Every finding on record at Beach Terrace Care Center

Based on observation, record review and interviews conducted during survey, the facility failed to ensure residents are free from abuse for one of three residents reviewed for abuse (Resident #1). Specifically, on 08/06/2026 Certified Nursing Assistant #1 punched Resident #1 in the face twice in response to the resident slapping Certified Nursing Assistant #1. Certified Nursing Assistants #2 and #3 witnessed the incident and did not intervene or remove Resident #1 from the situation. This resulted in actual harm to Resident #1 and the likelihood for serious injury, serious harm, serious impairment or death to all 174 residents that was Immediate Jeopardy.The findings are:The facility policy titled Abuse, Neglect, Exploitation, or Misappropriation last updated 10/14/2024 documented the residents have the right to be free from abuse and further states no staff may abuse a resident. The policy also includes that staff are in serviced on abuse upon hire and frequently throughout the year Resident #1 was admitted with diagnosis that includes psychotic disorder with delusions (a psychiatric condition characterized by a presence of one or more persistent, fixed false beliefs) and dementia (a decline in mental ability severe enough to interfere with daily life). The 07/21/2026 Minimum Data Set (a resident assessment tool) documented a score of 99 indicating severe cognitive impairment. The Comprehensive Care Plan Behavioral Symptoms-Inappropriate dated 07/15/2026 documented, goals of episodes or inappropriate behaviors will be reduced/ eliminated for three months. Interventions include approach in a calm manner, encourage discussion of cause and behavior, medicate as ordered by physician and monitor effectiveness, monitor for inappropriate behavior, offer diversional activities, psychiatrist consult as ordered and as needed, reinforce appropriate behavior, discourage inappropriate behavior.Behavior Note for Resident #1 dated 07/15/2026 documented Resident #1 exhibited behavioral issues, including restlessness, removed clothing twice despite staff assistance and redirection to remain dressed. Resident #1 also slapped a certified nursing assistant in the face during care.Behavior Note for Resident #1 dated 07/15/2026 documented Resident #1 became physically aggressive and punched a certified nursing assistant in the chest during care.Behavior Note for Resident #1 dated 07/17/2026 documented Resident exhibited physical aggression, including grabbing and attempting to hit a certified nursing assistant. Resident #1 was agitated and restless. Resident #1 was also noncompliant with treatment recommendation, including elevating right hand/arms due to swelling and pain complaint.A review of facility video dated 08/06/2026 at 12:11 PM revealed Resident #1 sitting in a wheelchair in the 2 [NAME] dining room with a lunch tray. Certified Nursing Assistant #1 was observed sitting on the left of Resident #1 feeding Resident #2. Resident #1 is observed slapping Certified Nursing Assistant #1 in the face from behind. Certified Nursing Assistant #2 is observed seated across from Resident #1. Certified Nursing Assistant #1 stood over Resident #1 and proceeded to point their finger at the face of Resident #1 who responded by grabbing their hand. Certified Nursing Assistant #1 grabs both of Resident #1's hands and punched Resident #1 in the face twice. Certified Nursing Assistant #2 got up during that struggle and placed a hand on Certified Nursing Assistant #1's back. Certified Nursing Assistant #1 left the dining room and Certified Nursing Assistant #2 then moved the resident to another table where Certified Nursing Assistant #3 was assisting another resident. Certified Nursing Assistant #3 was seen on video observing the incident while feeding another resident and did not intervene. No one appears to call for help. Resident #1 remains in the dining room and continues their meal. Resident #1 is observed on multiple occasions touching the left side of their face where they were struck. Certified Nursing Assistant #2 and Certified Nursing Assistant #3 were not observed reporting the incident to any nurse or supervisor. The facility accident and incident report dated 08/06/2026 documented at approximately 12:30 PM Registered Nurse #1 reported that Certified Nursing Assistant #3 reported that Certified Nursing Assistant #1 struck Resident #1. The report further documented Resident #1 was reassessed and complained of pain. A note to file dated 08/06/2026 and signed by the Director of Nursing documented Resident #1 hit Certified Nursing Assistant #1 in the face without provocation. Certified Nursing Assistant #1 stood up over the Resident, Resident #1 hit Certified Nursing Assistant #1 again. Certified Nursing Assistant #1 grabbed Resident #1's hands and hit Resident #1 twice in the face with closed fists. Certified Nursing Assistant #2 came around to tell Certified Nursing Assistant #1 to calm down. Certified Nursing Assistant #1 walked away. Interviews:During an interview Certified Nursing Assistant #2 who was sitting across the table when the incident occurred, stated that they observed Resident #1 slap Certified Nursing Assistant #1, but stated that they did not observe Certified Nursing Assistant #1 hit Resident #1. They further stated they did not report the incident. They stated they viewed the video tape but do not recall seeing Certified Nursing Assistant #1 punching Resident #1. During an interview on 08/12/2026 at 12:17 PM Certified Nursing Assistant #3 stated that they were sitting across the dining room from Certified Nursing Assistant #1 and Resident #1 and could see them during the meal. Registered Nurse #1 came into the dining room and asked what happened with Resident #1. They stated they did not report the incident because Registered Nurse #2 was standing nearby when the incident occurred. Registered Nurse #1 asked them if Certified Nursing Assistant #1 hit Resident #1 and they confirmed. They further reported that Resident #1 was crying and stated their head hurt. During an interview on 08/12/2026 at 12:26 PM with Registered Nurse #1, who stated they were notified by Certified Nursing Assistant #3, that Certified Nursing Assistant #1 hit Resident #1. They stated they had left the room to call the supervisor, and while they were on the unit Certified Nursing Assistant #1 was noted to be in another resident's room looking in the mirror. During an interview on 08/12/2026 at 12:46 PM Registered Nurse #2 stated they were not aware of the incident. They stated they were giving medication in the hallway and no one reported to them that Resident #1 was struck by Certified Nursing Assistant #1. They stated they heard a commotion in the dining room and Certified Nursing Assistant #1 walked past them but did not know where they went. [NAME] an interview on 08/12/2026 at 11:52 AM the Medical Doctor stated Resident #1 was hit by a certified nursing assistant. Resident #1 was assessed in the wheelchair, and the resident was at baseline. Neurological checks were ordered for three days along with Tylenol and an icepack. They further stated that it is not acceptable for a certified nursing assistant to strike a resident even if the resident is aggressive. During an interview on 08/12/2026 at 2:15 PM the Director of Nursing stated they were informed of the incident by Registered Nurse #1. They immediately located Certified Nursing Assistant #1 and removed them from their duties. They were interviewed, terminated and the police were notified. Resident #1 was seen by the physician with orders for a neuro check, and Tylenol. The Director of Nursing stated they investigated the incident and concluded that abuse did occur. They stated Certified Nursing Assistant #1 should not have hit Resident #1 and there should have been a nurse in the dining room while meals were being served and eating. Staff should have reported the incident immediately.During an interview on 08/27/2026 at 1:25 PM the Administrator stated they found out about the incident between Resident #1 and Certified Nursing Assistant #1 on 08/06/2026 when the Director of Nursing called them. They further stated that Certified Nursing Assistant #1 should not have hit Resident #1 and abuse is not acceptable. When the incident occurred the other staff should have removed the resident to safety. Certified Nursing Assistant #1 should have been removed immediately as well.10 NYCRR 415.3(d)(1)(vii)

Based on observations, record review, and interviews, the facility did not ensure it maintained a comfortable and homelike environment with comfortable temperatures between 71 degrees Fahrenheit and 81 degrees Fahrenheit in the resident rooms and areas. This was identified for 18 (Room G28, 124, 125, 127, 128, 133, 136, 201, 216, 219, 222, 225, 226, 228, 230, 232, 233, and 236) of the 83 resident rooms during the Environment Task. Specifically, 18 resident rooms and the first-floor shower room ambient temperature was measured to be below 71 degrees Fahrenheit. Multiple residents complained of being uncomfortable due to the cold room temperature.The finding is: The facility's policy titled Safe and Homelike Environment dated 12/2025 documented comfortable and safe temperature levels mean that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia/hyperthermia and is comfortable for the residents. The facility will maintain comfortable and safe temperatures levels. The facility should strive to keep the temperature in common resident areas between 71 and 81 degrees Fahrenheit. During observation of room [ROOM NUMBER] in Unit 1 [NAME] on 01/21/2026 at 11:20 AM, Resident #57 was observed in a Geri chair without a blanket. Resident #57 yelled out that the room was freezing. The room felt cold. Resident #68 was freely ambulating; they were wearing a heavy sweater and scarf and said the room was cold. During an interview on 01/21/2026 at 11:25 AM, Licensed Practical Nurse #1 entered room [ROOM NUMBER] and said the room was a little bit chilly. Licensed Practical Nurse #1 did not offer Resident #57 a blanket. During an observation on 01/21/2026 at 11:43 AM, Maintenance Director #1 measured the temperature in room [ROOM NUMBER] with their infrared laser thermometer, and the temperature was measured to be 62 degrees Fahrenheit. Maintenance Director #1 checked the windows and said they were closed. Maintenance Director #1 stated the heater was working but it may be dirty or not working properly. During an interview on 01/21/2026 at 12:00 PM, Maintenance Director #1 stated the bottom of the heater in room [ROOM NUMBER] was covered with dirt and debris from a recent renovation which was not allowing proper airflow, and the heater needed to be cleaned. During an observation on 01/21/2026 at 12:05 PM, Maintenance Director #1 measured the temperature in room [ROOM NUMBER] (Unit 1 West), which felt cool and was found to be 66 degrees Fahrenheit. Maintenance Director #1 stated the heater was probably dirty. During observations 01/22/2026 between 10:45 AM - 04:00 PM, room temperatures were measured throughout the facility using an infrared thermometer in the presence of Maintenance Director #1. The following temperature readings were obtained: -On the ground floor, room G28- 66 degrees Fahrenheit. - On unit 1 West: room [ROOM NUMBER] -68 degrees Fahrenheit; room [ROOM NUMBER]-66 degrees Fahrenheit, room [ROOM NUMBER] -69.9 degrees Fahrenheit; room [ROOM NUMBER] and room [ROOM NUMBER]-69 degrees Fahrenheit.-The first-floor shower room-65 degrees Fahrenheit. -On Unit 2 East, the corridor-66 degrees Fahrenheit. -room [ROOM NUMBER]-68 degrees Fahrenheit; room [ROOM NUMBER]-63 degrees Fahrenheit and room [ROOM NUMBER]-64 degrees Fahrenheit. -On Unit 2 West, room [ROOM NUMBER]-68 degrees Fahrenheit; room [ROOM NUMBER]-67 degrees Fahrenheit; room [ROOM NUMBER]-69 degrees Fahrenheit; room [ROOM NUMBER]-67 degrees Fahrenheit; room [ROOM NUMBER]-69 degrees Fahrenheit, room [ROOM NUMBER]-66 degrees Fahrenheit; room [ROOM NUMBER]-65 degrees Fahrenheit; and room [ROOM NUMBER]-67 degrees Fahrenheit. The corridor temperature outside room [ROOM NUMBER]was 67 degrees Fahrenheit. During a Resident Council meeting on 01/22/2026 at 2:14 PM, Resident #147 and Resident #10 complained that the rooms they resided in were cold. During an observation of Unit 1 [NAME] on 01/22/2026 at 2:25 PM, Resident #88 was in their room and was wearing a blanket over their head while sitting on the edge of the bed. The resident stated the room was cold. During an observation and interview on 01/23/2026 at 9:55 AM, Maintenance Director #1 conducted environmental heat rounds. Maintenance Director #1 stated the room heater was cleaned in room [ROOM NUMBER] and the temperature in the room was now 70.2 degrees Fahrenheit. The temperature in room [ROOM NUMBER] on Unit 1 [NAME] was now 69.3 degrees Fahrenheit. Maintenance workers were observed filling corrosion gaps in the heating unit enclosure with foam caulking in the room where the gaps were allowing cold air from outside into the room. The outside temperature on 1/23/2026 was 23 degrees Fahrenheit. Maintenance Director #1 proceeded to measure additional temperatures. The temperature in room [ROOM NUMBER] on Unit 2 East was 67 degrees Fahrenheit and the temperature in room [ROOM NUMBER] on Unit 2 [NAME] was 69 degrees Fahrenheit. Maintenance Director #1 said the heaters in room [ROOM NUMBER] had not been cleaned yet, and the heater underside had dirt and debris. The temperature in room [ROOM NUMBER] on Unit 2 East was 66 degrees Fahrenheit. Maintenance Director #1 checked the heater in room [ROOM NUMBER] and stated the bleeder valve (a valve that ensures proper hot water circulation) needed to be replaced, which affected the heat in the room. During a concurrent interview with Maintenance Director #1 and the Administrator on 01/23/2026 at 12:00 PM, Maintenance Director #1 stated the facility has cleaned the heaters in 96 rooms since 01/21/2026. Maintenance Director #1 stated they monitor room temperatures in random rooms but do not document daily temperatures. Maintenance Director #1 stated the maintenance workers randomly check temperatures every day and report any negative findings of less than 71 degrees to them. Maintenance Director #1 stated they were not notified of any resident room temperatures below 71 degrees. Maintenance Director #1 stated they routinely check the boilers, pumps, and the radiators. The radiators were generating heat. Maintenance Director #1 stated they do not remove the heater enclosures and did not know that the heaters were dirty, until the heat issue was identified on 01/21/2026. Maintenance Director #1 stated they do not have a preventative maintenance check list and only relied on residents and staff complaints regarding the heat issues. Maintenance Director #1 stated the construction that was done in every room two months ago created a lot of debris. Maintenance Director #1 stated they did not notice the layer of dust and dirt on the bottom of the heaters. Maintenance Director #1 stated the construction crew cleaned the top of the heaters but did not clean underneath the heaters. Maintenance Director #1 stated there is a maintenance logbook on every nursing unit, and there were no reports of heating problems. The administrator stated they will implement an action plan to conduct temperature checks in every room every two hours and maintain a log. On 01/27/2026 at 09:00 AM review of the temperature log for 01/23/2026-01/27/2026 revealed that the facility monitored temperatures every two hours in every room. The temperature readings throughout the facility were between 69 degrees Fahrenheit and 78 degrees Fahrenheit. The maintenance logs stored at each nursing unit were reviewed and revealed the following entries by the unit staff:- The ground floor maintenance book documented on 01/18/2026 there was cold air coming from the exit door by the shower room. On 01/20/2026 the wall heater in room [ROOM NUMBER] was not working and was blowing cold air.-The Unit 1 East maintenance book documented on 12/10/2025 room [ROOM NUMBER] was extremely cold and a request was made to please check the windows.-The Unit 1 [NAME] maintenance book documented on 12/26/2025 there was no heat in the 1 [NAME] Dining Room. On 12/28/2025 room [ROOM NUMBER] was noted to be extremely cold and there was a request to check the windows.- The Unit 2 East maintenance book documented on 11/07/2025 room [ROOM NUMBER] was very cold and a request was made to adjust the windows.-The Unit 2 [NAME] maintenance book documented on 12/10/2025 the resident in room [ROOM NUMBER] complained that the room was cold. On 01/20/2026 and 01/21/2026 the Dining room was cold.-The written response to each documented entry was done. During a concurrent interview with Maintenance Director #1 and the Administrator on 01/28/2026 at 2:00 PM, Maintenance Director #1 stated they did not know there was a problem with the heating system. Maintenance Director #1 stated as of 01/21/2026 they ordered 12 space heaters for the areas that were not meeting the ambient temperature requirements. Maintenance Director #1 stated they are in the process of checking each radiator to determine if radiators need to be replaced. Maintenance Director #1 stated they reviewed the unit maintenance books twice a day, and all the cold weather complaints in the maintenance books were because the windows were left open. 10 NYCRR 415.5(h)(4)

