Based on interview and record review conducted during a Complaint investigation (#NY00357991) during a Standard survey completed on 1/31/25, the facility did not ensure that a resident has the right to refuse treatment for one (1) (Resident #69) of five (5) residents reviewed for immunizations. Specifically, Resident #69's Representative did not give consent for a COVID-19 vaccine, and the resident received it. The finding is: The policy and procedure titled COVID-19 Vaccination for Residents, with a revised date of 12/2024 documented to obtain a verbal and/or written consent and/or declination from recipient or qualified representative and note in the immunization tab of the medical record prior to administration of the COVID-19 vaccination. The policy documented the administering nurse would verify consent prior to administering the vaccine. The policy and procedure titled Resident [NAME] of Rights, with a revised date of 8/2023 documented those resident rights included the right to consent to or refused treatment. Resident #69 had diagnoses that included dementia, schizoaffective disorder and diabetes. The Minimum Data Set (a resident assessment tool) dated 11/14/24 documented Resident #69 had severe cognitive impairment, was sometimes understood and sometimes understands. The comprehensive care plan dated 3/1/24 documented Resident #69 had advance directives, documented the resident had a Power of Attorney and a Health Care Proxy. The undated Vaccine Consent Form documented that Resident #69's Representative verbally declined the COVID-19 vaccination. The Immunization Report dated 1/26/25 documented that Resident #69 was administered the COVID-19 vaccination on 9/13/24 by Registered Nurse #4. The New York State Immunization Information System website information provided by the facility documented that Resident #69 received the COVID-19 vaccination on 9/13/24. The progress notes documented the following: -10/21/24 at 12:09 PM, the Director of Nursing documented that Resident #69 was assessed due to the COVID-19 vaccine given on 9/13/24. -10/21/24 at 12:46 PM, the Assistant Director of Nursing documented that per Resident #69's representative, the resident was not to receive any further vaccinations. Review of the Physician Visit notes dated on: - 10/23/24 at 6:26 AM, the Medical Director documented that Resident #69 was seen for an acute visit due Resident #69 receiving the COVID-19 vaccination and family had directed the facility not to have it. During an interview on 1/30/25 at 3:01 PM, Licensed Practical Nurse Unit Manager #8 stated that Resident #69's representative did not want the resident to receive the COVID -19 booster, there was miscommunication and Resident #69 received the booster in September 2024. A telephone interview was attempted with the former Assistant Director of Nursing/Infection Preventionist on 1/30/25 at 4:28 PM. During a telephone interview on 1/30/25 at 4:39 PM, Resident #69's Representative stated they received a few telephone calls from the facility that vaccines were coming around. They stated they were unsure who called them but they had declined the COVID-19 booster for Resident #69. They stated they also told Licensed Practical Nurse Unit Manager #8. Resident #69's Representative stated they were notified by Resident #69's Power of Attorney that during a visit with the resident, the resident told the Power of Attorney they received two shots that day. Resident #69's Power of Attorney questioned the nursing staff, and they replied that Resident #69 received the influenza and COVID-19 vaccination. Resident #69's representative stated that they advocate for Resident #69, as the resident could not advocate for themselves and by Resident #69 receiving the COVID-19 booster, their wishes were not honored. During a telephone interview on 1/30/25 at 5:00 PM, Registered Nurse #4 stated they would receive a list from the Assistant Director of Nursing for every resident and the vaccination they were to receive. Registered Nurse #4 stated that Resident #69's name was on the list, and they gave them the COVID-19 booster and influenza vaccination. They stated the Assistant Director of Nursing did not provide them with the actual acceptance/declination forms to review. If the form indicated decline, then the resident should have not been given the vaccination. They stated they do not know what Resident #69 vaccination acceptance/declination form indicated because it was not in front of them. Registered Nurse #4 stated the error appeared to be a communication error and they did not receive any education after the situation. They stated that if a resident does not want a vaccination, they had the right to refuse. During an interview on 1/30/25 at 5:14 PM, the Assistant Director of Nursing stated that when they assumed the role of Assistant Director of Nursing the former Assistant Director of Nursing/ Infection Preventionist gave them a stack of vaccination consent/declination forms for the residents. They stated they created a spread sheet and mistakenly added Resident #69 to the list to administer the COVID-19 booster. The Assistant Director of Nursing stated that Registered Nurse #4 did not have the consent sheets with them upon administration of vaccinations but just the list which residents and which vaccination they were to give. They stated that Registered Nurse #4 gave Resident #69 the COVID-19 booster due to the error and they did not mean for a resident to get a medication they did not want. After review of the Vaccine Consent Form for Resident #69, they stated that the form was not dated but it should have been. The Assistant Director of Nursing stated the Resident #69 rights, choices and wishes were unintentionally not honored by receiving a the COVID-19 vaccination. During an interview on 1/31/25 at 11:30 AM, the Director of Nursing stated the Assistant Director of Nursing oversaw the resident immunization efforts and Registered Nurse #4 would administer them. They stated the Assistant Director of Nursing inappropriately transcribed that Resident #69 was to have the COVID-19 booster on a list they made for Registered Nurse #4 to administer vaccinations. They stated since Resident #69 received the COVID-19 booster when their representative had declined the booster, it went against the resident wishes. During a telephone interview on 1/31/25 at 12:30 PM, the Nurse Practitioner stated that Resident #69 could not make their own decisions, their family declined the COVID-19 booster and the resident should not have received it. During an interview on 1/31/25 at 1:57 PM, the Administrator stated if a resident or their resident representative had declined to have a vaccination then the resident should not get the vaccination if the documentation was in place. The Administrator stated that it goes against a resident's choice. 10 NYCRR 415.3(f)(1)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard survey completed on 1/31/2025, the facility did not ensure residents were free from physical restraints imposed for purposes of discipline or convenience that were not required to treat the resident's medical symptoms, used for the least amount of time and document ongoing re-evaluation of the need for restraints for one (Resident #370) of three residents reviewed for physical restraints. Specifically, Resident #370 had no assessment/evaluation for the initiation of the use of a position change alarm. Additionally, there was no documented evidence to address the reason that warranted the use of the device. The finding is: The policy and procedure titled Personal Alarms dated 10/2023 documented to establish guidance for the appropriate use of personal alarms to ensure resident safety while maintaining dignity and autonomy. The procedure documented to conduct a comprehensive assessment of each resident to determine the need for the personal alarm based on their individual risk factors and needs. Document the rational for using the personal alarm and any alternative interventions considered. The State Operational Manual issued 11/2024 defines position change alarms as an alerting device intended to monitor a resident's movements and emits an audible signal when a resident moved in certain ways. Additionally, a position alarm may limit a resident's movement when the resident was afraid to move to avoid setting off the alarm. Resident #370 had diagnoses including depression, dementia and compression fractures of the spine. The Minimum Date set (resident assessment tool) dated 1/23/2025 documented they were severely cognitively impaired and was sometimes understood and sometimes understands. Resident #370 required extensive assist of one person for ambulation and transfers, a bed/chair alarm was used daily and wandering behaviors were documented during the assessment period. The comprehensive care plan with an initiation date of 1/18/2025 and a revision date of 1/30/2025 documented Resident #370 had an actual fall related to adjustment to a new environment, confusion and unsteady gait. The care plan documented a goal that included restraints used to prevent resident's falls will be minimized or eliminated. Interventions included the use of an electric chair alarm and staff were to ensure the device was in place and functioning every shift. The [NAME] (a guide used by staff to provide care) dated 1/30/2025 documented under Safety, the resident uses an electric chair alarm ensure the device is in place and functioning every shift. Review of the Order Recap Report dated 1/18/2025 documented check function of chair alarm every shift for safety. Review of the interdisciplinary progress notes dated 1/13/2025-1/30/2025 revealed there was no documented evidence that Resident #370 was assessed for the use and rational for the personal chair alarm. During an observation on 1/27/2025 at 2:11 PM Resident #370 was observed in the common area in front of the television the resident leaned forward in the wheelchair on several occasions activating the personal alarm. The resident would sit back in the wheelchair each time the alarm activated. During an observation on 1/29/2025 at 9:12 AM Resident #370 was observed in the main dining room in their wheelchair with a personal alarm on the seat of the wheelchair and the alarm box hanging from the back of the wheelchair, no unsafe movements were observed. During an observation on 1/29/2025 at 12:04 PM Resident #370 was observed in the main dining room in their wheelchair with the personal alarm on the seat of the wheelchair and the alarm box hanging from the back of the wheelchair. During these observations Resident #370 did not exhibit any attempts to self-transfer from the wheelchair. During an interview on 1/31/25 at 12:30 PM, Certified Nurse Aide #2 stated Resident #370 used and alarm because they would get up and try to walk without their walker and they were very unsteady on their feet. Resident #370 had a fall at home but could not recall if the resident had a fall in the facility. Certified Nurse Aide #2 could not recall any other interventions in place to prevent falls besides keeping them in the common area when out of bed, and using the chair alarm. During an interview on 1/31/2025 at 12:41 PM, Licensed Practical Nurse #1 stated Resident #370 had only been at the facility for a couple weeks. Licensed Practical Nurse #1 stated the resident wore an alarm because they believed the facility was afraid, the resident could fall, and the resident would get up on their own. Licensed Practical Nurse #1 was unsure if the resident fell when in the facility, or if any other fall prevention interventions were in place. They were unsure if there should be an assessment completed. During an interview on 1/31/2025 at 12:46 PM, Assistant Director of Nursing #1 stated the supervisors were responsible to determine if an alarm was needed based on the resident's fall assessment. Assessments should be done on admission, quarterly and as needed. The Assistant Director of Nursing #1 also stated they did not believe chair alarms were restraints as they don't restrict the resident. During an interview on 1/31/2025 at 1:17 PM, Director of Nursing #1 stated Resident #370 had a personal alarm because they had history of falls. Less restrictive devices that could be used were placing the resident in the common area, activity programs and recliner chairs. Director of Nursing #1 was unsure if other interventions were tried or not prior to placing the personal alarm and it would depend on the cause of the fall. They check with the staff to see how the resident is doing with the alarm but does not document those conversations. Director of Nursing #1 also stated it would be a good idea to document and or complete an assessment for the use of alarms. 10 NYCRR 415.4(a)(2)(3)

Based on interview and record review conducted during a Standard Survey completed 1/31/25, the facility did not ensure that all alleged violations including abuse were reported immediately, but not later than two hours after the allegation was made to the State Survey Agency for one (Resident #70) of seven residents reviewed. Specifically, the Director of Nursing was notified of an allegation of resident sexual abuse, and it was not reported to the New York State Department of Health as required. The finding is: The policy and procedure titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property last revised 10/19 documented the facility prohibits abuse. Abuse: Shall mean, inappropriate physical contact with a resident. Inappropriate physical contact includes but is not limited to sexual molestation. When to report: In response to allegations of abuse the facility must: Ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involved abuse to officials in accordance with State law through established procedures. 1. Resident #70 had diagnoses that included congestive heart failure, type 2 diabetes mellitus, and unspecified schizophrenia (mental disorder). The Minimum Data Set (a resident assessment tool) dated 10/6/24 documented Resident #70 was cognitively intact was understood and understands, and did not display any behaviors. The comprehensive care plan initiated 12/5/2024 documented Resident #70 had a behavior problem related to confabulations and accusatory statements against staff. Interventions included: administer medications as ordered, anticipate and meet the resident's needs, assist to develop more appropriate methods of coping and interacting, encourage to express feelings appropriately, if reasonable discuss behaviors, explain/reinforce why behavior is inappropriate and/or unacceptable, use female caregivers as able and two staff approach. During an interview on 1/27/25 at 12:52 PM, Resident #70 stated they had been sexually abused while at the facility. They stated a black male lifted their shirt, took their hands and rubbed Resident #70's breasts up and down. Resident #70 stated they were stunned when this happened. They felt ashamed, embarrassed and didn't talk about it at first. Resident #70 stated once they said something about it in therapy, everyone knew about, and staff asked them about it. Physical Therapy Treatment Encounter Note dated 12/5/2024 electronically signed by Physical Therapy Assistant #1 documented they notified Director of Rehab and Social Worker that Resident #70 reported a male certified nurse aide (not recently) was inappropriately touching their breasts. They documented Resident #70 was reporting anxiety/fear over this issue and discussing this issue. Physical Therapy Assistant #1 documented that Resident #70 was incontinent of urine that morning and had asked Resident #70 why they hadn't asked the male aide to assist them. They documented that Resident #70 stated I don't want a man to help me. Immediately after that conversation with Resident #70, Resident #70 told Physical Therapy Assistant #1 about the incident. Review of soft file provided by the Director of Nursing during standard survey completed 1/31/25 revealed there was no evidence the abuse allegation was reported to the New York State Department of Health. During an interview on 1/27/25 at 1:35 PM, the Director of Nursing stated when they talked to Resident #70 about the abuse allegation, there were no facts to support the allegation at that time and no further investigation was completed. During an interview on 1/31/25 at 8:31 AM, the Assistant Director of Nursing stated the Director of Nursing was responsible for reporting allegations of abuse to the Department of Health. The Assistant Director of Nursing stated they knew there were timeframes for reporting abuse to the Department of Health but wasn't aware of them and would have to speak to the Director of Nursing. During an interview on 1/31/25 at 9:34 AM, Licensed Practical Nurse #8 Unit Manager, stated all abuse allegations need to be reported to the Director of Nursing, and Administrator. They stated the police, medical provider, family may need to be notified and there was a two-hour time limit to report abuse to the Department of Health. During an interview on 1/31/25 at 11:25 AM, Licensed Practical Nurse #5, Supervisor, stated any abuse allegation made by a resident need to be reported to a supervisor, the Assistant Director of Nursing and/or the Director of Nursing. They stated the Director of Nursing was responsible to report allegations of abuse to the Department of Health, depending on the allegation within two hours or twenty-four hours. During an interview on 1/31/25 at 1:07 PM, the Director of Nursing stated Licensed Practical Nurse #8, Unit Manager notified them on 12/5/24 at unknown time of Resident #70's allegation of abuse. The Director of Nursing stated they did not report Resident #70's abuse allegation to the Department of Health. They felt that after speaking with Resident #70 they didn't have evidence to support their allegation. The Director of Nursing stated they notified the Administrator of the allegation the same day on 12/5/24. Additionally, the Director of Nursing stated, should have gone with my gut and reported. During an interview on 1/31/25 at 3:07 PM, the Administer stated they were made aware of Resident #70's allegation by Director of Nursing. The Administer stated typically any abuse, neglect, mistreatment was to be reported within two hours. 10 NYCRR 415.4(b)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a Complaint Investigation (#NY00338010) conducted during the Standard survey completed on 1/31/25, the facility did not ensure that all alleged allegations of abuse, neglect, or mistreatment were thoroughly investigated for two (Resident #70 and #320) of seven residents reviewed. Specifically, there was a lack of evidence thorough investigations were completed into an allegation of sexual abuse (#70) and a femur fracture of unknown origin (#320). The findings are: The policy and procedure titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, with a revised date of 10/19, documented both state and federal regulations require the facility to investigate incidents and complaints generated from residents and/or visitors. Documentation is required with respect to accidents and incidents that must be recorded. The policy documented with respect to allegations of abuse, mistreatment, and neglect, facilities must document that the allegations are thoroughly investigated, including any incident that is not consistent with routine operation of the facility or routine care of the resident, such as bruise, or any injury of unknown origin. The supervisor who has been informed of the allegation was to complete the initial investigation report and forward a copy to the Administrator. That notification is in addition to immediate notification to the Director of Nursing. The policy and procedure titled Resident Accident-Incident Report, with a revised date of 4/17, documented to obtain employee statements that would be needed to investigate the accident/incident. For an investigation of injuries of unknown origin, the charge nurse on duty at time of accident/incident occurs, will initiate accident incident investigation form. The policy documented that beginning with the shift the accident/incident occurred, charge nurse will get statements from the caregivers on that shift. The nurse will go back two more shifts within the 24-hour period prior to the accident incident, date the investigation form and list caregivers for the other two shifts and pass investigation on to the next shift for the other caregiver's statements. 