Every finding on record at BronxCare Special Care Center

Based on observation, record review, and interviews, the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. This was evident in one (1) (Resident #238) of one (1) resident reviewed out of 35 total sampled residents. Specifically, on 05/16/2025, Resident #238 was observed with thick, brownish, foul smelling penile discharge. The attending physician was not appropriately notified of Resident #238's change in condition resulting to a delay in medical intervention. The findings include:The facility's policy and procedure titled Change in Condition with a reviewed date of 01/2025 documented at the time a change in condition is identified, the nurse will notify the medical doctor, document all findings in the assessment and evaluation in a progress note, and document the change in condition on the 24-hour report.Resident #238 had diagnoses of Non-Alzheimer's Dementia, Coronary Artery Disease, and Benign Prostatic Hyperplasia without lower urinary tract symptoms.The quarterly Minimum Data Set (a resident assessment tool) dated 04/04/2025 documented Resident #238 had moderately impaired cognitive skills for daily decision making, and a short and long-term memory problem. Resident was dependent with activities of daily living and mobility.A comprehensive care plan for elimination/genitourinary was initiated on 10/04/2024 and was last reviewed on 04/01/2025. The care plan documented Resident #238 was incontinent of bladder. The facility interventions included to observe urine output and monitor for foul odor, dark color, cloudy urine, and other abnormalities.A progress note by Attending Physician #1 dated 05/19/2025 at 11:47 AM documented that Resident #238 had thick, penile discharge with a foul odor for 3 days, but changed from white to brownish color. The plan of care included urinalysis with culture, Rapid Plasma [NAME] (test used to screen for syphilis), and Sexually transmitted Infection Panel (screens for multiple sexually transmitted infections). A nurse's note by Registered Nurse #1 dated 05/19/2025 at 2:00 PM documented that Resident #238 was observed with thick, brownish penile discharge on [DATE]. Medical Doctor was made aware, evaluated the resident this morning, and ordered Ceftriaxone 100 milligram intramuscular for 1 dose and Doxycycline 100 milligram by mouth every 12 hours at 10:00 AM & 10:00 PM for 7 days for penile discharge.A review of interdisciplinary progress notes from 05/16/2025 through 05/18/2025 showed no documentation of Resident #238 having penile discharge or that a physician had been notified of Resident #238's foul smelling, abnormal penile discharge.The 24-hour Patient Care Report from 05/16/2025 through 05/18/2025 did not contain any documentation related to Resident #238.On 08/14/2025 at 12:41 PM, Certified Nursing Assistant #3 was interviewed and stated Resident #238 was on their assignment. They stated they could not remember the exact date but when they were taking care of Resident #238, they noticed yellowish, pus like penile discharge and the urine was foul smelling. They stated they spoke with the Registered Nurse, and the nurse came in to look at it. On 08/14/2025 at 9:23 AM, Registered Nurse #1, who was the unit Charge Nurse, was interviewed and stated Resident #238 was observed with abnormal penile discharge on a Friday, 05/16/2025 and verbally notified Attending Physician #1. They stated they do not remember if they followed up with the physician before the end of their shift. On 08/14/2025 at 9:35 AM, Attending Physician #1 was interviewed and stated they were covering on Resident #238's unit on 05/16/2025 and was not notified of Resident #238's brownish, foul smelling penile discharge. They stated they should have been notified right away as they would have examined Resident #238, ordered laboratory, and treated resident with antibiotics that same day. Attending Physician #1 also stated there was a note in the doctor's communication book located at the nurse's station that was dated 05/16/2025 but they checked the book prior to the note being written and therefore did not notice the note until they returned to work on 05/19/2025. Attending Physician #1 stated the Doctor's Communication Book is only meant for non-urgent matters.On 08/14/2025 at 10:59 AM, the Assistant Director of Nursing was interviewed and stated Registered Nurse #1 should have called the doctor on 05/16/2025 to report the penile discharge so Resident #238 could have been examined and treated that same day. Non-urgent issues can be communicated in the Doctor's Communication Book, but urgent matters such as this should be communicated directly to the physician and documented in the Electronic Medical Record. They stated Registered Nurse #1 also should have documented the abnormal penile discharge in the 24-hour report which provides communication from nurse to nurse. 10 NYCRR 415.12

Based on observation, record review, and interviews, the facility failed to ensure that the resident's representative was notified of a change in resident's condition. This was evident in 1 (one) (Resident #143) of 1 resident reviewed out of 35 total sampled residents. Specifically, the facility did not inform Resident #143's family representative that the resident's fourth fingernail on the right hand was detached. The findings include: The facility policy and procedure titled Change in Condition which was last reviewed on 01/2025 documented that the charge nurse/supervisor will notify the resident's family member or designee of any or all change in condition that differs from the resident's baseline. Resident #143 was admitted with diagnoses that included Cerebrovascular Accident and Hypertension. The quarterly Minimum Data Set assessment dated [DATE] documented Resident #143 was severely cognitively impaired. and that resident required substantial assistance with all activities of daily living.On 08/11/2025 at 10:28 AM, Resident #143 was observed resting in bed. The resident's right fourth-digit nail was off, and the nailbed was pink.On 08/08/2025 at 1:07 PM, Resident #143's family representative was interviewed and stated that they received an email from the doctor stating that the resident had an infection on the right 4th finger and that they had put medication on it. The family representative stated on 07/04/2025, their cousin picked up Resident #143 and called them to say that the resident's fingernail was gone. They stated no one had told them that the entire fingernail was gone.A nurse's progress note dated 05/23/2025 at 3:35 PM documented that at approximately 2:00 PM, the assigned certified nursing assistant reported that the resident had blood on their right fourth finger. On assessment, the resident was noted to have mild bleeding from the right-hand fourth fingernail outside the cuticle. The nail on the finger and all other fingernails was intact. Attending Physician #1's progress note dated 05/23/2025 at 2:57 PM documented that Resident #143 was seen at the bedside for fingernail bleeding. The note documented that Resident #143 had fresh blood coming from cuticle on their right finger. Treatment plans included applying Bacitracin two times a day. The resident's family representative was to be notified. A nurse's progress note dated 05/24/2025 at 11:52 PM documented Resident #143's right 4th finger was noted with no fingernail, nail bed was pink, dry, no swelling, no ecchymosis, no bleeding or signs and symptoms of pain.A nurse's progress note dated 05/26/2025 at 12:05 AM documented Resident #143's nail bed was pink, dry, no swelling, ecchymosis, tenderness to the finger.A review of the progress notes from 05/24/2025 to 05/31/2025 showed no documented evidence that Resident #143's family representative was informed that the resident's fingernail was detached.On 08/13/2025 at 11:05 AM, Registered Nurse #4, who was the charge nurse, was interviewed and stated that Resident #143's fingernail was observed bleeding during care. They assessed the resident and noted the fingernail was oozing with blood. Resident #143's family was notified of the bleeding. They stated the next day; the nurse told them that the fingernail was off. The nail bed was pink and not bleeding. Registered Nurse #4 stated they do not remember if the doctor or the supervisor was aware that the fingernail was off.On 08/12/2025 at 11:22 AM, Registered Nurse #5, who was the nurse manager, was interviewed and stated that they were informed that Resident #143 broke their nail and had some bleeding. They stated the doctor notified Resident #143's family. They stated they were not aware that the fingernail came off and that the resident's family noticed it on 07/04/2025. On 08/12/2025 at 11:38 AM, Attending Physician #1 was interviewed and stated they examined Resident #143's fingernail when they were told that it was bleeding. They stated they ordered Bacitracin ointment and notified the family by email. They stated Resident #143's nail came off, but they did not inform the resident's family. They stated the nurse manager of the social worker can notify the resident's family of change in condition. On 08/14/2025 at 8:28 AM, the Assistant Director of Nursing was interviewed and stated they became aware of Resident #143's bleeding from the cuticle during the morning report. They stated the nurse manager initiated the investigation, but they, the Assistant Director of Nursing did not follow up. They stated they knew about the fingernail being off after a family member visited. The Assistant Director of Nursing stated the nurse manager, and the doctor usually communicates with the family, but this was overlooked. On 08/14/2025 at 10:16 AM, the Director of Nursing was interviewed and stated that the resident's family must be notified of any change in resident's condition and that the nurses, social workers, or doctors are responsible for informing the family. They stated Resident #143's family should have been notified again that the nail was detached. 10 NYCRR 415.3(f)(2)(ii)(a)

Based on observation, record review, and interviews during the Recertification and Complaint (#668295) Survey, the facility failed to ensure that food was served at an appetizing temperature during meals. This was evident in one (1) (Unit 4) of five (5) units. Specifically, food served during meal service were not maintained at palatable and appetizing temperatures.The findings include:The facility's policy and procedure titled Food Temperatures with a reviewed date of 02/2024 documented all food is to be prepared, held, and served within the appropriate ranges to provide the highest quality of food and maintain aesthetic value of food. Minimum temperature for hot food is above 140 degrees Fahrenheit. During the Resident Council meeting on 08/08/2025, Residents #138 and #146 stated that food are often served lukewarm, and at times were served cold during meal service. The residents stated staff should not eat their meals prior to serving meals to the residents because meals are served late, not hot, and sometimes run out. Resident #66 stated food are served cold because meals are delivered late. On 08/12/2025 from 11:40 PM to 12:23 PM, food cart arrived in Unit 4. Meal trays were assembled and distributed to residents in the dining room and resident rooms. At 12:23 PM, test trays were conducted with the Food Service Director. It revealed the following: chicken noodle soup at 142.2 degrees Fahrenheit, baked chicken at 144 degrees Fahrenheit, jerk chicken at 150 degrees Fahrenheit, spinach at 126 degrees Fahrenheit, plantains at 116 degrees Fahrenheit, puree green beans at 132.6 degrees Fahrenheit, puree chicken at 128 degrees Fahrenheit, mashed potato at 134 degrees Fahrenheit. On 08/12/2025 at 12:37 PM, the Food Service Director was interviewed and stated in the past resident council meetings, residents brought up the food temperature issues. They stated the temperatures tested were not meeting the minimum temperature and that hot foods should be served above 140 degrees Fahrenheit. On 08/14/2025 at 11:28 AM, the Administrator was interviewed and stated they were not aware of resident concern about food temperature. They stated they are going to address this concern immediately because residents should be getting good quality meals. 10 NYCRR 415.14(d)(1)(2)

Based on observation, record review, and interviews, the facility failed to report all alleged violations involving neglect, abuse, and/or including injuries of unknown source to the State Survey Agency. This was evident for one (1) (Resident #143) of six (6) residents reviewed for abuse out of 35 total sampled residents. Specifically, on 05/23/2025, Resident #143's fourth finger on the right hand was bleeding and was subsequently noted with a detached fingernail on 05/24/2025. The resident was cognitively impaired and could not explain how the injury had occurred This incident was not reported to the New York State Department of Health. Cross Reference: F580 - Notify of ChangesThe findings include: The facility's policy and procedure titled Abuse Prevention Protocol with a last revised date of 06/2025 documented the investigator is trained to report incidents to the New York State Department of Health when there is reasonable cause for resident abuse. The policy stated that federal regulations require reporting of injuries of unknown origin to the Administrator of the facility and when required to the New York State Department of Health. Resident #143 was admitted with diagnoses that included Cerebrovascular Accident and Hypertension. The quarterly Minimum Data Set assessment dated [DATE] documented Resident #143's cognition as severely impaired and had never/rarely made decisions. The resident required substantial assistance with all activities of daily living. On 08/11/2025 at 10:28 AM, Resident #143 was observed resting in bed. The resident's right fourth-digit nail was off, and the nailbed was pink.A nurse's progress note dated 05/23/2025 at 3:35 PM documented that at approximately 2:00 PM, the assigned certified nursing assistant reported that the resident had blood on their right fourth finger. On assessment, the resident was noted to have mild bleeding from the right-hand fourth fingernail outside the cuticle. The nail on the finger and all other fingernails was intact. Attending Physician #1's progress note dated 05/23/2025 at 2:57 PM documented that Resident #143 was seen at the bedside for fingernail bleeding. The note documented that Resident #143 had fresh blood coming from cuticle on their right finger, traumatic. Treatment plans included applying Bacitracin two times a day. The resident's family representative was to be notified. A nurse's progress note dated 05/24/2025 at 11:52 PM documented Resident #143's right 4th finger was noted with no fingernail, nail bed was pink, dry, no swelling, no ecchymosis, no bleeding or signs and symptoms of pain.The facility's occurrence report dated 05/23/2025 documented that Resident #143 was noted with mild bleeding from the right-hand during transfer from bed to wheelchair. The Resident Care Follow-up completed by the Assistant Director of Nursing documented that there was no medical explanation found to cause the right fingernail bleeding and avulsion, and that the investigation was inconclusive. On 08/14/2025 at 10:20 AM, the Director of Nursing was interviewed and stated Resident #143 was unable to tell how they sustained the injury, and they cannot provide evidence of abuse or mistreatment. They stated an injury of unknown origin should have been reported to the New York State Department of Health. 10 NYCRR 415.4(b)(2)

Based on observation, record review, and interviews during the Recertification Survey, the facility failed to ensure residents, or their designated representatives, were provided appropriate notification at the termination of Medicare Part A benefits. This was evident in three (3) (Residents #187, #212, and #222) of three (3) residents reviewed for Beneficiary Notification out of 35 total sampled residents. Specifically, the facility did not provide residents with Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN- form CMS-10055) at the termination of their Medicare Part A benefits. The residents remained in the facility. The findings include: The facility policy titled Advanced Beneficiary Notice Non-Coverage with a last revised date of 01/2025, documented that the purpose of the policy was to ensure the facility issues, documents, and retains Advance Beneficiary Notices of Non-Coverage in accordance with Medicare/Center for Medicare & Medicaid Services rules so beneficiaries or their representatives are informed when the facility reasonably expects Medicare Fee for Service (MFS) will not pay for a particular item or service, and to protect the facility from improper billing and financial liability.1) Resident #187's last covered day for Medicare Part A skilled services was on 02/24/2025 with 61 benefits days remaining. Resident #187 remained in the facility. Resident #187 received a copy of the Notice of Medicare Non-Coverage form on 02/21/2025. There was no documented evidence that form CMS-10055 was given to the resident, informing them of their potential liability for payment.2) Resident #212's last covered day for Medicare Part A skilled was on 07/25/2025 with 22 benefits days remaining. Resident #212 remained in the facility. The resident's representative received a copy of the Notice of Medicare Non-Coverage form on 07/23/2025. There was no documented evidence that form CMS-10055 was given to the resident, informing them of their potential liability for payment.3) Resident #222's last covered day of Medicare Part A skilled services was on 06/06/2025 with 61 benefits days remaining. Resident #222 remained in the facility. Resident #222 received a copy of the Notice of Medicare Non-Coverage form on 06/03/2025. There was no documented evidence that form CMS-10055 was given to the resident, informing them of their potential liability for payment.On 08/12/2025 at 3:05 PM, the Director of Social Services was interviewed and stated that they give Notice of Medicare Non-Coverage to the residents two days before they are discharged from services. They stated they do not issue the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage to the resident or their representative.On 08/12/2025 at 3:13 PM, the Minimum Data Set Coordinator was interviewed and stated they do not issue the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage to the residents because they had not filed an appeal. They stated the residents are given Notice of Medicare Non-Coverage and that there is a phone number for them to call to file an appeal. On 08/14/2025 at 9:50 AM, the Director of Nursing Services was interviewed and stated that according to the Minimum Data Set Coordinator, the residents are issued Notice of Medicare Non-Coverage on admission. The Director of Nursing further stated that according to the social worker, they only give the residents Notice of Medicare Non-Coverage, and not the Advance Beneficiary Notice. The Minimum Data Set Coordinator and the social worker are responsible for providing appropriate forms. The Director of Nursing stated that the Minimum Data Set Coordinator provides the proper forms. On 08/14/2025 at 2:55 PM, the Administrator was interviewed and stated that the Minimum Data Set Coordinator gives the Notice of Medicare Non-Coverage forms to the social worker. The social worker explains the notice to the resident and asks the resident to sign the form.10 NYCRR 415.3(h)(2)(iii)