Based on observations, interviews, and record reviews, the facility did not maintain the heating system in proper working conditions to provide a healthy, functional, and comfortable environment for residents, personnel, and the public. This was identified for 19 (Room G28, 120, 124, 125, 133, 134, 136, 201, 216, 219, 222, 225, 226, 228, 230, 232, 233, and 236) of the 83 resident rooms during the Environment Task. Specifically, the heating system in multiple resident rooms did not function as intended to provide comfortable and safe environmental temperatures. Cross Reference-F584: Safe/Clean/Comfortable/Homelike Environment.The findings are:The facility's policy titled Building Management System Failure dated 05/2024, documented that problems with the Utilities Management system are typically indicated by: Comparing trend data of work requisitions; Alarms on major utility system components to provide immediate notification of problems on high priority systems; engineering incident reports; complaint calls; and unscheduled repairs. The collection of information from any of the assessment sources noted above initiates an investigation process. This process involves assessing the problem, providing back-up resources, if needed, troubleshooting to determine problem, planning for corrections and performing the actual repair. The repairs, the information and the solutions are recorded, and the system is trended and monitored to assess integrity of repair. During an interview on 01/22/2026, at approximately 10:00 AM, the Maintenance Director #1 stated that they check the heating system before the cold season starts and make sure that it is working properly. The heat in residents' rooms is provided by the coil heating units and the temperature in residents' rooms is checked twice per day. Maintenance Director #1 stated that there are maintenance logbooks in each nursing unit, for the staff to report any maintenance issues. Maintenance Director #1 stated they have not received any complaints about cold rooms or cold temperatures. Maintenance Director #1 stated that there are two boilers that provide heat and hot water and there are panels in the boiler room that monitor the temperatures in the residents' rooms. Maintenance Director #1 stated they monitor the temperatures by checking those panels. The Maintenance Director #1 showed a picture on their phone that revealed a thick layer of dirt and dust covering the bottom of a radiator and stated that the debris was preventing the radiator airflow causing the heat issue. During observations 01/22/2026 between 10:45 AM - 01:00 PM, room temperatures were measured throughout the facility using an infrared thermometer in the presence of Maintenance Director #1. The following temperature readings were obtained: -On the ground floor, room G28- 66 degrees Fahrenheit. - On unit 1 West: room [ROOM NUMBER] -68 degrees Fahrenheit; room [ROOM NUMBER]-66 degrees Fahrenheit, room [ROOM NUMBER] -69.9 degrees Fahrenheit; room [ROOM NUMBER] and room [ROOM NUMBER]-69 degrees Fahrenheit.-The first-floor shower room-65 degrees Fahrenheit. -On Unit 2 East, the corridor-66 degrees Fahrenheit. -room [ROOM NUMBER]-68 degrees Fahrenheit; room [ROOM NUMBER]-63 degrees Fahrenheit and room [ROOM NUMBER]-64 degrees Fahrenheit. -On Unit 2 West, room [ROOM NUMBER]-68 degrees Fahrenheit; room [ROOM NUMBER]-67 degrees Fahrenheit; room [ROOM NUMBER]-69 degrees Fahrenheit; room [ROOM NUMBER]-67 degrees Fahrenheit; room [ROOM NUMBER]-69 degrees Fahrenheit, room [ROOM NUMBER]-66 degrees Fahrenheit; room [ROOM NUMBER]-65 degrees Fahrenheit; and room [ROOM NUMBER]-67 degrees Fahrenheit. The corridor temperature outside room [ROOM NUMBER]was 67 degrees Fahrenheit. During an interview on 01/22/2026, at approximately 12:30 PM, Maintenance Director #1 stated that the heat radiator's bottom was dusty, and the thick layer of the dust was blocking and preventing the heat from circulating in the whole radiator. Maintenance Director #1 stated they started cleaning the radiator units yesterday (1/21/2026) and will be finished by the end of the day. Maintenance Director #1 stated that the rooms were renovated two months ago, and the construction crew cleaned the top of the unit, but not the bottom. Maintenance Director #1 stated before the start of winter, they checked all the radiators to make sure they were operational for the winter season. There were no issues with the radiators up until now when the surveyor alerted them of the heat issue on 1/21/2026. During a subsequent observation on 01/23/2026, between 10:00 AM -11:45 AM, the following room temperatures were recorded in the presence of Maintenance Director #1:room [ROOM NUMBER]: 69 degrees Fahrenheit. The maintenance staff members were observed filling air gaps inside the unit. The radiator was encased by a metal enclosure that was observed to be heavily rusted.room [ROOM NUMBER]: 67 degrees Fahrenheit.room [ROOM NUMBER]: 69 degrees Fahrenheit. Maintenance Director #1 stated that this unit was not yet cleaned. room [ROOM NUMBER]: 66 degrees Fahrenheit. Maintenance Director #1 checked the heater in room [ROOM NUMBER] and stated the bleeder valve (a valve that ensures proper hot water circulation) needed to be replaced, which affected the heat in the room. room [ROOM NUMBER]: 67 degrees Fahrenheit.During an interview on 01/23/2026, at approximately 12:00 PM, with the Administrator and Maintenance Director #1. Maintenance Director #1 stated that there is a preventive maintenance system in place before the heat system is turned on, they check when the season starts, so far heating units in 96 resident rooms have been cleaned. Maintenance Director #1 stated they monitor room temperatures in random rooms but do not document daily temperatures. Maintenance Director #1 stated the maintenance workers randomly check temperatures every day and report any negative findings of less than 71 degrees to them. Maintenance Director #1 stated they were not notified of any resident room temperatures below 71 degrees. Maintenance Director #1 stated they routinely check the boilers, pumps, and the radiators. The radiators were generating heat. Maintenance Director #1 stated they do not remove the heater enclosures and did not know that the heaters were dirty, until the heat issue was identified on 01/21/2026. Maintenance Director #1 stated they do not have a preventative maintenance check list and only relied on residents and staff complaints regarding the heat issues. Maintenance Director #1 stated the construction that was done in every room two months ago created a lot of debris. Maintenance Director #1 stated they did not notice the layer of dust and dirt on the bottom of the heaters. Maintenance Director #1 stated the construction crew cleaned the top of the heaters but did not clean underneath the heaters. Maintenance Director #1 stated there is a maintenance logbook on every nursing unit, and there were no reports of heating problems. The administrator stated they will implement an action plan to conduct temperature checks in every room every two hours and maintain a log. On 01/23/2026, at approximately 1:19 PM, record review of the maintenance logs located at each nurse unit revealed the following notes: - The ground floor maintenance book documented on 01/18/2026 there was cold air coming from the exit door by the shower room. On 01/20/2026 the wall heater in room [ROOM NUMBER] was not working and was blowing cold air. -The Unit 1 East maintenance book documented on 12/10/2025 room [ROOM NUMBER] was extremely cold and a request was made to please check the windows. -The Unit 1 [NAME] maintenance book documented on 12/26/2025 there was no heat in the 1 [NAME] Dining Room. On 12/28/2025 room [ROOM NUMBER] was noted to be extremely cold and there was a request to check the windows.- The Unit 2 East maintenance book documented on 11/07/2025 room [ROOM NUMBER] was very cold and a request was made to adjust the windows. -The Unit 2 [NAME] maintenance book documented on 12/10/2025 the resident in room [ROOM NUMBER] complained that the room was cold. On 01/20/2026 and 01/21/2026 the Dining room was cold. -The written response to each documented entry was done. On 01/23/2026, at approximately 1:30 PM, Maintenance Director #1 stated that these notes in the maintenance logs were because the windows were open, and that all the requests listed in the maintenance books were completed. During a subsequent observation on 01/27/2026, at approximately 9:50 AM the following air room temperatures were recorded:room [ROOM NUMBER] - 67 degrees Fahrenheit.room [ROOM NUMBER] - 69 degrees Fahrenheit.Room G28 - 66 degrees Fahrenheit.During a subsequent observation on 01/28/2026, at approximately 12:23 PM the following air room temperatures were recorded:room [ROOM NUMBER] - 65 degrees Fahrenheit. It was noted that the heating unit was off.room [ROOM NUMBER] - 69 degrees Fahrenheit. During a concurrent interview with the Administrator and Maintenance Director #1, on 01/29/2026, at 2:06 PM, the Maintenance Director #1 stated that they should have been aware that the bottom of the radiators was dirty. Maintenance Director #1 stated before winter sets they go through a set of steps such as turn on the pumps and ensure that all zone valves are activated; however, there is not a written checklist for them to document the maintenance checks, they just do it based on their knowledge. Maintenance Director #1 stated the heating system has issues in addition to the layer of the dust at the bottom of the units, and mechanical upgrades are needed such as replacement of some radiator valves. They called the heating company on the morning of 01/29/2026 to determine if the radiators need replacement. Maintenance Director #1 stated they have also ordered 12 wall mounted heaters for the areas that do not meet the heating requirements. 10 NYCRR:415.29 (h)(1)

Based on observation, record review, and interviews, the facility did not ensure that each resident who needs respiratory care is provided with such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. This was identified as one (1) (Resident #63) of four (4) residents reviewed for Oxygen administration. Specifically, Resident #63 had a physician order to receive supplemental oxygen therapy via a nasal cannula. During an observation on 01/21/2026, the resident was not utilizing the supplemental oxygen therapy and the oxygen tubing, and an oxygen mask was laying on top of an oxygen concentrator (a machine that delivers purified oxygen) adjacent to Resident #63's bed (not in use). There was no nasal cannula present at the resident's bedside. The inside of the mask was dirty, and the oxygen tubing had brown colored debris inside the tubing. There was no date label on the oxygen tubing indicating when the tubing was placed.The finding is:The facility's policy titled Care of Respirators/Oxygen Equipment, dated 04/2014, documented equipment used to administer oxygen will be maintained in a manner that reduces risk of infection. The equipment includes, but not limited to, oxygen tubing, oxygen mask, nasal cannula, humidifying bottle, and nebulizer. This equipment will be changed weekly and more often if indicated. Change all disposable equipment weekly on specified days including tubing, mask or cannula.Resident #63 was admitted with diagnoses including non-Alzheimer's dementia, seizure disorder, and traumatic brain injury. The 12/05/2025 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 2, indicating the resident had severe cognitive impairment. The resident received oxygen therapy while a resident.A physician's order dated 01/09/2026 documented oxygen at 3 liters per minute via nasal cannula every shift as needed for seizures and shortness of breath.During an observation with Licensed Practical Nurse #1, on 01/21/2026 at 11:10 AM, Resident #63 was asleep in bed. Next to the bed was an oxygen concentrator (not operating) with the oxygen tubing and an oxygen mask lying on top of the concentrator. The oxygen tubing was not dated. Inside the tubing, where the tube connected to the mask, was brown colored debris. The mask was visibly dirty with a blackish brown substance on the inside of the mask. Licensed Practical Nurse #1 observed the mask and stated the tubing and the mask were dirty. Licensed Practical Nurse #1stated the tubing should be labelled with a date and removed the tubing and the mask from the bedside. During an interview on 01/27/2026 at 10:35 AM, Registered Nurse Infection Preventionist #1 stated the oxygen tubing and mask should be dated and changed every seven days or as needed because the dirty tubing and mask increases the potential for infection. During an interview on 01/27/2026 at 11:20 AM, the Director of Nursing Services stated the oxygen tubing should be labelled and changed once a week on the 3:00 PM-11:00 PM shift. 10 NYCRR 415.12(K) (6)

Based on record review and interviews, the facility did not ensure the Minimum Data Set assessment was completed to accurately reflect each resident's current status. This was identified for one (1) (Resident #72) of two (2) residents reviewed for Dialysis. Specifically, 1) Resident #72 receives dialysis three times a week which was not identified in the Minimum Data Set assessment dated [DATE]. The finding is:The undated facility policy titled, MDS (Minimum Data Set) 3.0 documented that every department will be responsible for accurate completion of the assigned Minimum Data Set sections.Resident #72 has diagnoses that include end stage renal disease (when chronic kidney disease - the gradual loss of kidney function - reaches an advanced state when your kidneys no longer work as they should to meet your body's needs) and Parkinson's disease (a movement disorder of the nervous system that worsens over time). The Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 3, which indicated the resident had severely impaired cognitive skills for daily decision making. The Minimum Data Set assessment documented the resident did not receive dialysis on admission, while a resident, or at discharge. The physician's order dated 12/09/2025 and last renewed on 01/20/2026 documented for the resident to receive hemodialysis three times a week on Monday, Wednesday, and Friday at 10:00 AM at an outpatient dialysis facility.During an interview on 01/28/2026 at 10:58 AM, Registered Nurse Minimum Data Set Assessor #1 (who completed section O in the Minimum Data Set assessment dated [DATE]) stated they overlooked documenting that the resident received dialysis while a resident at the facility. During an interview on 01/28/2026 at 12:20 PM, Registered Nurse Minimum Data Set Coordinator #1 (who signed for completion of the Minimum Data Set assessment dated [DATE]) stated Registered Nurse Minimum Data Set Assessor #1 should have documented the resident was receiving dialysis in the Minimum Data Set assessment. Registered Nurse Minimum Data Set Coordinator #1 stated they reviewed the assessment for accuracy before signing off on it but missed that Registered Nurse Minimum Data Set Assessor #1 did not document the resident was receiving dialysis while a resident at the facility. During an interview on 01/28/2026 at 2:00 PM, the Director of Nursing Services stated that since there are physician's orders for the resident to receive dialysis, Registered Nurse Minimum Data Set Assessor #1 should have captured that information when they completed Section O in the Minimum Data Set assessment. The Director of Nursing Services stated that each discipline should complete their section of the Minimum Data Set assessment accurately. 10 NYCRR 415.11(b)