1. Resident #70 had diagnoses that included congestive heart failure, type 2 diabetes mellitus, and unspecified schizophrenia (mental disorder). The Minimum Data Set (a resident assessment tool) dated 10/6/24 documented Resident #70 was cognitively intact was understood and understands, and did not display any behaviors. The comprehensive care plan revised 10/11/2024 documented that Resident #70 used antidepressant medication related to depression and schizophrenia. Interventions initiated 10/1/2024 included to administer antidepressant as ordered, and monitor/document/report adverse reactions to antidepressant therapy. The care plan prior to the abuse allegation on 12/5/24 did not document the resident had behaviors director towards others or a history of making accusatory or false statements. Review of progress notes dated 10/31/24 through 12/12/2024 revealed there was no evidence that Resident #70 displayed behaviors or that an allegation of abuse was made, reported and or investigated. Review of Physical Therapy Treatment Encounter Note dated 12/5/2024, electronically signed by Physical Therapy Assistant #1 documented they notified the Director of Rehab and Social Worker that Resident #70 reported a male certified nurse aide (not recently) was inappropriately touching their breasts. They documented Resident #70 was reporting anxiety/fear over this issue and discussing this issue. Physical Therapy Assistant #1 documented that Resident #70 was incontinent of urine that morning and had asked Resident #70 why they hadn't asked the male aide to assist them. They documented that Resident #70 stated I don't want a man to help me. Immediately after that conversation with Resident #70, Resident #70 told Physical Therapy Assistant #1 about the incident. Review of soft investigation file provided by the Director of Nursing contained a Daily Census of 12/4/2024 of [NAME] South, total residents on unit 12 printed 12/5/24 at 12:31 PM. Handwritten notes present on Daily Census documented: assessed-no injuries (redness, discoloration, open areas), no complaints offered pain/discomfort, no signs/symptoms of fear, anxiety or stress, unable to give details on touching; Interviewed 12/5/24, no issues with any male staff member; Upset when told Monday they weren't ready to discharge due to safety. The file contained a copy of Resident #70's face sheet, brief interview for mental status evaluation, copy of updated care plan, a mini-mental state examination effective 10/1/24 with score of 27 out of 30 and an undated list of residents who require a two staff approach. The file did not contain interviews, and/or statements with staff and other residents. There was no investigation summary completed ruling out the abuse. During an interview on 1/27/25 at 12:52 PM, Resident #70 stated they had been sexually abused while at the facility. They stated they had only been at the facility for a short time when the abuse happened. They stated a black male lifted their shirt, took their hands and rubbed Resident #70's breasts up and down. Resident #70 stated it happened around bedtime, they couldn't remember their face, did not know the person's name and had not seen them since. Resident #70 stated they were stunned when this happened. They stated took happened at bedtime a short time after they were admitted to the facility, 12 weeks or more ago. They didn't talk about it at first and once they said something about it in therapy, everyone knew about, and staff followed up with them. During an interview on 1/29/25 at 11:06 AM, Certified Nurse Aide #11 stated approximately a month ago while taking care of Resident #70, Resident #70 stated to them they were assaulted by a guy on overnights. Certified Nurse Aide #11 stated that Resident #70 demonstrated with their hand a rubbing motion over their chest and down their side. Certified Nurse Aide #11 stated they reported the allegation immediately to Licensed Practical Nurse Unit Manager #8. Certified Nurse Aide #11 stated Licensed Practical Nurse Unit Manager #8 told them they were already aware of the allegation. Certified Nurse Aide #11 stated after reporting allegation, nothing further was discussed with them about the allegation. Additionally, Certified Nurse Aide #11 stated they would consider Resident #70's allegation, sexual abuse. During an interview on 1/31/25 at 8:40 AM, Social Work Director #1 stated they recall hearing about an abuse allegation made by Resident #70. They believed the Director of Nursing had mentioned it during morning meeting or in passing. Social Work Director #1 stated that Resident #70 demonstrated and stated to them that a male lifted their shirt and rubbed their chest. The Social Work Director #1 stated Resident #70 didn't display any emotions on how they felt about it, and they were not asked to write a statement about this. During an interview on 1/31/25 at 9:34 AM, Licensed Practical Nurse Unit Manager #8, stated they were not working the day Resident #70 made the sexual abuse allegation. Licensed Practical Nurse Unit Manager #8 stated they were notified by the Director of Nursing of Resident #70's allegation. They stated when they asked Resident #70 about the allegation, Resident #70 stated a man came into their room and touched their breasts in an inappropriate manner. They stated Resident #70 stated they never wanted that man to touch them again. Licensed Practical Nurse Unit Manager #8 stated they did not document on Resident #70's allegation because the Director of Nursing had stated they had started a soft file on the allegation. Licensed Practical Nurse Unit Manager #8 stated there were men that work in the facility and there were male residents that wander. During an interview on 1/31/25 at 12:09 PM, Physical Therapy Assistant #1 stated on 12/5/24 Resident #70 stated a male certified nurse aide, not recently, had touched their breasts inappropriately and that Resident #70 did not know the certified nurse aide name. Physical Therapy Assistant #1 stated Resident #70 stated they hadn't seen this aide in a while but reported being fearful and anxious over seeing them again. Physical Therapy Assistant #1 stated they notified the Director of Therapy, the Social Worker and the Director of Nursing of Resident #70's abuse allegation. The Physical Therapy Assistant #1 stated they did not remember if they were asked to write a statement. During an interview on 1/31/25 at 1:07 PM, Director of Nursing stated they were thought they were notified of Resident #70's abuse allegation on 12/5/24 by Licensed Practical Nurse Unit Manager #8. They stated they did not recall at what time they were notified. The Director of Nursing stated they completed a skin assessment on Resident #70 and assessed the other residents on the unit. The Director of Nursing stated that Resident #70 stated someone had touched their breasts. The Director of Nursing stated they did not feel it was sexual in nature. Resident #70 was upset over being told they weren't leaving the facility. The Director of Nursing stated they reviewed a whole week back of schedules and there were no male caregivers on Resident # 70's unit. The Director of Nursing stated they did not notify the medical provider or emergency contact, and can't give any excuse for that, I usually do. They stated Resident #70 did have capacity. The Director of Nursing stated they did not write down any verbal conversations or get statements from any staff and should have. Additionally, they stated they notified the Administrator the same day, 12/5/24 of the allegation. During a telephone interview on 1/31/25 at 2:29 PM, Medical Doctor #1 stated they expected to be notified of abuse allegations and did not recall being informed of Resident #70's sexual abuse allegation. They stated an investigation should be done to make sure the resident's needs, and safety were being maintained. During an interview on 1/31/25 at 3:07 PM, the Administrator stated the Director of Nursing made them aware of the abuse allegation made by Resident #70. They stated there was nothing collaborating Resident #70's allegation. The Administrator stated they would expect the Director of Nursing to start an investigation, obtain statements from residents, staff, assess the residents involved and document their findings, position on the abuse allegation. 2. Resident #320 had diagnoses that included a fracture of the left femur, dementia and atrial fibrillation (an irregular heart rate that causes poor blood flow). The Minimum Data Set, dated [DATE] documented Resident #320 had severe cognitive impairment, usually understands and was usually understood. The comprehensive care plan dated 3/29/24, documented Resident #320 had self-performance deficit related to limited mobility. Interventions included that Resident #320 may require a two-person approach due to combativeness. The care plan documented that Resident #320 was high risk for falls related to confusion and vision/hearing problems. Interventions included to anticipate needs, place call light within reach, lock bilateral wheelchair breaks, offer toileting every two hours and fall mats on both sides of the bed. The [NAME] (guide used by staff to provide care) dated 4/1/24, documented Resident #320 was dependent for wheelchair mobility; a maximal assist of one assist for toileting, bathing, dressing and hygiene; and a moderate assist of one for bed mobility and transfers. The [NAME] documented that Resident #320 may require a two-person approach due to combativeness. Review of the facility's undated Investigation Summary signed by the Director of Nursing, documented on 4/4/24 they were notified by a supervisor that Resident #320 has sustained a femur fracture to their left leg and the resident was sent to the emergency department. The summary documented that on 4/2/24 that the Director of Nursing was called to assess an area of bruising to Resident #320's left upper thigh and then again on 4/3/24. It was documented that there was swelling noted to Resident #320's left leg from the hip to knee with complaints of pain. X-rays from the pelvis to the foot were then ordered. The investigation documented there were three licensed practical nurse witnesses and six certified nurse aide witnesses. Facility Employee Statement forms were included in the facility's investigation folder from all three licensed practical nurse and six certified nurse aides that were listed in the Investigation Summary. After review of all the Employee Statement forms the following inconsistency was noted: -Licensed Practical Nurse #14 statement dated 4/7/24 at 7:00 AM, documented on 4/1/24 Resident #320 was noted with a yellow bruise the size of a hand from the knee to thigh and was reported to the house supervisor. Review of the facility's Staffing Worksheet from 3/30/24-4/1/24 revealed there was no documented evidence all staff working on the unit were interviewed. There were two additional nurses and five additional certified nurse aides that worked from when the bruise was documented as originally noted on 4/1/24. During an interview on 1/31/25 at 10:56 AM, the Director of Nursing stated on 4/2/24 staff alerted them to an area of discoloration to Resident #320 left inner thigh. They stated they assessed Resident #320 and noted the resident had older yellow tinge discoloration, at that time there was no pain or change in range of motion to the residents left leg. The Director of Nursing stated on 4/3/24 the staff alerted them again to assess Resident #320. They stated Resident #320 had more bruising, swelling and pain to their left leg. Resident #320 was ordered an x-ray, was found to have a left femur fracture. The Director of Nursing stated they started the investigation and interviewed staff members that could have had contact with the resident 48 hours back from 4/4/24. The Director of Nursing stated they had no further Employee Statements to present and had completed some telephone interviews some staff. They stated they did not document the telephone interviews but should have. The Director of Nursing stated they did read the employee statements at the time of investigation. The Director of Nursing was given Licensed Practical Nurse #14 statement dated 4/7/24 at 7:00 AM to review. The Director of Nursing stated it probably would have been a good idea to interview all staff that could have had interactions with Resident #320 48 hours prior to 4/1/24 because that is when the bruise was first noted and therefore, they did not complete a thorough investigation. During an interview on 1/31/25 at 1:57 PM, the Administrator stated their expectation for an investigation when a resident was noted to have a fracture of unknown origin was for one (an investigation) to be conducted. They stated they would have expected all staff that could have taken care of the resident to be interviewed, and the investigator would typically go back 48 hours from when an injury was noted. The Administrator stated staff statements should be detailed and include the date time and if something unusual was noted. They stated they would expect telephone interview to be documented and saved by the investigator. 10NYCRR 415.4(b)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard Survey completed on 1/31/25, the facility did not provide separately locked, permanently affixed compartments for the storage of controlled drugs for two (2) (Garden View and [NAME] View North) of three (3) medication rooms observed. Specifically, in both medication rooms, controlled drugs were stored in a locked metal box, inside a locked small refrigerator that was not permanently affixed to the wall or countertop. Additionally, the Garden View medication refrigerator housed a locked metal box, containing emergency narcotics, that was not permanently affixed to the refrigerator. This involved Residents #6, 8, 40, and 82. The findings are: The policy and procedure titled Controlled Medication Storage and Count, dated 1/2023, documented a controlled substance requiring refrigeration will be kept double locked in the med room refrigerator within the metal locked box. During an interview and observation of the Garden View medication room on 1/30/25 at 8:41 AM, a locked medication refrigerator was sitting on the counter, it was not secured to the counter or the wall. Licensed Practical Nurse #6 stated the keys to the medication refrigerator were kept by the Nursing Supervisor. Each medication nurse carried the keys to their unit narcotic box, but the medication refrigerator contained medications from all the Villages (Garden View, Orchard, Canal). Licensed Practical Nurse #6 stated the medication refrigerator had never been permanently affixed to the counter or wall. During an interview and observation of the Garden View medication room on 1/30/25 at 2:41 PM, Licensed Practical Nurse #5 (covering Supervisor), opened the locked medication refrigerator. The refrigerator contained 2 locked metal boxes. One locked box was permanently affixed to the shelf, and the second locked box was not permanently affixed. Licensed Practical Nurse #5 stated they did not have a key to the second metal box, because it was for emergency use only. The key to that box was locked inside the automated medication dispensing system and required pharmacy approval for access. They stated the refrigerator had never been permanently affixed and they did not know that it should be. The affixed metal box was opened by Licensed Practical Nurse #5 and contained: -one unopened, 10 milliliter vial of Lorazepam (a controlled substance and anti-anxiety/anti-seizure medication) and one unopened 30 milliliter bottle of Lorazepam for Resident #40 -three unopened, 1 milliliter vials of Lorazepam for Resident #6 -four unopened, 2.5 milliliter vials of Lorazepam for Resident #82 During an interview on 1/30/25 at 3:00 PM, Licensed Practical Nurse #2 stated the medications inside the second locked metal box were for emergency use. The key was only accessible by calling the pharmacy, getting an access code, and having two staff members type their credentials into the automated dispensing system. They stated the pharmacy monitored the contents of the emergency box. Licensed Practical Nurse #2 stated, not having the metal box secured to the inside of the refrigerator and by the refrigerator not being permanently affixed, made it a higher risk for diversion. During an interview and observation of the [NAME] View North medication room on 1/31/25 at 8:37 AM, the locked medication refrigerator contained: for Resident #8, one 10 milliliter vial of Lorazepam. The vial was located inside an unlocked stainless-steel box affixed to a shelf inside the refrigerator which was sitting on top of a foot-stool on the floor and was not permanently affixed. Licensed Practical Nurse #7 stated the refrigerator was not affixed to anything and was sitting on a stool. Licensed Practical Nurse #7 attempted to lock the stainless-steel box inside the refrigerator but could not and said the key wasn't working. They stated they counted the Lorazepam that morning and the key wasn't working then either. They were not sure how long the key didn't work. During an interview on 1/31/25 at 8:47 AM, Licensed Practical Nurse Unit Manager #8 stated they were the medication nurse on the [NAME] View North unit on Monday (1/27/25) and the key to the stainless-steel lock box worked, they just had to work with it and wiggle it. They stated the lock box in the refrigerator should have been locked when there was a controlled medication inside. They weren't sure how long the refrigerator had not been permanently affixed and they would call the pharmacy to fix the lock. During an interview on 1/31/25 at 10:58 AM, Pharmacy Manager #1 stated they expected the facility to keep their controlled drugs secured in a double locked container. They stated they did not know the refrigerator was not permanently affixed to the counter or that the emergency narcotics box was not affixed to refrigerator. They stated that pharmacy staff monitor and count the contents of the emergency box weekly, and they had not had any diversion. Pharmacy Manager #1 stated the box contained Lorazepam for emergency use. They stated, not having the box secured to the inside of the refrigerator and by the refrigerator not being permanently affixed, made it a higher risk for diversion. During an interview on 1/31/25 at 12:59 PM, the Director of Nursing stated they were aware that the medication room refrigerators were not permanently affixed and contained controlled drugs. The Director of Nursing stated they have had their pharmacy come in every six months and this was never an identified issue. If they were not permanently affixed, it could be a risk for diversions. 10NYCCRR 415.18 (e)(2)

Based on observation, interview, and record review conducted during a Standard survey completed 1/31/25, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, one of one Kitchen had issues with foods being unlabeled or outdated in the refrigerators; stained, worn ceiling tiles, lack of [NAME] #2 wearing a beard guard in food preparation areas. Additionally, during the puree observation texture modified bread mix was not prepared and used in accordance with the manufacturer's directions. The findings are: The policy and procedure titled Food Storage Refrigerator and Freezer dated 8/2017 documented to ensure foods are stored properly to minimize spoilage and contamination and ensure taste and quality of food. All food items must be labeled and dated. The policy and procedure titled Cleaning of Food Storage Areas documented to ensure maintenance and cleanliness to storage areas. All kitchen areas shall be kept clean and free litter and rubbish. All counters, shelves and equipment shall be kept clean and maintained in good repair. The facility policy and procedure titled Hair Coverings dated 3/2017 documented it is the policy of the facility to prevent hair from contaminating food or beverage. Food code recommends that food handles wear beard nets or other hair restraints when appropriate. However, the rule is not specific about the length or the beard that requires a net. It is the responsibility of the management staff in the food service department to monitor and enforce the policy. During an observation on 1/27/2025 at 9:32 AM of the main kitchen revealed the following: -reach in refrigerator ajacent to the stove had an open undated packages of sliced corn beef and turkey. -walk-in cooler had a tray of five (5) premade sandwiches in clear plastic baggies dated 1/24/25 and four (4) prepared 4-ounce cups of canned fruit dated 4-ounce cups of canned fruit dated 1/24/25. -3-tier metal cart across from the dish machine had approximately 29 plastic coffee mugs stored ready for use that were right side up uncovered, the cart had a large amount of brown liquid on the second and third tier. -ceiling tiles had brown and yellow discolored spots and stains throughout the kitchen, being more prevalent over the dish machine. -floor beneath the coffee station across from the tray line was soiled with large area of dried brown liquid. During an interview at the time of the observation 1/27/2025 at 9:32 AM the Food Service Director #1 stated all open foods should be dated and labeled if they are not, they should be discarded. The floor under the coffee station should be cleaned. The coffee mugs should be stored upside down or a tray covering them. The nourishments in the walk-in refrigerator should be discarded because they were three days old. During an observation on 1/29/2025 at 11:35 AM, [NAME] #2 had a surgical mask on with approximately ½ inch long facial hair that was exposed under their chin and both cheeks [NAME] #2 was on tray line and in and out of kitchen area with food service and preparation occurring. During the pureed food observation and interview on 1/30/25 at 10:33 AM with [NAME] #1 stated there were approximately 32 residents requiring a pureed diet texture and they would be pureeing hot dogs. [NAME] #1 added 6 to 8 cooked hot dogs to the food processer added a small amount of water and blended till smooth and repeated the same process twice, pouring the pureed hot dogs into a square metal pan. A discussion took place during the observation with [NAME] #1 and the Food Service Director #1. [NAME] #1 was instructed by the Food Service Director to use bread or the Texture Modified Bread Mix to substitute the hot dog bun. [NAME] #1 obtained a box of Texture Modified Bread Mix from under the prep station and placed an eight-ounce disposable cup in the contents of the box. [NAME] #1 added 6-8 cooked hot dogs to the food processer added a small amount of water and processed the hot dogs for approximately 30 seconds. [NAME] #1 then proceeded to take the eight-ounce cup and filled the cup approximately half full with the modified bread mixture without reviewing the manufactures preparation directions and added it to the pureed hot dogs in the food processer, blended the mixture and hotdogs together and added it to the square metal pan of hot dogs previously processed. [NAME] completed the same process three times adding the pureed hotdogs and bread mixture to the same metal pan. Review of the Texture Modified Bread Mix manufactures mixing directions documented the following for 18 slices of bread: -combined in a bowl 2 cups of bread mix 2/3 cup vegetable oil and stir with a fork till breadcrumbs are well coated. - add three cups of hot water -mix well with a fork or whisk, pour mixture into a nonstick pan sprayed with nonstick cooking spray, cover with plastic wrap and let stand at room temperature for at least 30 minutes. -slice and serve There was no recipe available for the preparation of hotdogs with buns puree. During an interview on 1/30/25 at 10:56 AM, [NAME] #1 stated they have used the Texture Modified Bread Mix in the past but not the way the Food Service Director #1 told them too. They would normally mix the bread mixture with water and serve it separately. They were unsure what the manufactures directions called for. [NAME] #1 after tasting a sample of the pureed hot dogs stated, it tastes like a hot dog. The Surveyor tasted the hot dog/bun puree, and it was gritty. During an interview on 1/30/25 at 10:57 AM, Dietary Aide #1 after trying a sample of the pureed hot dogs stated they did not like it, said it looked gross, tasted it made a face and walked away. During an observation on 1/30/25 at 2:57 PM [NAME] #2 was observed in the food preparation area across from the stove, prepping sandwiches. Their beard guard was around their neck below their chin. During an interview on 1/30/25 at 3:03 PM, [NAME] #2 stated they should be wearing a beard guard when in the kitchen or they would wear a surgical mask. They were unsure if a surgical mask would be considered a beard guard and would have to check with the Food Service Director. [NAME] #2 was observed during the interview to have their beard guard covering only their chin area leaving their mustache and cheek areas exposed and this was in a food prep area. During an interview on 1/31/25 at 11:12 AM the Food Service Director #1 stated staff who have facial hair should wear a beard guard, at all times when in the kitchen. They stated beard guards were available and were unsure if a surgical mask was an acceptable substitute. Food Service Director #1 stated they have used the Textured Modified Bread Mix in the past but was unsure what the directions called for when preparing the product and would have to clarify how it should be used. They were also unsure what could be done about the kitchen ceiling tiles. During an interview on 1/31/25 at 11:59 AM, the Registered Dietitian stated the directions should be followed in preparing the Texture Modified Bread Mix and it should not be added from the box directly into food. All open food should be labeled and dated, if not then it should be thrown away. The Registered Dietitian stated staff who have facial hair should always wear a beard guard when they were in the kitchen. 