State Agency on 8/14/2026 documented no staff witnessed the incident and that there was no staff by the name the resident's family member had reported. The report documented that statements were obtained from staff who worked on the floor on 08/06/2025 on the day shift. The report documented that prior to the resident's transfer to the hospital, the resident did not report any incident as claimed by the resident's family. The Registered Nurse Manger of the 4th floor and the unit nurse did not witness nor have knowledge of the alleged incident. The investigation was done by interviewing staff and residents present on the fth floor on 08/06/2025 to establish whether an unusual incident took place prior to Resident #140's transfer to the hospital. Records were also reviewed to find out if there were unusual observations that might support the suspicion of abuse. During an interview on 02/09/2026 at 8:25 AM, Resident #140 stated they remembered being forced to take a shower and being beaten by two staff members, who grabbed them, took their clothes off, and showered them. Resident #140 stated they screamed and yelled. They stated that the two aides gave them the shower after they had beaten them. During a telephone interview on 02/09/2026 at 11:28 AM, the family representative for Resident #140 stated the resident had an incident in which staff beat them in the shower room and gave the resident a cold shower.During an interview on 02/09/2026 at 1:50 PM, Certified Nurse Aide #1 stated they were not aware of the resident being beaten by staff in the shower room. They stated the resident showered on Tuesdays and Fridays during the day shift. They also stated this was their permanent assignment taking care of the resident and they were not asked to write a statement. During an interview on 02/09/2026 at 1:57 PM, Certified Nurse Aide # 14 stated they were not aware of the resident being beaten by any staff during a shower. They stated this was their regular unit and that the resident was not on their assignment. During an interview on 2/09/2026 at 2:10PM, Registered Nurse Unit Manager #3 stated they were not aware of Resident #140 having altercations involving staff or other residents. They stated the resident got along well with everyone. During an interview on 02/09/2025 at 2:25 PM, the Director of Nursing stated there was an allegation by Resident #140's family that the resident was hit by a specifically named person and the did not have staff by that name. They stated the resident was in the hospital when the family reported this incident. They stated the process of reporting incidents to the State Agency was for any witnessed or alleged incident of verbal or physical abuse that the staff were trained on. They stated incidents such as resident-to-resident altercations, abuse, burns, and resident elopement were all reportable. They stated an internal investigation would follow, involving interviews with staff and residents, including written statements, and a complete investigation summary would be produced within 5 days to rule out any allegations of mistreatment and to report the findings to the State Agency. When requested, the Director of Nursing was unable to provide the statements provided during interviews or written statements. During an interview on 2/10/2026 at 12:20 PM, the Administrator stated there were staff statements from the investigation on 8/7/2025. They stated it was unsubstantiated because the certified nurse aide named by the family was not a staff member of the facility. They stated that the Director of Nursing called all staff who were on duty that day, and that they did not witness any incident. They stated that the resident was sent to the hospital for an unrelated issue. They stated that the Director of Nursing spoke to all the staff by telephone but did not have written statements. 10 NYCRR 415.4(b)(3)

Based on record review and interview conducted during the recertification survey 02/05/2026 - 0212/2026 the facility did not ensure a significant change Minimum Data Set assessment was completed within the 14-day requirement for one (1) of six (6) residents (Resident #2) reviewed for Nutrition. Specifically, a significant change Minimum Data Set was not initiated within 14 days for Resident #2 who had weight loss of 5% or more in the last month or loss of 10% or more in last 6 months, a decline in activities of daily living, a decline in cognition and a decline in urinary continence. The findings include:The October 2025 policy and procedure titled Minimum Data Set documented ensure accurate and timely completion of the Minimum Data Set in accordance with the State and Federal Operation Manuals. Assessments will be completed by members of the interdisciplinary team in accordance with the completion date as determined by the Minimum Data Set Director. For comprehensive assessments that require completion of Care Area Assessments all disciplines will be required to complete the Minimum Data Set as assigned.Resident #2 was admitted with diagnoses that included but were not limited to cerebral infarction with hemiplegia and hemiparesis affecting left non-dominant side, and stage 3 chronic kidney disease.Resident #2's weights documented 9/6/2025 178.0 lbs. 10/5/2025 165.0 lbs.11/24/2025 147.0 lbs.The 11/29/2025 Medicare 5-day Minimum Data Set assessment documented Resident #2 had intact cognition, received substantial/maximum assistance for eating, was frequently incontinent of urine, and had weight loss of 5% or more in the last month or loss of 10% or more in last 6 monthsResident #2's weights documented 12/8/2025 132.2 lbs. 12/10/2025 134.4 lbs.The 01/05/2026 quarterly Medicare 5-day Minimum Data Set assessment documented Resident #2 had impaired cognition, was dependent on staff with eating, was always incontinent of urine, and had weight loss of 5% or more in the last month or loss of 10% or more in last 6 months.Resident #2's weight documented 01/16/2026 130.2 lbs. The 01/23/2026 dietitian note documented 01/2026 monthly weight 130.2 lbs. significant 21% weight loss x 3 months. Resident with multiple hospitalizations during this time, receives Remeron, goal to prevent further weight loss, current diet puree, suboptimal by mouth intake, received ensure plus 8 ounces 3x a day to aid with weight goal. Resident #2's weights documented 2/2/2026 117.6 lbs.The 02/04/2026 dietitian note documented significant weight loss 9.6% x 1 month, 20% sig wt. loss x 3 months. staff and Speech Language Pathologist report resident refusing meals with very poor intake. Supplements include ensure plus 8 ounces 3x a day, and prostat 30 cubic centimeter 2x a day.The 02/09/2026 nurse practitioner note documented acute delirium and auditory & visual hallucination, Human Immunodeficiency Virus, Failure to thrive in adult with weight loss and poor oral intake, Urinary Tract Infection contributing to acute mental status change, continue Mirtazapine 15 mg for appetite stimulation and mood support.During an interview on 02/10/2026 at 10:47 AM the Minimum Data Set Coordinator stated they scheduled the Minimum Data Set assessments, reviewed all assessments, and ensured accuracy/completion of assessments. They stated the facility did not have meetings to discuss weights/ weight loss. They stated nursing and dietary determined weight loss. They stated the dietitian filled out the weight section in the Minimum Data Set assessment. They stated they did not review the weight section. They stated they were not aware that Resident #2 had a weight loss. They stated they did not always review previous Minimum Data Set assessments when they completed new assessments. They stated between 11/29/2025 and 01/05/2026 Resident #2 had changes in activities of daily living, urine incontinence, cognition and weight loss. They stated a significant change Minimum Data Set assessment should have been completed when identified.During an interview on 02/10/2026 12:26 PM, the Clinical Nutrition Manager stated they coded the Minimum Data Set section pertaining to weights. The Clinical Nutrition Manager stated they discussed weights during morning meetings. and addressed weight loss in morning meetings with nursing staff. The Clinical Nutrition Manager stated they discussed Resident #2's significant weight loss with the Interdisciplinary team and Minimum Data Set assessment during morning meeting. They stated they were unable to recall the exact date of the discussion. The Clinical Nutrition Manager stated the facility did not have a system to review resident weights and did not conduct weight rounds. The Clinical Nutrition Manager stated there should have been a significant change Minimum Data Set assessment based on Resident #2's weight loss and decline in eating, but it was missed.The 02/10/2026 at 12:46 PM Minimum Data Set Coordinator note documented Resident #2 experienced a 9.6% unplanned weight loss in less than 30 days, meeting criteria for significant change in status. They stated this represented a non-self-limiting decline from baseline that required initiation of a significant change assessment to ensure accurate Minimum Data Set coding and appropriate care plan revision.During an interview on 02/11/2026 at 9:20 AM, the Director of Nursing stated Resident #2's weight loss was discussed several times during morning meetings. They stated the Minimum Data Set Coordinator was responsible for checking accuracy and completeness of all assessments. They stated there should have been a significant Minimum Data Set assessment completed at the time when weight loss, activity of daily living change and change in cognition was identified.10NYCRR 415.11(a)(3)(ii)