Based on record review and interviews, the facility did not ensure that its Facility Assessment considered specific staffing needs for each resident unit and each shift, such as day, evening, night, in the facility and adjusted as necessary based on changes to its resident population. This was identified during the Sufficient and Competent Staffing task. Specifically, the Facility assessment dated [DATE] did not document the number of nursing personnel needed to meet resident needs for each unit for each shift.The finding is:The facility policy titled Annual Facility assessment dated 01/2024 documented it is the policy of the facility to conduct and document a facility-wide assessment to determine the resources necessary to care for our residents competently during both day-to-day operations and emergencies to ensure that quality care and quality of life are maintained. The facility assessment must address or include the facility's resident population and the facility's resources. The Administrator, Medical Director, Director of Nursing will assist in completing the facility assessment relative to each department's personnel, services, and equipment. Based on the outcome of the facility assessment, each discipline will evaluate staff hiring, education, and training practices, and service and equipment needs to ensure that the resources necessary to meet the needs of the community are available and utilized appropriately. The results of the facility assessment will be reviewed by the Quality Assurance Performance Improvement Committee as needed.The Facility assessment dated [DATE] documented the facility assessment indicated the Director of Nursing Services and the Administrator are involved in the development and revision of the Facility Assessment. The facility census averaged between 170-182 residents. The facility needed a total of 19 licensed nurses per day providing direct care, 42 nurse aides per day, and six (6) administrative nursing personnel per day. The facility also utilizes 14 behavioral assistants per day. The facility has five (5) units including the ground floor, 1 East, 1 West, 2 East, and 2 West. The Facility Assessment did not document the number of nursing staff needed for each unit and each shift or the bed capacity per unit.During an interview on 01/28/2026 at 11:53 AM, the Staffing Coordinator stated they have memorized the staffing levels for each unit and each shift. The Staffing Coordinator stated the staffing levels have been in place for as long as they have been the staffing coordinator. The Staffing Coordinator stated they were not familiar with the Facility Assessment, they did not know where the staffing levels came from, and if there was documentation to reference the required staffing levels.During an interview on 01/28/2026 at 12:05 PM, the Director of Nursing Services stated they were not familiar with the requirement to document nursing staffing per unit and per shift in the Facility Assessment. The Director of Nursing Services stated the staffing levels for each unit and each shift are just known from experience. They did not know where the staffing levels for each unit and each shift were documented. During an interview on 01/28/2026 at 12:40 PM, the Administrator stated they were not aware that the staffing levels for each unit and each shift had to be incorporated in the Facility Assessment. The Administrator stated they were not sure where the staffing levels for each unit and each shift were documented. 10 NYCRR 415.26

Based on record review and interview during an abbreviated survey (NY00383402), the facility did not ensure that residents representative, for one of three residents reviewed for notification (Resident #1), who was designated as the emergency contact person was notified, provided education and given an opportunity to consent or decline prior to performing a treatment change/medical procedure. Specifically, Resident #1 was stated on intravenous antibiotic and Family Member#1 was not notified, additionally Resident #1 developed a facility acquired wound to left toe and Family Member #1 was not notified.The findings are:Resident #1 was admitted to the facility with diagnoses including Stroke, Hypertension, Diabetes and non-Alzheimer's dementia. The Minimum Data Set assessment, dated 6/6/2025 documented a Brief Interview Mental Score of 9 indicating the resident had moderately-impaired cognitive skills for daily decision making.The resident's medical record included the resident face sheet which listed Family member #1 as the emergency contact person for making decisions for the resident.The Policy regarding notification dated 01/2017 documented it is the policy of Beach Care Center to document any change in a resident's condition and to inform designated representative and physician in a timely fashion. The Policy further document Registered Nurse Supervisor and charge nurse or Medical Doctor notifies designated representative if a condition deteriorates, individual notifying designated representative documents same in medical records.A Nursing progress note dated 5/27/2025 documented Resident #1 was seen and examined by Primary Medical Doctor for redness to left foot, new order for Zosyn (antibiotic) 3/375 milligram intravenous every 8 hours for 5 day and Augmentin (antibiotic) 500 milligram by mouth three times a day for 5 days after zosyn is completed. The note further documented a heplock (catheter placed intravenously for infusion) was placed on right hand with 22 gauge needle and the1st dose was given. There was no documented evidence the family was notifiedA Medical Doctor progress note dated 5/27/2025 at 4:43 PM documented Resident was seen for redness on the left foot. No complaint of fever or chills complains of mild pain. On exam resident afebrile (without fever) and hemodynamically stable focal left foot erythema (redness) and edema (swelling) extending to the ankle and area of dark tissue necrotic second toe with tip of toe. No calf tenderness, neurovascular intact. Assessment indicated cellulitis of left foot. The plan was Zosyn 3.375 intravenous every 8 hours for 5 days after that start Augmentin 500mg 3 times a day. There was no documented evidence the family was notified.A review of the wound notes initiated 6/5/2025 documented Resident #1 had a facility acquired unavoidable wound located on left 2nd toe measuring 2.5x2.0 centimeters 100% eschar (dry harden skin) and the treatment order betadine. There is no documented evidence the family was notified.A review of the wound notes dated 7/18/2025 documented wound bed 30% slough 70 granulation measurement 1x1.5x.3 treatment order changed to meta honey. There is no documented evidence the family was notifiedDuring an interview conducted on 8/13/2025 at 2:38PM with Family member #1 they stated they arrived to the facility to find resident #1 in the dining room bleeding from removing the intravenous catheter. They stated the supervisor responded and cleaned the resident. Family member #1 stated they were never notified that Resident #1 would be started on intravenous medication or antibiotic. Family member #1 stated they would have refused the intravenous antibiotic because Resident #1 would not tolerate it. Family member #1 further stated she was not made aware on 6/5/2025 that Resident #1 had developed a wound on the left toe and was receiving treatment. Family member #1 state she is listed on the face sheet and wants to be notified of any changes in treatment or in Residents condition. During an interview conducted on 8/11/20205 at 2:30PM with the evening supervisor they stated they responded to the unit to observe resident #1 in the dinning room and had dislodged the intravenous catheter. Evening supervisor stated they cleaned the site and ensured the residents safety and reassured the family. Evening Supervisor stated that Family Member #1 stated they did not want medication administered intravenously so they notified the physician who ordered oral antibiotics. Evening supervisor stated the family member should have been notified by the unit coordinator on the previous shift.During an interview conducted on 8/6/2025 at 2PM with the unit coordinator they stated they worked as the unit coordinator on 5/27/2025 they further stated they do not recall notifying the daughter when the intravenous antibiotics were initiated.During an interview conducted on 8/6/2025 at 3PM with the Director of Nursing they stated when there is a change, and the resident is cognitively impaired the family is informed by the unit coordinator or the nursing supervisor. They were unable to locate any further evidence the family had been notified.415.3(e)(2)(ii)(c)

Based on record review and interviews during the Recertification Survey initiated on 6/27/2024 and completed on 7/8/2024, the facility did not ensure sufficient nursing staff were available to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was identified for five of the five units reviewed for the Sufficient Nursing Staffing task. Specifically, 1) a review of the Payroll-Based Journal (PBJ) Staffing Data Report Quarter 1, 2024 indicated excessively low weekend staffing and 2) a review of the daily staffing sheets revealed that the facility did not provide sufficient numbers of Certified Nursing Assistants as indicated in the facility assessment. The finding is: The facility's Policy and Procedure on Staffing last reviewed 7/2024, documented the facility maintains adequate staffing on each shift to ensure that our residents' needs and services are met. Certified Nursing Assistants are available on each shift to provide the needed care and services of each resident as outlined in the resident's comprehensive care plan. The Registered Nurse Supervisor on duty for each shift will update the daily staffing census sheet. Our facility furnishes information from payroll records setting forth the average numbers and types of personnel on each shift to the New York State Department of Health. The Payroll-Based Journal Staffing Data Report for Fiscal Year Quarter One 2024 (October 1-December 31) documented the facility triggered for the metric of excessively low weekend staffing. The Facility Assessment Tool dated 6/26/2024 documented the average daily census was 170-182 residents. The assessment documented the facility required 19 licensed nurses to provide care on a daily basis and 44 Certified Nursing Assistants to provide care on a daily basis. A review of weekend staffing sheets from 1/7/2024 to 3/17/2024 revealed there were less than 44 Certified Nursing Assistants available to care for residents on a daily basis. The Staffing Coordinator was interviewed on 6/28/2024 at 12:13 PM and stated the facility was having problems with staffing on the weekends, mainly on Sundays, because many of the full-time Certified Nursing Assistants have resigned. The Staffing Coordinator stated the 7:00 AM to 3:00 PM shift requires 19 Certified Nursing Assistants in total, the 3:00 PM to 11:00 PM shift requires 13 Certified Nursing Assistants, and the 11:00 PM to 7:00 AM shift requires 10 Certified Nursing Assistants based on the Daily Staffing Schedule sheets that they use to fill all of the Certified Nursing Assistant slots. The Staffing Coordinator was not sure why the Facility Assessment documented that 44 Certified Nursing Assistants were required on a daily basis because the Daily Staffing Schedule indicated a need for 42 Certified Nursing Assistants daily. The Staffing Coordinator reviewed the Daily Staffing Schedule sheets from 1/1/2024 to 3/31/2024 and stated that short staffing for Certified Nurse Assistants is an ongoing issue every other weekend. A review of weekend staffing from 1/1/2024 to 3/31/2024 revealed insufficient staffing. Examples included but were not limited to the following: -On 1/7/2024, during the 7:00 AM to 3:00 PM shift, there were 11 Certified Nursing Assistants on duty. Based on the Staffing Coordinator's Daily Staffing Schedule sheet there should be 19 Certified Nursing Assistants. There were 32 total Certified Nursing Assistants for 1/7/2024 compared to the 44 as indicated in the facility assessment. -On 1/21/2024, during the 7:00 AM to 3:00 PM shift, there were 13 Certified Nursing Assistants on duty. Based on the Staffing Coordinator's Daily Staffing Schedule sheet there should be 19 Certified Nursing Assistants. There were 31 total Certified Nursing Assistants for 1/21/2024 compared to the 44 as indicated in the facility assessment. -On 2/4/2024, during the 7:00 AM to 3:00 PM shift, there were 17 Certified Nursing Assistants on duty. Based on the Staffing Coordinator's Daily Staffing Schedule there should be 19 Certified Nursing Assistants. There were 38 total Certified Nursing Assistants for 2/4/2024 compared to the 44 as indicated in the facility assessment. -On 2/18/2024, during the 7:00 AM to 3:00 PM shift, there were 14 Certified Nursing Assistants on duty. Based on the Staffing Coordinator's Daily Staffing Schedule there should be 19 Certified Nursing Assistants. There were 35 total Certified Nursing Assistants for 2/18/2024 compared to the 44 as indicated in the facility assessment. -On 3/3/2024 and 3/31/2024, during the 7:00 AM to 3:00 PM shift, there were 15 Certified Nursing Assistants. Based on the Staffing Coordinator's Daily Staffing Schedule there should be 19 Certified Nursing Assistants. There were 40 total Certified Nursing Assistants for 3/3/2024 compared to the 44 as indicated in the facility assessment. -On 3/17/2024, during the 7:00 AM to 3:00 PM shift, there were 16 Certified Nursing Assistants. Based on the Staffing Coordinator's Daily Staffing Schedule there should be 19 Certified Nursing Assistants. There were 38 total Certified Nursing Assistants for 3/17/2024 compared to the 44 as indicated in the facility assessment. The Director of Nursing Services and the Staffing Coordinator were interviewed concurrently on 7/3/2024 at 9:35 AM. The Staffing Coordinator stated the facility has been short-staffed with Certified Nursing Assistants on the weekends for a long time because there is no public transportation to the facility on the weekends. The Director of Nursing Services stated there is a high turnover of Certified Nursing Assistants and the facility has difficulty retaining Certified Nursing Assistants. The Director of Nursing Services stated the facility utilizes a staffing agency; however, the agency staff cannot be mandated to work on the weekends. The Director of Nursing Services stated that full-time employees are required to work every other weekend as per their union contract. The Director of Nursing Services stated they know that the insufficient staffing issue on the weekends occurs on alternate weekends; however, they have not attempted to adjust the staffing schedules. The Director of Nursing Services stated they had been unable to come up with a solution to address the facility's insufficient staffing issue. The Administrator was interviewed on 7/8/2024 at 10:58 AM and stated they were aware of the insufficient staffing issue at the facility, especially on the weekends. The Administrator stated public transportation to the facility is limited and the full-time staff wants higher wages. The Administrator stated they have been thinking about doing a job fair but have not done one yet since becoming Administrator 13 months ago. The Administrator stated they assumed the Director of Nursing Services and the Staffing Coordinator were staggering the schedules to fill the weekend staffing needs. 10 NYCRR 415.13(a)(1)(i-iii)

Based on observations, record review and interviews conducted during a Recertification Survey initiated on 6/27/2024 and completed on 7/8/2024, the facility did not ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice. This was identified for one (Resident #113) of two residents reviewed for Respiratory Care. Specifically, Resident #113 had a physician's order to receive 3 liters of oxygen per minute every shift. The resident was observed receiving 4.5 liters of oxygen per minute on 6/27/20224 and 6/28/2024 and 5 liters of oxygen per minute on 7/1/2024. The finding is: The facility's policy and procedure titled Oxygen Concentrator last revised in March 2017, documented that while delivering oxygen via an oxygen concentrator, the flow meter knob is to be adjusted to the ordered flow rate. All precautions for traditional oxygen therapy will be adhered to for oxygen administration. The facility's policy and procedure titled General Oxygen Administration last revised in February 2017, documented to administer oxygen as per the physician's order. Assess the resident for signs of adverse reactions to oxygen therapy (hypoventilation and bradypnea-abnormally slow breathing), and therapeutic response to oxygen. Resident #113 was admitted with diagnoses including Heart Failure, Morbid Obesity, and Atrial Fibrillation. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, which indicated the resident had intact cognition. The Minimum Data Set further documented the resident did not receive oxygen therapy. A physician's order dated 5/29/2024 documented to administer oxygen at 3 liters per minute via a nasal cannula every shift. No diagnosis was indicated for the use of oxygen therapy. The Comprehensive Care Plan for Alteration in Respiratory Status dated 5/29/2023 revised on 5/30/2024, documented interventions including administering oxygen at 3 liters per minute. Resident # 113 was observed sitting in their wheelchair near their bed on 6/27/2024 at 11:16 AM. Resident #113 was using a nasal cannula that was attached to an oxygen concentrator. The oxygen concentrator was out of Resident #113's reach. The display window on the oxygen concentrator indicated Resident # 113 was receiving 4.5 liters of oxygen per minute. Resident #113 was observed in bed on 6/28/2024 at 9:20 AM. Resident #113 was using a nasal cannula that was attached to an oxygen concentrator, which was placed at the end of the resident's bed. The oxygen concentrator was out of Resident #113's reach. The display window on the oxygen concentrator indicated Resident # 113 was receiving 4.5 liters of oxygen per minute. Resident #113 declined to be interviewed at this time. Resident #113 was observed sitting in a wheelchair by their bed on 7/1/2024 at 11:52 AM. Resident #113 was using a nasal cannula that was attached to an oxygen concentrator. The display window on the oxygen concentrator indicated the resident was receiving oxygen at 5 liters per minute. The oxygen concentrator was out of Resident #113's reach. Resident #113 stated they were not able to change the setting on the concentrator and the oxygen therapy made no difference to their breathing. The display window on the oxygen concentrator was again observed with Licensed Practical Nurse #1 on 7/1/2024 at 11:58 AM. The display window on the oxygen concentrator indicated the resident was receiving oxygen at 5 liters per minute. Licensed Practical Nurse #1 adjusted the oxygen to 3 liters per minute and stated Resident #113 was not supposed to be receiving oxygen at 5 liters. Licensed Practical Nurse #1 was interviewed immediately after the observation on 7/1/2024 at 11:58 PM and stated any licensed nursing staff could check Resident #113's oxygen at the start of the shift. Licensed Practical Nurse #1 stated they could not recall if they had checked the resident's oxygen concentrator today, 7/1/2024. Licensed Practical Nurse #1 stated that Resident #113 could not reach the oxygen concentrator to change the oxygen setting. Licensed Practical Nurse #1 stated this was not the first time they had observed Resident #113's oxygen set at a higher rate than ordered. Licensed Practical Nurse #1 stated they did not know why the oxygen was set high on those occasions. Licensed Practical Nurse #1 stated the resident should receive oxygen as ordered by the Physician. The Treatment Administration Record from 5/1/2024 to 7/1/2024 was reviewed and indicated Resident #113 was receiving oxygen at 3 liters per minute every shift including on 6/27/2024, 6/28/2024, and 7/1/2024. Licensed Practical Nurse #2, who was Resident #113's regularly assigned medication nurse, was interviewed on 7/3/2024 at 1:30 PM. Licensed Practical Nurse #2 stated licensed nurses are responsible for ensuring that the oxygen is administered as per the physician's orders. Physician #2, the attending Physician for Resident #113, was interviewed on 7/2/2024 at 2:55 PM. Physician #2 stated the resident should receive oxygen at 3 liters per minute as per the written order. The Director of Nursing Services was interviewed on 7/8/2024 at 10:09 AM and stated they expected the licensed nurses to ensure that the residents receive oxygen therapy as per the physician's orders. 10 NYCRR 415.12(k)(6)