10 NYCRR 415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 1/31/25 the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and a comfortable environment, to help prevent the development and transmission of communicable diseases and infection for two (Resident #42 and Resident #89) of five residents reviewed for Enhanced Barrier Precautions. Specifically, Enhanced Barrier Precautions were not initiated for Resident #42 who had a sacral pressure ulcer and staff did not wear appropriate personal protective equipment (PPE) during pressure ulcer care. Additionally, staff did not wear appropriate personal protective equipment (PPE) while they emptied a urinary catheter bag (a urine collection bag) for Resident #89 who had an indwelling foley catheter (tube inserted into the bladder to drain urine) and was on Enhanced Barrier Precautions. The findings are: The policy and procedure titled Enhanced Barrier Precautions dated 12/2024 documented that Enhanced Barrier Precautions (EBP) were an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involved gown and glove use during high-contact resident care activities. High contact resident activities include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, urinary catheter care and wound care: any opening requiring a dressing. Enhanced Barrier Precautions should be used for the duration of a resident's stay in the facility or until the resolution of the wound of discontinuation of the indwelling medical device that placed them at higher risk. 1. Resident #42 had diagnoses that included sacral pressure ulcer stage 3 (area above the tail bone with full thickness tissue loss, with no bone, tendon or muscle exposed), spinal stenosis (narrowing of one or more areas in your spine), and acute kidney failure. The Minimum Data Set (an assessment tool) dated 1/13/25 documented Resident #42 was cognitively intact and had one stage 3 pressure ulcer that was not present upon admission. The comprehensive care plan revised on 1/31/25, documented Resident #42 had a sacral pressure ulcer related to immobility and urinary incontinence. Interventions included to administer treatments as ordered and to follow policies and protocols for the prevention/treatment of skin breakdown. The comprehensive care plan documented that Enhanced Barrier Precautions were resolved on 12/12/24 and had not been re-implemented on until 1/31/25. Review of the facility's Enhanced Barrier Precaution line list provided by the Assistant Director of Nursing and dated 1/29/25 revealed that Resident #42 was not on Enhanced Barrier Precautions. Review of Resident #42's medication administration record from 1/1/25 to 1/31/25 revealed that there was no physician order in place for Enhanced Barrier Precautions until 1/31/25. Additionally, the medication administration record documented that Resident #42 had been treated with antibiotics for a sacral wound infection from 1/7/25 to 1/17/25. Review of Resident #42 physician orders which included all active, completed and discontinued orders revealed that Enhanced Barrier Precautions for Resident #42 had been discontinued on 12/27/24 and had not been re-ordered until 1/31/25. Review of skin and wound note dated 1/15/25, the Wound Consultant documented that Resident #42 had a stage 3 sacral pressure ulcer. The wound status was documented as stable, peri wound was macerated, with a moderate amount of serous drainage (clear/yellow drainage) was noted. During intermittent observations on 1/27/25 at 11:05 AM, 1/28/25 at 9:12 AM, 1/29/25 at 9:00 AM and 1/30/25 at 8:48 AM, Resident #42 was sitting in wheelchair in their room. There was no Enhanced Barrier Precaution signage posted on Resident #42's door, and there was no personal protective equipment located outside or inside of Resident #42's room. One closed lid garbage can was noted in Resident #42's room and labeled isolation trash only. During an observation and interview on 1/20/25 at 8:48 AM, Licensed Practical Nurse #4 completed wound care to Resident #42's sacral wound. Resident #42 was able to stand up while Licensed Practical Nurse #4 completed their wound care. The pressure ulcer was noted to have yellow/brown drainage. Licensed Practical Nurse #4 stated the pressure ulcer was a stage 3 and had tunneling present (opening underneath the surface of the skin). Licensed Practical Nurse #4 described the pressure ulcer as being opened with small amount of brown drainage. They cleansed the wound with Dakins (antiseptic for wound care) solution, applied collagen powder (promotes new tissue formation), calcium alginate (absorbent fibrous material used for wound management) and covered the pressure ulcer with a dressing. Licensed Practical Nurse #4 utilized gloves for personal protective equipment and did not wear a gown during the observation. Licensed Practical Nurse #4 stated that Resident #42 was not on Enhanced Barrier Precautions, they stated that they believed if the wound was cultured and came back clear Enhanced Barrier Precautions would not be needed. They stated the Assistant Director of Nursing determined who was placed on enhanced barrier precautions. During an interview on 1/31/25 at 9:04 AM, Licensed Practical Nurse Unit Manager #8 stated any resident with a draining wound would be placed on Enhanced Barrier Precautions. They stated that Enhanced Barrier Precautions would be important to protect staff and residents from the spread of infections. Licensed Practical Nurse Unit Manager #8 stated that Resident #42 was not on Enhanced Barrier Precautions because their wound did not have drainage. During an interview on 1/31/25 at 10:45 AM, the Assistant Director of Nursing stated they would review and update the list of residents on Enhanced Barrier Precautions during morning report and conduct audits on the precaution signage, caddy, care plan and orders for Enhanced Barrier Precautions. The Assistant Director of Nursing stated any resident who had open wounds would be placed on Enhanced Barrier Precautions. They stated that if the wound was granulated and had scant to no drainage, they would remove the resident from Enhanced Barrier Precautions. The Assistant Director of Nursing stated that Resident #42 had been removed from Enhanced Barrier Precautions, their wound had improved and had no drainage. They stated that if Resident #42's wound started to drain again that they would be at risk for infection and should be placed back on Enhanced Barrier Precautions. The Assistant Director of Nursing stated that they were not aware Resident #42's wound had drainage. During an interview on 1/31/25 at 12:46 PM, the Director of Nursing/Infection Preventionist stated they reviewed the resident list of Enhanced Barrier Precautions daily at morning report. They stated that they would expect that any resident with an open draining wound would be placed on Enhanced Barrier Precautions. They stated it was important to protect the residents and prevent the spread of infection from staff to resident. The Director of Nursing /Infection Preventionist stated that Resident #42 had an open wound, they would be at risk for infection and should have been on Enhanced Barrier Precautions. 2. Resident #89 had diagnoses that included a history of urinary tract infections and low back pain. The Minimum Data Set, dated [DATE] documented Resident #89 was cognitively intact and had a foley catheter. The comprehensive care plan dated 12/12/24 documented Resident #89 was on Enhanced Barrier Precautions for use of an indwelling catheter and that a gown and gloves were to be worn for high contact resident care related to their foley catheter. Resident #89's current [NAME] (guide used by staff to provide care) documented to maintain Enhanced Barrier Precautions - use of gown and gloves - during high-contact resident care activities related to their foley catheter. During an observation on 1/27/25 at 1:21 PM, Licensed Practical Nurse #4 entered Resident #89's room to empty Resident #89's foley catheter bag of urine. Resident #89 had an order for Enhanced Barrier Precautions, which was posted at the door of their room along with a supply cart with personal protective equipment. Licensed Practical Nurse #4 stated this was going to be quick and told the surveyor they could remain in the room. Licensed Practical Nurse #4 was wearing gloves only, proceeded to empty the urine collection bag at the resident's bedside into a urinal, measured the urine, and then emptied the urinal into the toilet in the resident's room. Licensed Practical Nurse #4 did not wear an isolation gown while caring for the resident's foley. Review of the Enhanced Barrier Precautions sign on Resident #89's door documented gloves and gown were required for high contact resident care activities for device care or use of a urinary catheter. During an interview on 1/29/25 at 8:59 AM, Licensed Practical Nurse #4 stated they should have worn a gown along with the gloves when they emptied Resident #89's foley urine bag on 1/27/25. The reason for the gown was to protect residents from anything the nurse may carry and to protect the nurse and other residents from any possible source of infection the urine may carry. During an interview on 1/29/25 at 8:49 AM, Assistant Director of Nursing stated the personal protective equipment they expected staff to wear when a resident is on Enhanced Barrier Precautions was a gown and gloves, to empty a foley urine bag. This was important, in case there was any splashing and to protect the staff person and residents from contracting any possible infection. During an interview on 1/29/25 at 9:05 AM, Director of Nursing/ Infection Preventionist stated the personal protective equipment they expected a staff to wear when emptying a foley urine bag was a gown and gloves. This was important because urine could be a source of infection, and they would not want the staff person to carry any possible infection from one resident to another. 10NYCRR415.19 (a) (2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Recertification survey completed 1/31/25, the facility did not provide a safe, clean, comfortable and homelike environment; and did not maintain comfortable temperatures levels between 71 degrees Fahrenheit to 81 degrees Fahrenheit for three (Orchard View, [NAME] View South, and [NAME] View North) of five resident units. Specifically, air temperatures were not maintained above 71 degrees Fahrenheit in resident common areas (Orchard View) and a resident shower room ([NAME] View South). Additionally, the [NAME] View North nurse's station structure/area that was visible and used by to residents had broken hinged doors, chipped laminate countertops, scratched and chipped paint; recliner chairs and straight back chairs that were in disrepair; and a 2-person sofa that was visibly soiled. The findings are: The policy titled Environmental Comfort and Safety dated 8/2024 documented the facility was committed to providing a homelike environment that promotes the well-being and comfort for all residents. For temperature control the ambient temperatures in resident rooms, dining rooms and common areas would be maintained within the range of 71-81 degrees Fahrenheit. The policy titled Homelike Environment dated 8/2024 documented the facility aimed to create a setting that feels welcoming and comfortable, that enhanced the quality of life for residents. Common areas would be decorated with furnishing that reflect a homelike atmosphere. 1. During an observation and interview on the Orchard View Unit on 1/27/25 at 9:56 AM, Resident #17 stated it was not warm enough in the facility. They were wearing a zip up hoodie sweatshirt, t-shirt, and pajama pants. On 1/27/25 temperatures obtained on the Orchard View unit using the surveyor's stem type thermometer included: -at 10:30 AM, 68.9 degrees Fahrenheit in the center of the common area -at 10:44 AM, 69.1 degrees Fahrenheit in the hallway outside room [ROOM NUMBER] and #27. Resident #10 was seated in the hallway and stated it was a little nippy in here today. -at 10:50 AM, 68.4 degrees Fahrenheit in room [ROOM NUMBER] there was one resident in room at this time. On 1/27/25 at 10:32 AM, Licensed Practical Nurse #10 was observed wearing their winter jacket on the unit. They stated it was very cold in the facility. They stated they started their shift at 6:00 AM and it's been cold since they arrived. On 1/28/25 temperatures obtained on the Orchard View unit included: -at 9:08 AM, 70.1 degrees Fahrenheit in the hallway outside rooms [ROOM NUMBERS]. A resident seated in that area stated it was cold. -at 9:11 AM, 69.6 degrees Fahrenheit in the center of the common area, Resident #110 stated it was cold. On 1/30/25 at 8:15 AM, the temperature in the Orchard View common area was 67.5 degrees Fahrenheit, there were four residents seated in this area. Resident #10 stated it was chilly. During an interview on 1/30/25 at 8:18 AM, Certified Nurse Aide #6 stated it was cold in the facility, they were wearing black winter scarf because their neck got cold. During an interview on 1/30/25 at 9:30 AM, Licensed Practical Nurse #11 stated it was always cold in the facility. They covered the residents with blankets, and they had just got the electric fireplaces, but they weren't helping. During an observation interview on 1/30/25 at 9:33 AM, Resident #84 was seated in a recliner chair in the common area. They stated it was cold in the facility, and even with their coat on it was cold. The resident was observed wearing a thick buttoned up plaid flannel shirt/jacket. There were 12 other residents seated in the common area. During an observation and interview on 1/30/25 at 9:50 AM, the Director of Maintenance #1 stated the temperatures should be between 71-81 degrees Fahrenheit per the regulation. At 9:52 AM, the Director of Maintenance #1 used the facility's infrared thermometer and aimed it at a spot on the wall between rooms [ROOM NUMBERS], it was 70.0 degrees Fahrenheit, then aimed it at the floor in the middle of the common area and it was 68.0 degrees Fahrenheit. They stated that resident rooms were easier to control than the common areas on the units because they had their own separate control. They stated the common area temperatures depended on if the unit doors were open or closed and that they went around and closed those doors every morning, but it was hard to keep them closed because staff and residents go in and out. If the doors were open, the temperatures would go down. During an interview on 1/31/25 at 10:07 AM, the Licensed Practical Nurse Unit Manager #2 stated they bundled up the residents when they got cold, there were a couple residents who were always cold. If they thought the unit was cold, they would call the Director of Maintenance #1 to let them know, they were not sure how the temperatures were controlled. During an interview on 1/31/25 at 11:41 AM, the Director of Nursing stated they were not sure what the air temperatures were supposed to be, if they noticed a resident was cold, they would call Director of Maintenance #1. They were not aware if there was anything wrong with the heat. They have noticed the villages dining room being cold recently and maintenance had addressed that, with different interventions with the windows. They make sure the shades were down, and windows were shut. During an interview on 1/31/25 at 2:56 PM, the Administrator stated some areas of the building get a little colder when its colder outside. They expected temperatures to be between 71 and 81 degrees Fahrenheit. 2. During an initial observation on [NAME] View South Resident Spa shower room on 1/27/25 at 10:43 AM, upon entering the shower room the air/and room temperature felt cold. During an interview on 1/27/25 at 11:11 AM, Resident #78 stated the [NAME] View South shower room has no heat, it was always cold in there. During an observation on 1/28/25 at 3:09 PM [NAME] View South shower room felt cold, and a cold draft was present. The surveyor's stem type thermometer was used to measure the air temperature of that area, and the temperature was 62.2 degrees Fahrenheit. During an observation on 1/29/25 at 9:42 AM, the [NAME] View South shower room felt cold. During an interview at the time of the observation Resident #78 approached the Surveyor and stated they hadn't taken a shower in a week and would like to, but it was too cold in the shower room. Resident #78 added the staff were aware of the shower room being too cold. During an interview on 1/29/25 at 9:46 AM, Certified Nurse Aide #11 stated Resident #78 had complained of the shower room being too cold. Certified Nurse Aide #11 stated residents sometimes refuse or decline their showers due to the cold temperature in the shower room. Certified Nurse Aide #11 stated maintenance was aware of the shower room being cold. Certified Nurse Aide #11 stated it was important that resident felt comfortable while taking a shower. During an interview and observation on 1/29/25 at 10:27 AM-10:36 AM, Licensed Practical Nurse Unit Manager #8, stated there tends to be complaints about the temperature of the shower room on [NAME] View South in the winter, when it's cold. Licensed Practical Nurse #8 stated they felt a cold draft upon opening the door to the shower room. They stated the shower room was not homelike, and felt cold. They stated the temperature of the shower room was not acceptable for residents to be showered in there at that time. Licensed Practical Nurse #8 stated maintenance had been notified and it was suggested to keep shower room door open to allow heat in. During an observation and interview on 1/29/25 at 10:41 AM, in the [NAME] View shower room the Director of Maintenance pointed the facility's infrared thermometer at outside wall of the shower stale, obtaining a temperature of 61 degrees Fahrenheit and 65 degrees Fahrenheit on an inside wall in the shower room. The Director of Maintenance stated the room probably needed to be resealed and they could not feel any source of heat coming into that room. The surveyor's stem type thermometer obtained an air temperature of 65.5 degrees Fahrenheit at that time. Additionally, they stated were notified a couple of days ago about the shower room temperature. During a follow up interview on 1/31/25 at 8:26 AM, the Director of Maintenance stated room temperatures should be between 71-81 degrees Fahrenheit, including the shower rooms. They stated it was state regulation to maintain these temperatures to provide a comfortable and homelike environment to the residents. During an interview on 1/31/25 at 2:56 PM, the Administrator stated some areas of the building get a little colder when its colder outside. They expected temperatures to be between 71 to 81 degrees Fahrenheit. 3. During intermittent observations from 1/27/25-1/30/25 between 8:25 AM and 3:10 PM, the [NAME] View North nurse's station was in the middle of a large common area were the unit hallways and the dining room branched from. The five walled station was highly visible from the hallways, dining room and entrance onto the unit. The outside walls of the station were observed to have a laminated covering that was broken away in random areas, including the corners, of the five walls with exposed particle board. The countertop and edges were observed to also have chipped/missing laminate in numerous areas. There was an observed wooden support that was crooked under the countertop. Two hinged doors were present to enter the five walled station. They were observed to have chipped laminate, and one door had an area of peeling black (duct) tape at the bottom. Two recliners were observed to be inside of the walled station. A gray recliner was observed in the area with the footrest ripped and stuffing exposed, along with a blue recliner that was ripped at the arm rest with stuffing exposed. The recliners were placed at the inner wall and the wall was observed to have chipped and scratched paint. During an observation on 1/27/25 at 9:54 AM, Resident #52 was observed sitting within the nursing station with their head on the countertop. During an observation on 1/27/25 at 3:46 PM, 1/29/25 at 1:23 PM, and 1/29/25 at 4:00 PM, Resident #8 was observed to be sitting in the blue leather recliner that was in disrepair within the nursing station walls. During an interview on 1/29/25 at 1:23 PM, Certified Nurse Aide #14 stated that the nurse's station and the recliner chairs were not visually presentable, not home like and could be more sanitary. Certified Nurse Aide #14 stated that the [NAME] View North unit was not kept up as the other units were. During an interview and observation on 1/30/25 at 8:33 AM, a two-person sofa was observed to have a small hole on the seat, food debris and two black stains prior to entrance of the television lounge. In the television lounge Resident #108 was observed to be sitting in a green straight back chair that was ripped on the arm rest with stuffing exposed. Resident #71 was observed to be sitting in a brown leather recliner that had scratches down the left side. At Resident #71's left side was noted to be a pink straight back chair was ripped on the seat with the cushion exposed. During the interview at the time of the observation, Resident #71 stated that the pink straight back chair needed some maintenance and if the seat didn't get fixed, someone was going to go through it. During an interview on 1/30/25 at 3:01 PM, Licensed Practical Nurse Unit Manager #8 stated the gray and blue recliners were taken to the dumpster on 1/29/25 because the Director of Social Work saw how awful they were. They stated that there was peeling and chipping laminate on the nurse's station that did not present as homelike. Licensed Practical Nurse #8 stated the nurse's station was visible to the residents and visitors and should have been cleaner because it looked dingy. During an interview on 1/30/25 at 3:05 PM, Certified Nurse Aide #16 stated the nursing station was clean but looked old and needed to be remodeled. They stated residents had the right to look at nice things. During an interview on 1/30/25 at 3:10 PM, Resident #52's spouse stated they did not like the looks of the [NAME] View North unit, it was not homelike, and it was dirty. They stated the unit did not have enough chairs for the visitors to sit in. During an interview on 1/31/25 at 8:29 AM, the Director of Social Work stated that the [NAME] View North nurse's station could be visualized by residents, visitors and staff. They stated that the nurse's station was part of the resident's home, that the station had scuff marks in paint, and it was not new looking. The Director of Social Work stated that they did order some new recliners for the unit because the old furniture was not homelike for residents and visitors to be sitting in chairs that had rips with stuffing coming out of them. During an interview and observation on 1/31/25 at 10:02 AM, the Director of Housekeeping and Laundry was brought to the [NAME] View North Unit. After visualization of the nurse's station, they stated it did not have a home like appearance. They stated the station had been there for 20 years and needed to be replaced. They visualized the love seat at the entrance to the television lounge and stated it was clean but had two black marker stains on it. The two ripped straight back chairs were no longer present in the television lounge. During an interview on 1/31/25 at 11:25 AM, the Director of Nursing stated the [NAME] View North nurse's station could be seen as soon as one enters closed doors of the unit. They stated they did not like the station, it did not have a homelike appearance, and the laminate doors and countertops were peeling. During an interview on 1/31/25 at 1:57 PM, the Administrator stated they felt the [NAME] View North Nursing Station structure was sound and they had not received any complaints about the appearance of the station. They stated a homelike environment was a constant process and they look at all areas of the facility. During an interview on 1/31/25 at 2:05 PM, the Director of Maintenance stated they would describe the [NAME] View North nurse's station as panels, saw dust and glue. They stated that it was structurally safe, felt it was home like, but it was difficult to replace broken Formica. 