Every finding on record at Beacon Rehabilitation and Nursing Center

Based on observation, interview and record review, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was identified during the Kitchen Task. Specifically, multiple refrigerated food items were undated and stored in open packaging. Additionally, the kitchen staff were not monitoring the cold food temperatures. The findings are: A facility policy titled Food Storage documented all food stored is maintained in a safe, sanitary, and temperature-controlled manner in order to prevent foodborne illnesses, contamination, and spoilage. All food items shall be stored, labeled, dated, and monitored in accordance with the accepted food safety standards and regulatory requirements. All refrigerated food items must be covered, labeled, dated, and discarded according to the facility's guidelines. All prepared, opened or thawed foods must be labeled with date prepared/opened. Unlabeled or expired food shall be discarded immediately. A facility policy titled Food Temperature Control and Food Safety documented all food served to residents is prepared, held, transported, served, and stored at safe temperatures. Food temperatures are monitored, documented, and corrected when out of range. All cold foods must be maintained at 41 F or below. During a Kitchen observation, in the presence of the Food Service Director, on 01/08/2026 at 9:43 AM, the walk-in dairy refrigerator contained an open package of American cheese with no label, an open package of shredded cheddar cheese, an open one-gallon bottle of Italian salad dressing, and an open 64-ounce bottle of cranberry juice. All the items were not dated to indicate the open date. A low-boy refrigerator was observed with an unlabeled and undated pan of grape jelly that was covered with a plastic wrap cover. There were spots of peanut butter on the plastic wrap cover. During a concurrent interview on 01/08/2026 at 9:57 AM, Dietary Aide #1 stated that they forgot to put a date on the pan of grape jelly when they stored it. The Food Service Director stated that having the peanut butter on the plastic cover of the grape jelly pan was a concern due to potential cross contamination and the possibility of an allergic reaction to peanut butter. During an interview on 01/14/2026 at 11:43 AM, [NAME] #1 stated they only take the temperature of the hot food items at the start of the lunch meal service. They do not take the temperature of cold food items. During the kitchen observation and interview on 01/14/2026 at 11:46 AM, a tray of sandwiches was observed at the end of the tray line table. Dietary Aide #2 stated they do not take the temperature of the sandwiches because they just took them out of the refrigerator. Dietary Aide #3 measured the temperature of an American Cheese sandwich, and the temperature measured to be 50.5 degrees Fahrenheit. Dietary Aide #3 stated the cold food should be at or below 40 degrees Fahrenheit. During an interview on 01/14/2026 at 11:47 AM, the Food Service Director stated that food out of the proper temperature range is a hazard and increases the possibility of foodborne illness. 10 NYCRR 415.14(h)

Based on observation, record review and interviews the facility did not ensure each resident was treated with respect and dignity and cared for in a manner and in an environment that promotes maintenance or enhancement of their quality of life, recognizing each resident's individuality. This was identified for one (1) (Resident #70) of two (2) residents reviewed for Dignity. Specifically, on 01/12/2026 Certified Nursing Assistant #1 was observed in the hallway pulling Resident #70 backwards for approximately 100 feet while the resident was laying completely flat on a shower bed. At the time, there were other residents and staff in the hallway.The finding is:The facility's policy titled Resident Dignity, Respect, and Self-Determination, last reviewed 01/15/2025, documented the facility is committed to protecting and promoting each resident's right to dignity, respect, privacy, individuality, and self-determination. All residents shall receive care in a manner that supports their dignity, privacy, independence, and quality of life. All residents have a right to privacy in treatment, personal care, and communications. All staff must protect residents from embarrassment or humiliation. All staff must provide privacy during toileting, bathing, dressing, and treatments and protect residents from unnecessary exposure.Resident #70 was admitted with diagnoses including seizure disorder, fractures of right clavicle (collar bone) and right tibia (lower leg bone), and hypertension. The 10/30/2025 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 13, indicating the resident was cognitively intact.During an observation on 01/12/2026 at 10:00 AM on the second-floor nursing unit, Certified Nursing Assistant #1 was observed pulling Resident #70 backwards through the hallway from the resident's room to the shower room for approximately 100 feet while the resident was laying completely flat on a shower bed. The resident had a hospital gown covering the upper body and a sheet was covering the resident's legs. Other staff and residents were in the hallway at the time.During an interview on 01/12/2026 at 11:45 AM, Certified Nursing Assistant #1 stated they pulled Resident #70 backwards on the shower bed because they could see better where they were going and felt they could control the shower bed that way. Certified Nursing Assistant #1 stated they felt there may have been something wrong with the shower bed and it felt unstable.During an interview on 01/12/2026 at 11:55 AM, Resident #70 stated they were wondering why they were being pulled backwards. The resident also stated they would have preferred to be fully covered with a sheet during the transfer process because it was cold in the hallway.During an interview on 01/13/2026 at 08:30 AM, Registered Nurse Supervisor #1 stated after the observation by the surveyor, Certified Nursing Assistant #1 notified them that there was something wrong with the shower bed, and they were having difficulty pushing the shower bed. Registered Nurse Supervisor #1 stated if Certified Nursing Assistant #1 thought there was a problem with the shower bed, they should not have used the shower bed. Registered Nurse Supervisor #1 stated the maintenance department checked the shower bed on 01/13/2026, after the issue was brought to their attention. During an interview on 01/14/2026 at 1:30 PM the Director of Nursing Services stated pulling a resident backwards is a dignity issue and staff should ensure the resident is facing forward while being transported. The Director of Nursing Services stated residents should also be covered rather than just wearing a gown when being transferred through the hallway.10 NYCRR 415.5(a)

Based on observation, record review, and interviews 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 two (2) (Resident #7 and Resident #10) of three (3) residents reviewed for Pressure Ulcers. Specifically, 1) during the wound care observation for Resident #7, Licensed Practical Nurse #1 did not cleanse all surfaces of the wound bed, including the part of the wound with undermining (a pocket or shelf beneath the surface of the skin extending beyond the visible opening, making it harder to heal and prone to infection). Additionally, the air mattress weight setting for Resident #7 was not consistent with the resident's weight. 2) Resident #10's air mattress weight setting was not consistent with the resident's weight and the facility staff was unfamiliar with the pump functions and settings.The findings are:The facility's policy titled Wound Care and Dressing Change, last reviewed 01/15/2025, documented the facility provides safe, sterile, timely, and evidence-based wound care to promote healing, prevent infection, and prevent deterioration of all wounds, including pressure injuries. The procedure includes cleanse wound bed in a circular motion inside to outside and irrigate if needed.The facility's policy titled Pressure Injury (Pressure Ulcer) Prevention, Assessment and Treatment, last reviewed 03/20/2025, documented pressure injuries will receive appropriate treatment and monitoring to promote healing, prevent deterioration, and prevent new injuries. Treatment includes infection control and treating wounds according to physician or wound-care specialist orders. A Braden (a scale for determining pressure ulcer risk) score of 10-12: High Risk (needs intensive interventions).The facility's policy titled Air Mattress / Pressure-Reducing Support Surface, last reviewed 01/15/2025, documented air mattresses shall be implemented promptly, monitored routinely, and maintained in safe and working condition to support resident dignity, comfort, safety, and wound prevention. Nursing staff shall verify the mattress is functioning and set properly every shift and report any malfunction immediately. All nursing staff will receive training on proper use of air mattresses.1) Resident #7 was admitted with diagnoses including diabetes mellitus, non-Alzheimer's dementia, and cerebrovascular accident. The 12/02/2025 Minimum Data Set assessment documented no Brief Interview for Mental Status score as the resident had severely impaired cognitive skills for daily decision making. The Minimum Data Set assessment documented that the resident had one Stage 3 pressure ulcer (a deep wound involving full-thickness skin loss, where fat tissue is visible, but bone, tendon, or muscle are not exposed) and one Stage 4 pressure ulcer (a deep wound involving full-thickness skin and tissue loss with exposed muscle, tendon, or bone).A Comprehensive Care Plan, initiated 06/20/2025, titled Actual Alteration in Skin Integrity as Evidenced by Stage 4 Pressure Ulcer, documented an intervention dated 10/27/2025 for an air mattress.A Braden scale (a scale for determining pressure ulcer risk) dated 11/26/2025 revealed a score of 12, indicating the resident was at high risk for pressure ulcer development.A wound consult dated 12/31/2025 documented a sacral Stage 4 Pressure Injury measuring 5 centimeters length x 3 centimeters width x 2.5 centimeters depth with exposed muscle. Undermining at 3:00 o'clock and ends at 5:00 o'clock (as per a clock face), with a maximum distance of 4 centimeters was present. There was a moderate amount of purulent (pus) drainage. Wound bed had 40% granulation (healthy) tissue and 60% slough (dead tissue). The recommendations were to initiate antibiotics.A physician's order dated 12/31/2025 documented cleanse wound with Dakin's 1/4 strength (a topical antimicrobial liquid, essentially diluted bleach, used for cleansing wounds), then loosely packed the wound bed with a wet to moist Dakins moistened gauze, cover with dry protective dressing, twice daily.A physician's order dated 12/31/2025 documented Cephalexin (antibiotic) tablet 500 milligrams, give one (1) tablet by mouth every 12 hours for infection for 14 Days.The resident's weight as of 01/05/2026 documented in the weight monitoring section of the electronic medical record was 123 pounds.A wound consult dated 01/07/2026 documented a sacral Stage 4 Pressure Injury measuring 4.5 centimeters length x 2.8 centimeters width x 1.5 centimeters depth with exposed muscle. Undermining at 3:00 o'clock and ends at 5:00 o'clock with a maximum distance of 3.5 centimeters was present. There was a Moderate amount of purulent drainage. The wound bed had 40% granulation tissue and 60% slough.During an observation on 01/12/2026 at 9:36 AM, Resident #7 was in bed sleeping. The air mattress weight setting was set at 220 pounds.A review of the medical record revealed no physician's order for the air mattress or monitoring of the mattress.During the wound care treatment observation on 01/13/2026 at 08:35 AM, performed by Licensed Practical Nurse #1 and assisted by Certified Nursing Assistant #2, the air mattress weight setting was set at 220 pounds. Licensed Practical Nurse #1 stated the resident weighed about 200 pounds. After the surveyor informed Licensed Practical Nurse #1 that the resident's weight was 123 pounds, Licensed Practical Nurse #1 then adjusted the weight setting to 150 pounds. Periodically, the air mattress low-pressure light illuminated and sounded. Licensed Practical Nurse #1 and Certified Nursing Assistant #2 both stated the low air pressure alarm, and the light has been illuminating for about a day and the maintenance staff were aware. Neither of them checked if the bed was inflated properly. During the wound treatment, the wound appeared clean with light to moderate amount of serosanguinous drainage (blood tinged). Licensed Practical Nurse #1 only cleansed the center of the wound and not the entire surface of the wound bed including the undermining area. Licensed Practical Nurse #1 stated they always cleaned the wound this way and continued with the wound care. The nurse did not pack the Dakin's moistened gauze into the undermining area as ordered by the Physician.Resident #7's air mattress operating manual documented to press the weight button to set according to patient weight.During an interview on 01/13/2026 at 1:06 PM, the Registered Nurse Wound Care #1 (who is also the Infection Preventionists) stated the peri wound (around the wound) skin should be spread out and all areas of the wound, including the undermining, should be cleansed, and the moistened gauze should be packed into the undermining area. The air mattress weight setting should be consistent with the resident's weight to assist with wound healing. Registered Nurse Wound Care #1 stated the certified nursing assistants are supposed to check the air mattress for inflation and the weight setting. Registered Nurse Wound Care #1 stated they heard about the low-pressure alarm issue and the air mattress was changed today.During an interview on 01/13/2026 at 2:45 PM, Registered Nurse Wound Care #1 stated an order for air mattress and monitoring was just added on 1/13/2026.A physician's order dated 01/13/2026, documented apply pressure devices: Air Mattress- check air mattress inflation every shift. Machine weight should be the same as the patient weight.During an interview on 01/14/2026 at 1:00 PM, Certified Nursing Assistant #2 stated they do not adjust weight setting on the air mattress; they just look at the mattress to see if it is deflated.During an interview on 01/14/2026 at 1:30 PM, the Director of Nursing Services stated, for years the maintenance department was responsible for the weight setting adjustments on the air mattresses. The nursing staff is now responsible to ensure the air mattress weight setting was accurate. The air mattress weight setting should be consistent with the resident weight to aid in wound healing. The nurses are responsible for ensuring and changing the air mattress weight setting according to the resident's weight. The Director of Nursing Services stated the entire wound surface including the undermining area of the wound should be cleansed. The undermining area should be packed according to the Physician's order, especially if the wound is being treated for an infection. During an interview on 01/15/2026 at 2:45 PM, Maintenance Director #1 stated they were not informed of Resident #7's air mattress low-pressure alarm until 01/13/2025. The air mattress was changed as soon as they were informed. The flashing low-pressure light on the air mattress pump indicated a potential problem in maintaining proper inflation.2) Resident #10 was admitted with diagnoses including diabetes mellitus, paraplegia (paralysis affecting the lower half of the body), and opioid dependence. The 12/12/2025 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. The Minimum Data Set assessment documented a weight of 298 pounds. The resident had two Stage 3 (a serious wound involving full-thickness skin loss, where fat is visible, but bone, muscle, or tendon are not exposed) pressure ulcers. The resident utilized a pressure reducing device for the chair.A Comprehensive Care Plan titled, Actual Alteration in Skin Integrity, initiated 04/02/2025 and last updated 01/14/2026, added pressure ulcer unstageable to Right Heel (04/18/2025) and left heel pressure ulcer Stage 3 (06/11/2025). There was no documentation in the care plan that the resident had an air mattress. The Braden scale (a scale to determine pressure ulcer risk), dated 12/06/2025, documented a score of 15 indicating a mild risk for pressure ulcer development.A wound Consult dated 12/31/2025 documented right heel Stage 3 Pressure Ulcer measuring 1 centimeter length x 1 centimeter width x 0.2-centimeter depth; and left heel Stage 3 Pressure Ulcer measuring 0.2 centimeters length x 0.2 centimeters width x 0.1 centimeters depth.A physician's order dated 12/03/2025 documented cleanse left and right heel with normal saline, pat dry, apply collagen powder (a protein powder that helps heal the wound, absorbs drainage, and keeps the wound moist), then cover with dry protective dressing every evening shift.The resident's most recent weight in the electronic medical record was 305 pounds as of 01/07/2026.During an observation and interview on 01/08/2026 at 11:18 AM Resident #10 was in bed. The weight setting on the air mattress pump was set at 220 pounds. The resident stated they weighed about 300 pounds.A review of the medical record revealed no physician's order for the use of an air mattress and no documentation that the air mattress function and weight setting were being monitored.During an observation with Licensed Practical Nurse #2 on 01/14/2026 at 9:35 AM, Resident #10 was in bed. The air mattress pump weight setting was set at 220 pounds. Licensed Practical Nurse #2 observed the air mattress pump and stated they were supposed to check the mattress weight setting, but there was no physician's order, so the weight setting was not something that they sign off for in the treatment administration record. Licensed Practical Nurse #2 stated resident's weight was 305 pounds, and they were not sure how to set the weight on this type of air mattress to correspond with the resident's weight.During a re-interview in Resident #10's room on 01/14/2026 at 10:15 AM, Licensed Practical Nurse #2 stated they just had the Maintenance Director look at the air mattress pump who changed the air mattress pump mode to bariatric setting, because the resident weighed more than 300 pounds. Licensed Practical Nurse #2 stated the air mattress was previously on a standard mode. Licensed Practical Nurse #2 stated they did not know the setting was supposed to be on bariatric mode.During an interview on 01/14/2026 at 10:37 AM, Maintenance Director #1 stated the standard mode weight settings is from 80 pounds to 300 pounds. The bariatric mode weight settings are from 350 pounds to 1,000 pounds. Maintenance Director #1 stated they changed the mode to bariatric.During an interview on 01/14/2026 at 2:19 PM Wound Care Nurse Practitioner #1 stated the air mattress weight setting should be set as close to the resident's weight as possible. The correct weight setting helps with wound healing. 415.12(c)(1)