Based on record review and interview conducted during the Recertification Survey from 2/05/2026 to 2/12/2026, the facility did not ensure Minimum Data Set Assessments were submitted within 14 days after the facility completed the resident's assessment for two (2) of two (2) (Resident #83 and #96) residents reviewed for Minimum Data Set. Specifically, Resident #83 and #96's Minimum Data Set Assessments were completed on 10/07/2025, and were not transmitted until 02/09/2026. The findings include:Minimum Data Set Policy and Procedure dated October 2025, documented it was the policy for timely completion of the Minimum Data Set in accordance with the State and Federal Operation Manuals.Review of the submissions revealed:- Resident # 83 Discharge Minimum Data Set 3.0, with an assessment reference date of 09/22/2025 and completion date of 10/07/2025, was transmitted on 02/09/2026.- Resident #96 Discharge Minimum Data Set 3.0, with an assessment reference date of 09/26/2025 and completion date of 10/07/2025, was transmitted on 02/09/2026.During the interview on 02/10/2026 at 10:10 AM, the Minimum Data Set Coordinator stated after reviewing the Minimum Data Set schedule, two assessments were not transmitted, although completed. They further stated another Minimum Data Set nurse had documented an old code from a validation report into the electronic medical record software which indicated the record had been transmitted when it had not.During the interview on 02/10/2026 at 10:14AM, the Administrator stated the Minimum Data Set Coordinator was responsible for ensuring the Minimum Data Sets were completed and submitted timely, they were unaware the assessments were transmitted late.10 NYCRR 415.11

Based on record review and interview conducted during the Recertification Survey from 02/05/2026 to 02/12/2026, the facility did not ensure that the Minimum Data Set assessment accurately reflects the resident's status for (1) one of (3) three residents (Resident # 46) reviewed for Smoking. Specifically, the 12/10/2025 Minimum Data Set assessment was not accurately coded to reflect Resident #46's use of tobacco. The findings include:The October 2025 policy and procedure titled Minimum Data Set documented ensure accurate and timely completion of the Minimum Data Set in accordance with the State and Federal Operation Manuals. The assessments will be completed by members of the interdisciplinary team in accordance with the completion date as determined by the Minimum Data Set Director. For comprehensive assessments that require completion of Care Area Assessments all disciplines will be required to complete the Minimum Data Set as assigned.Resident #46 was admitted with diagnoses that included but were not limited to opioid dependence, acute kidney failure and obesity.The 12/04/2025 care plan for psychosocial history documented Resident #46 is a known smoker.The 12/05/2025 smoking assessment completed by Registered Nurse Unit Manager # 19 documented Resident #46 smoked. The 12/05/2025 smoking contract documented Resident #46's and the Recreation Directors signatures.The 12/10/2025 Minimum Data Set admission assessment (an assessment tool) documented Resident #46 was cognitively intact, had no impairment of the upper extremity, and did not use tobacco. During an interview on 02/05/2026 at 10:43 AM and on 02/06/2026 at 12:26 PM, Resident #46 stated they smoked cigarettes three (3) times a day in the smoking room. They stated their lighter and cigarettes were locked up in the cart downstairs. They stated smoking time was 30 minutes.During an interview on 02/10/2026 at 11:02 AM, the Minimum Data Set Coordinator stated they were responsible for the accuracy and completeness of all Minimum Data Set assessments. The Minimum Data Set Coordinator stated tobacco use should have been coded on the Minimum Data Set assessment. 10NYCRR 415.11(b)

Based on observations, interviews, and record review conducted during the recertification survey from 02/05/2026 to 02/12/2026, the facility did not ensure each resident received adequate supervision to prevent accidents. This was evident for one (Resident #19) of three residents reviewed for smoking. Specifically, Resident #19 was not reassessed for their ability to smoke safely and care plan interventions to prevent future noncompliance were not developed and implemented following the resident's noncompliance with facility smoking rules. The findings are:The facility policy titled Smoking dated 05/2025 documented smoking restrictions shall be strictly enforced in all nonsmoking areas. The staff should consult the Director of Nursing and Physician to determine restrictions on a resident's smoking privileges.Resident #19 had diagnoses of adjustment disorder, post-traumatic stress disorder, and nicotine dependence. The comprehensive Minimum Data Set 3.0 assessment dated [DATE] documented Resident #19 was cognitively intact, a smoker, and rejected care. The quarterly Minimum Data Set 3.0 assessment dated [DATE] documented Resident #19 remained cognitively intact and required supervision or setup assistance with activities of daily living.The admission Agreement dated 06/26/2024 and signed by Resident #19 documented the facility was a smoking facility and the resident agreed to abide by the facility smoking rules. The Smoking assessment dated [DATE] documented Resident #19 displayed accurate understanding of the smoking policy and had no history of noncompliance with the smoking rules. Questions regarding Resident #19's ability to follow the smoking policy and whether they had been observed sharing, selling, or asking others for cigarettes were left unanswered on the assessment form. The Comprehensive Care Plan related to smoking created 05/02/2025 documented Resident #19 would be allowed to smoke in the designated areas under supervision, and the smoking policy would be reviewed with the resident as needed. Resident #19's care plan was last reviewed on 12/18/2025 and documented that Resident #19 would accept the facility policy on smoking. The Comprehensive Care Plan related to physical aggression created 05/02/2025 documented Resident #19 had poor impulse control and a history of harming others. Interventions to prevent further risk of harm included increased behavioral monitoring, adequate supervision and monitoring, and removing Resident #19 from distress before their agitation escalated. The care plan was last revised 07/11/2025 and documented Resident #19 was removed from hourly safety monitoring.The Medical Doctor Note dated 09/05/2025 documented Resident #19 was noted with verbal outbursts, antagonistic behavior towards staff and other residents but remained stable. The Social Work Note dated 09/07/2025 documented Resident #19 was agitated following their smoking session and displayed unpredictable threatening behavior placing themselves and others at risk for abuse. The Social Services Interim assessment dated [DATE] documented Resident #19 was a smoker, and the smoking policy and contract were not reviewed or signed with the resident. The Activities Note dated 09/26/2025 documented Resident #19 reportedly smoked in their room. A strong cigarette smell was present, and staff found an empty cigarette box. Resident #19 was educated on the smoking rules and regulations. The Nursing Note dated 09/30/2025 documented Resident #19 had a verbal disagreement with the resident in the adjacent room with whom Resident #19 shared a bathroom. The other resident reported Resident #19 was smoking in the bathroom causing it to smell of cigarettes. The police were called and Resident #19 denied smoking in their room and refused a room change closer to the nursing station. The Social Work Note dated 10/01/2025 documented Resident #19 attended a care plan meeting with the interdisciplinary team and Resident #19's noncompliant smoking behavior and abusive behavior were discussed. A Smoking Contract dated 11/05/2025 documented Resident #19 agreed not to store tobacco or smoking materials in their room or on their person, Cigarette butts must be discarded in the appropriate trash receptacles. The contract also documented Resident #19 understood they may lose their smoking privileges and be subject to room search if they acted inappropriately.The Social Services Interim assessment dated [DATE] documented the smoking contract was not reviewed with Resident #19 although the resident continued to smoke and displayed agitation. There was no documented evidence Resident #19 was reassessed for smoking ability following episodes of noncompliance and smoking in their room. There was no documented evidence Resident #19's care plan related to smoking was reviewed and revised to include adequate interventions to address Resident #19's smoking noncompliance. There was no documented evidence Resident #19 was provided with supervision and monitoring to prevent further episodes of noncompliance with smoking rules. On 02/05/2026 at 11:27 AM, Resident #19's room was empty with the door open and was observed with a strong smell of stale smoke. A soda can was observed on the baseboard next to the radiator below a window. Cigarette ashes were lying on top of the soda can and the mouth of the can was burned along the edges. There were three brown burn marks on the floor near the resident's bed. At 11:32 AM, Resident #19 was interviewed in their room and stated they violated the smoking policy and smoked in their room several months ago in 2025. Resident #19 stated they have not smoked in their room since then and only had a soda can with ashes because there was no garbage can for them to use in the designated smoking area outside. Resident #19 denied smoking in their room and stated the burn marks on the floor were from previous occasions of smoking in their room. Resident #19 stated the recreation department held onto their cigarette and lighting materials and the facility offered three smoking times per day. On 02/05/2026 at 4:53 PM, Smoke Monitor #26 was interviewed and stated they were responsible for monitoring the designated smoking area while residents smoked during the facility's scheduled smoking throughout the day. The Recreation Department was responsible for holding onto residents' cigarettes and lighting materials in a locked smoking cart that was only brought out during smoking times. The Recreation Director was responsible for reviewing the smoking contract with residents identified as smokers. No residents were allowed to hold onto their own cigarettes or lighting materials, even if they were considered safe smokers. The smoking contract outlined repercussions for residents who violated the smoking rules. Nursing was responsible for assessing residents' smoking abilities. Smoke Monitor #26 stated they have observed residents violate the smoking contract by lighting each other's cigarettes in the designated smoke area but did not report all these violations to their supervisor. Smoke Monitor #26 stated they were unable to adequately monitor all the smokers in the designated smoking area on their own and could not supervise the actions of all the residents throughout the whole