10 NYCRR 415.5(h)(2,4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during a Complaint (Complaint #NY00349205, #NY00338010) investigation during the Standard survey completed on 1/31/25, the facility did not ensure that the resident environment remained as free from accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for six (Orchard View lounge area, Canal View lounge area, [NAME] View South lounge area, Main Lobby , Villages Dining Room, Garden View lounge area) of seven resident areas and three (Resident #s 11, 115 and 320) of five residents reviewed for accidents. Specifically, the facility did not identify as potential accident hazards electric fireplaces with hot surfaces that were in resident accessible areas (Villages Dining Room, Canal View lounge area, Garden View lounge area, Orchard View lounge area, [NAME] View South lounge area, and the main lobby). Additionally, a cognitively impaired resident with exit seeking behaviors eloped from the facility undetected (Resident #115); safety devices (bilateral foot pedals and calf protector/foot board) were not place as planned (Resident #11) and Resident #320 was transferred by a staff member and an untrained family member. The findings are: 1. Observation during the initial building tour on 1/27/25 from 9:30 AM until 11:30 AM revealed the facility had seven wall-mounted electric fireplaces. They were in the Villages Dining Room (two), Canal View lounge area, Garden View lounge area, Orchard Unit lounge area, [NAME] View South lounge area, and the main lobby. The six electric fireplaces located on resident units were Brand A and the one in the main lobby was Brand B. At the time of the initial building tour, all electric fireplaces were producing heat, except for the electric fireplace in the main lobby. During the initial building tour on 1/27/25 at 10:45 AM, the Director of Maintenance stated the electric fireplace in the main lobby was set to a thermostat, and it automatically produced heat when the temperature in the room dipped below the thermostat's setpoint. During observations and interviews of the electric fireplaces for (6) six resident areas revealed the following: Orchard View lounge: 1/30/25 at 10:25 AM revealed Resident #115 was sleeping in a wheelchair within inches of where heat emanated from the bottom the electric fireplace that was mounted on the wall. The electric fireplace was producing heat at this time, which came from the bottom center of the unit. The bottom of the unit was at Resident #115's shoulder level, had no shielding from the metal, and was very hot to the touch. At the time of the observation, Certified Occupational Therapy Assistant #1 stated to the Surveyor who was touching the electric fireplace, It's hot, it'll burn you. Certified Occupational Therapy Assistant #1 stated the electric fireplaces were installed throughout the facility about one month ago and they were usually producing heat. They stated they had periodically noticed that Resident #115 tended to wheel themselves up to the electric fireplace. Certified Occupational Therapy Assistant #1 stated the electric fireplaces were concerning because some residents had dementia and loss of sensation for hot surfaces. During an interview on 1/30/25 at 10:30 AM, Certified Nurse Aide #1, stated Resident #115 often wheeled themselves up to the fireplace. They stated they did not receive safety training from the facility when the electric fireplaces were installed. -1/30/25 at 12:07 PM, the electric fireplace in the Orchard View lounge was on and blowing warm air. A sticker on the front of the electric fireplace said, warning surface can get hot when the heater is on. The surface along the bottom center of the fireplace was hot to the touch, the surveyor had to pull their hand away after a few seconds. The temperature was measured of that area, and it ranged from 157.8 degrees Fahrenheit to 167.5 degrees Fahrenheit. During an interview on 1/30/25 at 12:13 PM, Licensed Practical Nurse #11 stated the electric fireplaces were always on and were told they were on the max setting. They never saw any residents touching it, but there were a couple residents who liked to sit by it for warmth. They were never told to keep the residents away from them. They were grateful they put the fireplaces in because it was cold in here. During an interview on 1/30/25 at 12:19 PM, Certified Nurse Aide #6 stated the electric fireplaces were always on. They stated they have touched it to see how much heat it put out, but didn't think it was hot enough to burn a person. They were never told to keep residents away from it. Canal View lounge: 1/20/2025 at 12:02 PM there was an electric fireplace mounted on the wall in the common area (lounge) under the TV. There were no residents near the electric fireplace at the time of the observation. The area at the bottom was producing heat, felt warm and measured 156 degrees Fahrenheit. During an interview on 1/30/25 at 12:17 PM, Certified Nurse Aide #3 stated a resident had asked them to turn up the heat and they were checking the fireplace to see how warm it was. Certified Nurse Aide #3 stated they felt heat at the bottom and was unsure how the electric fireplace worked. They stated they did not receive safety training from the facility when the electric fireplaces were installed. [NAME] View South lounge: 1/27/25 at 1:29 PM and 1/29/25 at 12:39 PM, the wall mounted electric fireplace was observed with warning label stating surface can get hot when heater was on. The electric fireplace was producing heat at this time, which came from the bottom center of the unit. At those times, the surveyor touched the metal area of the electric fireplace, emitting hot air with their fingers and immediately pulled back their hand as the surface was too hot to touch. On 1/30/25 at 12:03 PM, wall mounted electric fireplace was powered on and no heat was emitting from the unit at this time. Director of Maintenance stated this electric fireplace had a thermostat, and if the room was warm enough the electric fireplace would not run. Main Lobby: 1/30/25 at 12:04 PM, there was an electric fireplace was recessed into a wall. The electric fireplace had metal vents on top of a display of artificial blue fire flame lights and it was blowing out very hot air. The surveyor's digital thermometer was placed across the vents blowing out the hot air and it measured 230 degrees Fahrenheit. The vent grates were touched by the surveyor and immediately needed to be pulled away. During an interview on 1/30/25 at 12:09 PM, Certified Nurse Aide #10 stated they have not received any training or in-service on the use of the electric fireplaces and would contact maintenance if they had any concerns or questions. During an interview and observation on 1/30/25 at 12:15 PM, Certified Nurse Aide #10 stated they did not know how long the electric fireplace had been in the Main Lobby and did not know how it worked. At 12:19 PM Certified Nurse Aide #10 went into the lobby and placed their hand about three inches from where the air was blowing out. Certified Nurse Aide #10 stated the air was hot, and it was hot enough to burn someone especially if they touched it. During an interview on 1/30/25 at 12:16 PM, Licensed Practical Nurse #8, Unit Manager stated they have no responsibility with the functionality of the electric fireplaces on [NAME] View South and the Main Lobby. They stated they have seen the Director of Maintenance check them first thing in the morning during their rounds. Licensed Practical Nurse #8 stated they have never observed any residents on [NAME] View touching the electric fireplace and no concerns have been brought to their attention about the electric fireplaces being too hot. During an observation and interview on 1/30/25 at 12:26 PM-12:31 PM in the Main Lobby, the Administrator placed their hand on front of metal grate, of the electric fireplace emitting heat and stated they wouldn't want to keep their hand on it. They stated their natural response was to pull their hand away from the metal grate as it was too warm. The surveyor's thermometer was placed on the metal surface across the vent emitting hot air and it measured 240-245 degrees Fahrenheit. The temperature was verified by the Administrator. The Administrator stated anybody could touch the electric fireplace and they wouldn't recommend anyone holding their hand on the metal grate. The Administrator stated the Main Lobby was a highly unoccupied resident area. Villages Dining Room dining room: 1/30/25 at 12:05 PM, the wall mounted electric fireplace by the Servery revealed the bottom center metal grate surface temperature felt warm and ranged between 142 degrees Fahrenheit (F) to 163.3 degrees Fahrenheit. During an interview on 1/30/25 at 12:09 PM, Certified Nurse Aid #3 stated the Maintenance Director was responsible to turn on the electric fireplaces and adjust the temperatures. They stated they had not received any education on how far the residents needed to be kept away from the electric fireplaces. During an interview on 1/30/25 at 12:13 PM, Registered Nurse #2 the nursing staff did not have access to the electric fireplace remote. Registered Nurse #2 stated that they did receive verbal education by the Director of Nursing on the electric fireplaces to keep residents at a safe distance away but could not state specifically how far they had been instructed to keep the residents away from them. During an interview on 1/30/25 at 12:23 PM, Certified Nurse Aide #15 stated they were briefly educated on the electric fireplace and were told not to place residents too close to the electric fireplaces. They stated that the electric fireplace was hot underneath. Observation with the Director of Maintenance in the Villages Dining Room on 1/30/25 at 12:00 PM the Director of Maintenance pointed the facility's infrared thermometer into the electric fireplace from the bottom center and it read 100 degrees Fahrenheit. The Surveyor's stem type thermometer was set on the metal surface on the bottom center and measured 142.6 degrees Fahrenheit. At this time, the Director of Maintenance placed their hand on the bottom center of the unit, kept it there for greater than five seconds. The Director of Maintenance stated they felt there were no safety risks related to the electric fireplaces, as they had not seen any resident touch the units in a way that could burn them. The Director of Maintenance stated the two electric fireplaces located in the Villages Dining Room were set to on and produced heat constantly. They stated the electric heaters in the resident units and main lobby were set to a thermostat, which was set to 82 degrees Fahrenheit. The Director of Maintenance stated when the electric fireplaces were first installed in December 2024, they performed daily checks on them. The checks were now performed monthly. They stated their checks were performed by pointing the facility's infrared thermometer upward into the unit through the bottom center, where the heat came from. Additionally, on 1/31/25 at 10:10 AM, the Director of Maintenance stated the building's electric and hydronic heating systems were fully functional. It was their idea to purchase and install the electric fireplaces, and they did it for resident enjoyment. The most recent log titled Wall Heaters, dated 1/23/25, documented the seven electric fireplaces were operational and their temperatures ranged from 150 to 165 degrees Fahrenheit. During an interview on 1/31/25 at 2:39 PM, the Administrator stated the electric fireplaces had a safety UL (Underwriter's Laboratory) rating. They stated they knew there was a maximum temperature according to regulations, but were unable to specify the maximum temperature, and stated they liked the electric fireplaces because they were homelike. Garden View: 1/30/25 at 12:06 PM the electric fireplace was mounted on the wall approximately 3 feet from the floor. The electric fireplace was very hot to the touch on the bottom, and the surface temperature the metal vent and measured 175.8 degrees Fahrenheit. During an interview on 1/30/25 at 12:08 PM, Licensed Practical Nurse #6 stated they had observed residents approach the fireplace to warm themselves, but no one had attempted to touch it. Licensed Practical Nurse #6 stated the fireplace had a hot surface and could potentially burn someone if they touched it. During an interview on 1/30/25 at 12:10 PM, Certified Nurse Aide #12 stated the electric fireplace felt very hot to them and some of these residents don't know they shouldn't touch it. The policy and procedure titled Electric Heaters, issued 12/2024, documented only electric heaters that meet fire safety standards and are UL (Underwriter's Laboratory) listed or have equivalent safety certification can be used. Electric heaters should be used under supervision, especially in areas accessible to residents, to prevent accidents or misuse. Regular inspections and maintenance of electric heaters will ensure they are in good working condition and do not pose any safety hazards. Compliance with local and state regulations regarding the use of electric heaters will be ensured, including any restrictions or guidelines specific to healthcare settings. The Maintenance Supervisor is responsible for ensuring compliance with all safety standards. The user manual for Brand A electric fireplace documented this heater is hot when in use, to avoid burns, do not let bare skin touch hot surfaces. Keep combustible materials such as furniture, pillows, and clothes at least three feet from front, sides, and rear of the heater. Extreme caution is necessary when any heater is used by or near children or invalids, and whenever the heater is left operating and unattended. The user manual also documented to turn the heater fan on, press the heat button. Press and hold the heat button for five seconds to cycle through heat settings, which ranged from 62 to 82 degrees Fahrenheit. The user manual for Brand B electric fireplace documented always keep clothing, papers, and other combustibles at least three feet away from the front of this heater, and away from the bottom, sides, and rear of this heater. This heater is for residential use only, not for commercial use. Never leave this heater unattended. This heater is hot when in use. Avoid injury, do not touch hot surfaces or attempt to move this heater while it is hot. The user manual also documented the flame effect must be on for the heater to function, press the heat button once for low heat (750 [NAME]) and press heat button again for high heat (1500 [NAME]). Temperature can be set from 62 to 82 degrees Fahrenheit. 2. Resident #115 had diagnoses including nontraumatic intracerebral hemorrhage (brain-bleed), legal blindness, and heart failure. The Minimum Data Set (resident assessment tool) dated 7/15/24, documented Resident #115 was severely cognitively impaired, was understood and usually understands. There was no wandering behaviors documented. Review of Census data revealed Resident #115 was moved from another unit of the facility to their current room on the Orchard unit on 7/18/24. The comprehensive care plan initiated 5/3/24 documented Resident #115 had limited physical mobility related to weakness with a revision on 7/10/24 to allow for ambulation with a rolling walker with 1 assist by a Certified Nurse Aide for distance as tolerated. Locomotion, initiated 5/3/24 and revised 5/7/24, was to be with a standard wheelchair. Resident #115's comprehensive care plan initiated 5/23/24 documented they had impaired cognitive functioning or impaired thought process and the interventions to be addressed by Certified Nurse Aides were that they needed to be cued, reoriented and supervised as needed. Wandering Risk Assessments completed for Resident #115 documented for 7/15/24 that Resident #115 ambulated with 1 Assist and the assessment did not have a way to reflect that Resident #115 was capable of self-propelling in their manual wheelchair. The 7/15/24 assessment did not indicate a history of wandering and scored as a low risk for wandering. A progress note dated 7/15/24 documented that Resident #115 was encountered twice self-propelling through the double doors and down the hallway away from the villages asking staff am I going the right way?. Resident redirected both times back to unit. Nursing made aware. A progress note dated 7/22/24 documented Resident #115 was encountered going through the double doors with another resident stating they were going outdoors. Both residents were educated that they needed a staff member with them to be outside and were re-directed to their unit. A progress note dated 7/23/24 completed by Licensed Practical Nurse #3 documented that Resident #115 was missing at 7:20 PM and a search was started on the unit, then notified the supervisor and alerted all staff of the missing resident. A progress note dated 7/23/24 documented that Licensed Practical Nurse #12 found Resident #115 in the facility parking lot sitting in their wheelchair and brought Resident #115 back into the building and to their unit at 7:45 PM. Resident #115 was assessed by a Registered Nurse, was calm and cooperative with no distress or injuries noted. A progress note dated 7/23/24 documented that a wander alert device was applied to Resident #115's left ankle. Review of further Wandering Risk Assessments revealed the next assessment was completed on 7/24/24, the day following the elopement. The 7/24/24 assessment noted a room change as a recent experience. That room change took place on 7/18/24, prior to the elopement. The 7/24/24 assessment again noted Resident #115 as ambulating with 1 assist and did not reflect that Resident #115 was capable of self-propelling in their manual wheelchair independently. Resident #115 scored as moderate risk for wandering. During multiple observations on 1/30/25, Resident #115 was observed self-propelling in their wheelchair independently by using their feet to propel the manual wheelchair around the unit and their safety alert device was in place. During an interview on 1/31/25 at 10:59 AM, Licensed Practical Nurse/Unit Manager #2 stated Resident #115's Wandering Risk Assessment was updated after the two encounters in the hallway on 7/15/24 and should have been updated again on 7/22/24. After the 7/22/24 documented encounter, Resident #115's case should have been discussed by the Interdisciplinary team and supervision should have been increased. During an interview on 1/31/25 at 10:34 AM, Occupational Therapist #1 stated they were the staff person who encountered Resident #115 on 7/22/24 in the hallway going through the double doors from the villages side of the building with another resident and they stated they did report this encounter to nursing staff, at the time of redirecting the two residents to their unit. They did not recall who specifically they reported to. During an interview on 1/30/25 at 10:32 AM, Certified Nurse Aide #6 stated they were one of two staff who were on break in their cars in the parking lot and observed Resident #115 self-propelling in their wheelchair around the end of A-wing and into the parking lot on 7/23/24 at about 7:40 PM. They stated Resident #115 told them they had gotten out through the courtyard glass door and then through the fence gate. Certified Nurse Aide #6 stated they believed that the fence gate was not locked, and that gate usually was locked. During an interview on 1/30/25 at 10:53 AM, Licensed Practical Nurse #3 stated they noticed that Resident #115 was missing from the unit on 7/23/24 at about 7:20 PM. They reported this to the Registered Nurse Supervisor on shift and a search of the facility commenced. Licensed Practical Nurse #3 stated they were going down the main hall from the main lobby area toward the front door of the facility, when Licensed Practical Nurse #12 was bringing Resident #115 through the front doors. Licensed Practical Nurse #3 stated Resident #115 was very tickled by their experience and stated they had exited through the door and then the fence to get to the parking lot. They stated Resident #115 told them they were told if the door was unlocked, they could go outside. Licensed Practical Nurse #3 stated they believed Resident #115 had just recently moved to the Orchard unit from the Garden unit, at the time of the elopement. They also stated they were not aware of any other times Resident #115 had attempted to leave the unit and that Resident #115 was not wearing a wander alert device at the time. During an interview on 1/30/25 at 9:12 AM, Director of Nursing #1 stated they investigated this elopement and concluded Resident #115 used the glass door in the main lobby area to exit to the garden and from there the fence gate. They stated the glass door was usually unlocked until about 8 PM daily. They stated the fence gate was unlocked because the grass had been mowed and the pad lock had not been re-locked. They stated Licensed Practical Nurse #12 had noticed Resident #115 in the parking lot and observed them self-propelling around the corner of A-wing, the service wing of the facility. During an interview on 1/31/25 at 12:02 PM, the Administrator stated that supervision levels for Resident #115 should have been increased on 7/15/24 after the resident was encountered self-propelling through the double doors to the hallway from the villages section of the facility. After reading the progress note for 7/22/25 regarding Resident #115 being encountered with another resident exiting the villages through the double doors, the Administrator stated a wander alert device should have been placed at that time for Resident #115's safety. The Administrator stated the other resident was one who was allowed to use the garden area independently. The policy and procedure titled Elopement/Missing Resident revised 7/2024 documented the facility would provide a safe and secure environment for all residents and any resident identified as a risk for elopement will be reassessed monthly, upon admission/readmission, 7 days from admission/readmission, change in level of care, and/or environment. The Wander Risk Assessment will be completed to determine the resident's risk for elopement. Exit seeking behavior may include but was not limited to opening doors to the outside, making statements referencing leaving the facility, seeking to find someone/something outside of the facility. The policy and procedure titled Wanderguard Alarm Procedure revised 4/2017 documented that to ensure the safety of wandering residents at risk of elopement, the facility had a Wanderguard System installed on all exiting doors to the outside. 