Based on observation, record review, and interviews conducted during an abbreviated survey (NY00334677), the facility failed to protect a resident from physical abuse by nursing home staff. This was evident in 1 out of 3 residents sampled for abuse (Resident #1). Specifically, on 02/28/24 at approximately 7:00 pm, Resident #1 reported to Nursing Supervisor #1 that they were kicked in the scrotal area by Certified Nursing Assistant #2. Resident #1 reported that when they were kicked in the groin, they screamed out in pain. Certified Nursing Assistant #1 also reported to Nursing Supervisor #1 they witnessed Certified Nursing Assistant #2 kick Resident #1 in their private area and that Resident #1 screamed out in pain. A nursing note, by Nursing Supervisor #1, dated 02/28/24 at 6:33 pm documented that a head-to-toe assessment was done immediately and revealed no visible injuries. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy. The findings are: The facility's Policy and Procedure entitled Abuse Prohibition reviewed on 01/15/24, documented that all residents will be protected from abuse, neglect, mistreatment, exploitation, or misappropriation of property in accordance with State and Federal Regulations. It also states that the facility will report any incident or violation where abuse, neglect, or mistreatment is suspected to the New York State Department of Health according to protocol. Federal Law (1150B of the Social Security Act) requires that any individual employee having reasonable suspicion that a crime has occurred against a resident is required to report the suspicion to Law Enforcement and the State Survey Agency. If the crime involves serious bodily injury, it must be reported immediately, but no later than 2 hours after forming the suspicion or if the crime does not appear to cause serious bodily injury it must be reported within 24 hours of forming the suspicion. The policy did not indicate who staff should call in the event of an abuse or suspicion of abuse. Resident #1 was admitted to the facility with diagnoses including Diabetes, Congestive Heart Failure (a chronic condition in which the heart doesn't pump blood as well as it should), and Major Depressive disorder. It was documented that Resident #1 had blindness in their right eye. The Minimum Data Set assessment dated [DATE] documented that Resident #1 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) score of 10 associated with moderately impaired cognition. The Comprehensive Care Plan dated 02/20/24 documented that Resident #1 was at potential risk for abuse. The interventions documented that the Social Worker to provide supportive counseling, listen to resident and family concerns, explain facility goals, and measures to provide a safe environment. A Nursing Progress Note, by Nursing Supervisor #1, dated 02/29/24 at 6:30 pm documented that Resident #1 reported Certified Nursing Assistant #2 kicked Resident #1 in their scrotal area. A head-to-toe assessment was done immediately and revealed no visible injuries. Resident #1 denied pain and discomfort. Certified Nursing Assistant #2 was removed from the scene. The facility's Investigation Summary dated 02/29/24 documented that on 02/29/24 at around 3:30 pm, Nursing Supervisor #1 informed the Assistant Director of Nursing and Director of Nursing that on 02/28/24 at approximately 7:00 pm, Resident #1, who had moderately impaired cognition, reported that Certified Nursing Assistant #2 kicked Resident #1 in their scrotal area on 02/28/24. This occurred while Certified Nursing Assistant #1 was providing evening care to Resident #1. According to Certified Nursing Assistant #1, Certified Nursing Assistant #2 entered Resident #1's room on 02/28/24 at around 7:00 pm and Resident #1 and Certified Nursing Assistant #2 engaged in regular conversation that developed into a verbal argument. Certified Nursing Assistant #1 went on to say that they witnessed Certified Nursing Assistant #2 lift their left foot and kick Resident #1 in their private area causing Resident #1 to scream out. The facility concluded that there was evidence to support the allegation of abuse, and that mistreatment had occurred. A physician progress note dated 02/29/24 at 10:00 pm documented that a staff member (Certified Nursing Assistant #2) kicked Resident #1 on 02/28/24. It is documented that Resident #1 was assessed with no pain, no injuries, and mood and behavior were calm. Resident #1 refused to further discuss and claimed that they were okay. A Psychiatry evaluation and consultation note dated 03/01/24 documented that on 02/29/24 Resident #1 reported that Certified Nursing Assistant #2 kicked at them when Certified Nursing Assistant #2 came in their room to drop off their dinner. Resident #1 confirmed that they and Certified Nursing Assistant #2 had exchanged words and Certified Nursing Assistant #2 got upset and kicked at them while they were in bed. Resident #1 stated that they did not want to discuss the incident. Resident #1 reported that they were stable mentally. No traumatic feelings or ill will was expressed regarding the incident. Resident #1 did not appear to be in distress. Resident #1 presented with a euthymic (a feeling of being optimistic and in control, where a person is doing well, tranquil, and functioning) mood, showing no signs of depression or manic symptoms. Resident #1 appeared relaxed and attentive. During an interview on 03/12/24 at 10:45 am, Resident #1 stated that on 02/28/24 at approximately 7:00 pm while they were being provided with evening care by Certified Nursing Assistant #1, Certified Nursing Assistant #2 knocked and entered the room stating that they brought Resident #1's food. Resident #1 stated that they do not recall what preceded an argument between them and Certified Nursing Assistant #2, but that Resident #1 told Certified Nursing Assistant #2 that Certified Nursing Assistant #2 should drop dead. Resident #1 stated that they are blind in their right eye (normal vision in left eye) and did not see when Certified Nursing Assistant #2 kicked them, but that they felt a kick in their groin. Resident #1 stated that the kick was painful and that they screamed out in pain. Resident #1 stated that they were lying in bed on their left side facing the door when they were kicked in the groin. Resident #1 stated that they did not sustain any redness or swelling. During a telephone interview on 03/12/24 at 11:00 am, Certified Nursing Assistant #2 stated that on 02/28/24 at approximately 7:00 pm they entered Resident #1's room and dropped off their dinner. Certified Nursing Assistant #2 stated that Certified Nursing Assistant #1 was in Resident #1's room providing care to Resident #1. Certified Nursing Assistant #2 stated that they were engaged in an argument with Resident #1 and that Resident #1 told Certified Nursing Assistant #2 that they should drop dead. Certified Nursing Assistant #2 stated that they were in the process of leaving the room when Resident #1 started throwing multiple items at Certified Nursing Assistant #2. Certified Nursing Assistant #2 stated that Resident #1's bed was in a high position and Certified Nursing Assistant #2 kicked the mattress on the bed and left the room. Certified Nursing Assistant #2 stated that they did not kick Resident #1. During a telephone interview on 03/12/24 at 2:00 pm, Certified Nursing Assistant #1 stated that on 02/28/24 between 7:00 pm and 8:00 pm (not sure of the time) while giving care to Resident #1, Certified Nursing Assistant #2 entered Resident #1's room. Certified Nursing Assistant #1 stated that Certified Nursing Assistant #2 and Resident #1 engaged in regular conversation that developed into an argument. Certified Nursing Assistant #1 stated that Resident #1 told Certified Nursing Assistant #2 to drop dead and Certified Nursing Assistant #2 got upset and lifted their left foot and kicked Resident #1 in their private area. Certified Nursing Assistant #1 stated that Resident #1 screamed out in pain and said, what the hell. Certified Nursing Assistant #1 stated that they instructed Certified Nursing Assistant #2 to leave the room. Certified Nursing Assistant #1 stated that Certified Nursing Assistant #2 was wearing a Women's Crocs shoe and Resident #1 was wearing a night gown and was lying on their left side. Certified Nursing Assistant #1 stated that Resident #1 was upset and was in pain. Certified Nursing Assistant #1 stated that they handed Resident #1 the phone to call Nursing Supervisor #1 while Certified Nursing Assistant #1 instructed Certified Nursing Assistant #2 to leave the room. Certified Nursing Assistant #1 stated that Nursing Supervisor #1 came to the room immediately and Certified Nursing Assistant #1 informed Nursing Supervisor #1 that they witnessed Certified Nursing Assistant #2 kick Resident #1 in their groin and that Resident #1 screamed out in pain. During an interview on 03/12/24 at 12:21 pm, Nursing Supervisor #1 stated that on 02/28/24 at approximately 7:00 pm Resident #1 reported that Certified Nursing Assistant #2 kicked Resident #1 in the scrotum. Nursing Supervisor #1 also stated that Certified Nursing Assistant #1 informed them that they witnessed Certified Nursing Assistant #2 kicked Resident #1 in the groin and Resident #1 screamed out in pain. Nursing Supervisor #1 stated that they immediately conducted a head-to-toe assessment and there was no bruising, no redness, discoloration, or swelling on Resident #1's scrotum area or other body area. Nursing Supervisor #1 stated that during the assessment Resident #1 stated that they did not have any pain or discomfort. Nursing Supervisor #1 stated that they spoke with Certified Nursing Assistant #2 and Certified Nursing Assistant #2 stated that they raised their leg and kicked Resident #1's bed. Nursing Supervisor #1 stated that Certified Nursing Assistant #2 stated that they did not kick Resident #1. Nursing Supervisor #1 stated that Certified Nursing Assistant #2 was informed to leave the floor and do not return to Resident #1's unit. During an interview on 03/12/24 at 2:42 pm, the Administrator stated that they were informed of the incident on 02/29/24 at approximately 4:00 pm. The Administrator went on to say that Resident #1 was reassessed immediately on 02/29/24 and there were no visible injuries. The Administrator stated when they first spoke with Resident #1, Resident #1 was reluctant to talk, but stated that Certified Nursing Assistant #2 threw something at Resident #1. The Administrator stated Resident #1 stated that they are visually impaired and did not see what hit them. The Administrator stated they immediately called the Police Precinct for officers to come to the facility for report. The Administrator stated that the police arrived at 5:30 pm on 02/29/24 and interviewed Resident #1 who stated that they did not want to press any charges. During an interview on 03/12/24 at 5:00 pm, the Director of Nursing stated on 02/29/24 at approximately 4:00 pm they were informed about the incident by the Assistant Director of Nursing. The Director of Nursing stated they were informed that Resident #1 reported Certified Nursing Assistant #2 kicked Resident #1 in their scrotal area. The Director of Nursing stated there was an exchange of words between Resident #1 and Certified Nursing Assistant #2. The Director of Nursing stated Resident #1 reported Certified Nursing Assistant #2 got upset and kicked Resident #1 in the scrotal area. The Director of Nursing stated Nursing Supervisor #1 reported they were overwhelmed and had forgotten to immediately report the incident to the Assistant Director of Nursing. The Director of Nursing stated the investigation concluded that abuse had occurred. During an interview on 03/13/24 at 3:24 pm, the Medical Director stated they received a call (unable to recall the time) on 02/28/24 from Nursing Supervisor #2 who notified them of Resident #1's allegation of abuse. The Medical Director went on to say they assessed Resident #1 on 02/29/24 and there was no redness, discoloration, or injuries observed. The Medical Director stated Resident #1 did not exhibit any changes in mood or mental status. The Medical Director further stated Resident #1 did not want to give them any details of the abuse. Immediate Jeopardy was not identified. Facility Past Noncompliance was identified on 03/12/24. Based on the following corrective actions taken, there was sufficient evidence that the facility corrected the Past Noncompliance and was in substantial compliance for this specific regulatory requirement prior to surveyor's onsite visit on 03/12/24. The facility implemented the following corrective action prior to surveyor entrance on 03/12/24. The facility Assistant Director of Nursing investigated the allegation of abuse and the team concluded that abuse did occur. The facility developed an action plan which includes the following: On 02/28/24 and 02/29/24 Resident #1 was assessed with no visible signs of injuries and no complaints of pain. The police were called and responded to facility on 02/29/24. On 02/29/24 Resident #1's abuse care plan was updated. Additional interventions included monitoring for changes, 1:1 visit from Social Worker, and Psych/Psychotherapy consults were implemented. On 02/29/24 the Quality Assurance Committee held a meeting where the incident was discussed. Attendees included the Administrator, Director of Nursing, Assistant Director of Nursing, and other departmental heads. On 02/29/24, Policy/Procedure on Abuse, Neglect, Mistreatment, and Reporting was reviewed. No revisions were done to the policy. On 02/29/24, Certified Nursing Assistant #2 was suspended and subsequently terminated. On 02/29/24 Nursing Supervisor #1 and Nursing Supervisor #2 were both re-educated on abuse, reporting of abuse immediately to the Administrator, Director of Nursing, and Assistant Director of Nursing. The topic also covered removing staff from resident care pending investigation outcome. On 03/01/24 the facility's Social Worker interviewed multiple residents on Certified Nursing Assistant #2's assignment and there were no abuse, neglect, or mistreatment issues identified. On 03/01/24 the facility developed an audit tool to track if residents are being abused. No other residents were identified. The audit is ongoing monthly for four months. Any issues identified will be corrected. The facility started re-in-servicing staff on 02/29/24, ongoing. Lesson Plan: Prohibition of Resident Abuse that discussed the seven steps of abuse including prevention, protecting, and reporting. Facility has 116 staff of which 97 percent were in-serviced by the Assistant Director of Nursing (also in-service coordinator). o 41 out of 43 CNAs in-serviced o 17 out of 18 LPNs in-serviced o 7 out of 8 RNS in-serviced o 3 out of 3 Recreation staff in-serviced o 18 out of 19 housekeeping and maintenance staff in-serviced o 13 out of 15 dietary staff in-serviced o 13 out of 13 department head in-serviced o 7 out of 8 Physical Therapist/Occupational Therapist in-serviced. The Assistant Director of Nursing will contact the remaining 3 percent of staff for in-servicing prior to their return to work. The facility was back in compliance on 03/01/24. 10 NYCRR 415.4(b)(1)(i)