Based on record review, and interviews during the Recertification Survey initiated on 6/27/2024 and completed on 7/8/2024, the facility did not ensure the comprehensive care plan was reviewed and revised to meet each resident's current needs. This was identified for one (Resident #62) of two residents reviewed for Environment. Specifically, Resident #62, who resided on the second floor of the facility, had behaviors of stuffing the toilet with objects that clogged the toilet resulting in a leaked ceiling in other residents' rooms residing on the first floor. A comprehensive care plan was developed for the resident's behavior in 2014 with interventions to manage the resident's behavior. The resident continued to exhibit the behavior; however, the interventions on the comprehensive care plan remained unchanged since 2014. The finding is: The facility's policy and procedure titled Comprehensive Care Plan, last revised on 11/28/2017, documented each resident will have an individualized interdisciplinary plan of care in place. The Interdisciplinary Team will review and revise the Comprehensive Care Plan on a quarterly basis, with a significant change in condition, on readmission from in-patient hospital stay, and as requested by the Resident/Representative. The Comprehensive Care Plan will be ongoing, constantly evolving, focusing on each individual as a unitary being, constantly changing, and interacting with the environment/energy fields. The Comprehensive Care Plan will address all real/potential problems, needs, strengths, and individual preferences of the resident. Each discipline will be responsible for the initiation and ongoing follow-up for selected care plans as related to their areas of expertise. Resident # 62 was admitted with Diagnoses including Schizophrenia, Mood Disorder, and Anxiety disorder. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of two, which indicated the resident had severely impaired cognition. The Minimum Data Set (MDS) assessment documented Resident #62 had behaviors of hallucinations (an experience that involves a perception of something not present), Delusions (misconceptions or beliefs that are firmly held, contrary to reality), and wandering. Resident #62 was continent of bowel and bladder and was not on any toileting program. A physician's order dated 6/18/2024 documented to administer the following: Latuda (anti-psychotic medication) oral tablet 80 milligrams twice a day; Lorazepam (anti-anxiety medication) oral tablet one milligram twice a day; and Depakote Extended Release (mood stabilizer medication) 500 milligrams one tablet at bedtime. A Comprehensive Care Plan (CCP) dated 5/28/2014 and last reviewed on 6/17/2024 for Behavioral Symptoms- Disruptive or Dangerous to self or others as evidenced by: the resident with a history of entering staff offices and grabbing food from garbage/desk; stuffing items in the toilet; wandering into peers' room which may trigger aggression; and stealing food items off peers' tray, food cart and medication cart. Interventions included but were not limited to escorting Resident #62 to a less stimulating environment; involving Resident #62 in behavior programs; monitoring for antecedents (comes before) or early warning signs of problems behavior; and reviewing intensity, duration, frequency, the pattern of behaviors, their development over time, and their effect on resident and others. All the interventions were initiated in 2014 with no new interventions added since 2014. The care plan was evaluated on 6/19/2023, 7/18/2023, 8/21/2023, 9/25/2023, 10/23/2023, 11/20/2023, 12/18/2023, 1/22/2024, 2/19/2024, 4/15/2024, 5/14/2024, and 6/17/2024. Each time the evaluation note documented: Resident displays being preoccupied internally; Resident has a history of stuffing items in the toilet, disrupting immediate living environment. The resident benefits from the structure of the unit. No behaviors noted during the review period. The Maintenance Logbook from 1/4/2024 to 6/5/2024 documented entries that Resident #62's room needed maintenance due to a clogged toilet. The Behavior Follow-Up Assessment Form from 3/14/2024 to 3/19/2024 did not document Resident #62's behavior of stuffing items in the toilet. Certified Nursing Assistant #1 was interviewed on 7/3/2024 at 10:30 AM and stated that Resident #62 often backs up the toilet by stuffing cups, snacks, and other items in the toilet. Certified Nursing Assistant #1 stated they always report the issue to the Nurse for Maintenance to fix the toilet. Registered Nurse #4 was interviewed on 7/3/2024 at 11:00 AM and stated Resident #62 frequently throws different items in the toilet which causes the toilet to clog. Registered Nurse #4 stated the behavior has been ongoing for a long time. Registered Nurse #4 stated the Certified Nursing Assistant supervised Resident #62's continence needs, but most of the time, Resident #62 goes to the bathroom independently. Registered Nurse #4 stated they usually call the maintenance staff to unclog the toilet. The Maintenance Director was interviewed on 7/3/2024 at 11:30 AM and stated they had fixed Resident #62's toilet numerous times. Once the toilet is clogged, it causes a backflow, causing a leak in another resident's bathroom that is located below Resident #62's bathroom. The Maintenance Director stated they did not know what else to do because of Resident #62's continuing behavior of stuffing items in the toilet. The Behavior Program Director was interviewed on 7/3/2024 at 1:00 PM and stated they primarily worked on the Behavior Unit where Resident #62 resides. The Behavior Program Director stated updating Resident #62 care plan is their responsibility. The Behavior Program Director stated that Resident #62's care plan interventions have not been revised since 2014 because the behavior has been the same for a long time. The Behavior Program Director stated as far as the Behavior Department, Resident #62's behavior of stuffing items in the toilet had stopped. The Behavior Program Director stated that the Maintenance and Nursing department did not tell them that Resident #62 had been stuffing items in the toilet, otherwise the behavior team would have completed a Behavior Follow Up Assessment Form to trigger a new intervention in the care plan. The Behavior Program Director stated they had written the same evaluation on the care plan monthly for the past year because the resident's behaviors were the same and there were no reports from other disciplines that Resident #62 had been stuffing items in the toilet. The Behavior Supervisor was interviewed on 7/5/2024 at 12:09 PM and stated they had written the same evaluation note on the care plan for Resident #62 because there were no new behaviors reported. The Behavior Supervisor stated they did not know that Resident #62 was stuffing items in the toilet and clogging the toilet and if they knew, they would have triggered a behavior follow-up and added new interventions to the care plan. The Director of Nursing Services was interviewed on 7/5/2024 at 12:36 PM and stated the care plan for Resident #62 should have been updated for any changes, especially with new behaviors, but the resident's behaviors were not new. The Director of Nursing Services stated the intervention should have been evaluated for effectiveness and if ineffective, then a new care plan intervention should have been initiated to address the resident's needs. 415.11(c)(2) (i-iii)

Based on observations, record review and interviews conducted during a Recertification Survey initiated on 6/27/2024 and completed on 7/8/2024, the facility did not ensure the medical care of each resident is supervised by a Physician. This was identified for one (Resident #113) of two residents reviewed for Respiratory Care. Specifically, Resident #113 had a physician's order for supplemental oxygen therapy at 3 liters per minute every shift; there was no rationale documented for the use of supplemental oxygen. Additionally, the resident expressed that the oxygen therapy has not been effective. There was no documented evidence in the resident's medical record that the Physician monitored and evaluated the resident's oxygen therapy needs until after the Surveyor brought the concern to the facility's attention on 7/2/2024. The finding is: The facility's policy and procedure titled Clinical Operations dated April 2019 documented that the Physician will participate in the resident's assessment and plan of care, monitor changes in their clinical condition, provide consultation or treatment, and oversee the plan of care of the resident. The Physician will perform pertinent and timely medical assessments, prescribe an appropriate medical plan of care, and provide adequate information regarding the resident's condition and medical needs. Resident #113 was admitted with diagnoses including Heart Failure, Morbid Obesity, and Atrial Fibrillation. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, which indicated the resident had intact cognition. The Minimum Data Set documented the resident did not receive oxygen therapy. A physician's order dated 5/29/2024 documented to administer oxygen at 3 liters per minute via a nasal cannula every shift. No diagnosis was indicated for the use of oxygen. The Comprehensive Care Plan for Alteration in Respiratory Status dated 5/29/2023 was revised on 5/30/2024 to document an intervention for oxygen at 3 liters per minute. All progress notes were reviewed from 5/1/2024 to 5/29/2024. There was no documented evidence of any report, assessment, or evaluation related to Resident #113's change in respiratory status or reason for starting oxygen treatment on 5/29/2024. A Physician's progress note dated 5/30/2024, written by Physician #2, documented that Resident #113 was comfortable at examination, lung clear to auscultation (Lung sounds are normal), and cardiovascular S1 S2 (normal rate and rhythm of the heart). The progress note did not include an assessment or plan for oxygen therapy. The Monthly Physician Assessment and Plan of Care dated 6/6/2024 and 7/2/2024 written by Physician #2 did not include an assessment of the resident's lung and did not document the use of oxygen therapy. Resident #113 was observed and interviewed on 7/1/2024 at 11:52 AM. The resident was sitting in their wheelchair by their bed and was using a nasal cannula that was attached to an oxygen concentrator. Resident #113 stated that the oxygen therapy made no difference to their breathing, there's got to be something better. Resident #113 stated they had asked but did not receive any feedback from Nurses and doctors on weaning off their oxygen. Licensed Practical Nurse #1, who was the unit manager where Resident #113 resided, was interviewed on 7/1/24 at 11:58 AM. Licensed Practical Nurse #1 stated they believed Resident #113 was using oxygen because the resident had Chronic Heart Failure. Licensed Practical Nurse #1 stated they were not aware of any plan to re-assess and monitor whether Resident #113's continued use of oxygen is necessary. Resident #113's attending physician, Physician #2, was interviewed on 7/2/2024 at 2:55 PM and stated Resident #113 did not experience changes in respiratory status when oxygen therapy was initiated on 5/29/2024. Physician #2 stated that they believed they ordered the oxygen to encourage the resident to comply with care such as taking a shower as the resident was afraid of having a low oxygen level when they used the shower. Physician #2 stated they did not document a rationale for the oxygen therapy and parameters for monitoring the resident's oxygen saturation levels and should have. Physician #2 stated that the current oxygen order for Resident #113 was wrong as written. The order should have been included to check Resident #113's oxygen saturation every shift and provide oxygen therapy as needed if the oxygen saturation level was below 92%. Physician #2 stated that when a resident is on oxygen therapy, their oxygen saturation must be measured to monitor progress and to determine if a higher level of respiratory care is needed. The Medical Director was interviewed on 7/3/2024 at 12:28 PM and stated they expected the attending Physician to monitor the resident's condition regularly and adjust the course of treatment and interventions as appropriate. The Medical Director stated that Physician #2 should have documented their rationale when oxygen therapy was ordered and included the parameters. The Medical Director stated Resident #113 has been on oxygen therapy for five weeks and the resident cannot be on continuous oxygen forever. The Medical Director stated Physician #2 should have monitored the resident's respiratory status and re-evaluated the resident to determine if oxygen remains an appropriate intervention. 10 NYCRR 415.15(b)(1)(i)(ii)