session. Smoke Monitor #26 stated they tried to catch and discourage residents from bringing cigarette butts back into the facility at the end of their smoking sessions. After the recent snowstorm, Smoke Monitor #26 stated they observed many residents throwing their cigarette butts on the ground, a violation of the smoking contract, because the designated smoke area was not clear of snow and ice and the residents could not reach the ashtrays. Smoke Monitor #26 stated Resident #19 has been noncompliant with the smoking rules since admission to the facility. There were no special monitoring instructions for Resident #19 when in the designated smoke area. On 02/11/2026 at 11:56 AM, the Recreation Director was interviewed and stated Nursing determined a resident's smoking status upon admission and was responsible for completing the smoking assessment. Nursing then contacted the Recreation Director to educate the residents on smoking cessation, provide the smoking times and rules, and have the residents sign a smoking contract. The smoking assessment included information on the residents' respiratory status, oxygen use, cognition, physical limitations, and history of noncompliance with smoking rules. The Recreation Director stated they were responsible for taking possession of residents' smoking materials and lighters upon admission and securing them in the locked smoking cart. Repercussion for noncompliance with the smoking rules included room searches and smoking ban for 24, 48, or 72 hours. The Recreation Director stated Resident #19 consistently violated the smoking rules by possessing paraphernalia and smoking in their room. Room searches were done by interdisciplinary staff upon each alleged violation and were not a consistent intervention in Resident #19's plan of care. Resident #19 always denied smoking in their room and became agitated and threatening during room searches or conversations with staff regarding smoking noncompliance. Facility interdisciplinary staff discussed revoking Resident #19's smoking privileges but believed this would be a violation of resident rights and continued to allow Resident #19 to smoke. The Recreation Director stated they were not involved in the care plan documentation or most recent smoking assessment. The Recreation Director stated their department used to have a second smoke monitor during smoking times because it was difficult for one person to supervise all the residents during the smoking sessions. The second smoke monitor recently resigned, and the facility would be able to fill that role within the next few weeks to ensure adequate supervision of the designated smoking area. The Recreation Director stated they would be filling in as the second smoke monitor for the time being. On 02/12/2026 at 8:42 AM, the Director of Social Work was interviewed and stated, when available, they were involved in room searches for Resident #19 and care plan meetings to discuss Resident #19's smoking noncompliance. The Director of Social Work stated they were not involved in smoking assessments and was unsure how often they occurred for each resident. Resident #19 received psychological services routinely. The Director of Social Work was unable to find Resident #19's last psychiatry consultation. Resident #19 has been offered a room change closer to the nursing station so unit staff could better monitor the residents for smoking noncompliance; however, the residents refused to have their room changed. The Director of Social Work stated they would have to meet with interdisciplinary department heads and the Psychologist to develop a behavior management plan for Resident #19 that included interventions to address smoking noncompliance. There currently was no plan in place. On 02/11/2026 at 11:11 AM, Certified Nurse Aide #13 was interviewed and stated Resident #19 was known to be noncompliant with the smoking rules and there were several instances of this resident smoking in their room. Each time a staff member or other resident alleged Resident #19 was smoking in their room, the resident's room would be searched and, by the time staff were able to gain access, there were no smoking materials found. Resident #19 only required supervision and setup with activities of daily living and refused to allow anyone in their room without them present. Certified Nurse Aide #13 stated they could not recall the last time they had to report to the supervisor that Resident #19 was smoking in their room. There was no special supervision or monitoring for Resident #19 besides the normal daily hourly visual rounds performed for all residents on the unit. On 02/12/2026 at 10:51 AM, Registered Nurse #3 was interviewed and stated registered nurses were responsible for identifying smokers upon admission, offering residents smoking cessation, assessing a resident's ability to smoke safely, and updating the resident's smoking care plan. Registered Nurse #3 stated they were unsure how often smoking assessments were done for residents and did not believe there was any regularly scheduled reassessment. The interdisciplinary team conducted care plan meetings in line with the Minimum Data Set 3.o assessment schedule and only discussed care plans triggered during the assessment period. Registered Nurse #3 stated they have not personally assessed Resident #19 for smoking safety since 2024. The evening staff have reported Resident #19 smoked in their room. Registered Nurse #3 stated there was no plan in place to more closely monitor Resident #19 due to their noncompliant smoking behavior. Registered Nurse #3 stated the last care plan meeting for Resident #19 did not include discussions about the resident's smoking noncompliance.On 2/05/2026 at 5:52 PM and 02/12/2026 at 1:05 PM, the Director of Nursing was interviewed and stated the nursing staff were responsible for assessing a resident's ability to smoke safely. The Director of Nursing stated they were unsure how often the smoking assessments were conducted by the nursing staff. There was no accident/incident investigation required into Resident #19's alleged noncompliance in 09/2025 because no cigarettes were found in the resident's room during a room search and the resident had no burns. The recreation department staff were responsible for reporting smoking infractions to the rest of the interdisciplinary team during morning report and the social work department was responsible for addressing any inappropriate behaviors or smoking noncompliance. The Director of Nursing stated they were part of the brainstorming in morning report to develop effective interventions to address smoking noncompliance. The Director of Nursing stated revision to the facility's smoking policy and procedure were necessary and ongoing. 10 NYCRR 415.12(h)(2)

Based on observation, record review, and interviews conducted during the recertification survey from 02/05/2026 to 02/12/2026, the facility did not ensure a resident who needed respiratory care was provided with such care, consistent with professional standards of practice for one (1) of one (1) residents reviewed for respiratory care. Specifically, Resident #92 had a physician order for oxygen via nasal canula at 4 liters per minute, and was observed receiving oxygen via nasal cannula at a rate of 2 liters per minute. The findings include:Resident #92 had diagnoses that included Chronic Obstructive Pulmonary Disease, Type 2 Diabetes, and Asthma.The Quarterly Minimum Data Set, dated [DATE] documented Resident #92's cognition was intact, the resident required supervision or touching assistance with activities of daily living, and the resident used oxygen.The physician order dated 08/26/2025 documented continuous oxygen at 4 liters via nasal canula. The Oxygen Therapy Care Plan dated 01/26/26 documented oxygen at 4 liters via nasal canula. During observations on 02/05/2026 at 11:51 AM, and 02/09/2026 at 10:27 AM and 12:00 PM, Resident #92 was receiving oxygen via a nasal canula at 2 liters per minute. Resident #92 stated they had been on oxygen at 2 liters for 5 (five) years. During an interview on 02/09/2026 at 12:00 PM, Licensed Practical Nurse #15 stated the resident was on 2 (two) liters of oxygen via nasal canula. They did not check the order every day as it was documented on the Treatment Administration Record. They stated as far as they knew the resident was always on 2 (two) liters. During an interview on 02/09/2026 at 12:20 PM, Registered Nurse Unit Manager #10 stated they were unsure how often the nurse checked the orders for oxygen, and thought it was at least once a shift. They stated oxygen should have been delivered as prescribed in the physician order. During an interview on 02/09/2026 12:31 PM the Director of Nursing stated when a resident was receiving oxygen, the medical provider would write the order to include the liter flow and the delivery method. The unit nurse checked the physician order every shift and the orders were transcribed onto the Treatment Administration Record. They reviewed Resident # 92's Treatment Administration Record during the interview and stated they did not see the order. They did not know why the resident would receive 2 (two) liters of oxygen if the order documented 4 (four) liters. They were unsure why the care plan documented oxygen at 4 (four) liters. If the resident had been on 2 (two) liters for a while, the medical provider should have been consulted regarding the discrepancy. 10 NYCRR 415.12(k)(6)