Based on observation, record review, and interviews during an abbreviated survey (NY00334677), the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, was 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 serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This was evident in 1 out of 3 residents sampled for abuse (Resident #1). Specifically, Resident #1 and Certified Nursing Assistant #1 reported to Nursing Supervisor #1 on 02/28/24 at approximately 7:00 pm that Certified Nursing Assistant #2 kicked Resident #1 in the scrotal area. The allegation of abuse was not reported to New York State Department of Health within 2 hours after the report was made. The Department of Health was notified on 02/29/24 at 5:00 pm. Additionally, local law enforcement was not notified within 2 hours, local law enforcement was notified on 02/29/24 at 4:00 pm. The findings are: The facility's Abuse Prevention Policy and Procedure dated 01/15/24, states that the facility will report any incident or violation where abuse, neglect, or mistreatment is suspected to the New York State Department of Health according to protocol. Federal Law (1150B of the Social Security Act) requires that any individual employee having reasonable suspicion that a crime has occurred against a resident is required to report the suspicion to Law Enforcement and the State Survey Agency. If the crime involves serious bodily injury, it must be reported immediately, but no later than 2 hours after forming the suspicion or if the crime does not appear to cause serious bodily injury it must be reported within 24 hours of forming the suspicion. The policy did not indicate who staff should call in the event of an abuse or suspicion of abuse. Resident #1 was admitted to the facility with diagnoses including Diabetes, Congestive Heart Failure (a chronic condition in which the heart doesn't pump blood as well as it should), and Major Depressive disorder. It was documented that Resident #1 had blindness in their right eye. The Minimum Data Set assessment dated [DATE] documented that Resident #1 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) score of 10 associated with moderately impaired cognition. The facility's Investigation Summary dated 02/29/24 documented that on 02/29/24 at around 3:30 pm, Nursing Supervisor #1 informed the Assistant Director of Nursing and Director of Nursing that on 02/28/24 at approximately 7:00 pm, Resident #1, who had moderately impaired cognition, reported that Certified Nursing Assistant #2 kicked Resident #1 in their scrotal area on 02/28/24. This occurred while Certified Nursing Assistant #1 was providing evening care to Resident #1. According to Certified Nursing Assistant #1, Certified Nursing Assistant #2 entered Resident #1's room on 02/28/24 at around 7:00 pm and Resident #1 and Certified Nursing Assistant #2 engaged in regular conversation that developed into a verbal argument. Certified Nursing Assistant #1 went on to say that they witnessed Certified Nursing Assistant #2 lift their left foot and kick Resident #1 in their private area causing Resident #1 to scream out. The facility concluded that there was evidence to support the allegation of abuse had occurred. A nursing progress note, by Nursing Supervisor #2, dated 02/28/24 at 6:33 pm documented Resident #1 was alert and conversant. Resident #1 reported that they had a disagreement with Certified Nursing Assistant #2. Resident #1 denied being hit by Certified Nursing Assistant #2. Resident #1 was calm and collective. No signs of injury and no obvious distress. Resident #1 denies pain. Resident #1 stated that they do not want to report nor file a complaint against Certified Nursing Assistant #2. A Nursing Progress Note, by Nursing Supervisor #1, dated 02/29/24 at 6:30 pm documented that Resident #1 reported Certified Nursing Assistant #2 kicked Resident #1 in their scrotal area. A head-to-toe assessment was done immediately and revealed no visible injuries. Resident #1 denied pain and discomfort. Certified Nursing Assistant #2 was removed from the scene. A Webform submission from the Nursing Home Facility Incident Report dated 02/29/24, revealed that the facility notified New York State Department of Health at 5:00 pm on 02/29/24. During an interview on 03/12/24 at 10:45 am, Resident #1 stated that on 02/28/24 at approximately 7:00 pm while they were being provided with evening care by Certified Nursing Assistant #1, Certified Nursing Assistant #2 knocked and entered the room stating that they brought Resident #1's food. Resident #1 stated that they do not recall what preceded an argument between them and Certified Nursing Assistant #2, but that Resident #1 told Certified Nursing Assistant #2 that Certified Nursing Assistant #2 should drop dead. Resident #1 stated that they are blind in their right eye (normal vision in left eye) and did not see when Certified Nursing Assistant #2 kicked them, but that they felt a kick in their groin. Resident #1 stated that the kick was painful and that they screamed out in pain. Resident #1 stated that they were lying in bed on their left side facing the door when they were kicked in the groin. Resident #1 stated that they did not sustain any redness or swelling. During a telephone interview on 03/12/24 at 11:00 am, Certified Nursing Assistant #2 stated that on 02/28/24 at approximately 7:00 pm they entered Resident #1's room and dropped off their dinner. Certified Nursing Assistant #2 stated that Certified Nursing Assistant #1 was in Resident #1's room providing care to Resident #1. Certified Nursing Assistant #2 stated that they were engaged in an argument with Resident #1 and that Resident #1 told Certified Nursing Assistant #2 that they should drop dead. Certified Nursing Assistant #2 stated that they were in the process of leaving the room when Resident #1 started throwing multiple items at Certified Nursing Assistant #2. Certified Nursing Assistant #2 stated that Resident #1's bed was in a high position and Certified Nursing Assistant #2 kicked the mattress on the bed and left the room. Certified Nursing Assistant #2 stated that they did not kick Resident #1. During a telephone interview on 03/12/24 at 2:00 pm, Certified Nursing Assistant #1 stated that on 02/28/24 between 7:00 pm and 8:00 pm (not sure of the time) while giving care to Resident #1, Certified Nursing Assistant #2 entered Resident #1's room. Certified Nursing Assistant #1 stated that Certified Nursing Assistant #2 and Resident #1 engaged in regular conversation that developed into an argument. Certified Nursing Assistant #1 stated that Resident #1 told Certified Nursing Assistant #2 to drop dead and Certified Nursing Assistant #2 got upset and lifted their left foot and kicked Resident #1 in their private area. Certified Nursing Assistant #1 stated that Resident #1 screamed out in pain and said, what the hell. Certified Nursing Assistant #1 stated that they instructed Certified Nursing Assistant #2 to leave the room. Certified Nursing Assistant #1 stated that Certified Nursing Assistant #2 was wearing a Women's Crocs shoe and Resident #1 was wearing a night gown and was lying on their left side. Certified Nursing Assistant #1 stated that Resident #1 was upset and was in pain. Certified Nursing Assistant #1 stated that they handed Resident #1 the phone to call Nursing Supervisor #1 while Certified Nursing Assistant #1 instructed Certified Nursing Assistant #2 to leave the room. Certified Nursing Assistant #1 stated that Nursing Supervisor #1 came to the room immediately and Certified Nursing Assistant #1 informed Nursing Supervisor #1 that they witnessed Certified Nursing Assistant #2 kick Resident #1 in their groin and that Resident #1 screamed out in pain. During an interview on 03/12/24 at 12:21 pm, Nursing Supervisor #1 stated that on 02/28/24 at approximately 7:00 pm Resident #1 reported that Certified Nursing Assistant #2 kicked Resident #1 in the scrotum. Nursing Supervisor #1 also stated that Certified Nursing Assistant #1 informed them that they witnessed Certified Nursing Assistant #2 kicked Resident #1 in the groin and Resident #1 screamed out in pain. Nursing Supervisor #1 stated that they immediately conducted a head-to-toe assessment and there was no bruising, no redness, discoloration, or swelling on Resident #1's scrotum area or other body area. Nursing Supervisor #1 stated that during the assessment Resident #1 stated that they did not have any pain or discomfort. Nursing Supervisor #1 stated that they spoke with Certified Nursing Assistant #2 and Certified Nursing Assistant #2 stated that they raised their leg and kicked Resident #1's bed. Nursing Supervisor #1 stated that Certified Nursing Assistant #2 stated that they did not kick Resident #1. Nursing Supervisor #1 stated that Certified Nursing Assistant #2 was informed to leave the floor and do not return to Resident #1's unit. Nursing Supervisor #1 stated that Certified Nursing Assistant #2 went back to the 3rd floor and completed their assigned resident tasks and went home at the end of their shift (3:00 pm - 11:00 pm). Nursing Supervisor #1 stated that they were aware that the police should have been called immediately and that the Director of Nursing should have been immediately notified. Nursing Supervisor #1 stated that they reported the incident to incoming evening shift Nursing Supervisor #2. Nursing Supervisor #1 stated that they thought removing Certified Nursing Assistant #2 from Resident #1's unit would be okay. During a telephone interview on 03/12/24 at 04:32 pm, Nursing Supervisor #2 stated they worked on the 3:00 pm -11:00 pm shift on 02/28/24. Nursing Supervisor #2 stated they were informed by Nursing Supervisor #1 (7:00 am - 3:00 pm off-going supervisor) that Resident #1 reported they were kicked by Certified Nursing Assistant #2 in their scrotal area. Nursing Supervisor #2 stated they did not report the allegation of abuse to the Director of Nursing or the police because Nursing Supervisor #1 said that they would take care of it the following day. During an interview on 03/12/2024 at 2:42pm, the Administrator stated they were informed of the incident on 02/29/24 at approximately 4:00pm. The Administrator went on to say Resident #1 was reassessed immediately on 02/29/24 and there were no visible injuries. The Administrator stated that when they first spoke with Resident #1, Resident #1 was reluctant to talk, but stated that Certified Nursing Assistant #2 threw something at Resident #1. The Administrator stated that Resident #1 reported that they are visually impaired and did not see what hit them. The Administrator stated they immediately called the Police Precinct and the Police arrived at the facility at 5:30 pm on 02/29/24. The Administrator stated tht the police interviewed Resident #1 who stated that they did not want to press charges. The Administrator stated that Nursing Supervisor #1 did not follow protocol and report the incident to the Director of Nursing or the Assistant Director of Nursing and call the police. During an interview on 03/12/24 at 5:00 pm, the Director of Nursing stated on 02/29/24 at approximately 4:00 pm they were informed about the incident by the Assistant Director of Nursing. The Director of Nursing stated they were informed that Resident #1 reported Certified Nursing Assistant #2 kicked Resident #1 in their scrotal area. The Director of Nursing stated there was an exchange of words between Resident #1 and Certified Nursing Assistant #2. The Director of Nursing stated Resident #1 reported Certified Nursing Assistant #2 got upset and kicked Resident #1 in the scrotal area. The Director of Nursing stated Nursing Supervisor #1 reported they were overwhelmed and had forgotten to immediately report the incident to the Assistant Director of Nursing. The Director of Nursing stated the investigation concluded that abuse had occurred. The Director of Nursing stated that Nursing Supervisor #1 should have immediately reported the allegation to the Director of Nursing, or Assistant Director of Nursing, and report to law enforcement. The Director of Nursing stated that the investigation concluded that abuse had occurred. During a telephone interview on 03/13/24 at 3:24 pm, the Medical Director stated that they received a call (unable to recall the time) on 02/28/24 from Nursing Supervisor #2 who notified them of Resident #1's allegation of abuse. The Medical Director went on to say they assessed Resident #1 on 02/29/24 and there was no redness, discoloration, or injuries observed. The Medical Director stated Resident #1 did not exhibit any changes in mood or mental status. The Medical Director further stated Resident #1 did not want to give them any details of the abuse. The Medical Director stated that they thought that Nursing Supervisor #2 followed the facility's abuse protocol and that they did not offer any instructions to Nursing Supervisor #2. Facility Past Non-compliance was identified on 03/12/24. Based on the following corrective actions taken, there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement prior to surveyor's onsite visit on 03/12/2024. The facility implemented the following corrective action prior to surveyor entrance on 03/12/24. The facility Assistant Director of Nursing investigated the allegation of abuse and the team concluded that abuse did occur. The facility developed an action plan which includes the following: On 02/28/24 and 02/29/24 Resident #1 was assessed with no visible signs of injury and no complaints of pain. The police were called and responded to facility on 02/29/24. On 02/29/24 Resident #1's abuse care plan was updated. Additional interventions including monitoring for changes, 1:1 visit from Social Worker, and Psych/Psychotherapy consults were implemented. On 02/29/24 the Quality Assurance Committee held a meeting where the incident was discussed. Attendees included the Administrator, Director of Nursing, Assistant Director of Nursing, and other departmental heads. On 02/29/24, Policy/Procedure on Abuse, Neglect, Mistreatment, and Reporting was reviewed. No revisions were done to the policy. On 02/29/24, Certified Nursing Assistant #2 was suspended and subsequently terminated. On 02/29/24 Nursing Supervisor #1 and Nursing Supervisor #2 were both re-educated on abuse, reporting of abuse immediately to the Administrator, Director of Nursing, and Assistant Director of Nursing. The topic also covered removing staff from resident care pending investigation outcome. On 03/01/24 the facility's Social Worker interviewed multiple residents on Certified Nursing Assistant #2's assignment and there were no abuse, neglect, or mistreatment issues identified. On 03/01/24 the facility developed an audit tool to track if residents are being abused. No other residents were identified. The audit is ongoing monthly for four months. Any issues identified will be corrected. The facility started re-in-servicing staff on 02/29/24, ongoing. Lesson Plan: Prohibition of Resident Abuse that discussed the seven steps of abuse including prevention, protecting, and reporting. Facility has 116 staff of which 97 percent were in-serviced by the Assistant Director of Nursing (also in-service coordinator). o 41 out of 43 CNAs in-serviced o 17 out of 18 LPNs in-serviced o 7 out of 8 RNS in-serviced o 3 out of 3 Recreation staff in-serviced o 18 out of 19 housekeeping and maintenance staff in-serviced o 13 out of 15 dietary staff in-serviced o 13 out of 13 department head in-serviced o 7 out of 8 Physical Therapist/Occupational Therapist in-serviced. The Assistant Director of Nursing will contact the remaining 3 percent of staff for in-servicing prior to their return to work. The Facility was back in compliance on 03/01/24. 10 NYCRR 415.4(b)