3. Resident #11 had diagnoses of dementia, cerebral infarction (a type of stroke), and aphasia (absence or difficulty with speech). The Minimum Data Set, dated [DATE] documented Resident #11 was rarely understood, rarely understands and had severe cognitive impairment. The Minimum Data Set documented that Resident #11 required partial/moderate (helper does less than half the effort) assistance with transfers and ambulation and was dependent (helper does all of the effort) with wheelchair mobility. The comprehensive care plan with last revised on 1/16/25 documented Resident #11 had limited physical mobility related to weakness, utilized a manual wheelchair and required bilateral elevating footrests and a calf protector/footboard was to be in place. Review of the Kardex (a guide used by staff to provide care) dated 1/31/25 documented Resident #11 had a manual wheelchair with bilateral elevating footrests and calf protector/footboard. The Physical Therapy Treatment Encounter Notes from 7/18/24 through 7/23/24 documented Resident #11 had difficulty keeping their bilateral feet on elevating footrests which would increase the risk for skin integrity issues. The note also documented that when Resident #11 did not have footrests on their wheelchair their feet would not rest fully on the floor and would be at risk for bumping their feet into the wheelchair caster wheels. Nursing recommendations had been updated to include a calf protector/footboard when Resident #11 was to be in the wheelchair. Education had been provided to a certified nurse aide (unidentified) regarding the need to have bilateral elevating footrests and calf protector/ footboard in place. Observations made on 1/27/25 at 12:22 PM and 1/30/25 at 8:40 AM revealed that Resident #11 was sitting in their wheelchair and did not have bilateral foot pedals and calf protector/foot board in place as care planned. Observations made on 1/28/25 at 8:57 AM, Resident #11 was sitting in their wheelchair and did not have the calf protector/footboard in place as care planned. The resident's right foot was off the foot pedal and in between the foot pedals touching the floor. Continued observations on 1/29/25 at 10:58 AM, and 1/29/25 at 4:29 PM revealed that Resident #11 was sitting in their wheelchair and did not have the calf protector/footboard in place as care planned. Observation on 1/30/25 at 9:45 AM, Resident #11 was observed to be sitting in their wheelchair by the nurse's station and did not have bilateral foot pedals and calf protector/footboard in place. Certified Nurse Aide #14 reposition Resident #11 in wheelchair and transport Resident #11 to dining room (approximately 50 feet) with no foot pedals in place and was sliding forward in wheelchair. Resident #11 held their feet up extended outward approximately an inch off the floor during transport. During an interview on 1/30/25 at 9:52 AM, Certified Nurse Aide #14 stated that Resident #11 would frequently slide down in their wheelchair and that was why they had just repositioned them. Certified Nurse Aide #14 stated that Resident #11 did not have foot pedals or a calf board on and was unsure if they should have them in place. They stated Resident #11 was not on their assignment. During an interview on 1/30/25 at 10:00 AM, Certified Nurse Aide #20 stated they were assigned to Resident #11 and had provided care to them. Certified Nurse Aide #20 stated they had not checked Resident #11's care plan prior to providing care and did not see foot pedals or a calf protector/foot board in the resident's room. Certified Nurse Aide #20 stated they had not previously seen Resident #11 utilize foot pedals. Certified Nurse Aide #20 reviewed the transfer and ambulation section of Resident #11's care plan on the computer and stated they had not seen that Resident #11 was to have foot pedals or a calf protector/ footboard. During an interview on 1/30/25 at 10:26 AM, Licensed Practical Nurse #3 stated the residents care needs and safety devices would be documented on the care plan and Kardex (a guide used by staff to provide care). Both the nurses and certified nurse aides were responsible to ensure the care plan was followed. Licensed Practical Nurse #3 was observed to pull up Resident #11's Kardex on the computer and stated that Resident #11 was care planned to have bilateral foot pedals on their wheelchair and a calf protector/footboard was to be in place. They stated they were unaware that Resident #11 did not have both the foot pedals and calf protector/footboard on as care planned and it was important to prevent injury. During an interview on 1/30/25 at 10:39 AM, Licensed Practical Nurse Unit Manager #8 stated the cart nurses were responsible to make sure the certified nurse aides followed the care plan and all positioning devices were in place. The Licensed Practical Nurse Unit Manager #8 stated Resident #11 was to have bilateral foot pedals on due to edema. Resident #11 did not self-propel themselves and did not have the strength to hold up their legs while being transported and could be injured without the foot pedals. Licensed Practical Nurse Unit Manager #8 stated they were unaware that Resident #11 was care planned to have a calf protector/footboard. During an interview on 1/30/25 at 2:39 PM, the Director of Rehabilitation stated Resident #11's calf protector and footboard was added to their care plan in July 2024. They stated Resident #11 was having difficulty keeping their feet on their foot pedals and their feet were not touching the floor without the pedals. The Director of Rehabilitation stated the calf protector, and footboard was issued to prevent foot or leg injuries. They would expect nursing staff to follow the recommendations made for Resident #11 and that Resident #11 would be at risk for injury without having foot pedals or the calf protector/ footboard in place. During an interview on 1/31/25 at 12:40 PM, the Director of Nursing stated they expected the certified nurse aides to read the Kardex prior to providing resident care and ensure all safety devices including foot pedals and calf boards were in place as this would be important to prevent falls and injuries. 4. Resident #320 had diagnoses that included a fracture of the left femur, dementia and atrial fibrillation (an irregular heart rate that causes poor blood flow). The Minimum Data Set (a resident assessment tool) dated 3/7/24 documented Resident #320 had severe cognitive impairment, usually understands and was usually understood. The comprehensive care plan dated 3/29/24, documented Resident #320 had self-performance deficit related to limited mobility. Interventions included that Resident #320 may require a two-person approach due to combativeness. The care plan did not indicate that family could assist with transfers. The Kardex (guide used by staff to provide care) dated 4/1/24, documented that Resident #320 was dependent for wheelchair mobility; a maximal assist of one assist for toileting, bathing, dressing and hygiene; and a moderate assist of one for bed mobility and transfers. The Kardex documented that Resident #320 may require a two-person approach due to combativeness. The Kardex did not indicate that family could assist with transfers. Review of the facility's undated Investigation Summary signed by the Director of Nursing, documented on 4/4/24 they were notified by a supervisor that Resident #320 has sustained a femur fracture to their left leg and the resident was sent to the emergency department. The summary documented that on 4/2/24 that the Director of Nursing was called to assess an area of bruising to Resident #320's left upper thigh and then again on 4/3/24. It was documented that on 4/3/24 there was swelling noted to Resident #320's left leg from the hip to knee with complaints of pain. X-rays from the pelvis to the foot were then ordered. Certified Nurse Aide #14 statement within the facilities investigation dated 4/5/24 at 8:30 AM, documented that Resident #320's family requested for the resident to be toileted, and the family member assisted with the transfer. Certified Nurse Aide #14 documented Resident #320 complained of pain but could not located it. They documented they left the resident in bed with their family member. Review of the Progress notes dated 4/5/24 at 12:14 PM, the Director of Nursing documented that they spoke with Resident #320's family member and asked them if they had a history of transferring the resident. The Director of Nursing documented the family replied yes, and they had not been trained/cleared by therapy for activities of daily living care. They documented that staff had told the family numerous occasions that they were to ask for help from the staff and the family member replied they sometimes did not want to wait. During an interview on 1/29/25 at 1:26 PM, Certified Nurse Aide #14 stated that Resident #320 was a maximal assist of two for transfers. They stated the resident was easy to transfer but at times would not let go of the handrail in the bathroom. They stated they did transfer Resident #320 with the assist of their family member to the toilet, off the toilet and then into bed. Certified Nurse Aide #14 stated during the transfer on to the toilet Resident #320 complained of p[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a Partial Extended Abbreviated survey (Complaint #NY00331388) completed on [DATE], the facility did not ensure that required documentation was sent to the receiving provider in a hospital transfer for one (Resident #1) of three residents reviewed. Specifically, on [DATE] Resident #1 was transferred to the hospital emergently, after a significant medication error. Licensed Practical Nurse #6 did not provide the hospital provider with the correct Medical Orders for Life-Sustaining Treatment (advanced directives) form which resulted in a delay of treatment for Resident #1. The finding is: Resident #1 had diagnoses of metabolic encephalopathy (neurological disorder), dysphagia (difficulty swallowing), hypertension (high blood pressure), and traumatic brain injury. The Minimum Data Set, dated [DATE] documented the resident was moderately cognitively impaired, and no advance directives were documented. The comprehensive care plan with a revised date of [DATE], documented Resident #1 did not have advance directives and included a goal that resident's choice of advance directives would be honored. Interventions documented the resident as a full code. The nurses note dated [DATE] at 7:13 PM by Licensed Practical Nurse Supervisor #6 documented Resident #1 was exhibiting altered mental status, incoherent speech. The medical doctor was notified with a new order to send to emergency department. During an interview on [DATE] at 9:54 AM, Licensed Practical Nurse #6 stated Resident #1 experienced a change in condition (altered mental status, incoherent speech) on [DATE] at approximately 7:00 PM, the Medical Doctor was notified with a new order to send the resident to emergency department. Licensed Practical Nurse #6 stated they made copies of Resident #1's information from the electronic medical record, including the Medical Orders for Life-Sustaining Treatment form. Licensed Practical Nurse #6 stated there was a voided Medical Orders for Life-Sustaining Treatment scan dated [DATE] they scrolled past and sent a copy of a Medical Orders for Life-Sustaining Treatment form, dated, and reviewed by the Nurse Practitioner [DATE]. They further stated they were trained go to the Misc. (miscellaneous) tab of the electronic medical record to copy the most recent Medical Orders for Life-Sustaining Treatment. Review of the Medical Orders for Life-Sustaining Treatment form that was originally sent to the hospital on [DATE] revealed the form was dated and last reviewed by the Nurse Practitioner on [DATE]. The form documented Do Not Resuscitate, Do Not Resuscitate, Comfort Measures Only, Do Not Intubate, No IV fluids. Review of the Hospital ED (emergency department) to Hosp (hospital) admission note dated [DATE] documented the resident arrived at the emergency department [DATE] at 9:09 PM. The resident was sent to the emergency department after accidentally receiving another resident's medications. The Medical Orders for Life-Sustaining Treatment documents Do Not Resuscitate, Do Not Intubate, No IV fluids, do not send to hospital, and Comfort Measures Only. The resident was lethargic and unable to give any history. At 2:30 AM on [DATE], the resident continued to be hypotensive with a systolic blood pressure in the 70's and heart rate in the 50's. Nursing home staff was notified that the resident would be sent back to the nursing home in light of the comfort care status, and they can be monitored at the nursing home. Approximately 20 minutes later the facility Nursing Supervisor contacted the hospital stating the wrong Medical Orders for Life-Sustaining Treatment was inadvertently sent with the resident. At 3:30 AM on [DATE] the hospital received a fax (facsimile) of Medical Orders for Life-Sustaining Treatment, signed by the resident indicating full code. Review of the second Medical Orders for Life-Sustaining Treatment provided to the hospital revealed the form was signed and dated [DATE] by Resident #1 and Medical Doctor documented attempt cardiopulmonary resuscitation and no limitations on medical interventions. During an interview on [DATE] at 10:12 AM, the hospital Associate Chief Nursing Officer stated Resident #1 arrived at the hospital emergency room on [DATE] at 9:09 PM with a Medical Orders for Life Sustaining Treatment form signed by the resident on [DATE] and reviewed by the Nurse Practitioner [DATE]. The advanced directive documented: Do Not Resuscitate, Comfort Measures Only, Do Not Intubate, and No IV (intravenous) fluids. The hospital contacted the facility on [DATE] at 2:30 AM to notify the facility that Resident #1 would be returning to the facility secondary to a declining medical condition (arousable to sternal rub, firm rub on the chest to test responsiveness, and confusion) and the limitations of care documented (no laboratory values were to be obtained, no IV fluids administered). Licensed Practical Nurse #6 contacted the hospital approximately 20 minutes later stating the incorrect Medical Orders for Life-Sustaining Treatment form was sent with Resident #1 and the current form documented there was no limitations on medical interventions and to attempt cardiopulmonary resuscitation (CPR). The hospital received the correct Medical Orders for Life-Sustaining Treatment form dated [DATE] at 3:30 AM and began medical treatment. During an interview on [DATE] at 10:41 AM, the Director of Nursing stated the facility does not have a current policy and procedure regarding transferring residents to the hospital. During an interview on [DATE] at 1:24 PM, the Medical Doctor stated they were unaware the incorrect Medical Orders for Life-Sustaining Treatment form was sent to the hospital with Resident #1 and the current form should be scanned into the electronic medical record in chronological order. During an interview on [DATE] at 7:58 AM Licensed Practical Nurse Supervisor #5 stated when sending a resident to hospital they were trained go to the Misc. (miscellaneous) tab of the electronic medical record to copy the most recent Medical Orders for Life-Sustaining Treatment. During an interview on [DATE] at 10:21 AM, the Director of Nursing stated staff were to make a copy of the original Medical Orders for Life-Sustaining Treatment form, found in the supervisor's office Medical Orders for Life-Sustaining Treatment book to send with the resident when transferring the hospital. During an interview on [DATE] at 10:34 AM, the Administrator stated staff were expected to copy the original Medical Orders for Life-Sustaining Treatment form, found in a binder in the supervisor's office, to send with the resident when transferring to the hospital. 10 NYCRR 415.3(h)(1)(iv)(d)-

Based on interview and record review conducted during an Abbreviated survey (Complaint # NY00325970) completed on 10/18/23, the facility did not ensure that all alleged violations including abuse are reported immediately, but not later than 2-hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to appropriate officials (including the State Survey Agency) for one (Resident #1) of four residents reviewed. Specifically, facility staff did not report alleged physical and verbal abuse of a resident to the Director of Nursing (DON) or the Administrator which resulted in the alleged abuse not getting reported to the appropriate officials including the New York State (NYS) Department of Health (DOH) as required. This finding is: The policy and procedure (P&P) titled Signs and Symptoms of Abuse/Neglect Policy dated 10/26/16 documented the facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms to their supervisor or the DON. 1. Resident #1 was admitted to the facility with diagnoses including dementia, seizure disorder and anxiety. The Minimum Data Set (MDS- a resident assessment tool) dated 8/12/23 documented Resident #1 had moderate cognitive impairments, was usually understood, and usually understands. The comprehensive care plan (CCP) with revision date of 12/16/22 documented Resident #1 demonstrated the potential for physical and verbally aggressive behaviors towards staff and residents. The CCP also documented the resident was incontinent of bowel and bladder related to seizure disorder and confusion. During an interview on 10/17/2023 at 10:13 AM, Certified Nurse Aide (CNA) #1 stated, last Thursday on 10/12/23 Resident #1 was agitated, wandering the unit, and refused to use their walker. CNA #1 stated they were walking with the resident until they calmed down because they didn't want the resident to get hurt or hurt someone else. Resident #1's pants were wet, and they needed to be changed. The nurse (LPN #1) came up to the resident, started pointing in the resident's face, told the resident they needed to go to their room to get changed, and grabbed the resident by the shirt. CNA #1 stated they reported the incident yesterday (10/16) to Lead CNA #1. During an interview on 10/17/2023 at 12:22 PM, Lead CNA #1 stated CNA #1 reported to them yesterday (10/16/23) that last week LPN #1 grabbed Resident #1's shirt and got into the resident's face. Lead CNA #1 stated that they told CNA #1 they needed to report the incident right away, not to wait, and to go and report the incident to the Social Worker (SW). The aide (CNA#1) stated to them that they would go to the SW. Lead CNA #1 stated they did not report the incident to the supervisor or to the DON and thought the SW would take care of it. During an interview on 10/17/2023 12:34 PM, the Social Worker Assistant stated they were unaware of any abuse allegations involving Resident #1 and that no staff members reported any allegations of abuse to them. During an interview on 10/18/2023 at 9:57 AM, the Administrator stated an investigation was started yesterday (10/17) and the alleged abuse was reported to the NYSDOH when they became aware of the allegation. During an interview on 10/18/2023 at 12:37 PM, the DON stated that staff know better, and they know when to report an abuse concern. The DON stated LPN #1 denied the allegation and they were not sure why Lead CNA #1 did not report the incident to them or the Administrator. The DON stated an investigation had been started (10/17) and they were not sure at the time of the interivew if any other staff witnessed the incident. The DON stated, that if staff felt uncomfortable to report a supervisor, they know they can come to me or report to the hotline. The incident should have been reported within 2 hours. 10NYCRR 415.4 (b)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during an Abbreviated survey completed on 8/10/23, the facility did not ensure that each resident has the right to refuse treatment, participate in experimental research, and to formulate an advanced directive for three (Resident #1, #2, and #3) of four residents reviewed. The facility did not implement advanced directives following applicable state laws. Specifically, the facility Social Worker (SW #1) was appointed as Residents #1 and #2 Health Care Proxy (HCP) agent after the resident was admitted to the facility and the facility did not attempt to establish a guardianship for to make health care decisions for Resident #3. The policy and procedure (P&P) titled Health Care Proxy revised 1/1/2006 documented that upon admission, if necessary, a health care proxy shall be identified, and the appropriate paperwork shall be filed. Resident's and Responsible parties will be informed/educated about health care proxy law at the time of admission. They will be supplied with appropriate forms and given opportunity to appoint an agent. The P&P titled Medical Order for Life Sustaining Treatment (MOLST) revised 11/2021 documented, If a resident lacks capacity and does not have a health care proxy then a surrogate must be selected. A document titled Health Care Proxy Appointing Your Health Care Agent in New York State dated 8/22, form 1430 provided by the Corporate Administrator documented that you may choose any adult ([AGE] years of age or older), including a family member or close friend, to be your agent. If you select a doctor as your agent, he or she will have to choose between acting as your agent or as your attending doctor because a doctor cannot do both at the same time. Also, if you are a patient or resident of a hospital, nursing home or mental hygiene facility, there are special restrictions about naming someone who works for that facility as your agent. Ask staff at the facility to explain those restrictions. A guidebook titled The Health Care Proxy Law A Guidebook for Health Care Professionals dated January 1991 documented that an operator, administrator or employee of a general hospital, nursing home, mental hygiene facility or hospice may not serve as agent for any person who is a patient at the facility, unless the patient is related to the person they wish to appoint, or the patient created the proxy before being admitted to, or applying for admission to the facility. Physicians are the only exception to this rule. A patient can appoint his or her physician as agent, but the physician cannot serve as both the agent and the attending physician of a patient after the agent's decision-making authority begins. Any physician who has been appointed as a patient's agent cannot determine the patient's capacity to make health care decisions. The findings are: 1. Resident #1 had diagnoses that included dementia with moderate psychotic disturbance, anxiety disorder, and major depressive disorder (MDD). The Minimum Data Set (MDS-a resident assessment tool) dated 8/7/23 documented Resident #1 was severely cognitively impaired. The admission Record (resident demographics) documented SW #1 as Resident #1's first Emergency Contact #1 Health Care Agent, Relationship - Case Worker. Resident #1 MOLST (Medical Orders for Life- Sustaining Treatment) form, dated 2/12/21 completed as a verbal consent by Resident #1 and signed by Medical Director (MD) #1, documented the following orders: Do Not Resuscitate (DNR, allow natural death), Do Not Intubate (DNI, do not place a tube down the resident's throat or connect to a breathing machine), limited medical interventions (receive medication by mouth or through a vein, heart monitoring and all other necessary treatment based on MOLST orders), do not send to hospital unless pain or severe symptoms cannot be otherwise controlled, no feeding tube, a trial of IV (intravenous) fluids, and determine use or limitations of antibiotics when infection occurs. The MDS dated [DATE] documented Resident #1 was moderately cognitively impaired. Resident #1's Health Care Proxy dated 5/30/22 documented Resident #1 appointed Social Worker (SW) #1 as their health care agent and was the Proxy was witnessed by the Activities Department Director (#1) and the Receptionist (#1). Review of Health Care Proxy - Decision - Making Capacity Determination form dated 7/12/22 signed by MD (#1) and co-signed on 7/18/22 by Nurse Practitioner (NP) #1 documented Resident #1 does not have capacity to make own personal health care decisions. Resident #1's MOLST form dated 11/1/22 signed by SW #1 and MD #1, documented the following orders: DNR, DNI, do not send to hospital, determine use or limitations of antibiotics. In addition, the MOLST was updated to include comfort measures only (medical care and treatment provided with the primary goal of relieving pain, other symptoms and reducing suffering) and no IV fluids. Review of Progress Notes (Interdisciplinary (IDT)) dated 4/1/22 through 8/9/23 revealed there was no documented evidence that a discussion occurred with Resident #1 to appoint SW #1 as their HCP agent and as to the changes made to MOLST dated 11/1/22. Review of Progress Note dated 8/1/23 MD #1 documented that Resident #1 was without really any social supports and SW #1 was established as resident's healthcare proxy. During an interview on 8/8/23 at 12:15 PM, Licensed Practical Nurse (LPN) #1 Unit Manager (UM) stated that SW #1 was appointed as Resident #1's HCP agent, and they were not related. Resident #1 was admitted to the facility prior to SW #1 being appointed as their HCP agent. LPN UM #1 stated they believed the MD #1 wanted a HCP agent appointed for the resident to make health care decisions. During an interview on 8/8/23 at 12:42 PM, SW #1 stated they recall the MD #1 saying that they had multiple discussions with Resident #1 concerning appointing someone as their HCP agent. SW #1 stated they had a conversation with Resident #1 and the resident was comfortable with them being their HCP agent. So, they (SW#1) were appointed as the HCP agent May 2022 per the resident's request. SW #1 stated the MD #1 was informed agreed that SW #1 had a good rapport with Resident #1 and should be their HCP agent. SW #1 stated the Administrator and Director of Nursing (DON) were aware they were appointed as Resident #1's HCP agent. During an interview on 8/9/23 at 12:32 PM, MD #1 stated they believed Resident #1 had enough understanding to determine who they wanted to appoint as their HCP agent and believed there was no conflict for SW #1 to be appointed as the agent for Resident #1. MD #1 stated they had informed the Administrator and the DON that SW #1 was appointed as Resident #1's HCP agent. The MD stated SW #1 was not related to Resident #1 and was admitted to the facility before SW #1 was appointed as their HCP agent. The MD stated they do not know the regulatory guidelines for appointing a HCP agent. 