Every finding on record at Beach Gardens Rehabilitation and Nursing Center

Based on observation, record reviews, and interviews, conducted during a survey, the facility failed to ensure that a resident was free from physical abuse. This was evident for one (1) out of six (6) residents (Resident #1) sampled for abuse. Specifically, Resident #1 has history of aggressive behavior. On 03/16/2026 at approximately 10:15 AM while Resident #1 & 2 was standing in the lobby waiting on the elevator to go upstairs. Resident#1 was observed swinging left wheelchair armrest hitting Resident #2 twice before staff members intervened. Resident #1 was arrested by the Police and taken to the hospital. Resident #2 was also transferred to the hospital on [DATE] for evaluation. Resident #2 did not require any stitches. Resident #1 and Resident #2 returned to the facility on [DATE]. Resident #2 sustained a laceration to mid forehead and was transferred to hospital for treatment. The hospital evaluation did not reveal a serious injury or significant pain.The findings are:The facility's Policy and Procedure titled Abuse Prevention dated 08/27/2025 documented the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation by anyone in this facility. The policy also documented the facility is to provide a safe environment that protects residents from abuse including but not limited to verbal, mental, or physical abuse. The policy included resident to resident abuse of any type and visitors to resident abuse of any type.Resident #1 was admitted to the facility with diagnoses of Paraplegia, Mood Disorder, Major Depressive Disorder, Anxiety Disorder.The Minimum Data Set (a resident assessment tool) dated 02/12/2026 documented Resident #1 with intact cognition.A review of the facility's video surveillance footage revealed that on 03/16/2026 at 10:15AM Resident #1 and Resident #2 were waiting at the elevator in the front lobby. Other residents were also present. Resident #2 walked over to Resident #1's wheelchair and stood next to Resident #1. Resident #1 was observed making hand gestures while Resident #2 was still standing next to them. Resident #1 was observed taking off their left wheelchair arm rest, then using both hands to swing toward Resident #2. Resident #2 reached over toward Resident #1 to take the wheelchair arm rest away. Resident #1 was observed using the wheelchair armrest to hit Resident #2 on their forehead. Resident #2 started to bleed from their forehead. Staff members arrived immediately and separated both residents. Resident #2 observed going into the elevator.The facility documented the incident in a report dated 03/16/2026. The report documented that an incident of resident abuse did occur on 03/16/2026 at 10:15 AM, as evidenced by video surveillance and witnesses' statements which revealed that Resident #1 struck Resident #2 with the arm rest of their wheelchair. It was documented that the facility contacted local law enforcement at 10:15 AM and arrived at 10:25 AM on 03/16/2026. They responded and arrested Resident #1. In its investigative summary they concluded that Resident #1 was the victim of physical abuse perpetrated by Resident #2. The facility also concluded that staff immediately intervened and separated the residents to prevent further abuse or escalation. The summary noted that the physical assault resulted in Resident #2 sustaining an injury to the forehead, Medical Doctor #1 was notified and ordered the resident transferred the hospital for further evaluation and treatment. The hospital evaluation revealed no major injury to Resident #2. Resident #1 was escorted to the hospital by emergency transport with police escort. The summary also documented that both residents returned to the facility on 3/17/2026 and were evaluated by psychiatry. The residents were relocated to different units in the facility and Resident #1 was placed on one-to-one supervision by staff. A review of Resident #1's care plan initiated on 04/28/2025 revealed the resident had the potential to be physically aggressive and was also at risk of being abused. The interventions included assessing and anticipating resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain, administer medications as ordered. Monitor document for side effects and effectiveness of interventions.A review of nursing progress note dated 06/13/2025 at 1:59 PM by Registered Nurse documented around 09:10 AM Resident #1 was observed sitting in their wheelchair, yelling and cursing at another resident in the lobby in front of first floor dining area. Resident #1 stated that the other resident punched them in the face, and they hit him back.The care plan was updated on 06/13/2025 to document the physical altercation that happened between the resident and another resident on 6/13/2025. The care plan noted that Resident#1 was abused by peers. Interventions were to relocate the resident as needed; Psychiatry referral was made on 6/13/2025. The CCP was updated on 10/26/25 to reflect a resident to resident altercation. No new interventions were implemented.A review of behavior progress note dated 03/05/2026 at 9:25 AM by Registered Nurse Supervisor #1 documented that around 8:58AM Resident #1 was heard yelling in room. Writer went into the room and Resident #1 was yelling at Certified Nursing Assistant to get out of their room and continuously pushing Certified Nursing Assistant in his chest.A review of nursing progress note dated 03/16/2026 at 11:16 AM (late 03/20/2026 at 4:02 PM) by Assistant Director of Nursing documented Resident #1 observed swinging right arm rest of wheelchair at another resident hitting them at-least 2 times. Resident #1 was arrested on 03/16/2026 by the Police returned to the facility with no charges filed.The care plan was updated on 03/16/2026 to reflect the incident on 03/16/2026 where there was a resident to resident altercation ,psychology referral was made on 03/16/2026.Resident #1 was on every 30 minutes prior to 03/16/2026. Resident #1 was last seen on03/16/2026 at 10:00 AM on the unit before coming to the lobby.Psychiatry progress note dated 03/19/2026 at 2:41 PM documented resident was involved in an altercation with a peer. Resident hit a peer with handle of wheelchair armrest twice. Resident was taken to the hospital for evaluation the incident. Recommendations for new medication for mood stabilization and angry outbursts.Resident #2 was admitted to the facility with diagnoses of Schizophrenia, bipolar disorder, current episode manic without psychotic features.The Minimum Data Set (a resident assessment tool) dated 06/21/20226 documented Resident #1 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) score of 15 associated with intact cognition.Care plan dated 07/21/2025 Resident is at risk for abuse with interventions that included monitor for changes in mood and manner, encourage resident to voice concerns to staff regarding their peers.Abuse care plan was updated on 03/17/2026 with interventions for psych and psychology consult.A physician's order dated 03/02/2026 Invega oral tablet extended release 24 hours three milligrams, give one table by mouth at bedtime for SchizophreniaA review of nursing progress note dated 03/16/2026 at 11:35 PM by Registered Nurse Supervisor #1 documented at approximately 10:15 AM resident had physical altercation Infront of first floor elevator with another resident, hitting their head with a wheelchair handrest. Resident #2 sustained a bump on the right side of their forehead and abrasion on their right side of their head. Medical Doctor notified, ordered to transfer resident to emergency room for evaluation.Psychiatry progress note dated 03/19/2026 at 1:40 PM documented Resident #2had a physical altercation with a peer. Resident sustained a bump on their head and small laceration after a peer hit them with a wheelchair armrest. Resident #2 was evaluated in the emergency room and discharged back to facility. Resident #2 seen in their room, restless, agitated, anxious and hypomanic. Resident laughed and joked a lot. Resident #2 stated they are not worried at all about the recent altercation. Resident #2 is currently on Invega oral tablet three milligrams at bedtime for Schizoaffective Disorder Bipolar Type.During an interview on 03/24/2026 at 11:01 PM. Resident #1 stated this was the first physical altercation between them and Resident #2. Resident #1 stated, that on 03/16/2026 (not sure of the time) when Resident #2 came and stood beside them in front of the elevator, they informed Resident #2 not to stand beside them because they still remembered last year when Resident #2 called them a racial epithet. Resident #1 stated Resident #2 then touched them on their shoulder and again used the same racial epithet and that they did not belong in the facility. Resident #1 stated they took off their wheelchair armrest and hit Resident #2 for touching them and calling them a racial epithet.During an interview on 03/24/2026 at 11:30 AM, Resident #2 stated they were standing at the elevator in the lobby. Resident #2 stated that Resident #1 was saying something, but they ignored them. Resident #2 said that out of now where Resident #1 just hit them with their wheelchair armrest. Resident #2 stated this was the first physical altercation between them.During an interview on 03/24/2026 at 12:29 PM, Security Guard #1 stated, that on 03/16/2026 at approximately 10:15 AM they were sitting at the security desk in the lobby. They observed the two residents waiting at the elevator. Security Guard #1 stated they heard Resident #1 telling Resident #2 not to stand close to them, and asked Resident #2 if they did not remember what happened the last time. Security Guard #1 stated Resident #2 responded to Resident #1 that yes, they still remembered what happened. Security Guard #1 stated they heard Resident #1 telling Resident #2 to stop touching them. Security Guard #1 stated they then observed Resident #1 with the wheelchair armrest swinging at Resident #2 and hitting Resident #2 on the forehead. Security Guard #1 stated they called for staff to come to the lobby. Security Guard #1 stated staff members arrived and intervened immediately to separate both residents.During an interview on 03/24/2026 at 11:56 AM, Registered Nurse Supervisor #1 stated the incident occurred off the unit. Registered Nurse Supervisor #1 stated Resident #1 has history of verbal and physical abusive behavior toward staff members. They stated that the incident happened last year. They stated that they have not observed any recent abusive behavior towards staff or other residents. Registered Nurse Supervisor #1 stated this was the first time Resident #1 and Resident #2 have had a physical altercation. Registered Nurse Supervisor #1 stated Resident #2 was assessed and noted with a bump and small laceration to their mid forehead. Registered Nursing Supervisor #1 stated Medical Doctor #1 was notified and ordered Resident #2 to transferred to the hospital for evaluation and treatment. Registered Nurse Supervisor #1 stated Resident #1 was escorted out of the facility by local law enforcement to the hospital for evaluation. They stated that they were not aware of any other incidents between 06/13/2025 and 03/16/2026. During an interview on 03/25/2026 at 10:47 AM, Director of Nursing #1 stated on 03/16/2026 during morning report at 10:15 AM they heard calling from the hallway. Director of Nursing 31 stated they and the Administrator went out of the room and saw two residents in front of elevators in physical altercation and staff members were separating them. Director of Nursing 31 stated Registered Nursing Supervisor #2 escorted Resident #2 back to the unit and provided first aid to them. Director of Nursing #1 stated body assessment revealed a bump and a small laceration on Resident #2's forehead. Director of Nursing #1 stated Resident #1 was kept downstair by Security Guard #1 until 911 arrived. Director of Nursing stated after the Police watched the surveillance video, they made the decision to arrest Resident #1. Medical Doctor #1 was notified and recommended Resident #2 to be transferred to the hospital for evaluation. Director of Nursing stated both residents returned to the facility on [DATE]. Director of Nursing #1 stated Resident #1 was placed on 1:1 monitoring for safety. Director of Nursing #1 stated staff members were re-educated on behavior changes with Resident #1 they should notify Medical Doctor and call 911. Director of Nursing stated on 03/25/2026 Resident #1 was transferred to the hospital this morning for threatening the Registered Nurse Supervisor #1.During an interview on 03/25/2026 at 12.56 PM, Medical Doctor #1 stated Resident #1 has short fused and got upset easily. Medical Doctor #1 stated Resident #1 has history of incarceration, and substance abuse. Medical Doctor #1 stated Resident is seen by psychiatrists and refused psychology. Medical Doctor #1 stated Resident #1 was started on a new psychiatric medication and has been refusing the medications. Medical Doctor #1 stated Resident #1 was sent to the hospital this morning for threatening and telling Registered Nurse Supervisor #1 that they are going to hurt them.During an interview on 03/25/2026 at 2:30 PM, Administrator #1 stated they were in morning meeting on 03/16/2026 at 10:15 AM when they heard staff members calling for help. Administrator #1 stated they immediately went to see what was happening. Administrator #1 stated they observed Resident #1 and Resident #2 in a physical altercation. Administrator #1 stated staff members immediately separated both residents. Administrator #1 stated Resident #2 was observed bleeding from their forehead. Administrator #1 stated they call local law enforcement. Administrator #1 stated the Police responded and reviewed the surveillance footage. Administrator #1 stated they arrested Resident #1 and escorted them to the hospital.Based on the corrective actions taken by the facility there was sufficient evidence that the facility corrected the identified non-compliance and was in substantial compliance for this specific regulatory requirement on 03/20/2026, prior to surveyor's onsite visit on 03/24/2026. Corrective Actions taken by the facility On 03/16/2026 Emergency evaluation on Resident #2 completed with no significant Injury.On 03/16/2026 Policy and Procedure on Abuse Prevention was reviewed with no changesOn 03/16/2026 -03/17/2026 Behavioral Monitoring and Supervision Audit done on 14 residents03/17/2026 Social Worker conducted interviews with five (5) regarding their interactions with Resident #1.Physician's order dated 03/17/2026 Diazepam oral 2 milligram , give 1 tablet by mouth every 8 hours for anxiety; 03/19/2026 Trileptal oral tablet 150 milligram, give 1 tablet by mouth twice daily for mood stabilization.Physician's order dated 03/19/2026 1:1 monitoring for 3 days.On 03/17/20226 1:1 enhanced monitoring implemented for Resident #1On 03/17/2026 Care plans updated for both residentsOn 03/17/2026Quality Assurance Performance Improvement meeting with attendance record was held.On 03/17/2026 Wheelchair armrests were modified permanently for safety. Wheelchair transitioned to safer design (Pivot/secured armrests).On 03/19/2026 Social Worker #1 provided counseling to Resident #1On 03/19/2026 Resident #1 and Resident #2 was seen Psychosocial and psychiatric interventions initiatedResident was seen on 3/19/26. Yes Trileptal. Yes - refusal of drugs. Behavior CCP in place. Interventions include SW counseling and psych follow up for refusal and if behavior continues transfer to psych ER as needed.On 03/17/2026 - 03/20/2026 Wheelchair Armrest Safety & Environmental Hazard Audit completed to mitigate similar risks.On 03-17/2026 - 03/20/2027 Staff re-education on abuse prevention, altercation, behavior management and competency reinforcement completed. 100 percent of staff members were at service.Ongoing monitoring and Quality Assurance Performance Improvement oversight in place 10 New York Codes, Rules and Regulations 415.4(b)(1)(i)

Based on observation, record review, and interviews, the facility failed to ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety. This was evident during the kitchen and food service observations. This was evident during the kitchen and food service observation. Specifically, 1.) Dietary staff were observed not properly wearing hair restraint while in the kitchen; 2.) Expired enteral feedings were stored on the unit and by the security area; and 3.) Cold sandwiches were not stored at a safe temperature. The findings include: The facility policy on Dress Code with a revised date of 08/11/2025 documented all employees when working in the dietary department will wear a hairnet / hair restraint as per policy. This hairnet/hair restraint will cover all hair. [NAME] and facial hair should be contained. The undated facility policy on Temperature Controlled for Safety Food documented that egg and tuna salad must be kept in the refrigerator in 3-4 days, temperature of 40 Fahrenheit or below. 1. During kitchen observation on 08/12/2025 between 2:33 PM through 2:44 PM, Dietary Aide #3 was observed in the kitchen, without a beard net while washing the food cart and taking clean dishes from the dish machine. Dietary Aide #4 was in the kitchen, without a beard net while rinsing the dishes. Dietary Aide #5 was observed with beard not fully covered, and with hair net above their ears, not fully covering their hair, while they were putting relish into plastic cups. On 8/12/2025 at 2:44PM, a maintenance staff and outside vendor doing water sampling in the kitchen not wearing hair restraints or beard nets.On 08/13/2025 between 2:48 PM to 3:00 PM, Dietary Aide #5 was observed with their beard not fully covered, while opening preparing packets of thawed raw fish. During an interview on 08/12/2025 at 2:59 PM, Dietary Aide #3 stated they thought that only their beard had to be covered and not their mustache. They stated that they sometimes forget to grab a beard net when in the kitchen.During an interview on 08/12/2025 at 3:08 PM, Dietary Aide #4 stated they normally wear a mask because of their mustache. They stated they know they need to cover their facial hair, so it does not fall into the food. During an interview on 08/12/2025 at 3:02 PM, the Assistant food Service director stated all facial hair must be covered when in the kitchen. 2. On 08/12/2025 at 12:57 PM, a 1-liter bottle of Jevity 1.5 Cal was observed in the 5th floor pantry labeled with use before date of July 2025. On 08/12/2025 between 3:23 PM to 3:30 PM, boxes of 24 - eight (8) ounces Jevity 1.2 with use by date of 08/01/2025 and one (1) liter bottle of Jevity 1.5 with use by date of 07/01/2025 were stored in the visitor room by the security area. During an interview on 08/13/2025 at 10:30 AM, the Central Supply Aide stated the expired enteral feeding found in 5th Floor belongs to a resident who was in the hospital. The feeding was removed from the unit yesterday. They stated that the kitchen used to be in charge of the enteral feedings, and they took over four (4) months ago. During an interview on 08/14/2025 at 4:32PM, the Director of Nursing stated that the facility has a contract for enteral feeding and liquid nutritional supplements. They stated that dates are checked by the delivery person, and that supply is checked daily. They stated that if enteral feeding and liquid nutritional supplements are expired it is unsafe and would not provide proper nutrition. 3. On 08/12/2025 between 2:45 PM - 2:51 PM, the kitchen refrigerator was observed at 34 Fahrenheit. A tuna sandwich labeled with discard date of 08/14/2025 had a temperature of 68.8 Fahrenheit; and egg salad sandwich with a temperature of 51.2 Fahrenheit. During an interview on 8/12/2025 at 2:55PM, Dietary Aide #2 stated that the sandwiches were made at 11:30AM. They stated they did not put the ingredients on ice when they were making the sandwiches which they should have done to maintain the temperature. During an interview on 08/13/2025 at 2:59 PM, the Assistant Food Service Director stated the sandwiches should be between 35 to 40 Fahrenheit so no one can get sick with food poisoning. 10 NYCRR 415.14 (h)