Based on observation, record reviews, and staff interviews conducted during the Recertification survey from 6/1/23 through 6/8/23, the facility did not ensure that Gradual Dose Reduction (GDR) was attempted for a prescribed psychotropic medication. This was evident in 2 (Resident #113 and #82) of 5 residents reviewed for Unnecessary Medication out of a sample of 38 residents. Specifically, 1) Resident #113 had a diagnosis of dementia and was prescribed and administered Risperidone for agitation with no GDR attempted, and 2) Resident # 82 had a diagnosis of dementia and was prescribed Divalproex and Citalopram without a GDR attempt. The findings are: The facility policy titled Psychopharmacological Drugs/Chemical Restraints revised August 2022 documented that the policy is to ensure that all residents maintained on psychopharmacological medication are on the lowest dosage of drug to achieve effects and are reviewed on a regular basis to evaluate need for continued use. 1.) Resident # 113 was admitted to the facility with diagnoses that included Diabetes Mellitus, Dementia and Depression. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #113 was moderately cognitively impaired, displayed no psychosis or behavioral symptoms, and received antipsychotic medication 7 out of 7 days prior to the assessment. No gradual dose reduction (GDR) had been attempted, and GDR had not been documented as clinically contraindicated. On 6/5/23 at 9:29 AM, Resident #113 was observed sleeping in their room. On 6/6/23 at 8:21 AM and 12:25 PM, and 6/7/23 at 2:43 PM, Resident #113 was observed out of bed and in their wheelchair. The Comprehensive Care Plan (CCP) related to psychotropic drug use, initiated 8/10/22 and last revised 4/24/23, documented Resident #113 received Risperidone 0.5mg at bedtime for agitation. The Psychiatry Consult dated 01/26/2023 documented the reason for Resident #113's consult was neurocognitive disorder with mood problems. Resident #113 was hospitalized for hyperglycemia and their presentation was suspected secondary to delirium/altered mental status from hyperglycemia versus worsening dementia. Resident #113 was cooperative, had cognition within normal limits, and had a low risk level for violence. The primary psychiatric diagnosis was documented as dementia with mood disturbance. The consult documented a recommendation for Resident #113 to continue with Namenda 5mg twice daily, Risperidone .5mg at bedtime for dementia with mood disorder, and Melatonin 5mg at 6 PM for insomnia. A Drug Regimen Review (DRR) note dated 2/2023 documented please attempt to reduce the dose of Risperidone 0.5 mg oral at bedtime (started on 8/11/22). The Primary Medical Doctor (PMD) documented their response 3/28/23 that Resident #113's symptoms were controlled with the current dose. The Psychiatry Consult for Resident #113, dated 3/24/23, documented problems addressed in the note included depression, dementia, Hyperlipidemia, and hypertension. Resident #113 was oriented to person, place, and time, was listening to the radio, smiled appropriately, was in a good mood, and reported being in contact with their family. Resident #113 denied depressive, delusional, manic, and paranoid symptoms and was stable on the current regimen. Psychiatry Consult dated 4/30/23 documented Resident #113 had no reported violence, cognition within normal limits, insight within normal limits, was cooperative, and denied suicidal ideation. The consult documented the reason for the consult was neurocognitive disorder, problems addressed included Resident #113's dementia with mood disorder, and the recommendation was to continue with Memantine 5mg twice daily for dementia, Risperidone .5mg daily for mood disorder, and Melatonin 5mg at 6 PM. A DRR note dated 5/2023 documented to attempt to reduce the dose of Risperidone 0.5 mg orally at bedtime (started on 8/11/22). The PMD documented their response 6/5/23 that Resident #113 was prescribed the required dose for their symptoms. Nursing Note dated 5/22/23 documented Resident #113 was found seated on the floor in front of their bed at 7:02 AM. Resident #113 reported they were trying to move from the bed to the wheelchair. Continue to monitor. The Medical Doctor Order (MDO) 5/30/23 documented Resident #113's order to receive Risperidone 0.5 mg at bedtime for agitation would stop after 32 days. The Medication Administration Record (MAR) from 5/1/23 to 6/7/23 documented that Risperidone 0.5 mg was administered daily at bedtime. There was no documented evidence a GDR of Resident #113's Risperidone .5mg was attempted despite Resident #113 displaying appropriate behaviors and stable cognition. On 6/5/23 at 3:41 PM, an interview was conducted with Certified Nursing Assistant (CNA) # 3 who stated that Resident #113 does not exhibit behaviors. The resident does not get agitated and is very cooperative. On 06/06/23 at 08:22 AM, an interview was conducted with Licensed Practical Nurse (LPN) #2 who stated that Resident #113 has no behaviors The resident is always gentle and calm. Resident #113 sleeps at night and does not get agitated. On 06/06/23 at 12:16 PM, an interview was conducted with Clinical Nurse Manager (CNM) #1 who stated that Resident #113 does not exhibit agitation. They like to listen to the radio and play music loudly. Resident #113 interacts well with everyone. Resident #113 is on Risperidone 0.5 mg at bedtime for Agitation. The Psychiatrist sees the resident. On 06/06/23 at 12:24 PM, an interview was conducted with Attending Physician (AP) #1 who stated that Resident #113 is on Risperidone 0.5 mg at bedtime for Agitation, which was started on 8/11/22. There have not been any recent falls, so the medication is working well. They cannot taper the Risperidone, even though the pharmacist recommended tapering the medication, because it is helping the resident. AP #1 does not want Resident #113 to fall and sustain a head injury. Though there is a black box warning for the use of Risperidone, the benefits outweigh the risk, and AP #1 will not taper the medication. On 06/06/23 at 12:40 PM, an interview was conducted with the Psychiatrist who stated that Resident #113 has neurocognitive disorder and behavior problems. Resident #113 was started on a low dose of Risperidone, and the plan is to try to reduce it. There has not been any GDR since admission. Resident #113 is on a small dose, and it is tough to do a GDR. The Psychiatrist does not feel comfortable taking Resident #113 totally off of Risperidone. The resident is getting a little better. There is a black box warning, but the resident is on a lower dose. 43350 2.)Resident #82 was admitted [DATE] with diagnoses of Subdural Hematoma and Dementia with Behavioral Disturbance. The resident had no diagnosis of schizophrenia or bipolar disorder but was admitted with an order for Divalproex 250 mg twice a day for mood disorder and an order for Citalopram 10 mg daily for depression. The Behavioral Problem Care Plan initiated 02/27/2023 documented Resident #82 was verbally abusive. The care plan was updated 05/27/2023 and documented there had been no behavioral issues for the past 2 quarters. The Mood State Care Plan initiated 03/06/2023 documented Resident #82 had depression. The care plan was reviewed 05/29/2023 with a note stating that the resident's mood had been stable for the past 2 quarters A Drug Regimen Review (DRR) dated 02/2023 recommended to attempt to reduce the dosages of Citalopram and Depakote. The recommendations were repeated in 05/2023 but were not acted upon by the unit physician. Resident #82 was seen by the psychiatrist for initial evaluation on 04/29/2023. The psychiatrist noted that the resident had noticeable memory deficits but was coherent, calm, and cooperative, with stable mood, had been compliant with medications and had no behavioral disturbances. However, psychiatrist recommended to continue the Divalproex and Citalopram without Gradual Dose Reduction (GDR). There was no documented evidence a GDR was performed for Resident #82' prescribed antipsychotic medication. On 06/06/2023 at 10:44 AM, the Attending Physician (AP) #1 was interviewed and stated that the physician prescribes psychotropic medications based on the psychiatrist's recommendations. In the case of Resident # 82, they did not respond to the pharmacist's recommendations to reduce the dose of the resident's psychotropic medications because the resident was stable on their current medications, and they did not want the resident to relapse. On 06/07/2023 at 11:56 AM, the Medical Director was interviewed and stated that the facility remains committed to doing GDRs on psychotropic medications wherever possible. The Medical Director stated that they would communicate with the psychiatrists and encourage them to revisit GDRs when they are appropriate. On 06/07/2023 at 12:33 PM, the Pharmacy Director was interviewed and stated the physician chooses not to act, however, the pharmacist has no recourse other than to continue to remind them. 483.45(e)(1) 483.45(e)(2)

Based on record review and staff interviews during the Recertification and Complaint survey, the facility did not ensure that a surety bond or similar protection with the amount equal to at least the current total amount of resident's funds. Specifically, the surety bond held by the facility did not cover the total amount of resident personal funds deposited with the facility. This was evident for 111 residents with personal funds out of 238 residents in the facility. The findings are: On 6/7/23 at 10:16am, the Finance Manager presented a surety bond in the amount of $150,000 with an effective date of 5/4/2009. The finance ledger dated 6/7/2023 with residents funds amount documented the current total amount of resident's funds was $257,687.53. The facility did not ensure that the value of the surety bond covered funds currently held in all residents accounts. On 6/7/23 at 12:54pm, the Finance Manager stated the amount of the surety bond was established in 2007. The Finance Manager stated there is an additional $90,000 in a CD (certificate of deposit), totaling the amount of surety at $240,000. The Finance Manager reported since COVID residents have had extra money coming in so it increased the total amount of residents funds. The Finance Manager reported the facility has never reviewed the surety bond since it was established in 2007. 415.26(h)(5)(v)

Based on observation, record review, and interviews conducted during the Recertification survey from 6/1/23 through 6/8/23, the facility did not ensure a resident with an indwelling Foley catheter was provided care consistent with professional standards of practice. Specifically, a resident was observed several times with an indwelling Foley catheter without a Medical Doctor's Order (MDO). This was evident in 1 of the 1 residents reviewed for urinary catheter out of 38 sample residents. (Residents # 105). The findings include: The facility policy and procedure titled Urinary Catheterization dated 9/2022 documented that urinary catheter should be placed under the direction of a physician's order-catheter change monthly and as needed by a licensed nurse. Resident #105 was admitted to the facility with a diagnosis of Urinary Tract Infection and Manic Depression. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had an indwelling catheter. On 6/1/23 at 10:38 AM, 6/2/23 at 10:49 AM, 6/5/23 at 9:36 AM, and 6/6/23 at 9:14 AM Resident #105 was observed in bed with a Foley catheter drainage bag attached to the left side of the bed. An Elimination/Genitourinary Care Plan initiated on 2/13/23 documented that Resident # 105 has an indwelling catheter. A Medical Doctor Order (MDO) dated 5/11/23 to 6/7/23 did not contain an order for Foley catheter insertion or care. A Urology Consult Note dated 5/9/23 at 11:40 AM documented that Resident #105 was seen and examined, and a Foley catheter was seen in the urinary bladder. A care plan note dated 5/11/23 documented to continue with the plan of care. Foley is in place and intact. A Nurse's progress note dated 5/11/23 documented an indwelling Foley catheter in place with clear urine output. A Nurse's Progress Note dated 5/13/23 at 11:54 PM documented Foley intact/patent. A Certified Nursing Assistant (CNA) Accountability Record dated 5/15/23 through 6/7/23 documented that Resident #105 has a catheter. On 6/8/23 at 12:52 PM, an interview was conducted with Licensed Practical Nurse (LPN) #1 who stated that Resident #105 was admitted with a Foley catheter and the Foley catheter is changed every 30 days. LPN #1 also stated there is no active order for the Foley catheter and that there was an order before, but it fell off. On 6/8/23 at 1:11 PM, an interview was conducted with Clinical Nurse Manager (CNM) #1 who stated that Resident #105 had been on the floor for a while and was admitted with a Foley catheter for Benign Prostatic Hyperplasia (BPH). CNM #1 also stated that the Foley catheter is changed every month, and there is supposed to be an order for the Foley catheter, and the nurses are responsible for picking up the orders. CNM #1 further stated that they did not know why there was no order in the computer for the catheter. On 6/8/23 at 2:14 PM, an interview was conducted with the Director of Nursing (DNS) who stated that Resident #105 was admitted from the hospital with the Foley catheter, and as per the doctor, the Foley cannot be discontinued because of the resident's history of BPH. The DNS further stated that there should have been an order in place and the nurses and doctors are responsible for ensuring that the orders are in. 415.12(d)

Based on record review and staff interview conducted during the Recertification/Complaint survey from 6/1/23 to 6/8/23, the facility did not ensure that the resident and their representatives were provided with a written summary of the baseline care plan. This was evident for 1 of 3 residents reviewed for Advance Directive out of a sample of 35 residents. (Resident #229). The finding is: The facility policy and procedure titled Comprehensive Care Planning - Baseline Care Plans dated September 2022 documented: .The facility must provide the resident and their representative with a summary of the baseline care plan that includes but not limited to: The initial goals of the resident; A summary of the resident's medication and dietary instructions; Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; Any updated information based on the details of the comprehensive care plan, as necessary. Resident #229 was admitted to the facility with diagnoses that included Hypertension, Gastroesophageal Reflux Disease, Cerebrovascular Accident (CVA), Seizure Disorder. The Admission Minimum Data Set (MDS) dated [DATE] documented the resident had severe impairment in cognition with long and short-term memory problems and is total dependence of staff for all activities of daily living. The MDS also documented that resident's family or significant other participated in the assessment. Review of the Resident's medical record contained no documented evidence that a copy of the baseline care plan had been provided to the resident's designated representative. On 06/07/23 at 11:31 AM, an interview was conducted with the resident's representative who stated that they were not given a written summary about the baseline care plan. On 06/05/23 at 11:49 AM, an interview was conducted with the Charge Nurse (RN #1). RN #1 stated that after the completion of the baseline care plan, the Social Services department is responsible for giving out all the necessary paperwork, including the summary of the baseline care plan to the resident/resident's family. RN #1 also stated that they were not sure if, and when the copy of the Baseline care plan was given to the resident's family. On 06/07/23 at 12:08 PM, an interview was conducted with the Social Worker (SW) #1 who stated that they do not give a copy of the baseline Care Plan Summary to the family member unless they request it. On 06/07/23 at 12:20 PM, an interview was conducted with the Director of Social Services (DSS) who stated that the baseline care plan is completed by all interdisciplinary team (IDT) members within 48 hours of resident's admission, and a copy is supposed to be given to resident's family member if the resident is not able to make decision. On 06/07/23 at 01:15 PM, the Director of Nursing (DON) was interviewed and stated that they make sure that the baseline care plan was completed within 48 hours of admission, signed, and kept in the resident's file. The DON also stated that IDT members are always informed to ensure that a copy of the summary is given to the resident and/or to the family members. The DON further stated that they were surprised that this was not being done. 415.11 (c)

Based on observation, interview, and record review conducted during the Recertification Survey from 6/1/23 to 6/8/23, the facility did not ensure a comprehensive care plan (CCP) was reviewed and revised to reflect changes in the resident's care. This was evident for 1 (Resident #444) of 2 residents reviewed for Respiratory out of 38 total sampled residents. Specifically, Resident #444's CCP was not reviewed and revised to reflect that Resident #444 was receiving oxygen therapy. The findings are: The facility policy titled Comprehensive Care Planning (CCP) with no effective date and last updated in September 2022 documented the CCP will be kept current by all disciplines on an ongoing basis. It also documented each discipline will be responsible for updating the care plan and alerting the team that a new problem has been identified. Resident #444 was admitted to the facility with diagnosis including Respiratory failure with hypoxia, Heart failure, and Chronic Obstructive Pulmonary Disease) The Admission Minimum Date Set 3.0 (MDS) dated [DATE] documented Resident #444 had intact cognition, was on oxygen therapy, and only Resident #444 participated in the assessment. On 06/01/23 at 11:08 AM, Resident #444 was interviewed and stated they were on oxygen at all times before and after current admission to the facility. On 06/01/23 11:12 AM, 06/02/23 at 12:20 PM, 06/05/23 at 02:22 PM, 06/06/23 at 10:19 AM, 06/07/23 at 12:00 PM, 06/08/23 at 09:51 AM, and on other occasions during the survey, Resident #444 was observed receiving oxygen through nasal cannula from the oxygen delivery setting on the wall. Patient Orders dated 5/12/23 documented Oxygen via Nasal Cannula at 3 Liters per minute. Telephone order dated 5/20/23 documented give O2 2lt (liters) via nasal cannula. The CCP related to COPD/Respiratory initiated 5/11/23 documented Resident #444 had COPD and interventions included to observe for signs of acute respiratory distress, monitor for side effects of respiratory treatments, and administer respiratory treatment of Breo Ellipta. There was no documented evidence that the care plan had been updated to reflect that resident was placed on oxygen therapy. On 06/05/23 at 02:51 PM, Certified Nursing Assistant (CNA) #5 was interviewed and stated Resident #444 was alert and oriented and had been on oxygen all the time since they were admitted the unit. On 06/05/23 at 03:37 PM, the Clinical Nurse Manager (CNM) #1 was interviewed and stated the RNs on the unit were responsible for creating, reviewing, and updating the care plans for residents after the MDS assessments and as needed. CNM #1 also stated they remembered they called the physician to obtain the oxygen order for Resident #444 after their admission to the facility and the oxygen order was not discontinued. CNM #1 stated it was their error for not updating the care plan of COPD to reflect oxygen use for Resident #444. On 06/05/23 at 03:56 PM, the Director of Nursing (DON) was interviewed and stated all the RNs on the unit were responsible for updating the care plan if needed. The DON also stated the oxygen use had to be included in the care plan if a resident had oxygen therapy. The DON stated they were not familiar with Resident #444 and was not aware Resident #444 was on oxygen therapy. The DON also stated they were not able to explain why the oxygen use was not included in the care plan for Resident #444. 415.11(c)(2)(i-iii)