Based on record review, and interview conducted during the Recertification Survey and Abbreviated survey (2650146) from 02/05/2026 to 02/12/2026, the facility did not ensure medications were available to meet the needs of each resident for one (1) of three (3) residents reviewed for pain management. Specifically, when Resident #205 was re-admitted to the facility, Methadone was unavailable for timely administration.Findings include:The facility policy and procedure, Methadone Use last reviewed on 12/2025, documented when methadone is prescribed for narcotic addiction only: the resident is certified as a patient of an identified Opioid Treatment Program which will supply the methadone, prior to admission to the facility.Resident #205 was admitted to the facility with diagnoses including opioid abuse with unspecified opioid-induced disorder, anxiety disorder and obstructive uropathy,The Minimum Data Set (resident assessment) dated 10/12/2025 documented Resident #205 was cognitively intact and received opioid medication 7 of 7 days. The 10/6/2025 Physician Order documented Methadone HCl Oral Solution 10 MG/5ML, to give 40 milligrams by mouth one time a day for opioid dependency.The Comprehensive Care Plan, Substance Abuse dated 10/10/2025, documented administer medication as ordered.A nursing note dated 10/13/2025 at 12:15 PM, documented the resident was not feeling well. They were seen by the physician and sent out to the hospital for hypoxia; their oxygen saturation was 88% with oxygen administered at 3 liters/minute. A nursing note dated 10/14/2025 at 2:16 AM, documented the resident was admitted to the hospital with a diagnosis of pneumonia. Registered Nurse Supervisor #4's Admission/readmission progress note dated 10/18/2025 (Saturday) at 8:37PM, documented Resident #205 returned from the hospital with unchanged medications and was started on two (2) antibiotic medications. Physician #1 was made aware of the situation.The Medication Administration Record dated 10/19/2025 revealed order Methadone HCl oral solution 10 MG/5ML to administer 40 milligrams by mouth one time a day was signed by Registered Nurse #5 with chart code See Progress Notes.A medication administration progress notes dated 10/19/2025 at 12:28 PM documented Methadone 40 milligram for opioid dependency was not given and was not on hand. Registered Nurse #5's nursing progress notes dated 10/19/2025 at 2:31PM documented the resident was unable to get methadone since it was not in facility. The resident was yelling and using profanity since they were not able to get medication. Registered Nurse Supervisor #4 and Physician #1 were made aware of the situation.Registered Nurse Supervisor #4's nursing progress note dated 10/22/2025 at 12:08 AM, as a late entry for 10/19/25, documented they were informed by Registered Nurse #5 that Resident #205 did not have a bottle of methadone. Physician #1 was notified and stated that the resident would get methadone from clinic on Monday.During interview on 02/09/2026 at 4:11 PM Registered Nurse Supervisor #4 stated the hospital was expected to notify the facility prior to a resident's discharge to ensure medications, including methadone were available upon re-admission. Registered Nurse Supervisor #4 stated the facility was not notified of the resident's discharge and therefore did not have methadone available at the time of re-admission. As a result, the resident did not receive the scheduled methadone dose on Sunday 10/19/2025. Registered Nurse Supervisor #4 stated the methadone clinic was closed over the weekend. The Physician was notified of the missed dose. During interview on 02/09/2026 at 4:29 PM, the Director of Nursing stated that residents receiving methadone would not be admitted on weekends unless the medication was available. The Director of Nursing stated that the methadone clinic was closed on weekends, and the facility could not accept residents receiving methadone without ensuring medication availability. The Director of Nursing stated that if a resident on methadone were admitted over the weekend without the medication available, the facility would request that the resident returns to the hospital. The Director of Nursing stated that nurses were responsible for resident care and communication. The Director of Nursing did not know whether Resident #205 was offered the option to return to the hospital or refused to do so.During interview on 02/09/2026 at 5:01 PM Director of Admissions stated that discharge paperwork was not received from the hospital and that the facility was not notified of the resident's weekend transfer. Director of Admissions stated that they did not work on weekends, however, the hospital could have contacted either the facility's Marketer or the Director of Admissions directly. Director of Admissions stated that no notification was received by anyone at the facility.During interview on 02/12/2026 at 10:39 AM Medical Director stated that they were involved in developing policies and procedures related to methadone management. The Medical Director stated that coordination with the hospital should occur prior to discharge to ensure methadone availability at the facility. The Medical Director stated that a system should be in place for admissions or readmissions of residents receiving methadone, particularly since the methadone clinic may be closed on weekend. 10 NYCRR 415.18(a)

Based on observation, record review, and interviews conducted during the recertification and abbreviated surveys (2669870), the facility did not ensure a Quality Assurance and Performance Improvement (QAPI) program that put forth good faith attempts to identify and correct quality deficiencies. Specifically, the facility was aware of ongoing sightings of roaches and mice (see F925) and there was no evidence a QAPI plan was in place to to address pest control. The findings include:The Facility Quality Assurance and Performance Improvement Policy, last revised in March 2025, documented establishing a QAPI committee/subcommittee that works in tandem with the facility leadership and the Quality Assessment & Assurance committee.A review of the 2025 Quarterly Meeting Attendance Sheets titled Quality Assurance and Performance Improvement Employee Sign in Sheets for 4/8/2025, 7/23/2025 and 11/12/25 documented topics for discussion.The 4/8/2025 topics/agenda included Quality Assurance and Performance Improvement for Plan of Correction on staffing, dignity, maintenance repairs, accident/incident report, smoking compliance, pressure ulcers, antibiotic stewardship, documentation.The 7/23/2025 topics/agenda included Quality Assurance and Performance Improvement for Plan of Correction on staffing, dignity, maintenance repairs, exercise of rights, smoking compliance, accident/incident reports, pressure ulcers and antibiotic stewardship.The 11/12/2025 topics/agenda included Quality Assurance and Performance Improvement for Plan of Correction on staffing, dignity, maintenance repairs, accident/incident reports.During interviews with staff and residents from 02/06/2026 to 02/10/2026 there were ongoing concerns regarding pest control (see F925). During an interview on 02/12/2026 at 9:51 AM, the Administrator stated they were aware of the issues regarding roaches and mice being seen on the units. They had not discussed the pest problem as part of the Quality Assurance Performance Improvement program.10 NYCRR 415.27(a-c)

Based on record review and interview conducted during the recertification survey from 2/5/2026 to 2/12/2026, the facility did not ensure the Quality Assurance & Performance Improvement Committee consisted at a minimum of the Infection Control Practitioner, the Medical Director, the Administrator and the Director of Nursing. Specifically, the Infection Control Practitioner did not participate in Quality Assurance & Performance Improvement meetings for three (03) out of the three (03) quarterly meetings in 2025. The findings include:The Facility Quality Assurance and Performance Improvement Policy, last revised in March 2025, documented establishing a QAPI committee/subcommittee that works in tandem with the facility leadership and the Quality Assessment & Assurance committee.A review of the Quality Assurance and Performance Improvement Committee members documented the Administrator, Director of Nursing, Director of Social Services, Minimum Data Set Coordinator, Medical Director, Infection Preventionist, and two (02) Registered Nurse Unit Managers.A review of the 2025 Quarterly Meeting Attendance Sheets titled Quality Assurance and Performance Improvement Employee Sign in Sheets for 4/8/2025, 7/23/2025 and 11/12/25 revealed the Infection Control Preventionist did not sign the attendance sheets.During an interview on 02/12/2026 at 01:31 PM, the Administrator stated they held Quality Assurance Performance Improvement meetings quarterly. They stated that the Infection Control Practitioner/Preventionist had not been attending the Quality Assurance Performance Improvement meetings. The Administrator was unable to explain the absence of Infection Control Preventionist for three (3) quarterly meetings in 2025.10 NYCRR 415.27(a-c)

Based on record review and interviews during abbreviated surveys (NY00378486, NY00339264 and NY00343082), the facility did not ensure that the resident environment remained free of accident hazards and that each resident received adequate supervision for three (3) of three (3) residents (Residents #1 and #2 and #3) reviewed for elopement. Specifically, 1) on 4/20/2025 at approximately 7:00 PM Resident #1 walked unsupervised through the facility's alarmed rear exit patio door through the tunnel to the hospital emergency department, was evaluated and returned to the facility on 4/20/2025 at 11:00 PM in stable condition, and 2) on 04/14/2024 sometime after 7:10 PM Resident #2 exited the facility unsupervised and ambulated to a friend's house, the resident was picked up by facility staff and evaluated at the emergency room and returned to the facility on [DATE] at 11:50 PM in stable condition, and 3) Resident #3 was last seen at the facility on 05/22/2024 at 4:00 PM and was not found until 05/23/2024 by the police. Resident was brought to the hospital and returned to the facility at 5:45 PM on 05/23/2024.The findings are: The facility Security Guard Policy last reviewed January 2024 documented the responsibilities of the security guards included to monitor all facility entrances and exits, verify identification of visitors, ensure visitor log-in procedures are followed, and monitor cameras, alarms, and security systems. Resident #1 was admitted on [DATE] with diagnoses including schizoaffective disorder, cerebral infarct (stroke), and type two (2) diabetes mellitus. The 04/15/2025 Quarterly Minimum Data Set (resident assessment tool) documented Resident #1 had moderately impaired cognition and required supervision with activities of daily living including ambulation. The 04/16/2025 Elopement Evaluation documented that Resident #1 wandered. The 04/20/2025 Incident and Accident Investigation Report documented that Resident #1 was last seen by facility staff on 4/20/2025 at 4:50 PM and their whereabouts were unknown to facility staff on 4/20/2025 at 8:10 PM. The 04/21/2025 facility investigation report documented that Resident #1 exited unsupervised through the