Based on observation, record review, and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This was evident during environmental observation. Specifically, the visitor's waiting area by the security desk had a hole on the baseboard, had cobwebs, debris on top of the air-conditioning unit; staff bathrooms had a hole in the wall and black colored stain on the floor; and resident's bathroom was out of order. The findings include but is not limited to: The facility's policy titled Preventive Maintenance with a last reviewed date of 04/11/2024 stated that all broken equipment that affect resident or staff safety must be reported immediately to the Building Service Director or Administrator for immediate plan of action. The following were observed from 08/08/2025 through 08/13/2025:The visitor's waiting area by the security desk was noted with cobwebs in the right lower edge of the window; there was a hole on the baseboard on the right of the air conditioning unit. The air conditioning unit had a clear tape on top with black debris under the tape. The 3rd Floor staff bathroom had dirty corners and had corroded metal door frame. The staff bathroom in the Rehabilitation Department had holes in the wall under the soap dispenser, the floor had black colored debris, and the toilet handle was difficult to flush. The resident's bathroom in the Rehabilitation Department had an out of order sign and was noted with stained tile ceiling; had brown and black stains on the floor. During an interview on 08/14/2025 at 12:51 PM, the Physical Therapist stated that the bathroom has been in this condition over the last three (3) years. During an interview on 08/14/2025 at 3:48 PM, the Maintenance Director stated they made a list of issues that need to be addressed and provided it to the Administrator. During an interview on 08/14/2025 at 3:33 PM, the Administrator stated they walk around the facility daily and weekly and had no issues with the cleanliness of the resident units. The Administrator stated when doing rounds, they do not look at the door structure, but they look to see if the floor and counters are clean. 10 NYCRR 415.29

Based on observation, record review, and interviews, the facility failed to report all alleged violations involving neglect, abuse, and/or including injuries of unknown source to the State Survey Agency. This was evident in two (2) (Residents #154 & #46) of five (5) residents reviewed for Abuse out of 35 total sampled residents. Specifically, 1.) on 07/09/2025, Resident #154 was observed with a black and blue discoloration on their right eye. The resident was cognitively impaired and could not explain how the injury occurred. There was no witness to how the resident sustained the injury. This incident was not reported to the New York State Department of Health. 2.) On 05/30/2025, Resident #46 had a fall occurrence and sustained laceration on the forehead and cut on the bridge of the nose while being provided care by Certified Nursing Assistant #3. This incident was not reported to the New York State Department of Health.The findings include: The facility's policy titled Abuse Prevention with a last reviewed date of 12/29/2023 documented that the facility staff must report alleged violations related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property immediately to the Administrator and or Director of Nursing , who in turn must report to the New York State Department of Health and or Police Department within the prescribed time frames as stipulated by Centers for Medicare and Medicaid Services.1. Resident #154 was admitted to the facility with diagnoses that included Non-Traumatic Brain Dysfunction and Non-Alzheimer's Dementia.The quarterly Minimum Data Set, dated [DATE] documented resident's cognition as severely impaired, no behavior symptoms and no wandering.A nurse's note by Registered Nurse #1 dated 07/09/2025 at1:30 PM documented they were informed by the Certified Nursing Assistant that Resident#154 was noted with bruise around their eye. A black and blue discoloration observed around Resident's #154 right eye and right side of their forehead. The nurse's note further documented that Resident #154 was unable to state what happened. The facility's Accident/Incident Report dated 07/09/2025 at 7:10 AM documented that the nature of the occurrence was an unknown injury. The report further documented a black and blue discoloration around right eye, and a small discoloration on the right side of forehead. The investigation documented that Resident #154 was interviewed and had no recollection of the event. The resident was unable to explain how they sustained the injury due to confusion secondary to dementia. On 08/12/2025 at 4:38 PM, the Assistant Director of Nursing was interviewed and stated they review all resident incidents. They stated Resident #154 could not remember what occurred due to their cognition and resident has memory loss. They stated that this incident was an injury of unknown origin, but they do not believe it has to be reported to the Department of Health. On 08/14/2025 at 3:21 PM, the Director of Nursing was interviewed and stated that the Assistant Director of Nursing is responsible for reviewing all incidents, and that the supervisors notify them if there is an allegation of abuse or neglect. The Director of Nursing stated that the incident/accidents are discussed as a team, and they take each situation personally. They stated for this incident, it was not reported to the Department of Health because by the time the nursing supervisor came to relay the information, the team did not feel there was any suspicion of abuse. 2. Resident #46 was admitted to the facility with diagnoses that included Coronary Artery Disease, Diabetes Mellitus and Non-Alzheimer's Dementia. The Quarterly Minimum Data Set, dated [DATE] documented Resident #46's cognition as severely impaired, no behaviors, moderate assistance for eating, supervision for bed mobility, dependent on staff for transfer and impairment on both sides to lower extremity.A nurse's note dated 05/30/2025 documented writer responded to a loud noise from the room, observed resident lying face down on floor on the right side of the bed, with the Certified Nursing Assistant at the bedside. Resident was alert and verbally responsive. Registered Nurse supervisor called to unit. Resident noted with skin tear to forehead and nose.The Director of Nursing Summary dated 06/05/2025 documented Resident #46 had an accidental fall during care on 05/30/2025 at around 7:51 AM. The summary documented that Resident #46 was receiving care when the Certified Nursing Assistant turned the resident to their side and fell out of bed. The resident sustained laceration on their nose and forehead and was transferred to the hospital for evaluation. A nurse's note dated 05/30/2025 documented Resident#46 returned from the emergency room at 2.05 PM, status post fall with laceration to forehead and nose bridge, resident had sutures done, dressing in place, blood smear to nose bridge dressing seen and evaluated by the medical doctor with no new orders, denies pain at this time. Swelling to forehead and nose bridge noted. On 08/14/2025 at 3:32 PM, the Director of Nursing was interviewed and stated that the reason the incident was not reported to the New York State Department of Health was because it was a minor laceration and from nursing assessment, it was not deemed to be major. The Director of Nursing also stated that the incidents are all discussed with the team, and the decision is made to report or not.10 NYCRR 415.4(b)(2)

Based on observation, record review, and interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment to the residents. This was evident in three (3) (2nd, 3rd, and 4th Floors) of 4 units observed. Specifically, residents' closets were in disrepair; resident wheelchairs were dirty; feeding pumps and poles were observed with feeding stains; curtains had dirt; walls had missing paint; and floors were stained and dirty. The findings include but is not limited to: The facility's policy titled Environment Services with a last reviewed date of 04/25/2025 stated it is the policy of the facility to ensure that all residents' rooms are comfortable, cleaned, and sanitized according to set standards to maintain a safe sanitary and comfortable homelike environment. 1. From 08/07/2025 – 08/13/2025, the following were observed on the 3rd Floor: The dining room had dusty ceiling tile; the window blinds had black colored debris. A green chair was observed with ripped cushion. The floor had brown stains, and the tables had chipped and brown stain edges. The dry wall was chipped. The communal shower room had cracked tiles behind the door; the bottom of the door was missing a metal frame; and the ledge on the wall had brown colored stains. The following rooms had damaged or cracked closet veneers: Rooms 302, 303, 304, 305, 306, 307, 315, 317, 318, 320, and 322. In room [ROOM NUMBER], the curtain had brown stains, and the air-conditioning unit was leaking. In room [ROOM NUMBER], the window curtain was ripped, and the bathroom had missing tile and had dirty edges. In room [ROOM NUMBER], the curtains had brown stains, and the window mesh was ripped; the enteral feeding pump had feeding stains, and the ceiling tiles were stained. In room [ROOM NUMBER], the enteral feeding pole, feeding pump, and the floor had cream colored stains. The pillowcase had brown stains. In room [ROOM NUMBER], the dry wall was scraped. In room [ROOM NUMBER], the window screen was torn and the window blinds had brown stain. In room [ROOM NUMBER], the window screen was torn, the window blinds had brown stain and frayed edges. In room [ROOM NUMBER], the edge of the bathroom door had brown colored chipped metal and the corners were dirty. The dry wall was damaged; the window curtain had frayed edges, and the curtains had hole in mesh and stained. In room [ROOM NUMBER], the curtain hook was hanging, the dry wall above the baseboard was damaged, the blue privacy curtain had brow stains. In room [ROOM NUMBER], the window screen and curtain were ripped. In room [ROOM NUMBER], there was a blues stain on the window. In room [ROOM NUMBER], the curtains had frayed edges and black debris. In room [ROOM NUMBER], the wall had missing paint behind the television. In room [ROOM NUMBER], there was dried enteral feeding on the floor and feeding pump; and the curtain had black stain. Resident #58's wheelchair had ripped arm rest. Resident #74's wheelchair was noted with dust and debris. The wheels had white colored stains. During an interview on 08/13/2025 at 12:06 PM, Housekeeper #4 stated the rooms are cleaned when dirty, the baseboards are cleaned monthly, and that they wipe and clean 17 rooms every day. They stated they change the privacy curtains when necessary. During an interview on 08/14/2025 at 3:48 PM, the Maintenance Director stated they are aware of the torn window screen and that the residents' closet needs to be replaced. They stated some of the curtains are ripped and some hooks were stuck. The Director stated they made a list of issues that need to be addressed and provided it to the Administrator. They stated the facility should be homelike because if your family or loved ones are here, you want them to be comfortable and decent. During an interview on 08/14/2025 at 3:33 PM, the Administrator stated they walk around the facility daily and weekly and had no issues with the cleanliness of the resident units. They stated they do a quick check of the dining rooms and the cleanliness of the curtains. The Administrator stated when doing rounds, they do not look at the door structure, but they look to see if the floor and counters are clean. 2. On 08/08/2025 at 9:22 AM the following observations were made: Several residents' closets were in disrepair. room [ROOM NUMBER] was observed with stained walls, chipped painting, and the baseboard was falling off. room [ROOM NUMBER] was observed with dirt stains in the corner of the room. room [ROOM NUMBER] was observed with a wet towel under the air conditioner. room [ROOM NUMBER] had a broken bed side table and there were scuff marks on the floor. room [ROOM NUMBER] had a broken bed side table, and the floor was dirty around bedside table. room [ROOM NUMBER] had an unpainted area on the wall facing the resident's bed. A lot of dirt and dust was observed under the ice machine and the suction machine. On 08/13/2025 at 11:37 AM, Housekeeper #2 was interviewed and stated they are the regular Housekeeper on the 2nd Floor, and they are responsible to clean all the rooms every day. Housekeeper #2 stated they also clean the dining room and that sometimes if anything is broken, then they call maintenance. Housekeeper #2 stated that they are only responsible for mopping the floor and there is a separate person who does the buffing. On 08/13/2025 at 12:00 PM, the Maintenance and Housekeeping Director was interviewed and stated 2nd Floor is in need of cleaning and that the buffing machine was broken, so they borrowed from the other facility. They stated they are aware of the closets that are in disrepair and that these were reported to the Administrator. 3. During multiple observations from 08/07/2025 at 10:55 AM to 08/14/2025 at 11:00 AM the following were observed in 4th Floor: On 08/07/2025 at 10:55 AM, in room [ROOM NUMBER], observed with unpainted wall besides residents' bed. room [ROOM NUMBER] was observed with scraped paints on the lower wall. room [ROOM NUMBER] had a full garbage container. room [ROOM NUMBER]-bathroom door had rusty chopped paint. The shower room had whitish sticky dry stains in the floor On 08/08/2025 at 11:45 AM, Resident #2 was interviewed and stated their garbage bin is not emptied regularly. On 08/14/2025 at 12:07 PM, Resident #15 was interviewed and stated they noticed the unpainted wall, but nobody came to fix it. On 08/14/2025 at 12:14 PM, the Director of Maintenance and Housekeeping was interviewed and stated the unpainted walls were assigned to the maintenance staff but do not know why they were not done. They stated housekeepers are assigned to each floor and does not know why the floor is still dirty. On 08/14/2025 at 1:14 PM, the Administrator was interviewed and stated they are aware that some residents room needs to be repainted and that some rooms need to be cleaned but they do not know why those things were not done. They stated now that they know the problem, they will do an audit of what needs to be done and repaired. 10 NYCRR 415.5(h)(2)

Based on observation, record review, and interviews, the facility failed to ensure each resident received food that accommodated their allergies, intolerances, and preferences. This was evident in one (1) of 20 residents reviewed. Specifically, Resident #115 received lunch trays that included foods that did not accommodate their documented preferences and diet. The findings include: The facility policy titled Reading meal tickets/cards documented that it is the policy of the facility that there are accurately assembled meals for residents based on reading all of the information on the meal tickets. All staff will read and review for accuracy during meal assembly. This is essential to achieving resident satisfaction. Resident #115 had diagnoses of Diabetes Mellitus and Gastroesophageal Reflux disease without esophagitis. The Minimum Data Set, dated [DATE] documented that Resident #115 is cognitively intact, is supervision assistance for eating, has no swallowing disorder and no weight changes. The Physician's order dated 08/01/2025 documented Regular diet, regular texture and regular/thin consistency. The Dietary assessment dated [DATE] documented that Resident #115 is on a regular diet consistency, thin/regular fluid consistency with double portion size. Facility's Menu Ticket for Resident #115 dated 08/07/2025 documented: Lunch: Chef Salad, Double meat, Gravy, Grilled Cheese Sandwich (1 each), Garlic Mashed Potatoes ( 4oz), Ice Cream Sandwich ( 1 each). The bottom of the ticket documented Resident #115 to receive double entree. On 08/07/2025 at 12:56 PM, Resident #115 stated that they receive wrong items on their tray, while at other times items are missing from the tray. Resident #115 stated this happens daily and that they do not get what they are supposed to be getting. On 08/07/2025 at 12:56 PM, during the lunch meal, Resident #115 tray was observed with one grilled cheese sandwich, mashed potatoes and one ice cream sandwich. There was no double portion of meat on tray, no chef salad or gravy. The Facility's Menu Ticket for Resident #115 dated 08/11/2025 documented: Lunch: Chef Salad, Double meat, Gravy, cottage cheese and fruit plate with [NAME] sauce (1 each), white rice (4oz), mandarin oranges (4oz) and dinner roll/margarine (1 each). The bottom of the ticket documented that Resident #115 is to receive double entree. On 08/11/2025 at 12:27 PM, Resident #115 tray was observed and was noted to be missing cottage cheese. On 08/12/2025 at 10:59 AM, the Registered Nurse Supervisor #3 was interviewed and stated that the Dietitian will usually go around to each resident and ask them for their like/dislikes for that week or month. Then the ticket will be printed with residents' preference for their meals. The Registered Nurse Supervisor #3 stated that residents often have items missing from there tray. The residents will notify the staff and a call is then placed to the kitchen for a substitute. A resident is not notified beforehand if something is unavailable. When the tray is brought up then items are noted to be missing. The Registered Nurse Supervisor #3 further stated that residents should receive what is stated on their meal ticket because that's what they are expecting for lunch and since this is their home, it is important to respect their preferences. Regarding Resident #115, it is not often that items are missing from her tray. On 08/14/2025 at 10:28 AM, the Dietary Aide #1 was interviewed and stated that they sometimes help with setting up the meal trays for residents. Every resident has a tray ticket with their name and a list of everything they are supposed to get. The dietary staff is responsible for placing the respective items on the lunch tray. If there isn't a food item available, then it is marked on the sheet and alternatives are offered. The Dietary Aide #1 further stated that it is important residents receive what is on their ticket because they are paying for it and the facility is responsible for providing them with it. On 08/14/2025 at 10:34 AM, The Dietary Aide #6 was interviewed and stated that they have worked at the facility for 7 years and usually assist with the tray lines. The Dietary Aide #6 stated they read the ticket and assemble the listed items to ensure that residents receive whatever is documented in their meal ticket. The Dietary Aide #6 stated that when they work the tray lines, they don't usually have issues with residents complaining of missing items from their tray or resident receiving wrong items because they always double check to make sure residents receive what is on their tray ticket. The Dietary Aide #6 further stated that it is important that residents receive what they ask for. If there are items unavailable, the manager is informed, and a substitute is offered. On 08/14/2025 at 10:38 AM, the Food Service Director was interviewed and stated that the supervisors are responsible for overseeing the tray line and the setting up of the food items. The tray tickets list residents allergies, preferences and their diet. If items are missing, staff are reprimanded, written up or disciplinary actions are taken. There are food committee meetings ongoing where topics such as accurate food assembly of resident's food are discussed. The Food Service Director further stated that while the kitchen puts together the tray, they are not responsible for distributing the food on the floor. Sometimes trays and food get switched out when carts arrive to the units. Other times things are taken off the tray and given to other residents. The Food Service Director stated that they do get calls from the units regarding missing items from residents tray, and they try to rectify it. The Food Service Director further stated that it is important that residents receive what they are supposed to get. 10 NYCRR 415.14(d)(4)