Based on observation, record review, and interviews conducted during the Recertification and Complaint survey, the facility did not ensure that residents are informed and provided written information concerning their right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. This includes a written description of the facility's policies to implement advance directives and applicable State law. This was evident for 3 of 3 residents reviewed for Advance directive out of 35 sample residents (Residents #23, #121, and #229). Specifically, the facility failed to discuss and provide information concerning the resident's right and option to formulate an advance directive for newly admitted resident. The findings are: The facility Policy and Procedures titled Advance Directives dated June 2009, last revised August 2022, documented that the facility will conform to all applicable laws and regulatory agencies requirement while maintaining a program that ensures residents wishes regarding self-determination. 1) Resident #23 was admitted to the facility 03/27/2003, with diagnoses that included coronary artery disease (CAD), Cerebrovascular accident (CVA), Non-Alzheimer's Dementia. The Significant Change in Status Minimum Data Set 3.0 (MDS) dated [DATE] documented the resident had moderately impaired cognition, clear speech, made self understood, and understood others. The MDS also documented the resident participated in the assessment, and no family or significant other participated in the resident's assessment. On 06/02/23 at 09:48 AM, Resident #23 was interviewed and stated they have been in the facility for a long time, and nobody has had any discussion with them about Advance Directive since admission. The Comprehensive Care Plan (CCP) for Advance Directives dated 3/4/23, updated 5/3/23 documented that Resident #23 has a Designated Representative. The interventions included: Social Worker will review choices and options about Advance Directives on quarterly basis The CCP Evaluation note dated 3/4/23 documented that the resident's designated Representative remain in effect and the Plan of Care (POC) would be continued. The CCP Evaluation note dated 5/31/23 documented that there have been no changes requested at this time and to continue the POC. There was no documented evidence that Advance Directives (AD) were discussed with the Resident #23 or their designated representative, and no AD were noted in the medical record. 2) Resident #121 was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included Non-Alzheimer's Dementia, Seizure Disorder, and Schizophrenia. The Admission Minimum Data Set (MDS) dated [DATE] documented the resident had severe impairment in cognition with long and short-term memory problems. The MDS documented the resident is sometimes understood and had clear speech. The MDS also documented that Resident #121 participated in assessment and had no family or significant other. The Admission Minimum Data Set (MDS) dated [DATE] documented the resident had severe impairment in cognition with long and short-term memory problems. The MDS documented the resident is sometimes understood had clear speech. The MDS also documented Resident #121 participated in the assessment and had no family or significant other. On 06/02/23 at 10:49 AM, no documented evidence of Advance Directives noted in resident's chart. Resident was interviewed and stated that he/she cannot remember any staff discussed Advance Directive with him/her. There was no documented evidence that Advance Directives has been discussed with the resident or their designated representative in the medical record, and there were no AD noted in the medical record. 3) Resident #229 was admitted to the facility 03/02/2023, with diagnoses that included Hypertension, Cerebrovascular Accident (CVA), and Seizure Disorder. The Admission Minimum Data Set (MDS) dated [DATE] documented the resident had severe impairment in cognition with long and short-term memory problems. On 06/07/23 at 11:31 AM, an interview was conducted with the Resident #229's family member. The family member stated that no staff has ever discussed advance directive with them. The CCP for Advance directives dated 3/3/23 documented the resident has a designated representative. The CCP goals included: Resident will be able to make informed decisions about advanced directives; Respect advance directive. The interventions included: - Social worker will review choices and options about Advance Directives. The CCP for Advance directives Quarterly Note dated 5/30/23 documented that the resident's designated representative remains in effect. There was no documented evidence in the medical record that Advance Directives were discussed with the designated representative. On 06/05/23 at 11:49 AM, an interview was conducted with RN #1. RN #1 stated that when a resident is admitted , the Social Worker (SW) discusses the Advance Directives with the resident and the family and is to be documented in the Social Services Progress note in the resident's charts. RN also stated that resident's Advance Directive is discussed during the resident's CCP meeting, and the care plan on Advance Directive is expected to be updated by the SW to indicate the status of resident's Advance directive discussed with the resident/resident's family. On 06/07/23 at 11:34 AM, an interview was conducted with Registered Nurse Supervisor (RNS #3). RNS #3 stated that the Advance directive is the responsibility of the SW, unless if the resident's family notify the Admission Nurse of their wishes for the resident's AD, which the admission nurse will communicate to the Social Services to follow up with necessary paperwork. If the resident comes in with the DNR or Full Code paper, the admission nurse will document and inform the SW to follow up. If there is no Advance Directive for DNR/DNI, resident will be Full code pending SW discussion with the family. On 06/07/23 at 12:08 PM, an interview was conducted with the Social Worker (SW#1). SW #1 stated: Upon admission, initial assessment is completed, if resident is able to make decision, all the options of Advance Directive is discussed, if residents are not able to make the decision, and they don't have any upon admission, Advance Directive is not discussed with family member unless they have Health Care proxy. SW #1 stated that this will be documented in the initial notes. SW stated that if resident that is unable to make decision is admitted without DNR/DNI, resident will be treated as full code if there is no Healthcare Proxy for the resident. SW stated that they did not discuss the advance Directives with the family member/designated representative with the residents' designated representatives because they are not the Health Care Proxy. On 06/07/23 at 12:20 PM, an interview was conducted with the Director of Social Services (DSS). DSS stated that when residents are admitted , the Social Service discuss Advance Directive with the resident if they are alert and oriented, if resident is unable to make decision, it is discussed with the family members or designated representatives. They discuss DNR/DNI, life sustaining treatment options available when newly admitted , and also review it with them during the quarterly meeting. DSS stated that the discussion is supposed to be documented in the resident charts during initial assessment and during quarterly review. DSS stated that they were surprised that Advance Directives were not being discussed with the resident/residents' designated representative; and they are not aware that it is not being documented in the resident's charts. On 06/07/23 at 12:40 PM, an interview was conducted with the Director of Nursing (DON). DON stated that when residents are admitted , the social worker will discuss options of Advance Directives with the resident or the family member, if resident comes with Advance directives, the doctor will be notified and will be ordered, if there is none upon admission, the doctor and the social worker will discuss the advance directives with the family, which should be documented in the residents' chart. DON stated that they are not aware that this is not being done. 415.3 (e) (2)(iii).

Based on record review and interviews conducted during the Recertification survey from 6/1/23 through 6/8/23, the facility did not ensure that each resident or resident representative was offered the opportunity to participate in the review of their Comprehensive Care Plan s (CCP). This was evident for 2 out of 4 residents reviewed for care planning out of a sample of 38 residents. (Resident #54 and Resident #444). Specifically, Resident #54 and Resident # 444 were not invited to participate in their care plan meeting. The findings are: The facility policy titled Comprehensive Care Planning (CCP) with no effective date and last updated in September 2022 documented the CCP will be prepared by the interdisciplinary team that includes the input from the resident when appropriate and the resident's family or legal representative. It also documented the Social Work Department staff will make a phone call and/or mail a letter of invitation to the designated representative prior to the meeting to invite them to participate. It further documented the resident will be verbally notified of the meeting at least 48 hours in advance, and again on the day of the meeting by both Social Services and Nursing Staff. 1) Resident #54 was admitted with the diagnoses that include Urinary Retention and Osteomyelitis. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] identified Resident #54's cognition as intact with a Brief Interview for Mental status score of 15. An initial Interdisciplinary Care Conference Record/CCP Meeting note dated 2/14/23 documented that Resident #54 can participate in the CCP meeting. However, there were no documented evidence that the resident was invited or participated in the care plan meeting. A Quarterly Interdisciplinary Care Conference Record/CCP Meeting note dated 5/2/23 documented that Resident #54 can participate in the care plan meeting. However, there was no documented evidence that Resident #54 participated in the CCP meeting. On 6/7/23 at 10:00 AM an interview was conducted with Resident #54. Resident #54 stated that they were not invited to the care plan meeting and has never attended the meeting. On 6/6/23 at 4:06 PM, an interview was conducted with Social Worker #3 (SW #3). SW # 3 stated that they invite residents who have capacity to the care plan meeting. Residents' family representatives are invited if the resident has no capacity. Resident #54 was invited to the initial and quarterly care plan meeting, but they did not document if the resident attended the meeting. They should have documented it in the chart. On 6/8/23 at 9:54 AM, an interview was conducted with the Director of Social Services (DSS). The DSS stated the social worker is supposed to invite the residents and family representatives to the CCP meetings. They are supposed to document that the resident is invited and if they refuse to come. The social worker should have documented if the resident participated or did not participate. On 6/7/23 at 9:25 AM an interview was conducted with the Director of Nursing (DNS). The DNS stated that the social worker is supposed to invite the family representatives and/or the resident either by letter or phone and document that is done in all care plan meeting notes. They should have invited Resident #54 to the care plan meeting. 44843 2) Resident # 444 was admitted to the facility with diagnosis including Respiratory failure with hypoxia, Heart failure, and COPD (chronic obstructive pulmonary disease). The Admission Minimum Date Set 3.0 (MDS) dated [DATE] documented Resident # 444 had intact cognition (BIMS score 15) and only Resident #444 participated in the assessment. On 06/01/23 at 11:08 AM, Resident #444 was interviewed and stated they had been admitted to the facility for about 1 month (5/11/23) and did not recall they were invited to any care plan meeting. Resident #444 also stated they made decisions for themselves. The MDS 3.0 Schedules and CCP documented Resident #444's CCP was scheduled for 5/31/23. The Interdisciplinary Care Conference Record/CCP Meeting dated 5/31/23 had no documentation of Resident #444's or their designated representative's signature to indicate their attendance of the care plan meeting. There was no documented evidence in the electronic medical record (EMR) or hard copy chart that Resident # 444 and/or their designated representative was invited to attend or refused to attend the care plan meeting held on 5/31/23. On 06/05/23 at 03:18 PM, the Social Worker (SW) # 2 was interviewed and stated they were responsible for inviting residents and/or their designated representatives to the care plan meetings after receiving the CCP schedule from the MDS department. The SW # 2 also stated the residents and/or their designated representatives were invited to all care plan meetings including initial, quarterly, annual, significant change, or as needed. The SW # 2 further stated the care plan meeting was an opportunity and right for the residents and their designated representative to participate in the development and implementation of their person-centered plan of care and establishing the expected goals and outcomes of care. The SW # 2 stated they documented the invitation to the care plan meeting in the electronic medical record under social services. The SW # 2 was not able to find any documented evidence in the EMR or hard copy chart that Resident # 444 and/or their designated representative was invited to, attended, or refused to attend the care plan meeting held on 5/31/23. The SW # 2 stated they might have forgotten to document the invitation in the EMR. On 06/05/23 at 04:12 PM, the Director of Social Services (DSS) was interviewed and stated the social worker was responsible for inviting residents and their designated representatives to all the care plan meetings. They should documented the invitation in the medical record. The DSS checked Resident #444's medical record and was not able to find any documented evidence that Resident #444 and/or their designated representative were invited to the care plan meeting on 5/31/2023. The DSS also stated they were not able to explain the reason Resident #444 and/or their designated representative was not invited to the care plan meeting on 5/31/2023. The DSS further stated it was an error if Resident # 444 and/or their designated representative were not invited to the care plan meeting as a resident should be given the opportunity to participate in their own care plan development and set up the goals. 483.10 (c) (2-3)

