Every finding on record at Carmel Richmond Healthcare and Rehabilitation Cent

Based on record reviews and interviews during survey, the facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice to maintain their highest practicable physical wellbeing. This was evident for one (1) out of four (4) residents (Resident #1) sampled. Specifically, Resident #1 was admitted to the facility with intact skin to the sacrum (a triangular, shield-shaped bone at the base of the spine) and buttocks and subsequently developed moisture associated skin damage (erosion of the skin caused by prolonged exposure to urine, stool, sweat, or wound drainage.) Treatment was not initiated until [DATE] without documented evidence of the effectiveness of treatment between [DATE] and [DATE]. Resident #1 was transferred to the hospital on [DATE] with increased leukocytosis (increased white blood cells indicating infection) and was readmitted to the facility on [DATE] with eight (8) new wounds, four (4) of which lacked a nursing assessment or physician's order for further treatment. This deficient practice resulted in actual harm to Resident #1 that was not Immediate Jeopardy. The findings are: A facility policy titled Nursing admission Assessment with a revision date of 08/2014 indicated that it is the policy that all residents are assessed on admission and care plans are developed based on the assessments. The purpose is to ensure that all residents' needs are identified and met. The Registered Nurse completes the nursing admission assessment by reviewing all questions with the resident/family member to obtain past medical history/hospitalization and current concerns and risk factors. Addresses all care plans for potential concerns (falls, pressure ulcers). Document all other pertinent information in the integrated progress notes. A undated facility policy titled Wound Management, Pressure Injury/Ulcer Care and Prevention indicated that the purpose of the policy is to ensure that evidence based best practices, national guidance are followed and standardized to minimize the potential of inconsistencies that may lead to infections, prevent pressure injury formation whenever possible by effectively treating existing pressure injuries, recognizing those residents at risk for pressure injury, and effectively implementing individualized treatment plans utilizing the most effective pressure injury prevention and management strategies. Resident #1 was admitted to the facility with diagnoses including end stage renal disease (permanent kidney failure) on hemodialysis (three days a week), diabetes mellitus (refers to a group of diseases that affect how the body uses blood sugar), and protein calorie malnutrition (a severe nutritional deficiency caused by inadequate intake of calories, protein, or both). The Minimum Data Set (a resident assessment tool) dated [DATE] documented Resident #1 had moderately impaired cognition. Resident #1 was dependent on toileting hygiene and is always continent of bladder/bowel and requires substantial/maximal assistance for bed mobility (helper does more than half the effort.) The assessment identified Resident #1 with no skin problem or pressure ulcer present. A review of the admission assessment, revealed Registered Nurse #1 performed a skin assessment of Resident #1's sacrum and bilateral buttocks and documented no wounds or redness were present. A review of the Braden Scale Pressure Injury Risk dated [DATE] revealed that Wound Care Registered Nurse #2 assessed Resident #1 to be at moderate risk for developing pressure injury as indicated by a score of 14. A review of the electronic medical record revealed that on [DATE] at 10:11 AM, Registered Nurse #3 requested a wound care consultation for Resident #1. Further review of the electronic medical record revealed no documentation by Registered Nurse #3 of an identified wound. There is also no documented evidence of the attending physician being notified of a wound. There is no documented evidence that a wound assessment was conducted until [DATE] when Wound Care Registered Nurse #2 performed a wound assessment. A review of the wound assessment dated [DATE] at 12:22 PM, revealed Resident #1 was assessed by Wound Care Registered Nurse #2 and was identified with moisture associated dermatitis (common skin inflammation causing itchy, dry rashes or irritated skin) on the sacrum and bilateral buttocks, appeared moist, pink/red, no odor, no drainage and no pain. A Physician's Order written by Medical Doctor #1 dated [DATE] documented Hydrophilic Cream (designed to absorb moisture, soothe skin, or manage wound exudate, often acting as a protective barrier) apply paste topically every shift. Apply Triad cream mixed with A&D Ointment to sacrum and bilateral buttocks every shift and when soiled after cleansing with soap and water for 30 days. Diagnosis: Irritant contact dermatitis (a nonallergic skin reaction occurs when an irritant damages the skin outer protective layer) due to fecal, urinary or dual incontinence. A nursing note dated [DATE] by Registered Nurse #4 documented skin opening to bilateral buttocks. Wound Nurse notified and Medical Doctor to evaluate. A Medical Note written by Nurse Practitioner #1 dated [DATE] at 10:53 AM, revealed Resident #1 was seen and examined for the moisture associated skin damage to bilateral buttocks. There were no new orders documented for Resident #1. A review of the treatment record that is dated [DATE] through [DATE], revealed the last treatment was applied on [DATE] at 6:00 AM. The next documented assessment of wound progression is dated [DATE] by Nurse Practitioner #1 who noted that Resident #1 was observed with moisture associated skin damage to the sacrum.A Physician's Order dated [DATE] by Nurse Practitioner #1 documented Hydrophilic Cream to be applied to the sacrum after cleansing with soap and water. A wound consultation was ordered on [DATE]. On [DATE] the order for the treatment was discontinued and new treatments ordered and administered until Resident #1 was transferred from dialysis to the emergency room on [DATE] for increased leukocytosis. Review of a surgical note written by Wound Care Specialist Physician Assistant #1 dated [DATE], revealed an examination of Resident #1's buttocks, sacrum, coccyx (tailbone), left ischium and right ischium (lower posterior back) was done. The sacrum has moisture associated skin damage with moderate serosanguinous exudate (drainage mixed with blood and yellow fluid). Measurements identified as length 6.0 centimeters, width 5.0 centimeters, depth 0.1 centimeters, and wound area 30.00 centimeters. It was documented that the wound was stable, and to continue with topical wound dressing therapy. A Physician's Order dated [DATE] documented Honey (Medi-Honey) 80%, apply Gel, topically, during the day shift, after cleansing sacral moisture associated skin damage with normal saline. Apply Medi-honey followed by calcium alginate then cover with silicone bordered dressing daily and as needed. There is no documented evidence that the current treatment was evaluated for effectiveness.Record review revealed Resident #1 was transferred to the hospital on [DATE] from dialysis due to increased leukocytosis.A review of a hospital Nursing Inpatient Note dated [DATE] at 1:08 AM documented Braden Scale score 13 indicating moderate risk for development of pressure ulcers/injuries. Mobility very limited, friction and shear- problem. Localized abnormality: Moisture Associated Skin Damage (MASD) location: sacrum. Stage 1: Trochanter left- no edema. Stage II: Trochanter right- no edema- wound drainage-none. Second stage II: Sacrum/coccyx 6-centimeter x 4 centimeters, no edema, wound drainage none. Deep Tissue Injury: right