Based on observation, interviews, and record review conducted during an Abbreviated Survey (NY00374494), the facility failed to ensure a resident's medical record contained complete nursing notes in accordance with professional standards of practice. This was evident in one out of six residents (Resident #2) reviewed for Abuse. Specifically, on 03/08/2025, at 2:30 PM, Resident #2 complained to Registered Nurse Supervisor #2 that Certified Nursing Assistant #2 had hit them on the arm. Registered Nurse Supervisor #1 performed a body assessment but did not document it in Resident #2's Electronic Medical Records. There were also no nursing notes in Resident #2's Electronic Medical Record addressing Resident #2's behavior witnessed by Licensed Practical Nurse #2. The findings are: The facility Policy and Procedure entitled Accident and Incident Investigation and Reporting, last review date of 12/29/2023, documented that the Unit Nurse will be responsible for documenting his/her observations with regard to the Accident/Incident in the medical record. The documentation should include a detailed account of the occurrence, description of any injuries, first aid administered, the resident‘s condition, and the time when the Registered Nurse Supervisor was notified. The Registered Nurse Supervisor RNS is responsible for documenting in the medical record his/her assessment findings, the time the Medical Doctor was notified, the Medical Doctor's response/instructions, the resident's response to any treatment/interventions, and the time the family member was notified. Resident #1 was admitted to the facility with diagnoses including Hemiplegia, Hemiparesis, and Cerebral Infarction.The Minimum Data Set (a resident assessment tool), dated 03/05/2025, identified that Resident #1 had intact cognition. A review of the facility's investigation dated 03/08/2025 documented that Resident #2 called police and accused Certified Nursing Assistant #2 of hitting them on their arm at approximately 2:30 PM. Registered Nurse Supervisor completed body assessment with no visible injury noted. The facility concluded that the abuse accusation was not substantiated. Review of the nursing progress notes from 03/08/2025 to 03/10/2025 revealed no documented evidence that the resident was assessed by a Registered Nurse. There was also no documented evidence of Resident #2 exhibiting behavior on 03/08/2025 During an interview on 07/31/2025 at 10:35 AM, Licensed Practical Nurse #2 stated that they were the charge nurse on the 7-3 shift on 03/08/2025. Licensed Practical Nurse #2 stated that they were by the pantry, which is opposite from the Resident #2 room, and they heard Resident #2 was talking loudly. Licensed Practical Nurse #2 stated that they went to see what happened and observed Certified Nursing Assistant #2 serving coffee. Certified Nursing Assistant #2 was approximately four feet away and had an overbed table between them and Resident #2. Resident #2 was sitting on their bed and yelling. Licensed Practical Nurse #2 stated that they asked Certified Nursing Assistant #2 what was happening, and Certified Nursing Assistant #2 said they were picking up the cups from the overbed table, and Resident #2 became upset, started throwing stuff from their table to the floor, and yelling. Licensed Practical Nurse #2 stated that they told Certified Nursing Assistant #2 to leave the room and let the resident calm down. Licensed Practical Nurse #2 stated that they provided emotional support and called Registered Nurse Supervisor #2. Licensed Practical Nurse #2 stated that they don't recall why they did not document Resident #2's behavior in the resident's medical chart, and they should have documented. During an interview on 07/31/2025 at 11:07 AM, Registered Nurse Supervisor #2 who worked on 03/08/2025 7-3 shift, stated that on 03/08/2025 around 2:30 PM, Resident #2 came to the office and reported Certified Nursing Assistant #2 hit their shoulder, took their coffee, threw coffee on the bed, and all staff from the overbed table to the floor. Registered Nurse Supervisor #2 stated that they went immediately to the unit with Resident #2 and assessed their skin. Registered Nurse Supervisor #2 stated that no injury or redness was noted. Registered Nurse Supervisor #2 was not able to recall which arm Resident #2 was complaining about. Registered Nurse Supervisor #2 stated they don't remember why they did not document the body assessment in Resident #1's Electronical Medical Record. Registered Nurse Supervisor #2 stated that they are responsible and should have documented the body assessment, that they called the Medical Doctor and Psychiatry and Psychology consults orders were taken and that the police came. Registered Nurse Supervisor #2 stated they notified the Director of Nursing right away and initiated the incident report. Registered Nurse Supervisor #2 also stated that they are responsible for monitoring if Licensed Practical Nurses are writing behavior notes. Registered Nurse Supervisor #2 stated that Licensed Practical Nurse#2 should have documented Resident #2's behavior on 03/08/2025 in the progress note, the resident's Electronic Medical Record, and the intervention that was implemented. During an interview on 07/31/2025 at 12:05 PM, Registered Nurse Supervisor #3, who worked on 03/08/2025 3PM-11PM shift, stated they checked Resident #2's well-being and interviewed Resident #2 after 5:00 PM due to an incident at 2:30 PM, but did not document in Resident#2's medical record, and should have. During an interview on 07/31/2025 at 12:44 PM, the Director of Nursing stated that Registered Nurse Supervisor #2 did not document Resident #2's body assessment in their Electronic Medical Record chart and should have. The Director of Nursing stated that the Registered Nurse Supervisor is responsible for documenting body assessment in the resident's medical chart and any interventions that were taken. The Director of Nursing stated that Licensed Practical Nurse #2 should have documented in the resident's medical chart the resident's behavior, and that the police had come. The Director of Nursing stated that they oversee the nursing department and are responsible for investigating and reporting the incident. 10 NYCRR 415.22(a) (1-4)

Based on observation, interviews, and record review conducted during an Abbreviated Survey (NY00374237), the facility failed to ensure that all alleged violations are thoroughly investigated in response to allegations of abuse, neglect, exploitation, or mistreatment, and that the results of all investigations are reported to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency. This was evident for one out of six residents (Resident #1) reviewed for abuse. Specifically, during an interview on 07/30/2025 at 11:30 AM, Licensed Practical Nurse #1 stated that on 03/01/2025 or 03/02/2025, Resident #1's family complained to them that Certified Nursing Assistant #1 was verbally rough with Resident #1. Licensed Practical Nurse #1 stated that they called and notified Registered Nurse Supervisor #2. Registered Nurse Supervisor #2 did not initiate an investigation, did not remove Certified Nursing Assistant #1 from the schedule pending investigation, and did not inform the Director of Nursing or the Administrator.The findings are: The facility's Policy and Procedure entitled Abuse Prevention with last review date of 12/29/2023 documented it is the policy of this facility that if any staff is made aware of any alleged violation of abuse, neglect or mistreatment the facility will thoroughly investigate the alleged violation, attempt to prevent further abuse, neglect, exploitation and mistreatment from occurring while the investigation is in progress, and take appropriate corrective action as a result of investigation findings. The facility's Policy and Procedure entitled Accident and Incident Investigation and Reporting, last review date of 12/29/2023, documented that the Registered Nurse Supervisor is responsible for initiating the Accident and Incident form by ensuring that all required investigation statements are completed in a timely manner. Resident #1 was admitted to the facility with diagnoses including Hemiplegia, Hemiparesis, and Cerebral Infarction.The Minimum Data Set (a resident assessment tool), dated 03/05/2025, identified that Resident #1 had intact cognition. A Care Plan Behaviors: Risk for Abuse, effective date 02/26/2025, documented interventions include assisting the resident with concerns as they arise. A review of the Accident/Incident Log dated from 03/01/2025 to 03/31/2025 revealed that no incident for Resident #1 was registered in the log A review of the Grievance Log dated from 03/01/2025 to 03/31/2025, no grievance was documented regarding Resident #1's family complaint.A review of the Nursing Notes dated 03/01/2025-03/05/2025 revealed no documented evidence that Licensed Practical Nurse #1 and Registered Nurse Supervisor #1 spoke with Resident #1's family. During an interview on 7/30/2025 at 11:06 AM, the assigned Certified Nursing Assistant #1, who worked on the 7-3 shift on 03/01/2025 and 03/02/2025, stated that they remember Resident #1. Certified Nursing Assistant #1 stated they don't remember the exact day they observed Resident #1 ambulate to the bathroom with no assistance. Certified Nursing Assistant #1 stated they got a wheelchair that was close and placed it behind the resident to prevent a fall. A day or two after, the family came, and they spoke with Licensed Practical Nurse #1. Certified Nursing Assistant #1 stated that after Licensed Practical Nurse #1 talked with the family, Licensed Practical Nurse #1 told them that they could not go to Resident #1's room, and no one explained why. Certified Nursing Assistant #1 stated they were not asked to write a statement. During an interview on 07/30/2025 at 11:30 AM, Licensed Practical Nurse #1 stated that they worked on 03/01/2025 and 03/02/2025, 7-3 shifts. Licensed Practical Nurse #1 stated on 03/01/2025 or 03/02/2025 that they went to the room and the family member was there, who said they don't want Certified Nursing Assistant #1 to provide care for Resident #1. Licensed Practical Nurse #1 stated that a family member told them that Certified Nursing Assistant #1 spoke in the manner that Resident #1 did not like, and that Certified Nursing Assistant #1 was not nice to Resident #1 and was rough verbally. Licensed Practical Nurse #1 stated that they asked Resident #1, but they did not say anything except that they don't want Certified Nursing Assistant #1 providing care. Licensed Practical Nurse #1 stated that it was a form of abuse to be verbally rough with Resident #1. Licensed Practical Nurse #1 stated that they removed Certified Nursing Assistant #1 from Resident #1's care assignment, but they continued with the rest of their resident care assignments. Licensed Practical Nurse #1 stated that they had notified the Registered Nurse Supervisor #1, who came and spoke with the family member. Licensed Practical Nurse #1 stated that they were not asked to write a statement. During an interview on 07/30/2025 at 12:46 PM, Registered Nurse Supervisor #1, who worked on 03/02/2025 7-3 shift, stated Licensed Practical Nurse #1 informed them that the family doesn't want Certified Nursing Assistant #1 to take care of Resident #1. Registered Nurse Supervisor #1 stated they spoke with a family member who said that Resident #1 doesn't like Certified Nursing Assistant #1 because the tone of their voice was not nice when Resident #1 was ambulating by themself, and Certified Nursing Assistant #1 said it was not safe for Resident #1 to be ambulating by themself. Registered Nurse Supervisor #1 stated they switched Certified Nursing Assistant #1's assignments. Registered Nurse Supervisor #1 stated they did not report the incident to the Director of Nursing because there was no harm to Resident #1, and it was not a big deal. Registered Nurse Supervisor #1 stated that they did not ask Certified Nursing Assistant #1 what had happened, did not remove them from the unit, and did not initiate an investigation. During an interview on 07/30/2025 at 1:08 PM, the Director of Nursing stated that they were not informed on 03/02/2025 of any incident regarding Resident #1. The Director of Nursing stated that they should have started an investigation or grievance when Resident #1's family member complained of Certified Nursing Assistant #1 being verbally inappropriate and reported it immediately to the Director of Nursing. The Director of Nursing stated it should have been investigated to rule out abuse, neglect, or mistreatment. The Director of Nursing also stated that Certified Nursing Assistant #1 should have been sent home pending investigation. The Director of Nursing further stated that any alleged abuse should be thoroughly investigated and reported to the Department of Health. During an interview on 07/31/2025 at 1:39 PM, the Administrator stated that they were not made aware of any family complaint against Certified Nursing Assistant #1 being verbally rough with Resident #1. The Administrator stated it should be investigated. The Administrator stated Registered Nurse Supervisor #1 should have notified the Director of Nursing and the Administrator immediately. The Administrator stated it should be investigated, and based on the nature of the allegation, the proper authorities and necessary staff should be notified, and appropriate action should be taken. 10 NYCRR 483.12(c)(2)(4)

Based on observation, interviews, and record reviews conducted during Abbreviated Survey (NY00351660), the facility failed to protect a resident from physical abuse by nursing home staff. This was evident in 1 out of 3 residents (Resident #1) sampled for abuse. Specifically, on 08/17/2024 at 3:25 PM, Certified Nursing Assistant #1 reported that they observed Dietary Worker #1, used their foot to push the wheel of Resident #1's wheelchair out of the elevator. Resident #1 slipped out of their wheelchair into a sitting position on the footrest of their (Resident #1) wheelchair and on to the floor. Resident #1 was assessed by Registered Nurse Supervisors #1 with no visible injuries. The findings are: The Facility's Policy on Abuse Prevention reviewed 12/20/2023, documented that it is the policy to provide a safe environment that protects residents from abuse- including verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. This includes staff to resident abuse of any type, resident to resident abuse of any type and visitor to resident abuse of any type. The Facility's Policy and Procedure on Fall Prevention reviewed 02/2024, documented that each resident will be assessed by his/her risk for falls on admission, re-admission, quarterly and with a change in condition. Each resident will have an individualized care plan outlining their fall prevention measures. Resident #1 was admitted to facility with diagnoses including Major Depressive Disorder and Psychotic Disorder with Borderline Personality Disorder. The Minimum Data Set, dated dated dated [DATE] documented that Resident #1 had intact cognition. A Risk for Abuse Care Plan dated 01/06/2023 (updated quarterly) documented interventions for staff to encourage Resident #1 to voice concerns to staff. Staff to address Resident #1's concerns as they arise. The care plan was updated 08/17/2024 to reflect on the abuse allegation. The Accident/Incident Report dated 08/17/2024 at 3:25 PM documented that Resident #1 was pushed back out of the elevator and slipped out of the wheelchair falling on to the floor. Resident #1 was assessed by Registered Nurse Supervisors #1 in the presence of Certified Nursing Assistant #1, and there were no visible injuries. The Incident Summary Investigation dated 08/19/2024 concluded that there was credible evidence that abuse occurred. During an interview on 08/26/2024 at 10:00 AM, Resident #1 stated that they were sitting on their wheelchair attempting to enter the elevator and Dietary Worker #1, who was in the elevator, pushed their wheelchair and they (Resident #1) fell out of their wheelchair. Resident #1 stated that they fell landed in a sitting position on the footrest of the wheelchair and on to the floor. Resident #1 stated that they do not recall if Dietary Worker #1 used their hand or foot to push their wheelchair. Resident #1 stated that they did not have any pain or injury. Resident #1 stated that Certified Nursing Assistant #1, who was in the dining room, saw what happened and ran to assist them (Resident #1) and called for help. Resident #1 stated that Law Enforcement arrived and interviewed them, but they did not give them a report. During a telephone interview on 08/27/2024 at 10:16 AM (with the use of an interpreter- Director of Recreation), Dietary Worker #1 stated that they exited the elevator on the 5th floor to deliver a garbage can on 08/17/2024. Dietary Worker #1 stated as they (Dietary Worker #1) reentered the elevator, they observed Resident #1 also entering the elevator and they (Dietary Worker #1) put their hands up (as a gesture for Resident #1 to stop) to prevent Resident #1 from entering the elevator. Dietary Worker #1 stated that they had three garbage cans in the elevator to be delivered to other floors. Dietary Worker #1 stated that when they put their hands up, Resident #1 backed their wheelchair out of the elevator and put themself (Resident #1) on the floor. Dietary Worker #1 stated that when Resident #1 was on the floor, Certified Nursing Assistant #1 came and assisted Resident #1. Dietary Worker #1 stated that a staff member (does not know the name of staff) saw them exited the elevator with the garbage can and saw them reentered the elevator. Dietary Worker #1 stated that they did not touch or push Resident #1's wheelchair. During an interview on 08/26/2024 at 3:15 PM, Certified Nursing Assistant #1 stated that they were standing in the dining room between the air conditioner and close to the television (about 50 feet) where they were able to see the elevator. Certified Nursing Assistant #1 stated from where they were standing in the dining room, they were able to see persons entering the elevator, but was unable to see inside the elevator. Certified Nursing Assistant #1 stated that Resident #1 notified them that they were leaving the unit and they observed Resident #1 entered the elevator and a foot (wearing a black sneaker) pushed the wheel of Resident #1's wheelchair. Certified Nursing Assistant #1 stated that they ran to the elevator as they saw that Resident #1 was in the process of sliding out of the wheelchair, but Resident #1 fell out of the wheelchair landing on the footrest of the wheelchair and on to the floor. Certified Nursing Assistant #1 stated that they grab the arm of the wheelchair to prevent the wheelchair from falling forward. Certified Nursing Assistant #1 stated that they called for Registered Nurse Supervisor #1. Certified Nursing Assistant #1 stated that Dietary Worker #1 was inside the elevator and was wearing black sneakers. Certified Nursing Assistant #1 stated that Resident #1 got up from the floor by themself. During an interview on 08/26/2024 at 11:06 AM, Registered Nurse Supervisor #1 stated that Certified Nursing Assistant #1 notified them that Resident #1 was entering the elevator and Dietary Worker #1 pushed Resident #1's wheelchair out of the elevator. Registered Nurse Supervisor #1 stated that Certified Nurse Supervisor #1 also reported that Dietary Worker #1 used their foot to push the wheel of Resident #1's wheelchair and Resident #1 subsequently fell out of their wheelchair onto the floor. Registered Nurse Supervisor #1 stated that they assessed Resident #1 and there were no injuries and Resident #1 did not complain of pain or discomfort. Registered Nurse Supervisor #1 stated that they notified Law Enforcement, and no arrest was made. During an interview on 08/26/2024 at 10:23 AM, the Administrator stated that they were notified by Registered Nurse Supervisor #1 on 08/17/2024 (cannot recall the time) that Resident #1 alleged that the Dietary Worker #1 pushed their wheelchair to prevent them from entering the elevator. Administrator stated that, they and the Corporate Nurse #1 conducted the investigation, and that Dietary Worker #1 was suspended pending investigation. The Administrator stated that Registered Nurse Supervisor #1 called 911 and they responded. The Administrator stated that there was no video footage because the 5th floor camera was not functioning. The Administrator stated that they reviewed the video footage in the lobby, (1st floor) to view the color of that sneakers that Dietary Worker #1 was wearing. The Administrator stated that the video footage confirmed that Dietary Worker #1 was wearing black sneakers. The Administrator stated that the investigation concluded that the allegation of abuse was substantiated because of Certified Nursing Assistant #1's statement. 10 NYCRR 415.4(b)(1)(i)