Based on record review and interviews conducted during a recertification/complaint survey (NY00312233 and NY00317121), the facility did not ensure that each resident is free from abuse, neglect, and corporal punishment of any type by anyone. Specifically, on 3/7/23 Resident # 222 was touched inappropriately on their left side of body by CNA # 7 in their room and on 5/23/23 Resident # 129 was struck on the left shoulder by Resident # 238 in the hallway outside of their room. This was evident for 2 out 9 residents reviewed for Abuse. The findings include: The facility's Policy and Procedures titled Abuse Prevention Protocol dated January 2023 documented the facility shall not use or permit verbal, mental, sexual, or physical abuse of residents. It also documented all potential employees are screened against the Nursing Home Nurse Aide Registry and other responsible background checks by the nursing staffing coordinator or the personnel administrator. The facility will not employ individuals who have been found guilty of abusing , neglecting, or mistreating individuals by a court of law or had a finding entered into the New [NAME] State Nurse Aide Registry concerning abuse, neglect, mistreatment of residents. All employees would be trained on abuse prevention policy. All incidents will be investigated. The facility will report all incident or violations where abuse, neglect, mistreatment of misappropriation of property is suspected to NYSDOH according to protocol. Resident #238, the initial aggressor and later victim, was admitted to the facility on [DATE] with diagnoses including, but not limited to Depression, Cognitive Complaints, and Dementia. Accident/Incident reported dated 5/23/23 documented on 5/23/23 at approximately 2:40pm resident #129 was struck by resident #238 in the hallway outside of their room. Resident #129 was struck on the left shoulder. The incident was unprovoked. On 06/05/23 at 09:12 AM resident #238 was observed sitting calmly in dining room waiting for breakfast. The Admission Minimum Data Set 3.0 (MDS) dated [DATE] the resident had a BIMS of 12, indicating mild cognitive impairment, and requires extensive assistance with activities of daily living (ADL) Baseline care plan dated 4/21/23 documented behavioral concerns of dementia with behavioral disturbances and noted to be aggressive in the community. Psychiatric Disorders care plan dated 4/21/23 documented resident has a diagnosis of Depression and Dementia with behavioral disturbances. Interventions included monitor residents behavior, set limits to behavior, provide psychiatric medicine as ordered. Minimize environmental stimulus that might trigger symptoms, provide resident with diversional activity. Resident Safety Care plan dated 4/21/23 and updated 5/23/23 documented resident is at risk for potential abuse and actual abuse (5/23/23) related to dementia and cognitive impairment. Interventions included keep resident away from residents who were aggressive or can be potentially abusive, 5/23/23 q15 minute check (rotation), room change on 5/24/23, and psychiatric and psychological eval 5/23/23 Care plan note dated 5/23/23 at 3pm documented resident hit another resident with a plastic hanger, incident was unprovoked. Resident was standing in the hallway on his phone when this resident walked up to them and hit them on the left shoulder and returned to their room. Resident stated he hit the other resident because they were preventing their daughter from entering their room. (Residents daughter was not in the facility at the time of the incident) Resident was arrested at 5pm. Will change room when resident returns to the facility. At 9:30pm resident was assaulted by the resident they assaulted earlier in the day. The resident sustained a cut 1.5(L) x 0.5 (D), bleeding noted, local treatment applied. Unit change was canceled because the other resident was arrested. Actual/at risk for resident to resident altercation care plan dated 5/23/23 documented actual abuse on 5/23/23 at 3pm and 9pm. Interventions included keep resident away from residents who are aggressive and have unprovoked aggression, keep resident within viewing distance for observations as much as possible, protect resident from further harm with room change and floor change. Altered thought process care plan dated 4/23/23 documented dementia. Interventions included provide cues and redirection and reality orientation as needed, monitor effects of psych meds (Memantine and Mirtazapine) Mood state/behavior problems are plan dated 4/22/23 documented agitation related to dementia with behavioral disturbances. Interventions included give psych meds as ordered, provide emotional support, monitor effects of meds. Accident/Incident reported dated 5/23/23 further documented on 5/23/23 The social worker interviewed resident #238 and the resident reported resident #129 was preventing resident #238 daughter from entering their room. Resident #238's daughter was not in the facility at the time of the incident. The social worker interviewed #129 and the resident reported they were listening to music on their phone with headphones in. Resident #129 reported resident #238 approached them and asked them to move and when they didn't move resident #238 struck them with a plastic hanger on the shoulder. The facility reviewed 7th floor video footage. The footage revealed at 2:22pm Resident #129 was standing in the hallway by their room. At 2:24pm resident #238 came out of their room and approached resident #129 and hit them with a plastic hanger. Again at 2:24pm staff were observed talking to resident #129 in the hallway. At 2:25pm resident #129 returned to their room. The investigative report noted both residents were assessed by the physician and #238 was referred to psychology and psychiatry and ordered to be transferred to the hospital for a psychiatric evaluation. The social worker called 911 and reported the incident. The social worker reported they spoke to resident #238 and told them to stay away from resident #129. The incident report stated the police arrived at the facility at 3:45pm and resident #129 wanted to press charges. Resident #238 was handcuffed and escorted from the facility. Resident #238 returned to the facility at 7pm. The facility reported they informed #238 family to notify the staff when they were leaving so they could implement Q15 min monitoring. The facility concluded there was unintentional abuse. Nursing note dated 5/23/23 at 3:13pm documented the resident is alert and responsive verbally and physically. Resident ambulates ad lib and is on 30 min observation for elopement risk, wanderguard in place to left wrist. Resident visited with daughter today, remains in room. Approximately 2:30pm writer was coming from another resident's room in the north wing and observed one of the staff members trying to stop another resident from going into this residents room. Writer was informed by the Certified Nursing Assistant (CNA) the resident hit another resident with a hanger and the other resident was trying to retaliate. Staff assigned to stay with resident while write called the nurse manager and residents social worker. MD was made aware by phone and evaluated resident. The resident stated they hit the other resident because the resident was in their way and they hit them. The resident went to their closet and presented the plastic hanger and demonstrated how they hit the other resident. The social worker called 911 at 3:09pm. Police arrived at 4:07pm. Resident was arrested and escorted off the unit at 4:30pm Resident #129, initial victim and later aggressor, was admitted to the facility on [DATE] with diagnoses including, but not limited to Mood Disorder, Bipolar Disorder, and Schizophrenia. Quarterly MDS dated [DATE] documented the resident is cognitively intact with BIMS 15, no behavioral symptoms observed. Resident safety care plan dated 5/23/23 documented resident was at risk for actual abuse on 5/23/23- resident was hit with hanger. Interventions included encourage to stay away from residents who can be aggressive or potentially abusive, monitor residents behavior, redirect and refocus resident's attention by offering diversional tactics, monitor well being using minimal or no environmental restrictions. Care plan note dated 5/23/23 at 3:30pm documented the resident was standing in the hallway in front of their room on the phone when another resident walked up to them and hit them with a hanger on the left shoulder. Resident was instructed to seek/speak to staff and not approach resident to retaliate, he verbalized understanding. Actual/at risk for resident to resident altercation dated 5/23/23 documented the resident unprovoked attacked another resident. Interventions included keep the resident away from residents who are aggressive and have unprovoked aggression, monitor well being without environmental restrictions, provide emotional support, refer to psychologist, provide talk therapy. Care plan note dated 5/23/23 documented the resident was hit unprovoked by another resident. Emotional support was provided as well as a referral to see the psychologist. Staff to follow up with talk therapy until seen by psychologist. Staff advised resident to not engage with the resident that assaulted them and if the resident approached them they were advised to let staff know and not take matters into their own hands. Resident verbalized understanding Physicians note dated 5/23/23 at 2:50pm documented the resident had a physical altercation with another resident. The resident was hit by another resident with a clothing hanger. It was unprovoked. Resident was upset and said he would hit the other resident. Resident had small redness over the shoulder, not swollen. Denied any pain. Social Work (SW) note dated 5/23/23 at 3:54pm documented the social worker was called to the 7th floor after a physical altercation between two residents. Resident was in the hallway when the other resident approached them and told them to move, the resident did not move and was then struck with a plastic hanger. staff intervened to prevent the situation from escalating. A referral to psychotherapy was written in the MD book. SW called 911 Nursing note dated 5/23/23 at 4:38pm documented the resident stated they were standing in the hallway in front of their room when the other resident came over and hit them on the left shoulder. Write and staff calmed resident down and escorted them to their room. The nurse manager, social worker, and MD were notified. the resident was evaluated by the MD. Resident continued to threaten to hit the other resident back except if the other resident is moved off the floor. 911 was called and the police escorted the resident that assaulted this resident off the unit. The resident informed the social worker that the resident wanted to press charges. The resident remained in their room resting in no acute distress. On 06/05/23 at 11:35 AM resident #238 was interviewed. Resident #238 reported their daughter was at the facility on 5/23/23 and was trying to get some food for them. The resident stated resident #129 was blocking the door for their daughter so resident #238 took a hanger and hit resident #129. The resident went to their closet in their room and showed the State Agent (SA) how they hit the resident#129 and how the hanger broke. On 06/05/23 at 12:07 PM CNA #8 was interviewed. CNA #8 reported they were on the unit when the incident happened. The CNA reported the first incident happened they were down the hall and saw resident #129 standing outside of their room not facing resident #238. Resident #238 exited there room quickly and walked aggressively up to resident #129 and hit them with a hanger. The CNA reported resident #129 stated they wanted to hit resident #238 back and the staff were trying to calm him down. Both residents were brought back to their rooms On 06/05/23 at 12:19 PM Registered Nurse, RN, #4 was interviewed. RN #4 reported they were coming from the high side of the unit and they noticed a CNA was stopping resident #129 from going into resident #238 room. RN #4 said they asked the CNA what was going on and the CNA reported resident #238 hit resident #129 for no reason and resident #129 wanted to retaliate and hit resident #238 back. RN #4 stated they asked resident #129 what happened and they said resident #238 hit them with a hanger. Resident #129 was escorted to their room and interviewed and attempted to calm down. RN#4 called the nurse manager who called the DON. The MD was called and evaluated resident #129. Resident #129 said they wanted to be moved off the unit or they were going to retaliate. There was staff with resident #238 monitoring them. There was no one monitoring #129. RN #4 reported usually the aggressor is moved off of the unit. Resident #238 was arrested. After resident #238 was arrested resident #129 was calm. The managers were deciding if they were going to move resident #238, but they were arrested. On 06/06/23 at 09:15 AM Social Worker (SW) #2 was interviewed. SW#2 reported they were assigned to both residents. SW #2 stated they received a call that there was an altercation in the afternoon on the 7th floor. SW#2 reported when they got up to the unit both residents were in their rooms. They called 911 per protocol when a physical altercation happens. The SW reported they notified the residents family that doesn't have capacity, resident #238. SW #2 reported the plan was to move resident #238 off the unit, but the resident was arrested when the police came. SW #2 reported when they spoke to resident #129 they reported they wanted to attack resident #238. SW#2 reported they told resident #129 to let staff know if they need anything. SW #2 reported when a resident comes back from being arrested we want to place them in a room away from the other resident. The plan was to put resident #238 in a different bed because we knew they were coming back. SW#2 reported they were not sure why resident #238 returned to their original room on the unit with resident #129. At approximately 7pm on 5/23/23 Resident #238 returned to the facility, to their room on the 7th floor where the original incident occurred. Accident/Incident report dated 5/23/23 documented on 5/23/23 at approximately 9pm resident #129 hit resident #238 with an unknown object on the left side of the forehead. Resident #238 sustained a linear cut with some bleeding. The facility stated the incident may have been a result of the previous altercations with the residents earlier in the day. Accident and incident reported stated when resident #238 returned to the unit at approximately 7pm the nursing supervisor stated since there were 4 CNAs on the unit resident #238 should be placed on 1:1. The LPN reported the CNAs decided they would prefer to take turns and monitor the resident every 15 minutes after the family leaves and pending unit change. 991 was called and EMS arrived at 9:10pm. Video surveillance revealed at 8:55pm resident #129 came out of their room and went into resident #238 room. Within the same minute, at 8:55pm resident #129 was seen exiting resident #238's room and the resident was seen exiting the room. At 9:57 resident #238 approached the nursing stations. EMS arrived 9:10pm and at 9:20pm resident #129 was handcuffed, arrested, and escorted out of the facility. During an interview with police resident #129 admitted to hitting #238 because the resident struck them earlier in the evening. Resident #238 was ordered to be transferred to the hospital for evaluation. Resident #238 refused to go to the hospital and EMS deemed the resident stable. Family of resident #238 was interviewed and stated they left the facility around 8:45pm and forgot to inform the staff they were leaving, but went back and did. The facility reported the unit staff were interviewed and reported they were not informed the residents family was leaving and to being Q15 minute monitoring. The facility reported resident #129 was charged with assault and possession of a weapon. WR was discharged from the facility as a result. Nursing note 5/23/23 at 11:56pm documented the resident #129 attacked resident #238 in their room as retaliation from an earlier physical altercation. Resident #129 was arrested and escorted out of the facility by the police. Care plan note for resident #129 dated 5/23/23 at 9:35pm documented resident #129 assaulted resident #238 with an unknown object. Resident #129 admitted to staff and NYPD to hitting resident #238 in retaliation from an earlier incident. The resident was arrested and escorted out of the facility. Care plan note for resident #238 dated 5/23/23 documented at 9:30pm resident #238 was assaulted by resident #129, the resident they assaulted earlier in the day. Resident #238 sustained a cut 1.5(L) x 0.5 (D), bleeding noted, local treatment applied. Unit change was canceled because the other resident #129 was arrested. Nursing note dated 5/24/23 at 2:45am documented resident #238 was observed at beginning of shift being hand cuffed and escorted off the unit at 4:30pm after a physical altercation with another resident. Resident #238 returned to the unit at 7:06pm accompanied by 2 daughters. At approximately 9:00pm the resident came to the nursing station with face bloody on the left side. Resident #238 reported they were resting in their room when the resident they assaulted earlier in the day came into their room and hit them on the forehead for retaliation. 911 was called, family and MD were made aware. Resident #238 refused to go to the ER. Placed on q 15 minute monitoring. Physician note dated 5/24/23 at 11:29am documented resident #238 had an physical altercation with resident #129 who hit them on the head, resulting in a small skin laceration on the left side of the head. Superficial about 0.1 cm deep and 1.5 cm long. Apply Bacitracin twice a day for seven days. On 06/05/23 at 12:07 PM CNA #8 was interviewed. CNA #8 reported when resident #238 returned to the facility both residents appeared to be calm in their rooms. The CNA reported the staff were doing checks on the residents, but both of them were calm so no one was concerned. The CNA reported they were in the dining room in the evening when resident #238 came in with blood on their head and stated they were hit by resident #129. On 06/06/23 at 09:27 AM Registered Nursing, RN, #5 was interviewed. RN#5 reported when they first came on their shift they did rounds on seventh floor and they were notified there was an incident between the residents. RN #5 reported they told security to notify them when resident #238 returns from the hospital or being arrested. RN #5 reported thetr was supposed to be a room change for resident #238 and they did not recall what happened with that. RN#5 reported resident #238 should have been put on a different unit. RN #5 reported administration or the Director of Nursing (DON) will move the residents room. RN#5 reported they were told to put resident #238 on q15 minute monitoring. RN #5 stated they told the staff they wanted to put the resident on 1:1 but the DON wanted q15 minute. RN #5 stated. They got a phone call when about the incident in the evening. Resident #238 had a laceration on the left side of the head. RN #5 reported they were told resident #238 was hit by resident #129. Resident #129 was standing in the doorway of their room and on the phone. RN #5 reported they called 911 and ems. On 06/05/23 at 11:51 AM the DON was interviewed. The DON stated resident #238 was put on q15 minute monitoring after the initial incident, but it was taken away when the resident was arrested. The DON reported resident #238 returned to the facility around 7pm with their 2 daughter. The DON stated staff were told to do rotating Q15 minute monitoring of the resident once their family leaves. The DON reported the residents daughter was informed to notify staff when they were leaving so staff could start the official Q15 minute monitoring. The DON reported up until the daughters left the staff were just observing resident #238. The DON reported since the family was with the resident they did not want to interrupt their family time. The DON reported the residents daughter told them they notified staff when they left, but couldn't not say who. The DON reported they interviewed the staff on the unit and no one was able to confirm they had been notified when the daughters left. The DON reported the daughter left around 8:45pm. On 06/06/23 at 09:56 AM the DON was re-interviewed. The DON stated resident #238 was supposed to be move to another unit. Resident #238 came back around 7pm and the plan was to move them to the 2nd floor. The DON reported the room was occupied with other belongings and was supposed to be cleaned and made ready when the resident returned. The room on the second floor was not ready when resident #238 returned from being arrested. The plan was to monitor resident #238 and move them when the room was ready. The DON reported an hour and a half later they got the call that the second incident happened. After the second incident resident #129 was arrested the room change was canceled. The DON reported resident #129 tried to retaliate on resident #238 earlier and that's why we put the room change into action. 44843 2) Resident # 222 was admitted to the facility on [DATE] with diagnoses including CHF, Acute on Chronic Respiratory failure, and Shortness of breath on exertion. The Quarterly Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident # 222 had BIMS score 15 or cognitively intact and required supervision with setup for most ADLs. It also documented only Resident # 222 participated in the assessment. Resident # 203 (roommate of Resident # 222) had the Quarterly MDS conducted on 1/25/23 and it documented Resident # 203 had BIMS score 15 or cognitively intact. On 06/01/23 at 10:30 AM, Resident # 222 was interviewed and stated the CNA # 7 entering their room on 3/7/23, standing behind them, placing head closed to their left shoulder, and touching their left breast. Resident # 222 also stated the CNA # 7 was not assigned to them that day or before. Resident # 222 stated they talked to the roommate Resident # 203 about the incident and Resident # 203 reported it to the Social Worker (SW) # 2. Resident # 222 stated they only wanted to confirm the arrangement for the cardiologist appointment on 3/9/23 was set up when the CNA # 7 entered their room, did not complain of having pain nor receive any snack. The facility's Incident Reported documented on 3/7/23 at 10:30 AM, Resident # 222 stated they were touched inappropriately at left shoulder and breast by a male CNA. CNA Assignment Sheet on 3/7/2023 documented the CNA # 7 was not assigned to Resident # 222. The background check of the CNA # 7 before hiring was clear and revealed no finding of abuse during the investigation of alleged sexual abuse on 10/7/22. The National Sex Offender search on 10/7/22 had no records returned. The Department of Corrections and Community Supervision Incarceration Lookup on 10/7/22 indicated no individual on file bearing the CNA # 7's name. The DOH CHRC completed upon hire. Resident # 222 statement dated 3/7/23 documented they were in the room appropriately between 10:30 AM and 11:00 AM when they were touched on the side of waist and breast from the back by CNA # 7. Resident # 222 pulled away from the CNA # 7 and told the CNA # 7 not to touch them. Resident # 222 had conversation with the CNA # 7 about the upcoming clinical appointment and there was no further issue afterward. Resident # 203 (the roommate) statement dated 3/7/23 documented Resident # 222 told them in confidence that Resident # 222 was touched by the CNA # 7 on the side, massaged at shoulders, and then touched breast at appropriately 11:30 AM. Resident # 203 stated they were in the room when the CNA # 7 entering the room with empty-handed. Resident # 203 also stated their bed was by the door and Resident # 222's bed was by the window. The CNA # 7 statement dated 3/7/23 documented they were dropping a yogurt for Resident # 222 when Resident # 222 was concerned about the upcoming cardiologist appointment on 3/9/23. The CNA # 7 also documented they touched Resident # 222's shoulders to check for bruise after Resident # 222 complaining pain at the shoulders and Resident # 222 expressed discomfort for the touch. The CNA # 7 further documented they informed the nurse of Resident # 222's concern afterward. The RN Supervisor (RNS) #1 statement dated 3/7/23 documented the CNA # 7 reported to them that Resident # 222 wanted to confirm the arrangement of cardiac appointment on 3/9/23 was set up and had pain. The RNS # 1 also documented Resident # 222 did not mention any pain to them when they conveyed the upcoming cardiac appointment arrangement to Resident # 222. The Medicine note dated 3/7/223 documented the MD # 2 assessed Resident # 222 same day after an alleged touching incident happened in the morning. It also documented Resident # 222 did not feel comfortable in taking off their sweater for the MD # 2 to assess and touch their shoulders. The Psychology Consult note dated 3/8/23 documented the visit was a request after the Resident # 222 alleged they were touched inappropriately by a male CNA. It also documented Resident # 222 was clear and credible when reporting this incident and had no serious psychological problems. It further documented Resident # 222 spoke congruently about what happened. The Facility Investigation Report documented the CNA # 7 stated entering Resident # 222's room and touching Resident # 222's shoulders to check for bruises after Resident # 222 complaint of having pain at bilateral shoulders. The Resident # 222 refused to call 911 for reporting the incident. The CNA # 7 did not enter Resident # 222's room for the rest of day according to the camera review. Video review was conducted on 6/5/23 at 2:14 PM with the presence of Director MIS (Management of Information System) and Assistant Director of Nursing (ADON). The video played the hallway surveillance outside Resident # 222's room from 11:04:11 to 11:10:42 on 3/7/23. It showed the CNA # 7 had nothing at right hand and held a dark flat thing at the left hand when entering Resident # 222's room at 11:04:52. The CNA # 7 left Resident # 222's room at 11:08:32. At 11:09:16, it showed the CNA # 7 talked to the RN Supervisor # 1 outside the nursing station and pointed to the direction of hallway where Resident # 222's room was. The video ended at 11:10:42. On 06/05/23 at 10:27 AM, the Certified Nursing Assistant (CNA) # 6 was interviewed and stated they worked on the unit for about 5 years and was assigned to Resident # 222 on 3/7/23 when the incident happened. The CNA # 6 also stated Resident # 222 was intact in cognition and quiet, stayed in their room most of time, and did not want anyone to see their body all the time. The CNA # 6 did not observe Resident # 222 had change in emotion and behavior after the incident. The CNA # 6 stated the CNA # 7 did not work long time for the facility and had not much image about the CNA # 7. On 06/05/23 at 10:39 AM, the CNA # 7 was interviewed and stated they were from the agency and worked at the facility for about 3 months. The CNA # 7 also stated male CNA were not assigned to female residents. The CNA # 7 was dropping off a snack for Resident # 222 in the room on the day. The Resident # 222 asked them if the arrangement for cardiologist appointment on 3/9/23 was confirmed and complained of pain at the upper chest area to shoulders. The CNA # 7 stated they stood in front of Resident # 222 and touched Resident # 222's bilateral shoulders to check for bruise with consent of Resident # 222. The CNA # 7 also stated it was not their responsibility to assess resident's pain. The CNA # 7 had no explanation why they did not report to the nurse if Resident # 222 complained of having pain at chest area. The CNA stated they were removed from the schedule after the incident and did not work at the facility anymore. On 06/05/23 at 10:50 AM, the Social Worker Assistant (SW) # 2 was interviewed and stated Resident # 203 reported the incident to them on 3/7/23. The SW # 2 did not observe Resident # 222 had much change in emotion or in behavior and did not request to be discharged from the facility after the incident On 06/05/23 at 11:06 AM, RN Supervisor (RNS) # 1 was interviewed and stated the CNA # 7 reported to them around 10:30 AM to 10:45 AM on 3/7/23 that Resident # 222 wanted to talk to them about the arrangement of cardiologist appointment on 3/9/23. The RNS # 1 also stated the CNA # 7 did not report Resident # 222 had pain. The RNS # 1 stated Resident # 222 did not say anything about being touched by a male CNA or having pain when they confirmed the arrangement of the clinical appointment with Resident # 222 in their room. The RNS #1 stated Resident # 222 was a cardiac patient with CHF. The CNA should not touch and should report to the nurse immediately if Resident # 222 complaining of pain at chest area. The RNS # 1 stated they were not able to explain why the CNA # 7 touched Resident # 222 and not reporting to them if Resident # 222 complained of having pain. The RNS # 1 stated Resident # 222 was quiet and only left their room for meals and activities and did not observe Resident # 222 had much change in emotion or behavior after the incident. The RNS # 1 stated the CNA # 7 worked on the unit for a couple of months, was not assigned to female residents, and had no problem before. The RNS # 1 also stated they requested a male staff to be accompanied by a female staff to enter Resident # 222's room after the incident. The RN further stated the CNA # 7 was removed from the schedule after the incident and did not see them anymore. On 06/05/23 at 11:37 AM, the Registered Nurse (RN) # 3 was interviewed and stated they were administering medications to residents on 3/7/23. The RN # 3 also stated Resident # 222 did not complain of having pain and no staff reported Resident # 222 had pain that morning. On 06/05/23 at 11:48 AM, the attending physician (MD) # 2 was interviewed and stated they assessed Resident # 222 with a female RN (RN # 3) on the same day after the incident. The MD # 2 also stated they were not able to tell if Resident # 222 was touched or not by a male staff. The MD # 2 referred Resident # 222 to a psychologist for consultation. The MD # 2 stated they reviewed the psychologist consult note dated 3/8/23 and it was very likely that Resident # 222 was touched by a male staff according to the note. On 06/05/23 at 11:58 AM, the Assistant Director of Nursing (ADN) was interviewed and stated they completed the investigation of the allegation and were educator of the facility and provided training to the CNA. The ADN also stated they instructed the CNA to report to the nurse and not to touch the residents if they complained of pain. The ADN stated the CNA # 7 admitted touching Resident # 222 in their statement. The ADN also stated they were not able to explain it. The ADN further stated they removed the CNA # 7 from schedule and did not have the CNA # 7 back to work afterward. On 06/05/23 at 12:31 PM and 06/06/23 at 09:20 AM, calls were made to the psychologist, and it was said the phone number was not working now. The DON stated the psychologist was out of country from 5/29/23 to 6/14/23. 415.4(b)(1)(i) Resident #222 Abuse Based on record review and staff interviews conducted during a recertification /complaint survey (NY00312233), the facility did not ensure that each resident is free from abuse, neglect, and corporal punishment of any type by anyone. The intake: It was a facility report intake. Resident # 203 (Garcia, [NAME]), roommate of Resident # 222, reported to Social Worker [NAME] that Resident # 222 told her in confidence that the male CNA [NAME] ([NAME] Sackie) went into their room massage their shoulders and then touched their breast. Resident # 222 was interviewed by SW [NAME] and stated that at approx. 10:30am - 11am she was i [TRUNCATED]