and left heel, no edema, wound edema none. Wound-other than pressure ulcer/injury (includes open surgical wounds/incisions): Left bunion, no edema, no drainage. Discoloration bilateral toes. Resident #1 was uncooperative and combative to measure the wound properly. The hospital discharge assessment dated [DATE] identified Resident #1 with unstageable wound to the right hip, deep tissue injury to left hip, deep tissue injury to left/right heel, dry gangrene of the left toe, right great toe as black and necrotic, all toes gangrene, left bunion with partial thickness (damage extending through the epidermis and potentially into the dermis) and skin loss. A review of a hospital Discharge Medical Record dated [DATE], revealed Resident #1 was discharged to the facility on [DATE] with several wounds to various body areas including but not limited to Stage III ulcer to sacrum measured 4.0-centimeter by 5.0-centimeter by 0.2 centimeters. A review of a nursing Admission/readmission note by Registered Nurse #5 dated [DATE] at 6:45 PM documented pressure wound to sacrum, wounds to bilateral hips, gangrene to all toes and bilateral heels. A Physician's History and Physical note by Medical Doctor #2 dated [DATE] at 7:10 PM documented Resident #1 with moisture associated skin damage to sacrum. The note did not identify the Stage III ulcer to the sacrum or the other wounds documented on the hospital discharge summary. A Physician's Order dated [DATE] by Medical Doctor #3 documented Collagenase Clostridium (an enzyme that breaks done collagen, acts as a debriding agent for wounds) 250 unit/gram, apply ointment topically daily. Cover with clean dressing and secure with tape, transparent film dressing, Kling (medical bandage), bordered gauze daily for diagnosis of dermal ulcer (an open, crater-like sore on the skin caused by the loss of the epidermis and top layers of the dermis, often due to pressure, poor circulation, or infection). The order did not identify a specific body site for the treatment to be applied.A review of the Treatment Administration Record dated from [DATE] through [DATE], revealed treatment was applied on [DATE] and [DATE] as indicated by letter G (Given). The order was discontinued on [DATE]. A review of the Impaired Skin Integrity care plan dated [DATE] assessed Resident #1 with impaired skin integrity and presence of skin breakdown as evidenced by moisture associated skin damage to sacrum. The care plan did not identify the presence of left hip deep tissue injury, right hip unstageable, left/right heel deep tissue injuries, left toes dry gangrene, right toe black/necrotic, all toes gangrene, and left bunion partial thickness skin loss. A Wound/Skin Assessment note written by Wound Care Registered Nurse #2 dated [DATE] at 12:18 PM, documented that they assessed Resident #1 with a right hip superficial abrasion, moisture associated dermatitis to sacrum with partial thickness erosion, bilateral lower extremities unremarkable, bilateral heels without redness, bruising, open areas or signs and symptoms of breakdown. Bilateral feet are unremarkable. This assessment did not correlate with the hospital discharge assessment. A Physician's Order dated [DATE] documented Honey (Medi honey) 80 percent, apply gel topically. Apply Medi honey followed by calcium alginate and over with silicone bordered gauze daily and as needed. Diagnosis: Irritant contact dermatitis due to fecal, urinary or dual incontinence. A Physician's Order dated [DATE] documented Hydrophilic cream (Triad). Apply paste topically after cleansing left hip abrasion with normal saline. Apply triad cream and cover with silicone bordered gauze daily and as needed for Diagnosis: Other skin changes. A review of the Treatment Administration Record dated [DATE] through [DATE], revealed that the physician's order for Hydrophilic cream (Triad) was applied as ordered. The treatment was changed on [DATE] to Honey (Medi honey) 80 percent followed by calcium alginate to apply topically daily to left hip after cleansing with normal saline. There was no documented evidence of treatment for four (4) wounds: right hip, left bunion full thickness skin loss, bilateral gangrene toes. A review of a facility Surgical Note by Wound Care Specialist Physician Assistant #1 dated [DATE] documented a detailed skin examination of Resident #1's buttocks, sacrum, coccyx, left ischium, right ischium, left trochanter and right trochanter (thigh bone). The sacrum wound was identified as moisture associated skin damage and the left hip identified as Kennedy terminal ulcer phenomenon (a type of skin sore that typically develops in patients during the final stages of life). There was no documented evidence that an assessment was done of the unstageable ulcer to the right hip, gangrene toes and wound to left bunion - partial thickness skin loss. During an interview on [DATE] at 11:26 AM, Nurse Practitioner #1 stated they assessed Resident #1 on [DATE] with redness and no skin break to the sacrum and bilateral buttocks. Nurse Practitioner #1 stated they did not follow up with the moisture associated with skin damage to sacrum and bilateral buttocks because the unit nurse would notify them if the wound was healed or if they needed additional treatment. Nurse Practitioner #1 stated they do not recall Resident #1 having gangrenous feet and toes during the times they examined Resident #1. Nurse Practitioner #1 stated they frequently examined Resident #1 because of sporadic refusal of care, treatment, and treatment with dialysis. Nurse Practitioner #1 stated Resident #1's refusal of care/treatment could have contributed to the moisture associated skin damage. During an interview on [DATE] at 4:27 PM, Registered Nurse #3 stated they worked on Resident #1's unit from [DATE] through [DATE]. Registered Nurse #3 stated they were notified that Resident #1 was observed with a skin problem to their sacrum (unsure of details) on [DATE]. Registered Nurse #3 stated they wrote an order for wound consultation on [DATE] after they assessed Resident #1. Registered Nurse #3 stated they do not see any documentation of their assessment or that they notified the medical doctor to obtain treatment. Registered Nurse #3 stated Resident #1 was assessed by Wound Care Registered Nurse #2 on [DATE] and local treatment was ordered on [DATE]. Registered Nurse #3 stated that the unit nurses were responsible for providing treatment and notifying Wound Care Registered Nurse #2 if the moisture associated skin damage/bilateral buttocks deteriorated, but not if the wounds were improving. Registered Nurse #3 stated Wound Care Registered Nurse #2 was responsible for monitoring/documenting the effectiveness of treatment. Registered Nurse #3 stated Wound Care Registered Nurse #2 should have known the last day of treatment and documented wound healing. During an interview on [DATE] at 5:33 PM, Registered Nurse #5 stated they readmitted Resident #1 on [DATE] at 6:45 PM. Registered Nurse #5 stated Resident #1 was assessed with pressure injury to the sacrum and open wounds to bilateral hips. Registered Nurse #5 stated Resident #1's legs were wrapped from below the knees down to the feet. Registered Nurse #5 stated they unwrapped the dressing from the lower extremities and observed that the bilateral heels and all the toes were necrotic. Registered Nurse #5 stated they did not notify Medical Doctor #2 or Nursing Supervisor #1 who were on duty that Resident #1 had multiple wounds, but they notified the incoming night shift nurse (unsure of name). Registered Nurse #5 stated they did not initiate a care plan for the wounds because Wound Care Registered Nurse #2 would reassess the wounds. Registered Nurse #5 stated they should have notified Medical Doctor #2 and obtained wound care treatment orders on [DATE]. During an interview on [DATE] at 2:04 PM, Wound Care Registered Nurse #2 stated they assessed Resident #1 upon initial admission to the facility and there was no pressure injury observed. Wound Care Registered Nurse #2 stated Resident #1 developed the moisture associated skin damage to sacrum and bilateral buttocks on [DATE]. They stated they were not aware treatment was not ordered on [DATE] and that the unit nurse should have notified the doctor and obtained treatment orders. Wound Care Registered Nurse #2 stated that the unit nurses should not have waited for them to assess Resident #1 because they (wound care nurse) were covering the units and making weekly wound rounds, they cannot cover everything. Wound Care Registered Nurse #2 stated that the nurse on the unit could have documented progress of the wound and effectiveness of treatment in Resident #1's progress notes. Wound Care Registered Nurse #2 stated that the nurses conducted skin assessments on Resident #1's shower days and could have notified them when the treatment was completed. Wound Care Registered Nurse #2 stated they do not know why the treatment was ended on [DATE] and no one notified them if the wounds were healed. Wound Care Registered Nurse #2 stated they reviewed Resident #1's readmission ([DATE]) discharged documents from the hospital but did not review the hospital skin assessment, they wanted to assess Resident #1's skin with their own eyes; they do not read other people's assessments. Wound Care Registered Nurse #2 stated Resident #1 did not develop pressure ulcers in the facility. During an interview on [DATE] at 3:30 PM, Registered Nurse #6 stated they were the unit manager on Resident #1's unit when Resident #1 was readmitted on [DATE]. Registered Nurse #6 stated they reviewed the hospital medical record (unsure of date) and saw the documentation of the wounds but did not notify the wound care nurse. Registered Nurse #6 stated they do not get involved with skin assessment because Wound Care Registered Nurse # 2, is responsible for skin assessment. Registered Nurse #6 stated they are aware of the discrepancies with the wounds identified in the hospital records and the wounds documented in Resident #1's medical record. During an interview on [DATE] at 3:53 PM, Hospital Doctor #1 stated Resident #1 was admitted to their hospital on [DATE] and was discharged on [DATE] to the facility. Hospital Doctor #1 stated Resident #1 had previously eight (8) documented wounds ([DATE]) and they found a new one when Resident #1 was readmitted to the hospital on [DATE]. The additional wound was on the right middle finger in the proximal interphalangeal joint (joints between the bones of the fingers), and the bone was exposed. Hospital Doctor #1 stated Resident #1 had multiple risk factors for the development of pressure ulcers including being bedbound and malnourished. Hospital Doctor #1 stated they did not know if the wounds were avoidable or unavoidable given Resident #1's comorbidities. Hospital Doctor #1 stated Resident #1 expired on [DATE] with a presumed infection due to infection of wounds and ischemic, necrotic tissues in their legs and feet. During a follow up interview on [DATE] at 1:00 PM, Hospital Doctor #1 stated Resident #1 was admitted to the hospital with multiple pressure ulcers as evidenced by the wound care team note dated [DATE] (Hospital Doctor #1 was reading the assessment from hospital wound nurse documentation) documenting Resident #1 had sacral stage III, left hip deep tissue injury (refers to damage that occurs beneath the skin's surface), left heel deep tissue injury, right heel deep tissue injury, right hip unstageable, left toes gangrene, right great toe black necrosis and left bunion (bony bump that forms on the joint at the base of the big toe). During an interview on [DATE] at 2:17 PM, Medical Doctor #2 stated they readmitted Resident #1 on [DATE] in the evening (unsure of time). Medical Doctor #2 stated they reviewed Resident #1's hospital discharge medical record (unsure of date) and observed the moisture associated with skin dermatitis but did not observe the wounds to Resident #1's bilateral hips. Medical Doctor #2 stated they attempted to assess Resident #1's lower extremities but Resident #1 refused. Medical Doctor #2 stated Resident #1 has the right to refuse to be examined. Medical Doctor #2 stated the procedure for the facility when a resident refuses, is to endorse to the incoming doctor but they do not recall endorsing to another doctor. Medical Doctor #2 stated that they did not order a podiatry consult because they did not assess Resident #1's lower extremities that were wrapped in bandages. There was no documentation evidence that Medical Doctor #2 documented Resident #1 refused to be examined on [DATE]. During an interview on [DATE] at 1:10 PM, Wound Care Specialist Physician Assistant #1 stated they visit the facility every Wednesday for weekly wound rounds. Wound Care Specialist Physician Assistant #1 stated they do not assess the whole body of a resident because Wound Care Registered Nurse #2 tells them what part of the body to assess. Wound Care Specialist Physician Assistant #1 stated they initially assessed Resident #1 on [DATE] with moisture associated skin damage to sacrum. Wound Care Specialist Physician Assistant #1 stated they and Wound Care Registered Nurse #2 examined Resident #1 on [DATE] when they were readmitted back to facility ([DATE]). Wound Care Specialist Physician Assistant #1 stated Resident #1 had moisture associated skin damage to sacrum and a left hip Kennedy terminal ulcer. Wound Care Specialist Physician Assistant #1 stated the left hip was observed to be necrotic. Wound Care Specialist Physician Assistant #1 stated they did not see the wound on Resident #1's right hip and they were not aware of the wounds on Resident #1's left bunion and gangrenous toes.During an interview on [DATE] at 6:13 PM, the Director of Nursing stated they observed there was an order for wound consultation on [DATE], but there is no documented evidence Registered Nurse #3 assessed the wound area, notified the medical doctor and obtained treatment for skin changes. The Director of Nursing stated Registered Nurse #3 should have notified the Medical Doctor and obtained treatment order. The Director of Nursing stated Registered Nurse #3 should not have waited for Wound Care Registered Nurse #2 to evaluate the skin changes unless the wound nurse was on the unit. The Director of Nursing stated the wound care nurse should have reviewed the hospital discharge documentation and compare if Resident #1 was admitted with all the wounds identified in the hospital records. The Director of Nursing stated Registered Nurse #5 (readmitted Resident #1 on [DATE]) should have notified Medical Doctor #2 of the wounds identified since Resident #1 refused assessment from Medical Doctor #2. During an interview on [DATE] at 7:40 PM, the Administrator stated they think the root cause analysis of their case with Resident #1 was that Wound Care Registered Nurse #2 did not review the hospital records which led to discrepancy of documentation and possibly delaying of treatment and that is why the wound care nurse is no longer with them. The Administrator stated the podiatry consultation is not warranted because Resident #1 was being seen by Wound Care Specialist Physician Assistant #1 and that includes assessing Resident #1's skin. The Administrator stated they were not aware Resident #1's lower extremities were not examined by Wound Care Specialist Physician Assistant #1 because the wound care nurse did not address the wounds on Resident #1's lower extremities. 10 New York Codes, Rules, and Regulations 415.12