Based on interviews and record review conducted during an abbreviated survey (NY00296544), the facility failed to implement their policy and procedure on reporting an alleged violation involving abuse to law enforcement and to New York State Department of Health (NYSDOH) 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, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials. This was evident in 1 out of 5 residents reviewed (Resident #1). Specifically, 1) Resident #1 reported to the facility Concierge, on 05/23/2022, that they were sexually assaulted by Resident #2. The Concierge did not report the alleged allegation to their supervisor immediately. The allegation was reported on 05/25/2022 at approximately 10:00 AM, during a morning report, by the Director of Recreation (DOR). 2) The Minimum Data Set (MDS) Coordinator also became aware of the alleged incident on 05/24/2022 and did not report the allegation immediately. 3) The facility Administrator became aware of the allegation on 05/25/2022. As a result, there was a delay in staff assessment of Resident #1 and a delay in implementing appropriate interventions to protect Resident #1 and other Residents. The Findings include: The facility's Policy and Procedure titled Abuse Prevention reviewed on 04/2022 documented that it is the policy of the facility to provide a safe resident environment that protects residents from abuse - including verbal, mental, sexual, or physical abuse, corporate punishment, or involuntary seclusion. This includes staff to resident abuse of any type, resident to resident abuse of any type and visitor to resident abuse of any type. Under Procedure it was documented that any staff member that observes or is informed of any potentially abusive situation is mandated to report this to the RN supervisor on staff. All allegations of mistreatment, neglect, and abuse, including injuries of unknown origin and misappropriation of resident property will immediately reported to the Administrator and Director of Nursing (DON). All allegations of abuse and accidents resulting in serious bodily injuries must be reported to the New York State Department of Health (NYSDOH) within 2 hours. All reasonable suspicious of crimes (Elder Justice Act) must be reported to the police and the NYSDOH, regardless of whether it is perpetrated by facility staff, residents, or visitors. Resident #1 was initially admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Schizophrenia, and Pain. The MDS (a resident assessment tool) dated 04/14/2022 documented that Resident #1 had moderately impaired cognition. Resident #1 required extensive assistance of one person assist with toileting and limited assistance of one person with walking in room and corridor. Resident #2 is a [AGE] year-old male, initially admitted to the facility on [DATE] with diagnoses Diabetes Mellitus and Pain. The MDS dated [DATE] documented that Resident #2 had severely impaired cognition. Resident #2 required supervision of one person with bed mobility, transfer, walking in room and corridor. A Nurse's Note, written by Registered Nurse Supervisor (RNS) #1, dated 05/25/2022 documented that the DOR reported during morning report that Resident #1 verbalized that they were sexually assaulted by another Resident in the unit. Resident #1 was interviewed and stated that the incident occurred on Sunday 05/22/2022 in their bathroom with the door closed. Resident #1 stated that a man came into their room and tried to take their dress off. Resident #1 fought back, and the man backed off. Resident #1 said that they did not scream for help or report the incident to the nurse supervisor. Resident #1 later stated that they reported the incident to a blonde hair Certified Nurse Assistant (CNA). Resident #1 said they were fearful because they had a history of multiple rape incidents when they were homeless. Resident #1 was examined with no injuries found. The Medical Doctor was informed and gave an order to transfer Resident #1 to the hospital. A Facility summary of investigation dated 05/26/2022 documented that on 05/25/2022 at approximately 10:45 AM Resident #1 alleged that on 05/22/2022 at around 4:00 PM a male Resident (Resident #2) attempted to sexually assault them in the bathroom in their room. Resident #1 said that they did not scream for help or report to the nurse supervisor because they were shocked. Resident #1 stated that they reported the incident to a staff (CNA #1) who served them dinner. Resident #1 was examined and was found with no injuries. Resident #1 complained of right hip pain, there were no changes in Range of Motion (ROM), no discoloration, or bruises found. The Police Officers arrived and interviewed Resident #1. Resident #1 was transferred to the hospital for an evaluation. The investigation concluded that there was no evidence of sexual assault noted. During an interview on 05/23/2022 at 10:35 AM, Resident #2 stated that they did not recall Resident #1 and the incident. CNA #1 provided a written statement to the facility dated 05/25/2022. The statement documented that on Monday 05/23/2022 CNA #1 entered Resident #1's room with the dinner tray and witnessed Resident #2 coming out from the bathroom with Resident #1. CNA #1 asked Resident #2 what they were doing in the bathroom with Resident #1 and Resident #2 said that they were looking for their room. CNA #1 asked Resident #1 what they were doing in the bathroom with Resident #2 and Resident #1 said nothing. CNA #1 stated that both Residents were dressed, so CNA #1 did not report the incident to the nurse. During an interview on 11/23/2022 at 12:14 PM, the Concierge stated that on 05/23/2022 after lunch time Resident #1 reported that they were sexually harassed by another resident in the unit. The Concierge stated that Resident #1 did not mention the name of the other resident. The Concierge stated that Resident #1 said that they did not tell anybody about the incident. The Concierge stated that Resident #1 said that it happened so fast that they froze. The Concierge stated that Resident #1 could not describe the aggressor and stated that the aggressor was tall. The Concierge stated that they reported the incident to their supervisor (DOR) the next day. The Concierge stated that it was a busy day and when they did remember to report the allegation their supervisor had already gone for the day. During an interview on 11/23/2022 at 12:27 PM, with Registered Nurse Supervisor (RNS) #1 stated that they worked on 11/25/2022 on the 8:00 AM to 4:00 PM shift. RNS #1 stated that on 05/25/2022 at around 10:00 AM during the morning meeting, the DOR reported that Resident #1 alleged that they were sexually assaulted by another Resident in their unit. RNS #1 stated together with the Social Worker (SW) they went to Resident #1's room to interview Resident #1. RNS #1 stated that Resident #1 stated that a man from their unit came into their room on Sunday (05/22/2022) around 4:00 PM and the man was very aggressive and tried to take off their dress. Resident #1 stated that they fought and pulled back from the man. Resident #1 said that they were wearing a red dress and the incident happened in the bathroom in their room with the door closed. Resident #1 stated that they did not scream for help. RNS #1 stated that Resident #1 initially stated that they did not report the incident to the supervisor, but then they said that they reported the incident to the blonde hair CNA. RNS #1 stated that they interviewed staff who worked at the time, and no one fit the description. RNS #1 stated that a total body audit was done for Resident #1 and no signs of trauma, bruises, or discoloration was observed. RNS #1 stated that the MD was called and gave an order to transfer Resident #1 to the hospital. RNS #1 stated that the police were called, and the Police Officers came and interviewed Resident #1. During an interview on 11/23/2022 at 1:05 PM, the DOR stated that on 05/25/2022 at around 10:00 AM the Concierge informed them that Resident #1 reported that Resident #1 was sexually harassed by another resident in the unit. The DOR stated that they reported the incident to the morning report immediately on 05/25/2022 at about 10:20 AM. During an interview on 11/23/2022 at 11:40 AM, the Director of Nursing (DON) stated that they learned about the incident from the DOR on 05/25/2022 during morning report around 10:30 AM. The DON stated that on 05/23/2022 CNA #1 observed Resident #2 coming out from Resident #1's bathroom and Resident #1 followed behind Resident #2. The DON stated that CNA #1 did not report the occurrence to the nurse. The DON stated that Resident #1 reported the incident to the Concierge who also failed to report the incident immediately stating that they were distracted by other residents at the time. The DON stated that the Police were called and interviewed Resident #1. The DON stated that Resident #1 told the police a whole different story. The DON stated that Resident #1 told the police that 5 different people came into their bathroom attempting to sexually assault them. The DON stated that Resident #1 told the police that there was no sexual penetration occurred at the time of the incident. The DON stated that Resident #2 did not recall going into Resident #1's room and denied the allegation. The DON stated that both residents were examined and found with no injuries. The DON stated that there was no evidence of sexual assault found to conclude that abuse had occurred. During an interview on 11/23/2022 at 12:50 PM, with the MDS Coordinator stated on 5/24/2022 around 3:30 PM they went to see Resident #1's roommate (Resident #3) and that Resident #3 told them that two days ago (05/22/2022) at around lunch time a female staff came in with a tray and did not find Resident #1 in their bed. The MDS Coordinator stated that Resident #3 stated that the staff opened the bathroom door, and Resident #3 could hear Resident #1 saying no, no. Resident #3 stated that Resident #1 said that they had blue marks. The MDS Coordinator stated that Resident #3 also stated that Resident #1 told Resident #3 that it was an older guy with a mustache and beard about 70 - [AGE] years old and wearing a red shirt. The MDS Coordinator stated that Resident #3 said that the staff was a young lady with long hair. The MDS Coordinator stated that they forgot to report the incident promptly. The MDS Coordinator stated that they recalled the incident when it was reported during the morning report by the Director of Recreation. 10 NYC RR 415.4(b)

Based on observation, interviews and record review conducted during an abbreviated survey (NY 387) on 11/8/2021, the facility did not maintain medical record on a resident that was complete. This was evident for 1 out of 4 residents sampled (Resident #1). Specifically, Resident #1 eloped from the facility on 04/09/2021 at approximately 3:34 PM and did not return to the facility. There was no documentation of the elopement in Resident #1's progress notes. The findings are: A facility policy entitled Elopement Policy and Procedure, revised on 02/19/2018, revealed that documentation regarding the elopement will be done in the nurses' notes as well as the physician's progress notes. Other departmental progress notes will be documented as indicated. Resident #1 was admitted to facility on 04/08/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) was not done because Resident #1 resided in the facility for less than 24 hours. The Hospital Discharge record documented that Resident #1 was alert and oriented to name, time, and place. A Facility's Accident/Incident Report and Internal Investigation dated 04/09/2021 documented that the surveillance video recording documented that Resident #1 left the facility at 3:24 PM. Resident #1 was wearing black and gray long-sleeved sweater, black pants, shoes, and a mask. The resident was last seen by Licensed Practical Nurse (LPN) #1 at 3:00 PM. It's documented that LPN #1 reported Resident #1 was missing at approximately 6:30 PM. LPN #1's written statement dated 04/09/2021 documented that LPN #1 last saw Resident #1 at 3:00 PM. The statement also documented that LPN #1 went to check Resident #1's vital signs at 3:15 PM and Resident #1 was not in his/her room. LPN #1 documented that he/she immediately informed the Registered Nurse Supervisor (RNS). RNS #1's written statement dated 04/09/2021 documented that LPN #1 reported between 6:00-6:30 PM that Resident #1 was missing. The Home Health Aid (HHA's) written statement documented that while he/she was in the Temperature room, he/she observed that a person came from the elevator and he/she asked the Security Guard (SG) #1 if he/she saw a person just went through the door. SG #1 denied seeing a person. The HHA documented that he/she shouted to a Housekeeping Staff (HS) that a man just went through the door and the HS informed the senior person. The HS's written statement documented that that a little after 3:00 PM, they were told that a resident walked out the building. The HS documented that he/she immediately informed the Social Worker who told him/her that it would be looked into. The HS documented that he/she went outside but did not see anyone. SG #1's written statement documented that he/she was dealing with visitors and answering phone calls. At approximately 3:27 PM, SG #1 documented that he/she was told that a strange person had left, and the HS informed the Social Worker. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #1 documented that the medications were not given as Resident #1 was not in his/her room. Review of Resident #1's progress notes revealed that the elopement was not documented. A follow-up interviewed was conducted with the RNS #1 on 11/24/2021 at 11:44 AM. RNS #1 stated that he/she did not see it necessary to write a note in Resident #1's medical record. RNS #1 stated that he/she did not see or assessed Resident #1 and that she had written a statement. A follow-up interviewed was conducted with the DNS on 11/24/2021 at 12:20 PM, The DNS stated that LPN #1 should have documented the elopement in the progress note and that the RNS should have documented on the elopement and interventions implemented in Resident #1's progress note, or the care plan. The DNS reported that the RNS should have ensured that LPN #1 documented in progress note as the LPN was the first person who had knowledge that the resident was missing. The DNS voiced that it was documented in Accident/Incident form which is a part of the legal resident's record. 415.12

Based on observation, interviews and record review conducted during an abbreviated survey (NY 387) on 11/08/2021, the facility failed to ensure that a resident received adequate supervision to prevent elopement. This was evident for 1 out of 4 residents sampled (Resident #1). Specifically, the facility surveillance camera documented on 04/09/2021 at approximately 3:34 PM, Resident #1 walked out of the facility via the main entrance door in the lobby. Resident #1 was missing for approximately three and-a-half hours before facility staff started searching for Resident #1 (at approximately 6:30 PM). Resident #1's family member notified a facility staff at 10:30 PM that Resident #1 was at their home and would not be returning to the facility. The findings are: A facility policy entitled Elopement Policy and Procedure, revised on 02/19/2018, documented that it is the policy of the facility that residents will be maintained in a safe and secure manner and be protected from actual harm while encouraging a restrain free environment. This document also revealed that documentation regarding the elopement will be done in the nurses' notes as well as the physician's progress notes. Other departmental progress notes will be documented as indicated. A facility Policy and Procedure titled Medication Administration dated 09/20/2021, documented that each resident will be provided with medication administration as ordered by the PMD (Private Medical Doctor). Medications will be administered in appropriate texture/form for oral medications in accordance with their order. Residents will be monitored for response to medication regime by licensed nurse. PMD will be informed when resident refuses scheduled medications. The Policy did not specify what staff should do if a resident was not available for medication. A facility Policy titled Criteria for Resuming Visitation, superseded 03/28/2021, documented that a designated staff will be assigned to escort visitors to the designated visitor location and to ensure limited visitor movement around facility. There was no instruction for visitors to sign out of the facility. An unsigned Receptionist/Security Guard Job Description documented that the Receptionist/Security duties included documenting in the logbook for all residents who are leaving the building, i.e., Out on Pass, Clinic Appointments, and Transfers. Receptionist/Security should review the documentation to ensure that the resident paperwork matched armband. Ensure visitors sign in and ensure that only authorized persons enter and exits the building. There was no instruction for visitors to sign out of the facility. Resident #1 was admitted to facility on 04/08/2021 with diagnoses including [CONDITION(S)] secondary to COVID-19, Diabetes Mellitus and Developmental Delay. The Minimum Data Set (MDS, a resident assessment tool) was not done because Resident #1 resided in the facility for less than 24 hours. The Hospital Discharge record documented that Resident #1 was alert and oriented to name, time, and place. A Facility's Accident/Incident Report and Internal Investigation dated 04/09/2021 documented that the surveillance video recording documented that Resident #1 left the facility at 3:24 PM. Resident #1 was wearing black and gray long-sleeved sweater, black pants, shoes, and a mask. The resident was last seen by Licensed Practical Nurse (LPN) #1 at 3:00 PM. It's documented that LPN #1 reported Resident #1 was missing at approximately 6:30 PM. LPN #1's written statement dated 04/09/2021 documented that LPN #1 last saw Resident #1 at 3:00 PM. The statement also documented that LPN #1 went to check Resident #1's vital signs at 3:15 PM and Resident #1 was not in his/her room. LPN #1 documented that he/she immediately informed the Registered Nurse Supervisor (RNS). RNS #1's written statement dated 04/09/2021 documented that LPN #1 reported between 6:00-6:30 PM that Resident #1 was missing. The Home Health Aid (HHA's) written statement documented that while he/she was in the Temperature room, he/she observed that a person came from the elevator and he/she asked the Security Guard (SG) #1 if he/she saw a person just went through the door. SG #1 denied seeing a person. The HHA documented that he/she shouted to a Housekeeping Staff (HS) that a man just went through the door and the HS informed the senior person. The HS's written statement documented that that a little after 3:00 PM, they were told that a resident walked out the building. The HS documented that he/she immediately informed the Social Worker who told him/her that it would be looked into. The HS documented that he/she went outside but did not see anyone. SG #1's written statement documented that he/she was dealing with visitors and answering phone calls. At approximately 3:27 PM, SG #1 documented that he/she was told that a strange person had left, and the HS informed the Social Worker. A Physician's Order dated 04/08/2021 documented to monitor Resident #1's Vital Signs every day at 11:00 pm-7:00 am; 3:00 pm-11:00 pm; and 7:00 am-3:00 pm. [MEDICATION(S)] 1,000 mg tablet give 1 tablet (1000 mg) by oral route 2 times per day with food; [MEDICATION(S)] (U-100) 100 unit/mL subcutaneous solution inject 4 units by subcutaneous route 3 times per day. The Medication Administration Record (MAR) dated 04/09/2021, revealed that Resident #1 did not receive his/her 4:30PM [MEDICATION(S)] and [MEDICATION(S)] 1000mg at 6:00 PM. LPN #1 documented that the medications were not given as Resident #1 was not in his/her room. A Resident CNA Documentation Record dated from 04/08/2021 to 04/9/2021, revealed that there was no instruction for Resident #1 to be monitored. Review of Resident #1's medical record revealed that there was no documentation to reflect that Resident #1 eloped from the facility on 04/09/2021. Multiple attempts to contact SG #1, who worked on 04/09/2021 when Resident #1 eloped from the facility, was unsuccessful. No return calls to date. During an interview on 10/27/2021 at 12:55 PM, SG #2 stated that all visitors are required to sign in, but they are not required to sign out of the facility. During an interview on 10/27/2021 at 1:30 PM, CNA #1, who worked on 04/09/2021 on the 3-11 shift, stated that when he/she came to the unit at 3:00 PM to 5:00 PM and was not assigned to Resident #1. CNA #1 stated that he/she never saw Resident #1 on the unit. CNA #1 stated that Resident #1 was re-assigned to another CNA (CNA #2) after dinner time (5:00-5:30 PM). CNA #1 stated that he/she learnt of the elopement from another staff member. CNA #1 stated that he/she does rounds as often as possible. Residents at risk for elopement are on scheduled monitoring every 15 to 30 minutes or they are placed on 1:1 as directed by the charge nurse. During an interview on 10/27/2021 at 1:55 PM, CNA #2, who worked a double shift (7-3 & 3-11) on 04/09/2021, stated that he/she was not assigned to Resident #1 on the 7-3 shift. CNA #2 stated that he/she observed Resident #1 walking on the unit with no behavior and that he/she last saw Resident #1 at 2:55 PM in his/her room. CNA #2 stated that Resident #1 was initially assigned to CNA #1 on the 3-11 shift, but at around 5:00 PM, LPN #1 reassigned Resident #1 to him/her (CNA #2). CNA #2 stated that he/she did not check on Resident #1 immediately because he/she was busy changing another resident. CNA #2 stated that another CNA informed him/her that Resident #1 was missing (does not recall time) and everyone started searching for Resident #1. CNA #2 stated that all staff members are responsible for the residents on the unit and that he/she does rounds as often as possible. CNA #2 stated if a resident was not at risk for elopement, the resident would not be on a scheduled visual monitoring. All staff are responsible for checking the residents' whereabouts. During an interview on 10/27/2021 at 3:00 PM, the Housekeeping Staff (HS) stated that someone (Home Health Aide) who was in the Temperature room next to the security desk, told him/her that he/she saw a resident ran out of the building. The HS stated that he/she immediately went to the Social Worker (SW) office, was the closest, and told the SW (does not know name) that a resident left the facility. The HS stated that the SW told him/her that he/she would look into it. The HS stated that he/she went outside the building to check but did not see anyone. The HS stated that he/she does not know if the SW reported the information right away because later, he/she assisted in the search for Resident #1. During an interview on 10/27/2021 at 2:27 PM, LPN #1, who worked on 04/09/2021 on the 3-11 shift, stated that he/she observed Resident #1 at the beginning of the shift and that Resident #1 was walking around the unit calmly. Resident #1 was not looking for an exit and Resident #1 was not an elopement risk. LPN #1 stated that Resident #1 was being monitored by staff every 1-2 hours (not documented). LPN #1 stated that staff only document on residents who are on scheduled monitoring. LPN #1 reported that a CNA, notified him/her that Resident #1 was not in his/her room (LPN does not recall CNA's name, and time he/she was notified). LPN #1 stated that they checked the resident's room and everywhere on the unit, but they could not locate Resident #1. LPN #1 stated that he/she notified the supervisor (does not recall time) much earlier than the facility wrote in investigation. Interview with LPN #1 was terminated as the surveyor was unable to redirect LPN #1's attention to answering questions. During an interview on 10/27/2021 and 11/24/2021, Registered Nurse Supervisor (RNS) #1, who worked per diem on the 3-11 shift, stated that he/she came to Resident #1's unit at approximately 4:00 PM to assist with another resident. RNS #1 stated that LPN #1 notified him/her between 6:00 and 6:30 PM that it looks like one of the residents is missing. RNS #1 stated that a search was initiated but Resident #1 was not located. RNS #1 stated that he/she notified the Assistant Director of Nursing and the Administrator right away. The Code for Elopement was initiated by Security immediately. The Police, Medical Doctor, and Resident #1's family member was notified. During an interview on 10/27/2021 at 4:45 PM, the Administrator stated at about 7:20 PM on 04/09/2021, he/she was notified of the elopement and an investigation was initiated. The Administrator stated that Resident #1's family member was contacted at 7:30 PM and the family member called the facility at 10:25PM notifying that Resident #1 just came to their home safely. The family reported that Resident #1 was not returning to the facility. The Administrator stated that the Director of Social Service (DSS) failed to inform nursing about Resident #1 exiting the facility. The Administrator voiced that the DSS denied any knowledge about the elopement, however, during camera review, it was observed that a HS went toward the DSS's office. The Administrator stated that the DSS was the only SW in the facility and that the HS identified the DSS by the name. The Administrator also reported that during the investigation they found that LPN #1 failed to give due medications to Resident #1 at 4:30 PM. LPN #1 wrote that Resident #1 was not in his/her room. LPN #1 did not look for Resident #1 and lied in the statement that he/she notified the supervisor, that Resident #1 was missing, at around 3:00 PM. During an interview on 11/05/2021 at 2:22 PM, the former Director of Social Service (DSS) left a voice message on the surveyor's voicemail stating that he/she was not aware of any elopement from the facility. The DSS stated that no one notified him/her of any resident leaving the building. The DSS stated that he/she did not see the HS in him/her office. The DSS stated that he/she was the only Social Worker at that time in the facility. The DSS voiced that he/she recalled receiving a phone call from head of security between 4:00 PM and 5:00 PM regarding the elopement. The DSS stated that he/she told head of security that he/she had no knowledge of the elopement. The DSS stated that he/she did not call and asked anyone questions about the elopement because it was not his/her concern. A Follow up interview with the Administrator was conducted on 11/12/2021 at 3:34 PM. The Administrator stated that the security guards are hired by an outside company and have their own managers. The Administrator voiced that the facility provided the related in-service training to the Security Guards. The Administrator also stated that there are no requirements for visitors to sign out of the facility. The visitation policy requires all visitors to be always supervised and to be escorted out of the facility. The Security Guard must sign visitors in but not out. During an interview on 11/15/2021 at 4:40 PM, the DNS stated that he/she was not working in the facility at the time of the elopement. The DNS stated that it is standard of practice for a nurse to locate a resident on the unit for medications. If a resident cannot be located on the unit, the nurse should ask the staff about the resident's whereabouts. If the resident is not located on the unit, staff should look for the resident throughout facility. If resident cannot be located, code for Elopement should be initiated and reported according to the elopement policy. The DNS stated that it is unacceptable for staff to document in MAR that a resident is not in the room during med pass. The DNS also stated if a resident is not on scheduled monitoring, staff should monitor the resident during rounds at the beginning of shift and to eyeball the residents soon as they can. Each CNA is responsible for monitoring his/her assigned resident. If the CNA goes on break, another CNA is to cover the residents. The DNS stated that the nurse on the unit is responsible for overseeing staff on the unit to ensure that they are complying with resident's care and monitoring. 415.12(h)(1)(2)