Based on observation, record review and interviews during an abbreviated survey (NY00334677), the facility failed to protect residents from potential abuse while an investigation was in progress. This was evident in 1 out of 3 residents sampled for abuse (Resident #1). Specifically, Resident #1 and Certified Nursing Assistant #1 reported to Nursing Supervisor #1 on 02/28/24 at approximately 7:00 pm, that Certified Nursing Assistant #2 kicked Resident #1 in their scrotal area. Nursing Supervisor #1 instructed Certified Nursing Assistant #2 to leave Resident #1's unit and to return to their unit on the 3rd floor. Certified Nursing Assistant #2 was allowed to complete their resident care assignment until their shift ended at 11:00 pm on 08/28/24. Certified Nursing Assistant #2 was removed from the schedule on 02/29/24. This occurred when the Director of Nursing and Assistant Director of Nursing became aware of the allegation of abuse on 02/29/24. The findings are: The facility's Abuse Prevention Policy and Procedure dated 01/15/24 documented that the facility will investigate all incidents, grievances, and complaints. The facility will protect all residents during an investigation by reassigning staff. In the event of suspicion of abuse, the staff will be suspended or reassigned until the investigation is completed. Resident #1 was admitted to the facility with diagnoses including Diabetes, Congestive Heart Failure (a chronic condition in which the heart doesn't pump blood as well as it should), and Major Depressive disorder. It was documented that Resident #1 had blindness in their right eye. The Minimum Data Set assessment dated [DATE] documented that Resident #1 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) score of 10 associated with moderately impaired cognition. The facility's Investigation Summary dated 02/29/24 documented that on 02/29/24 at around 3:30 pm, Nursing Supervisor #1 informed the Assistant Director of Nursing and Director of Nursing that on 02/28/24 at approximately 7:00 pm, Resident #1, who had moderately impaired cognition, reported that Certified Nursing Assistant #2 kicked Resident #1 in their scrotal area on 02/28/24. This occurred while Certified Nursing Assistant #1 was providing evening care to Resident #1. According to Certified Nursing Assistant #1, Certified Nursing Assistant #2 entered Resident #1's room on 02/28/24 at around 7:00 pm and Resident #1 and Certified Nursing Assistant #2 engaged in regular conversation that developed into a verbal argument. Certified Nursing Assistant #1 went on to say that they witnessed Certified Nursing Assistant #2 lift their left foot and kick Resident #1 in their private area causing Resident #1 to scream out. The facility concluded that there was evidence to support the allegation of abuse had occurred. A nursing note, by Nursing Supervisor #1, dated 02/29/24 at 06:30 pm documented that Resident #1 reported that Certified Nursing Assistant #2 kicked Resident #1 in their scrotal area. During an interview on 03/12/24 at 10:45 am, Resident #1 stated that on 02/28/24 at approximately 7:00 pm while they were being provided with evening care by Certified Nursing Assistant #1, Certified Nursing Assistant #2 knocked and entered the room stating that they brought Resident #1's food. Resident #1 stated that they do not recall what preceded an argument between them and Certified Nursing Assistant #2, but that Resident #1 told Certified Nursing Assistant #2 that Certified Nursing Assistant #2 should drop dead. Resident #1 stated that they are blind in their right eye (normal vision in left eye) and did not see when Certified Nursing Assistant #2 kicked them, but that they felt a kick in their groin. Resident #1 stated that the kick was painful and that they screamed out in pain. Resident #1 stated that they were lying in bed on their left side facing the door when they were kicked in the groin. Resident #1 stated that they did not sustain any redness or swelling. During a telephone interview on 03/12/24 at 11:00 am, Certified Nursing Assistant #2 stated that on 02/28/24 at approximately 7:00 pm they entered Resident #1's room and dropped off their dinner. Certified Nursing Assistant #2 stated that Certified Nursing Assistant #1 was in Resident #1's room providing care to Resident #1. Certified Nursing Assistant #2 stated that they were engaged in an argument with Resident #1 and that Resident #1 told Certified Nursing Assistant #2 that they should drop dead. Certified Nursing Assistant #2 stated that they were in the process of leaving the room when Resident #1 started throwing multiple items at Certified Nursing Assistant #2. Certified Nursing Assistant #2 stated that Resident #1's bed was in a high position and Certified Nursing Assistant #2 kicked the mattress on the bed and left the room. Certified Nursing Assistant #2 stated that they did not kick Resident #1. During a telephone interview on 03/12/24 at 2:00 pm, Certified Nursing Assistant #1 stated that on 02/28/24 between 7:00 pm and 8:00 pm (not sure of the time) while giving care to Resident #1, Certified Nursing Assistant #2 entered Resident #1's room. Certified Nursing Assistant #1 stated that Certified Nursing Assistant #2 and Resident #1 engaged in regular conversation that developed into an argument. Certified Nursing Assistant #1 stated that Resident #1 told Certified Nursing Assistant #2 to drop dead and Certified Nursing Assistant #2 got upset and lifted their left foot and kicked Resident #1 in their private area. Certified Nursing Assistant #1 stated that Resident #1 screamed out in pain and said, what the hell. Certified Nursing Assistant #1 stated that they instructed Certified Nursing Assistant #2 to leave the room. Certified Nursing Assistant #1 stated that Certified Nursing Assistant #2 was wearing a Women's Crocs shoe and Resident #1 was wearing a night gown and was lying on their left side. Certified Nursing Assistant #1 stated that Resident #1 was upset and was in pain. Certified Nursing Assistant #1 stated that they handed Resident #1 the phone to call Nursing Supervisor #1 while Certified Nursing Assistant #1 instructed Certified Nursing Assistant #2 to leave the room. Certified Nursing Assistant #1 stated that Nursing Supervisor #1 came to the room immediately and Certified Nursing Assistant #1 informed Nursing Supervisor #1 that they witnessed Certified Nursing Assistant #2 kick Resident #1 in their groin and that Resident #1 screamed out in pain. During an interview on 03/12/24 at 12:21 pm, Nursing Supervisor #1 stated that on 02/28/24 at approximately 7:00 pm Resident #1 reported that Certified Nursing Assistant #2 kicked Resident #1 in the scrotum. Nursing Supervisor #1 also stated that Certified Nursing Assistant #1 informed them that they witnessed Certified Nursing Assistant #2 kicked Resident #1 in the groin and Resident #1 screamed out in pain. Nursing Supervisor #1 stated that they immediately conducted a head-to-toe assessment and there was no bruising, no redness, discoloration, or swelling on Resident #1's scrotum area or other body area. Nursing Supervisor #1 stated that during the assessment Resident #1 stated that they did not have any pain or discomfort. Nursing Supervisor #1 stated that they spoke with Certified Nursing Assistant #2 and Certified Nursing Assistant #2 stated that they raised their leg and kicked Resident #1's bed. Nursing Supervisor #1 stated that Certified Nursing Assistant #2 stated that they did not kick Resident #1. Nursing Supervisor #1 stated that Certified Nursing Assistant #2 was informed to leave the floor and do not return to Resident #1's unit. Nursing Supervisor #1 stated that they thought removing Certified Nursing Assistant #2 from Resident #1's unit would be okay. During a telephone interview on 03/12/24 at 04:32 pm, Nursing Supervisor #2 stated that they worked on the 03:00 pm -11:00 pm shift on 02/28/24. Nursing Supervisor #2 stated that they were informed by Nursing Supervisor #1 (07:00 am - 03:00 pm off-going supervisor) that Resident #1 reported that they were kicked by Certified Nursing Assistant #2 in their scrotal area. Nursing Supervisor #2 stated they did not remove Certified Nursing Assistant #2 from resident care because Certified Nursing Assistant #2 was already removed from Resident #1's unit. During an interview on 03/13/24 at 03:24 pm the Medical Director stated that they received a call (unable to recall the time) on 02/28/24 from Nursing Supervisor #2 who notified them of Resident #1 allegation of abuse. The Medical Director stated that they thought Nursing Supervisor #2 followed the facility's abuse protocol and that they did not offer any instructions to Nursing Supervisor #2. Facility Past Non-compliance was identified on 03/12/24. Based on the following corrective actions taken, there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement prior to surveyor's onsite visit on 03/12/2024. The facility implemented the following corrective action prior to surveyor entrance on 03/12/24. The facility Assistant Director of Nursing investigated the allegation of abuse and the team concluded that abuse did occur. The facility developed an action plan which includes the following: On 02/28/24 and 02/29/24 Resident #1 was assessed with no visible signs of injury and no complaints of pain. The police were called and responded to facility on 02/29/24. On 02/29/24 Resident #1's abuse care plan was updated. Additional interventions including monitoring for changes, 1:1 visit from Social Worker, and Psych/Psychotherapy consults were implemented. On 02/29/24 the Quality Assurance Committee held a meeting where the incident was discussed. Attendees included the Administrator, Director of Nursing, Assistant Director of Nursing, and other departmental heads. On 02/29/24, Policy/Procedure on Abuse, Neglect, Mistreatment, and Reporting was reviewed. No revisions were done to the policy. On 02/29/24, Certified Nursing Assistant #2 was suspended and subsequently terminated. On 02/29/24 Nursing Supervisor #1 and Nursing Supervisor #2 were both re-educated on abuse, reporting of abuse immediately to the Administrator, Director of Nursing, and Assistant Director of Nursing. The topic also covered removing staff from resident care pending investigation outcome. On 03/01/24 the facility's Social Worker interviewed multiple residents on Certified Nursing Assistant #2's assignment and there were no abuse, neglect, or mistreatment issues identified. On 03/01/24 the facility developed an audit tool to track if residents are being abused. No other residents were identified. The audit is ongoing monthly for four months. Any issues identified will be corrected. The facility started re-in-servicing staff on 02/29/24, ongoing. Lesson Plan: Prohibition of Resident Abuse that discussed the seven steps of abuse including prevention, protecting, and reporting. Facility has 116 staff of which 97 percentage were in-serviced by the Assistant Director of Nursing (also in-service coordinator). o 41 out of 43 CNAs in-serviced o 17 out of 18 LPNs in-serviced o 7 out of 8 RNS in-serviced o 3 out of 3 Recreation staff in-serviced o 18 out of 19 housekeeping and maintenance staff in-serviced o 13 out of 15 dietary staff in-serviced o 13 out of 13 department head in-serviced o 7 out of 8 Physical Therapist/Occupational Therapist in-serviced. The Assistant Director of Nursing will contact the remaining 3 percent of staff for in-servicing prior to their return to work. The facility was back in compliance on 03/01/24. 10 NYCRR 415.4(b)