Based on record reviews and interviews during a survey, the facility failed to ensure that medical care for each resident was effectively supervised by a physician. This was evident for one (1) out of four (4) residents (Resident #1) sampled. Specifically, 1) Resident #1 developed Moisture Associated Skin Damage (erosion of the skin caused by prolonged exposure to urine, stool, sweat, or wound drainage) to the sacrum (a triangular, shield-shaped bone at the base of the spine) and bilateral buttocks on 08/12/2025 and treatment was ordered on 08/14/2025 to be completed for 30 days. A Surgical Note by Physician Assistant #1 dated 12/17/2025 indicated wound deterioration. There was no documented evidence of effectiveness of treatment between 08/14/2025 and 09/14/2025.2) Resident #1 was readmitted to the facility on [DATE] with eight (8) wounds to various body areas, four (4) of which lacked nursing and physician assessment from 01/02/2026 through 01/10/2026. Additionally, there was no documented evidence of a physician's order for treatment of four (4) of the wounds. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy.The findings are:The facility's policy titled Physician Services /MD Communication Log with a revised date 09/2025 states that the facility's purpose is to ensure medical care of each resident is supervised by a physician, and that another physician supervises the medical care of the resident when their attending physician is unavailable. Supervising the medical care of residents means participating in the residents' medical status and providing consultation or treatment when called by the facility. Physicians are assigned to specific nursing units to provide consistent coverage for the resident's medical needs. Physician visits after the initial admission visit may alternate between personal visits by a physician assistant, nurse practitioner or clinical specialist.Resident #1 was admitted to the facility with diagnoses including end stage renal disease (permanent kidney failure) on hemodialysis (three days a week), diabetes mellitus (refers to a group of diseases that affect how the body uses blood sugar), and protein calorie malnutrition (a severe nutritional deficiency).The Minimum Data Set (a resident assessment tool) dated 07/25/2025 documented Resident #1 had moderately impaired cognition. Resident #1 is dependent on toileting hygiene and is always continent of bladder/bowel and requires substantial/maximal assistance for bed mobility (helper does more than half the effort.) The assessment identified Resident #1 with no skin problem or pressure ulcer present. A review of the Braden Scale Pressure Injury Risk dated 07/24/2025 revealed that Registered Nurse #2 (Wound Care Nurse) assessed Resident #1 to be at moderate risk for developing pressure injury as indicated by a score of 14. According to the document a total score of 18 would indicate the resident was at risk for developing pressure injuries. A review of the electronic medical record revealed that on 08/12/2025 at 10:11 AM, Registered Nurse #3 requested a wound care consultation. Further review of the electronic medical record revealed no documentation by Registered Nurse #3 of an identified wound. There is also no documentation of the attending physician being notified of a wound. There is no documented evidence that a wound assessment was conducted until 08/14/2025 when Registered Nurse #2 performed a wound assessment. A review of the wound assessment by Registered Nurse #2 dated 08/14/2025 at 12:22 PM, revealed Resident #1 was assessed by Registered Nurse #2 and was identified with moisture associated dermatitis (common skin inflammation causing itchy, dry rashes or irritated skin) in sacrum (a triangular, shield-shaped bone at the base of the spine) and bilateral buttocks, appeared moist, pink/red, no odor, no drainage and no pain. A Physician's Order written by Medical Doctor #1 dated 08/14/2025 documented Hydrophilic Cream (designed to absorb moisture, soothe skin, or manage wound exudate, often acting as a protective barrier) apply paste topically every shift. Apply Triad cream mixed with A&D Ointment to sacrum and bilateral buttocks every shift and when soiled after cleansing with soap and water x 30 days. Diagnosis: Irritant contact dermatitis due to fecal, urinary or dual incontinence. A nursing note dated 08/15/2025 by Registered Nurse #4 documented skin opening to bilateral buttocks. Wound Nurse notified and Medical Doctor to evaluate. A Medical Note written by Nurse Practitioner #1 dated 08/16/2025 at 10:53 AM, revealed Resident #1 was seen and examined for the moisture associated skin damage to bilateral buttocks. A review of the treatment record from 08/14/20225 through 09/14/2025, revealed the last treatment was applied on 09/14/2025 at 6:00 AM. Following the treatment session on 09/14/2026, there is documented evidence of wound progression or a clinical until 11/29/2025 when Nurse Practitioner #1 documented that Resident #1 was observed with moisture associated skin damage to sacrum.A Physician's Order dated 11/29/2025 by Nurse Practitioner #1 documented Triad Cream to be applied to the sacrum after cleansing with soap and water. A wound consultation was also ordered on 11/29/2025. On 12/01/2025 the order for treatment was discontinued and new treatments were ordered and administered until Resident #1 was transferred from dialysis to the emergency room on [DATE] for increased leukocytosis. A review of a facility Surgical Note written by Wound Care Specialist Physician Assistant #1 dated 12/17/2025, revealed there was an examination of Resident #1's buttocks, sacrum, coccyx (tailbone), (left ischium and right ischium (lower posterior back). The sacrum has moisture associated skin damage with moderate serosanguinous exudate (drainage mixed with blood and yellow fluid). Measurements identified as length 6.0 centimeters, width 5.0 centimeters, depth 0.1 centimeters, and wound area 30.00 centimeters. It was documented that the wound was stable, and to continue with topical wound dressing therapy. A Physician's Order dated 12/18/2025 documented Honey (Medi-Honey) 80%, apply gel, topically, during the day shift, after cleansing sacral moisture associated skin damage with normal saline. Apply Medi-honey followed by calcium alginate then cover with silicone bordered dressing daily and as needed. There is no documented evidence indicating if the treatment was effective or if the wounds were healed. Record review revealed Resident #1 was transferred to the hospital on [DATE] from dialysis due to increased leukocytosis (high white blood cell count).A review of a hospital Discharge Medical Record dated 12/30/2025, revealed Resident #1 was discharged to the facility on [DATE] with several wounds to various body areas including but not limited to a Stage III ulcer to sacrum measured 4.0-centimeter by 5.0-centimeter by 0.2 centimeters. The hospital discharge assessment dated [DATE] identified Resident #1 with unstageable wound to the right hip, deep tissue injury to left hip, deep tissue injury to left/right heel, dry gangrene of the left toe, right great toe as black and necrotic, all toes gangrene, left bunion with partial thickness (damage extending through the epidermis and potentially into the dermis) skin loss. A review of a nursing Admission/readmission note by Registered Nurse #5 dated 01/02/2026 at 6:45 PM documented pressure wound to sacrum, wounds to bilateral hips, gangrene to all toes and bilateral heels. A Physician's History and Physical note by Medical Doctor #2 dated 01/02/2026 at 7:10 PM documented Resident #1 with moisture associated skin damage to sacrum. The note did not identify the Stage III ulcer to