Based on record review and interviews during an abbreviated survey (NY 00302577), the facility failed to protect resident's right to be free from sexual abuse and psychological harm using the reasonable person concept. The facility did not ensure that each resident was free from resident to resident sexual abuse for 1 out of 3 residents, sampled for sexual abuse (Resident #1). Specifically, on 09/19/2022 at 3:30 PM, a Certified Nursing Assistants #1(CNA #1) observed that Resident #1's bedroom door was closed and entered Resident #1's room. Resident #1 was lying on the abdomen on the bed with the pants down to the legs. Resident #2 was sitting in the wheelchair next to Resident #1's bed with the left middle finger inside of Resident #1's rectum. The Findings are: The Facility's Policy titled Abuse Prevention Protocol dated 12/2020, documented: The facility shall not use or permit verbal, mental, sexual, misappropriation of funds or physical abuse, including corporal punishment, or involuntary seclusion of residents. The Facility's Incident Report dated 09/19/2022, written by the Registered Nurse Manager #1 (RNM #1) documented, that Resident #2 was observed by CNA #1 with the left middle finger in Resident #1's rectum. Resident #1 was examined by the Physician on site. There were no visible injuries to the rectum, no bleeding was noted. Resident #1 was confused, and unable to recall what happened. The Facility's Investigation Summary dated 09/19/2022, at approximately 03:35 PM, documented that CNA #1 went looking for Resident #1 who had left the hallway, upon entering Resident #1's room, CNA #1 observed Resident #1 lying on abdomen with pants and diaper down and buttocks exposed. Resident #2 was sitting in wheelchair next to Resident #1's bed with finger in Resident #1's rectum. Both residents were separated for safety. Resident #1 was physically assessed by Physician and there were no signs of trauma noted to anal or rectal area. The Incident was reported to The New York State Department of Health (NYSDOH). Resident #2 was transferred to Psychiatric emergency room for an evaluation. The Facility concluded that Resident -to-Resident-sexual abuse occurred. Interventions were to prevent reoccurrence included updating resident safety abuse care plan, and monitoring of residents. All staff were educated on abuse prevention. Resident #1 with diagnoses that included [NAME]- [NAME] disease, Mental retardation, Dementia, and Multiple Cardio-Vascular Accidents. The Minimum Data Set (MDS) assessment dated [DATE], documented that Resident #1 had a Brief Interview of Mental Status (BIMS) score of 6 out of 15, indicating that Resident #1 had impaired cognition. A Potential for Abuse Care Plan, dated 08/15/2022, documented that Resident #1 was at risk for abuse due to Dementia, and Mental Retardation. The plan to prevent abuse included, minimize environmental stimuli, monitor, reassure resident, and provide diversional activity. The Abuse Care Plan was updated on 09/19/2022, with documented interventions to keep the resident away from potentially abusive residents, protect resident from further harm /sexual abuse, provide emotional support, and to monitor the wellbeing using minimal or no environmental restrictions. The Interventions did not include Psychiatric evaluation and psychological counseling. There are no staff instructions on how to monitor resident and prevent reoccurrence. Resident #2 with diagnoses that included Opiate Use disorder, Dependent on Methadone, Dementia, and Left below the knee amputation. The MDS dated [DATE], documented that Resident #2 had a BIMS score of 12 out of 15 indicating that Resident #2 had intact cognition, and no behavioral symptoms. Resident #2 required moderate assistance with activities of daily living. A Potential for Abuse Care Plan dated 05/10/2022, documented that Resident #2 had difficulty adjusting to the facility. The interventions included keeping the resident away from aggressive residents, redirect, monitor behavior, and provide emotional support. An Abuse Care Plan updated 09/19/2022, documented that the resident displayed inappropriate sexual contact with another resident. The interventions were to maintain the resident on intermittent observation, room change, and monitoring behavior. A Nursing Progress Note, by Licensed Practical Nurse #1(LPN #1) dated 09/19/2022 at 06:32 PM, documented that Resident #2 was caught molesting another resident by staff. Resident #2 had Resident #1 lying face down on bed and Resident #2 had the finger in Resident #1's anus. The residents were separated, and the Social Worker was informed. A Nursing Progress Note, by Registered Nurse (RN #1), dated 09/20/2022 at 06:30 PM documented that Resident #2 was on every 30 minutes visual observation rounds until transported to emergency room at 06:30 PM for inappropriate sexual contact with another resident. A Social Worker's note dated 09/19/2022, documented that the resident's sibling was notified via the phone of the incident involving sexual abuse imposed on Resident #1 by another resident. The resident will be monitored and provided with support. A Nursing Progress Notes written by RN #1 on 12/07/2022, documented that Resident #2 was on every 30 minutes visual monitoring. Resident was calm and did not display any inappropriate behavior. During an interview on 12/06/2022 at 02:20 PM, Resident #1 was unable to recall the date of the incident but stated that Resident #2 wheeled themselves to the room, and put Resident #1 in the bedroom, lying on bed on the stomach, then Resident #2 stuck his finger into their bottom. Resident #1 stated that they were in shocked, and did not scream, or yell for help. Resident #1 said that they are afraid of Resident #2 after what happened and felt very ashamed. Resident #1 was not assessed by the Psychiatrist and the Psychologist. During interview on 12/06/2022 at 2:55 PM, CNA #1 stated they saw Resident #1 sitting in wheelchair in the hallway, and at approximately 3:30 PM, then noticed that the resident was no more in the hallway and observed that Resident #1's room door was closed. CNA #1 said they opened the room door and saw Resident #1 lying on stomach, pants, diaper down to legs, that Resident #2 was sitting in their own wheelchair by Resident #1's bed and had their left middle finger up in Resident #1's rectum. CNA #1 said they stood at doorway and yelled for the charge nurse who came immediately and separated the two residents. During interview on 12/19/2022 at 03:00 PM, LPN #1 stated that CNA #1 called for help, as they entered Resident #1's room, CNA #1 stated they saw Resident #2 with a finger in Resident #1's rectum. LPN #1 stated that Resident #2 had feces on the left wrist, and fingers. LPN #1 stated that they took Resident #2 out of room. Resident #2 denied ever putting Resident #1 on the bed and sexually abusing Resident #1. LPN #1 said that they called the Social Worker, and Nurse Manager and reported the incident. LPN #1 said the doctor was on the unit and examined Resident #1, and they cleaned the resident up after, took Resident #1 out of room and offered emotional support. LPN #1 denied they ever witnessed Resident #2 abuse any other resident, that it was a strange and bizarre behavior on the part of Resident #2. LPN #1 stated that Resident #2 was on monitoring and every resident on the unit are on Q-30 minutes visual checks for safety but Resident #1 and Resident #2 had no prior contact or behavioral issues and were not on strict observation. LPN #1 said that the Resident #2 was transferred to psychiatric emergency and Resident #1 was placed on every 30 minutes documented observation for emotional support. During interview on 12/06/2022 at 02:30 PM, the Social Worker #1 (SW#1), stated that they met with Resident #1 after the incident and was unable to get any information out of the resident due to cognitive impairment. SW #1 said that they visited Resident #1 daily to get any information and was unable to get answers about what happened. The SW #1 said Resident #1 and Resident #2 contact was not consensual as Resident #1 lacks the capacity to consent due to impaired cognition. SW #1 said Resident #2 sexually abused Resident #1. The SW #1 said that Resident #1 was offered emotional support regularly but was not seen by a psychologist after the incident. During interview on 12/06/2022 at 04:00 PM, the Director of Nursing #1(DON #1) stated that they viewed the Facility surveillance camera to obtain a timeline of the incident and said both residents were in the hallway at 03:30 PM, and at 03:34 Pm, Resident #2 pushed Resident #1 into room. CNA #1 entered Resident #1's room at 03:39 PM. The DON said that the Facility surveillance camera video was no more available and had been recorded on. The DON #1 stated that based on eyewitness, residents and staff interview, Resident #2 did sexually assaulted Resident #1. Resident #1 was not sent to the emergency room for evaluation but received complete physical exam by in-house Physician and there was no trauma to rectum or bleeding noted. The DON #1 said that Resident #2 was admitted to Psychiatric Hospital and is currently on a different unit on closed monitoring. DON #1 said Resident #1 is doing well, had not received psychologic examination after the incident, and was closely monitored by the staff and there had been no changes in their mental status. During an interview on 12/07/2022 at 11:00 AM, Resident #2 denied touching anyone and said that they went to the Psychiatric Hospital and just returned. 10NYCRR: 415.4 (b) (1) (i)