facility's alarmed rear exit patio door and walked through the tunnel to the hospital emergency department and documented that the rear exit patio door alarm was going off and the door was open. Wander guard was initiated on admittance to facility however Resident did not have one during the elopement as he refused and removed the prior wander guards. Other interventions in place such as - redirection, initiate code purple if elopement occurs, occupy resident with activities, place name band on admission/readmission, and place resident on frequent checks/monitoring.The Medical Center Patient Information Page documented date and time of Resident #1's arrival on 04/20/25 was at 7:12 PM. The resident was medically cleared and in stable condition on return to the facility. During an interview on 09/08/25 at 1:58 PM, the facility Administrator stated they determined that Resident #1 did not exit during the smoking activity, rather they exited through the rear exit patio door, the alarm went off and the security officer did not respond to the alarm. During an interview on 09/8/25 at 2:25 PM, Certified Nurse Aide #3 stated that on 04/20/2025, they did not look for Resident #1 around 5:30 PM when dinner was served because Resident #1 usually went down to the lobby and came up later for a sandwich or asked them to heat up their dinner later. The Certified Nurse Aide last saw Resident #1 on 4/20/2025 at 4:50 PM. During an interview on 09/8/25 3:36 PM, Licensed Practical Nurse #2 stated they were not worried about Resident #1 because Resident #1 usually went to different floors for activities and went to smoke and stayed in the lobby with his friend in the evenings. During a follow-up interview on 09/8/25 at 4:27 PM, the facility Administrator stated the investigation conclusion was determined from another resident who told the nurse they saw Resident #1 go through the tunnel to the hospital. The Administrator stated they went to the hospital emergency department and the hospital staff told them Resident #1 arrived in the emergency department at around 7:15 PM. The Administrator referenced the Medical Center Patient Information Page which documented the date and time of arrival as 04/20/25 at 7:12 PM. On 09/11/2025 at 11:13 AM, a voicemail was left for Security Guard #1. No return call was received. On 09/11/2025 at 11:17 AM, a voicemail was left to Security Guard #2. No return call was received. Resident #2 was admitted on [DATE] with diagnoses including schizophrenia, alcohol abuse, traumatic subdural hemorrhage without loss of consciousness, and type two (2) diabetes mellitus. The 4/13/2024 Minimum Data Set admission assessment documented Resident #2 had moderately impaired cognition, no behavioral symptoms, and no wandering behavior. The resident had no functional limitations in range of motion, utilized a wheelchair, required partial/moderate assistance with toileting, hygiene, dressing, footwear, personal hygiene, rolling in bed sit to stand transfers. Ambulation did not occur. The 04/14/2024 Incident and Accident Investigation Report documented that Resident #2's whereabouts were unknown to facility staff at 7:10 PM, and the resident was last seen by facility staff at around 6:40 PM.The 04/14/2024 Nurse's Note written by Registered Nurse Supervisor #7 documented Resident # 2 returned to the facility on [DATE] at 11:50 PM. The 04/15/2024 Facility Investigation Report documented that Resident #2 exited the facility unsupervised. The facility called Resident #2's family to inform them of the elopement, and during the call the family stated that Resident #2 was with a friend. Facility staff picked up Resident #2 and brought them to the hospital for evaluation and to be medically cleared. Resident #2 returned to the facility on [DATE] at 11:50 PM. The 04/17/2024 Five (5) Day Report documented Resident #2 was alert with moderately impaired cognition and ambulated independently on the unit with no difficulty. On 04/14/24 at 7:10 PM, the resident could not be found on the unit. The resident left the facility unauthorized and returned to the facility in stable condition after ER evaluation. During an interview on 09/09/2025 at 12:14 PM, Registered Nurse Supervisor #6 stated they answered the questions on the Nursing admission Assessment Elopement Evaluation form based on Resident #2's behaviors at that time. During an interview on 09/09/2025 at 2:07 PM, the facility Administrator stated they never determined for certain whether Resident #2 went out the front door. They stated that the rear entry patio door alarm was not sounding, so they believed Resident #2 went out the front door. They stated that the security officer should ask every person leaving the facility to sign out. They stated that at that time, the security desk was in the back corner of the lobby and there was a large support pillar in the lobby which partially obstructed the view of the lobby although both doors were visible. They stated that after the incident they notified the security company to send a different security officer, and they moved the security desk to the other side of the pillar where the officer has full view of the corridor and lobby and both doors. They stated that residents who are confused or have psychiatric diagnoses or are on antipsychotic medications are not necessarily exit seeking and stated that elopement risk is based on resident's behaviors and history of elopement, although any person exiting the facility should be asked to sign out by the security officer. Resident #3 was admitted on [DATE] with diagnoses including dementia, major depressive disorder, opioid dependence, and hypertension. The 02/17/2023 admission Minimum Data Set (resident assessment tool) documented Resident #3 had moderately impaired cognition and required supervision with care and was ambulatory. The 04/11/2025 Quarterly Minimum Data Set documented Resident #3 had moderately impaired cognition and was ambulatory.The 05/22/24 Incident and Accident Investigation Report documented Resident #3 was last seen by facility staff at 4:00 PM on 05/22/24.The summary of investigation dated 05/22/24 documented at 6:30 PM while the staff was passing the trays for dinner, the resident could not be found in the dining area. The last time resident was seen on the unit was 4:00 PM, interacting with peers. Unit search was initiated, code purple (elopement code) was activated. 911 was called and police assistance was requested. Building and neighborhood search was initiated. Next of kin and primary Physician were informed. The resident left the facility unauthorized. The resident was assessed as not a risk for elopement prior to this incident. There were no precipitating events or attempts to leave the facility, no opening of exit doors, no verbalization to leave the building, no signs of agitation, restlessness prior to leaving the unit. The resident was located by the police close to the facility and brought to St. Joseph's Medical Center for evaluation. The resident returned to the facility on [DATE] in stable condition, with no recommendations from the hospital. During an interview on 09/15/2025 at 10:40 AM, the Receptionist stated nobody should leave without a pass. They ensure that no one goes out without a pass, and they verify if a resident is okay to go out of the facility. The reception desk has a camera that the receptionist can monitor. The camera shows the smoking area. When an alarm is activated on the door to smoking area, the receptionist will have staff stand by and go to the smoking rear exit door to check why the alarm was activated. Receptionist displayed a form of a resident that was Out on Pass on this day. The form was titled Resident Release Form and documented resident name, date, time and destination, and was signed by resident and staff. During an interview on 09/15/2025 at 2:15 PM, Certified Nurse Aide # 11. They stated they get report from nurse at start of shift, safety checks are completed on paper and Point of Care in computer. Safety check is every hour on the unit. During an interview on 09/15/2025 at 2:18 PM, Certified Nurse Aide # 12 stated that an elopement is a resident leaving the building without authorization from the social worker, the doctor and/or family. Certified Nurse Aide # 12 stated that Certified Nurse Aides should report missing residents to the nurse, a search is conducted, and the code is announced. They stated they should make rounds early on their shift to makes sure that residents are on the unit. During an interview on 09/15/2025 at 3:26 PM, Registered Nurse # 13 stated that for residents with dementia, they redirect residents, provide safety, and monitor them. They check orders for Out on Pass, call the manager or the doctor if resident wants to go Out on Pass, and inform the social worker. Registered Nurse # 13 stated as part of elopement prevention, there is a binder at the nurse station with names and pictures of residents of the whole building who are at risk for elopement, and that they place tag/wander guards on residents if elopement risk, in-serviced on dementia and behavior management. They stated there is a list of residents who smoke, recreation staff monitors residents that smoke. Recreation department oversees the cigarettes and lighters. Recreation staff transports residents to smoking area. If a resident is missing for five to ten minutes, the nurse calls the code. When resident does not come back from Out on Pass, will call family, will inform the Director of Nursing, doctor and police. During an interview on 09/15/2025 at 4:10 PM, the Director of Nursing stated they have worked at the facility since April 2025. They stated that the elopement process is part of admission process, assessment for elopement risk, smoking risk, develop care plan, put wander guard for non-alert residents, alert other disciplines during morning meeting, recreation staff is responsible for smoking. Exit doors are wired and alarmed. The Certified Nurse Aide accountability documents wander guard every shift. The Out on Pass process is usually determined by the team, there is a physician order. The supervisor or social worker will explain the process of Out on Pass to the family. During an interview on 09/16/2025 at 11:47 AM, Resident #3's family stated that in May of 2024 around 12 or 1 AM Resident #3 walked out, and nobody found them until 14 hours later, on a corner