Based on observations, record review, and interviews during the Recertification Survey initiated on 6/27/2024 and completed on 7/8/2024, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles. This was identified on two (Unit 2 East and Unit 2 West) of three units reviewed during the Medication Storage Task. Specifically, 1) a used vial (bottle) of insulin for Resident #86 was observed in the medication refrigerator, on Unit 2 East on 7/2/2024, with an open date of 5/29/2024; 2) two opened bottles of Latanoprost Ophthalmic Solution for Resident #76 and Resident #109 were observed in the medication cart on Unit 2 [NAME] on 7/2/2024 without a date that indicated when the eye drop bottles were opened; and 3) a used vial of insulin for Resident #55 was observed in the medication refrigerator, on Unit 2 [NAME] on 7/2/2024, with an opened date of 5/27/2024. The findings are: The facility policy titled Medication: Storage and Handling dated 2/23/2017 and revised on 7/5/2024 documented that the unit nurse will ensure that all resident medications are to be properly labeled, restored, and locked securely in the medication room. Medications and other solutions past their noted expiration date are to be removed from usage and returned to the pharmacy to ensure the desired effect when utilized. No discontinued, outdated, or deteriorated drugs or biologicals are to be used for resident care. All eye drops and insulins for resident care will be discarded 28 days from the opening date. 1) Resident #86 was admitted with diagnoses including Type 2 Diabetes Mellitus and End Stage Renal Disease. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, indicating the resident's cognition was intact. The Minimum Data Set assessment documented the resident was receiving insulin injections during the assessment period. A physician's order for Resident #86 dated 3/8/2024 and renewed on 6/28/2024 documented to administer Humalog insulin (fast-acting insulin) Subcutaneous Solution 100 units per milliliter three times daily before meals for Type 2 Diabetes Mellitus according to blood sugar readings as follows: 151 milligrams per deciliter-200 milligram per deciliter=2 units, 201 milligrams per deciliter-250 milligram per deciliter=4 units, 251 milligrams per deciliter-300 milligram per deciliter=6 units, 301 milligrams per deciliter-350 milligrams per deciliter=8 units, 351 milligrams per deciliter-400 milligrams per deciliter=10 units, and notify the Physician for a blood sugar reading below 60 milligram per deciliter or over 400 milligrams per deciliter. An observation of the Medication Storage was conducted with Licensed Practical Nurse #5 on Unit 2 East on 7/2/2024 at 10:55 AM. A used vial of Humalog insulin solution for Resident #86 was observed in the medication refrigerator. The insulin vial had an open date of 5/29/2024 documented on the vial indicating the vial had been opened for more than 28 days. Licensed Practical Nurse #5, the medication nurse for Unit 2 East, was interviewed on 7/2/2023 at 1:49 PM. Licensed Practical Nurse #5 stated they thought the Humalog insulin vial for Resident #86 that was in the medication refrigerator was new and overlooked the date documented on the insulin vial. Licensed Practical Nurse #5 further stated the vial of Humalog insulin solution should have been removed from the medication refrigerator and discarded after 28 days the insulin vial was opened. Licensed Practical Nurse #4, Nurse Manager for Unit 2 East, was interviewed on 7/3/2024 at 9:47 AM and stated that the insulin vial should have been discarded after 28 days from when it was first opened. 2) Resident #76 was admitted with diagnoses including Glaucoma (an eye condition that can cause vision loss) and Type 2 Diabetes Mellitus. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 3, indicating the resident had severe cognitive impairment. A Physician's Order for Resident #76 dated 7/12/2023 and renewed on 6/11/2024 documented to administer one drop of Latanoprost Ophthalmic Solution 0.005 percent into the left eye at bedtime for Glaucoma. Resident #109 was admitted with diagnoses including Bilateral (both eyes) Pre-Glaucoma (a condition in which the pressure in the eye is higher than normal) and Hypertension. The Significant Change in Status Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 7, indicating the resident had severe cognitive impairment. A Physician's order for Resident #109 dated 4/26/2024 and renewed on 7/5/2024 documented to administer one drop of Latanoprost Ophthalmic Solution 0.005 percent to both eyes at bedtime for Bilateral Pre-Glaucoma. An observation of the Medication Storage was conducted with Licensed Practical Nurse #3 on Unit 2 [NAME] on 7/2/2024 at 11:31 AM. Two used bottles of Latanoprost Ophthalmic solution 0.005 percent for Resident #76 and Resident #109 were observed in the medication cart. There was no date documented on the bottles to indicate when they were first opened. 3) Resident #55 was admitted with diagnoses including Type 2 Diabetes Mellitus with Diabetic Neuropathy (a type of nerve damage) and Hypertension. The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 8, indicating the resident had moderate cognitive impairment. The Minimum Data Set assessment documented the resident was receiving insulin injections during the assessment period. A Physician's Order for Resident #55 dated 6/6/2024 and renewed on 6/21/2024 documented to administer 35 units of Insulin Glargine-yfgn (a long-acting insulin) 100 unit per milliliter subcutaneous Solution daily for Type 2 Diabetes Mellitus with Diabetic Neuropathy. An observation of the Medication Storage was conducted with Licensed Practical Nurse #3 on Unit 2 [NAME] on 7/2/2024 at 11:53 AM. A used vial of Insulin Glargine-fygn solution was observed for Resident #55 in the medication refrigerator. The insulin vial had an open date of 5/27/2024 documented on the vial indicating the vial had been opened for more than 28 days. Licensed Practical Nurse #3, the medication nurse for Unit 2 West, was interviewed on 7/2/2024 at 2:33 PM. Licensed Practical Nurse #3 stated the Ophthalmic Solution bottles should be discarded 30 days from opening. Licensed Practical Nurse #3 stated the bottles of Latanoprost Ophthalmic Solution for Resident # 76 and Resident #109 should have been dated when they were first opened so that the unit nurses could determine when to discard the medication. Licensed Practical Nurse #3 stated the vial of insulin Glargine solution should be discarded 28 days after opening. Licensed Practical Nurse #1, the Nurse Manager for Unit 2 West, was interviewed on 7/3/2024 at 9:43 AM and stated the unit nurses were responsible for proper labeling and storage of medications on the unit. Licensed Practical Nurse #1 stated the bottles of Latanoprost Ophthalmic solution for Resident #76 and Resident #109 should have been dated when first opened by nursing staff. The used vial of insulin Glargine for Resident #55 should have been discarded 28 days after the vial was first opened. The Pharmacist was interviewed on 7/5/2024 at 10:23 AM and stated Humalog insulin and Glargine insulin should be discarded 28 days after opening. The potency of the insulin decreases and the medications may become less effective after 28 days of opening. The Pharmacist stated Latanoprost 0.005 percent Ophthalmic solution should be discarded six weeks after opening because the medication becomes less effective. The Director of Nursing Services was interviewed on 7/5/2024 at 12:35 PM and stated all ophthalmic solutions and insulin solutions should be discarded 28 days after they were opened. All unit nurses should ensure proper labeling and storage of medications. The Director of Nursing Services further stated the bottles of Latanoprost Ophthalmic Solution for Resident #76 and Resident #109 should have been dated when the bottle was first opened. The insulin vials for Resident #86 and Resident #55 should have been discarded 28 days after the vials were first opened. 10 NYCRR 415.18 (d);10 NYCRR 415.18(e)(1-4)

Based on record review and staff interviews during the Recertification Survey initiated on 6/27/2024 and completed on 7/8/2024 the facility did not ensure that each allegation of abuse, neglect, exploitation, mistreatment, or injury of unknown origin was thoroughly investigated. This was identified for one (Resident #48) of three residents reviewed for skin conditions and one (Resident #83) of seven residents reviewed for Accidents. Specifically, 1) Resident #48 sustained a scrotal avulsion (a forcible tearing off the skin of the scrotum) that required surgical intervention on 1/25/2024. The cause of the injury was unknown. There was no investigation to determine the root cause of the injury. 2) Resident #83 sustained a discoloration to the right eye and right forehead on 6/22/2024. Resident #83's injury was of unknown origin. There was no investigation to determine the root cause of the injury. The findings are: 1) The facility's Accident/Significant Event policy dated 6/17/2019 documented that a significant event shall be defined as an unintended event resulting in serious bodily harm, such as fracture, laceration that requires closure, second or third-degree burns, or any injury requiring hospital admission. If an accident occurs that causes injury or presents the potential for injury or recurrence, the facility will investigate in conjunction with the facility's quality improvement program within five calendar days. All accidents, unexplained bruises, or injuries are reported to the charge nurse immediately. The charge nurse informs the Registered Nurse Supervisor. The policy then describes each step of the investigation process. Resident #48 was admitted with diagnoses including Cerebrovascular Accident, Non-Alzheimer's Dementia, and Psychotic Disorder. The 1/15/2024 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 99, indicating the resident could not complete the interview. The Minimum Data Set assessment documented the resident had behavior symptoms that were not directed toward others. There were no skin conditions documented. A Comprehensive Care Plan for Behavioral Symptoms-Disruptive or Dangerous to Self or Others effective 6/23/2014 and last updated 7/1/2024 documented the resident has a history of self-injurious behavior. A care plan update on 1/22/2024 documented that Resident #48 was verbally and physically aggressive; the resident was kicking and punching staff as the Certified Nursing Assistant was performing evening care. The interventions included utilizing behavior management strategies, monitoring early warning signs of problem behaviors, and escorting the resident to a less stimulating environment as needed. A nursing progress note dated 1/25/2024 at 8:10 PM, written by Registered Nurse #1, documented Resident #48 was noted with a scrotal wound; the skin came off the sack with moderate bleeding. The nurse cleaned the wound with normal saline, applied bacitracin, and then covered the wound with a dry sterile dressing. The physician was made aware and the resident was transferred to the hospital. A nursing progress note dated 1/26/2024 at 10:04 AM, written by Registered Nurse #5, documented Resident #48 was admitted to the hospital and transferred to the operating room for surgery to repair the Scrotal Avulsion. A nursing progress note dated 1/26/2024 at 9:34 PM, written by Registered Nurse #1, documented the resident returned from the hospital with the diagnosis of Scrotal Avulsion. The resident's scrotal wound area was noted with sutures. Certified Nursing Assistant #1, Resident #48's assigned Certified Nursing Assistant, was interviewed on 6/28/2024 at 11:52 AM. Certified Nursing Assistant #1 stated the resident has aggressive behaviors during care. The resident would fight, hit, kick, and punch the caregivers and also kick the wheelchair. Certified Nursing Assistant #1 added that the resident also has a history of fondling (their scrotal area) themselves. Registered Nurse #1, the 3:00 PM-11:00 PM supervisor, was interviewed on 7/1/2024 at 12:26 PM. Registered Nurse #1 stated Resident #48's scrotal wound was identified during care in the evening shift on 1/25/2024. Certified Nurse Assistant #2 reported there was blood in the resident's brief. Upon assessment, the scrotal area had opened skin and was bleeding. Registered Nurse #1 notified the Physician and the resident was transferred to the hospital for evaluation. Registered Nurse #1 stated they did not initiate an investigation to identify how the resident sustained the scrotal injury. Registered Nurse #1 stated that Resident #48 occasionally placed their hand in their brief, which they believed to be the cause of the injury. There were no reports of the resident being aggressive during care on 1/25/2024. Certified Nursing Assistant #2, who was assigned to Resident #48 on 1/25/2024 during the 3:00 PM-11:00 PM shift, was interviewed on 7/1/2024 at 2:24 PM. Certified Nursing Assistant #2 stated on 1/25/2024, they transferred Resident #48 back to bed via a mechanical lift with another Certified Nursing Assistant and provided care. The resident did not exhibit aggressive behaviors on 1/25/2024 during the evening shift. Certified Nursing Assistant #2 stated when they removed the resident's brief, they saw blood in the brief. Certified Nurse Assistant #2 denied incident or injury during care. There were no problems with the mechanical lift transfer. Certified Nursing Assistant #2 immediately reported the injury to Registered Nurse #1. Physician #1, the Medical Director, was interviewed on 7/1/2024 at 2:59 PM and stated they could only speculate the cause of Resident #48's scrotal injury; the injury was most likely self-inflicted because the resident had a behavior of putting their hands in their brief I never saw anything like this, and I was surprised by the [scrotal avulsion] diagnosis. Physician #1/Medical Director stated they evaluated Resident #48 on 1/28/2024 after the resident returned from the hospital; however, they did not document the cause of injury. The Director of Nursing Services was interviewed on 7/2/2024 at 8:30 AM. The Director of Nursing Services stated the resident sustained Scrotal Avulsion and had to be transferred to the hospital for sutures. The resident had a history of putting their hands in their brief; however, I never saw anything like this kind of injury. I cannot imagine this kind of injury could be caused by the resident just putting their hands in their pants. The Director of Nursing Services stated an investigation was not initiated because there were no known falls or accidents. The Director of Nursing Services stated they did not consider abuse as a possible cause of Resident #48's injury at the time. The Director of Nursing Services stated the resident's injury was of unknown origin and should have been investigated to rule out abuse, neglect, and mistreatment. Registered Nurse Risk Manager #1 was interviewed on 7/3/2024 at 8:10 AM and stated an investigation related to the resident's injury was not completed because Resident #48 had a history of fondling their (Resident #48's) scrotum which could have caused the injury. Registered Nurse Risk Manager #1 stated that an investigation should have been completed to rule out abuse, neglect, and mistreatment because the injury sustained by the resident was a significant injury of unknown origin. 48827 2) Resident #83 was admitted with diagnoses including Dementia, Type 2 Diabetes Mellitus, and Anxiety. The Annual Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 3, which indicated the resident had severely impaired cognition. The Falls Comprehensive Care Plan dated 7/25/2022 and revised on 9/27/2023 documented Resident #82 had a history of falls. The interventions included bed alarm and monitoring for increased confusion, agitation, or behavior changes. A nursing progress note, written by Registered Nurse #3 on 6/22/2024 at 8:05 AM, documented Certified Nurse Assistant #3 reported the resident had a blue/purple discoloration to the right eye. The resident was unable to verbalize or recall what happened. A nursing progress note, written by Registered Nurse Supervisor #4 on 6/22/2024 at 8:30 AM, documented Resident #83 was noted with discoloration to the right eye and right forehead. The resident was unable to describe what happened. Resident #83's family member declined to transfer the resident to the emergency room for a Computerized Tomography (CT) scan. The Accident and Incident report dated 6/22/2024 at 7:30 AM documented that Resident #83 had a discoloration to the right eye and right forehead. The resident was unaware of what happened and the incident was unwitnessed. The written statements obtained from nursing staff during the day shift indicated no one observed a fall or an incident that may have resulted in the identified discoloration. The Accident Investigation Report, Summary of investigation, dated 6/27/2024 documented the nature of the incident: Fall- Discoloration to Right Eye and Forehead. The summary documented there was no sufficient evidence of resident abuse, mistreatment, or neglect. The summary was signed by the facility Administrator and the Director of Nursing Services. Certified Nursing Assistant #3 was interviewed on 7/1/2024 at 2:11 PM and stated they were not assigned to care for Resident #83. They saw Resident #83 in the hallway walking to the dining room on 6/22/2024 during the 7:00 AM to 3:00 PM shift. They noticed the resident had discoloration on the right eye and reported the discoloration to the Nurse. Certified Nursing Assistant #2 was interviewed on 7/1/2024 at 2:19 PM and stated that they were assigned to care for Resident #83 on 6/22/2024 but they did not see Resident #83 until after Certified Nurse Aide #3 reported the bruise on the resident's right eye. Registered Nurse #3 was interviewed on 7/3/2024 at 10:14 AM and stated they observed Resident #83 in bed sleeping when they conducted their morning rounds on 6/22/2024. Registered Nurse #3 stated they were unable to see the resident's face and did not observe the bruise to the resident's right eye. Registered Nurse Supervisor #4 was interviewed on 7/3/2024 at 8:41 AM and stated that when they were notified of the discoloration to the resident's forehead on 6/22/2024, they called the Director of Nursing and investigated the incident. Registered Nurse Supervisor #4 stated they assumed Resident #83 fell . Registered Nurse Supervisor #4 stated they obtained statements from the nursing staff on the day shift. Registered Nurse Supervisor #4 stated the incident occurred on the weekend and they left the report documents in the Risk Manager's mailbox. The Risk Manager was interviewed on 7/3/2024 at 8:52 AM and stated they reviewed Resident #83's incident report on 6/24/2024. The Risk Manager stated they usually do not investigate the previous shift staff and did not know if the previous shift staff should have provided statements related to the resident's injury. The Director of Nursing Services was interviewed on 7/3/2024 at 9:14 AM and stated they were informed of Resident #83's injury on the morning of 6/22/2024. The Director of Nursing Services stated the resident's assigned nursing staff from the previous shifts should have been interviewed to rule out abuse for the injury of unknown origin. 10 NYCCR 415.4(b)(3)