2. Resident #2 had diagnoses that included disorder of psychological development, anxiety disorder, and MDD. The MDS dated [DATE] documented Resident #2 was moderately cognitively impaired. The admission Record documented SW #1 as Emergency Contact #1 Health Care Agent, Relationship - Case Worker. The MDS dated [DATE] documented Resident #1 was cognitively intact. Resident #2's Health Care Proxy dated 8/1/22 documented Resident #2 appointed SW #1 as their health care agent and the document was witnessed by the Activities Department Director (#1) and the Receptionist (#1). The Progress Notes (IDT) dated 7/1/22 through 8/9/23 revealed there was no documented evidence that a discussion occurred with Resident #2 to appoint SW #1 as their HCP agent. During an interview on 8/9/23 at 11:23 AM, Activities Department Director #1 stated that SW #1 asked them to witness a discussion with Residents #1 and #2 regarding appointing a HCP agent. The Activities Director stated Residents #1 and #2 were already residents at the facility and recalled Residents #1 and #2 were educated and expressed they wanted SW #1 to be their HCP agent. The Activities Director stated SW #1 was not a relative to Resident #1 and #2 and did not know if SW #1 was court appointed as their guardian. During an interview on 8/9/23 at 11:31 AM, Receptionist #1 stated that SW #1 asked them to witness a discussion with Residents #1 and #2 regarding appointing an HCP agent. The Receptionist stated Residents #1 and #2 were already residents at the facility and recalled Residents #1 and #2 were educated and expressed they wanted SW #1 to be their HCP agent. Receptionist stated SW #1 was not a relative to Resident #1 and #2 and did not know if SW #1 was court appointed as a guardian. During an interview on 8/8/23 at 12:42 PM, SW #1 stated they were Resident #2's HCP agent and acted as the resident's social worker. SW #1 stated Resident #2's HCP agent had passed away and the resident had no family left, therefore Resident #2 appointed them as their HCP agent. During an interview on 8/9/23 at 11:35 AM, SW #1 stated they were not related to Resident #2, was not appointed as a guardian by the courts and the resident was admitted to the facility before they were appointed as their HCP agent. SW #1 stated they did not know the NYS Health Care Proxy rules that applied to health care workers for residents in a long-term care. SW #1 stated the Administrator and DON were aware they were appointed as HCP agent. During an interview on 8/9/23 at 11:53 AM, the DON stated they do not know the facility's process of appointing a HCP agent and/or the New York State guidelines for appointing a HCP agent. The DON stated they were aware SW #1 was the HCP agent for both residents (#1, #2) and believed this was acceptable. During an interview on 8/9/23 at 12:32 PM, MD #1 stated they were not aware SW #1 was appointed as HCP agent for Resident #2 and believed if the resident appointed SW #1, they could be Resident #2's HCP agent and acting social worker. 3. Resident #3 had diagnoses that include Alzheimer's Disease, schizoaffective disorder bipolar type, and chronic obstructive pulmonary disease. The MDS dated [DATE] documented the resident was severely cognitively impaired. The admission Record documented SW #1 as the Emergency Contact #1, Care Conference Person, Relationship - Case Worker and Community Registered Nurse (RN) #1 as Emergency Contact #2, Relationship - Case Worker. Review of the Health Care Proxy - Decision - Making Capacity Determination form dated 5/25/22 signed by MD #1 and co-signed on 5/27/22 by NP #1 documented Resident #3 does not have capacity to make own personal health care decisions. Review of SW Progress Notes 5/24/22 through 8/9/23 revealed a note dated 5/24/23 that documented Resident #3 was admitted to the facility, does not have a MOLST and will be a full code. Review of Medical Record 5/24/22 through 8/9/23 there was no documented evidence there was a MOLST form, a health care proxy form, and no documented evidence a guardianship process had been initiated. During an interview on 8/9/23 at 10:48 AM, RN #1 Community Mental Health Nurse stated they were aware they were listed as contact person for Resident #3's only for the purpose that they may receive health information to assist with managing Resident #3's care. RN #1 stated they were unable to make any health care decisions because it was a conflict of interest. RN #1 stated Resident #3 was not able to make any health care decisions, was admitted over a year ago and the facility should have ensured a guardian was appointed to make their health care decisions. During an interview on 8/9/23 at 10:54 AM, SW #1 stated Resident #3 was admitted without a MOLST, HCP or surrogate therefore the resident was a full code. SW #1 stated they had appointed themselves as the emergency contact #1 because there was no one they knew of to contact for medical changes. SW #1 stated they did not make any health care decision for Resident #3. SW #1 stated they had not informed the Administrator, and the DON Resident #3 did not have a guardian, surrogate, friend, or family member to make any health care decision because they forgot. SW #1 stated they should have followed up and ensured Resident #3 had a surrogate/ guardian appointed by the courts to act on their behalf for health care decisions. During an interview on 8/9/23 at 12:11 PM, the DON stated they were not aware SW #1 was Resident #1's emergency contact and believed contact the second contact the residents HCP agent. The DON stated they did not know contact #2 (RN #1) was the community mental health nurse for Resident #3. The DON stated if Resident #3 did not have any family, friends, or surrogate then the facility should have initiated the guardianship process to have the court appoint a guardian to make health care decisions. In addition, the DON stated they would have expected SW #1 to have informed the Administrator and the Administrator ensure a guardian was appointed. During an interview on 8/9/23 at 12:32 PM, MD #1 stated they were not aware Resident #3 did not have an HCP agent, or an appointed surrogate and they should have. The MD stated SW #1 should not be Resident #3's emergency contact and would have expected SW #1 to have informed them, the Administrator, and the DON to ensure Resident #3 was appointed a guardian through the courts to ensure someone was responsible to make the resident's health care decisions. During an interview on 8/10/23 at 9:45 AM, the Corporate Administrator/ Acting Administrator stated they were aware SW #1 was the HCP agent for Resident's #1 and #2. They stated that SW #1 was not related to either resident, and that SW #1 continued act as both resident's (#1, #2) social worker. Both residents were admitted before SW #1 was appointed as their HCP agent. The Corporate Administrator stated they followed the New York State Department of Health 1430 HCP form instructions and did not believe there was a conflict of interest or that there were additional restrictions for employees of long-term care health facilities. The Corporate Administrator stated they were not aware SW #1 was listed as Resident #3's emergency contact and that the resident did not have a HCP agent. The Corporate Administrator stated Resident #3 should have a guardian appointed for health care decisions and does not know if the Administrator was aware. 415.3 (e)(2)(iii)

Based on interview and record review conducted during an Abbreviated survey completed on 8/10/23 the facility did not develop, implement and maintain an effective compliance and ethics program. Specifically, at a minimum the facility did not establish written compliance and ethics standards, policies, and procedures to follow that are reasonable capable of reducing the prospect of criminal, civil, and administrative violations under the Act. and promote quality of care, which include, but are not limited to, the designation of an appropriate compliance and ethics program contact to which individuals may report suspected violations, as well as an alternate method of reporting suspected violations anonymously without fear of retribution; and disciplinary standards that set out the consequences for committing violations for the operating organization's entire staff/ individuals providing services under a contractual arrangement; and volunteers, consistent with the volunteers' expected roles. Additionally, the facility did not take steps to effectively communicate the standards, policies, and procedures in the compliance and ethics program to the organizations entire staff. Review of a New York State DAL (Dear Administrator Letter), dated May 28, 2010, titled Family Health Care Decision Act FHCDA, revealed that nursing homes are required to complete the following activities by June 1, 2010, to be compliant with the FHCDA, which includes developing general policies and procedures to comply with the provisions of the FHCDA, and provide for the governance of the Ethics Review Committee (ERC) functions, composition, and procedure. The ERC must include a minimum of five members; at least three must be health or social service practitioners, including one RN and one physician. At least one member must be a person without any governance, employment, or contractual relationship with the nursing home. Additionally, the residents' council must be given the opportunity to appoint two members. These individuals may not be either a resident of the facility or a resident's family member. The finding is: During an interview on 8/8/23 at 12:42 PM, Social Worker (SW) #1 stated they did not know if the facility had a compliance and ERC policy and procedure. Additionally, SW #1 stated they have not met with a committee to discuss appointing health care surrogates. During an interview on 8/9/23 at 11:53 AM, the Director of Nursing (DON) stated they were unable to locate a compliance and ethics review committee policy and procedure. The DON stated that they did not believe the facility had a compliance and ERC Program. During an interview on 8/9/23 at 12:32 PM, the Medical Director (#1) stated they did not know if the facility had a compliance and ERC policy and procedure. The MD stated they had ethics meetings in the past and the committee members include themselves, SW #1, Administrator, and the DON. During an interview on 8/10/23 at 9:45 AM, the Corporate Administrator/ acting Administrator stated they did not have access to the facility's P&P's and did not know if the facility had a compliance and ERC policy and procedure. The Corporate Administrator (acting Administrator) stated the Administrator who was on vacation, was unable to be reached so they were unable to verify if the facility had a compliance and ERC program with written policies and procedures that meet the requirements. 10 NYCRR 415.26 (b)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a complaint investigation (#NY00299607) completed on a Standard survey completed 7/21/23, the facility did not ensure that all alleged violations including abuse are reported immediately, but not later than 2-hours after the allegation is made to the appropriate officials (including the State Survey Agency). Specifically, two (#69 and #124) of two residents reviewed for alleged sexual abuse was not reported timely to the New York State (NYS) Department of Health (DOH) as required. The finding is: The policy and procedure (P&P) titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property with revision date of 10/19 documented that identified professionals are to report to the NYSDOH when they have reasonable cause to believe that abuse has occurred. The P&P documented the facility would require all employees who have reasonable cause to believe that any situation of Resident abuse, neglect or mistreatment had occurred to immediately notify the supervisor. The P&P documented the facility must ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property, are reported immediately, but not later than two hours after the allegation involve abuse or result in serious bodily injury. 1. Resident #69 had diagnoses including Alzheimer's, dementia, and anxiety. The Minimum Data Set (MDS- a resident assessment tool) dated 6/16/22 documented Resident #69 had severely impaired cognitive skills, rarely/never understood, and rarely/never understands. The MDS documented the resident was supervision for ambulation. The comprehensive care plan (CCP) with revision date of 7/26/22, documented Resident #69 had a potential for victimization related to being highly mobile, history of wandering into other resident's rooms and being affectionate. The CCP documented that Resident #69 likes to hug and touch and there was an incident with a resident on 7/25/22. Resident #124 had diagnoses including dementia, Parkinson's disease, and psychotic disorder. The MDS dated [DATE] documented Resident #124 was cognitively intact, usually understood and usually understands. The MDS documented that Resident #124 was a limited assist for transfers and walking. The CCP with revision date 7/25/22, documented Resident #124 had a potential for victimization related to recent altercation with roommate and an incident with female resident on 7/25/22. Review of a Progress noted dated 7/25/22 at 10:18 PM, Licensed Practical Nurse (LPN) #6 documented that Resident #69 was found at 6:30 PM in another resident's (#124) room on their knees while the other resident was holding their head with their private area visibly showing. LPN #6 documented that Resident #69 was not capable of making decision and escorted them out of the room. LPN #6 documented the supervisor was notified. Review of the facility document labeled Investigation Summary completed by the Director of Nursing (DON) documented on 7/25/22 at approximately 6:30 PM, Licensed Practical Nurse (LPN) #6 walked by Resident #124 room and observed Resident #69 with their head being held by Resident #124 on their lap. Resident #124 genitals were exposed. The DON documented the incident was reported to the Supervisor at 6:30 AM on 7/26/22 and they were notified at 7:30 AM. Review of the Health Electronic Response Data System (HERDS) Nursing Home Incident Form documented that an any other reportable incident occurred on 7/25/22 and 6:00 PM and the DON reported the incident at 7/26/22 at 8:21 AM. During an interview on 7/20/23 at 10:47 AM, LPN #5 Unit Manager stated that a resident-to-resident incident occurred between Resident #69 and Resident #124 on 7/25/22 and it was reported to them on 7/26/22 around 6:30 AM by LPN #6. LPN #5 stated that a resident-to-resident incident needed to be reported to the DON immediately and then the DON would need to report it to the DOH within two hours. During a telephone interview on 7/20/23 at 11:22 AM, LPN #6 stated LPN #6 stated they had Resident #69 leave the room and they did not witness any actual physical sexual act taking place. They stated immediately walked to the supervisor's office in the other part of the building and notified the Nursing Supervisor. A telephone interview was attempted with RN Supervisor #2 on 7/20/23 at 1:20 PM and at 7/21/23 9:48 AM without success. During an interview on 7/21/23 at 1:41 PM, the DON stated the resident-to-resident incident between Resident #69 and Resident #124 occurred on the evening shift on 7/25/22 at 6:30 PM and they were notified of the incident on 7/26/22 around 7:30 AM when they arrived at work. They stated they were responsible for reporting potential situations of abuse to the DOH and they would need to report it to the DOH within two hours after the incident occurred. The DON stated the reporting of the incident was overdue because LPN #6 did not report it to the evening supervisor they reported it to the Unit Manager when they arrive at work the next day. 10 NYCRR 415.4(b)(1)

Based on interview and record review conducted during a complaint investigation (Complaint #NY00310713) conducted during the Standard survey completed on 7/21/23, the facility did not ensure completion of the discharge summary to included but not limited to a recapitulation of the residents stay and any arrangements that have been made for the resident's follow up care and post-discharge medical and non-medical services for one (Resident #420) of four residents reviewed for discharge. Specifically, the resident was discharged to home without a recapitulation of the resident's stay, a final summary of the resident's status or a post discharge plan of care. The finding is: The undated policy and procedure titled Discharge Summary and Plan provided by the Administrator, documented when the facility anticipates a resident's discharge to a private residence, a discharge summary and a post-discharge plan will be developed. The discharge summary will include a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge. A post-discharge plan will be developed by the care planning/interdisciplinary (IDT) with the assistance of the resident. 1. Resident #420 had diagnoses including osteomyelitis (infection of the bone), chronic pain, and congestive heart failure. The Minimum Data Set (MDS, a resident assessment tool) dated 11/22/22 documented the resident was cognitively intact and there was an active discharge plan for the resident to return to the community. Review of the comprehensive care plan initiated on 6/8/22, documented the resident wished to return home in the community. Interventions included establish a pre-discharge plan with the resident/family/caregivers and evaluate progress and revise plan; make arrangements with required community resources to support independence post-discharge PT (physical therapy), OT (occupational therapy), aide. Review of the physician verbal order dated 1/10/23 at 12:54 PM, revealed may discharge home on 1/10/23 with services when available. Review of the social work Progress Notes dated 1/10/23 at 12:31 PM, revealed resident was provided discharge instructions, along with meds. Scripts were sent to their pharmacy. Review of the nursing Progress Note dated 1/10/23 at 1:20 PM, revealed the resident was discharged home with all personal affects. The resident was educated on discharge medications usage/schedule. Review of the electronic medical record (EMR) miscellaneous section revealed no documentation that a discharge summary including a recapitulation of the resident's stay at the facility and a final summary of their status was completed for Resident #420. During an interview on 7/20/23 at 1:04 PM, the Director of Social Work (DSW) stated when a resident was being discharged , nursing reviewed their medication instructions, residents got a list of their medications with the instructions, and their discharge notice which was a recap of their stay, it's something all department heads were supposed to fill out. The DSW stated they used to just give it to the resident but now they scan them in the EMR (electronic medical record). The DSW provided a blank Interdisciplinary Discharge Summary form and stated that the facility was supposed to complete one for all discharges. During further interview on 7/21/23 at 11:45 AM, the DSW stated there was nothing in the medical record to show a recapitulation of the resident's stay was done. During an interview on 7/21/23 at 10:05 AM, the Licensed Practical Nurse (LPN) Unit Manager (UM) #1 stated for discharges, nursing made sure the physician completed a discharge visit indicating that the resident was suitable and cleared for discharge. The LPN UM #1 stated they do have a form they fill out to give to the residents, and they weren't sure if Resident #420 got that form because it wasn't in the EMR. LPN UM #1 stated they have told the DSW that anything they do for a resident needed to go into their EMR. During an interview on 7/21/23 at 1:03 PM, the Director of Nursing (DON) stated when a resident was discharged , staff go through the paperwork, usually staff (nursing, social work, therapy, dietary) all sign the form in the morning meeting the day the resident was discharged . The form should be uploaded into the EMR and that would show up in the miscellaneous tab. It might be what happened back then that the SW wasn't uploading it. They should also have the resident sign it. During a telephone interview on 7/21/23 at 2:18 PM, Resident #420 stated they never got any kind of discharge plan that they could understand and only got bits and pieces of information. NYCRR 415.11(d)(1)(2)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard Survey completed on 7/21/23, the facility did not provide adequate supervision and assistive devices to prevent accidents for two (Residents #31 & #32) of four residents reviewed for falls. Specifically, staff used the wrong size sling when Resident #31 was transferred from the wheelchair to the bed which resulted in the resident falling to the floor. In addition, during an observed mechanical lift transfer of Resident #32 from the bed to the Geri-chair, staff incorrectly attached the sling to the lift. The care plans for Resident's #31 & #32 did not include the size or type of transfer sling to use. The findings are: The policy & procedure (P&P) titled Safe Patient Handling/Safe Transfers and Movement with a revised date of 7/2021, documented that licensed therapy professionals will assess resident lifting and transferring needs and determine the appropriate method to lift/transfer the resident. The P&P does not specify how to determine which sling is appropriate for each resident. Guidelines are provided based on resident weights, however, it specifically states these are guidelines only, each resident needs to be individually assessed. 