Based on observation, interview and record review, the facility failed to ensure food was prepared in accordance with professional standards of food safety. Specifically, (1) staff were observed not performing hand hygiene during food preparation; (2) meat was observed thawing in a sink without cold running water; (3) bulk items were not dated with open and use by dates and containers/lids were not clean; (4) bulk thickening agent being used after the best used by date. This was evident for the Kitchen Observation. The findings are: 1) The Policy & Procedure Manual titled Proper Hand Sanitation, (policy number: SAN-201, created [DATE], Reviewed: ,d+[DATE]) documented: Employees must always thoroughly wash their hands as part of proper food handling and personal hygiene procedures during food preparation and service. Procedure #2 documented, Use a sanitary nail brush to remove dirt from under fingernails. On [DATE] at 09:15 AM, Dietary Worker #2 was observed donning gloves without handwashing before preparing sandwiches. On [DATE] at 09:19 AM, the Cook was observed reentering the kitchen and going directly to the oven to remove food with hot mitt and then filling a coffee pitcher without washing hands. No nail brush was observed at any time at the hand washing sink area. On [DATE] at 09:34 AM, the Cook was observed returning to work area without handwashing. On [DATE] at 09:40 AM, the Cook was observed putting on gloves without handwashing. Then, the Cook proceeded to prepare food on the slicer. On [DATE] at 09:08 AM, the Cook was interviewed and stated the policy is to wash hands every time you change gloves, between tasks, and every time you enter in the kitchen. 2.) The Policy & Procedure Manual Titled Defrosting of Frozen Foods - General (Policy No. SAN-153, created [DATE], reviewed ,d+[DATE] page 1 of 1), 2b. frozen meats and poultry, may also be defrosted under portable running water. On [DATE] at 09:02 AM, meat packages were observed thawing in standing water in the sink without cold water running over them. On [DATE] at 02:30 PM, the Dietary Manager and VP of Culinary Services was interviewed. The VP stated that food should be thawed in the refrigerator (best practice) or under cold running water. 3.) Specifically, bulk items were not dated with open and use by dates and containers/lids were not clean. On [DATE] at 09:02 AM, bulk containers of rice and soup base had smudged fingerprints and food residue; lid of bulk container of mashed potato had a layer of clear residue; open container of chicken soup base with a delivery date and open date, but no use by date; open container of beef base with a delivery date, but no open date or use by date; closed container of Eucalyptus leaves had no delivery date; open container of peanut butter with a delivery date, but no open/use by date. Nutrition Management Services Company Policy & Procedure Manual Titled HACCP Receiving Procedures (Policy No. OPS-119 created [DATE] reviewed ,d+[DATE]) page 1 of 2 Procedure: General Procedures: 3. Record the date received on the outside of each package and a use-by date, if applicable. 4.) On [DATE] at 09:00 AM Easy Mix Simply Thick bulk package was observed with open date of [DATE]. Package Best if used by 04 JUN 2021. On [DATE] at 09:00 AM, Dietary Worker #4 was interviewed and stated they used the product in juice to make thick liquid. On [DATE] at 09:04 AM, Dietary Worker (DW) #5 was interviewed and stated that they used the thickener to make thickened liquids. DW #5 further stated they check the expiration dates and tells the Supervisor if a product is not good. DW #5 was asked to look for dates on the container and they observed the open date of [DATE] and expiration date of 04 JUN 2021 Best if used by date and acknowledged it was expired. On [DATE] at 09:07am an interview was conducted with the Dietary Manager who was asked to observe the container's open date and Best Used by date. The Dietary Manager noted that is was the only container of this product, and it should not have been used. Same was removed from work area. 415.14(h)

Based on observation, record review, and interviews conducted during the recertification survey from 11/3/2021 to 11/10/021, the facility did not ensure that infection control practices and procedures were maintained to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, a Registered Dietitian, a Certified Nursing Assistant, a Licensed Practical Nurse, and a Lead Mechanic were observed entering COVID-19 positive residents' room without wearing full PPE including N-95, goggle/face shield, gloves, and gown for droplet and contact precautions. This was evident for 3 out of 3 residents reviewed for Infection Control Task (Residents # 314, 312, and 316). The findings are: The CDC guidance for Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection updated on 9/10/2021 documented health care provider entering the room of a resident with suspected or confirmed COVID-19 positive should use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection like goggles or a face shield that covers the front and sides of the face. The facility policy & procedure titled Droplet Precautions with effective date 11/3/2020 and last review date 8/1/2021 documented Staff caring for residents on Droplet Precautions should wear a facemask for contact with the resident. When caring for residents with significant cough or respiratory secretions, staff should consider adding goggles or a face shield to protect their eyes from exposure to respiratory droplets. PPE should be donned upon entry to the resident's room and discarded prior to exiting the room. It also documented Gowns/masks are required when entering the resident room for any reason. The facility policy & procedure titled Contact Precautions with effective date 11/3/2020 and last review date 8/1/2021 documented Staff caring for residents on Contact Precautions should wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. PPE should be donned upon entry to the resident's room and discarded prior to exiting the room to contain organisms spread by direct or indirect contact. It also documented The use of gowns is to be worn whenever entering a transmission-based precaution room and Gloves are necessary whenever entering an isolation room. 1) Resident # 314 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Comprehensive Care Plan (CCP) for Isolation Precautions with effective date 10/28/2021 documented Resident has an active infection requiring isolation precautions and the goal was Staff will prevent the spread of infection within the next 90 days with review date 01/26/2022. The interventions included Apply isolation equipment upon entry to the room, Place patient in an isolation room and Maintain contact precautions. The CCP for COVID-19 with effective date 10/28/2021 documented Resident is at risk for contracting Coronvirus/Covid 19 due to global pandemic. The goal was Resident will remain free from symptoms related to COVID-19 with review date 1/26/2022. The interventions included Initiate facility protocol if resident is suspected of having COVID-19 and Resident and staff will be educated on appropriate infection control methods. On 11/03/21 at 10:28 AM, Registered Dietitian (Staff #4) was observed in Resident #314's room and spoke to Resident # 314 from the rear side of bed. Staff # 4 was observed wearing surgical mask and goggle but not gown or gloves or N-95 mask in the room. Resident #314 was observed not wearing face mask lying in bed about 8 feet away from Staff # 4. Staff # 4 was observed leaving the room after conversation without any other contact with Resident # 314. There were signs of Droplet Precautions and Contact Precautions placed outside Resident # 314's room. The Droplet Precaution signage states Everyone Must Clean their hands, including before entering and when leaving the room, make sure their eyes, nose and mouth are fully covered before room entry and Remove face protection before room exit. The Contact Precaution signage states Everyone Must: Clean their hands, including before entering and when leaving the room and Providers and Staff Must Also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. There was a drawer cart storing gloves, gown, and disinfecting hand wipes outside the room. On 11/03/21 at 10:45 AM, Certified Nursing Assistant (CNA) # 1 was observed in Resident #314's room with N-95 mask and surgical mask outside N-95 mask but no goggle/face shield, no gown and no gloves. CNA # 1 was observed speaking to Resident #314 about 7 feet from right side of bed. Resident # 314 was observed not wearing a face mask in the room. On 11/03/21 at 10:36 AM, an interview was conducted with Staff # 4. Staff # 4 stated all residents on the unit were COVID positive and were on droplet and contact precautions. Staff # 4 also stated they had in-service of infection control and were instructed to wear full PPE including gown, goggle/face shield, face mask and gloves when entering rooms on contact and droplet precautions and discarded them before leaving the room. Staff # 4 further stated he/she should put on the gown and gloves, but he/she forgot to do so prior to room entry. On 11/03/21 at 10:51 AM, an interview was conducted with CNA # 1. CNA # 1 stated all the residents on the unit were COVID-19 positive and were on droplet and contact precautions. CNA # 1 also stated they had to wear full PPE including N-95, gown, gloves and goggle/face shield if they needed to enter the room to provide care to resident or had direct contact with residents. CNA # 1 further stated they did not have to put on full PPE before room entry if they were not to provide direct care to resident. CNA # 1 admitted they were not able to predict if they had direct contact with resident after entering the room and should wear full PPE including gown, gloves, goggle/face shield, and N-95 mask before room entry. CNA # 1 stated they received infection control training every year and was instructed the appropriate use of PPE including wearing full PPE before entering room on droplet and contact precaution. CNA # 1 admitted they did not follow the instructions from the in-service of infection control and the droplet and contact precautions. 2) Resident #312 was admitted to facility on 10/23/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician ordered on 10/23/2021 for Contact / droplet Isolation 2/2 covid +, Oxygen at 3 liters/minute via nasal cannula as needed, and Keep HOB elevated when in bed due to shortness of breathing when lying flat. The Comprehensive Care Plan (CCP) for COVID - 19 with effective date 10/25/2021 documented Resident is at risk for contracting Coronvirus/Covid 19 due to global pandemic and Resident has had changes in routine schedules and/or practices related to COVID-19. The goal was Resident will maintain psychosocial well-being during the changes in routine schedules and/or practices related to COVID-19 with review date 01/23/2022. The interventions included Resident and staff will be educated on appropriate infection control methods and RN/SW to provide education to resident/legally authorized representative regarding the changes of federal and state regulations related to the COVID-19 pandemic. On 11/03/21 at 11:06 AM, Licensed Practical Nurse (LPN) # 2 was observed wearing N95 and goggle and did not wear gloves or gown in Resident # 312's room speaking to Resident #312 from the rear side of bed on right side, about 7 ft away. Resident #312 was not wearing a mask Resident # 312 was on droplet and contact precaution and there were signs outside the room to remind everyone to put on full PPE including gown, gloves and cover eyes, nose and mouth before room entry. There was also a drawer cart storing gloves and gown outside Resident # 312's room. On 11/03/21 at 11:14 AM, an interview was conducted with LPN # 2. LPN # 2 stated all the residents on the unit were COVID positive and were on droplet and contact precautions. LPN # 2 also stated the droplet and contact precautions required everyone to wear full PPE prior room entry and discard the PPE before room exit. LPN # 2 stated they monitored vital signs and administered medications but did not provide direct care to residents. LPN # 2 also stated they did not wear gloves or gown when entering Resident # 312's room because they did not provide direct care or have contact with resident. LPN # 2 stated they had in-service of infection control like every 2 months and it did not specify the requirement to wear full PPE if no direct care was provided when entering resident's room on contact and droplet precaution. 3) Resident # 316 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician ordered on 10/30/2021 for Contact/Droplet isolation secondary to +COVID-19, Oxygen at 2 liters/minute via nasal cannula continuously, Keep HOB elevated when in bed due to shortness of breathing when lying flat. The Comprehensive Care Plan (CCP) for Isolation Precautions with effective date 11/4/2021 documented Resident has an active infection requiring isolation precautions. Evidence by: (specify) Dx: COVID 19. The goals were Staff will prevent the spread of infection within the next 90 days with review day 02/04/2022. The interventions included Maintain contact precautions, Place patient in an isolation room, and Apply isolation equipment upon entry to the room The CCP for COVID - 19 with effective date 11/1/2021 documented Resident is at risk for contracting Coronvirus/Covid 19 due to global pandemic and Resident has had changes in routine schedules and/or practices related to COVID-19. The goal was Resident will maintain psychosocial well-being during the changes in routine schedules and/or practices related to COVID-19 with review date 01/30/2022. The interventions included Resident and staff will be educated on appropriate infection control methods and Staff will educate and remind resident to wear facemask while outside his/her room. On 11/05/21 at 03:28 PM, Lead Mechanic (Staff # 5) was observed kneeling down on a clean blanket on the floor about 7 feet away from Resident # 316 at the rear side of bed. Staff # 5 was also observed checking the bottom part of the bed frame by observation without touching anything in the room with only surgical mask on. Resident # 316 was lying in bed with oxygen via nasal cannula in use and a surgical mask on. Staff # 5 was also observed not wearing gown, face shield/goggle, N-95 mask and gloves in Resident # 316's room. There was signs of droplet precautions and contact precautions outside Resident # 316's room to request everyone to wear gloves, gown, and have eyes, nose and mouth fully covered before room entry. There was also a drawer cart storing gloves, gown, and disinfecting wipes outside the room. On 11/05/21 at 03:32 PM, an interview was conducted with Staff # 5. Staff # 5 stated they were checking the bed for Resident # 316 as it was reported the bed was not moving up and down for position change. Staff # 5 stated they were aware the residents on the unit were COVID positive. Staff # 5 also stated they saw the Droplet and Contact precautions posted outside Resident # 316's room but did not pay attention to the content. Staff # 5 further stated they did not remember when they had in-service of infection control last time. Staff # 5 stated they wore face mask in the facility and wiped hands with sanitizer outside the room prior to room entry and room exit. Staff # 5 also stated they did not wear other PPE including goggle/face shield, gown, or gloves prior entering Resident # 316's room. Staff # 5 stated they should wear full PPE including gown, gloves, goggle/face shield and mask prior to room entry for residents on droplet and contact precaution after reading the Droplet and Contact Precautions signs on the wall. On 11/05/21 at 09:57 AM, an interview was conducted with Registered Nurse Supervisor (RN # 2). RN # 2 stated all the residents on the unit were COVID positive admitted from hospitals and other facilities and were on droplet and contact precautions. RN # 2 also stated all staff were made aware the unit was designed for COVID positive residents and had to wear full PPE including gloves, N-95, goggle/face shield, and gown prior to room entry no matter they provided direct care or not to the residents. RN # 2 further stated all staff had in-service of infection control and they were instructed to wear full PPE including gloves, gown, N-95 and goggle/face shield before room entry to residents on droplet and contact precautions. RN # 2 stated supervisors did rounds on the units to make sure all staff were compliant to the infection control. On 11/05/21 at 10:42 AM, an interview was conducted with Infection Preventionist (IP). IP stated all residents on 5th floor were COVID positive admitted from hospitals and other facilities and staff were aware of it. IP also stated all residents on 5th floor were on droplet and contact precautions. IP further stated all staff had to wash hands, wear N-95, gloves, gown, and face shield/goggle before entering the rooms on droplet and contact precautions whether they provided direct care or not to the residents. IP stated all staff had in-service for infection control and it covered the use of PPE on droplet and contact precautions. IP also stated they provided infection control training periodically more than 1 time in a year. IP further stated RN supervisors and IP did the rounds on the units to make sure staff were compliant to infection control and PPE use. On 11/09/21 at 10:50 AM, an interview was conducted with Director of Nursing (DON). DON stated the 5th floor was designated for COVID-19 positive residents admitted from hospitals and other facilities. DON also stated they had one resident in one room on 5th floor. DON further stated all the residents on the 5th floor are on droplet and contact precautions and signages for droplet and contact precautions were placed outside every room. DON stated residents had to stay in their rooms until they got 2 PCR negative tests before they were transferred to other floors. DON also stated all staff entering the rooms had to wash hands and be fully dressed up in PPE including N-95, goggle/face shield, gown and gloves and undressed themselves and washed hands before leaving he room. DON further stated all staff had to put on full PPE prior to room entry and it did not matter if they provided direct care or not to the resident. DON stated the nurse and nurse supervisor on the unit were responsible to make sure the staff were compliant to infection control. DON also stated all staff had in-service of infection control at least once a year and as needed and they reviewed the droplet and contact precaution and appropriate use of PPE in the in-service. 415.19 (a)(1-3)