Based on interviews and record review conducted during the Recertification survey from 01/28/2024 to 02/02/2024, the facility did not ensure the resident's right to participate in the development and implementation of their person-centered plan of care. This was evident for 2 (Resident #83 and #4) of 26 total sampled residents. Specifically, 1) Resident #83 and their representative were not invited to their care plan meeting, and 2) Resident #4 was not invited to their care plan meeting. The findings are: The facility policy titled Comprehensive Care Plan dated 02/2023 documented the plan of care will be reviewed and revised quarterly, annually, with significant change of status and as needed to enhance the resident's ability to meet resident objectives. 1. Resident #83 had diagnoses of hypertension and obstructive uropathy. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #83 was moderately cognitively impaired, and the resident and family participated in the assessment. Social Service Note dated 3/2/2023 documented a care plan meeting consisting of the interdisciplinary team was held for Resident #83. There was no documented evidence Resident #83, or their representative were invited to the care plan meeting held on 3/2/2023. 44843 2. Resident #4 had diagnoses of major depression and atrial fibrillation. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #4 was cognitively intact and participated in the assessment. On 01/28/2024 at 09:34 AM, Resident #4 was interviewed and stated they made decisions themselves and did not recall being invited to any care plan meeting since their admission to the facility on [DATE]. The Care Plan Meeting Schedule documented Resident #4 was scheduled for care plan meetings on 4/6/2023, 10/5/2023, and 1/4/2024. There was no documented evidence Resident #4 was invited to attend their care plan meetings scheduled 4/6/2023, 10/5/2023, and 1/4/2024. On 01/31/2024 at 11:27 AM, the Acting Director of Social Services was interviewed and stated residents and their representatives were invited to admission, annual, and significant change care plan meetings. The interdisciplinary team met to discuss the resident's plan of care during the quarterly care plan meetings. The residents and their representatives were not invited to the quarterly care plan meetings. On 02/01/2024 at 10:31 AM, the Administrator was interviewed and stated the Social Work Department was responsible for inviting the residents and their representative to all care plan meetings, including quarterly meetings. 10 NYCRR 415.11(c)(2)(i-iii)

Based on interviews and record review conducted during the recertification survey from 1/28/2024 to 2/2/2024, the facility did not ensure a resident, or their designated representative was provided with a Notice of Medicare Non-Coverage and Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage at the termination of Medicare Part A benefits. This was evident for 1 (Residents #62) of 3 residents reviewed for Beneficiary Notification out of 26 total sampled residents. Specifically, Resident #62 and their designated representative were not provided with a Notice of Medicare Non-Coverage and Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage once Resident #62 was terminated from skilled services and remained in the facility. The findings are: The facility policy titled Notice of Medicare Non-Coverage and Advance Beneficiary Notice of Non-coverage Benefits Exhaust Letter dated 1/2024 documented it is the policy of the facility to give a completed copy of notices to beneficiaries receiving skilled services and have benefits days remaining but are being discharged from Part A services. The Advance Beneficiary Notice of Non-coverage is given to beneficiaries ending skilled care with Part A benefit days remaining and the resident will remain in the facility. Resident #62 had diagnoses of adjustment disorder and unspecified pain. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #62 was severely cognitively impaired. The undated Notice of Medicare Non-Coverage documented Medicare skilled services for Resident #62 would end on 10/3/2023. The form did not document a signature from the resident or the resident representative. The undated Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage documented, beginning 10/4/2023, Medicare would not pay for Resident #62 because skilled services would be ending on 10/3/2023. The form did not document a signature from the resident or their representative. There was no documented evidence the Notice of Medicare Non-Coverage or the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage were provided to Resident #62 or their representative in writing. On 01/31/2024 at 03:00 PM, the Minimum Data Set Coordinator was interviewed and stated they notified residents or their designated representatives a few days before their discharge from Medicare Part A service. Resident #62 was cognitively impaired, and their representative was called and informed Resident #62 would be discharged from Medicare Part A services. The Minimum Data Set Coordinator was not aware they had to provide the resident and/or their representative a copy of the Notice of Medicare Non-Coverage and Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage when a resident was discharged from Medicare Part A and remained in the facility. On 01/31/2024 at 03:27 PM, the Administrator was interviewed and stated the Minimum Data Set Coordinator was responsible for providing forms to residents and designated representatives to review and sign before discharging them from Medicare Part A. The Administrator also stated they should mail, email, or use other methods the representative can receive the forms and keep proof of it. 10 NYCRR 415.3(g)(2)(i)

Based on observation, interviews, and record review conducted during the Recertification Survey from 1/28/2024 to 2/2/2024, the facility did not ensure a comprehensive person-centered care plan was reviewed and revised to address a resident's needs. This was evident for 2 (Resident #4 and Resident #98) of 26 total sampled residents. Specifically, 1) Resident #4's comprehensive care plans were not reviewed and revised to reflect Resident #4's diagnosis management and medication administration, and 2) Resident #98's comprehensive care plan was not reviewed and revised to reflect their risk for elopement. The findings are: The facility policy titled Comprehensive Care Plans dated 2/2023 documented the plan of care will be reviewed and revised quarterly, annually, with significant change of status and as needed to enhance the resident's ability to meet their objectives. 1) Resident #4 had diagnoses of right humerus fracture and atrial fibrillation. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #4 was cognitively intact, had diagnoses of diabetes mellitus, depression, and unspecified atrial fibrillation, and received insulin, antidepressant, anticoagulant, and opioid medications. Physician's Orders documented Resident #4 was ordered Percocet 5-325mg every 6 hours as needed for pain on 11/26/2023, Novolin Flexpen 15 units subcutaneously two times a day for diabetes mellitus on 1/17/2023, and Eliquis 5mg twice daily for deep vein thrombosis on 1/17/2023. The comprehensive care plans related to Resident #4's pain and diabetes mellitus were created 3/31/2023 and last reviewed on 10/5/2023. The comprehensive care plans related to Resident #4's pain medication use, antidepressant use, and anticoagulant use were initiated 6/29/2023 and last reviewed on 10/5/2023. There was no documented evidence Resident #4's comprehensive care plans related to pain, diabetes mellitus, pain medication use, antidepressant use, and anticoagulant use were reviewed and revised upon Minimum Data Set 3.0 assessment dated [DATE]. 2) Resident #98 had diagnoses of anxiety disorder and wandering. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #98 was moderately cognitively impaired and wander/elopement alarm was used daily. On 01/28/2024 at 11:53 AM, Resident #98 was observed with a wander alert device to their left wrist. Physician's Order dated 9/19/2023 documented Resident #98 had a wander alert device placed on their left wrist. The comprehensive care plan related to Resident #98's elopement potential initiated 7/21/2023 was last reviewed 9/21/2023. There was no documented evidence the comprehensive care plan related to Resident #98's elopement potential was reviewed and revised upon Minimum Data Set 3.0 assessment dated [DATE]. On 02/01/2024 at 11:35 AM, Registered Nurse #1 was interviewed and stated they were responsible for reviewing and updating care plans quarterly upon Minimum Data Set 3.0 assessment based on a list of residents that were due. Registered Nurse #1 stated they made a mistake when they reviewed and updated some on the care plans for Resident #4 and Resident #98 but not all of them. On 02/01/2024 at 11:58 AM, the Director of Nursing was interviewed and stated they monitored whether the Registered Nurses completed their assignments by looking in the electronic medical record at the care plan updates. The Director of Nursing was not able to explain why the care plans for Resident #4 and Resident #98 were not updated in a timely manner. 10 NYCRR 415.11(c)(2)(i-iii)

Based on observation, record review, and interviews conducted during the recertification survey from 1/28/2024 to 2/2/2024, the facility did not ensure an ongoing activities program was provided to meet the interests of and support the physical, mental, and psychosocial well-being of the resident. This was evident for 1 (Residents #57) of 26 sampled total residents. Specifically, Resident #57 was not provided an activity program according to their interests and experienced cancellation of activities with no alternative and without resident notification. The findings are: The undated facility policy titled Therapeutic Recreation documented that the facility Recreation Therapist/Aide will provide each resident with daily choices, options, and program alternatives to spend their time and will maintains an attendance log for each activity to assess participation and socialization to ensure meaningful activities are being offered. Resident #57 had diagnoses of coronary artery disease and anemia. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #57 was cognitively intact. On 1/29/2024 at 9:44 AM, Resident #57 was interviewed and stated the facility did not involve them in daily activities and weekend activities were often cancelled when a staff member was not available to run the activity program. Residents were not informed, and the activity calendar was not changed to reflect frequent cancellations. Resident #57 stated they discovered scheduled activities were cancelled when they traveled to the Recreation Room and found the door locked and no activity program being conducted. On 1/30/2024 at 9:46 AM, the activity calendar for Resident #57's unit was observed posted and 1 to 1 visits with residents were scheduled at 9:30 AM for 1/30/2024. Observations were made of each room on the unit and Recreation staff were not present on the unit. There were no 1 to 1 visits observed taking place in any resident room on the unit. The Comprehensive Care Plan related to activities initiated 8/8/2023 and last reviewed 1/13/2024 documented Resident #57 was provided with a program of activities that was of interest and empowering. Resident #57 was provided an activity calendar and was notified of any changes to the activities on the calendar. The Activity Participation Sheet for January 2024 documented Resident #57 was not provided with and did not participate in any activities for 10 out of 31 days. There was no documented evidence Resident #57 was provided with an activity program that supported their physical, mental, and psychosocial wellbeing. On 2/1/2024 at 12:15PM, jewelry-making was announced as the activity being offered currently in the Recreation Room on the main floor. Resident #57 and their unit were served lunch and were in the process of eating during the announcement. Activity Aide #1 was interviewed and stated the jewelry-making activity was on the calendar and scheduled for 2PM, but Activity Aide #1 changed the time to 12:15 PM because they wanted to take their break and did not want to run the program at 2PM. On 02/01/2024 at 10:27 AM, the Director of Recreation was interviewed and stated the Recreation Department was unable to cover staff callouts and shortages, especially on the weekends. There was no system in place to notify residents when a scheduled activity was changed or cancelled. Residents showed up to the Recreation Room for scheduled activities and knew an activity was cancelled when they saw the door was locked. The Director of Recreation did not schedule substitute activities if one was cancelled. The Recreation Department had 1 staff member working this week and was unable to provide 1 to 1 visits with residents in their rooms on the units as scheduled on the activity calendar. The Director of Recreation stated they did not arrive to work until 11AM on Sunday, 1/28/2024 and the scheduled 9AM coffee social for residents did not take place. The Director of Recreation stated they did not have a system in place to determine which activities were offered to residents and they devised an activity program based on what was already available in the Recreation Room. The Director of Recreation was unable to provide a policy and procedure related to activities. 10NYCRR 415.5(f)(1)

Based on observation, record review, and interviews conducted during the Recertification and Complaint survey (NY00297169) from 1/18/2024 to 2/2/2024, the facility did not ensure a resident received timely radiologic or other diagnostic services. This was evident for 1 (Resident #57) of 26 total sampled residents. Specifically, gynecology and vascular consults were not ordered and completed timely Resident #57 had delay in receiving medical management at consultation services. The findings are: The facility policy titled Consultations dated 2/5/2023 documented Licensed Practical Nurses will follow up all consultation orders as ordered and written by the physician for all resident's consultations. This includes any request for medical or clinical office visits. If there is a delay of more than 30 days before the consultant could examine the resident, the Registered Nurse Supervisor and the Medical Director will be notified. Resident #57 had diagnoses of deep vein thrombosis and coronary artery disease. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #57 was cognitively intact. On 01/30/2024 at 09:06 AM, Resident #57 was interviewed and stated they had unexplained vaginal bleeding and required consultation with gynecology. Nursing staff informed Resident #57 they were scheduled for an appointment with the gynecologist but Resident #57 never had a consultation and Resident #57 was hospitalized as a result. Resident #57 stated the Vascular Doctor evaluated them in 6/2023 and informed the resident they would return to the facility in a few weeks for a follow-up consultation. The Vascular Doctor did not return to follow-up with the resident and Resident #57 stated facility staff informed them in 8/2023 they were going to be scheduled to visit an outpatient vascular clinic. Resident #57 was informed they had an appointment in 12/2023 but it was cancelled, rescheduled for 1/14/2024, and then cancelled again. Resident #57 stated the facility rescheduled the vascular appointment for 2/14/2024. The Nursing Note dated 4/10/2022 documented Resident #57 had blood in their adult brief. The Nursing Note dated 4/20/2022 documented Resident #57 observed with vaginal bleeding, Primary Medical Doctor made aware, gynecology consult ordered. The Nursing Note dated 4/20/2022 documented Medical Doctor Order for Resident #57 to be transferred to the hospital due to vaginal bleeding. The Nursing Note dated 4/21/2022 documented Resident #57 returned from the hospital emergency room and will be evaluated by the gynecologist at a later date. The Nursing Note dated 4/28/2022 documented Resident #57 still presenting with blood in their adult brief. The Situation, Background, Assessment, Recommendation Communication Form dated 5/19/2022 documented Resident #57's symptoms worsened, they ha recurrent vaginal bleeding, and Primary Medical Doctor ordered gynecology consult secondary to persistent bleeding and anemia. Resident #57's symptoms started 3/20/2022. The Nursing Note dated 5/20/2022 documented Resident #57 was transferred to the hospital. The Nursing Note dated 5/25/2022 documented Resident #57 was readmitted from the hospital with diagnosis of postmenopausal bleeding and pelvic mass. The Nursing Note dated 5/30/2022 and 5/31/2022 documented Resident #57 continued to have vaginal bleeding. The Nursing Note dated 6/15/2022 documented Resident #57 was transferred and admitted to the hospital on 6/14/2022 due to vaginal bleeding. The Nursing Note dated 6/15/2022 documented Resident #57 was readmitted from the hospital with discharge instructions for Resident #57 to have a scheduled endometrial ablation with the Gynecologist in one week to address pelvic mass and postmenopausal bleeding. The was no documented evidence Resident #57 received a timely consultation appointment with the Gynecologist after vaginal bleeding and Primary Medical Doctor order to see the Gynecologist. The Vascular Consult dated 6/9/2023 documented Resident #57 presented with leg swelling and new wound to their left toe. Venous ultrasound and venogram recommended to rule out deep vein thrombosis. Arterial ultrasound was recommended to evaluate the resident's left toe wound. The Medical Doctor Note dated 6/28/2023 documented Resident #57 was evaluated, and their leg swelling was worse. The Medical Doctor Note dated 9/18/2023 documented a Vascular Consult was requested on 9/9/2023 due to left 1st distal phalanx discoloration. The Nursing Note dated 12/26/2023 documented Resident #57 was scheduled for vascular consult at a clinic on 12/27/2023 and this appointment was cancelled and rescheduled for 1/14/2024. There was no documented evidence a vascular consult was scheduled for Resident #57 in a timely manner to address left toe wound and leg swelling. On 02/01/2024 at 08:09 AM, an interview was conducted with the Assistant Director of Nursing who stated they were not aware of any concerns or delays related to scheduling vascular or gynecology consults for Resident #57. The Medical Doctor was responsible for placing a Physician Order for a resident to see a consulting physician with the nursing supervisor or charge nurse on the unit. The nurse who received the consult order from the Medical Doctor was responsible for scheduling the appointment with the consulting physician, filling out the consult form, and bringing the form to the nursing office for transportation to be scheduled. The Registered Nurse maintained a list of residents with pending consults and followed up with the Medical Doctor to confirm a resident's continued need for evaluation by consulting physician. The Assistant Director of Nursing stated the nurses were also responsible for updating the Physician Order in the medical record with appointment information when a resident was scheduled to see a consulting physician. On 02/01/2024 at 09:44 AM, the Director of Nursing was interviewed and stated they were aware there was an issue with scheduling Resident #57's gynecological consult upon return from the hospital. The Director of Nursing could not recall whether they addressed the concern with a delay in obtaining the consult with the Medical Director. On 01/31/2024 at 03:56 PM, the Medical Director was interviewed and stated they were Resident #57's Medical Doctor. The nurses on the unit were responsible for writing consult orders once the Medical Doctor determined it was necessary for a resident to see a consulting physician. The Medical Director stated the Medical Doctors were responsible for signing the consult orders once the nurses wrote them and the nursing department was responsible for scheduling the appointments. The Medical Director stated they reported concerns related to delays in obtaining an appointment for Resident #57's gynecology consult to the Assistant Director of Nursing and the Director of Nursing. There was no documented evidence of a discussion related to Resident #57's delays in having consultations scheduled. A gynecology appointment was scheduled for Resident #57 by the hospital when she was admitted due to vaginal bleeding. 10NYCRR 415.21