Based on record reviews and interviews during an abbreviated survey (NY 00302577), the facility failed to ensure that an alleged violation of sexual abuse, were reported immediately, but no later than two hours after the allegation was made, if the event that caused the allegation involve abuse or result in serious bodily injury to the New York State Department of Health (NYSDOH) and Law enforcement. This was evident in 1 out of 3 residents sampled for abuse. Specifically, on 09/19/2022 at approximately 03:36 PM, Certified Nursing Assistant #1(CNA #1) observed Resident #2 sexually abuse Resident #1. The incident occurred on 09/19/2022 at approximately 03:36 PM, and the facility reported the incident to New York State Department of Health on 09/20/2022 at 03:49 PM. The facility did not have a Policy and Procedure on reporting crimes to Law Enforcement and the incident was not reported to Law Enforcement. The findings are: The facility's policy titled Abuse Prevention, last reviewed 12/2020, documented upon review of circumstances, there is sufficient evidence that there is reasonable cause to believe that abuse has occurred, the identified professionals must report incident to the NYSDOH within 2 hours. The HCS (health care commerce) report revealed the incident of sexual abuse occurred 09/19/2022 and was reported to NYSDOH on 09/20/22 at 3:49PM The facility did not have a policy and procedure on reporting incidents of reasonable suspicion of a crime to local law enforcement. Resident # 1 was admitted to the facility with diagnoses of mental retardation, and dementia. The Minimum Data Set (MDS) dated [DATE], documented that Resident #1 was severely cognitively impaired and required extensive assistance with activities of daily living (ADLs). Resident #2 was admitted to the facility with diagnoses which included Opiate Use Disorder, Dependent on Methadone, and Dementia. A Facility's Incident Report dated 09/19/2022, written by the Nurse Manager (RNM #1) documented that Resident #2 was observed by CNA #1 with their left middle finger in the rectum of Resident #1. Resident #1 was examined by the Physician on site. There were no visible injuries to rectum, or no bleeding. Resident #1 was confused, and unable to recall what happened. A Facility Investigation Summary dated 09/19/2022, documented that at approximately 3:35 PM, CNA #1 went looking for Resident #1who had left the hallway, upon entering Resident #1's room, observed Resident #1 lying on abdomen with pants and diaper down and buttocks exposed. Resident #2 was sitting in wheelchair next to Resident #1's bed with their finger in Resident #1's rectum. Both residents were separated for safety. Resident #1 was physically assessed by Physician and had no signs of trauma to the anal/rectal area. The Incident was reported to NYSDOH, and Resident #2 was transferred to Psychiatric emergency room for an evaluation. The Facility conducted Inservice on abuse prevention to all staff. The Facility concluded that resident -to-resident-sexual abuse occurred. The Interventions were to prevent reoccurrence included updating resident safety abuse care plans, and monitoring of residents. A Nursing Progress Note dated 09/19/2022 at 6:32 PM, written by Licensed Practical Nurse (LPN #1) documented that Resident #2 was caught molesting another resident by staff. Resident #2 had Resident #1 lying face down on bed and Resident #2 had finger in the anus of Resident #1. The residents were separated, and the Social Worker (SW #1) informed. There was no documented evidence that the facility reported the resident-to-resident sexual assault to the NYSDOH within 2 hours of occurrence or to Law Enforcement. During interview on 12/06/2022 at 04:00 PM, the Director of Nursing (DON) stated that they are aware that the facility was required to report incidents to NYSDOH within a time frame of 2 hours, the incident was reported on 09/20/2022 which was a day after the incident occurred. The DON also said they did not report the abuse to law enforcement as they were not aware that resident to resident contact was also reportable to law enforcement. The DON said the residents were separated, and Resident #2 was sent to Psychiatric Comprehensive Emergency for evaluation and is currently on another unit. The Facility Administrator was on leave and could not be reached during the onsite visit. 10 NYCRR: 415.4(b)

Based on observation, interview and record reviews conducted during an Abbreviated Survey (NY00305948), the facility failed to ensure that a resident received adequately supervised to prevent elopement. This was evident for 1 out of 3 residents sampled for Elopement (Resident #1). Specifically, on 11/22/2022 at 10:35 AM, the facility's surveillance video recording showed Resident #1 exited the facility's main lobby to the street while Security Guard (SG) #1 was sitting at the security desk. Resident #1 was able to exit the facility undetected by staff. Resident #1 was missing for approximately 6 hours before facility staff at 4:20 PM became aware that Resident #1 was missing. Additionally, Every 2-Hours Resident Round Sheet dated 11/22/2022 documented that Resident #1 was in the dining room at 12:00 PM after Resident #1 eloped the facility at 10:35 AM. The facility located Resident #1 at the hospital on 11/25/2022 and Resident #1 was readmitted to the facility on [DATE]. The findings are: The facility Policy and Procedure entitled Missing Residents with a revised date of 07/12/2022 documented that the policy is to ensure that the residents of the facility do not leave the facility without appropriate authorization and accompaniment and to ensure residents' well-being and safety while residing at the facility. The facility Policy and Procedure entitled Resident Check sheet dated 07/12/2022 documented that every resident within the facility will be visualized at least every 2 hours. CNA completes residents' hourly rounds on every 2 hourly bases and writes their initials accordingly. A Security Job Description documented to ensure all residents are escorted by a staff member and have a pass for leaving the facility. Verify all information on the pass to ensure the information coincides with the resident who is requesting to leave the facility. Resident #1 was admitted to the facility with diagnoses including Dementia-Confabulation, Depression, Mild Cognitive Disorder, and Delirium. The Minimum Data Set (MDS, a resident assessment tool) dated 10/10/2022 documented that Resident #1 had moderately impaired cognition. A Resident Care Profile dated 02/05/2022 documented that Resident #1 was being monitored for safety A Comprehensive Care Plan (CCP) for Resident's Safety secondary to Dementia was initiated on 07/18/2022. The interventions documented to monitor well-being using minimal or no environmental restriction and provide emotional support. The surveillance camera was reviewed with the Director of Nursing (DON) on 11/28/2022 at 10:30 AM. As per the DON, camera # 1 was recorded 29 minutes late, and cameras #2 and # 3 were recorded in real-time. On 11/22/2022, Camera #1 showed Resident #1 following another resident (Resident #1's roommate) and their family member onto the elevator (on the 7th floor) and all exited the elevator in the lobby. At 10:35 AM, Camera #2 showed Resident #1's roommate and their family member approached a locked turnstile. SG #1 buzzed/opened the locked turnstile and Resident #1's roommate and their family member passed through the turnstile and Resident #1 followed them through the turnstile. They were all then standing in the lobby when a hospital staff opened the locked turnstile with their ID Badge and walked past them and then past SG #1. SG #1 buzzed the main entrance/exit door, and the hospital staff exited the building and Resident #1 followed behind and exited the building. Camera #3 showed Resident #1 outside the building and going down several steps to the sidewalk and then disappearing from the camera's view. A Daily Assignment Sheet dated 11/22/2022 documented CNAs to perform rounds every 2 hours. This document revealed that each CNA on the shift was assigned to do round at a certain time (8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, and 4:00 PM). Every 2 Hours Resident Round Sheet dated 11/22/2022 documented that Resident #1 was monitored every 2 hours and the last location (dining room) was entered at 12:00 PM. There was no entry for 2:00 PM. A CNA Accountability record dated 11/22/2022 at 2:00 PM documented that Resident #1 ate 76-100 % of their lunch. The facility's surveillance camera recording showed Resident #1 exited the facility at 10:35 AM. A facility summary of the investigation dated 11/22/2022 documented that at approximately 4:20 PM, staff reported during the evening shift round that Resident #1 was not in their room and not on the unit. Code M was announced by Security at approximately 4:20 PM. The Police were notified at 6:00 PM. A Late Entry Nursing Progress Note, written by Registered Nurse (RN) #1, dated 11/23/2022 at 9:28 AM, documented that at 4:00 PM while the incoming staff was making round, Resident #1 could not be accounted for, and the initial search as per facility protocol was activated. The Nurse Manager and Assistant Director of Nursing (ADON) were on the unit and were made aware. During an interview on 12/01/2022 at 1:00 PM, CNA #5 stated that they worked the 4:00 PM - 12:30 AM shift on 11/22/2022. CNA #5 stated that they conducted an incoming round and Resident #1 was not in the unit. CNA #5 stated that they checked other residents' rooms, toilets, and dining rooms, CNA #5 went downstairs to check the activity room and Resident #1's friends' rooms on another unit. CNA #5 stated that Resident #1 was missing. CNA #5 stated that the morning shift was still on the unit, and they asked the morning staff why the 2:00 PM slot on the round sheet was not filled out for Resident #1. CNA #5 stated that no one could recall the last time they saw Resident #1. CNA #5 stated that they notified the charge nurse immediately and code M was called. All staff went to look for Resident #1, but they could not find the resident. During an interview on 11/28/2022 at 11:19 AM, CNA #1 stated that they were assigned to Resident #1 from 8:00 AM to 4:30 PM. CNA #1 stated that Resident #1 ambulates with a cane and was allowed to go to other floors to visit residents and participate in activities. CNA #1 stated that Resident #1 never voiced that they wanted to leave the facility and never exhibited exit-seeking behavior. CNA #1 stated that Resident #1 was on every 2 hours observation like all residents on the unit. CNA #1 stated that CNAs are assigned certain time slots to do rounds and document on the round sheet. CNA #1 stated that when doing rounds, they must physically see every resident and note the residents' locations on the round sheet. CNA #1 stated that they last saw Resident #1 between 10:00 AM and 10:30 AM when Resident #1 was going into the elevator. CNA #1 stated that they did not check Resident #1's location because other CNAs were assigned to monitor Resident #1. CNA #1 stated that they do end-of-shift rounds, but if they don't see Resident #1 in their room, they would assume that Resident #1 was in activity or with friends. During a follow-up interview on 11/30/2022 at 10:30 AM, CNA #1 stated that Resident #1 had their meal in the unit's dining room. CNA #1 stated that on 11/22/2022 they were not in the dining room during lunch, they were serving residents in their rooms. CNA #1 stated that they fill out the Activity of Daily Living sheet on 11/22/2022 based on what Resident #1 usually eats. CNA #1 stated that they were supposed to ask the CNAs who were in the dining room how much Resident #1 ate and then document the percentage on the sheet. During an interview on 11/28/2022 at 11:46 AM, CNA #2 stated that their responsibility is to do COVID-19 monitoring at the main entrance from 10:00 AM to 4:00 PM. CNA #2 stated that it was not their responsibility to monitor residents leaving the facility as there is a SG who is responsible for checking those entering and exiting the facility. CNA #2 stated that they did not see Resident #1 standing in front of them before Resident #1 exited the facility. During an interview on 11/28/2022 at 12:14 PM, CNA #3 stated that they were not assigned to Resident #1, and they were not the staff who signed the round sheet at 12:00 PM. CNA #3 stated that they were not assigned to do the 2:00 PM round but noted that Resident #1 was not accounted for on the 2:00 PM round. CNA #3 stated that they were planning to look for Resident #1, but a Registered Nurse (RN) asked them to help with wound care and afterward, they forgot to look for Resident #1. During an interview on 11/28/22 at 12:20 PM, SG #1 stated that they worked on the 7:00 AM to 3:00 PM shift on 11/22/2022. SG #1 stated that their responsibility is to make sure that residents who attempt to exit the facility have a pass and or is being escorted. SG #1 stated that they are supposed to make sure that all attempting to leave the facility had a pass and or an escort. Also stated that the security must identify that it is the same resident on the sticker on the pass is leaving the facility. SG #1 stated that the sticker on the pass has the resident's name and date of birth. Also stated that the nurse on the unit issues the sticker on the pass. Also stated that the escort must confirm the resident's identity. SG #1 stated that if the resident does not have a pass or not if security is not sure the resident can go out, Security will call the nurse or management for assistance. SG #1 stated that they did not see Resident #1 exiting the lobby. SG #1 stated that they were not told to check the resident's wristband. SG #1 stated that they must buzz both main doors to let resident or staff or visitors enter or exit the facility. The facility uses Code M for missing resident. SG #1 stated that they never saw Resident #1 trying to exit the facility. During an interview on 11/28/2022 at 1:03 PM, Registered Nurse (RN) #1 stated that they worked the 8:00 AM to 4:00 PM shift on 11/22/2022. RN #1 stated that Resident #1 never voiced that they wanted to leave the facility or had wandering behavior. RN #1 stated that Resident #1 had a routine to leave the unit and visit residents and then come back to their unit. RN #1 stated that CNAs are responsible for doing rounds every 2 hours and the RN is responsible to make sure that the round was done. RN #1 also stated that they are responsible to make sure that CNAs do their tasks and document accordingly. RN #1 stated that staff did not report until 4:00 PM that Resident #1 was not on the unit. RN #1 stated that an incoming staff reported that Resident #1 was missing. RN #1 directed the morning staff to look for Resident #1 and when Resident #1 was not located RN #2 called Security to activate Code M (Missing); then RN #1 notified Unit Manager and Assistant Director of Nursing (ADON), and Police were called. During a follow up interview with RN #1 on 11/30/2022 at 10:00 AM, RN #1 stated that the Unit Manager is responsible for checking if CNA is doing the Activity of Daily Living (ADL) task properly. During an interview on 11/28/2022 at 4:52 PM, CNA #4 stated that when they filled out the 12:00 PM slot on the monitoring sheet, they believed that they saw Resident #1. CNA #4 also stated they were in the dining room during lunch at 12:00 PM and saw Resident #1 in the dining room. During a follow up interview on 12/01/2022 at 1:41 PM, CNA #4 stated that it was their turn to do the 2-hour round at 12:00 PM and they believed that they saw Resident #1 in Dining Room and entered the location in the monitoring sheet that Resident #1 was in Dining Room at 12:00 PM. During an interview on 11/29/2022 at 1:54 PM, the Unit Manager (UM) #1 stated that they worked on 11/22/2022 at 8-4 shift. UM #1 stated that the facility has a protocol for residents who were not at risk for an elopement to monitor their whereabouts every 2 hours and document it. UM #1 stated that the Charge Nurse is responsible to make sure that the CNAs do proper rounding. UM #1 stated that if the resident is not out of pass or appointment, the staff should go and look for the resident. UM #1 stated that the RN on the unit is supposed to verify the 2 hours monitoring but there is no requirement for the nurse to sign at the end of the sheet. During a follow up interview on 11/30/22 at 10:44, UM #1 stated that CNAs should observe how much residents consumed and document the percentage in the accountability record. UM #1 stated that if CNA did not assist the resident with meal, they should ask the staff who assist the resident and document how much the resident consumed. Stated that the Charge Nurse is responsible to oversee if CNAs does and documented their task properly. During an interview on 11/29/22 at 4:00 PM, the DON stated that the assigned CNA entering information about how much the resident consumed, should get the information from staff who monitored the dining room. The DON stated that during the investigation on 11/22/2022 they discovered that CNA #1 entered information in the accountability record that Resident #1 had lunch while Resident #1 was not in the facility. During an interview on 11/29/2022 at 9:30 AM, the Administrator stated that they were notified of the elopement on 11/22/2022 at about 4:30 PM. The Administrator stated that Security must verify the resident identity upon attempting to leave the facility. During a follow up interview on 11/30/2022 at 2:00 PM, the DON stated that the ADON informed them on 11/22/2022 at 4:28 PM that CNA #5 from the 4:00 PM -12:00 AM shift discovered Resident #1 missing during the in-incoming round and that the Police were called. The DON stated that staff called the hospitals and again on 11/25/2022 and one of the hospitals confirmed that Resident #1 was admitted on [DATE] with UTI. The DON stated that Resident #1 was wearing the facility's wristband and the hospital was able to confirm that it was Resident #1. The DON stated that Resident #1 was readmitted to the facility on [DATE] in the evening. The DON stated that they reviewed the camera and saw that Resident #1 left the facility undetected by SG #1 via the main entrance on 11/22/2022 at 10:35 AM. The DON stated that SG #1 buzzed out the hospital staff but did not stop Resident #1. The DON stated that Resident #1 went out behind the hospital staff. The DON stated that during the investigation they discovered that CNA #1, CNA #3, and #4 failed to monitor Resident #1 and CNA #1 documented in ADL accountability that Resident #1 had lunch, while Resident #1 was not in the facility. The DON also stated that CNA # 4 document in the 2 hours monitoring sheet that Resident #1 was in the dining room at 12:00 PM. The DON stated that they have a protocol in place to monitor residents every 2 hours. At beginning of each shift, the Charge Nurse makes an assignment that all CNAs will take turns every 2 hours to do a round. The DON stated that the staff must visually see the residents before documenting on the log and if the resident is not on the unit the staff must go downstairs and check the for the resident's whereabouts. The DON stated that the Charge Nurse is responsible for checking the monitoring sheet at the end of the shift to validation that a safety check was done. The DON further stated that the staff should report negative findings. The DON also stated that the Charge Nurses should do rounds and observations to make sure that CNAs do what they are supposed to do. 10 NYC RR 415.12(h)(1)(2)