Based on observations, staff interviews and record reviews conducted during the recertification survey, the facility did not ensure that a person-centered comprehensive care plan (CCP) was developed and implemented in a timely manner to address the residents' medical, physical, mental, and psychosocial needs. Specifically, (1) No CCP was developed and implemented to address a resident's use of [CONDITION(S)] medications; and (2) A care plan with measurable goals and interventions was not developed for a resident receiving total assistance with Activities of Daily Living (ADL) care. This was evident for 1 out of 5 residents observed for Unnecessary Meds, [CONDITION(S)] Meds (Resident #82) and 1 of 2 residents observed for ADL care (Resident #70), out of an investigative sample of 25 residents. The Findings are: 1) The facility Policy and Procedure on Comprehensive care Plan dated 03/23/2011, last revised 02/24/2019, documented: The Interdisciplinary team will develop and implement the CCP within 21 days of admission. This CCP will address Resident/Representative Goals area/potential problems, needs, strengths and individual preferences of the resident .The residents CCP will be updated by the IDT with any episodic changes to include but not limited to: Medication changes, changes in ADL function, Behaviors/Mood State Changes Resident #82 was admitted to the facility 07/30/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set 3.0 (MDS), Assessment Reference Date (ARD) 10/04/2021 documented that the resident had severe impairment in cognition with long and short-term memory problems, had adequate hearing, sometimes understands - responds adequately to simple, direct communication only, and have altered level of consciousness. MDS also documented that resident is on [CONDITION(S)] medications, and the physician documented GDR (Gradual Dosage Reduction) was clinically contraindicated on 8/17/2021. The Comprehensive Care Plan (CCP) for Behavior dated 8/05/2021 documented that resident has behavior, attempt to stand from wheelchair unassisted; with interventions that included: - Address resident concerns as they arise; Attempt to ascertain reason for behavior; Staff to maintain clean and clutter free environment; Approach resident in calm manner; Encourage participation in programs of choice; Redirect resident as needed. No documented evidence of resident's use of [CONDITION(S)] medications. The Comprehensive Care plan (CCP) for Cognitive Loss/Dementia dated 8/2/2021, last updated 10/29/2021 documented that resident has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included: - Encourage participation in programs of choice; Encourage resident to voice concerns to staff; Explain procedures before completion. Monitor for changes in mental/cognitive status. Provide daily stimulation. Staff to introduce self when approaching resident. No documented evidence of resident's use of [CONDITION(S)] medications. Progress Note Psychiatry dated 10/14/2021 at 12:31 pm, documented that resident was seen and evaluated 10/14/2021 for psychiatric follow up. Resident was hospitalized in September for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . As per unit's staff, resident is easily confused, anxious, paranoid and demanding at times. The Psychiatrist also documented that resident is irritable and annoyed but refused to state why. The plan/recommendations were: Continue current [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]; Supportive therapy and reassurance provided; Psychiatry follow up in 3 months and PRN. Progress note Nursing dated 10/21/2021 11:52 am documented: Called by assigned CNA to see resident. Resident with eyes closed but able to respond to name by opening eyes and to focus when directed, unable to respond verbally, did not have breakfast and unable to pull tongue back into the mouth. MD made aware, ordered given to transfer resident to the ER for evaluation. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Lorazepam 2 mg tablet 1 tablet (2 mg) by oral route 3 times per week on Hemodialysis days Tuesday Thursday Saturday at 2pm for Anxiety disorder due to known physiological condition. [MEDICATION(S)] 2.5 mg tablet 1 tablet (2.5 mg) by oral route once daily for Delusional disorder. A Progress note Nursing dated 10/29/2021 at 12:00 am documented that resident was readmitted from the hospital. admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no Comprehensive Care Plan developed to address the resident's psychiatric diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/08/21 at 11:46 AM, an interview was conducted with the Licensed Practical Nurse, LPN #1. LPN #1 stated Resident #82 has been on [CONDITION(S)] medications since admission to the facility in July. Resident #82 was transferred to the hospital recently and readmitted [DATE] with [CONDITION(S)] meds. LPN #1 further stated that resident's CCP are supposed to be initiated and updated by the RN Supervisors. On 11/08/21 at 11:52 AM, an interview was conducted with RN Supervisor, RN #1. The RN stated that resident is on Lorazepam 2mg 3 times per week prior to [CONDITION(S)] for anxiety disorder, [MEDICATION(S)] 10mg daily for Major depressive disorder, [MEDICATION(S)] 2.5mg daily for delusional. RN #1 was not able to see a Comprehensive Care Plan for the resident's use of [CONDITION(S)] meds and psych diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/09/21 at 09:53 AM, an interview was conducted with RN MDS Coordinator, RN-MDS. RN-MDS stated that the Registered Nurses that admit the resident initiate the care plans and are also responsible for the update or reactivation of the necessary care plans. RN-MDS stated that based on the documentation seen in the record, Resident #82 has been on the [CONDITION(S)] medication since admission on 7/30/21. A CCP on [CONDITION(S)] meds was started on 8/15/21, and Resident #82 went to the hospital on 9/14/21 and returned 9/16/21. The care plan for [CONDITION(S)] meds was not reactivated due to omission by the nurse that readmitted the resident. 2.) The facility policy titled Resident Hygiene and ADL care dated last reviewed 10/15/2021 documented residents' preferences regarding grooming and hygiene that interfere with dignity will be reviewed by the IDT and a plan of care will de developed to promote dignity. Resident #70 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident required total dependence of two plus persons for bed mobility, transfers eating, toilet use and personal hygiene. The Nursing Admission assessment dated [DATE] documented resident required total dependence with all ADLs care. Medical progress notes dated 10/26/2021 documented Patient needs help with food preparation, bowels and bladder training, grooming, toilet use. Improving transfer and ambulate monitor for safety and independence. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing progress note dated 11/3/2021 documented resident alert and verbally responsive. Refused out of bed despite encouragement, turned and positioned by staff. The Certified Nursing Assistant Accountability (CNAAR) dated ,11/2021, 10/2021, 9/2021, 8/2021, 7/2021, 6/2021 documented the resident required total dependence for ADL care. There was no documented evidence in the medical record that an active CCP for ADL care: Mobility, transfers, Personal Hygiene, eating, grooming, oral care was in place. The Facility provided surveyor with an ADL CCP initiated 11/5/2021 when the surveyor requested a copy of Resident #70's ADL CCP. On 11/05/21 at 02:32 PM, an interview was conducted with Certified Nursing assistant (CNA #2). CNA #2 stated the resident needs total care with all ADLs, and at times, the resident refuses to participate in ADL care despite encouragement. CNA #2 stated the resident refuses shower so give she gives the resident a bed bath. CNA #2 also stated the resident is total care with all ADLS including bed mobility, transfers, eating, all personal hygiene and toileting. CNA #2 documents in the Accountability record that total care was given. On 11/05/21 at 02:38 PM, an interview was conducted with Licensed practical Nurse, (LPN#3). LPN #3 stated is responsible for medication administration, monitoring the resident for any change in condition as well as monitoring the staff. LPN #3 stated the resident required total assistance with all ADLS and needs two staff for transfers. LPN #3 stated the resident refuses out of bed at times, receives bolus feeding by peg tube and is offered a soft diet but refuses to eat. LPN #3 is not responsible for developing the CCP but reports to the supervisor any concerns or changes in the resident. On 11/05/21 at 02:40 PM, an interview was conducted with Registered Nurse Supervisor (RNS #3). RNS #3 stated the resident is alert and oriented x 3 and requires total assistance from staff to complete all ADL care. RNS #3 stated the basic care plans are initiated on admission, and the team evaluates and ensures the care plans are in place. RNS #3 stated they were not sure how this care plan was missed, and it was an oversight. When the resident was last admitted , the CCP was not activated. RNS #3 stated the nurse who does the admission will do the basic CCP. On 11/09/21 at 12:00 PM, an interview was conducted with the Director of Nursing (DNS). The DNS stated that when a resident is newly admitted , the RN Supervisor initiates the necessary care plans needed for the resident. If the facility has a lot of admissions at a time, the other necessary care plans are initiated within the next 24 or 48 hours of the resident's admission. If the RNS is unable to complete the care plans, it is noted and passed on to the next shift. The Supervisor on the same floor is expected to check the next day to ensure that all the care plans are done. DNS stated that the care plan should have been checked for the affected residents by the other supervisors that worked thereafter to see that all the care plans are documented. DNS stated that moving forward, it has to be enforced that all relevant care plans are in place on time. 415.11 (c)(1)

Based on record review and interviews conducted during the Recertification and Abbreviated Complaint Survey from 11/3/2021 to 11/10/2021 (NY 123), the facility did not ensure residents' Comprehensive Care Plans (CCP) were reviewed and revised by the interdisciplinary team after each assessment. Specifically, there was no documented evidence the CCP related to Falls was updated to accurately reflect the effectiveness of interventions after a resident had a fall on 1/23/2021. This was evident for 1 of 1 resident reviewed for Accident (Resident #207). The findings are: The facility Policy and Procedure titled Fall Prevention with effective date 04/2015 and last review date 9/20/2021 documented Each Resident will be assessed for his/her risk for falls on admission, quarterly, and with a change in condition. Each resident will have an individualized care plan outlining his/her fall prevention measures. It also documented When a resident sustains a fall, the IDT will attempt to identify the route cause, a rehab referral will be made when indicated, the CCP and CNAAR will be updated reflecting the new interventions. Resident #207 was first admitted to the facility on [DATE] and transferred to hospital on 2/5/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Baseline Care Plan dated 1/22/2021 documented Resident #207 's cognitive condition was confused and able to follow instructions. It also documented Resident # 207 had clear speech and was usually able to understand others and be understood. The initial goals for the baseline care plan included Maintain safety/prevent falls/prevent injuries related to falls. The interventions included Perform routine and comprehensive assessments per protocol and Assess ability to perform ADL's and establish priority needs. It documented ambulating was not performed by Resident # 207. It also documented Resident # 207 had history of being resistive to care. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing progress note dated 01/22/2021 at 10:01 pm, documented Resident #207 was admitted from the hospital. Resident #207 was alert, verbally responsive, and confused. It further documented Resident #207 required extensive assistance for ADLs and would benefit from skilled OT/PT. It documented Fall and safety precautions were maintained and call bell was placed within reach. A Physical Therapy note dated 01/23/2021 at 11:44 am documented Resident #207 was evaluated and would benefit from skilled PT intervention to improve functional mobility/ambulation status. Nursing note dated 01/23/2021 at 04:10 pm documented Resident #207 was found lying on hallway floor on right side by unit nursing station and was not able report how the fall occurred. Resident #207 had no visible signs of injury. The attending physician and Resident # 207's spouse were notified. Occurrence Report (Fall) dated 1/23/2021 documented Resident #207 had a fall in the unit at 1:30 PM. It also documented Resident #207 was unable to stated how the fall occurred. It further documented Resident #207 had no visible injury and no change in condition. Assigned CNA Occurrence Statement for fall on 1/23/2021 documented they observed Resident #207 walking outside room, appearing confused, restless, reported needing to use bathroom. Occurrence Investigation Summary (Fall) dated 1/23/2021 documented Resident #207 had no injury at the time of assessment, Neuro check Q15 minutes x 24 hours, CCP updated. Review of the CCP revealed the CCP for Falls was not updated or Falls (Actual) was not created after the fall on 1/23/2021. Nursing note dated 01/26/2021 at 07:17 am documented Resident # 207 had another fall on the unit and had no visible injury and level of consciousness was at baseline. The CCP for Falls or Injury (Actual) with effective date 1/26/2021 was created after Resident #207 had a second fall on 1/26/2021. On 11/08/21 at 10:07 AM, an interview was conducted with Registered Nurse Supervisor (RN # 2). RN #2 stated they created two care plans for actual fall and potential of fall if a newly admitted resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . RN # 2 also stated the admitting nurse assessed the resident upon admission and created the care plan for fall. RN # 2 further stated the care plan for fall would be updated afterward if needed and they created a care plan for Falls (Actual) if resident had an actual fall on the unit. RN # 2 stated Resident # 207 had their first fall on 1/23/2021 on the unit, and the Registered Nurse (RN) or the RN Supervisor working during the shift should update CCP for Falls or create CCP for Falls (Actual). RN # 2 also stated it was documented in the Occurrence Investigation Summary (Fall) dated 1/23/2021 that CCP was updated. RN # 2 checked the notes and CCP in the medical records of Resident #207 and stated the CCP for Falls was not updated or the CCP for Falls (Actual) was not created after the fall on 1/23/2021. On 11/09/21 at 10:28 AM, an interview was conducted with Director of Nursing (DON). DON stated the admitting nurse assessed every newly admitted resident for fall risk. DON also stated the admitting nurse should enter the care plan for falls if the resident had an actual fall in the past or at risk of fall. DON further stated the registered nurse (RN) or the registered nurse supervisor (RNS) should enter a new care plan for actual fall if a resident had a fall on the unit. DON stated RNS and DON reviewed all care plans for newly admitted residents. DON stated they had safety committee meeting during weekdays if there was a resident fall incident or safety concern and they reviewed the updated care plan for effective interventions to be implemented. DON checked the electronic medical record (EMR) for Resident # 207 and admitted there was no care plan for actual fall or the CCP for falls was updated after the fall on 1/23/2021. DON stated the RN or RNS working during the shift when the fall occurred was expected to enter the CCP for actual fall or revised and updated the CCP for falls. 415.11(c)(2) (i-iii)

Based on observations and interviews, the facility did not ensure that appropriate hand hygiene and procedures governing the use of Personal Protective Equipment (PPE) were followed during direct care of a resident on Isolation precautions. This was evident on for 2 Staff Members a Respiratory Therapist (RT#1) and a Certified Nurse Assistant (CNA#1) providing treatment and or services on two separate occasions for one resident. (Resident # 147.) The finding is: On 03/07/19 at 10:54 AM, posted outside of room [ROOM NUMBER] was a sign See Nurse and a plastic three (3) drawer bin that contained Personal Protective Equipment (PPE). PPE are face masks, yellow paper gowns and gloves which are necessary to don prior to entering an Isolation room. On 03/07/19 at 12:44 PM, a male staff member was observed wearing a blue paper mask and gloves while suctioning the Resident #147 without wearing a paper yellow gown. At approximately 12:45 PM, he was observed gathering up soiled and used equipment in a plastic bag while wearing gloves. At 12:47 PM, the same staff member was observed talking to the resident before leaving the bedside. He proceeded to remove his gloves and used hand gel upon leaving the room. At 12:48 PM, the staff who identified himself as a Respiratory Therapist (RT) was interviewed. The RT stated that he read the posted sign and was aware that the resident is on Isolation Precautions. He further stated that he did not put on the yellow paper gown before entering the room as the resident was in respiratory distress. He also stated that hand washing should be done after gloves are removed after suctioning. On 03/07/19 at 12:50 PM, a Certified Nursing Assistant (CNA) #1 was observed entering the room of Resident #147. CNA #1 did not don PPE before entering the room. CNA#1 proceeded to speak to the resident, handled the resident's lunch tray, and handed the resident a plastic cup. At 12:52 PM, CNA#1 exited the room and was interviewed immediately. CNA#1 stated the resident is on isolation for a respiratory reason and she is aware of the posted sign and that you are supposed to wear a gown, mask and gloves when taking care of anyone is on Isolation precautions. This protects other residents that are in facility. She also stated that she knows she's supposed to wear PPE but she just went in to give the resident the water that she asked for earlier. On 03/13/19 at 03:14 PM, the Assistant Director of Nursing was interviewed. The interview specifically addressed how the facility educates staff on infection control practices including; hand hygiene and the use of PPEs when residents are on Isolation precautions. She stated that RT #1 joined here in (MONTH) or December, (YEAR) and received mandatory orientation which included infection control practices and hand washing. She stated that during competencies on hand hygiene the importance of preventing cross contamination is stressed. The In-service coordinator also trains and does pop quizzes with all facility staff including the CNA's on isolation precautions. Mandatory training is done during orientation and annually thereafter. 415.19(c)

Based on record review and interviews the facility did not ensure that the comprehensive assessment accurately reflected the resident's status. Specifically, Resident #195 had behaviors (refusals of medications) that were documented in their medical record, but were not captured on the Admission Assessment MDS 3.0 (Minimum Data Set.) The finding is: Resident #195 has [DIAGNOSES REDACTED]. The MDS Admission assessment dated [DATE] documented that the resident has a (Brief Interview for Mental Status) score of 15, which indicates intact cognition. There were no mood indicators, no behaviors, no rejection of care documented for the 7 day look back period. The nurse's notes from 1/3/19-3/11/19 were reviewed. The notes documented the resident refused multiple medications despite education and encouragement by Nursing staff. The Medical Doctor was notified and is aware of her refusals. The Medication Administration Record [REDACTED] 1/2/19: refused [MEDICATION NAME] (it treats constipation and it also can treat liver disease). 1/3/19: refused [MEDICATION NAME], Nephro vite 0.8 mg, (combination of B vitamins), [MEDICATION NAME] 550 mg (relief of Irritable bowel symptoms such as abdominal pain and diarrhea) and [MEDICATION NAME] ER 60 mg (blood pressure medication) 1/4/19: refused [MEDICATION NAME] 15 ml x2 and Sucrafate 1 Gram x1 [MEDICATION NAME] 80 mg, [MEDICATION NAME] 50 mg. On 03/12/19 at approximately 12:00 PM LPN (#1), charge nurse on the unit stated that she knows the resident well. She continued to state that the resident is cooperative with care: she doesn't refuse care, she refuses medications only. On 03/14/19 at approximately 2:44 PM an interview with the MDS coordinator ( RN #1) was conducted. Prior to the start of the interview RN #1 reviewed the MDS dated [DATE],the Nurse's notes, and the Medication Administration Record [REDACTED]. She stated also the assessors do not wait for more than one refusal. She stated she might have overlooked it when reviewing the nurse's notes. The behavior should have be captured under Section E, titled Behavior and indicated that it was prevalent 1-3 days.