the sacrum or the other seven (7) wounds documented on the hospital discharge summary. A Physician's Order dated 01/02/2026 by Medical Doctor #3 documented Collagenase Clostridium (a debriding agent used to remove necrotic tissue) 250 unit/gram, apply topically daily. Cover with clean dressing and secure with tape, transparent film dressing, Kling (medical bandage), bordered gauze daily for diagnosis of dermal ulcer (an open, crater-like sore on the skin caused by the loss of the epidermis and top layers of the dermis). The order did not identify a specific body site for the treatment to be applied.A review of the Treatment Administration Record dated from 01/02/2026 through 01/10/2026, revealed treatment ordered on 01/02/2026 was applied on 01/03/2026 and 01/04/2026 as indicated by letter G (Given). However, the area where the treatment was applied was not identified. A Wound/Skin Assessment note written by Registered Nurse #2 (wound care nurse) dated 01/05/2026 at 12:18 PM, documented that they assessed Resident#1 with a right hip superficial abrasion, moisture associated dermatitis to sacrum with partial thickness erosion, bilateral lower extremities unremarkable, bilateral heels without redness, bruising, open areas or signs and symptoms of breakdown. Bilateral feet are unremarkable. This assessment did not correlate with the hospital discharge assessment. A Physician's Order dated 01/05/2026 documented Honey (Medi honey) 80 percent, apply gel topically. Apply Medi honey followed by calcium alginate and over with silicone bordered gauze daily and as needed. Diagnosis: Irritant contact dermatitis due to fecal, urinary or dual incontinence. A Physician's Order dated 01/05/2026 documented Hydrophilic cream (Triad). Apply paste topically after cleansing left hip abrasion with normal saline. Apply Triad cream and cover with silicone bordered gauze daily and as needed for Diagnosis: Other skin changes. There was no documented evidence for treatment of four (4) wounds: right hip, left bunion partial thickness skin loss, bilateral gangrene toes. There was no documented evidence a podiatry consultation was ordered. A review of a facility Surgical Note by Wound Care Specialist Physician Assistant #1 dated 01/07/2026 documented a detailed skin examination of Resident #1's buttocks, sacrum, coccyx, left ischium, right ischium, left trochanter and right trochanter (thigh bone). The sacrum wound was identified as moisture associated skin damage and the left hip identified as Kennedy terminal ulcer phenomenon (a type of skin sore that typically develops in patients during the final stages of life). There was no documented evidence for an assessment of the gangrene toes and wound to left bunion - partial thickness skin loss was completed. There was no documented evidence of treatment to the right hip, gangrene toes, and left bunion partial thickness wound. During an interview on 01/27/2026 at 2:17 PM, Medical Doctor #2 stated they readmitted Resident #1 on 01/02/2026 during the evening (unsure of time). Medical Doctor #2 stated they reviewed Resident #1's hospital discharge medical record (unsure of date) and observed the moisture associated skin dermatitis but did not observe the wounds to Resident #1's bilateral hips. Medical Doctor #2 stated they attempted to assess Resident #1's lower extremities but Resident #1 refused. Medical Doctor #2 stated Resident #1 has the right to refuse to be examined. Medical Doctor #2 stated the procedure for the facility when a resident refuses, is to endorse to the incoming doctor but they do not recall endorsing to another doctor. Medical Doctor #2 stated that they did not order a podiatry consult because they did not assess Resident #1's lower extremities that were wrapped in bandages. There was no documentation evidence that Medical Doctor #2 documented Resident #1 refused to be examined on 01/02/2026. During an interview on 02/04/2026 at 1:10 PM, Wound Care Specialist Physician Assistant #1 stated they conduct weekly wounds rounds at the facility on Wednesdays. Wound Care Specialist Physician Assistant #1 stated they did not assess Resident #1's entire body because Registered Nurse #2 (wound care nurse), tells them what part of Resident #1's body to assess. Wound Care Specialist Physician Assistant #1 stated they initially assessed Resident #1 on 12/17/2025 with moisture associated skin damage to sacrum. Wound Care Specialist Physician Assistant #1 stated they and Registered Nurse #2 examined Resident #1 on 01/07/2026 when they were readmitted back to facility (01/02/2026) and Resident #1 was assessed with moisture associated skin damage to sacrum and a left hip Kennedy terminal ulcer. Wound Care Specialist Physician Assistant #1 stated the left hip was observed to be necrotic. Wound Care Specialist, Physician Assistant #1 stated they did not see the wound on Resident #1's right hip and they were not aware of the wounds on Resident #1's lower extremities. During an interview on 02/18/2026 at 2:42 PM, Medical Doctor #3 stated they were the attending physician on Resident #1's unit from October 2025 through 01/10/2026. Medical Doctor #3 stated they never saw Resident #1 when they were readmitted to the unit on 01/02/2026. Medical Doctor #3 stated Resident #1 was readmitted to the facility on [DATE] by Medical Doctor #2 and that they believed the appropriate treatment was ordered. Medical Doctor #3 stated Resident #1 was examined by the wound care team (Registered Nurse #2 and Physician Assistant #1) and that if Resident #1 arrived with multiple wounds, they believed everything was put in place. Medical Doctor #3 stated they were not aware Resident #1 refused to have their extremities examined by Medical Doctor #2 during their readmission. Medical Doctor #3 stated that the unit nurses should have communicated with them. Medical Doctor #3 stated they were not aware Resident #1 was readmitted with gangrenous toes and multiple wounds. Medical Doctor #3 stated they did not order podiatry consultation because they did not examine Resident #1. During an interview on 01/26/2026 at 2:45 PM, the Medical Director stated they were aware of the readmission of Resident #1 to the facility. The Medical Director stated they reviewed Resident #1's hospital discharge notes and saw the list of wounds documented. The Medical Director stated Medical Doctor #2 should have ordered treatments for all the wounds. The Medical Director stated they reviewed Resident #1's diagnoses and medications on 01/02/2026 but did not physically examine Resident #1. The Medical Director stated they are responsible for overseeing the medical doctors and if Resident #1 refused to be examined, Medical Doctor #2 should have endorsed the refusal to the incoming doctor. 10 New York Codes, Rules, and Regulations 415.15(b)(1)(i)(ii)