Based on observation, record review, and interviews conducted during the Recertification Survey from 01/28/2024 through 02/02/2024, the facility did not ensure a resident's records were accurately documented. This was evident in 2 (Resident #61 and #67) of 26 total sampled residents. Specifically, 1) Licensed Practical Nurse #1 inaccurately documented Resident #61 was administered antianxiety medication, Xanax, and 2) Resident #67 was documented as having a Foley catheter after the Foley catheter had been removed. The findings are: The undated facility policy titled Medication Administration documented the nurse signs off on the Medication Administration Record immediately after administration of the medication. 1) Resident #61 had diagnoses of anxiety and bipolar disorder. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #61 was cognitively intact. On 01/31/2024 at 12:06 PM, the North 4 medication cart was observed with Resident #61's 8 AM Xanax .25mg dose present on the cart. During an interview on 01/31/2024 at 4:04 PM, Resident #61 stated they chose not to take their prescribed Xanax this morning because they did not go to their radiation appointment. They requested to have their antianxiety medication administered at 12 PM when they were ready to leave for their radiation appointment because this was when they felt anxious. The Medical Doctor's Order dated 12/24/2023 documented give Resident #61 Xanax 0.25 mg every 8 hours for anxiety. The Medication Administration Record for January 2024 documented Resident #61 was scheduled to receive Xanax .25mg at 8AM, 4PM, and 12 AM. The Medication Administration Record documented Licensed Practical Nurse #1 administered Resident #61 their Xanax .25mg at 8AM on 1/31/2024. The Control Substance Record did not document Resident #61 received Xanax .25 mg at 8AM on 1/31/2024. During an interview on 01/31/2024 at 12:15 PM, Licensed Practical Nurse #1 stated they documented on the Medication Administration Record that they administered Xanax .25mg to Resident #61 at 8AM. Licensed Practical Nurse #1 signed the record before taking the medication from the blister pack. Resident #61 then refused to take the Xanax .25mg because they were not going to radiation treatment and wanted to take the antianxiety medication prior to radiation treatment. Licensed Practical Nurse #1 stated they informed the Medical Doctor and the Assistant Director of Nursing that Resident #61 requested a change in their Xanax administration times. During an interview on 01/31/2024 at 3:44 PM, the Director of Nursing stated nurses signed the Medication Administration Record after they administered the medication to residents. If the resident refused to take medication, the nurse documented the resident's refusal on the Medication Administration Record. 10 NYCRR 415.22(a)(1-4) 48711 2) Resident #67 had diagnoses of paraplegia and neurogenic bladder. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #67 was cognitively intact and had a Foley catheter. The Comprehensive Care Plan related to bladder and bowel incontinence, thoracic myelopathy, and neurogenic bladder initiated 1/1/2024 documented on the Foley catheter for #67 was discontinued on 1/16/2024. The Physician Order dated 1/16/2024 documented Resident #67 had their Foley catheter removed and voiding would be monitored. Nursing Note dated 1/16/2024 documented Resident #67 had their Foley catheter removed and urine was collected. Nursing Note dated 1/17/2024 documented Resident #67's Foley catheter was removed yesterday and the resident had one wet adult brief this tour. Nursing note dated 1/24/2024 documented Resident #67's Foley bag and drainage system were changed every Wednesday on the day shift. There nursing note dated 1/24/2024 inaccurately documented Resident #67 required Foley catheter care after Foley catheter was discontinued on 1/16/2024. During an interview on 01/30/2024 at 09:56 AM, Licensed Practical Nurse #3 stated Resident #67 had a Foley catheter and it was discontinued. They do not recall whether Resident #67 used an adult brief for voiding their bladder. Licensed Practical Nurse #3 stated they inaccurately documented in Residnt #67's chart that the resident required Foley catheter care after the Foley catheter had already been discontinued. They wrote a progress note for another resident in Resident #67's chart. During an interview on 01/30/2024 at 09:12 AM, the Assistant Director of Nursing #1 stated Licensed Practical Nurse #3 documented the information meant for another resident in Resident #67's medical record and this was the wrong chart. Resident #67 did not have a Foley catheter when Licensed Practical Nurse #3 documented they required Foley catheter care. It was a mistake. 10NYCRR 415.22(a)(1-4)

Based on observations, and staff interviews conducted during the Recertification survey, the facility did not ensure that infection control practices and procedures were maintained. Specifically, 1). oxygen tubing was observed touching the floor on multiple occasions, and 2). the facility-specific water management plan for Legionella was missing the following required components: (a) environmental assessment of water system. (b) Legionella sampling plan in place for the potable water system. This was evident for 2 out 2 residents reviewed for Respiratory Care out of a sample of 24 residents and during review of Infection Control. (Resident # 6 and Resident # 54) The findings are: 1 (a). Resident #6 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Annual Minimum Data Set (MDS) dated [DATE], documented that resident's cognition was moderately impaired and that extensive assistance with 2 persons physical assistance was needed for transfers and toilet use. The MDS also documented Oxygen therapy while a resident. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Comprehensive Care Plan (CCP) titled Use of supplemental oxygen, resident requires supplemental oxygen therapy, 2L/min continuous, created on 11/20/20 with goals that include resident will have no signs/symptoms(s/s) respiratory distress x 90days, resident will tolerate oxygen therapy x 90 days. Interventions include to change oxygen tubing weekly and prn as ordered, provide oxygen as ordered by Medical Doctor (MD). On1/30/22 at 10:00AM, Resident # 6 was observed in bed with an oxygen concentrator attached to oxygen tubing which was laying on the floor. There was no date observed on the oxygen tubing. On 01/31/22 at 10:37 AM, Resident # 6 was observed out of bed in the wheelchair, with an oxygen concentrator attached to oxygen tubing which was laying on the floor. There was no date on the tubing. On 02/02/22 at 09:34 AM, Resident # 6 was observed in bed asleep and oxygen tubing was observed to be touching the floor. No date observed on the tubing. On 02/02/22 at 12:01 PM, Resident # 6 was observed out of bed having lunch in their room. Oxygen was being administered while attached to the concentrator, with the tubing observed touching the floor. (b). Resident # 54 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) dated [DATE] documented that resident's cognition was moderately impaired, and that resident required extensive assistance of one person physical with bed mobility, transfers, and toilet use. The MDS also documented that resident received Oxygen therapy. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Comprehensive Care Plan (CCP) titled Medical Diagnosis (Dx) [CONDITION(S)], created 05/04/21, had interventions which included administer oxygen as per MD order. On 01/30/22 at 10:20 AM, Resident # 54 was observed sitting in a wheelchair with an oxygen tank placed at the back of the wheelchair and oxygen tubing was observed touching the floor. On 01/31/22 at 11:22 AM, Resident # 54 was observed sitting in a wheelchair with oxygen tubing attached to the concentrator in the resident's hand and touching the floor. On 02/02/22 at 12:04 PM, Resident # 54 was observed in a wheelchair in the doorway of the room. The Oxygen tubing for the nares was in the resident's hands and the oxygen tubing connected to the concentrator was laying on the floor. On 02/04/22 at 12:28 PM, an interview was conducted with Registered Nurse (RN) #1. RN #1 stated that oxygen tubings are changed weekly and that if staff observes the tubing is on the floor, they change them and date the tubings. RN #1 also stated that when they made rounds earlier today, they did not observe ant tubing on the floor. On 02/04/22 at 12:47 PM, an interview was conducted with Certified Nursing Aide (CNA) #1 who stated that when a resident is on oxygen, they make sure that oxygen tubing is not on the floor. If tubing is on the floor, they would tell the nurse and the nurse would change the tubing. CNA #1 also stated that they did not see the tubing on the floor during the 7-3 tour. On 02/04/22 at 12:55 PM, an interview was conducted with the RN Manager (RNM) #1. The RNM stated that it is the responsibility of the staff to see if oxygen tubing is in the floor, and if it is, it must be thrown out and replaced. RNM #1 also stated that the resident tends to move with the oxygen and is reminded to take the tubing off the floor. On 02/04/22 at 1:10 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that staff has been educated that it is a breach of infection control for oxygen tubing to be on the floor. The DON also stated that staff should ensure that the residents oxygen tubing is monitored to prevent it from touching the floor. 2(a) Review of the facility's Legionella water management plan for potable water system titled Domestic water management plan dated 6/1/2021 revealed the plan lacked the required description of environment risk assessment plan which identifies where Legionella and other opportunistic waterborne pathogens (e.g., Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system. In an interview with the Administrator on 02/01/2022 at approximately 1:40PM, the Administrator stated, the Director of Building Service is in-charge of the water management plan at the facility. The Director of Building Service stated in an interview on 02/01/2022 at approximately 1:42 PM, the facility did not complete the environment risk assessment. They inquired of knowing what the environment risk assessment looked like. After showing them a sample, the Director of Building Service stated, they did not complete it. (b) Record review revealed the facility did not have a functional legionella sampling plan in place for the portable water system. Further review of their policy revealed that the facility lacked required components of a Legionella sampling plan including but not limited to specific monitoring sites; frequency at which each monitored site is evaluated; control limits at each control location; and policies and procedures for personnel. In an interview on 02/01/2022 at approximately 1:42 PM, the Director of Building Service stated even though the facility had no plan in place for collecting sampling for testing, there was still a method the facility uses. The Director of Building Service further explained the procedure of collecting samples for testing and analysis. On 02/02/2022 at approximately 5:30 PM, the Administrator submitted a one-page document titled Legionella Sampling plan location. 415.19 (a)(1-3)