Based on record review and staff interviews during the Recertification Survey initiated on 6/27/2024 and completed on 7/8/2024 the facility did not ensure that all alleged violations, including injuries of unknown source, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in a serious bodily injury, to the New York State Department of Health. This was identified for one (Resident #48) of three residents reviewed for skin conditions and one (Resident #83) of seven residents reviewed for Accidents. Specifically, 1) Resident #48 sustained a scrotal avulsion (a forcible tearing off the skin of the scrotum) on 1/25/2024 requiring surgical intervention. The cause of the injury was unknown, and the facility did not report the injury of unknown origin to the New York State Department of Health. 2) Resident #83 sustained a discoloration to the right eye and right forehead on 6/22/2024. Resident #83's injury was of unknown origin and was not reported to the New York State Department of Health. The findings are: The facility's Resident Accident/Significant Event policy dated 6/17/2019 documented that a significant event shall be defined as an unintended event resulting in serious bodily harm, such as fracture, laceration that requires closure, second or third-degree burns, or any injury requiring hospital admission. If an accident causes injury or presents the potential for injury or recurrence, the facility will investigate in conjunction with the facility's quality improvement program within five calendar days. Any identified neglect or abuse relating to the accident will be promptly reported to the New York State Department of Health. All accident reports will be screened for evidence of failure to follow the care plan, delay in assessment/treatment, and injuries of unknown origin. The policy did not specifically state the incident must be reported within 2 hours if the event involved suspected abuse or caused serious bodily injury. Resident #48 was admitted with diagnoses including Cerebrovascular Accident, Non-Alzheimer's Dementia, and Psychotic Disorder. The 1/15/2024 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 99, indicating the resident could not complete the interview. The Minimum Data Set assessment documented the resident had behavior symptoms that were not directed toward others. A Comprehensive Care Plan for Behavioral Symptoms-Disruptive or Dangerous to Self or Others effective 6/23/2014 and last updated 7/1/2024 documented the resident has a history of self-injurious behavior. A care plan update on 1/22/2024 documented that Resident #48 was verbally and physically aggressive and was kicking and punching staff during evening care. The interventions included utilizing behavior management strategies, monitoring early warning signs of problem behaviors, and escorting the resident to a less stimulating environment as needed. A nursing progress note dated 1/25/2024 at 8:10 PM, written by Registered Nurse #1, documented Resident #48 was noted with a scrotal wound; the skin came off the sack with moderate bleeding. The nurse cleaned the wound with normal saline, applied bacitracin, and then covered the wound with a dry sterile dressing. The Physician was made aware, and the resident was transferred to the hospital. A nursing progress note dated 1/26/2024 at 10:04 AM, written by Registered Nurse #5, documented Resident #48 was admitted to the hospital and was transferred to the operating room for the surgical repair of the Scrotal Avulsion. A nursing progress note dated 1/26/2024 at 9:34 PM, written by Registered Nurse #1, documented the resident returned from the hospital with a diagnosis of Scrotal Avulsion. The resident's scrotal wound area was noted with sutures. Certified Nursing Assistant #1, the assigned Certified Nursing Assistant, was interviewed on 6/28/2024 at 11:52 AM. Certified Nursing Assistant #1 stated the resident has aggressive behaviors and would fight with caregivers by hitting, kicking, and punching the caregivers during care. Certified Nursing Assistant #1 stated that the resident also has a behavior of fondling themselves. Registered Nurse #1, the 3:00 PM-11:00 PM supervisor, was interviewed on 7/1/2024 at 12:26 PM. Registered Nurse #1 stated Resident #48's scrotal wound was identified during care in the evening shift on 1/25/2024. Certified Nurse Assistant #2 reported there was blood in the resident's brief. Upon assessment, the scrotal area had opened skin and was bleeding. Registered Nurse #1 notified the Physician, and the resident was transferred to the hospital for evaluation. Registered Nurse #1 stated they did not initiate an investigation to identify how the resident sustained the scrotal injury. Registered Nurse #1 stated that Resident #48 occasionally placed their hand in their brief, which they believed to be the cause of the injury. There were no reports of the resident being aggressive during care on 1/25/2024. Certified Nursing Assistant #2, who was assigned to Resident #48 on 1/25/2024 during the 3:00 PM-11:00 PM shift, was interviewed on 7/1/2024 at 2:24 PM. Certified Nursing Assistant #2 stated on 1/25/2024, they transferred Resident #48 back to bed via a mechanical lift with another Certified Nursing Assistant and provided care. The resident did not exhibit aggressive behaviors on 1/25/2024 during the evening shift. Certified Nursing Assistant #2 stated when they removed the resident's brief, they saw blood in the brief. Certified Nurse Assistant #2 denied incident or injury during care. There were no problems with the mechanical lift transfer. Certified Nursing Assistant #2 immediately reported the injury to Registered Nurse #1. The Director of Nursing Services was interviewed on 7/2/2024 at 8:30 AM. The Director of Nursing Services stated I never saw anything like this kind of injury. I cannot imagine this kind of injury could be caused by the resident just putting their hands in their pants. The Director of Nursing Services stated an investigation was not initiated because there were no known falls or accidents. The Director of Nursing Services stated they did not consider abuse as a possible cause of Resident #48's injury at the time. The Director of Nursing Services stated the resident's injury was of unknown origin and should have been reported to the New York State Department of Health. Registered Nurse Risk Manager #1 was interviewed on 7/3/2024 at 8:10 AM and stated an investigation related to the resident's injury was not completed because Resident #48 had a history of fondling their (Resident #48's) scrotum which could have caused the injury. Registered Nurse Risk Manager #1 stated that an investigation should have been completed to rule out abuse and the incident should have been reported to the New York State Department of Health within two hours because the injury sustained by the resident was a significant injury of unknown origin. 48827 2) The facility's policy titled Resident Accident/Significant Event dated 06/17/2019 documented that any identified neglect or abuse relating to the accident will be promptly reported to the Department of Health. Resident #83 was admitted with diagnoses including Dementia, Type 2 Diabetes Mellitus, and Anxiety. The Annual Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 3, which indicated the resident had severely impaired cognition. The Falls Comprehensive Care Plan dated 7/25/2022 and revised on 9/27/2023 documented Resident #82 had a history of falls. The interventions included bed alarm and monitoring for increased confusion, agitation, or behavior changes. A nursing progress note, written by Registered Nurse #3 on 6/22/2024 at 8:05 AM, documented Certified Nurse Assistant #3 reported the resident had a blue/purple discoloration to the right eye. The resident was unable to verbalize or recall what happened. A nursing progress note, written by Registered Nurse Supervisor #4 on 6/22/2024 at 8:30 AM, documented Resident #83 was noted with discoloration to the right eye and right forehead. The resident was unable to describe what happened. Resident #83's family member declined to transfer the resident to the emergency room for a Computerized Tomography (CT) scan. The Accident and Incident report dated 6/22/2024 at 7:30 AM documented that Resident #83 had a discoloration to the right eye and right forehead. The resident was unaware of what happened and the incident was unwitnessed. The written statements obtained from nursing staff during the day shift indicated no one observed a fall or an incident that may have resulted in the identified discoloration. The Accident Investigation Report, Summary of investigation, dated 6/27/2024 documented the nature of the incident: Fall- Discoloration to Right Eye and Forehead. The summary documented there was no sufficient evidence of resident abuse, mistreatment, or neglect. The summary was signed by the facility Administrator and the Director of Nursing Services. Certified Nursing Assistant #3 was interviewed on 7/1/2024 at 2:11 PM and stated they were not assigned to care for Resident #83. They saw Resident #83 in the hallway walking to the dining room on 6/22/2024 during the 7:00 AM to 3:00 PM shift. They noticed the resident had discoloration on the right eye and reported the discoloration to the Nurse. Certified Nursing Assistant #2 was interviewed on 7/1/2024 at 2:19 PM and stated that they were assigned to care for Resident #83 on 6/22/2024 but they did not see Resident #83 until after Certified Nurse Aide #3 reported the bruise on the resident's right eye. Registered Nurse #3 was interviewed on 7/3/2024 at 10:14 AM and stated they observed Resident #83 in bed sleeping when they conducted their morning rounds on 6/22/2024. Registered Nurse #3 stated they were unable to see the resident's face and did not observe the bruise to the resident's right eye. Registered Nurse Supervisor #4 was interviewed on 7/3/2024 at 8:41 AM and stated that when they were notified of the discoloration to the resident's forehead on 6/22/2024, they called the Director of Nursing and investigated the incident. Registered Nurse Supervisor #4 stated they assumed Resident #83 fell . Registered Nurse Supervisor #4 stated they obtained statements from the nursing staff on the day shift. Registered Nurse Supervisor #4 stated the incident occurred on the weekend and they left the report documents in the Risk Manager's mailbox. The Risk Manager was interviewed on 7/3/2024 at 8:52 AM and stated they reviewed Resident #83's incident report on 6/24/2024. The Risk Manager stated they usually do not investigate the previous shift staff and did not know if the previous shift staff should have provided statements related to the resident's injury. The Risk Manager stated the Director of Nursing Services was responsible for reporting injuries of unknown origin to the New York State Department of Health. The Director of Nursing Services was interviewed on 7/3/2024 at 9:14 AM and stated they were informed of Resident #83's injury on the morning of 6/22/2024. The Director of Nursing Services stated the resident's assigned nursing staff from the previous shifts should have been interviewed to rule out abuse for the injury of unknown origin. The Director of Nursing stated they were responsible for reporting an injury of unknown origin to the New York State Department of Health. The Director of Nursing further stated they should have reported Resident #83's injury of unknown origin to the New York State Department of Health because the cause of the injury was unknown and they were unable to determine how the resident sustained bruises. 10 NYCRR 415.4(b)(2)

Based on observations, record review, and interviews during the Recertification Survey initiated on 6/27/2024 and completed on 7/8/2024, the facility did not ensure that each resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing. This was identified for two (Resident # 107 and Resident #138) of five residents reviewed for Pressure Ulcers. Specifically, Resident #107 and Resident #138 had a physician's order for an alternating pressure relief air mattress. During multiple observations, the adjustable weight setting on the air mattress pump was not accurately set according to each resident's weight. The findings are: The facility's Pressure Ulcers policy and procedure last revised on 5/21/2019 documented that residents who have pressure ulcers receive the necessary treatment to promote healing, prevent infection, and prevent new ulcers from developing. Residents will be assessed for pressure ulcer risk factors upon admission, re-admission, quarterly, and with change in condition. It is the Nurse's responsibility to oversee the Pressure Ulcer program which includes ensuring an appropriate Plan of Care is implemented and carried through, conducting weekly pressure ulcer rounds with the Physician, and completing the pressure ulcer progress assessment form. The Operation Manual for the Alternating Pressure and Low Air Loss Mattress System documented the adjustable patient weight settings allow for optimal immersion, patient comfort, and compliance. The weight capacity was documented to be 350 pounds. 1) Resident #107 was admitted with diagnoses including Spinal Stenosis, Pressure Ulcer of the Sacral Region, and Respiratory Failure. The Admission Minimum Data Set assessment dated [DATE] documented no Brief Interview for Mental Status score due to Resident #107's severe cognitive impairment. The Minimum Data Set assessment documented Resident #107 was at risk for developing a pressure ulcer and had one Stage 4 (defined as full-thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer on the sacrum. A Comprehensive Care Plan for Pressure Ulcer dated 4/11/2024 documented interventions included heel and elbow protectors as needed, and the use of an air mattress. A physician's order dated 4/11/2024 documented the use of an alternating pressure relief air mattress. A physician's order dated 6/5/2024 documented to apply Santyl (medication that removes damaged tissue from the area) ointment to the sacral ulcer; lightly pack the wound with Calcium Alginate (medication that absorbs excess moisture and promotes healing); and then cover with silicone border gauze twice a day. A review of the electronic medical record indicated that Resident #107's most recent weight was 156 pounds on 6/13/2024. A Wound Care Progress Note dated 6/21/22024 documented the resident's sacral wound measured 5.5 centimeters in length 3.0 centimeters in width and 0.5 centimeters in depth. The wound bed was noted with 100 percent granulation (new tissues and blood vessels) tissue and the surrounding skin was intact. There was a moderate amount of serous (pale, yellow watery fluid) drainage with no odor. The progress note documented multiple other wounds with measurements and treatment recommendations including a left hip Deep Tissue Injury, a left elbow ulcer, a right lateral ankle wound, and a right inner thigh wound. Resident # 107 was observed lying in bed on 6/27/2024 at 12:15 PM. The alternating air mattress pump was set at 350 pounds. Resident #107 was observed in lying bed on 6/28/2024 at 9:00 AM. The alternating air mattress pump was set at 350 pounds. Resident # 107 was observed in lying bed on 7/1/2024 at 11:55 AM. The alternating air mattress pump was set at 350 pounds. Registered Nurse #4, the Unit Manager, was interviewed on 7/1/2024 at 11:40 AM and stated that Licensed Nurses are responsible for monitoring that the weight setting on the air mattress is set based on the resident's actual weight. Registered Nurse #4 stated there was a physician's order for the use of an alternating air mattress; however, there was no order to monitor the air mattress settings and therefore the monitoring was not being completed and documented every shift. Certified Nursing Assistant # 5 was interviewed on 7/1/2024 at 11:20 AM and stated they were responsible for checking the resident's alternating air mattress was appropriately inflated. Certified Nursing Assistant #5 stated they do not touch the alternating air mattress pump nor change the settings on the air mattress. The Wound Care Manager was interviewed on 7/2/2024 at 9:15 AM and stated the alternating air mattress weight setting should correspond with the resident's weight. All staff are responsible for monitoring the air mattress. The Wound Care Manager stated Resident #107 weighed 156 pounds and they were not sure why the alternating air mattress weight setting was set at 350 pounds. Physician #1, the Wound Care Physician, was interviewed on 7/2/2024 at 1:29 PM and stated it was up to the facility to ensure that the air mattress setting was properly monitored. Physician #1 stated for optimal wound healing the alternating air mattress weight setting should be calibrated to match the resident's actual weight. The Director of Nursing Services was interviewed on 7/2/2024 at 2:12 PM and stated the nursing staff should have monitored the alternating air mattress weight setting every shift. Monitoring the air mattress can be documented every shift by the nurses in the treatment administration record or the medication administration record. 34798 2) Resident #138 was admitted with diagnoses including Alzheimer's Disease, Seizure Disorder, and Aphasia. The 6/24/2024 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 1, indicating the resident had severe cognitive impairment. The Minimum Data Set assessment documented that the resident had one Stage 4 pressure ulcer (full-thickness tissue loss with exposed bone, tendon, or muscle) with an intervention for a pressure-reducing device for the bed. The resident's documented weight was 139 pounds. An actual Pressure Ulcer Comprehensive Care Plan, effective 2/15/2024 and last updated on 6/21/2024, documented the resident had a Stage 4 pressure ulcer to the sacral area. The intervention included the use of an alternating air mattress for Resident #138. A physician's order as of 7/2/2024 documented to cleanse the resident's sacral ulcer with normal saline, apply Calcium Alginate (an absorptive wound dressing) to the wound bed, and cover with silicone-bordered gauze twice a day. A wound assessment completed by Registered Nurse #1, the wound care nurse, dated 6/21/2024 documented the resident had a Stage 4 sacral ulcer measuring 1.7 centimeters in length, 1.2 centimeters in width, and 1.0 centimeters in depth with tunneling/undermining (occurs when significant erosion occurs underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface; the clock scale provides the basic location of the undermining) 1.5 centimeters at 5-12 o'clock. The wound care recommendations included providing a special alternating air mattress or offloading devices if indicated. Resident #138 was observed in their room sitting in a Geri chair (a chair used for residents who have difficulty sitting upright in a conventional wheelchair) adjacent to their bed on 6/27/2024 at 2:03 PM. The resident's bed had an alternating air mattress with the weight setting set at 350 pounds. Resident #138 was observed in bed on 6/28/2024 at 8:05 AM. The alternating air mattress weight setting was set at 350 pounds. Registered Nurse #4, who is the supervisor, was interviewed on 6/28/2024 immediately after the observation. Registered Nurse #4 stated the resident did not weigh 350 pounds and the setting on the mattress should be set to the resident's weight of 139 pounds. Registered Nurse #4 adjusted the alternating air mattress setting to 139 pounds. Registered Nurse #1, the wound care nurse, was interviewed on 7/2/2024 at 9:00 AM and stated it is the facility's policy that residents with Stage 3 and 4 sacral pressure ulcers are provided an alternating air mattress. The alternating air mattress weight setting is based on the resident's weight. The nurses are supposed to check the alternating air mattress weight setting; however, there is no documentation to confirm. The certified nursing assistants are supposed to check the alternating air mattress to make sure the mattress is not deflated, but they do not adjust the weight setting. Certified Nursing Assistant #1 was interviewed on 7/2/2024 at 11:32 AM and stated the Certified Nursing Assistants do not adjust the alternating air mattress weight setting; they just check the alternating air mattress to make sure the mattress is not deflated and let the nurse know if there is a problem. Certified Nursing Assistant #1 stated they do not check the weight setting. Resident #138's wound care treatment was observed on 7/2/2024 at 11:36 AM. Registered Nurse #2 performed the wound care treatment and was assisted by Certified Nursing Assistant #7. The alternating air mattress weight setting was set at 150 pounds. Wound Care Physician #1 was interviewed on 7/2/2024 at 1:29 PM and stated they recommended the use of an alternating air mattress for Resident # 138, but it was up to the facility to ensure that the alternating air mattress was monitored properly. Wound Care Physician #1 expected the facility to follow the weight of the resident and calibrate the alternating air mattress accordingly. Wound Care Physician #1 stated proper calibration of the alternating air mattress was important to ensure effective wound healing. The Director of Nursing Services was interviewed on 7/2/2024 at 1:59 PM and stated the facility did not have a plan in place for monitoring the alternating air mattress weight setting. The nurses should monitor the air mattress setting, including the weight setting, every shift. The Certified Nursing Assistants should notify the nurse when they notice that the mattress is overinflated or underinflated. 10 NYCRR 415.12(c)(2)