Based on record review and interviews conducted during an abbreviated survey (ID#2720832), the facility failed to ensure that a designated resident representative was notified of changes in the resident's condition. This was evident in one (1) out of four (4) residents sampled (Resident #1). Specifically, Resident #1 was assessed on 08/14/2025 to have developed moisture associated skin damage (caused by prolonged exposure to moisture from sources such as urine, stool, sweat or wound drainage) to sacrum and bilateral buttocks and treatment was ordered. Resident #1's designated representative was not notified of changes in Resident #1's skin condition. The findings are: The facility policy and procedure titled Notification of Resident's Change in Condition dated 04/2020 documented detection of a resident's change in condition can be reported to a licensed nurse by staff at any level, and to the resident's responsible party. The nurse is responsible for documenting in the medical record the date, time, and name, each time the Physician/Physician Extender, Resident or Responsible Party was notified (how they were notified such as telephone, face to face) actions taken, and resident's response to treatment. Resident #1 was admitted to the facility with diagnoses including Dementia, Anemia, End Stage Renal Disease on Hemodialysis (three (3) days a week), Diabetes Mellitus, Atrial Fibrillation, Coronary Artery Disease, Heart Failure, Chronic Obstructive Pulmonary Disease, Malnutrition, and Respiratory Failure. The admission Minimum Data Set (a resident assessment tool) dated 01/09/2025, documented Resident #1 had moderately impaired cognition. A review of the Electronic Medical Record revealed that on 08/12/2025 at 10:11 AM Registered Nurse #3 requested a wound care consultation. Further review of the Electronic Medical Record revealed no documentation by Registered Nurse #3 of an identified wound. There is also no documentation of the attending physician being notified of a wound. There is no evidence that a wound assessment was conducted until 08/14/2025 when Registered Nurse #2 performed a wound assessment. An altered skin notes by Wound Care Nurse, Registered Nurse #2 dated 08/14/2025, documented Resident #1 was assessed with moisture associated dermatitis at the sacrum and bilateral buttocks. It appeared moist, pink/red, no odor, no drainage and no pain. Treatment was ordered. A review of the Treatment Administration Record dated from 08/14/2025 - 08/31/2025 Hydrophilic Cream (Triad) 0/1 Paste Topical, every shift. Apply Triad Cream mixed with A&D Ointment to the sacrum and bilateral buttocks every shift and when soiled after cleaning with soap and water times 30 days. There was no documented evidence that Resident #1's designated representative was notified of the moisture associated skin damage. On 01/23/2026 at 10:00 AM, Resident #1's designated representative was interviewed and stated they were not aware Resident #1 had developed moisture associated skin damage to their sacrum and bilateral buttocks in the facility. On 02/04/2026 at 4:27 PM, Registered Nurse #3 (Unit Manager) was interviewed and stated they did not notify Resident #1's designated representative because the wound care nurse, Registered Nurse # 2, is responsible for notifying family members of skin problems. Registered Nurse #3 stated that the wound care nurse, Registered Nurse #2 assessed Resident #1 and received the treatment order. Registered Nurse #3 stated they were the unit manager on the unit, but they were not very involved with wounds since the facility has a wound care nurse that comes into the facility daily to follow up with the wounds. On 02/05/2026 at 12:01 PM, Wound Care Nurse, Registered Nurse # 2, was interviewed and stated they usually notify the family when a resident has a skin issue, but they missed notifying Resident #1's representative. Wound Care Nurse, Registered Nurse #2 stated that the nurses on the unit can also notify family members and could have notified Resident #1's representative of the moisture associated with skin damage. On 02/04/2026 at 6:13 PM, the Director of Nursing stated was interviewed and stated they have a full-time wound nurse responsible for notifying the family when a resident develops any skin changes. The Director of Nursing stated the wound nurse should have notified Resident #1's designated representative when Resident #1 developed the moisture associated skin damage to sacrum and bilateral buttocks. The Director of Nursing stated if there is a concern happening on the weekends or holidays, it is the unit nurse's responsibility to notify the family of any change in skin condition. 10 New York Code, Rules, and Regulations 415.3(e)(2)(ii)(b)

Based on observation, record review, and interviews during the Abbreviated Survey (ID #2720832) the facility failed to ensure the Minimum Data Set assessments accurately reflect each resident's status. This was evident in one (1) out of four (4) residents (Resident #1) sampled. Specifically, 1) Resident 1 was admitted to the facility from the hospital on [DATE] and was identified with Cellulitis (a common, potentially serious bacterial skin infection). The Minimum Data Set, dated [DATE] assessment did not reflect Resident #1's skin condition. 2) the hospital discharged , and Patient Review Instrument dated 12/30/2025, revealed Resident #1 was discharged to the facility with eight wounds to various body areas. A facility admission note dated 01/02/2026 documented Resident #1 had wounds to sacrum, bilateral buttocks, bilateral hips, and gangrene to all toes and bilateral heels. The Minimum Data Set assessment dated [DATE] did not reflect Resident #1's wounds. The findings are: The facility policy titled Minimum Data Set Completion Policy dated 10/2020 documented the purpose to identify each resident's needs problems and strengths to establish a course of action through an individualized comprehensive care plan and to assure accurate and timely completion of the Minimum Data Set 3.0 and to fulfill Federal regulations. Resident #1 was initially admitted to facility with diagnoses including Atrial Fibrillation, Anemia, Coronary Artery Disease, Heart Failure, Respiratory Failure, Chronic Obstructive Pulmonary disease, Malnutrition, End Stage Renal disease (on dialysis three days a week), and Muscle weakness. The Minimum Data Set (a resident assessment tool) dated 07/25/2025 documented Resident #1 had moderately impaired cognition. Resident #1 is dependent on toileting hygiene and is always continent of bladder/bowel and requires substantial/maximal assistance for bed mobility (helper does more than half the effort.) The assessment identified Resident #1 with no skin problem or pressure ulcer present. A review of the hospital discharge record and Patient Review Instrument dated 07/15/2025 documented primary diagnosis Bacteremia (the presence of bacteria in the bloodstream) with Cellulitis. The lower right extremity has full thickness skin loss (a wound that goes through the entire skin layers and into the fat subcutaneous tissue) measuring 8.0-centimeter x 6.0-centimeter x 0.2-centimeter, wound bed 20 percent fibrinous tissue (stringy, gel-like consistency may appear white or yellowish), peri-wound intact. The Patient Review Instrument also documented Resident #1 has statis ulcer and wound care required. A review of a Nursing admission Assessment by Registered Nurse #4 dated 07/21/2025 documented antibiotic for skin infection (did not identify area of skin). Resident #1 was referred to Medical Doctor and wound care for bilateral lower legs. A medical admission notes by Medical Doctor #2 dated 07/22/2025 at 10:15 AM identified Resident #1 with diabetic foot ulcer and cellulitis. A review of a hospital Discharge Medical Record dated 12/30/2025 revealed Resident #1 was discharged to the facility with several wounds to various body areas: Stage III ulcer to sacrum measured 4.0-centimeter x 5.0-centimeter x 0.2. Left hip deep tissue injury measured 5.0-centimeter x 4.0 centimeter.Right hip is unstageable. Dry scab came off measured 1.0-centimeter x 0.8.Left heel deep tissue injury measured 6.0-centimeter x 4.0-centimeterRight heel deep tissue injury measured 5.0-centimeter x 5.0-centimeterLeft toes dry gangrene, cold to touch.Right great toe black necrosis, dry stable. Cold to touch and all toes gangrene.Left bunion towards left dorsum has partial thickness skin loss. A review of a nursing Admission/readmission note by Registered Nurse #5 dated 01/02/2026 at 6:45 PM documented pressure wound to sacrum, wounds to bilateral hips, gangrene to all toes and bilateral heels. A Physician History and