Based on observation, record review and staff interviews during the Recertification survey, the facility did not ensure individual resident financial records were made available to resident and resident representatives through quarterly statements. Specifically, quarterly statements were not provided in writing to residents and/or resident representatives within 30 days after the end of the quarter. This was evident for 2 of 2 residents reviewed for Personal Funds out of total sample of 24 residents sampled. (Residents #46 & #67) The findings are: The facility policy titled Resident Fund dated 10/1/2018, documented after each quarter or as requested, Quarterly statements will be distributed to all the residents with capacity accompanied by a signature confirming their receipt. For all other residents who lack capacity, the Quarterly statement will be emailed/mailed to their designated rep with a signature by the Finance Coordinator/designee. 1.Resident #46 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) dated [DATE] documented that the resident had moderate impairment in cognition; has clear speech, with distinct intelligible words, makes self-understood, and understands others. On 01/31/22 at 11:23 AM, an interview was conducted with Resident #46. Resident #46 stated I have a lot of money coming from my social security, but the guy in charge of the money is not giving me the money when I need it, they are not giving me any statement either since being here, that is why I want to take out all my money. Residents Fund Account Trial Balance - Balances as of 02/01/22 documented Resident #46 had a current balance of $40.00 and a pending balance of $40.00. There was no documented evidence that resident had been provided quarterly statements. 2. Resident #67 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) dated [DATE] documented the resident has moderate impairment in cognition; has clear speech, with distinct intelligible words, makes self-understood, and understands others. On 01/31/22 at 09:25 AM, an interview was conducted with Resident #67. Resident #67 stated that sometimes when they ask for money the person in charge will say they have not gone to the bank, and they should come back. Resident # 67 also stated that they have an account with the facility, but they have not been getting updated quarterly statements from the facility to know how much is spent and how much is remaining. Residents Fund Account Trial Balance - Balances as of 02/01/22 documented Resident #67 had a current and pending balance of 1,962.68. There was documented evidence that resident was provided with only one quarterly statements in June 2021 since admission. On 02/02/22 at 01:28 PM, an interview was conducted with the Director of Social Worker (DSW). The DSW stated that the Director of Recreation is in charge of distributing statements to the residents and they believe that residents are given their statement quarterly and upon request anytime they want. The DSW stated that they were not aware that Residents #46 and #67 were not being given their statements quarterly and as needed. On 02/02/22 at 01:50 PM, an interview was conducted with the Director of Recreation (DOR). The DOR stated that resident/resident's representatives are given statements every 3 months, and if any resident or family members request for the statement at any time it is printed and given to them. The DOR also stated that Resident #46 was newly admitted and does not have any money in the account as of January this year, as it took time for the money to get to the facility. The DOR stated that no statement had been provided to Resident #46 since admission. The DOR further stated that residents' statements are handled and printed out by Human Resources (HR), given to recreation to distribute to residents, and the statements are always given out as soon as they are received from HR. The DOR stated that Resident #67 had received one statement from HR which had been signed for. The DOR was not able to explain why only one statement had been given to Resident #67 since admission. On 02/02/22 at 02:05 PM, an interview was conducted with the Director of Human Resources (DHR). The DHR stated that residents are provided with statements every 3 months, and residents are informed of their balances every month. The Recreation department distributes the statement to the residents for them to sign. The DHR further stated that Resident # 46 has a tendency of getting confused and will ask the same questions repetitively and the resident might have been given the statement but will still be asking for it repeatedly. The DHR stated that the recreation staff is supposed to keep a record of the statements given out to the residents. The DHR stated that they were not aware that the residents were not being given the statements regularly. 415.26(h)(5)(i)

Based on interviews and record review conducted during a Recertification and Complaint survey (NY 530), the facility did not ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the State Survey Agency. Specifically, the facility did not report an allegation of abuse to the New York State Department of Health (NYSDOH) within the required timeframe. This was evident for 1 of 4 residents reviewed for Abuse out of a sample of 24 residents. (Resident #75). The facility policy titled Abuse Neglect and Exploitation,, implemented June 2021, documented that it is the policy of BRNC ([NAME] Rehabilitation Nursing Center) to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The policy also documented that the facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency, adult protectives services and to all other required agencies(example law enforcement when applicable) within specified timeframes 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 involve abuse do not result in serious bodily injury. The facility's undated investigation summary documented that Resident #75 called 911 on 06/08/21 and complained to the Registered Nurse (RN) Manager that they were very upset that the Certified Nursing Assistant (CNA) did not change their sheets immediately. The resident later stated that around 12PM, while being assisted with their Activities of Daily Living (ADLs), the CNA who was providing care hurt the resident on the cheek, head, and right leg. The summary also documented that the resident did not elaborate on further with regards to how the CNA hurt them or what triggered the alleged occurrence. RN promptly performed head to toe assessment of resident and notified family. Emotional support, Psychiatry consults and psychotherapy consults ordered. Staff and residents interviewed. The Health Electronic Response Data System (HERDS) Data Entry report, documented that the incident occurred on 6/08/21 at 12:00PM and was submitted on 6/10/21 at 12:02AM, via the Health Commerce System. On 02/04/22 01:01 PM, the Director of Nursing (DON) was interviewed. The DON stated that they were not aware of the incident until the next day. The DON also stated that Resident #75 has a tendency to call 911, and had been making these accusations for a long time which they think is related to the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON further stated that two CNAs were providing care to the residents at the time of the incident and that circumstances pointed more to a behavior and not abuse, so they reported it as an incident and not an allegation of abuse. 415.4(b)2

Based on record review and staff interview conducted during the Recertification and Complaint survey (NY 829), the facility did not ensure that the resident Comprehensive Care Plan was reviewed and revised to reflect the resident's needs. Specifically, interventions were not updated after resident's behavior of self -injurious behavior was identified. This was evident in 1 of 4 residents reviewed for Abuse out of a sample of 24 residents. (Resident #197). The finding is: The facility policy titled Care Planning Policy revised on 10/24/2021 documented the care Planning/Interdisciplinary team is responsible for the review and updating of care plans. Resident # 197 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented that the resident had severely impaired cognition and was dependent on staff for transfer, mobility, locomotion, toileting, eating and dressing. The facility submitted a report to the NYS DOH Hot line on 02/21/2020 at 14:45 PM which documented that the resident was observed with bruising to the upper chest, left hand, bilateral upper arms and right lower lip and chin. Resident has advanced dementia and was unable to articulate what occurred. Resident did not appear to be fearful or in any kind of distress. The Comprehensive Care Plan (CCP) titled Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The goals included that the resident would be safe in the facility with no falls, no injuries, no decline in mood, and no decline in behavior pattern. Interventions included provide 24 hours reality orientation, provide access to clocks and calendars, assist with decision making, monitor for changes in cognition, medication as ordered by Medical Doctor (MD). The CCP titled Anticoagulant/Antiplatelet Therapy initiated on 12/13/2019 related to resident use of an anticoagulant secondary to [CONDITION(S)] (DVT) prophylaxis. Interventions included medications as ordered by the MD, assess effectiveness of medications, monitor lab as ordered, assess for signs and symptoms of abnormal bleeding example petechia, severe bruising, blood in stool or urine, discourage resident from crossing legs. The CCP titled Behavior initiated on 12/13/2019 documented resident has physical behavioral symptoms, was noted to be hypersensitive, constantly moving, picking face, wiping table with arm sweeping and banging table with fists. Goal was other behavior will continue to soothe and calm the resident. Interventions included anticipate needs, encourage family/significant other support, maintain a calm and safe environment and ongoing assessment of behavior. Nurses Notes dated 02/19/2021 at 02:37 PM, documented resident is alert and verbally responsive with confusion, noted with discoloration to right mandible, left hands and lips. Family was notified, and MD was made aware. The Registered Nurse Supervisor was informed and report was escalated to the Director of Nursing. Upon further assessment, resident was observed with swelling and discoloration to left fifth finger. Resident was able to move the fingers. Assessment also revealed discoloration in both arms and mid chest measuring 1x1 cm. MD was informed with orders for Tylenol and resident was moved to a room nearer the nursing station for close monitoring. The facility Accident/Incident report dated 02/19/2020 documented that all staff were interviewed, and statements were taken. No falls nor mistreatment was reported. The facility reviewed the footage for camera located in the dayroom for the preceding 72 hours which revealed that resident was noted to be constantly moving arms and tapping feet. Resident was noted on multiple occasions to be picking at face in particular the chin, lips, and forehead. Resident was noted displaying behavior evident by rocking self back and forth and sideways. Resident pushed their chest against the table to move a locked wheelchair to a sideways position using the table as a support. There was no documented evidence that the care plan had been updated following the incident with interventions to prevent the resident from causing continued harm to themselves. On 02/03/2022 at 3:45 PM, the Registered Nurse Supervisor (RNS) # 3 was interviewed. RNS #3 stated that it the Nursing Supervisors responsibility to revise and update the CCP. RNS # 3 stated that after review of the record they noted that there were no revision with interventions to address the resident's behavior of banging the table with resident's fist and moving back and forth that may have contributed to the bruising. 415.11(c)(2)(i-iii)

Based on observations, record review, and staff interviews conducted during the Recertification survey, the facility did not ensure that needed services, care and equipment are provided to assure that resident with limited range of motion and mobility maintain or improve function based on the residents' clinical condition. Specifically, a resident was not provided with the handroll, and splint device ordered to improve resident's contractures. This was evident for 1 out of 2 residents reviewed for Limited ROM out of 24 residents sampled. (Resident #53) The findings are: The facility's policy titled Use of Assistive Devices dated 2/20/2018, last revised 10/20/2021 documented that the purpose of the policy is to provide a reliable process for the proper and consistent use of assistive devices for those residents requiring equipment to maintain or improve function and/or dignity .If recommended but not utilized, if this is by resident's choice, must be documented in the Comprehensive Plan of care. Resident #53 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) dated [DATE] documented the resident had severe impairment in cognition with long and short-term memory problems. The MDS also documented the resident is sometimes understood, has clear speech, and rarely/never understands. The MDS further documented that the resident is extensive assistance of 1 to 2 staff for most Activities of Daily Living (ADL). The Comprehensive Care Plan (CCP) titled Rehab dated 10/7/2021 documented that resident required assistance with ADL task performance and had a goal of encourage resident to participate in ADLs. Interventions included (L) Hand roll to be worn at all times, remove for skin check, hygiene and during ADLs, (L) Heel relief boot in bed or in Gerichair as tolerated, Lateral support R or L as needed and Left resting hand splint as tolerated, remove for hygiene. There was no Comprehensive Care Plan in place that addressed that the resident had been refusing to wear the devices. CNA Accountability Record (CNAAR) dated December 2021 to February 2022, contained no documented evidence that resident refused the devices during the 7-3 shift. The CNAAR revealed that resident refused the hand rolls only during 11pm to 7am shift on 12/27/2021 and 12/29/2021. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Left resting hand splint as tolerated, remove for hygiene Lateral support, to be placed L or R as needed. On 01/30/22 at 10:51 AM, during the initial tour of the unit, resident was observed in bed with contracture on left hand with no device in place. On 01/31/22 at 01:27 PM, Resident #53 was observed on reclining chair in the room, no hand roll or splint device noted on the resident. On 02/01/22, between 08:43 AM and 12:00 PM, Resident #53 was observed in room with no device in place. On 02/02/22, between 09:35 AM and 11:15 AM, Resident #53 was observed in bed awake, no device noted. On 02/02/22 at 11:28 AM, an interview was conducted with the Certified Nursing Assistant CNA #2. CNA #2 stated that resident is total care, has to be fed, requires total help for dressing, assisted in doing range of motion for the legs and arms. CNA #2 also stated that resident has contractures on both hands and has a hand roll for the left hand and splint for the right hand. CNA #2 also stated that resident sometimes complains of pain when the hand roll is applied and will try to remove it when it is placed. CNA #2 further stated that the hand roll may have been in the resident's drawer when it was not observed on the resident, and they cannot deny or confirm that resident is wearing the device all the time. CNA #2 stated that the charge nurse and the Supervisor were informed that the resident sometimes refuses to wear the devices. On 02/02/22 at 11:38 AM, an interview was conducted with the Charge Nurse, Licensed Practical Nurse (LPN) #1. LPN #1 stated that the resident is supposed to be given the hand roll and the splint device all the time except during care. LPN #1 also stated that they were not aware that the resident was not being given the device and had not been informed that resident is refusing. LPN stated that it would have been documented in the resident's chart and brought to the Supervisor's attention if they have been made aware that resident is refusing to wear the devices. LPN stated that they did not notice that the Resident #53 was not wearing the devices when they administered medications to the resident. On 02/02/22 at 11:45 AM, an interview was conducted with the Registered Nurse (RN) #2, the Nursing Supervisor. RN #2 stated that it was a mistake that resident had not been having the devices, and staff had not been reporting that resident is refusing to wear it. RN #2 also stated it would have been documented in the resident's chart if it was reported that resident had been refusing the device. RN #2 further stated that they do make rounds on the unit but did not observe that Resident #53 had not been wearing the ordered devices. 415.12 (e)(2)