near the facility. From what the family was told by the facility, the resident was found sitting on the floor, leaning up against a wall, sleeping. The facility told resident's family that they didn't realize their family was missing at first as the resident never showed signs of potential for elopement. Since the incident they have put a wrist band on Resident #3 so that going forward the facility is notified if resident tries to leave floor or facility. The family questioned why the facility didn't already have a wrist band on Resident # 3 since he has dementia. During an interview on 09/16/2025 at 11:56 AM, Resident #3's family stated they do not understand why the nursing home took so long to report the incident. They further stated they do not understand why someone with dementia would not have a wander guard. Family claimed there was no one at the nurse's station or front desk keeping an eye on residents so it was too easy for Resident #3 to leave the facility. Resident #3's family mentioned several times how frustrated they were with the delay in the investigation and stated they are still very upset about Resident #3 missing. Family stated that Resident #3 never expressed intention to leave facility. Family stated that they put Resident #3 in a nursing home to get quality care and because family could no longer look after Resident #3. Family noted that when Resident # 3 di live with family, they never eloped or went missing. Family states that Resident # 3 now expresses a wish to leave this prison and that family is making plans to bring them back home. Family feels facility needs to pay more attention to their residents or find a new profession. During an interview on 09/16/2025 at 1:19 PM, Registered Nurse # 13 stated that Resident #3 was friendly, fully dressed and talking with other residents on the day of the incident. They stated Resident #3 never mentioned wanting to leave the place and that they never noticed Resident #3 going to the elevator alone. They stated that at around 4:30 PM Resident #3 was laughing with fellow residents and that at around 6:00 PM Resident #3 was observed in the dining room. They stated that the Certified Nurse Aide # 3 realized resident was missing and informed them, who then reached out to the supervisor, who called the elopement Code Purple and called local police. Staff searched facility and then went out into the streets to search for Resident #3. Attempted to call Security Guard # 16 on 09/16/2025. Message left at 2:51 PM. Message left at 3:04 PM. No call back.During an interview on 09/16/2025 at 2:25 PM, Nursing Supervisor # 10 stated they do not have exact recollection of incident. Stated that the responsibility of a nursing supervisor is to act once staff informs them of a missing resident, then organizes a head count of all residents throughout the facility, instructs staff to go around the immediate area surrounding the nursing facility, contact the resident's physician, the local police, and Out on Pass/emergency contact. Nursing Supervisor #10 stated that it is the Director of Nursing's is responsible for reporting the incident to the NYS DOH. During an interview on 09/16/2025 at 3:12 PM, the facility Administrator stated that Resident #3 left the facility without permission, and the facility investigation concluded that there was an elopement. There was camera footage showing the resident leaving the main entrance on 5/22/25 with three other people who were leaving the facility. Stated the security guard was in view of the front entrance. States that the double doors of main entrance were not locked at the time of incident, and a lock has since been added. Stated education was done, security guard was replaced, and lock was added to the front door after incident. Security guard on date of incident was from the agency and he was replaced by another agency security guard. 10NYCR 483.25 (d)(1)(2)

[NAME] Gardens Center for Nursing and Rehab F600 J, Event ID: DSWK11 Exit Date 5/28/2025 Due Date 6/11/2025 [NAME] NR /[NAME] Based on record review and interviews conducted during an abbreviated survey (NY00367662), the facility failed to ensure residents were free from abuse for one (1) of three (3) residents reviewed for abuse (Resident #1). Specifically, Resident #1 had a history of sexually inappropriate behaviors towards other residents on 9/20/2024 and 12/23/2024 and there was no documented evidence the facility revised care plans or implemented interventions and/or physician orders to prevent the resident from sexually abusing other residents. Subsequently, on 1/5/2025, Resident #1 was observed by Certified Nurse Aide #1 half-naked in bed, on top of Resident #2, who at the time of this incident was a severely cognitively impaired resident with their mouth on Resident #2's genital area. After this incident, Resident #1 was moved to a different unit on a different floor. However, during the same week of the incident, Resident #1 was able to leave undetected by staff from their new unit and again found in the room of Resident #2. The facility's failure to implement adequate interventions to prevent abuse resulted in Immediate Jeopardy and Substandard Quality of Care with the likelihood of serious injury and harm to the health and safety to Resident #2 and all residents in the facility. The findings include: The facility's Abuse policy revised 5/2024 documented the resident has the right to be free from verbal, sexual, physical and mental abuse. The facility promotes any effort to prevent abuse. Resident #1 had diagnoses which included cerebral infarction (a condition where blood flow to a part of the brain is blocked or reduced, leading to tissue death) and vascular dementia (caused by an impaired supply of blood to the brain, such as may be caused by a series of small strokes). The 6/18/2024 Quarterly Minimum Data Set, (an assessment and screening tool) documented Resident #1 was cognitively intact, had no behaviors and received supervision with ambulation. The 7/27/2024 Comprehensive Care Plan for Resident #1 titled Risk for Potential Verbal/Physical/Sexual Abuse Secondary to Cerebral Infarction included: assess for signs and symptoms of physical trauma/sexual abuse, such as bruising in the genital area and other parts of the body, assess the resident for abuse and/or neglect ex. bruises, behavior, weight loss and report to appropriate resources, encourage the resident to seek out staff or assistance if having difficulties with others, ensure the resident stays in a room with a compatible roommate, monitor mood and behaviors and provide early interventions on any changes, observe/assess for changes in normal behavior such as crying, withdrawal, guarding, provide support and encouragement for the resident to express feelings, provide support and ensure the resident is free from abuse. Resident #2 had diagnoses which included vascular dementia, Parkinson's Disease (a progressive neurodegenerative disorder that affects the brain, specifically the nerve cells that produce dopamine) and major depressive disorder. The 6/14/2024 Annual Minimum Data Set documented Resident # 2 had moderate cognitive impairment, was usually understood, had no behaviors, required assistance with dressing, bed mobility and was non-ambulatory (unable to walk). The 7/24/2024 Comprehensive Care Plan for Resident #2 titled Risk for Potential Verbal/Physical/Sexual Abuse documented the resident would not experience any form of abuse. Assess the resident for signs and symptoms of abuse and was updated on 1/5/2025 to include staff to visually monitor the resident. The 9/20/2024 Nurse Progress Note documented Resident #1 was in the hallway near the nurses' station and was observed touching the delicate area and rubbing the arm and back of a female resident that was passing by. There was no documented evidence Resident #1's care plan was updated with interventions to address Resident #1's behavior and protect other residents after the 9/20/2024 incident. The 11/11/2024 Comprehensive Care Plan for Resident #1 titled Risk to be Victimized Secondary to Impaired Judgement/Confusion/Dementia and Cerebral Infarction included keep the resident within viewing distance for observation as much as possible in activities, day room and nursing station, monitor for change in mood or behavior triggered by environmental factors i.e. noise, crowds, other residents with behavioral symptom, etc., monitor wellbeing without environmental restrictions, redirect and re-focus attention, offer alternatives i.e. small groups, comfort foods, manipulative tasks or engage the resident in 1:1 as necessary. The 12/12/2024 Annual Minimum Data Set, documented Resident #1 had moderate cognitive impairment, no behaviors and was ambulatory (able to walk). The 12/23/2024 Nurse Progress Note documented Resident # 1 was observed standing outside a resident's room watching the residents inside and would get close. This note did not further document any details about Resident #1's behaviors or identify the other residents. There was no documented evidence Resident #1's care plan was updated with interventions to address Resident #1's behavior or to protect other residents after the 12/23/2024 observation. The 1/5/2025 at 3:52 PM Nurse Progress Note written by Registered Nurse Unit Manager/Supervisor #5 documented at about 1:30 PM, Resident #1 was found with their head between Resident #2's legs. No obvious injuries were noted. The Physician and Administration were notified. Residents #1 and #2 were to be transferred to the emergency room for evaluation. The 1/5/25 Accident Investigation Report written by the Director of Nursing documented the residents were immediately separated, Resident #1 was placed on 1:1 watch, and Resident #2 was sent to the emergency room for evaluation. It further documented the residents would be separated; one would be moved to a different unit. The incident was reported to law enforcement on 1/5/2025, law enforcement arrived at 5:42 PM. There was no documented evidence that Resident #1 and Resident #2 were transferred to the hospital for evaluation. The 1/5/2025 Accident Investigation Report Statement written by Certified Nurse Aide #1 documented that at 1:30 PM, Resident #1 was half naked on top of Resident #2 with their mouth in Resident #2's genital area. The 1/5/2025 Accident Investigation Report Statement written by Registered Nurse Unit