Based on observation, interviews and record review conducted during an abbreviated survey (NY 754), the facility did not ensure that a resident receive adequate supervision to prevent elopement. This was evident in 1 out of 3 residents sampled (Resident #1). Specifically, Resident #1 was assessed as a high risk for elopement and had a previous elopement attempt on 06/13/2022. On 07/09/2022 at 9:56 AM, Resident #1 successfully eloped from the facility through the front exit door when Security Guard (SG) #1 buzzed two staff members into the facility. Resident #1 has not been located. The findings are: Review of the facility's policy and procedure entitled Missing Residents updated 09/2021 documented: It is the policy of the facility to ensure that residents do not leave the facility without appropriate authorization and accompaniment. It is the responsibility of all facility personnel to act promptly when residents are seen attempting to leave the building without authorization or found outside an authorized area. Security and all facility personnel shall attempt to prevent departure, obtain assistance from others in the vicinity, announce code M, resident initials, and room number. Review of the facility's policy and procedure entitled Resident Check updated 09/2021 documented: Every resident within the facility will be visualized at least every 2 hours, in a 24-hour day. The CNA completes residents' hourly rounds on a every 2 hourly basis and writes his/her initials accordingly. The CNA visualizes each resident and indicates whereabouts/status according to the code indicated on the resident check sheet. Resident #1 was admitted to the facility with diagnoses including Rhabdomyolysis (breakdown of muscle tissue), [CONDITION(S)], [CONDITION(S)] Disorder and Dementia due to Alcoholism. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11/15, indicating moderately impaired cognition. The MDS documented that the resident required supervision for self- performance for bed mobility, transfer, walking, toilet use and personal hygiene. A review of the Hospital Course Notes from 04/08/2022-04/11/2022 documented that Resident #1 wanted to leave Against Medical Advice (AMA), Psychiatry was consulted and stated that the resident did not have capacity. A review of the Hospital and Community Patient Review Instrument dated 04/21/2022 documented that Resident #1 was under 1:1 observation due to wandering and high risk for elopement. A review of the Elopement Risk Assessment tool dated 04/22/2022 documented that Resident #1 was high risk for elopement. A review of the Comprehensive Care Plan (CCP) titled Risk for Elopement was initiated on 04/22/2022. The interventions included: apply wander guard to left ankle, close monitoring, alert security of resident risk for elopement, provide picture and check wander guard daily with monitor for accuracy. There was no documented frequency for monitoring Resident #1 on the Care Plan. A review of a Psychiatry Consult dated 05/13/2022 at 10:21 AM documented that Resident #1 had limitations on orientation but was able to name the place where they were working before. Resident #1 was able to recall how to go from their workplace to their house. Resident #1 did not have capacity to participate in discharge plan due to cognitive limitations. Continue [MEDICATION(S)] 5mg once a night. A review of a Nursing Progress Note, by Nurse Manager #3, dated 06/13/2022 at 3:56 PM documented that Resident #1 was alert and oriented x 3. At around 11:20 AM, the resident left the unit to go on the first floor. Resident #1 ran through the front door when the SG #2 opened the front door to let an employee out the building. SG #2 went after the resident and an employee who was standing outside brought the resident back inside the facility. Resident #1 was not wearing their wander guard and stated that they cut it off. A new wander guard was placed on the resident's left wrist. A review of an Elopement Risk Assessment tool dated 06/13/2022 documented that Resident #1 had risk factors for elopement. A review of the Elopement Care Plan revised on 06/13/2022 documented that Resident #1 ran out the building when the SG opened the front door to let an employee out of the building. The interventions included: apply wander guard to left wrist, observe the resident for any behavior that might indicate impeding elopement, monitor resident for wander guard placement every shift, actively involve resident or encourage resident to participate in activities. There was no documented intervention for Resident #1 to leave the unit independently. A review of the Room Check Every 30 minutes sheet from 07/01/2022 to 07/09/2022 documented that Resident #1 was being monitored every 30 minutes as indicated by staff signatures. Documentation showed that Resident #1 was last seen at 9:30AM in the hallway. A review of Nursing Progress Note by LPN #1 dated 07/09/2022 at 4:59 PM documented that Resident #1 was received on the unit at the beginning of the shift alert and responsive. At approximately 10:15 AM, staff reported that Resident #1 ran out the building. The staff reported that he/she and the SG ran after the resident. The resident ran towards 169th Street towards 3rd Avenue then got on a bus. A review of Nursing Progress Note, by Nurse Manager (NM) #1, dated 07/09/2022 at 8:12 PM documented that the CNA #1 reported that Resident #1 exited the building by prying open the second sliding door. CNA #1 alerted the SG #1. According to the CNA #1, he/she and the SG #1 pursued the resident who went towards 3rd Avenue. The staff were told by a pedestrian that the resident boarded a city bus that was going towards [NAME] Road. A search party was activated, and they searched the neighborhood for two and a half hours. 911 and the Police were informed, and the DON was notified. A review of the facility Investigation dated 07/12/2022 documented that on 07/09/2022 at around 9:56 AM, Resident #1 exited the building through the front door. A staff member was entering the facility, saw Resident #1 and tried to redirect Resident #1 without success. The staff member immediately notified Security and they both pursued Resident #1 who began to run left down 169th Street and right into 3rd Avenue. Resident #1 went on to a bus heading towards [NAME] Road. Security thought Resident #1 was a staff member. SG #1 opened, the door to let a visitor and staff into the facility. The staff asked the resident where they were going but the resident kept walking. Resident #1 was assessed as an elopement risk and had a history of removing their wander guard. The facility concluded that the staff responded promptly and alerted the Security. Resident #1 was kept under close monitoring. The facility concluded that staff responded promptly. The facility surveillance video was viewed with the DON on 07/12/2022. Recording of 07/09/2022 revealed the following: 9:56AM - SG #1 was observed sitting at the Security's desk. 9:56 AM- Resident #1 appeared in the camera walking in the lobby through the security swing gate (turnstile) opposite the Security desk. Resident #1 went directly to the front exit door. Resident #1 had a red bandana on their head and was wearing a dark colored short sleeve T-shirt and pants. 9:56 AM- Resident #1 pressed the button to the right of the inner exit door and was seen pulling on the left side of the inner sliding door as SG #1 buzzed in a staff member through the entrance. 9:56AM- Security Guard still sitting at Security's desk. 9:56AM - Resident #1 was seen going through the front doors and as DS was entering the facility. 9:56AM - Just behind the DS, CNA #1 was entering through the front door. CNA #1 seen turning in the direction of Resident #1 while Resident #1 was on the top platform outside the front door. 9:56AM -CNA #1 observed talking to SG #1 while Resident #1 continued down the steps and started running. 9:56AM -SG #1 got up from the desk and went outside with CNA #1. 9:56AM -SG #1 and CNA #1 went down the steps and started running after Resident #1. 10:02 AM- SG #1 and CNA #1 returned to the facility without Resident #1. Observations were conducted of the facility's Security System and of all residents' units on 07/12/2022. There were two sets of sliding doors in the front lobby to the left of the Security desk. Security Guard must buzz to let staff and visitors in and out. The inner sliding door can also be manually opened if one presses hard on the knob to the right. In the lobby there is a security swing gate (turnstile) opposite the Security desk that everyone must walk through to get to the Security desk and to the front exit doors. The swing gate must be opened by a SG. The facility has 4 alarm systems, 3 alarms are in the lobby and one at the back entrance. One alarm is at the first sliding door and one alarm is at the side entrance. No staff or residents are allowed to use the side doors. Two video cameras observed in the main lobby. At the SG's desk there are 16 monitors, monitoring the units and outside of the front entrance. There was no wander guard alarm system on the two elevators. During an interview on 07/12/2022 at 11:00 AM, CNA #2 stated that he/she was assigned to Resident #1 on 07/09/2022. CNA #2 stated that he/she observed Resident #1 lying in bed awake while he/she made rounds at 8:00 AM. CNA #2 stated that Resident #1 went in the Dining Room for breakfast at around minutes to 9:00 AM but Resident #1 did not eat breakfast. CNA # 2 stated that he/she monitored Resident #1 every 30 minutes. CNA #2 stated that he/she last observed Resident #1 walking in the hallway at around 9:30 AM. CNA #2 stated that Resident #1 did not have on a wander guard on 07/09/2022. During an interview on 07/12/2022 at 10:55 AM, the Dietary Supervisor (DS) stated that on 07/09/2022 around 10:00 AM, when reporting to work, he/she buzzed at the front door to gain access to the facility. The Dietary Supervisor said that someone exited the building that he/she did not recognize. DS stated that CNA #1 came in behind him/her. During an interview on 07/12/2022 at 11:10 AM, CNA #1 stated that on 07/09/2022 around 10:00 AM, he/she saw Resident #1 on the stairs outside the building and asked the resident where they were going. CNA #1 stated that Resident #1 did not answer. CNA #1 stated that he/she was entering the building just behind the Dietary Supervisor and informed SG #1 that Resident #1 was outside. CNA #1 stated that he/she and SG #1 both went outside to catch Resident #1. CNA #1 stated that Resident #1 was seen running and they could ' t catch up to the resident. During an interview on 07/12/2022 at 11:20 AM, SG #1 stated that he/she was the SG on duty when Resident #1 left the faciity on [DATE]. SG #1 stated that he/she worked at the facility on weekends. Stated that he/she was not aware that Resident #1 was a resident and that they were at risk for elopement. SG #1 stated that he/she thought that Resident #1 was a staff member, since Resident #1 was young. SG #1 stated that visitors do not sign out at the Security desk. SG #1 stated that Resident #1 first went through the swing gate in the building (the gate leads to the front desk) which SG #1 had opened for a staff member and left the gate in an open position. SG #1 stated that he/she buzzed the front door open for CNA #1 and another staff member (the DS) and Resident #1 exited the front door around at 10;00 AM. SG #1 stated that CNA #1 alerted him/her that Resident #1 was a resident. SG #1 stated that he/she and CNA #1 immediately went after Resident #1 and saw Resident #1 running up the street in front the building ([NAME] Street). Stated that Resident #1 turned unto 3rd Avenue and when SG #1 and CNA #1 got to 3rd Avenue, a bystander informed them that Resident #1 had boarded a bus. During an interview on 07/12/2022 at 11:00 AM, Registered Charge Nurse (RCN) #1 stated that all the residents are monitored every two hours. RCN #1 stated if a resident is at high risk for elopement, then the resident is placed on every 30 minutes monitoring. RCN #1 stated that he/she heard Resident #1 stating that they wanted to leave and will go downstairs. RCN #1 stated that Resident #1 did not have a home in the community and did not have capacity to make decision for discharge. RCN #1 stated that SG #2 previously called staff member to get Resident #1 from the lobby. RCN #1 stated that Resident #1 did not show any indication that he/she wanted to leave the facility prior to June 13, 2022. RCN #1 stated that a wander guard was reapplied on Resident #1. RCN #1 said Resident #1 had a history of removing the wander guard. RCN #1 stated when Resident #1 removed the wander guard, RCN #1 placed it in a different area. RCN #1 stated when he/she left work on 07/08/2022, Friday evening Resident #1 was wearing a wander guard on their right ankle. RCN #1 stated he/she checked the monitoring sheet to ensuring that staff members are signing the sheet. During a follow up interview on 08/08/2022 at 9:56 AM, RCN#1 stated that he/she observed Resident #1 left the unit independently several times after their first elopement attempt (06/13/2022). RCN #1 stated that Resident #1 had the right to go on the elevator and leave the unit independently. RCN #1 stated that the facility could not restrain Resident #1. RCN #1 also stated that there was no care plan in place for Resident #1 to go off the unit independently. During an interview on 07/22/2022 at 9:55 AM, the Registered Nurse Manager (RNM) #1 stated that he/she worked at the facility part time on weekends. RNM #1 stated that he/she made rounds during the morning on 07/09/ on Resident #1 ' s unit prior to the elopement (could not recall the time) but did not see Resident #1. RNM #1 stated that he/she went to the nurse's station. RNM #1 stated that Resident #1 was on frequent checks every 30 minutes and Resident #1 should have been wearing a wander guard. RNM #1 stated that on 07/09/2022 at around 10:00 AM, CNA #1 alerted him/her that Resident #1 had left the building. RNM #1 stated that he/she immediately initiated a search party and informed the Director of Nursing. RNM #1 stated that he/she was informed that Resident #1 entered a city bus and was not found. During a follow up interview on 08/08/2022 at 10:30 AM, RNM #1 stated that Resident #1 was allowed to leave the unit independently after their first elopement attempt (06/13/2022). RNM #1 stated that he/she was not sure if there was a care plan in place for Resident #1 to leave the unit independently. RNM #1 also stated that there should have been a care plan for Resident #1 to go off the unit independently. During an interview on 07/22/2022 at 11:14 AM, Licensed Practical Nurse #1 (LPN #1) stated that he/she was regularly assigned to the unit and was familiar with Resident #1 ' s care. LPN #1 stated that on 07/09/2022, he/she arrived at work between 8:00 AM-8:15 AM and made rounds. LPN #1 stated that he/she saw Resident #1 in their room in the bathroom. LPN #1 stated that around 8:30 AM- 9:00 AM (not sure of exact time), he/she saw Resident #1 sitting in the dining room. LPN #1 stated that he/she last saw Resident #1 walking in the hallway between 9:30 AM and minutes to 10:00 AM. LPN #1 stated that around 10:15 AM, he/she was made aware that Resident #1 left the facility. LPN #1 stated that he/she then informed the RNM #1. LPN #1 stated that Resident #1 was on every 30 minutes, and he/she observed Resident #1 with their wander guard on one of their wrists when he/she made rounds but Resident #1 had a habit of removing their wander guard. LPN #1 stated that Resident #1 was allowed to go off the unit independently. LPN #1 stated that he/she was not aware that Resident #1 made a prior attempt to leave the facility on 06/13/2022. LPN #1 also said that Resident #1 never informed him/her that they wanted to go home. During an interview on 07/12/2022 at 6:35 PM, the Director of Nursing (DON) stated that Resident #1 was assessed as high risk for elopement on admission and a wander guard was applied on Resident #1. The DON stated that he/she was aware that Resident #1 was on 1:1 in hospital but the facility could not implement 1:1 due to staffing issues. The DON stated that a wander guard was applied on Resident #1 but Resident #1 kept removing the wander guard. The DON stated that staff checked for placement and functionality of wander guards, but it was not documented. The DON stated that Resident #1 was on every 30 minutes monitoring. The DON said that Resident #1 was quiet and did not verbalize wanting to leave until an attempt on 06/13/2022 when Resident #1 was stopped by SG #2. The DON stated that wander guard was reapplied on Resident #1 and every 30 minutes monitoring continued. The DON stated that the unit nurses oversee that the CNAs perform the monitoring. The DON stated that Resident #1 was allowed to go off the unit to activities on the first floor independently and staff would alert Security when Resident #1 left the unit by elevator to the first floor. The DON stated that on 07/09/2022, staff did not see when Resident #1 left the unit therefore SG #1 was not notified. The DON stated that Resident #1 ' s picture was at the Security desk and the picture was probably given to the police for identification purpose. The DON stated that Resident #1 was still not found. The DON stated that on 07/09/2022, SG #1 did not follow the facility protocol: SG #1 left the turn style (swing gate) open and did not validate the identity of Resident #1. The DON stated that SG #1 was supposed to sign in and sign out visitors. The DON stated that the standard monitoring for residents is every 2 hours. The DON stated that the facility is looking into placing alarms in the elevators, making residents at risk for elopement pictures colored, having staff document on wander guard checks ever shift and re-in-servicing all staff on elopement prevention and Security on visitation sign in and out protocol. The DON stated that approximately 80 % of staff were re-in-serviced. 415.12(h)(2)