Based on observation, record review, and interviews during abbreviated survey (NY00326327), the facility did not ensure that an incident of a resident-to-resident altercation was reported immediately, but not later than 2 hours if there were serious bodily injuries or not later than 24 hours if there were no serious bodily injuries. This was identified for one (Resident #1) of 3 residents reviewed for Abuse. Specifically, on 10/12/2023 Resident #1 reported to the nursing staff that Resident #2 yelled and hit them multiple times. The facility did not report the resident-to-resident altercation incident to the New York State Department of Health (NYSDOH). The findings are: The undated policy and procedure title Resident to Resident altercation prevention documented the facility will monitor and document peer to peer behavioral events to allow for proper assessments and effective care planning as well as to evaluate the effectiveness of interventions and programing in maintain a safe therapeutic environment. The policy does not include reporting criteria to state/federal or local agencies. The Policy and Procedure titled Abuse, Neglect and Mistreatment dated 10/24/22 documented any case in which abuse neglect mistreatment exploitation or misappropriation of resident's property has been identified via the investigation or a conclusion can not be drawn, will be reported promptly to the state department of Health for further investigation. Resident #1 has a medical diagnosis including Dementia without behavioral disturbance and generalized muscle weakness. The Minimum Data Set (MDS) dated [DATE] documented a Brief interview mental status (BIMS) score of 13 indicating intact cognition. The MDS further documented Resident #1 has no behavior directed towards others and does not reject care. Resident #2 has a medical diagnosis including Dementia without behavioral disturbances, Alzheimer's disease and age-related osteoporosis. The MDS dated [DATE] documented a BIMS score 11. Resident requires supervision with bed mobility, transfer, eating, toilet use, personal hygiene and requires extensive assistance for dressing. The MDS further documented Resident #2 has no behavior directed towards others and does not reject care. The Nursing Progress note dated 10/12/23 documented Resident #1 had a verbal altercation with roommate and the roommate proceeded to hit Resident #1 on her arms. The community police were notified and interviewed the resident and the roommate. There is no documented evidence of a Patient Accident/ Incident Report for Resident #1. There is no documented evidence a comprehensive care plan related to behavior, altercation with peer or abuse was developed. The Resident Altercation occurrence report dated 10/23/23 in the electronic medical record documented on 10/12/23 Resident #1 reported that her roommate yelled and hit them. The Certified Nursing Assistant instructions (CNA) documented no evidence of monitoring, or intervention related to the altercation. On 10/24/23 at 2PM an interview was conducted with Resident #1 who stated some days ago while on the phone during the night Resident #2 came over to the bedside demanding that Resident #1 stops talking and slapped her multiple times on both arms and hands. Resident #1 stated after screaming for help and Resident #2 walked out. Resident #1 further stated the Resident Representative (RR #1) who was on the phone notified the facility and local law enforcement. On 10/24/23 an interview was conducted with Registered Nurse #1 (RN #1) who stated they were notified by Resident Representative #1 (RR#1) via telephone that Resident #1 was hit. RN #1 stated they reported to the unit to observe resident #2 at the nurse's station. RN#1 stated on interview resident #2 denied hitting resident #1 however resident #1 stated that her arm was slapped. The local police department responded and questioned both residents. In response RN#1 stated he relocated the resident 4 doors down on the same unit. RN #1 stated that staff continued to monitor both residents and they did not verbalize feeling afraid or thoughts of retaliation. RN #1 states that facility administration is notified via the supervisor report of incidents and are responsible for reporting to regulatory bodies. RN #1 state he is not aware if the incidents are reported. On 10/24/23 an interview was conducted with the Director of Nursing (DON) who stated they are made aware of incidents via the supervisor report and discussed in morning meeting. The DON further stated they do not report resident to resident altercations because they deal with them in house. The DON stated she is aware of the state reporting manual and the regulatory requirement however the resident did not have any injuries and so it was determined it did not need to be reported. The DON further stated they are responsible to report to Department of Health and did not report this incident. On 10/24/23 an interview was conducted with the Facility Administrator who stated the Director of Nursing is responsible to report incident to regulatory bodies. The administrator stated the facility has frequent resident to resident altercations, so they are managed in house. The Facility Administrator further stated he became aware of the incident today (10/24/23) and was not aware if it was reported. 10 NYCRR 415.4(b)(2)

Based on observations, interviews, and record review conducted during the Recertification Survey initiated on 10/11/2022 and completed on 10/18/2022, the facility did not ensure that pain management was provided for each resident who requires such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. This was identified for four (Residents #39, #40, #121 and #79) of four residents reviewed for pain management. Specifically, the facility did not consistently assess residents for pain and did not monitor the effectiveness of pain medication. The findings include but were not limited to: The current facility policy for Pain Assessment and Management, revised on 2/22/18, documented that all residents will be assessed for pain upon admission/re-admission, quarterly, annually, significant change in condition, acute pain or change in pain medication, and 72 hours after medication change. The need for assessment for the medications prescribed on an as needed (PRN) bases is not addressed in the policy. 1). Resident #39 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment, dated 7/26/2022, documented Resident #39 had clear speech, was usually understood, and had severely impaired cognition. The resident was on a scheduled pain medication regimen and received PRN pain medication. The resident vocalized they occasionally experienced pain or hurting over the last five days and rated the intensity of their worst pain over the last five days as a 2 indicating moderate pain. The current Comprehensive Care Plan for Pain and Alteration in Comfort, dated 8/10/2022, documented the resident has a history of bilateral ankle pain related to Diabetic [CONDITION(S)]. Interventions included but were not limited to assessing pain for location, severity, and intensity; medicate as ordered and observe for effectiveness. Resident #39 was observed in bed on 10/11/2022 at 12:40 PM, and again on 10/18/2022 at 10:40 PM. Resident #39 complained of pain and stated, My feet hurt all the time and My pain is a 10 out of 10. The resident further stated, The pain medications don't work most of the time. The resident appeared calm; however, was noted with facial grimacing. The current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Records (MARs), dated September 2022 and October 2022, documented Resident #39 received [MEDICATION(S)] daily, received the PRN [MEDICATION(S)] on 24 occasions in September 2022 and on 21 occasions through October 18, 2022, and received the as needed Acetaminophen on 52 occasions in September 2022 and on 26 occasions through October 18, 2022. There was no documented evidence that Resident #39's pain was assessed prior to or after administration of the PRN pain medication to monitor effectiveness. The Nurse Practitioner (NP) was interviewed on 10/18/2022 at 10:35 AM and stated that they (NP) saw the resident today for their (Resident #39) monthly evaluation. The NP stated that Resident #39 has bilateral Diabetic [CONDITION(S)] with pain. The NP stated the resident reported pain of 10 out of 10 on a pain scale during the evaluation. The NP stated that an increase to the [MEDICATION(S)] would be considered. The NP stated that they would expect a pre and post assessments of pain for PRN pain medication administration. The Licensed Practical Nurse (LPN) #1 was interviewed on 10/18/2022 at 10:49 AM and stated that Resident #39 does report when they (Resident #39) have pain. LPN #1 stated they (LPN #1) do not conduct pain evaluations each time prior to or after administering PRN pain medications. The only time a pain assessment is conducted is upon admission, readmission, or change of medication. This assessment is done by the nursing supervisor. The Director of Nursing Services (DNS) was interviewed on 10/18/2022 at 11:10 AM and stated an evaluation is not conducted prior to or after administration of pain medication each time. The DNS stated that staff observe residents for facial expressions of pain and nursing staff perform general rounds during the day. The resident is expected to report to the staff if the medication is not working. The DNS stated that it is the responsibility of the nurse to know if the medication is working or not. The DNS stated that the facility's pain policy does not reflect assessment of pain for non-verbal residents. The DNS stated that the facility policy does not include guidance for staff to perform pre and post evaluation for PRN medications. 2). Resident #40 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13 which indicated Resident #40 was cognitively intact. The MDS documented the resident had clear speech and was usually understood. The resident did not receive a scheduled pain medication regimen, or PRN pain medication during the last 5 days of the MDS review period. The resident did not vocalize any pain or hurting over the last five days of the review. The current Comprehensive Care Plan for Pain and Alteration in Comfort, dated 10/13/2022, documented the resident was receiving pain medication secondary to general discomfort. Interventions included but were not limited to assessing pain for location, severity, and intensity; medicate as ordered and observe for effectiveness. Resident #40 was interviewed on 10/18/2022 at 2:57 PM and stated they get Tylenol for back pain with adequate relief. Resident #40 stated, sometimes they follow-up to see if I feel better and sometimes, they don't. The current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Records (MARs), dated September 2022 and October 2022, documented that the resident received Acetaminophen once in September 2022 and three times in October 2022. There was no documented evidence that Resident #40's pain was assessed prior to or after administration of the PRN pain medication to monitor effectiveness. The Director of Nursing Services (DNS) was interviewed on 10/18/2022 at 11:10 AM and stated an evaluation is not conducted prior to or after administration of pain medication each time. The DNS stated that staff observe residents for facial expressions of pain and nursing staff perform general rounds during the day. The resident is expected to report if the medication is not working to the staff. The DNS stated that it is the responsibility of the nurse to know if the medication is working or not. The DNS states that the facility's pain policy does not reflect assessment of pain for non-verbal residents. The DNS stated that the facility policy does not include guidance for staff to perform pre and post evaluation for PRN medications. 3). Resident #121 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment, dated 9/3/2022, documented that the resident had clear speech, makes self-understood, and had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had intact cognition. The resident was not on a scheduled pain medication regimen but did receive as needed (PRN) pain medication during the five-day MDS look back period. The resident vocalized they frequently experienced pain or hurting over the last five days and rated the intensity of their worst pain over the last five days as a 2 which indicated moderate pain. The current Comprehensive Care Plan for Pain and Alteration in Comfort, dated 9/3/2022, documented the resident is receiving pain medication secondary to [CONDITION(S)] and complaints of generalized pain. Interventions included but were not limited to assessing pain for location, severity, and intensity; medicate as ordered and observe for effectiveness. Resident #121 was interviewed on 10/18/2022 at 2:51 PM. The resident stated that they notify the nursing staff when experiencing pain and receive pain medication but did not recall the nursing staff following up on the effectiveness of the medication. The current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Records (MARs) dated September 2022 documented that the resident received the [MEDICATION(S)]-Acetaminophen 5-325 milligram on 40 occasions and Acetaminophen 650 milligrams on one occasion. In October 2022 the resident received the [MEDICATION(S)]-Acetaminophen 5-325 milligram on 23 occasions and Acetaminophen 650 milligrams on zero occasions. There was no documented evidence that Resident #121's pain was assessed prior to or after administration of the PRN pain medication to monitor effectiveness. The Director of Nursing Services (DNS) was interviewed on 10/18/2022 at 11:10 AM and stated an evaluation is not conducted prior to or after administration of pain medication each time. The DNS stated that staff observe residents for facial expressions of pain and nursing staff perform general rounds during the day. The resident is expected to report if the medication is not working to the staff. The DNS stated that it is the responsibility of the nurse to know if the medication is working or not. The DNS states that the facility's pain policy does not reflect assessment of pain for non-verbal residents. The DNS stated that the facility policy does not include guidance for staff to perform pre and post evaluation for PRN medications. 415.12