Manager/Supervisor #5 documented they observed Resident #1 at Resident #2's bedside putting their pants on, and they overheard Resident #2 tell Resident #1 to come tomorrow. Registered Nurse Unit Manager/Supervisor #5 further documented Resident #2 was in no acute distress. There was no documented evidence Resident #1's care plan was updated with interventions to address their behavior after the 1/5/2025 incident. The 1/7/2025 Social Work Note written by the Director of Social Services documented Resident #1 had a room change. The 1/9/2025 Investigative Summary 5-day Report completed by the Assistant Director of Nursing at that time documented Resident #1 would be monitored closely and redirected as needed, additional recreation activity for both residents, (Resident #1 and Resident #2) staff reeducation to report immediately any inappropriate behavior. The investigative summary conclusion documented Resident #1 was placed on 1:1 monitoring from 1/5/2025 to 1/7/2025 until a bed was available on another unit. There was no documented evidence Resident #1 was placed on 1:1 monitoring from 1/5/2025-1/7/2025. During an interview on 5/12/2025 at 12:29 PM, Certified Nurse Aide #2 stated that on 1/5/2025 they observed Resident #1 on top of Resident #2. After the incident Resident #1 was moved to the 6th Floor. Four (4) days later, Resident #1 returned to Resident #2's room but Certified Nurse Aide #2 stopped the resident and told them This is not your room, go back upstairs. They stated they escorted Resident #1 to the elevator and informed a nurse on Resident #2's unit. There was no documented evidence this incident was documented in either of the Resident's progress notes. The 1/27/2025 Nurse Progress Note documented Resident #1 tried to grab staff buttocks and the Nurse Manager was made aware. There was no documented evidence Resident #1's care plan was updated with interventions to address Resident #1's behavior after the 1/27/2025 incident. During an interview on 5/14/2025 at 12:50PM, Licensed Practical Nurse #9 reviewed the note they wrote on 12/23/2024 that documented Resident #1 was observed standing in front of the door of other residents and got close. Licensed Practical Nurse #9 stated Resident #1 liked to roam around because there are female residents. These behaviors were reported to the supervisor. They further stated the supervisor told them to monitor the resident, but they did not indicate who or how the residents should be monitored. During an interview on 5/12/2025 at 2:53 PM, Certified Nurse Aide #1 stated they were assigned to Resident #1 on 1/5/2025. They stated around 1:30 PM, they went room to room looking for Resident #1 and found Resident #1 in Resident #'2's bedroom. Resident #1 was on top of Resident #2. Resident #1 had their pants down with their face on Resident #2's private part. Certified Nurse Aide #2 stated Resident #2 was lying in bed, they looked comfortable, and did not say a word. They stated they asked Resident #1 what they were doing, and Resident #1 said something in Spanish to Resident #2 and got up. Certified Nurse Aide #1 stated Resident #2 was holding on to Resident #1 and both residents spoke in Spanish. Certified Nurse Aide #1 stated they came out of the room and called the supervisor. They stated they could not recall the name of the supervisor. They stated the supervisor escorted Resident #1 out of the room. They stated they had never seen both residents together. They stated Resident #2 hardly came out of bed or their room. Certified Nurse Aide #1 stated they were very surprised the incident happened. During a phone interview on 5/13/2025 at 10:31 AM, the former Assistant Director of Nursing stated they remembered the 1/5/2025 incident. They stated the Director of Nursing was the one who gave instruction to send both residents to the hospital. They stated the two (2) residents should have been assessed and transferred to the hospital. They stated the supervisor is responsible for updating care plans as per facility protocol. They stated they could not recall if the care plan was updated or if they checked the care plan. They stated there should have been a care plan when it happened. During an interview on 5/13/2025 at 10:57 AM, Licensed Practical Nurse #3 stated they were called to the room of Resident #2. They stated they saw Resident #1 in the room with their pants off. Resident #2 was exposed with no bottoms on. They stated they saw Resident #1 was on top of Resident #2. Both residents were talking in Spanish and laughing. They stated they told Resident #1 to get up and Resident #1 got up and put their pants back on. They stated the supervisor came in the room. Licensed Practical Nurse #3 stated they saw Resident #1 again, walking in the hallway, but they did not go back to Resident #2's room. During an interview on 5/15/2025 at 9:41 AM, Registered Nurse Unit Manager/Supervisor #5 stated on 1/5/2025 after being alerted by Certified Nurse Aide #1, they went to the room of Resident #2 and found Resident #1 in the room. They observed Resident #2 telling Resident #1 manana (tomorrow in Spanish). Resident #1 pulled their pants on. Resident #2 was not sent to the hospital. Resident #1 was not arrested. They further stated the facility protocol is to call the doctor. During an interview on 5/15/2025 at 12:57 PM, the Medical Director stated they generally recommend hospitalization of residents if there is resident to resident allegation of abuse. They were unable to provide a reason why both residents were not transferred to the hospital. During an interview on 5/20/2025 at 9:58 AM ,Registered Nurse #4 stated when they arrived at the nursing home on 1/5/2025, they saw the police. They stated the police went to the room of Resident #2 and interviewed the resident. Police told Registered Nurse #4, Resident #2 said they and Resident #1 are both married that Resident #1 did not do anything wrong. They stated as per the police, there was no need for Resident #1 to go to the hospital. Registered Nurse #4 stated they told the police the residents are not married. Registered Nurse #4 stated they could not remember if they told the Director of Nursing what the police said to them. During an interview on 5/20/2025 at 10:53 AM, the facility Administrator stated they were notified of the incident involving Resident #1 and Resident #2 on 1/5/2025 by the Director of Nursing at the time of the incident. The protocol is to separate residents, call the physician and if there was resident to resident contact, transfer the residents to the hospital. The Administrator stated they did not know that the residents were not transferred to the hospital. 10 NYCRR 415.4(b)(1)(i) Based on the following, immediacy was removed on 5/22/2025 at 6:00 PM 1. The facility provided staff training sign-in sheets indicating 99% of Nursing staff were trained in Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Residents property. Elderly Justice Act. Abuse care plans. 2. Resident #1 and Resident #2 were observed in their rooms and on their units. Resident #1 had staff assigned on 1:1 monitoring. 3. Interviews were conducted with the staff on the 1:1's and they were trained as well as four (4) other random staff to ensure they were recently trained on Abuse.

Based on interviews and record reviews, the facility failed to ensure that the resident's environment was free of accident hazards for one Resident (#5) of 9 residents reviewed for accidents. Specifically, Resident #5 with a known history of polysubstance abuse was not supervised to prevent the availability of non-prescribed drugs and their usage within the facility. Resident #5 had suspected drug overdoses that occurred in the facility on 12/9/2023, 1/5/24,1/10/24, 1/18/24, 1/23/24, and 1/29/24 for which Narcan (an opioid reversal agent) had to be administered by facility staff. Resident #5 continued to obtain illicit drugs which required hospitalization . The facility failed to initiate an investigation into the drug overdoses or update the care plan for Resident #5. This resulted in the likelihood for serious injury or death that was Immediate Jeopardy for Resident #5 and 9 other residents with a history of polysubstance use disorder. A facility policy titled Resident Possession of Illegal Substance revised on 11/1/2023 stated to protect the health and safety of residents, the facility will provide additional monitoring, and supervision, which includes providing supervised visitation, to individuals who are suspected of bringing illegal substances into the facility. A facility policy titled Residents with Alcohol/Drugs Substance Use Disorder dated 2/20/2022 documented the facility will make efforts to prevent substance use through scheduled care plan meeting with resident and/or family members which may include providing substance use treatment services, such as behavioral health services, medication assisted treatment, alcoholic/narcotics anonymous, self-help groups as applicable. Resident #5 was admitted to the facility on [DATE] with diagnoses including but not limited to cerebral infarction, adult failure to thrive, and other psychoactive substance abuse (a drug that affects the function of the mind and nervous system). The Quarterly Minimum Data Set, (a resident assessment tool) dated 10/11/2023, documented Resident #5 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and the ability to recall) of 14 associated with intact cognition. Resident #5 was on a scheduled pain medication regimen and was receiving opioid medication. A review of the hospital admission and discharge summaries dated 12/9/2023 and 12/11/2023 documented Resident #5 was treated for polysubstance use drug low blood pressure that is caused by use of many illicit substances). The urine toxicology was positive for opiates, cannabinoid, and cocaine following their transfer to the hospital from the nursing home. The discharge summary documented the emergency room Physician (Physician #3) held Oxycodone 10mg every 6 hours for pain and recommended to consider referral to outpatient rehabilitation for treatment of the resident's substance use disorder. There is no documented evidence an outpatient referral to rehabilitation was initiated. Physician #2's order dated 12/14/2023 documented to start Oxycodone 10mg by mouth every 6 hours for severe pain. A review of a hospital admission and discharge summary dated 1/10/2024 