Based on observations, staff interviews and record reviews conducted during an abbreviated (NY 608), the facility failed to ensure that a resident Comprehensive Care Plan was revised to reflect changes in Advance Directive. This was evident in for 1 out of 10 residents sampled (Resident #1). Specifically, Resident #1 verbally informed the Social Worker (SW) #1 on 11/04/2021 that he/she wanted to change the Advance Directives from Do Not Resuscitate (DNR) to be full code. SW #1 failed to convey this information to the Interdisciplinary Team (IDT). As a result, the Physician did not change the DNR order and the resident's care plan was not revised to reflect the change. The findings are: The facility Policy and Procedure titled Comprehensive Care Planning with revised date of 08/20/2016 documented that all disciplines are responsible for reviewing, revising, and dating the plan of care and documenting interventions. The comprehensive care plan will be kept current by all disciplines on an ongoing basis. All disciplines will be responsible for updating and revising the plan of care when there is a new problem that requires intervention. Resident #1 was readmitted to facility on 11/03/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 11/10/2021 documented that Resident #1 had Brief Interview of mental Status (BIMS, used to determine attention, orientation, and ability to recall information) and scored 15/15 associated with intact cognition. The Medical Orders for Life Sustaining Treatment (MOLST) dated 09/14/2021 documented that Resident #1 had a DNR/DNI order in place. Review of Resident #1's Face Sheet documented that Resident #1 was DNR and DNI. A Resident Care Identification Codes form (no date) documented that Resident #1 was DNR. This was identified by a blue dot on the form. A Care Plan on Advance Directives initiated on 09/24/2021 documented that Resident #1 had a Living Will. The interventions documented to review choices and options about Advanced Directives and counsel on the importance of Advanced Directives. The Care Plan did not mention that Resident #1 had a MOLST form, and that Resident #1 was DNR/DNI. There were not interventions. The CNA Accountability Record had no instructions regarding Resident #1's Advance Directives status. A Social Work's (SW) Note dated 11/04/2021 documented that Resident #1 was asked about Advance Directives and that Resident #1 verified and confirmed that he/she wanted to be full code. It was documented that Resident #1 wanted to revoke the DNR/DNI that was completed in the hospital. During an interview on 11/19/2021 at 4:40 PM, Social Worker (SW) #1 stated that he/she interviewed Resident #1 and discussed Advance Directives with the resident. SW #1 stated that Resident #1 stated that he/she was revoking the DNR/DNI and wanted to be full code. SW #1 stated that he/she wrote the information in Resident #1's chart, but he/she did not complete the revoked form. SW #1 also stated that he/she did not notify the team of Resident #1's changes in Advance Directive. SW #1 stated that he/she did not revised Resident #1's care plan to reflect a change in Advance Directive. During an interview with the Director of Social Work (DSW) on 11/19/2021 at 6:00 PM, the DSW stated if a resident wanted to revoke a DNR it must be first conveyed to the Medical Doctor (MD) who will discontinued the DNR order. All DNR identifiers must be removed, the care plan updated, and the resident's wristband changed (from blue to white). The DSW also stated, if a resident is a DNR, the Social Worker assigned to the unit must ensure that all identifiers are put in place and the care plan updated. 415.11 (c) (2) (i-iii)

Based on observations, staff interviews and record reviews conducted during an abbreviated (NY 608), the facility failed to ensure that a resident received Cardiopulmonary Resuscitation (CPR). This was evident in for 1 out of 10 residents sampled (Resident #1). Specifically, on [DATE], Resident #1 verbally informed Social Worker (SW) #1 that he/she wanted to change the Do Not Resuscitate (DNR) order to full code. On [DATE] at approximately 5:15 PM, Resident #1 was observed unresponsive and without audible vital signs and CPR was not initiated. Resident #1 expired in the facility on [DATE]. SW #1 did not convey Resident #1's request to the Physician and the DNR order was not changed. The findings are: The facility Policy and Procedure titled: Advanced Directives, Do Not Resuscitate Order, Living Will, Health Care Proxy, Designated Representative revised ,d+[DATE] documented that facility will assume all residents consent to Cardiopulmonary Resuscitation (CPR) unless there is a Do Not Resuscitate (DNR) in place or the resident's condition make CPR medically futile. Revocation of DNR Order by Resident or Surrogate: A resident may revoke his or her consent to a DNR Order at any time by an oral or written declaration made to a physician or member of the nursing staff, or by any act evidencing specific intent to revoke. The facility Policy and Procedure titled: Emergency Interventions with a revised date ,d+[DATE], documented; if DNR is not in place, cardiopulmonary resuscitation must be initiated if signs of recent cessation of vital signs are in place. Call security to announce Code Blue in the PA system, call 911, initiate CPR until MD or EMS arrives to continue or pronounce. Resident #1 was readmitted to facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated [DATE] documented that Resident #1 had Brief Interview of mental Status (BIMS, used to determine attention, orientation, and ability to recall information) and scored ,d+[DATE] associated with intact cognition. The facility Resident Care Internal investigation dated [DATE] documented that Resident #1 expired on 11//,d+[DATE] and no CPR was initiated. Resident #1 identifiers identified that Resident #1 was a DNR. On [DATE] at approximately 5:15 PM during suppertime, a Certified Nurse Assistant (CNA) observed Resident #1 to be unresponsive. The nurse was immediately notified and responded to Resident #1's room. Resident #1 was observed with no pulse, blood pressure or respiration. Resident #1's eyes were fixed and dilated. Resident #1's mouth and lips ashen pale and skin on the forehead was still warm to touch. During the investigative process, it was noted that Resident #1 had revoked his/her DNR/DNI status with the Social Worker on [DATE]. However, it was not conveyed to the team, neither was the identifier removed from the chart. The DNR status was not removed from Resident #1's Face Sheet. Therefore, CPR was not performed. The Medical Orders for Life Sustaining Treatment (MOLST) dated [DATE] documented that Resident #1 had a DNR/DNI order in place. A Resident Care Identification Codes form (no date) documented that Resident #1 was DNR. This was identified by a blue dot (blue dot means DNR) on the form. A Care Plan on Advance Directives initiated on [DATE] documented that Resident #1 had a Living Will. The interventions documented to review choices and options about Advanced Directives and counsel on the importance of Advanced Directives. The Care Plan did not mention that Resident #1 had a MOLST form, and that Resident #1 was DNR/DNI. There were no interventions for DNR. The Hospital Discharge Summary dated [DATE] documented that Resident #1 was DNR/DNI. The Integrated Admission Assessment note dated [DATE] documented that Resident #1 was DNR and DNI. A Social Work's (SW) Note dated [DATE] documented that Resident #1 was readmitted from hospital with stage 4 left breast cancer. It was documented that Resident #1 was asked about Advance Directives and Resident #1 verified and confirmed that he/she wanted to be full code. It was documented that Resident #1 wanted to revoke the DNR/DNI that was completed in the hospital. During an interview on [DATE] at 4:30 PM, the Registered Nurse Supervisor (RNS) stated that while he/she was conducting rounds on [DATE] at approximately 5:15 PM, he/she received a call from a nurse on unit. The nurse reported that Resident #1 was found with no pulse, no respiration and that CPR was not initiated. The RNS stated that the nurse reported that Resident #1 had a DNR/DNI. The RNS stated that he/she responded to unit immediately and assessed Resident #1 who had no vital signs appreciated. The RNS also stated that Resident #1 was wearing a white wristband when the resident was found unresponsive. During an interview on [DATE] at 4:40 PM, Social Worker (SW) #1 stated that he/she interviewed Resident #1 and discussed the Advance Directives. SW #1 stated that Resident #1 stated that he/she was revoking the DNR/DNI and wanted full code. SW #1 stated that he/she wrote the information in Resident #1's chart, but he/she did not complete a revoked form. SW #1 also stated that he/she did not notify the team of Resident #1's changes in Advance Directive from DNR/DNI to full code. SW #1 reported that Resident #1's Face Sheet also documented that Resident #1 had a DNR/DNI in place. During an interview on [DATE] at 4:40 PM, CNA #1 stated that he/she worked from 4:00 PM to 12:00 AM on [DATE]. CNA #1 stated that during dinner time around 5:15 PM, he/she went to Resident #1's room and observed that Resident #1 was unresponsive. CNA #1 stated that he/she checked Resident #1's pulses and called the nurse. CNA #1 stated that they both checked Resident #1's vital signs again and everything was dead on the machine. CNA #1 stated that no CPR was initiated. During an interview with the Director of Social Work (DSW) on [DATE] at 6:00 PM, the DSW stated that if a resident wanted to revoke a DNR it must be first conveyed to the Medical Doctor (MD) who will discontinued the DNR order. All DNR identifiers must be removed, the care plan updated, and the resident's wristband changed (from blue to white). The DSW also stated, if a resident is a DNR, the Social Worker assigned to the unit must ensure that all identifiers are put in place and the care plan updated. The MD is informed and the DNR list updated. During an interview with the Director of Nursing (DON) on [DATE] at 6:00 PM, the DON stated that while he/she was reviewing Resident #1's expiration on Friday [DATE], it was identified that the SW #1 wrote a note stating that Resident #1 had an Advanced Directive (DNR/DNI) that was revoked on [DATE]. The DON stated that the SW # did not convey to the information to the team and the DNR identifiers were not removed from Resident #1's chart. The DON stated that CPR was not performed on Resident #1 because there were no signs of life. The DON stated that Resident #1's overall prognosis, before the [CONDITION(S)], was poor. The DON stated that CPR probably would not have made a difference. During an interview with the Administrator on [DATE] at 11:00 AM, the Administrator stated that DON notified him/her that Resident#1 expired on [DATE]. The Administrator stated that an investigation was initiated on [DATE] for the Advanced Directives because CPR was not performed. 415.5

Based on observation, record review, and interview conducted during the COVID-19 Focused Infection Control Survey completed on 12/18/20, the facility failed to establish and maintain an Infection Control Program to ensure the health and safety of residents to help prevent the transmission of COVID-19. This was evident for 1 out of 6 units observed for Infection Control (Unit 3). Specifically, 1.) facility staff were observed going in and out of the residents' rooms on quarantine without donning (applying) gowns and gloves. 2. facility staff did not disinfect multiuse medical equipment in between resident use. The findings are: The Centers for Disease Control and Prevention (CDC) guidance titled Preparing for COVID-19 in Nursing Homes, updated 6/25/2020, documents the facility should create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP (Healthcare Personnel) should wear an N95 or higher-level respirator (or facemask if respirator not available), eye protection, gloves, and gowns when caring for the resident. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected. Because of the higher risk of unrecognized infection among residents, universal use of all recommended (Personal Protective Equipment) PPE for the care of all residents on the affected unit (or facility-wide depending on the situation) is recommended when even a single case among residents or HCP is newly identified in the facility. The CDC guidance titled Responding to Coronavirus (COVID-19) in Nursing Homes, dated 4/30/20, documented that in the 48 hours prior to symptom onset of a newly identified [DIAGNOSES REDACTED]-CoV-2-infected Health Care Provider (HCP), the residents who were cared for by the HCP should be restricted to their room and be cared for using all recommended COVID-19 PPE (in accordance with CDC guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated November 4, 2020) until the HCP's COVID-19 test results are known. If the (Healthcare Personnel) HCP is diagnosed with [REDACTED]. CDC guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated November 4, 2020 provides: HCP who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), gown, gloves, and eye protection. The NYSDOH Health Advisory titled COVID-19 Cases in Nursing Homes (NH) and Adult Care Facilities dated 3/13/20 revised 7/10/20, documented that if there are confirmed cases of COVID-19 in a NH, all residents on affected units should be placed on droplet and contact precautions, regardless of the presence of symptoms and regardless of COVID-19 status. HCP and other direct care providers should wear gown, gloves, eye protection (goggles or a face shield), and N95 respirators (or equivalent) if the facility has a respiratory program with fit tested staff and N95s. Otherwise, HCP and other direct care providers should wear gown, gloves, eye protection, and facemasks. Facilities may implement extended use of eye protection and facemasks/N95s when moving from resident to resident (i.e. do not change between residents) unless other medical conditions which necessitate droplet precautions are present. However, gloves and gowns must be changed, and hand hygiene must be performed. The facility policy and procedure, titled, COVID-19 Infection Prevention and Control Measures for Residents, dated 03/2020, revised 10/2020 documented, it is the policy of the facility to prevent the spread of COVID-19. The Policy also documented that, residents who are confirmed to have COVID-19 must be isolated in a room by themselves or cohorted with another resident who is also a confirmed COVID-19 positive, and contact isolation and droplet precaution measures will be maintained. The facility policy further documented that all staff entering the rooms on isolation must wear a facemask, gloves, gown and eye protection (goggles or face shield) if available. The policy documented that any residents who have been in close contact with a COVID-19 positive must be quarantined for 14 days. On 12/18/2020, on the 3rd Floor Unit between 11:23 AM and 11:25 AM, Certified Nursing Assistant #1 (CNA #1) was observed entering and exiting resident rooms wearing a facemask and face shield and not wearing an isolation gown and gloves. Resident rooms had contact/droplet precaution signage posted on their doors. CNA#1 entered and exited Resident rooms, 366, 350, 354, 359, 362 and 364, collecting resident meal trays. CNA#1 then entered resident room [ROOM NUMBER], collected the resident's meal tray and exited the room. Resident in room [ROOM NUMBER], had tested positive for COVID-19 on 12/05/2020. CNA#1 entered and exited all resident rooms wearing a facemask and face shield and did not wear an isolation gown and gloves. On 12/18/20 from 9:55AM to 11:30 AM, observation on the 3rd Floor Unit revealed, the unit was quarantined for 14 days due to a resident testing positive for COVID-19 on 12/05/2020. Contact/droplet precaution signs were observed on the residents' doors. LPN #1 was observed in the rooms, 362, 364, 366 and 368, wearing a facemask, face shield and gloves, administering medications and performing blood pressure monitoring. LPN # 1 was not wearing an isolation gown and did not disinfect the blood pressure cuff in between each resident. On 12/18/20 at 11: 31 AM, a recreation staff was observed entering room [ROOM NUMBER] and 366 with a newspaper cart; offering newspaper to the residents. These rooms had contact/droplet signage on the doors. The recreation staff was not wearing gloves and gown. The recreation staff was only wearing a facemask. On 12/18/20 at 12: 39 PM, CNA #2 was observed in room [ROOM NUMBER] feeding a resident. The room had a contact/droplet precaution signage on the door. CNA was only wearing a facemask and was not wearing gloves and gown. LPN #1 was interviewed on 12/18/2020 at 12:20 PM and stated that the whole unit is quarantined due to a resident who recently tested positive. The LPN stated that she was fully aware that the rooms were on contact droplet isolation, but the residents are COVID-19 negative. We are just monitoring them for 14 days. The LPN further stated, there is no need to wear a gown when passing medication. The LPN stated that she only wears a gown when performing task that requires 15 minutes or more. Upon inquiry, the LPN was unable to explain why she did not clean the blood pressure cuff in between residents. CNA #1 was interviewed on 12/18/2020 at 12: 30 PM and stated that he was aware that every resident on the unit was negative for COVID-19 and that he did not need to wear a gown into the rooms. Upon inquiry, CNA #1 stated that he did not wear gloves into the rooms because he was just collecting resident food trays. A gown is only needed if performing major tasks like changing linen or transferring a resident. CNA #2 was interviewed on 12/18/2020 at 12:38 PM and stated that he was aware that every resident on the unit was COVID-19 negative and that he would not need to wear a gown into the rooms. He stated that he would only wear full PPE if the resident was COVID-19 positive. The Director of Nursing Service (DNS) was interviewed on 12/18/2020 at 1:00 PM and stated that the entire 3rd Floor Unit is quarantined until 12/14/2020 due to a resident who was tested positive for COVID-19 on 12/05/20. All residents have been tested negative for COVID-19, and they are being monitored for 14 days. The DNS stated there is no special unit dedicated to COVID-19 resident therefore; the positive resident was moved to another room. Upon inquiry, the DNS stated that the staff members are not required to wear an isolation gown when administering medications except, when performing treatments, such as aerosol type. The DNS verbalized, there are CDC and NYS DOH recommendations for extended time of exposure greater than 15 minutes when providing care. That is when full PPE is required. Picking up food trays and passing medications does not require full PPE. Upon inquiry, the DNS was unable to provide surveyor with CDC and NYS DOH recommendations. DNS voiced that gloves, face mask and face shields are to be worn all the time. 415.19(a)(1),(b)(1);400.2