Based on interviews and record review conducted during an abbreviated survey, (NY 730), the facility did not ensure that a resident received an appropriate discharge. Specifically, Resident #1 was unable to perform her Activities of Daily Living (ADL) needs independently, but the facility discharged her home alone on 12/21/2019. In addition, the facility discharged Resident #1 despite knowing that her home care services were not scheduled to start until 12/24/2019. This was evident for 1 out 3 residents sampled (Resident #1). The finding is: The facility's Transfer and Discharge Policy, revised 11/2016, documented that the facility permits each resident to remain in the facility unless the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. The interdisciplinary team should collectively determine the appropriate transfer and discharge of each resident based on medical need or necessity. The team will determine if the discharge is facility initiated or resident initiated. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition (00-07 severe impairment, 08-12 moderate impairment and 13-15 cognitively intact). Resident #1 required extensive assistance of 1 person with bed-mobility, transfer, walking with walker, personal hygiene and toilet use. The resident also required total assistance with bathing and supervision with eating. The resident was incontinent of bowel and bladder. The Complainant was interviewed on 09/03/2020 at 9:50AM and stated that the Social Worker called him about Resident #1's discharge and informed him that the resident's insurance coverage was expiring. He did not agree with Resident #1 going back home because he knew that resident could not manage at home. Resident #1 was not physically able to take care of herself. The resident was a hoarder, and the house was in a deplorable state. No one checked Resident #1's living conditions prior to discharge. One of the neighbors found the resident alone in the house with the door open on 12/22/2019. The resident was wet and had no food in the house. He called 911 and Resident #1 was hospitalized for [REDACTED].#1 was transferred to an Enhanced Assisted Living facility. Resident #1 was interviewed on 09/04/2020 at 9:50AM and stated she recalled living at the facility. The resident stated she walked with a walker and had rehabilitation therapy while in the facility. The resident stated that she could not wash, dress, complete grooming, or use the toilet independently while in the facility. Staff assisted the resident with those tasks. A Comprehensive Care Plan (CCP) for Risk for Falls related to unsteady gait, initiated on 09/13/2019, documented interventions that included anticipate needs, provide restorative rehab and keep call bell within reach. The Care Plan documented that Resident #1 had falls to the floor on 10/29/2019, 11/19/2019 and 12/11/2019. A CCP for Discharge Planning with Return to the Community Referral dated 09/15/2019, indicated that Resident #1 had a plan to return to her prior residence. The goal was that Resident #1 would be discharged to the community within 90 days. Interventions included engage resident and family in discharge planning, A Cognition Care Plan dated 09/15/2019 documented that Resident #1 had short term memory problems and modified independence with daily decision-making skills. The ADL Care Plan, updated on 12/12/2019, documented that Resident #1 required limited assistance with bathing, dressing, personal hygiene, toileting and transfer. A Social Services Progress Note dated 11/25/2019 at 4:26PM documented that Social Worker (SW) spoke to Resident #1 about discharge plan. Resident #1 stated that she wanted her nephew to guide that decision. A Social Services Progress Note dated 12/02/2019 at 4:04PM documented that the writer went to speak to Resident #1 about the discharge plan. The resident still maintained an apartment. The resident was alert and oriented x (times) 2-3, able to make modified decisions, and had intact short/long-term memory. The resident was able to make needs known, however, was unsure of what was the best for them in the situation. A Notice of discharge date d 12/05/2019 documented that Resident #1's anticipated date of discharge was 12/21/2019. The reasons were end of therapy treatment and insurance completed with last covered day 12/21/2019. The resident and/or representative had the right to appeal. A Psychology Consult dated 12/10/2019 documented that Resident #1 was being followed for Depressive and Anxiety Disorders. Resident #1 was negative in her ideations, working to reduce negative thoughts and helping to reduce anxiety. A Social Services Progress Note dated 12/13/2019 at 2:45PM documented that SW met with the resident and left 2 messages for the nephew regarding discharge planning next week (12/21/2019). A Home Care Agency met with the resident and SW and explained services covered by Medicare. The Agency will follow up with SW once nephew is involved, per resident's request. The resident was independently ambulating with a rolling walker. physician progress notes [REDACTED].#1 was seen on 12/14/2019 due to status [REDACTED]. Resident #1 was alert, orient x 3, Extremities: Range of Motion, no pain, no bruises, Unspecified abnormalities of gait and mobility. Plan: Encouraged use of call bell to ask for assistance. A Social Services Progress Note dated 12/17/2019 at 1:51PM documented the following discharge plans: SW met with Resident #1 and discussed discharge plan to go home Saturday,12/21/2019 via car service. Referral made to Home Care Agency and support given. Nephew notified and returned SW call with two messages. Plans continue. Resident/nephew are agreeable to Discharge Plan as resident is independently ambulating with a rolling walker. Discharge Notice/Checklist/and Booklet in progress. Interdisciplinary Team and Physician agree to this Discharge Plan to home. Family to see resident on/after 12/27/2019 as nephew lives in Maryland (MD). Social Services Progress Note dated 12/20/2019 at 1:17PM documented that Resident #1's nephew notified in voicemail that a bill was accruing starting on 12/22 as a private pay $400 + per day. A Social Services Progress Note dated 12/20/2019 at 3:29PM documented that SW met with Resident #1 and confirmed they had their apartment keys. Discharge continues for 12/21/2019 as planned. Nursing to call local car service for discharge transport as resident has money. Family to follow up with Peapod/food delivery until they come to New York (NY) on 12/27/2019. Discharge paperwork in resident's pocketbook. SW spoke with Home Care Agency Representative and confirmed Home Care services were scheduled to start on Tuesday (12/24/2019). A Physical Therapy Discharge Summary dated 12/20/2019 documented that Resident #1 could ambulate 350 feet with 2-wheel rolling walker and modified independence. An Occupational Therapy Discharge Summary dated 12/20/2019 documented that Resident #1 required contact guard assistance for bathing, stand by assistance for dressing, set up with hygiene/ grooming, and had modified independence with eating and toileting. A Nursing Progress Note dated 12/21/2019 at 2:52 PM documented the resident was medically cleared and discharged home in the morning. The resident was alert and verbally responsive and left in stable condition. Discharge instructions were given, and the resident verbalized understanding. A Social Services Progress Note dated 12/22/2019 at 10:06AM documented that Resident #1 was discharged home on[DATE]. Electronic prescriptions were sent, and the discharge booklet/notice was given to the resident. The resident declined to sign on 12/20/2019. A Social Service Progress Note dated 12/23/2019 at 1:33PM documented: Post discharge, the resident's nephew left a message on 12/22/2019 informing SW that Resident #1 returned to the hospital on [DATE]. The family stated that the resident did not do well in the apartment, hence hospitalization . SW received a call from the hospital Physician to inquire about Resident #1's discharge medications, diagnoses, pharmacy and discharge status. A Medical Discharge Summary dated 12/23/2019 documented that Resident #1 was discharged home, and the resident/family requested discharge. The resident completed therapy and no longer required skilled services of the facility. The Director of Social Services was interviewed on 09/03/2020 at 1:10PM and stated that Resident #1 was alert and oriented x 3 and had a BIMS score of 12. She started Resident #1's discharge planning on 12/02/2019. The resident was coming to the end of her 100 days insurance coverage on 12/21/2019, and her therapy had completed. A Discharge Notice was given, and the resident's nephew did not appeal the discharge. She made a referral for Home Care Services on 12/17/2019. The resident's discharge was scheduled for 12/21/2019, and the arrangement was for the Home Care Agency to evaluate her within 48 hours. Resident #1 would have gotten around 2-3 hours of Home Care services daily. She arranged for Resident #1 to leave the facility by car service. The facility determined that the resident was ready for a safe discharge through assessment, Medical Doctor clearance , Social Worker, Therapy outcome and subsequently communicating with the resident ' s nephew. Resident #1's number 3 contact was interviewed on 09/04/2020 at 4:40PM. She stated that she was Resident #1's friend/neighbor. She checked on Resident #1 around 1:00PM on 12/22/2019, she found the door open and the house was cold. Resident #1 was in bed, wet and appeared weak. Resident #1 had no food or nothing to drink in the house. She brought Resident #1 some food then called Resident #1's nephew and alerted him of the situation. The Registered Nurse Supervisor (RNS) was interviewed on 09/17/2020 at 11:36AM. She was on duty when Resident #1 was discharged home and stated that Resident #1 went home by taxi. She further stated that Resident #1 required limited assistance of staff with bathing, dressing and grooming. 415.3(h)(1)(ii)(a)(b)

Based on record review and interviews conducted during a recertification survey, the facility did not ensure that care and services were provided for 1 of 3 residents (#181) reviewed for pressure ulcers from a total Stage 2 sample of 31 residents. Specifically, the attending physician was not informed in a timely manner of the results of a pelvis ultrasound (used to determine the amount or volume of residual urine in the bladder) in order to provide timely treatments, including insertion of an indwelling Foley catheter to relieve [MEDICAL CONDITION]. The finding is: Resident #181 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 9/15/17 Admission Minimum Data Set (MDS) assessment documented the resident's Brief Interview for Mental Status (BIMS) score as 12 out of 15, which indicated the resident had moderate cognitive impairment. This MDS originally documented that the resident either had a urinary catheter, urinary ostomy, or no urine output for the prior 7 days. The Registered Nurse (RN) MDS Coordinator was interviewed on 10/13/2017 at 10:45 AM and stated at the time of the MDS assessment the resident did not have a urinary catheter and the resident was incontinent. She stated the MDS was an error. The attending physician's progress note dated 9/8/2017 documented the resident had a history of [REDACTED]. The Physician documented that the resident was voiding but the post-void residual urine was not checked. The attending physician further documented that the resident may need a Foley catheter and planned for a bladder sonogram to check for post-void residual urine. The physician's orders [REDACTED]. A note in the order required the use of a portable ultrasound due to the resident's physical or mental limitations to be transported from the facility. The initial nursing progress note written by the unit Registered Nurse (RN) Supervisor #1 dated 9/13/2017 at 1:01 PM documented the pelvis ultrasound was done during the shift and the result was pending. The ultrasound report was uploaded to the facility's computer system on 9/15/17 at 12:00 PM. The report documented the date of service was 9/13/17 and the pre-void volume was 1,285 cc. The report documented that post-void residual was not documented. The Attending Physician saw the resident on 9/16/17. A Physician's progress note dated 9/16/17 at 11:53 PM documented that the bladder appeared to be distended. Bladder sonogram and [MEDICAL CONDITION] (GU) consults for Foley catheter placement was ordered and report was pending. Further review of the physician's orders [REDACTED]. The computer documentation showed that the physician reviewed and signed-off on the report on 9/17/17 at 7:07 AM, four days after the bladder sonogram was done. A nursing progress note dated 9/17/2017 at 7:29 AM written by the overnight RN Supervisor #2 documented that a Foley catheter was inserted. The urine output from the catheter on 9/17/17 at 7:20 AM was documented as 700 cc. The Comprehensive Care Plan (CCP) dated 9/18/2017 titled Urine Incontinence/and Indwelling Catheter documented that the resident has a history of retention. The bladder sonogram revealed pre-void volume of 1,285 cc and an order obtained to insert Foley catheter secondary to [MEDICAL CONDITION] and the urology consult was pending. A representative from the diagnostic company that performed the ultrasound was interviewed on 10/13/17 at 11:10 AM and stated the portable ultrasound was done at the facility on 9/13/17. The technician immediately notified the unit RN Supervisor #1 of severe [MEDICAL CONDITION] of 1,300 cc pre-void and 1,300 cc post-void. The representative stated that official report was faxed to the facility on [DATE] at 12 PM and uploaded the report to the facility's computer system on 9/15/17 at 12 PM. She stated that the facility was not called regarding the results. RN Supervisor #1 was interviewed on 10/13/17 at 11:42 AM and she stated she did not recall the technician reporting the results of the bladder ultrasound to her. Regarding the ultrasound report that was uploaded to the computer system on 9/15/2017, she stated that the section of the computer that it was uploaded to, is the physician's section and she did not review it or receive notification that the report was there. RN Supervisor #1 further stated the resident was urinating and she did not follow up with the diagnostic company for the results because the test was routine. The Director of Nursing Services (DNS) was interviewed on 10/13/17 at 12:33 PM and she stated that the fax number the diagnostic company had was wrong and therefore the faxed report was not received by the facility. She stated the report that was uploaded to the computer was to notify the physician and was unclear if the nurse's received notification. The DNS stated that it was not routine policy for the nurse's to follow up with the diagnostic company. Review of the Resident Bowel and Bladder by Shift Chart documented by the Certified Nursing Aides revealed that between 9/13/17 and 9/17/17, the resident had one incontinent episode per shift, with the exception of 9/15/2017 during the 11 PM - 7 AM shift, when the resident had two incontinent episodes. The nursing progress notes between 9/13/17 and 9/18/17 did not reveal any urinary assessments. A call was placed to the Attending Physician on 10/16/17 at 10:06 AM. The Physician was not available for an interview. 415.12(d)(2)

Based on observation, record review, and staff interviews during the recertification survey, the facility did not ensure that the medication error rate was less than 5%. This was evident for one of three residents observed for the administration of medications. Specifically, Resident #99 was observed to receive [MEDICATION NAME] (a diuretic medication) 20 milligrams (mg) by mouth (po) on the wrong day and [MEDICATION NAME] (an oral diabetic medication) two hours after the prescribed time resulting in an 8% medication error rate. The finding is: Resident #99 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 14 indicating that the resident was cognitively intact. The current monthly physician's orders [REDACTED]. The resident was also to receive [MEDICATION NAME] 10 mg po twice a day (BID) before meals for Diabetes Mellitus. A medication administration observation was conducted on 9/15/15 at 9:30 AM on the 3rd Floor unit where Resident #99 resided. The Medication Licensed Practical Nurse (LPN) was observed to dispense [MEDICATION NAME] 20 mg and [MEDICATION NAME] 10 mg in addition to eight other medications. The LPN proceeded to sign for the [MEDICATION NAME] and [MEDICATION NAME] medications in the Electronic Medical Record (EMR) in the presence of the surveyor. Upon reconciliation of the medications for Resident #99, it was documented that the [MEDICATION NAME] had been signed for at 7:30 AM as prescribed, rather that 9:30 AM as was administered. Additionally, it was noted that the [MEDICATION NAME] should not have been administered on 9/15/15. On 9/17/15 at 10:45 AM, the LPN Medication Nurse who completed the administration on 9/15/15 was interviewed. The LPN stated that when she went to administer the [MEDICATION NAME] at 7:30 AM on 9/15/15 the resident was in the process of dressing. Additionally, the LPN acknowledged that the [MEDICATION NAME] should not have been administered on 9/15/15. On 9/17/15 at 11:45 AM, the Registered Nurse (RN) Charge Nurse was interviewed. The RN stated that the LPN should have notified her when the [MEDICATION NAME] had been administered in error. The RN further stated that when the [MEDICATION NAME] was administered two hours late, the LPN should have also informed her. The RN stated that a Progress Note should have been written and the Physician should have been notified. On 9/17/15 at 12:00 PM, the Assistant Director of Nursing (ADON) was interviewed and stated that the RN should have informed her when the errors occurred. The ADON stated that she would have completed a medication error report and conducted the necessary inservices. 415.12(m)(1)