1. Resident #31 had diagnoses including Parkinson's (a disease that causes tremors and rigidity of movement), cerebral infarct (stroke), dementia. The Minimum Data Set (MDS- a resident assessment tool) dated 7/10/23 documented the resident was severely cognitively impaired, usually understands and was usually understood. The MDS also documented Resident #31 required total dependence of two staff members to transfer between surfaces. The Physical Therapy PT Recert, Progress Report & Updated Therapy Plan dated 5/16/23 revealed Resident #31 was completely dependent for transfers. The care plan dated 7/21/23 documented Resident #31 was a transfer of 2 assist with a sling lift. The care plan did not include the size or type of sling to use for the resident. The [NAME] (guide used by staff to provide care) dated 7/21/23, revealed that the resident was a transfer of 2 assist sling lift. The [NAME] did not include the size or type of sling to use for Resident #31. Review of the nursing Progress Notes dated 5/25/23 at 2:08 PM, written by Licensed Practical Nurse (LPN) #3, documented they entered Resident #31's room and saw the resident on the floor laying over the mechanical lift legs and two (certified nurse aides) CNAs (#6, #8) were standing over the resident asking if the resident was ok. The CNAs stated the resident slipped through the sling and fell to the floor. Review of the nursing Progress Note dated 5/25/23 at 4:21 PM, written by Registered Nurse (RN) #1, documented the resident was being transferred from their wheelchair to their bed via a mechanical lift and the resident slid out of the sling onto the floor landing on their back, hitting their head on one of the legs of the lift. An assessment was completed, and a small amount of bleeding was noted from a 1 cm (centimeter) laceration on the resident's head. Review of the accident and injury (A&I) report dated 5/25/23, documented at 1:30 PM Resident #31 had a witnessed fall from a transfer sling. It was documented the CNAs were using a sling that was too large and they attempted to cross the straps of the sling under the legs, not between. During an interview on 7/19/23 at 1:17 PM, CNA #6 stated the issue was with the sling that they had used to transfer Resident #31 (5/25/23). CNA #6 stated they used a shower sling because there weren't any small slings available, allowing the resident to slip through the hole in the bottom. CNA #6 stated that they could tell what size the sling was by the color on the rim. CNA #6 thought therapy should tell them what size sling to use but did not recall any training. CNA #6 stated that the sling size or type were not listed on the resident's care plan. During an interview on 7/20/23 at 9:35 AM, LPN #3 stated they believed the CNAs used the wrong sling to transfer Resident #31(5/25/23). LPN #3 did not know who was responsible for choosing the sling size. LPN #3 stated that if the CNAs had a question about a sling, they should have asked the nurse or the unit manager. During an interview on 7/20/23 at 9:50 AM, Unit Manager (UM) LPN #2 stated they did not recall anything about the sling that was used. After LPN #2 reviewed the A & I report, stated that the sling was too large. LPN #2 UM stated therapy should determine the proper sling for each resident. LPN #2 stated they felt the sling size should be listed on the care plan & [NAME]. During an interview on 7/21/23 at 8:22 AM, Director of Rehab, Certified Occupational Therapy Assistant (COTA), stated that the aids chose the sling that was appropriate for each resident. The slings were all rated for up to 600 pounds. The CNAs had to measure from behind the resident's knees to the top of their head. They stated, the facility had too many different sling manufacturers to assign a specific sling to each resident. They didn't feel that sling size should be listed on the care plan. Regarding the fall with Resident #31, the Director of Rehab stated that since the CNAs were using a sling that was too large, it was an unsafe transfer. During an interview on 7/21/23 at 9:56 AM Lead can #1 stated, the CNAs just look at the sling and decide if it will work for each resident. They stated sling size should be listed on the care plan. During an interview on 7/21/23 at 11:37 AM, Supervisor RN #1, stated they could tell that the sling was too large for Resident #31 when they walked into the room. 2. Resident #32 had diagnoses including multiple sclerosis (a progressive disease involving damage to the nerve cells in the brain and spinal cord), anxiety, and acquired absence of the right and left legs below the knee. The MDS dated [DATE] documented the resident was cognitively intact and was totally dependent on 2 people for transfers between surfaces. The [NAME] dated 7/19/23 documented Resident #2 was a 2-assist sling lift for transfers. There was no sling type or size listed on the [NAME]. The comprehensive care plan revised on 6/26/23 documented Resident #32 was a 2-assist sling lift for transfers. There was no sling type or size listed on the care plan. During an observation on 7/19/23 at 12:37 PM, CNA #2, CNA #3, and CNA #8 were in Resident #32's room to transfer Resident #32 from the bed into a Geri chair (a large, padded chair that is designed to help seniors with limited mobility). CNA #2 and #3 placed the transfer sling (blue mesh with black border) under the resident and CNA #3 stated they thought there was a different sling to use for amputees and the loops needed to be crossed between the resident's legs. CNA #2 stated that was the sling they always used, and they didn't need to cross the loops. The CNAs (#2, #3) hooked the transfer sling loops (located on the 4 corners of the sling) to the mechanical lift. Then they hooked the small black handle loops, located in the middle of the transfer sling to the mechanical lift. CNA #3 operated the mechanical lift to raise the resident into the air, while CNA #2 and CNA #8 supported the resident. Resident #31 remained in a flat supine (back lying) position while in the air. CNA #3 widened the base of the mechanical lift and turned the lift toward the chair, while CNA #2 and CNA #8 guided the resident toward the chair. The resident's lower body wouldn't fit past the actuator (part that produces movement) part of the lift, CNA #3 stated they would have to turn the resident around, so their body was correctly aligned with the chair. CNA #2, CNA #3 and CNA #8 turned/swung the resident in a full circle, while in sling was in the supine position, causing the resident's head to be passed close to the lift. CNA #3 guided the resident's head as it went by the actuator and they continued to turn the resident until their head was back toward the top of the chair, in the correct position to lower into their chair. CNA #3 then lowered the resident into their chair. During an interview on 7/19/23 at 12:51 PM, CNA #3 stated they didn't think it was the proper sling to use for the resident and that usually the type of sling to use was on the resident's [NAME] but they didn't do that in this facility. CNA #3 stated they worked for agency and if they had a question about the proper sling they could go to a supervisor, but that they went along with it because CNA #2 said it was the sling they always used. CNA #3 stated they knew something was wrong during the transfer because the Resident #31 wasn't in a seated position during the transfer, and it was probably the wrong sling. During an interview on 7/19/23 at 12:57 PM, CNA #2 stated that was the worst transfer and it was the way the loops were hooked up to the mechanical lift. CNA #2 stated they hooked the middle loop because CNA #3 thought the resident would fall. CNA #2 stated they just did what the CNA in charge said (CNA #3). CNA #2 stated the [NAME] just said the resident transfers with 2 assist, it didn't say which size sling to use. CNA #2 stated they didn't know about the sizes; they just grabbed a sling they thought would work or just use the sling that's already in the room. CNA #2 stated the sling they used was technically a shower sling. During an interview on 7/20/23 at 9:35 AM, LPN #3 stated they didn't know who determined which sling to use for resident transfers and that they believed the wrong sling was used during Resident #32's transfer on 7/19/23. LPN #3 stated they relied on the CNAs to know or sent them to the UM if they had questions. During an interview on 7/20/23 at 10:33 AM, LPN UM #2 stated therapy decided which size sling should be used for a resident and it's on the care plan, or it should be. LPN UM #2 stated the care plans only said 2 assist sling lift, but the sling size should be on the care plan and thought that it used to be. LPN UM #2 stated they didn't know the sling size wasn't on the care plan and if therapy didn't put it on the care plan, they could let nursing know which size and they would put it on the care plan. During an interview on 7/21/23 at 8:22 AM, the Director of Rehab COTA, stated the CNAs chose the sling that was appropriate for each resident, all their slings were rated for the same weight. The aides would determine which sling they should use by holding the sling and measuring from behind the resident knees to the top of their head, which is more based on height. The Director of Rehab stated the slings used to be based on color but now they are all rated up to 600 pounds and they don't tell staff which sling to use and that the staff measure based on resident's height. The sling size can't be on the care plans because each sling is different, they don't use one brand of sling. At 8:40 AM, observed the sling type (blue mesh with black border) used by staff during the transfer on 7/19/23, the Director of Rehab stated they usually only used the loop on the middle of the sling for positioning a resident already in the chair, it was not ideal to swing the resident around while in the lift sling and they tried to avoid that when they could. During an Interview on 7/21/23 at 9:00 AM, Director of Nursing (DON), stated the type of sling used for a resident's was based on a therapy evaluation where they figured out what type of sling to use. The DON stated they had discussed putting it on the care plan and would try to initiate that soon. The DON stated they didn't know how many different sling types they used in the facility. During an interview on 7/21/23 at 12:45 PM Administrator, when asked if they were aware that it was left up to the CNAs to determine what sling to use for each resident, they answered that they were aware and that they felt the CNAs should be qualified to determine which sling is appropriate. They felt the CNAs had been trained in how to properly use the slings and lifts. They felt that if the CNAs were unsure of which sling to use that they should go to nursing or therapy and ask for help. NYCRR 415.12 (h) (2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard survey completed on 7/21/23, the facility did not ensure developed and prepared menus to meet resident choices including their nutritional, religious, cultural, and ethnic needs were met. One of one kitchen did not provide correct food items as listed on residents' meal tickets. Specifically, Resident #20 on 7/20/23 had No Pork printed on the meal ticket and received a BBQ (barbequed) pork sandwich. Resident #86 on 7/17/23 was to receive a puree diet with honey thick liquids in bowls and received a regular texture diet with their honey-thick liquids in glasses. During additional meal observations both Resident #20 and #86 did not receive food items that were listed on their meal tickets. The findings are: The policy and procedure (P&P) titled Meal: Service dated 3/17 documented that nursing personnel will ensure the residents are served the correct tray. If an incorrect meal has been delivered, nursing staff will report it to the Food Service Supervisor so that a new tray can be issued. Assistive devices will be made available to residents who need them as per therapy recommendation. Review of the undated document Tray Line Accuracy provided by the facility documented trays must be accurate: needed for residents to maintain nutritional adequacy, decrease complaints, improves satisfaction of families and survey results and portions and items must be correct. Menus must be followed: menus are planned to provide nutritionally complete meals within the State/ Federal guidelines. Menus are built to address color, texture, nutritive value, food combinations, preparation, and resident acceptance. Review of the Resident Council Minutes revealed the following dietary issues/ concerns: -3/1/23 there were concerns with missing items on trays -4/5/23 dietary is to double check tray tickets -5/3/23 trays have no condiments and tickets don't match what is on the trays -6/7/23 missing items, quantity of portions on trays, and adaptive utensils not on trays. Dietary Supervisor requested at next meeting. -7/12/23 dietary concerns/ side meeting set up for end of July with Dietary Director. 1. During an observation on 7/17/23 at 12:49 PM Resident #20 had their lunch tray in front of them. The meal ticket documented No Pork at the top of the ticket and BBQ (barbeque) pork sandwich was listed on the meal ticket. On the plate there was a BBQ pork sandwich, which had a couple of [NAME] bits from it. At that time Resident #20 stated, they know I do not want pork and it's on my ticket. But they keep giving it to me anyway. I like pork, but it does not like me. They often send me the breakfast sausage patties, which also has pork in it. During an observation on 7/18/23 at 9:09 AM Resident #20 was out of bed sitting in the lounge area eating breakfast. They stated they did not receive their fruit cup that was listed on the breakfast ticket. Resident #20 stated they often forget to put things on my tray that are listed on the ticket. During a Lunch meal observation on 7/20/23 at 1:45 PM Resident #20 had meatloaf printed on their ticket and was blackened out with Chicken and Dumpling written on it. Resident stated they would have preferred the meatloaf and did not know why they did not get it. Review of the Week-At-A-Glance Spring/ Summer Menu 2023 Week 4 revealed on Thursday 7/20/23 at Lunch meal consisted of Meatloaf with Chicken and Dumplings as the alternate. During an interview on 7/20/23 at 10:35 AM, the Dietary Consultant stated residents should receive the food items that are printed on the tickets and that dietary staff need to be checking that what is on the tickets is on the tray. The Consultant stated they do have food committee meetings once a month but was unable to produce minutes from these meetings. They stated they bring the areas of concerns to Quality Assurance meetings once a month. During an interview on 7/20/23 at 12:30 PM, the Registered Dietitian (RD) stated if the tray ticket states no pork the resident should not get pork. They may have had an intolerance or allergy to it. Whatever was printed on the ticket the resident should receive that food item as it is all calculated in so that they receive adequate nutrition. If an item was missing or was wrong the nursing staff should call down and let the kitchen know. 2. Resident #86 was admitted with diagnoses of dysphagia (difficulty swallowing), cerebral infarction (a stroke), and dementia. The Minimum Data Set (MDS - a resident assessment tool) dated 5/22/23 documented Resident #86 had severely impaired cognitive skills, unclear speech, sometimes understood, and sometimes understands. The MDS documented the resident had loss of foods and liquids from mouth when swallowing. The Comprehensive Care Plan (CCP) with revised date of 6/30/23 documented Resident #86 was to eat all meals, as accepted, in the dining room with supervision. The CCP documented Resident #86 was to receive a regular pureed diet with honey thick liquids via teaspoon, with no straws and drinks where to be in bowls. The Order Recap Report dated 7/21/23 documented that Resident #86 had an active order with start date of 6/23/23 for Regular diet with a pureed texture and honey consistency. The order documented that liquids were to be in bowls and all liquids were to be spooned (no cups). During a lunch meal observation on 7/17/23 at 12:55 PM, Certified Nursing Assistant (CNA) #7 severed Resident #86 a meal tray that consisted of a regular texture pulled pork on a hamburger roll and regular textured mixed vegetables. The lunch tray had honey thick milk and regular coffee in standard hard plastic cups. Resident #86 took bite of pulled pork sandwich as CNA #7 held up a package of thickener to Licensed Practical Nurse (LPN) #4. LPN #4 removed the pulled pork sandwich from Resident #86 hands and removed the lunch tray explaining to Resident #86 they needed to get them a different tray. A new lunch tray arrived at 1:03 PM for Resident #86 that had pureed pulled pork and pureed mixed vegetable. Resident #86 drinks remained in glasses and LPN #4 removed them from the lunch tray and told the staff member that delivered the tray that the liquids needed to be in bowls. At 1:10 PM Resident #86 drinks arrived to them in bowls. Review of the lunch meal ticket dated 7/17/23 documented Resident #86 was to have a regular pureed honey drinks in bowls, no cups. Resident #86 was to have pureed barbequed pork sandwich, pureed mixed vegetables, honey milk and honey coffee. During a lunch meal observation on 7/20/23 at 1:04 PM, LPN #4 severed Resident #86 their lunch tray that consisted of pureed meatloaf, mash potatoes and chocolate pudding. Review of the lunch meal ticket dated 7/20/23 documented that Resident #86 should have receive pureed fruit cocktail. During an interview on 7/20/23 at 1:49 PM, the Speech Language Pathologist (SLP) #1 stated that Resident #86 was on a pureed textured diet with honey thick liquids that were to be served in bowls taken via teaspoon. The SLP #1 stated that the lunch tray should have been checked for accuracy prior to it leaving the kitchen and the staff member that served the tray on the unit was the final check prior to the resident receiving a tray. During an interview on 7/21/23 at 9:58 AM, CNA #7 stated they did not read the meal ticket on 7/17/23 prior to serving Resident #86 their lunch tray and that they should have. During an interview on 7/21/23 at 10:50 AM, LPN #4 stated that Resident #86 was served a regular textured diet and their fluids were in cups for the lunch meal on 7/17/23. LPN #4 stated the staff should have read the meal ticket prior to serving the resident to ensure it was correct and for resident safety. During an interview on 7/21/23 at 10:55 AM, the Dietary Supervisor in the presence of the Dietary Consultant stated Resident #86 being served a regular texture pull pork sandwich, regular textured mixed vegetables with their fluids in cups was not an appropriate tray preparation and should have been caught prior to leaving the kitchen. They stated that Resident #86 should have been served a pureed diet and their fluids in a bowl. The Dietary Consultant stated that they agreed with the Dietary Supervisors interview. During an interview on 7/21/23 at 1:38 PM, the Director of Nursing (DON) stated they expected the staff member serving the meal tray to ensure the resident was receiving the appropriate diet prior to placing it in front of the resident. The DON stated the purpose of following the correct diet was for safety and to ensure the resident was receiving the proper nutrition. 10 NYCRR 415.14(c)(1-3)

Based on interview and record review conducted during a Standard survey completed 7/21/23, the facility did not employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. Specifically, one of one facility reviewed for sufficient staffing did not have a full-time (working 35 or more hours a week) qualified Director of Food and Nutrition services. The finding is: Refer to F 802, F 803, and F 812 for related information. The undated policy titled Role of the Dining Services Director documented the Dining Services Director effectively manages the Dietary Department to assure that the food service is safe, appetizing, and nutritious. Qualifications include enrollment and/or completion of an approved educational program. Responsibilities include supervises the food preparation and service for resident meals according to established menus and standardized recipes, insures food is prepared by methods that conserve nutritive value, is palatable and attractive to residents and of a quality that is acceptable to residents, insures that sanitation and safety standards are maintained above levels that are acceptable according to State and Federal regulations, and insures residents receive the proper food items to meet dietary needs and that food is served at the appropriate temperature for safety and palatability. Review of the Time Cards from 4/9/23 through 6/17/23 revealed the Dietary Consultant did not work full-time. 6/18/23 through 7/15/23 revealed they did not work at all at the facility. Review of the Time Cards from 5/14/23 through 5/20/23 revealed the Dietary Supervisor did not work full-time and between 5/21/23 through 7/15/23 did work full-time. During an interview on 7/17/23 at 9:20 AM the Dietary Supervisor introduced themselves as the Food Service Director/ Supervisor. They stated they were new and recently started the position in May 2023. Further interview on 7/20/23 at 10:45 AM they stated again that they were the Food Service Director and was trained for one month by the Dietary Consultant at which time they took over the dietary department. They stated they had no food service background prior to this job or food service education and that they used to be a Certified Nurse Aide (CNA) in a nursing home. They stated they were not a certified dietary manager or food service manager. During an interview on 7/17/23 at 11:00 AM, the Dietary Consultant stated they were no longer the Food Service Director as they have retired and only come in 2-3 days a week to help when they were short. They stated they had not even been there or worked for the past 3 weeks and that the Dietary Supervisor was now the Food Service Director. On 7/18/23 at 8:54 AM they stated once again they were retired and only comes in as a consultant when they are needed. They stated they have not been at the facility for 3 weeks and was asked to come in because the State was here. On 7/20/23 at 10:45 AM they stated technically the Dietary Supervisor was the Food Service Director and that they had trained them for a month at which time the Dietary Supervisor told them they felt comfortable doing the job. The Dietary Consultant stated, they are retired and have not worked for the past 3 weeks and that they only agreed with the Administrator to come in and help on occasion. During an interview on 7/20/23 at 2:58 PM, the Human Resource Director stated the Dietary Supervisor was the Food Service Director and had not been here that long since the end of April/ May. They stated the Dietary Consultant was retired but was still on the books and will come in on occasion to help. They stated the Dietary Consultant was no longer the Food Service Director. During an interview on 7/20/23 at 3:36 PM, the