Based on observation, record review, and staff interviews during the Recertification Survey the facility did not ensure that each resident's Comprehensive Care Plans were reviewed and revised to meet the needs of the resident for 1 of 1 resident reviewed for Urinary Incontinence from a total Stage 2 sample of 29 residents. Specifically, Resident #134's room was observed on multiple occasions with urine odor and sticky floors; however, the Comprehensive Care Plans for Toileting/Continence and Activities of Daily Living (ADLs) did not accurately address the resident's urinary incontinence. The finding is: Resident #134 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 4/22/2017 Annual MDS assessment documented a Brief Interview of Mental Status (BIMS) score of 4, indicating the resident had severe cognitive impairment. The MDS documented that the resident required supervision for ADLs, including toilet use, and limited assistance of one staff member for personal hygiene. The MDS documented that the resident was always continent of bowel and bladder. A Comprehensive Care Plan (CCP) dated 4/13/2017 and titled Toileting/Continence documented that the resident was continent of bowel and bladder. The CCP did not indicate that the resident was on a toileting schedule. A CCP dated 4/13/2017 titled ADL Comprehensive Care Plan documented that the resident was continent of bowel and bladder. A CCP dated 4/13/2017 and titled Behavior did not document any behaviors related to the resident urinating on the floor. On multiple occasions (6/14/2017 at 1:32 PM, 6/15/2017 at 11:02 AM, 6/16/2017 at 11:38 AM, and 6/19/2017 at 8:29 AM) Resident #134's room was observed to have a urine odor and a sticky floor. On 6/16/2017 at 11:40 AM the 4th floor housekeeper was interviewed. He stated, The resident urinates on the floor all day long. That is why it smells like urine. On 6/16/2017 at 12:08 PM Resident #134's Certified Nursing Assistant (CNA) was interviewed. He stated the resident is confused. He stated that the resident wets himself all the time and that this was not new. He stated the resident does not purposely urinate on the floor. On 6/19/2017 at 11:30 AM the Registered Nurse (RN) Unit Manager was interviewed. She stated that sometimes Resident #134 cannot make it to the bathroom in time and urine gets on the floor and his clothes. She stated that the resident was having accidents and is incontinent and the care plans needed to be updated. She stated that the resident does not purposely urinate on the floor. She added that Resident #134's roommate requires total care, stays in bed, and does not urinate on the floor. On 6/20/2017 at 9:42 AM the Director of Nursing Services (DNS) and the RN MDS Coordinator were interviewed concurrently. They stated that the resident's Attending Physician did a urinary incontinence assessment last evening (6/19/2017) and a determination was made that the resident has an overactive bladder and overflow incontinence and that the care plans need to be updated. 415.11(c)(2)(i-iii)

Based on observation, record review, staff and resident interviews during the Recertification Survey the facility did not ensure that housekeeping and maintenance services were provided to maintain a sanitary, orderly, and comfortable interior on two of four nursing units. Specifically, 1) Resident #7 stated that the hallway training toilet on the 5th floor often does not have soap in the soap dispenser. An observation of the empty soap dispenser was made on 6/15/2017; and 2) multiple observations were made of urine odor and a sticky floor in Resident #134's room on the 4th floor. The findings are: 1) Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 4/28/2017 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview of Mental Status (BIMS) score of 15, indicating the resident is cognitively intact. The MDS documented that the resident required extensive assistance for toilet use. On 6/15/2017 at 8:45 AM Resident #7 was interviewed. He stated he prefers to use the training toilet in the hallway because it has more room and he can maneuver better with his wheel chair. He stated that there are two training toilets in the hallway--one that is closer to his room and another further down the hallway. He stated that most of the time when he uses the training toilet bathroom there is no soap in the soap dispenser. He stated that he had told one of the nurses on the unit. On 6/15/2017 at 8:58 AM the hallway training toilets were observed. The training toilet closer to Resident #7's room did not have soap in the dispenser and the adjacent training toilet further down the hallway only had a scant amount of soap that came out of the dispenser. On 6/15/2017 at 9:02 AM the two soap dispensers were observed by the Director of Maintenance and Housekeeping. He refilled the empty soap dispenser and stated that the one with the scant amount of soap would be addressed. On 6/15/2017 at 9:17 AM the Director of Maintenance and Housekeeping was interviewed. He stated the training toilet soap dispensers are checked on a daily basis by the housekeepers on daily rounds and that the soap will last about a week. On 6/15/2017 at 10:04 AM the 5th floor housekeeper was interviewed. He stated the soap dispensers are supposed to be checked at the beginning and end of the housekeepers' shifts. He stated that he had not checked the training toilet soap dispensers yet. On 6/20/2017 at 9:00 AM the Director of Nursing Services was interviewed. She stated that the 5th floor housekeeper's shift on 6/15/2017 started at 7 AM. On 6/20/2017 at 9:09 AM Resident #7's Certified Nursing Assistant (CNA) was interviewed. He stated that the resident uses the training toilet himself and that the training toilets are actively used. 2) Resident #134 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 4/22/2017 Annual MDS assessment documented a BIMS score of 4, indicating the resident had severe cognitive impairment. Resident #134 resides in a double-bedded room and has the bed closest to the door. On 6/14/2017 at 1:32 PM, 6/15/2017 at 11:02 AM, 6/16/2017 at 11:38 AM, and 6/19/2017 at 8:29 AM Resident #134's room was observed. There was a urine odor in the room and the floor was sticky. On 6/15/2017 at 11:10 AM the 4th floor housekeeper was interviewed. He stated that he had not gone into Resident #134's room to clean yet. On 6/16/2017 at 11:40 AM the 4th floor housekeeper was re-interviewed. He stated, The resident urinates on the floor all day long. That is why it smells like urine. He stated that he mops the room 3 or 4 times per day and that the floor has to be stripped. He added that the floor is sticky because the residents in the room keep the heat on. On 6/19/2017 at 12:35 PM the Director of Housekeeping and Maintenance was interviewed. He stated that the resident's floors are stripped every 2-3 weeks. He stated that the odor in the room and the sticky floors were because of urine saturation and the humidity. On 6/20/2017 at 10:38 AM a maintenance worker was interviewed who was filling in for the Director of Housekeeping and Maintenance (who was unavailable). He said he was not aware of a log sheet of when floors were stripped. He said that generally 3 or 4 rooms on a unit receive a total cleaning once per week and the other rooms get a spot mopping. He said it would not be documented if a housekeeper mopped a particular room several times per day. 415.5(h)(2)

Based on observation, record review, resident and staff interviews during the recertification survey, the facility did not ensure that the care and services to prevent the development of an avoidable pressure ulcer were implemented timely. This was evident for one of three resident reviewed for pressure ulcer in a total of twenty one Stage 2 sampled residents. Specifically, Resident #165 was admitted to the facility with [DIAGNOSES REDACTED]. There was no documented evidence that measures for the prevention of pressure ulcers were implemented prior to the development of a Deep Tissue Injury (DTI) to the resident's left heel and an Unstageable Pressure Ulcer to the right heel. This resulted in actual harm that is not Immediate Jeopardy. The finding is: Resident #165 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. A Nursing Admission/Readmission History and Physical assessment dated [DATE] at 4:30 PM documented under Physical Condition that the skin was not intact and the area was described as a Left Knee wound, status [REDACTED]. A review of the Skin Breakdown Diagram revealed no documentation of skin break down on admission. A Braden Scale for Predicting Pressure Score Risk dated 9/11/14 documented a score of (14) which indicated the resident was at moderate risk for developing pressure ulcers. A Pressure Ulcer Comprehensive Care Plan (CCP) dated 9/11/14 documented that the resident was at risk for pressure ulcer related to decrease mobility. The CCP documented that the resident had left foot drop, and poor tissue perfusion of the left foot. There was no documented evidence in the CCP to offload the pressure on the heels. A review of the Nurses Notes dated 9/11/14 through 9/16/14 lacked any documentation of any skin breakdown or that any measures to prevent skin breakdown were implemented prior to 9/16/14. A Nurses Note dated 9/16/14 at 4:00 PM documented that the staff reported Resident #165 was noted with skin changes to the left heel. A Registered Nurse (RN) Supervisor assessed the resident's left heel. A Deep Tissue Injury (DTI) was observed on the left heel about 2.5 centimeters (cm) x 2.0 cm. An interim physician's orders [REDACTED]. A review of the medical record and the skin check worksheets lack documented evidence that skin checks were conducted 9/12/14 to 9/14/14. A Body Check Worksheet from 9/15/14 to 9/18/14 documented on 9/15/14 that on all shifts the resident's skin was intact. On 9/16/14 the 3:00 PM to 11:00 PM and the 11:00 PM to 7:00 AM shifts documented right heel redness and on 9/16/14 the 7:00 AM to 3:00 PM and 11:00 PM to 7:00 AM shifts documented ulcer/skin breaks to heel (left/right heel not specified). A Pressure Ulcer (P/U) CCP for left heel DTI dated 9/16/14 documented that the pressure ulcer will show signs of healing as evidence by: decreased in size and granulation x 30 days. Interventions include nursing to perform treatment as ordered by the physician, assess size, color, surrounding tissue, and presence of drainage weekly and PRN, pressure relieving device as indicated, protective dressing to left heel. The Wound Assessments were reviewed and they lacked documented evidence that weekly wound assessment and measurements were conducted after the left heel DTI was identified on 9/16/14 through 10/9/14. An Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview of Mental Status (BIMS) Score was (15). The resident required extensive assist of one staff for bed mobility, transfer, dressing, and bathing. During the entire 7 days period prior to the assessment the resident had not ambulated. The resident was assessed on the MDS to be at risk for the development of a pressure ulcer and had one unstageable pressure ulcer documented. The tissue of the pressure ulcer was described as slough. The MDS Assessment documented that the resident was on a turning and positioning program, but there was no documentation of a pressure reducing device being used for the chair or bed. An updated P/U CCP dated 10/9/14 documented a left heel 5 cm x 4 cm unstageable pressure ulcer. Interventions noted to include T/P (turn and positioning), assess size, color surrounding tissue, pressure relieving device as indicated, provide therapeutic meals and encourage resident to consume at least 75% of food and fluids on tray, check [MEDICATION NAME] level, Complete Blood Count (CBC) per MD order. Evaluate appropriate device needed for healing. A Telephone physician's orders [REDACTED]. A Nurses Note dated 12/11/14 at 3:30 PM documented that the resident was seen on wound rounds today for left heel, right heel, left dorsal foot and sacrum. Continue with current treatment of [REDACTED]. Telephone order from the physician was received to cleanse right heel with Normal Saline (NS), apply Hydrogel and cover with dry sterile dressing daily. There was no description of the right heel wound documented in the nurse's note. A Wound assessment dated [DATE] documented an Unstageable Pressure Ulcer to the right heel measuring 5 cm x 7 cm. The wound bed presents with moist eschar and the surrounding skin was macerated. The recommendations included to provide special air mattress or offloading devices if indicated. An Ultrasonography Report dated 1/1/15 of Arterial Study of both Lower Extremities of Resident #165 documented in impression section no significant Arterial Stenosis. A Vascular Consultant Report dated 1/9/15 at 1:00 PM documented that Resident #165 was an eighty year old female who had over a two month history of non-healing bilateral lower extremity ulcers and decreased pulses to bilateral lower extremities. The Finding, Opinion, and Recommendation section of the Consult documented that the resident has a 5 cm x 5 cm unstageable pressure ulcer with eschar to the Left heel and a 4 cm x 5 cm unstageable pressure ulcer with overlaying eschar to the right heel. It is further documented that the Ulcers to the resident ' s heels were not Vascular Surgical, and that the Ulcers were secondary to constant pressure on the heel surface. Recommendations included the resident required boots to offload pressure on heel, keep dressing clean and dry, heel support and lower extremity elevation. The Certified Nursing Assistant (CNA) Accountability Record (CNAAR) dated 9/11/14 documented the resident required extensive assist of one staff for bed mobility, and required two staff for physical lift for transfers. The record lacked documentation that the resident's heels must be off loaded. The CNAAR dated 10/2014 documented that the resident required extensive assist of one staff for bed mobility, and two staff for physical lift. The CNAAR documented on five occasions that the resident had been turned and positioned on the 7:00 AM to 3:00 PM shift. The CNAAR documented on one occasion that the resident had been turned and positioned on the 3:00 PM to 11:00 pm shift. There was no documentation of any devices to offload the pressure on the resident's heels. The CNAAR dated 11/2014 documented the resident required extensive assist of one staff for bed mobility, and two staff for constant supervision or physical lift. There was no documented evidence that the resident was turned and positioned for the entire month of November 2014. Additionally, there was no documentation of any devices to offload the pressure on the resident's heels. On 6/19/15 at 11:10 AM an interview was conducted with the resident. The resident stated that she was not admitted to the Nursing Home with the pressure ulcer on the left heel or any other pressure ulcers. The resident stated that she did not receive heel booties on admission. The resident stated that it was a while later that she received the booties and that she had already developed the ulcer on the right heel. The resident stated that they ordered a special boot for her feet, but when she stood she still felt the pressure on both heels. The resident stated that after the P/U was developed the staff started putting on the heel booties. The resident stated that she developed the ulcer because her feet were always resting on the bed. On 6/22/15 at a wound care observation of Resident #165's bilateral heels was conducted. The left lateral heel was observed with a large area of black necrotic tissue approximately 4 cm x 6 cm. There was no odor or drainage present and the surrounding area was intact. The right heel was observed with a quarter size area of yellow necrotic tissue. There was no odor or drainage present. The surrounding area was also intact. On 6/22/15 at 1:00 PM an interview was conducted with the third floor Unit RN Manager. The RN Manager stated that the RN Supervisor on duty was responsible for assessing the resident on admission. The RN Manager stated that if the resident is assessed to be at risk for skin break down or is admitted with pressure ulcer the RN Supervisor that completed the assessment is responsible for initiating all appropriate devices on admission and refer the resident to wound care for evaluation. The RN stated that at times the RN Supervisor will initiate the CCP however, the MDS RN was responsible for initiating the CCP for all new admissions. The RN stated that interventions are initiated based on the assessment of the resident Activities of Daily Living (ADL) status. The RN stated that heel booties should have been initiated on admission especially because the resident was admitted S/P surgery on her left Knee. On 6/22/15 at 1:30 PM an interview was conducted with the Wound Care Licensed Practical Nurse (LPN). The LPN stated that he was employed as of 3/2015 as a Wound Care LPN. He stated that after receiving notification from the nurse verbally or through a Pressure Ulcer Notification Form his role was to see the wound and document what he observes in the nurse ' s note. He stated that he does not stage a wound, and that during weekly Wound rounds the Physician does the staging. The LPN stated that he updates the CCP monthly, quarterly and as needed if there are any drastic changes in the wound. On 6/22/15 at 2:16 PM an interview was conducted with the day shift assigned CNA. The CNA stated that she cared for the resident on and off for one month at a time. The CNA stated that the resident required extensive assist for all care and even required at one point to be fed by staff. The CNA stated that she receives in-service on the prevention of pressure ulcers and to report any changes in the resident ' s skin. The CNA stated that the CNAs are responsible for checking the resident's skin every shift and documenting on the Body Check Worksheet. The CNA stated that she does not recall if the resident had a pressure ulcer on her heels or if heel booties were ordered for the resident on admission, but she did recall the resident was very protective of her left leg. An interview was conducted on 6/23/15 at 8:25 AM with the MDS RN Coordinator. The RN stated that the RN Supervisor was responsible for initiating the resident's CCP based on her assessment. The RN stated that if the resident has skin problems on admission the RN Supervisor is responsible for initiating the CCP, obtaining orders from the Physician and implementing appropriate devices for the resident. On 6/23/15 at 9:30 AM a interview was conducted with the evening shift assigned CNA. The CNA stated that she could not recall if she cared for the resident when she was first admitted . She stated that the resident receives a bed bath on the evening shift and requires extensive assist for care. She stated that the resident skin is checked every shift by the CNA and that the resident's feet were always bad. When asked to explain what she meant by the resident's feet was always bad the CNA stated that the resident could not walk, she was weak and could not balance herself. The CNA further stated that she did not recall if the resident had a pressure ulcer or if the resident had heel booties on admission, but does recall the resident developing a pressure on the sacrum that has healed. On 6/23/15 at 10:40 AM a interview was conducted with the Wound Care Physician. The Physician stated that the first time he saw the resident was when he was called in 10/2014. The Physician stated that his expectation would be that the resident's feet would be offloaded to prevent the development of a pressure ulcer due to Knee Surgery upon admission. The Physician stated for all residents that would be the expectation, turning and positioning, offloading, heel booties and good vitamins for the prevention of skin break down. The Physician further stated that these pressure ulcers could have been prevented. On 6/23/15 at approximately 11:00 AM an interview was conducted with the Director of Nursing Services (DNS) and the Assistant Director of Nursing Services (ADNS). Both the DNS and the ADNS stated that based on the admission assessment by the RN Supervisor it is the expectation that interventions such as turning and positioning, pressure reducing mattress and offloading are implemented on admission based on the resident's needs. The Facility Policy and Procedure for Pressure Ulcers revised 5/13/15 documented the RNS/designee will develop and implement a preventative CCP for all residents at risk for the development of a pressure ulcer. The RN will document all appropriate interventions on the CNAAR 415.12(c)(1)