and 1/16/2024 indicated Resident #5 was found with a pill box that contained many different drugs which was confiscated by the emergency room staff. Resident #5 was diagnosed with altered mental state and treated for a likely drug overdose. An order from Physician #2 dated 1/16/2024 documented to discontinue the Oxycodone 10mg every 6 hours starting on 1/16/2024. A review of a hospital emergency room discharge summary dated 1/18/2024 documented Resident #5 was treated for drug overdose and provided no additional discharge treatment recommendations. There was no documented evidence that a facility investigation was initiated after the resident overdosed on 12/9/2023, 1/5/2024,1/10/2024, 1/18/2024, 1/23/2024, and 1/29/2024. An individual facility psychotherapy progress note dated 1/20/2024 and written by Therapist #1 documented Resident #5 will be seen 2-6 times/month for individual psychotherapy sessions for depression and adjustment disorder. The note documented that Resident #5 expressed the desire to stay clean. There was no notation addressing Resident #5's overdose events or how Resident #5 obtained drugs. A review of a hospital emergency room discharge summary dated 1/23/2024 documented Resident #5 was treated for a drug overdose. Resident #5 had a subsequent overdose on 1/29/2024 and no investigations was initiated. During an interview with Resident #5 on 2/1/2024 at 07:40 AM, Resident #5 stated they were previously clean from substance use for [AGE] years and began using illicit substances again in the facility to deal with depression. Resident #5 stated they have not made the decision whether to get clean and if they do, they will reach out to the facility. Resident #5 stated they obtain drugs through the family members of other residents in the facility when they come to visit. Resident #5 refused to provide any further details. Resident #5 stated they have not been offered treatment programs, narcotics/alcoholics anonymous meetings, or medication-assisted therapies by the facility. Resident #5 stated they used to receive oxycodone for pain, however after they had overdosed a few times, the facility physician discontinued their pain medication completely and his back pain has been unmanaged. Resident #5 stated they have not been offered any assistance from the social worker and Physician #2 (Resident #5's primary physician) has, told the resident to stop doing drugs with no further treatment options. Resident #5 stated they will reach out to staff when they are ready to get sober. Resident #5 had a subsequent overdose on 2/1/2024 and no investigation was initiated. During interviews conducted on 1/24/2024 and 1/26/2024, Certified Nursing Assistant #5, Licensed Practical Nurse #5, and Registered Nurse Unit Manager #10 stated staff were informed they are not allowed to search Resident #5's room for illicit substances. During an interview on 1/29/2024 at 10:45 AM, the Director of Social Services stated they were never made aware of Resident #5's multiple overdoses. There was documented evidence that the Social Worker met with Resident #5. During an interview on 1/29/2024 at 11:20 AM, Physician #2 stated they have discussed the case with the Director of Nursing regarding Resident #5's overdoses. Physician #2 stated Resident #5 denied use of illicit substances when questioned. Physician #2 was not aware Resident #5 expressed a desire to get clean during their psychotherapy session on 1/20/2024. Physician #2 stated they are surprised the facility had not provided more supervision for Resident #5 to prevent further overdoses. Physician #2 stated most facilities they had worked at in the past handled situations after the first time a resident overdose. During an interview on 2/1/2024 at 8:25AM, Registered Nurse Unit Manager #5 stated they are responsible for creating care plans for Resident #5. Registered Nurse Unit Manager #5 stated prior to Department of Health (DOH) arrival on 1/22/2024, there was no care plan to address the Resident #5's illicit substance uses or any interventions in-place to prevent further relapses. Registered Nurse Unit Manager #5 stated for Resident #5, staff communicated using word of mouth between staff to watch out for signs of overdose. Registered Nurse Unit Manager #5 stated they discussed with the Director of Nursing Services and the Administrator at morning huddle each of Resident #5 overdose events. Registered Nurse Unit Manager #5 stated facility administration was planning on not re-admitting the resident to the facility. Registered Nurse Unit Manager #5 was not aware of any further plans to address Resident #5's illicit drug use and overdoses. Registered Nurse Unit Manager #5 stated these issues had never been discussed in Resident #5's care plan meetings. During an interview on 2/1/2024 at 10:04 AM, the Director of Nursing Services stated no previous overdoses of Resident #5 had been investigated because they did not think it is in the facility's policy to do so. The Director of Nursing Services stated that on 1/18/2024, they spoke with Resident #5's brother regarding referring Resident #5 to a drug treatment program. The Director of Nursing Services stated the facility's plan is to offer Resident #5 a drug once they no longer require skilled nursing services. During an interview on 2/1/2024 at 5:15 PM, the facility's Administrator stated they are aware of Resident #5's recent overdoses but not the extensive history details. The Administrator stated they are limited in things they can do or cannot do because of the Centers for Medicare and Medicaid Services guidelines. The Administrator stated the residents have rights and the facility cannot search a residents' room. The Administrator's designee (facility director of nursing) was informed of the Immediate Jeopardy and provided the Immediate Jeopardy template on 2/2/2024 and signed it at 6:19PM. The facility employed corrective measures prior to the completion of the survey. Based on surveyor observation and interviews and evidence provided by the facility, the immediacy was removed on 2/7/2024 prior to survey exit. The following was presented and observed to remove the immediacy: - Observations conducted on 2/3/2024, 2/5/20244 and 2/6/2024 revealed Resident #5 remained on 1:1 monitoring. - A review of in-service attendance sheets titled, Residents with Alcohol/Drugs Substance Use Disorder revealed 164/170 (96.47%) Inservice for all staff in all disciplines. All education was provided in-person or via telephone. - A review of in-service attendance sheets titled Safety of Residents with Substance Use Disorder and Resident Possession of Illegal Substance revealed 164/170 (96.47%) staff were in-serviced. All education provided in-person or via telephone. - A review of in-service attendance sheets for an Inter Disciplinary Team (IDT) Meeting with topics: Comprehensive Care Plan, effective interdisciplinary approach, and investigation of any illegal overdose case revealed 38/38 Registered Nurses/Licensed Practical Nurses (100%) were in-serviced in facility. All education provided in-person or via telephone. - A review of the comprehensive care plans of the 9 residents identified with polysubstance use disorder revealed the facility updated their care plans and interventions consistent with their diagnosis. - A review of Resident #5's Certified Nurses Assistants accountability sheets revealed 100% compliance with 1:1 monitoring documentation from 2/2/2024 to 2/6/2024. - Resident council meeting minutes dated 2/5/2024 documented residents were provided resources for substance abuse care and services. Resident council meeting minutes also revealed the Director of Recreation has reached-out to Narcotics Anonymous to establish a 12-step program meeting in the facility. - An audit form titled; Social Services Interim Assessment (Screening of Residents with History of Substance Abuse Upon Admission with Appropriate Care Plan) was provided. - The facility had 6 newly admitted residents since 2/2/2024. Completed 'Social Services Interim Assessments' were provided for all 6 residents. - An audit form titled, Investigation of Overdose Case or Possession of Illegal Substance was provided. - Care plan meeting dated 2/2/2024 revealed the Inter-Disciplinary Team (IDT) discussed Resident #5's substance uses, and the resident is being referred to substance abuse treatment programs. - Substance abuse resource titled An introductory guide to narcotics anonymous, revised provided to residents during the resident council meeting on 2/5/24 was reviewed and appeared consistent with the facility's IJ removal plan. - Narcotics Division of [NAME] Police has launched an investigation upon the request of the facility to assist in identifying the source of illicit substance in the facility. - Interviews conducted on 2/5/2024 and 2/6/2024 of 6 Registered Nurses, 4 Licensed Practical Nurses,13 Certified Nurses Assistants, 2 Physical Therapists,1 Occupational Therapist, 4 Rehab Aides, 2 maintenance staff, and 4 housekeepers revealed staff were educated and stated proper policy and procedure on how to detect and respond to residents using illicit substances. - Interviews conducted on 2/5/2024 and 2/6/2024 of 6 Registered Nurses and 4 Licensed Practical Nurses revealed staff were educated on care planning and Inter Disciplinary Team approach and stated proper procedures consistent with the facility's policy. - Interview was conducted with [NAME] Narcotics Detective #2 on 2/7/2024 at 9:30 AM, detective confirmed the initiation of an investigation into illicit substances being distributed at [NAME] Gardens. - Facility interventions listed: Cameras installed in the lobby per police recommendation (surveyors observed cameras in the lobby and in front of both entry doors to the facility) - Director of Nursing Services educated receptionist to notify administration if unusual/suspicious activity is noted. Administrator will request permission from residents to search all packages that are witnessed being handed. - 24-hour front desk coverage was maintained. Lunch breaks will be covered by activities staff. 2 receptionists were interviewed by surveyors and verbalized appropriate response to reporting suspected/unusual activity. - Resident #5, #7 and #15 remained on 1:1 supervision/monitoring. Director of Nursing Services will reinforce purposeful hourly rounding on the 11PM-7AM shift. 10 NYCRR 415.12(h)(1)