Based on observation, record review, and interviews during the Recertification Survey initiated on 10/11/2022 and completed on 10/18/2022, the facility did not ensure that each resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This was identified for one (Resident #81) of four residents reviewed for pressure ulcers. Specifically, Resident #81 was identified with a small opening on the sacrum on 7/14/2022; however, the wound was not assessed until 7/19/2022, five days after the wound was first identified. On 7/19/2022 the wound care Nurse Practitioner (NP) assessed the wound as an unstageable pressure ulcer. The finding is: The facility's policy and procedure for Pressure Ulcers, dated 12/13/2021, documented the unit coordinator will notify the Rehabilitation Nurse for any in-house development of pressure ulcers. The skin assessment sheet will be done by the Registered Nurse (RN) Supervisor and submitted to the wound care nurse to assess the resident with the newly identified pressure ulcer. The assessment of the pressure ulcer is to include the location, size, stage, and exudate (drainage). Resident #81 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/11/2022 Quarterly Minimum Data Set (MDS) assessment documented no Brief Interview for Mental Status (BIMS) score as the resident had severely impaired cognitive skills for daily decision making. The MDS documented the resident had one Stage 4 pressure ulcer and was at risk for developing pressure ulcers. The MDS also documented that the resident was always incontinent of bowel and bladder and required extensive assistance of one staff member for bed mobility. The 5/11/2022 Braden scale assessment (a predictor of pressure ulcer risk) documented a score of 13, which indicated the resident was at moderate risk for pressure ulcer development. Review of the medical record revealed Resident #81 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . A Comprehensive Care Plan (CCP) effective 9/6/2019 and last updated 5/11/2022 (prior to the wound development on 7/14/2022) documented interventions to turn and position every 2 hours, barrier cream to the buttock area after incontinence and when needed, change diaper every 2-4 hours and when needed, monitor to ensure adequate nutritional intake, maintain proper body alignment in and out of bed, and monitor skin integrity every shift. There were no new interventions added on 7/14/2022 when the open area to the sacrum was first identified. A CCP dated 7/19/2022 for Actual Pressure Ulcer documented interventions which included a ROHO cushion (a specialized pressure relieving wheelchair cushion), Air Mattress, and limited out of bedtime to 4 hours daily. A nursing progress note dated 7/14/2022 at 6:36 AM, written by the 11 PM-7 AM Registered Nurse (RN) Supervisor (RN #1), documented that Resident #81 was noted with a small open area to the sacrum. The physician was notified, and an order was obtained to cleanse the area with normal saline, apply [MEDICATION(S)] cream, and apply a dry dressing twice a day for 10 days. A nursing progress note dated 7/14/2022 at 9:11 AM, written by the 7 AM-3 PM RN charge nurse (RN #2), documented (for the same wound) that Resident #81 was noted with a small open area to the sacrum. A new order from the physician was obtained to cleanse the area with normal saline, apply Triad Cream, and apply a dry dressing twice a day for 10 days. Review of the medical record revealed that there was no assessment of the sacral wound until 7/19/2022 when the resident was seen during wound rounds and examined by the wound NP and the wound care Registered Nurse (RN) #3. The 7/19/2022 NP wound assessment documented that the sacral wound was an unstageable pressure ulcer, measuring 3.5 centimeters (cm) long x 1.0 cm wide x 0.8 cm deep with 100% slough (dead cells that accumulate in the wound) with a small amount of exudate. The treatment was changed to [MEDICATION(S)] (an enzymatic [MEDICATION(S)] wound gel). The next documented wound assessment dated [DATE] indicated the sacral wound was now identified as a stage 4 pressure ulcer measuring 4.0 cm long, x 1.5 cm wide x 2.0 cm deep. The wound was noted with 30 % slough and 70 % granulated tissue with moderate amount of exudate. RN #1, the overnight RN supervisor who first identified the sacral wound on 7/14/2022 at 6:36 AM, was interviewed on 10/18/2022 at 9:14 AM. RN #1 stated the sacral wound was just a small opening. RN #1 stated they (RN #1) are supposed to do a full assessment when a wound is identified, including the size and any drainage, but it was just a small opening. RN #1 further stated they should have done a full assessment. RN #2, who was the RN charge nurse who wrote the nursing progress note on 7/14/2022 at 9:11 AM, was interviewed on 10/18/2022 at 9:30 AM. RN #2 stated they (RN #2) did not do an assessment of the identified open area to the sacrum because the sacral wound was just a small opening. RN #2 stated they (RN #2) did notify the wound care RN on 7/14/2022 when they (RN #2) first identified the wound. RN #2 stated the treatment was changed from [MEDICATION(S)] to Triad cream because RN #2 thought Triad would be better for the wound. RN #2 stated they (RN #2) knew the wound NP would be making rounds on 7/19/2022. RN #2 stated that upon identification of the wound on 7/14/2022 the only documentation that was done was the progress note. Review of the medical record revealed no documentation from the wound care RN until 7/19/2022. RN #3, the wound care RN, was interviewed on 10/18/2022 at 9:47 AM. RN #3 stated when any wound is identified, the nurses are supposed to notify them (RN #3) and there is supposed to be a full assessment documented by the third day following the identification of the wound. RN #3 stated it was an oversight that Resident #81's sacral ulcer was not assessed timely; however, the treatment that was initiated on 7/14/2022 was appropriate for Resident #81. RN #3 stated they (RN #3) did not recall if they (RN #3) were notified when the wound was first identified. The sacrum wound was observed on 10/18/2022 at 10:16 AM. RN #2 removed the dressing while the resident was in bed. RN #2 was assisted by the Infection Control RN. The wound was full thickness [damage extends below the epidermis and dermis (all layers of the skin) into the subcutaneous tissue], Stage 4, about the size of a quarter, round, fully granulating, with minimal exudate, no odors, and no signs of infection. The surrounding tissue was intact. The Director of Nursing Services (DNS) was interviewed on 10/18/2022 at 11:10 AM and stated the nurses are supposed to let the wound nurse know on day one whenever any new wound is identified, and a full assessment should be done within three days. The DNS also stated there should be documentation in the nursing notes that the wound nurse is notified when a wound is identified. 415.12(c)(2)

Based on record review, observation, and interviews during the Abbreviated Survey (Complaint # NY 5) completed on 3/29/2022 the facility failed to ensure resident rights to be free from abuse, neglect, and mistreatment for one of three residents reviewed for abuse. Specifically, video was provided by witness #1 which contained evidence of verbal and physical abuse by the perpetrator (Behavioral Aide #1) against Resident#1 on 3/20/22. The finding is: Review of the facility policy dated 2016 documented that Residents of this facility will be protected from abuse, neglect, mistreatment, exploitation, and misappropriation of property in accordance with state and federal regulations. Resident #1 was admitted to the facility with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 3 indicating severely impaired cognition. The Comprehensive Care Plan (CCP) dated 11/2021 and titled Behavioral Symptoms /Wandering documented Resident#1 has a history of wandering behavior, wanders safely on neurobehavioral unit. The Facility Investigation dated 3/22/2022 documented that the Director of Nursing (DON) received a call from Registered Nurse Supervisor#1 (RNS#1) on 3/20/2022. RNS #1 stated to the DON that a cell phone video was provided by witness #1 and contained evidence of verbal and physical abuse by BA#1 against Resident#1. Review of Accident/Incident Report dated 3/20/22 documented that Resident#1 was observed with sight discoloration on the left periorbital area left ear and left 5th digit. There was no swelling, pain or discomfort observed. Resident#1 was unable to make a statement due to severe cognition loss. Review of BA#1s employee's personnel file revealed that all in-services including abuse, neglect, and mistreatment were completed. In an interview on 3/29/22 at 9:30 AM with witness #1, who stated that on 3/20/2022 Resident #1 was brought back to the room Resident #1 and witness #1 share three times. Each time resident #1 was brought back to the room BA#1s voice would get louder toward the resident. Witness #1 stated that they were worried that the fourth time the situation would escalate. At first witness #1 stated, BA#1 was just raising his voice to resident#1 but then began pushing Resident #1 and that is when witness #1 recorded the interaction and could only see some of the interaction but heard an impact of a slap. Witness #1 stated the occurrence was reported to RNS#1. In an interview with the DON on 3/29/22 at 10:00 AM who stated that a full body assessment was done by RNS#1 after the incident was reported. On the video the perpetrator was heard being verbally abusive to Resident #1 and then approximately 4 slaps are heard. The DON stated the perpetrator was removed from the schedule and denied abusing the Resident#1 until the perpetrator viewed the video and then acknowledged the occurrence. Resident #1 was observed at 12:00 PM in the Day Room on 3/29/22. Resident #1 was friendly and pleasant, ambulating freely. Resident #1 was not able to be interviewed due to the cognitive status. In a telephone interview with RNS#1 on 3/30/22 who stated that they were notified by a Certified Nursing Assistant #1 (CNA#1) that Witness #1 wanted to speak to the RNS#1. Witness #1 informed them that they had taken a video on their cell phone the previous night 3/20/22 and wanted them to see it. The RNS#! viewed the video and stated that they performed a total body assessment of Resident #1 at which time slight ecchymosis to Resident #2's left ear, left periorbital region, and left finger. The RNS#! Notified the DON and the DON stated to remove BA#! from the schedule and start an investigation. In a telephone interview at 1:00 PM on 4/4/22, BA#1 stated that they no longer work at the facility and acknowledged that they were taking care of Resident # 1 on the overnight shift 3/19/22 to 3/20/22. The BA stated Resident #1 kept getting up and walking around the Unit and stated that Resident#1 cursed at BA#1 when the resident was brought back to the room. BA#1 stated that they then yelled at Resident#1 and told them to stay in the room; and then proceeded to slap the resident on the legs. BA#1 further stated that this was the only way that Resident #1 would behave. In a subsequent interview on 4/26/22 at 9:00 AM with the RNS#1, who stated that witness #1 had informed them that they had trouble sleeping that night and that was why witness #1 was awake when the incident occurred, and they began recording the incident with their cell phone. 415.4(b)(1)(1)

Based on observation, record review, and interviews during a COVID-19 Focus Infection Control Survey completed on 1/6/2022, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of COVID-19 on 1 of 5 nursing units. Specifically, the facility staff did not supervise a COVID-19 positive resident (Resident #6) on the Neurobehavioral Unit (1 East) to prevent the resident from exiting the COVID-19 designated area thru double doors to a non-COVID-19 area on the same unit. The finding is: The facility's policy, titled Cohorting Residents during COVID-19, revised 8/6/2021, documented all residents with COVID-19 positive results will be transferred to a dedicated COVID-19 unit and placed on contact/droplet precautions. Neurobehavioral Unit residents will be isolated for COVID-19 on the unit that they reside on and the door will be eased [to the resident rooms]at 12 inches due to the nature of the unit (behavior, peer-to-peer altercation, etc). Resident #6 was admitted with Non-Alzheimer's Dementia, Unspecified Dementia with Behavioral Disturbance, and Difficulty Walking. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident had severe cognitive impairment. A nursing progress note dated 12/25/2021 documented that Resident #6 felt weak, had a hoarse voice, and the Physician ordered a rapid COVID-19 swab. A COVID-19 test result dated 12/25/2021 documented Resident #6 was positive for COVID-19. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Comprehensive Care Plan (CCP) effective 11/11/2021, titled Potential for Infection of COVID-19, documented an update dated 1/5/2022 that Resident #6 was COVID-19 positive, and Contact and Droplet Precautions were maintained. A nursing progress note dated 1/6/2022 documented the resident was COVID-19 positive with contact and droplet precautions maintained. No signs and symptoms of COVID-19. The Assistant Director of Nursing Services (ADNS) and the Registered Nurse (RN) Infection Preventionist were interviewed concurrently on 1/6/2022 at 9:30 AM. They both stated there were 20 COVID-19 positive residents in the facility situated on Unit 1 East (Neurobehavioral Unit) and 2 West. They both stated the COVID-19 positive residents on Unit 1 East are located behind the closed double doors, and the area is on contact/droplet precautions. They both stated that COVID-19 positive residents on the Neurobehavioral Unit (1 East) are redirected to stay in their rooms by the behavioral aides. Resident #6 was observed standing in front of the 1 East nursing station, which is located outside the closed double doors that lead to the part of the unit designated for COVID-19 positive residents on 1/6/2022 at 1:30 PM. Resident #6 was not wearing a mask. The Registered Nurse (RN) wound care nurse was present at the nursing station. Signs on the double doors read entry was restricted, and the area was under Contact and Droplet Precautions. Moments later Resident #6 went thru the double doors and entered the COVID-19 restricted area. The RN wound care nurse was interviewed on 1/6/2022 at 1:32 PM and stated that they (wound care nurse) were not aware of Resident #6's COVID-19 status. On 1/6/2022 at 1:34 PM Resident #6 was observed re-attempting to exit the COVID-19 area thru the double doors, but the RN wound care nurse directed the resident to go back to their (Resident #6) room. At this time, there was no behavioral aide present on the COVID-19 side of the double doors. The Licensed Practical Nurse (LPN) #2, charge nurse, returned to Unit 1 East from the nursing office and was interviewed on 1/6/2022 at 1:35 PM. LPN #2 stated Resident #6 is COVID-19 positive. LPN #2 was observed looking thru a glass window in the double doors and stated that a behavioral aide was not present to supervise and redirect residents in the COVID-19 area. LPN # 2 immediately paged and called the Neurobehavioral Department Director and Assistant Director. RN #1 (1 East Unit Manager) was interviewed on 1/6/2022 at 1:38 PM and stated there is supposed to be a behavioral aide on the COVID-19 side of the double doors to keep the residents there. RN #1 stated that their (RN #1) observation of the COVID area revealed there was no behavioral aide present. RN #1 and LPN #2 concurrently stated there is one behavioral aide assigned to the COVID-19 area. Behavioral Aide (BA) #1, who was also the Assistant Director of the Neurobehavioral Department, was interviewed on 1/6/2022 at 2:15 PM. BA #1 stated they (BA #1) left the COVID-19 area to get lunch and did not communicate this to the Department Director or any of the other behavioral aides or nursing staff. BA #1 stated if there is blame, it is because they (BA #1) did not communicate that they (BA #1) were leaving the unit. The Neurobehavioral Department Director was unavailable for an interview as they (Neurobehavioral Department Director) left the building after this incident and the facility was unable to reach them. The Certified Nursing Assistant (CNA) #2, who is assigned to Resident #6, was interviewed on 1/6/2022 at 2:45 pm. CNA #2 stated if a behavioral aide is leaving the COVID-19 behavioral unit, they are supposed to get another behavioral aide to help, not a CNA. CNA #2 stated behavioral aides are always replaced with another behavioral aide. The RN Infection Preventionist (IP) was interviewed on 1/6/2022 at 2:55 PM and stated BA #1 should not have left the COVID-19 area without someone replacing them (BA#1). The IP stated there was no excuse. The Assistant Director of Nursing Services (ADNS) was interviewed on 1/6/2022 at 3:15 PM and stated that BA #1 should have communicated that they (BA #1) were leaving the unit to ensure that the COVID-19 residents on the behavioral unit are monitored to prevent them from exiting the COVID-19 designated area on Unit 1 East to prevent the spread of COVID-19. The Director of Nursing Services (DNS) was unavailable for an interview. 415.19(b)(1)