Based on observation, staff interviews and record review during an abbreviated and partial extended survey, the facility failed to ensure that each resident assessed and identified as being at risk for elopement, was provided adequate supervision and monitoring to prevent elopement. Specifically, one (Resident #1) out of six residents reviewed for elopement prevention was admitted with a history of elopement and voiced an active intent to leave the facility on 3/5/12. Resident #1 was assessed as an immediate risk for elopement and was placed on 15 minute visual checks. These visual checks were not being completed on a daily basis. On 3/9/12, Resident #1 was not on the visual check clipboard and was able to exit the facility undetected by staff through the front door, which was opened for the resident by the security guard. Resident #1 was noted missing by staff two hours later and remained missing for approximately four hours when the resident's brother called the facility to report that Resident #1 was found in another county. This resulted in no actual harm with the potential for serious harm that is Immediate Jeopardy and Substandard Quality of Care for 13 residents currently in the facility that have been identified as elopement risks. Complaint Number: NY 229 The findings are: Resident #1 is [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) (performed by the Psychologist) dated 3/11/12 documented that Resident #1's cognition is severely impaired. The Hospital Patient Review Instrument dated 2/21/12 documented that Resident #1 has a severe cognitive impairment and was admitted to the hospital after being found wandering in the street with altered mental status and obvious evidence of head trauma. The Hospital Comprehensive Discharge Summary dated 3/5/12 documented that Resident #1 was on 1:1 (one to one supervision) for safety. The Physician Admission History & Physical dated 3/5/12 documented that Resident #1's mental status is cognitively impaired. The Nurse's Admission assessment dated [DATE] documented that Resident #1 was "mentally confused, manic, moaning about attempting to leave ...unable to stay in one place for a short period of time." Resident #1 was placed on 15 minute visual checks. The Integrated Progress Notes (IPN) dated 3/5/12 documented that Resident #1 was admitted to the facility and "presents with severe cognitive deficit, confused, hyperactive, immediate elopement risk seeking exits." The IPN documented that security was made aware and 15 minute visual checks were implemented to maintain safety. The Elopement assessment dated [DATE] documented that the resident was assessed to be at risk for elopement. The Social Work Admission Note dated 3/6/12 documented that Resident #1 has a history of elopement attempts with a plan to place the resident on the elopement list and follow facility protocol. The Comprehensive Care Plan (CCP) for Wandering/Elopement dated 3/6/12 documented that the resident is at risk for possible injury related to elopement risk. Interventions included providing safety visual checks, redirection and ensuring proper photograph at the front door. The CCP for Maintaining Independence, Socialization & Participation in a Structured Environment dated 3/7/12 documented that the resident requires structured daily schedule evidenced by agitation history and history/high risk for elopement. The Social Service Department Initial Assessment & Psychosocial History (SSDIAPH) dated 3/8/12 documented that Resident #1 has severe cognitive deficits, poor safety awareness and was disoriented times three. The SSDIAPH documented that the resident "does not appear to fully comprehend where he is or why he is here. He is not able to follow a conversation or explanation all the way through. He believes this is still the 1970's and that he is visiting this place. Resident's brother states (Resident #1) has been in other places and has made attempts to elope from them as well." The plan for intervention included placing the resident on the elopement list-have picture by security desk, assigned pink arm bands for residents identified at risk for elopement and 15 minute checks. The Visual Check Sheets documented that Resident #1 was being monitored every 15 minutes on 3/5/12 and 3/7/12. There was no documented evidence of monitoring Resident #1 on 3/6/12 or 3/8/12. The Visual Check Sheet (VCS) dated 3/9/12 documented that Resident #1 was being monitored every 15 minutes from 7:00 AM to 10:00 AM. There was no documented evidence of monitoring Resident #1 after 10:00 AM. (There was no documented evidence of monitoring any resident on the VCS from 10:00 AM to 12:15 PM.) The CNA Assignment Accountability Record dated March 2012 documented that Resident #1 is "at risk for elopement. Close Monitoring." The facility's Surveillance Camera recorded Resident #1 exiting the front door of the facility on 3/9/12 at 10:25 AM. The security guard was at the lobby desk and unlocked the door. The IPN dated 3/9/12 documented that, at approximately 12 Noon, Resident #1 could not be located on the unit. A search for the resident commenced. The IPN dated 3/9/12 at 2:30 PM documented that Resident #1's brother called and said the resident was at his house. The nursing supervisor was notified. The facility's Investigation of Complaint (IC) dated 3/14/12 documented that the CNAs (Certified Nursing Assistants) who worked the 7:00 AM to 3:15 PM tour on 3/9/12 neglected to monitor the resident's whereabouts and the security guard unlocked the front door for the resident to exit the building. The IC documented that, when Resident #1 returned to the facility, the resident was placed on strict 15 minute monitoring. The facility's Policy and Procedure on Visual Check dated 3/24/04 documented that the staff member assigned to the resident being monitored will be primarily responsible for observing the resident; however, all staff assigned must refer to the checklist and note that the log is current. The facility's undated Policy and Procedure on Identification of Resident (PPIR) documented that all residents will have means of being identified. The PPIR documented that staff and agency personnel will be in-serviced on resident identification to assure that staff members are fully knowledgeable and able to correctly identify residents at all times. An interview was conducted with the Registered Nurse Unit Manager (RNUM) on 3/13/12 at 12:50 PM. The RNUM stated that, on 3/9/12 at approximately 12 Noon, CNA #1 advised the RNUM that Resident #1 could not be located on the unit and a search for the resident began throughout the facility and in the neighborhood. The police were also notified as well as the attending physician and Resident #1's brother. The RNUM stated that Resident #1 was not found until around 2:30 PM on 3/9/12 when the resident's brother called the facility to say that he had Resident #1 in New York City. The RNUM stated that Resident #1 had a history of [REDACTED]. The RNUM stated that the resident should have been on 15 minute visual checks for which CNAs are responsible. The RNUM stated that any CNA can do the visual check of a resident, "It's whoever picks up the board." During a subsequent interview with the RNUM on 3/14/12 at 11:08 AM the RNUM stated that, on 3/9/12, no CNA followed through on monitoring residents on the 3rd floor but the RNUM did not know why. The RNUM stated that Resident #1 should have been at high risk for elopement and on constant 15 minute visual checks. The RNUM stated that she does not look at the visual check forms and would not expect the charge nurse to be looking at the forms, because "the CNAs take care of it." A telephone interview was conducted with the assigned 7:00 AM to 3:00 PM Certified Nursing Assistant (CNA #1) on 3/13/12 at 12:22 PM. CNA #1 stated that she also had been on duty on 3/5/12 in the evening when Resident #1 was admitted to the facility and Resident #1 had been looking to leave. CNA #1 stated that Resident #1 was put on 15 minute checks on 3/5/12 and CNA #1 thought that the resident was supposed to be on 15 minute checks on 3/9/12 as well. CNA #1 stated that Resident #1 was not on the visual check board on the morning of 3/9/12 but CNA #1 did not ask anyone about it. CNA #1 stated that it is not any one staff member's responsibility to do 15 minute checks. CNA #1 stated, "We all do it. Whoever passes the board can sign for the check." CNA #1 stated that the 15 minute check form has more than one resident on it and whoever signs for one resident, signs for all the residents on the form. An interview was conducted with the Director of Environmental Services (DES) on 3/14/12 at 9:59 AM. The DES stated that he oversees the security guards and that, prior to Resident #1's elopement on 3/9/11, the security guards were not in-serviced by the facility. The security guards would receive a general in-service from their agency. The DES stated that there are no in-service records for the security guards. The DES stated that, after the elopement of Resident #1, the DES developed his own policy on entering and exiting the building and in-serviced the security guards. The DES stated that the security guard on duty when Resident #1 eloped from the facility has been terminated. An interview was conducted with a 7:00 AM to 3:00 PM CNA (CNA #2) on 3/14/12 at 10:23 AM. CNA #2 stated that she signed the visual check form on 3/9/12 for four residents from 7:00 AM to 8:00 AM every 15 minutes. CNA #2 reviewed the form dated 3/9/12 and stated, "He (Resident #1) was not on the form. Only the ones (residents) typed were on the form. He (Resident #1) was written in afterwards." CNA #2 stated that, although she signed the visual check form, it does not mean that she actually saw those four residents each time. CNA #2 stated that "sometimes you'll hear someone say they saw a resident, so you just sign the form." An interview was conducted with a 7:00 AM to 3:00 PM CNA (CNA #3) on 3/14/12 at 10:29 AM. CNA #3 stated that she did not sign the visual check form on 3/9/12. CNA #3 stated, "Whoever passes the board, you just sign the board if someone (a resident) is supposed to be on 15 minute checks. There's no individual person to sign. We're all supposed to." CNA #3 stated that she saw the visual check form when she first came on duty at 7:00 AM on 3/9/12. CNA #3 stated, "I don't recall (Resident #1) on the list." An interview was conducted with a 7:00 AM to 3:00 PM CNA (CNA #4) on 3/14/12 at 10:56 AM. CNA #4 stated that, although she did not work on 3/9/12, CNA #4 is assigned to Resident #1 daily. CNA #4 stated that Resident #1 should always be on the visual check form because the resident tries to leave. CNA #4 stated that she did work on 3/8/12 but Resident #1 was not on the visual check form. CNA #4 stated, "We just go by whoever is on the list that day. I don't remember seeing him (Resident #1) on the list." CNA #4 stated that Resident #1 would not have been monitored if the resident were not on the list for the day. CNA #4 further stated, "One person is not really assigned to fill out the sheet (visual check form). You just pick up the board and someone will check." A telephone interview was conducted with the Security Guard (SG) on 3/14/12 at 11:38 AM. The SG stated that, on 3/9/12, he was at the front desk taking care of someone else. The SG stated that he saw Resident #1 and buzzed the resident out of the facility. The SG stated that he did not recognize Resident #1. The SG stated that there was an elopement book with pictures but the SG did not see Resident #1 in the book. The SG stated that he did not receive in-service training on elopement from the facility. A telephone interview was conducted with a 7:00 AM to 3:00 PM CNA (CNA #5) on 3/14/12 at 12:04 PM. CNA #5 stated that, on 3/9/12, Resident #1 was not on the visual check form. CNA #5 stated, "I put him (Resident #1) on the sheet (visual check form) at 10:00 AM, because he was supposed to be on the sheet. I just knew, so I filled in the times before 10:00 AM." CNA #5 stated, "When we have a patient, anyone (staff members) who goes around can check. There's no special person but we try to make turns in doing the checking." CNA #5 further stated, "After 10:00 AM I didn't check on anybody else (residents). I was busy. I guess someone was doing it." An interview was conducted with a 7:00 AM to 3:00 PM CNA (CNA #6) on 3/14/12 at 12:35 PM. CNA #6 stated that she normally would not work on Resident #1's floor but, on 3/9/12, floated to the resident's floor. CNA #6 stated, "I didn't know he (Resident #1) was an eloper. The nurse should say it but the nurse didn't tell me." CNA #6 stated that, on 3/9/12, she did not do visual checks or sign the visual check form. CNA #6 stated, "We all on the unit should check and sign (the visual check form). If you pass the nurse's desk, you can pick up the board (visual check form)." A telephone interview was conducted with the 7:00 AM to 3:00 PM charge Licensed Practical Nurse (LPN) on 3/14/12 at 12:55 PM. The LPN stated that she was the nurse in charge on 3/9/12 but had not worked the two days prior. The LPN stated that she was not aware that Resident #1 was not on the unit on 3/9/12, because "the CNAs are supposed to watch for the residents every 15 minutes and, if they don't see, report it to me. No one reported that he (Resident #1) couldn't be found." The LPN stated that there are "CNAs on the floor and any one of them can pick up the 15 minute board and put down their signature. Just CNAs check the board. I don't." The LPN stated that the last time she worked prior to Resident #1's elopement was on 3/6/12 and was unaware whether or not Resident #1 required visual monitoring. The LPN stated, "I can't recall because CNAs always have the board (visual check form). I don't check it." A telephone interview was conducted with the Attending Physician (AP) on 3/15/12 at 11:09 AM. The AP stated that Resident #1 has a history of elopement and was very agitated on admission. The AP stated that he would recommend monitoring of Resident #1 for elopement and risk of seizures. The AP further stated, "There is a possibility that he (Resident #1) would likely try to elope again." An interview was conducted with the Director of Staff Development (DSD) on 3/15/12 at 11:55 AM. The DSD stated that a CNA in charge of a resident is responsible to go and visually check where a resident is. The DSD stated that he is not aware of any concerns regarding this procedure. The DSD stated that, if a resident is at risk for elopement, then the resident should be on 15 minute visual checks. The DSD further stated that he believed the visual checks were covered with staff members during the annual elopement in-service but the DSD could not locate it. An interview was conducted with the Medical Director (MD) on 3/15/12 at 3:03 PM. The MD stated that he was notified by e-mail on 3/9/12 that the security guard inadvertently released the front door and Resident #1 eloped. The MD stated that an investigation was started but the MD has not been involved. The MD stated that he is not aware of any policy changes or concerns with monitoring residents. An interview was conducted with the Director of Nursing (DON) on 3/16/12 at 9:18 AM. The DON stated that the RNUM notified her on 3/9/12 at around 12:15 PM that Resident #1 was missing and a full search of the facility and community occurred. The DON stated that Resident #1 could not be found and, a couple of hours later at around 2:30 PM, Resident #1's brother called the facility to say he had found Resident #1 in New York City. The DON stated that, when Resident #1 returned to the facility, Resident #1 was placed on "strict, more diligent 15 minute monitoring." The DON stated that, during the investigation of Resident #1's elopement, staff was unable to give the DON a reason as to why 15 minute checks were not being done on Resident #1. The DON stated that CNAs told the DON that they (CNAs) all do 15 minute checks. The DON stated that she plans to start having one staff member monitor residents on visual checks but this has not begun yet. The DON stated that she would also like to change the front desk pictures to be on a board so security does not have to go into a binder but the DON has not made any changes yet. A telephone interview was conducted with the Director of Social Services (DSS) on 3/16/12 at 10:43 AM. The DSS stated that Resident #1 is very cognitively impaired and has tried to elope from facilities in the past. The DSS stated that "(Resident #1) is stuck in the '70 ' s. His (Resident #1's) brother told me that any place he'd been, he'd tried to leave." The DSS stated that the nursing staff was aware of the resident's elopement history and the DSS believed Resident #1's picture was at the front desk. 415.12 (h)(2)

Based on observation, staff interviews and record review during an abbreviated and partial extended survey, the facility's administration failed to ensure that there were systems in place to assure that each resident reached and maintained the highest practicable level of physical and psychosocial well being. The Administration failed to implement policies and procedures for monitoring and supervising residents at risk for elopement and failed to provide in-service training to security personnel regarding elopement prevention. Specifically, Resident #1 had a known history of elopement and upon admission to the facility was assessed as an immediate risk for elopement and placed on 15 minute visual checks. Four days after admission Resident #1 exited the facility undetected by staff through the front door, which was opened for the resident by the security guard. Resident #1 was noted missing by staff two hours later and remained missing for approximately four hours when the resident's brother called the facility to report that Resident #1 was found in another county. This resulted in no actual harm with the potential for serious harm that is Immediate Jeopardy for thirteen (13) residents currently in the facility that have been identified as at risk for elopement. Refer to citations under F 323 K (Quality of Care, Accidents and Supervision) Complaint Number: NY 229 The findings are: The facility's Policy and Procedure on Visual Check dated 3/24/04 documented that the staff member assigned to the resident being monitored will be primarily responsible for observing the resident; however, all staff assigned must refer to the checklist and note that the log is current. The facility's undated Policy and Procedure on Identification of Resident (PPIR) documented that all residents will have means of being identified. The PPIR documented that staff and agency personnel will be in-serviced on resident identification to assure that staff members are fully knowledgeable and able to correctly identify residents at all times. The facility's Investigation of Complaint (IC) dated 3/14/12 documented that the CNAs (Certified Nursing Assistants) who worked the 7:00 AM to 3:15 PM tour on 3/9/12 neglected to monitor the resident's whereabouts and the security guard unlocked the front door for the resident to exit the building. The IC documented that, when Resident #1 returned to the facility, the resident was placed on strict 15 minute monitoring. An interview was conducted with the Director of Environmental Services (DES) on 3/14/12 at 9:59 AM. The DES stated that he oversees the security guards and that, prior to Resident #1's elopement on 3/9/11, the security guards were not in-serviced by the facility. The security guards would receive a general in-service from their agency. The DES stated that there are no in-service records for the security guards. The DES stated that, after the elopement of Resident #1, the DES developed his own policy on entering and exiting the building and in-serviced the security guards. The DES stated that the security guard on duty when Resident #1 eloped from the facility has been terminated. A telephone interview was conducted with the Security Guard (SG) on 3/14/12 at 11:38 AM. The SG stated that, on 3/9/12, he was at the front desk taking care of someone else. The SG stated that he saw Resident #1 and buzzed the resident out of the facility. The SG stated that he did not recognize Resident #1. The SG stated that there was an elopement book with pictures but the SG did not see Resident #1 in the book. The SG stated that he did not receive in-service training on elopement from the facility. An interview was conducted with the Director of Staff Development (DSD) on 3/15/12 at 11:55 AM. The DSD stated that a CNA in charge of a resident is responsible to go and visually check where a resident is. The DSD stated that he is not aware of any concerns regarding this procedure. The DSD stated that, if a resident is at risk for elopement, then the resident should be on 15 minute visual checks. The DSD further stated that he believed the visual checks were covered with staff members during the annual elopement in-service but the DSD could not locate it. An interview was conducted with the Medical Director (MD) on 3/15/12 at 3:03 PM. The MD stated that he was notified by e-mail on 3/9/12 that the security guard inadvertently released the front door and Resident #1 eloped. The MD stated that an investigation was started but the MD has not been involved. The MD stated that he is not aware of any policy changes or concerns with monitoring residents. An interview was conducted with the Director of Nursing (DON) on 3/16/12 at 9:18 AM. The DON stated that the Registered Nurse Unit Manager notified her on 3/9/12 at around 12:15 PM that Resident #1 was missing and a full search of the facility and community occurred. The DON stated that Resident #1 could not be found and, a couple of hours later at around 2:30 PM, Resident #1's brother called the facility to say he had found Resident #1 in New York City. The DON stated that, when Resident #1 returned to the facility, Resident #1 was placed on "strict, more diligent 15 minute monitoring." The DON stated that, during the investigation of Resident #1's elopement, staff was unable to give the DON a reason as to why 15 minute checks were not being done on Resident #1. The DON stated that CNAs told the DON that they (CNAs) all do 15 minute checks. The DON stated that she plans to start having one staff member monitor residents on visual checks but this has not begun yet. The DON stated that she would also like to change the front desk pictures to be on a board so security does not have to go into a binder but the DON has not made any changes yet. A brief interview was conducted with the Administrator on 3/15/12 at 3:45 PM. The Administrator was informed by the surveyors that the investigation was ongoing. The Administrator stated, "The majority of my CNAs are illiterate and incompetent. I don't know how they passed the CNA test." During a subsequent interview with the Administrator on 3/16/12 at 10:21 AM the Administrator stated that he was called on his cell phone as soon as it was determined that Resident #1 eloped. The Administrator stated that he ensured all department heads and law enforcement authorities were aware of the elopement. The Administrator further stated that he believes that Resident #1 had been admitted with a beard and the picture of Resident #1 in the front desk elopement book probably did not match the resident. 416.26