Registered Dietitian (RD) stated they only work part time 3 days a week. They stated the Dietary Supervisor has been the Food Service Director for a couple of months with one month being trained by the Dietary Consultant. During an interview on 7/21/23 at 9:15 AM, the Administrator stated that they were aware of the regulations regarding the qualifications for the Food Service Director. They stated the Dietary Consultant was the Food Service Director and the Dietary Supervisor was still in training for that position. They stated they had No such arrangement with the Dietary Consultant that they are retired and only comes in on an as needed basis. They stated, Nothing has changed with their operational status or on the books. They further stated the Dietary Supervisor was qualified for the position because they had worked as a CNA in a long-term care facility and had management experience. When asked if it was food service management experience they stated No. 10NYCRR 415.14(a)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard survey completed 7/21/23, the facility did not provide food and drink that was palatable, and at a safe and appetizing temperature for five ([NAME] View North and South, Canal View, Garden View, and the Villages Main Dining Room) of five test trays. Specifically, food and beverages during meals were served at suboptimal temperatures and were not palatable. Residents #37, #87, and #114 were involved. The findings are: Review of the undated policy and procedure (P&P) titled Food Temperature Monitoring documented to ensure that all foods and beverages are served in a manner that is safe for consumption and that the food is attractive to the residents. Potentially hazardous food shall be kept at 41°F (degrees Fahrenheit) or below when cold and 135°F or above when hot. During an interview on 7/17/23 at 10:52 AM, Resident #87 stated the food always comes cold and the milk was always warm. During an interview on 7/17/23 at 1:41 PM, Resident #114 stated the food was served cold, was too salty and too spicey. During an interview on 7/18/23 at 10:39 AM, Resident #37 stated the food the facility serves does not taste good at times and the hot food was served cold. During a lunch meal tray line observation on 7/20/23, the unit carts left the kitchen at the following times: -[NAME] View South - 11:51 AM -[NAME] View North (cart 1) - 11:59 AM -[NAME] View North (cart 2) - 12:06 PM -Canal View - 12:18 PM -Garden View - 12:32 PM -Orchard View - 12:42 PM -Villages Main Dining Room (cart 1) - 12:58 PM. -Villages Main Dining Room (cart 1) - 1:11 PM 1. During an observation on 7/20/23 the dietary cart arrived on [NAME] View South at 11:54 AM. Resident #87 stated at 12:03 PM the four 8 oz (ounces) skim milks were served warm on their tray. The following temperatures of the milk were taken by the Dietary Consultant and were as follows: Skim milk #1 65.9°F, Skim milk #2 65.9 °F, Skim milk #3 66.9°F, and Skim milk #4 68.1°F. During an interview on 7/20/23 at 12:08 PM, the Dietary Consultant stated the skim milks were warm. The Dietary Consultant stated milk was to be served cold and cold items were served between 40-41 °F. The temperatures of the milk were unacceptable. During a lunch meal observation on 7/20/23 residents on [NAME] View South had been served their meals by 12:17 PM. The test tray temperatures were taken by the Dietary Consultant using the facility's digital thermometer at 12:18 PM. The results were as follows: -Meatloaf 112°F and tasted cold -Mashed potatoes 99.8°F, tasted cold and had no flavor -California blend vegetables 98.5° F, tasted cold and bland -2 % milk 65° F and tasted warm During a further interview on 7/20/23 at 12:20 PM, the Dietary Consultant stated hot foods were to be served above 130°F. There was no reason for these temperatures to be this low. 2. During a lunch meal observation on 7/20/23 the dietary carts arrived on [NAME] View North Unit at 12:01 PM and 12:08 PM. All the meal trays from the dietary carts were passed to the residents by 12:29 PM. The test tray temperatures were then taken by Dietary Consultant, using the Dietary Consultants digital thermometer at 12:30 PM. The results were as follows: -Meatloaf with gravy 122.3°F, tasted cold, looked dry and unappetizing -Mashed potatoes and gravy 116°F, tasted cold and were bland - California blend vegetables 105°F, tasted cold and were mushy -2% milk 55.1°F and tasted lukewarm -Cranberry juice 52.4°F and tasted lukewarm During an interview 7/20/23 at 12:36 PM, the Dietary Consultant on [NAME] View North stated hot foods at the lowest should be in the 120's when served, and ice cream and cold drinks should be below 40°F. The kitchen was short staffed this morning. The food was cold because the trays were not passed timely. 3. During a lunch meal observation on 7/20/23 on the Canal View unit, the lunch meal cart arrived on the unit at 12:19 PM. Staff started passing the lunch trays upon arrival of the cart and completed the tray pass at 12:28 PM. The following temperatures we obtained on the test tray by the surveyor using the surveyor's digital thermometer at 12:28 PM. The facility did not provide facility representation during the test tray observation. The results were as follows: -2 % milk 54.6 °F and tasted lukewarm -California blend vegetables 105°F and tasted lukewarm 4. During a lunch observation of the Garden View Unit on 7/20/23 at 12:32 PM revealed the first food cart for lunch arrived on the unit, the second cart arrived at 12:37 PM, all the trays were passed to the residents by 12:40 PM. The test tray temperatures were then taken by Dietary Consultant, using the Dietary Consultants digital thermometer at 12:42 PM. The results were as follows: -Vegetables 88.3°F and tasted cold -Cranberry juice 63.8°F and tasted lukewarm During an interview on 7/20/23 at 12:47 PM, the Dietary Consultant that all the temperatures for this test tray were off. The hot foods should be in the 120s, the Jell-O and cranberry juice should be colder, would like to see them below 50 degrees, but anything over 55 degrees was getting too warm. 5. During a lunch observation on 7/20/23 the last cart for the Main Dining Room arrived on the unit at 1:13 PM and the last tray was served at 1:18 PM. Test tray was by the surveyor using the surveyor's digital thermometer. The Dietary Consultant and Registered Dietitian came to the unit after the test tray temperatures were completed. The results were as follows: -Meatloaf was 108°F, tasted cold and had a gritty texture -No vegetable was provided on the tray -Cranberry juice 59.8°F and tasted warm -Chocolate ice cream was not solid and had the consistency of melted liquid. During an interview on 7/20/23 at 1:30 PM, the Dietary Consultant stated the tray line was really bad. I had no staff this morning. Most of them came in late and that is why the cranberry juice was warm as I had no one to pour it. The meatloaf temperature is lower than I would like. We ran out of vegetables on the line and that is why you did not receive them. I am not sure why the ice cream was so melted, but it should be solid, not like liquid. This whole tray line was a mess. During an interview on 7/20/23 at 1:34 PM, the Registered Dietitian stated there were many issues with the tray line as we ran out of the vegetables and meatloaf, both the regular and puree consistency. The tray line ran very late because of the issues. 10 NYCRR 415.14(d)(1)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard survey completed 7/21/23, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, one of one Kitchen had issues: undated or outdated food items, improper use of the dish machines heat booster causing low rinse temperatures with multiple blanks on the temperature log for July 2023, walk in freezer was not functioning correctly causing ice build around the door frame, ice buildup on the boxes under the condenser, and ice bubbles forming on the ceiling of the freezer. In addition, two (The Villages and [NAME] View North) of three-unit nourishment kitchens had outdated, undated and/or unlabeled food items, no thermometer in freezer, multiple blanks left on temperature logs for the refrigerator/ freezer for the month of July 2023, and disposable ice packs. The findings are: The undated policy and procedure (P&P) titled Food Storage Refrigerator/ Freezer documented the purpose is to ensure foods are stored properly to minimize spoilage and contamination, and to ensure taste and quality of food. All food items should be labeled and dated and discarded after three days. The undated P&P titled Food Temperature Monitoring documented the temperatures of each refrigeration unit used for food or beverage storage shall be monitored twice a day. The temperatures shall be monitored at the start of the first shift and just prior to closing the area for the day. The document titled Dish Machine provided with the P&Ps documented high temperature machines use hot water to clean and sanitize. The final sanitizing rinse must be at least 180° F (degrees Fahrenheit). Check and log temperatures according to guidelines for high temp machines. If temperatures are not within the desired range- alert manager prior to washing dishes. 1. During an observation of the main kitchen on 7/17/23 between 9:20 AM to 10:00 AM the following was observed: Reach in cooler by the cook's area contained: - A metal pan of approximately 30 assorted sandwiches (peanut butter and jelly, turkey, and cheese) that were undated, some were very mushy and wet. - A metal pan with one package of pancakes undated or labeled. - One bag of hamburger rolls with a hole in the bag and no date. - 5# (pound) opened bag of hot dogs with no date. - One bag of opened bread with 6 slices left with no date. - 3 opened bottles of soda with no date. - 8 opened containers of thickened juice and 3 opened containers of thickened water with no date on them when opened. Review of the container labels revealed storage & handling: refrigerate unused portions. Discard if not used within 10 days of opening. Walk in cooler contained: - A metal pan labeled tuna noodle casserole dated 7/7. - 8 unlabeled and undated clear plastic zip lock sandwich bags filled with sliced pepperoni which appeared grey and discolored. -5# opened plastic bag of mozzarella cheese with no date. -1 quart clear plastic zip lock bag with food that appeared to be mozzarella cheese dated 6/20. -1-quart size clear plastic zip lock bag with sliced ham wrapped in foil with no label or date. Walk-in freezer contained: -A thick layer of ice buildup inside approximately .5 to 1 (inch) thick, along the door frame which caused the freezer not to close properly. -Ice buildup on the condenser on the fans. -Ice buildup on 8 boxes of foods items stacked under the condenser. -Ice bubbles forming on the ceiling near the condenser. -Frost buildup on some of the boxes inside the freezer. High Temp Dish machine: - Rinse gauge did not move off 120°F and wash cycle stayed at 144°F through five cycles. Machine had on it, rinse should be at least 180°F and wash at 150 °F. - Review of the Dishwasher Temperature Log for July 2023 revealed no temperatures recorded for July 12-17, 2023. - Heat booster on the dish machine was noted to be off and was not turned on. During an interview on 7/17/23 at 9:40 AM, the Dietary Supervisor stated after 3 days foods should be thrown away. They stated they had been off the weekend and had not had a chance to go through everything and throw out the outdated food items. They stated the rinse cycle of the dish machine should be 180°F or above and the heat booster should have been turned on in the beginning before running the dishes through the dish machine and was not. They stated that is why the temperatures were low. They stated the dietary aides should be checking and recording the temperatures of the machine before using it and it wasn't. They stated they should be recording the temperatures on the Dishwasher Temperature Log and stated the log has not been filled in for the past week. They stated the staff should know to do all this, but they have new staff and they probably forgot to do it. During an interview on 7/18/23 at 8:54 AM the Dietary Consultant stated the seal of the freezer needed to be fixed. They stated they had spoken with maintenance about it at least 3 weeks ago prior to them leaving. They stated maintenance assured them that they would fix it and was told it was fixed. During a follow-up observation of the main kitchen on 7/20/23 at 11:00 AM the freezer still had a build-up of ice along the inside door frame causing the freezer door not to shut properly. There was a thick buildup of frost on the condenser fans causing it to blow throughout the freezer. There were ice bubbles formed on the ceiling of the freezer. At that time the Dietary Consultant stated they thought maintenance had been down already to fix it and apparently there was still an issue with the freezer. 2. During an observation of the Villages nourishment kitchen on 7/17/23 at 11:15 AM the following was observed: -In the refrigerator there was one opened thickened water container not dated with use by date 7/19/23. Review of the container labels revealed storage & handling: refrigerate unused portions. Discard if not used within 10 days of opening. There were two small containers labeled vanilla pudding dated 7/12/23, and one large container marked vanilla pudding dated 7/14/23. -There was no thermometer in either the refrigerator or the freezer. Review of the Freezer/Cooler Temperature Log sheet for July which was posted on the door of the refrigerator had multiple blanks for both the fridge and the freezer. -On the counter there was an opened 1.5# plastic tub of peanut butter with best date used by 3/30/24 but no date of when it was opened. During an observation of the Villages nourishment kitchen on 7/18/23 at 8:46 AM the following was observed: -Three opened containers of thickened water with no date, one thickened water container dated 7/7 and one container of thickened apple juice dated 7/5. Review of the container labels revealed storage & handling: refrigerate unused portions. Discard if not used within 10 days of opening. During an interview on 7/18/23 at 8:54 AM, the Dietary Consultant stated dietary was responsible for the nourishment kitchens on the unit. There should be a thermometer in both the freezer and refrigerator. Dietary staff should be filling out the temperatures for the freezer and refrigerator on the log sheets every morning and evening. The thickened water and juices should be marked with the date when they were opened. They stated food should be discarded after 3 days. 3. During an observation on 07/17/23 at 11:43 AM on [NAME] View North Unit the following was observed: -Nourishment room freezer had two frozen brown bananas and an open 4 oz (ounce) cup of rainbow sherbet with a disposable spoon stuck in it, and two disposable ice packs. -The temperature log on the outside of the refrigerator had multiple blanks. -The refrigerator had an expired 32 oz container of vanilla yogurt with manufactures date of July 15, 2023, and an unlabeled and undated quart of blueberries. 10 NYCRR 415.14(h) 14-1.113(b), 14.1.43(e), 14-1.72(c), 14-1.85, 14-1.95

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Standard survey completed on 10/25/21, the facility did not honor the resident's right to formulate an advance directive for two (Resident #18, 24) of two residents reviewed. Specifically, Resident #18 and Resident 24 had Medical Orders for Life Sustaining Treatment (MOLST, a set of medical orders for advance directive status) that included the instructions for no weights and no laboratory (labs) testing (blood work); weights and laboratory tests were obtained for resident #18 and Resident #24. The findings are: The facility policy and procedure (P&P) titled Medical Order for Life Sustaining Treatment (MOLST) dated 1/17/13, included Medical Orders for life sustaining treatment program is based on the premise that individuals have the right to make their own health care decisions. MOLST is based upon communication between the resident or health care proxy or legal decision maker, and the health care professionals that ensures informed medical decision making. The MOLST form is a bright pink medical order form signed by a New York State licensed physician that communicates resident's wishes regarding life-sustaining treatments to health care providers. The MOLST form includes types of intervention that the resident may or may not want. 1. Resident #18 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), dementia, and gastro-esophageal reflux disease (GERD, acid from stomach enters the esophagus). The Minimum Data Set (MDS, a resident assessment tool) dated 7/23/21 documented Resident #18 had severe cognitive impairment, and had Advance Directives that included feeding restrictions, and other treatment restrictions. Additionally, the MDS documented Resident #18 received comfort care (medical care and treatment provided with the primary goal of reducing suffering) in the last 14 days. The MOLST dated 9/18/19 included Other instructions of no labs and no weights. Resident #18's Weights and Vital Summary included weights were obtained on 10/7/21, 8/3/21, 6/2/21, 5/10/21, 5/2/21, and 4/30/21. Additionally, laboratory testing was obtained on 5/26/21. The comprehensive care plan (CCP) included Resident #18 had Advanced Directives, with the goal, revision dated 5/18/21, choice of directive(s) will be honored through next review, and the intervention of a MOLST. There was no documented evidence in the Electronic Medical Record (EMR) the responsible party was contacted regarding obtaining weights and labs. 2. Resident #24 was admitted to the facility with diagnoses including dementia, anxiety, and depression. The MDS dated [DATE] documented Resident #24 had severe cognitive impairment, and had Advance Directives that included feeding restrictions, and other treatment restrictions. Additionally, the MDS documented Resident #24 received comfort care in the last 14 days. The MOLST dated 7/13/21 included Other instructions of no labs and no weights. Resident #24's Weight Summary included weights were obtained 10/5/21 and 8/2/21. The CCP included Resident #24 was on Comfort Care, initiated 7/13/21, with an intervention to evaluate diagnostics as per MOLST. There was no documented evidence in the EMR the responsible party was contacted regarding obtaining weights. During an interview on 10/19/21 at 9:11AM, Licensed Practical Nurse (LPN) #3, MDS trainee, stated they request weights for residents when they are completing the MDS'. LPN #3 stated they do not check the MOLST prior to requesting weights from unit staff, and if the MOLST indicates no weights residents should not be weighed as that would be going against the residents wishes and physician orders. During an interview on 10/19/21 at 9:37AM, LPN #1 stated they were aware Resident #18 and Resident #24 had physician orders for no weights. LPN #1 stated weights were obtained per the request of the MDS trainee. Additionally, LPN #1 stated the responsible parties for Resident #18 and Resident #24 nor the physician were consulted prior to obtaining weights. During an interview on 10/22/21 at 8:32 AM, the Medical Director stated MOLSTs are reviewed every 60 days, and if the MOLST documents no weights and no labs, the expectation would be to avoid obtaining weights and labs. Additionally, the Medical Director stated the responsible party would be included in discussions related to the limitations of care prior to obtaining weights or labs. 415.3(e)(1)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Complaint investigation (Complaint # NY00278907) during the Standard survey completed on 10/25/21, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #27) of seven residents reviewed for accidents. Specifically, Resident (#27) with a history of a bruise of unknown origin, that the facility concluded occurred during a transfer, was observed to be transferred by staff without the use of a gait belt (assistive device used to help safely transfer a resident). The finding is: The facility policy and procedure (P&P) titled Safe Patient Handling/Safe Transfers and Movement, revised date 7/2021 documented all lifting and transferring of residents shall be performed utilizing the approved lift transfer devices and methods to prevent resident and employee injury. Attachment #2 - Safe Resident Handling Assessment Tool of the P&P documented transfer status of limited assist of one or two staff members and extensive assist of one staff member requires the use of a gait belt. 1. Resident #27 was admitted to the facility with diagnoses including dementia, generalized muscle weakness, and hypertension. The Minimum Date Set (MDS, a resident assessment tool) dated 8/13/21 documented Resident #27 had severe cognitive impairment, required extensive assistance (staff provide weight bearing support) of two or more staff for bed mobility and transfers. The comprehensive care plan (CCP) documented Resident #27 required extensive assistance of one staff member for bed mobility and transfers (date initiated 3/10/21). The facility Incident/Accident Form dated 7/3/21 documented bruising of unknown origin in the right axillary (armpit) region. The facility Investigation Summary dated 7/3/21 and signed by the Director of Nursing (DON) documented Resident #27's transfer status was an extensive assist of one. Certified Nurse Assistants (CNAs) reported they do not use a gait belt, and transfers were performed by holding on to trunk of the body. The DON concluded that it appears resident may have been bruised during transfer. Upon investigation bruising aligns with transfer with staff hand position during bed to chair/wheelchair and toilet transfer. During an observation on 10/22/21 at 7:57 AM, CNA #1 and Licensed Practical Nurse (LPN) #2 transferred Resident #27 from the bed to the wheelchair by each placing an arm under the resident's arm, grabbing the back of the resident's pants, pulling the resident to a standing position, and pivoting the resident into a wheelchair without the use of a gait belt. During an interview on 10/22/21 at 9:53 AM, the Director of Rehab stated gait belts were required for any resident that required weight bearing assistance with a transfer. During an interview on 10/22/21 at 10:34 AM, CNA #1 stated they were unsure if gait belts were required during the transfer of Resident #27. During an interview on 10/22/21 at 10:36 AM, LPN #2 stated they were unsure if gait belts were required during the transfer of Resident #27. During an interview on 10/22/21 at 10:40 AM, the Director of Rehab stated staff should avoid reaching under residents' arms to assist with transfers as it could cause bruising and dislocation of the shoulder. During an interview on 10/22/21 at 10:45 AM, the DON stated that all transfers requiring weight bearing assistance from staff required the use of a gait belt. Additionally, the DON stated Resident #27 has a history of bruising to the right axillary region from staff not utilizing a gait belt during transfer. During an interview on 10/22/21 at 1:17 PM, the Administrator stated gait belts were required for any transfer that required weight bearing assistance. Additionally, the Administrator stated gait belt was not on the CCP or [NAME] (guide used by CNAs to provide care) because it was the facility policy to utilize a gait belt for any limited or extensive assist transfer. 415.12(h)(2)