Physical note by Medical Doctor #2 dated 01/02/2026 at 7:10 PM documented Resident #1 with moisture associated with skin damage (refers to skin inflammation or erosion caused by prolonged exposure to moisture from sources such as urine, stool, sweat or wound drainage). A Wound/Skin Assessment note written by Registered Nurse #2 (wound care nurse) dated 01/05/2026 at 12:18 PM, documented that they assessed Resident#1 with a right hip superficial abrasion, moisture associated dermatitis to sacrum with partial thickness erosion, bilateral lower extremities unremarkable, bilateral heels without redness, bruising, open areas or signs and symptoms of breakdown. Bilateral feet are unremarkable. This assessment did not correlate with the hospital discharge assessment. A review of a Surgical Note by Wound Care Specialist, Physician Assistant #1 dated 01/07/2026 documented a detailed skin examination of Resident #1's buttocks, sacrum, coccyx, left ischium, right ischium, left trochanter, and right trochanter. The sacrum wound was identified moisture associated skin damage and the left hip identified as Kennedy terminal ulcer phenomenon (a type of skin sore that typically develops in patients during the final stages of life). The Minimum Data Set (a resident assessment tool) dated 01/09/2025, documented Resident #1 had moderately impaired cognition. The skin condition section only documented Moisture Associated Skin Damage. There was no documented evidence that assessment was done of the unstageable ulcer to the right hip, gangrene toes and wound to left bunion - full thickness skin loss. During an interview on 02/04/2026 at 9:43 AM, Minimum Data Set Coordinator #1 stated they are responsible for the completion of the Minimum Data Set assessment dated [DATE]. Minimum Data Set Coordinator #1 stated they reviewed the hospital discharge record for Resident #1 and were aware of the multiple wounds treated in the hospital. Minimum Data Set Coordinator #1 stated they called the Wound Nurse - Registered Nurse #1 and asked if they had evaluated Resident #1 and Wound Nurse - Registered Nurse #1 told them they and Medical Doctor #1 examined Resident #1 and that the assessments are accurate. Minimum Data Set Coordinator #1 stated they noticed the multiple wounds were not reflected in Registered Nurse #2's assessment but did not question them. Minimum Data Set Coordinator #1 stated they validated the accuracy of their assessment when they asked Registered Nurse #1 if the skin assessment was done. Minimum Data Set Coordinator #1 stated they trusted Registered Nurse #2 and based their assessments on them. Minimum Data Set Coordinator #1 also stated each assessor is responsible for the accuracy of assessment. Minimum Data Set Coordinator #1 stated they do not physically assess or visually check residents' skin as the facility has a wound nurse to perform skin assessments. During an interview on 02/04/2026 at 9:18 AM, the Minimum Data Set Director stated they are responsible for entering Resident #1's diagnoses and coordinating with nursing and medical doctors. The Minimum Data Set Director stated the Minimum Data Set coordinators are responsible for reading the hospital records when residents are admitted to the facility and to look for the medications and diagnoses. The Minimum Data Set Director stated they read the hospital records and maybe they overlooked the ulcers that were in the hospital records. The Minimum Data Set Director stated that the Minimum Data Set completion is based on the assessment documented in the medical record. 10 New York Code, Rules, and Regulations 415.11(b)

Based on observation, record review, and interviews conducted during an Abbreviated Survey (NY00353123), the facility failed to provide adequate supervision to a resident to prevent accident. This was evident for one (1) of six (6) residents (Resident #3) sampled. Specifically, Certified Nursing Assistant #9 transferred Resident #3 out of bed to the recliner chair by themself at 8:00 AM [DATE]. After breakfast, Certified Nursing Assistant #9 transferred Resident #3 back to bed by themself at 10:51 AM. While Certified Nursing Assistant #9 was in the process of providing morning care to Resident #3 at 10:51 AM, they observed Resident #3 with a discoloration on the left inner thigh. Registered Nurse #2 and Registered Nurse Supervisor #3 assessed Resident #3 who had a bruise on the left inner thigh. An x-ray result dated [DATE] documented an acute fracture of the left hip. Resident #3 was transferred to hospital on [DATE] at 9:21 PM and returned to the facility on [DATE] at 3:45 PM with principal discharge diagnosis of an acute Left Intertrochanteric Comminuted fracture (a type of bone fracture where the bone is broken into multiple fragments more than two). Resident #3 underwent an Open Reduction Internal Fixation surgery. A Treatment Administration document (Resident Instructions for Certified Nursing Assistants) dated [DATE] had documented instructions for Resident #3 to be transferred by two people using a stand pivot (technique). Certified Nursing Assistant #7, Certified Nursing Assistant #8 and Certified Nursing Assistant #9 did not follow Resident #3's plan of care from [DATE] to [DATE]. The findings include: The facility's policy titled Nurse Aide Assignment and Accountability Record dated ,d+[DATE] documented the purpose of the policy is to ensure that nurse aides are properly assigned, and their activities are documented accurately in the Electronic Health Record (EHR) system to maintain quality care, accountability, and regulatory compliance in the nursing home. The Certified Nurse Aide reviews the Nursing Instructions of those residents he/she is assigned, to ensure that the resident plan of care is followed. The facility's policy titled Safeguarding the Resident was revised on ,d+[DATE]. The policy documented that all residents will be provided with care in a safe manner and according to the resident plan of care. The staff is educated regarding safety issues and how to avoid injury to the residents. Resident #3 admitted to the facility with diagnoses including Dementia and Anxiety Disorder. The Minimum Data Set, a resident assessment tool, dated [DATE] documented Resident #3 had severe cognitive impairment. Resident #3 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provide less than half the effort) for transfer. An Activities of Daily Living Care Plan dated [DATE] documented Resident #3 was total dependent for two persons using a stand pivot for chair-to-bed and bed-to-chair transfer. The Treatment Administration (Resident Instructions for Certified Nursing Assistant) dated [DATE] documented that Resident #3 required two persons for transfer using a stand pivot. The Accident/Incident Report dated [DATE] at 10:51 AM and Investigative Summary dated [DATE] documented Resident #3 was observed with increased restlessness in the dining room by yelling and swinging their arms and legs over their recliner chair. Resident #3 stated, my clothes pain me. Resident #3 was transferred back to bed by Certified Nursing Assistant #9 who reported Resident #3 had a left inner thigh discoloration that was observed during care. Resident #3 was assessed by Registered Nurse #2 and Registered Nurse Supervisor #3 to have a purplish discoloration on left inner thigh. Medical Doctor #2 and Resident #3's family member was notified. Medical Doctor #2 ordered an x-ray of left the hip and femur. The x-ray result dated [DATE] revealed an acute intertrochanteric fracture of left hip. Osteopenia and degenerative changes noted. The investigation also documented that they reviewed the video footage from [DATE] to [DATE] and it showed Certified three Certified Nursing Assistants (#7, #8, and #9) transferred Resident #3 without assistance. The investigation concluded that abuse and neglect did not occur as the Certified Nursing Assistants had no malicious intent to hurt Resident #3. The Certified Nursing Assistants were also suspended pending the investigation outcome. A nursing note by Registered Nurse Supervisor #3 dated [DATE] at 11:39 AM, documented Resident #3 was observed with increased yelling, restlessness and agitation. Resident #3 was swinging their arms and legs over the recliner and was shifting their body. Registered Nurse Supervisor #3 was called and examined Resident #3 who was observed with a purpura discoloration to their left inner thigh. The resident skin was intact and positive range of motion to all extremities was at baseline. Resident #3 was asked if they were in pain and stated, my clothes pain me. The clothing was changed, and Resident #3 had no further complaints of pain. Registered Nurse Supervisor #3 reviewed the resident chart, and the resident was on Aspirin and recently gradual dose reduction of Depakote was done on [DATE]. Medical Doctor #2 ordered an x-ray of left hip and femur. A Radiology Report dated [DATE] at 8:19 PM, documented an Acute Intertrochanteric Fracture of Left Hip. Fracture was not present on previous study of [DATE]. Osteopenia degenerative changes noted. During an interview on [DATE] at 1:26 PM, Certified Nursing Assistant #9 stated on [DATE] they transferred Resident #3 out of bed by themself and brought the resident into the dining at 8:00 AM for breakfast. Certified Nursing Assistant #9 stated they did not experience any difficulty when they transferred Resident #3 out of bed, and they did not observe any discoloration on Resident #3's skin. Certified Nursing Assistant #9 stated that they observed Resident #3 with the discoloration between their left inner thigh after they transferred Resident #3 back to bed on [DATE] at 10:51 AM and while they were providing care to the resident. Certified Nursing Assistant #9 stated they reported their observation to Registered Nurse #2. Certified Nursing Assistant #9 stated Resident #3 had behaviors of being loud, restless, agitated, and swinging their arms and legs when sitting in their recliner. Certified Nursing Assistant #9 stated that they violated Resident #3's plan of care which called for two persons for transfer. Certified Nursing Assistant #9 stated it is their responsibility to read Resident #3's instructions prior to providing care. During a telephone interview on [DATE] at 1:00 PM, Certified Nursing Assistant #8 stated that they floated to Resident #3's unit on [DATE] on the night shift (10:00 PM-6:00 AM). Certified Nursing Assistant #8 stated Resident #3 was not a regular on their assignment and they received training to read the instructions prior providing care. Certified Nursing Assistant #8 stated they transferred Resident #3 back to bed by themself without calling another staff member for assistance. Certified Nursing Assistant #8 stated they recalled checking the computer and it states that Resident #3 requires one person assistance. Certified Nursing Assistant #8 stated after the incident they (facility) updated the plan of care for two persons assist for transfer. Certified Nursing Assistant #8 stated they did not have any issues when they transferred Resident #3 on [DATE] and there was no discoloration to the resident's inner thigh. Certified Nursing Assistant #8 stated they received report every night from the charge nurse prior starting to their work. During an interview on [DATE] at 1:21 PM, Certified Nursing Assistant #7 stated they were new on the job and their regular shift was night shift (10:00 PM-6:00 AM), but they were asked to stay over on [DATE] and was assigned to the day shit from 6:00 AM to 2:00 PM. Certified Nursing Assistant #7 stated they gave Resident #3 a shower on [DATE] and transferred the resident by themself. Certified Nursing Assistant #7 stated it was the first time being assigned to Resident #3 and that the resident did not fall or hurt themself during the transfer. Certified Nursing Assistant #7 stated they received training /orientation on providing care, documentation and using the buddy system prior to starting their work assignments. Certified Nursing Assistant #7 stated they did not know what a Kardex (Instructions to Certified Nursing Assistant) means and did not know where to find the Kardex or Resident Instructions in the computer during their orientation. Certified Nursing Assistant #7 stated they do not recall receiving hands-on training in reading the instructions in the computer. Certified Nursing Assistant #7 stated they did not observe any of the staff on the unit transferring Resident #3 with two persons assist. Certified Nursing Assistant #7 stated they were suspended during the investigation, and they did not return to the facility. A follow up telephone interview was done on [DATE] at 3:30 PM. Certified Nursing Assistant #7 stated they buddied with other staff during their orientation and assist them with their residents' assignments. Certified Nursing Assistant #7 stated when they were in buddy system orientation, they were shown where in the computer to document but was not shown where to locate the residents' instructions. Certified Nursing Assistant #7 stated they did not notify the nurse or supervisor of not knowing where to locate and review the residents' instructions. Certified Nursing Assistant #7 stated they were not aware of the Kardex and the nursing instructions. During an interview on [DATE] at 2:10 PM, Registered Nurse #2 stated Certified Nursing Assistant #9 notified them of skin changes on left inner thigh. Registered Nurse #2 stated they assessed Resident #3 and observed a purplish bluish discoloration on the left inner thigh. Registered Nurse #2 stated Resident #3's skin was intact, there were no swelling or external rotation of the thigh. Registered Nurse #2 stated they notified Registered Nurse Supervisor #3. Registered Nurse #2 stated they did not observe when Certified Nursing Assistant #9 transferred Resident #3 by themself. Registered Nurse #2 stated they are responsible for monitoring the staff on the unit to ensure the plan of care is being followed. Registered Nurse #2 stated they gave report to the staff prior start of the shift and to report anything unusual. Registered Nurse #2 stated Resident #3 did not sustain any trauma or fall during their shift. During an interview on [DATE] at 1:48 PM, Registered Nurse Supervisor #3 stated Registered Nurse #2 notified them of Resident #3's discoloration on [DATE] at approximately 10:50 AM. Registered Nurse Supervisor #3 stated they assessed the Resident #3 and observed a purpura (a purple spot due to small blood vessels leaking blood into the skin) on the resident's left inner thigh. Registered Nurse Supervisor #3 stated Resident #3 was confused and was unable to state what happened. Registered Nurse Supervisor #3 stated they asked if Resident #3 had any pain and the resident stated, my clothes pain me. Registered Nurse Supervisor #3 stated that Certified Nursing Assistant #9 changed Resident #3's clothes and Resident #3 did not make any further complaints. Registered Nurse Supervisor #3 stated prior to the incident, Resident #3 was observed with increased restlessness, yelling, swinging their arms and legs over the recliner chair. Registered Nurse Supervisor #3 stated they notified the Medical Doctor of the discoloration, and they examined Resident #3 and ordered an x-ray of the left hip and femur. During an interview on [DATE] at 3:50 PM, the Assistant Director of Nursing stated they were notified of the discoloration on [DATE] (does not remember the time) by Registered Nurse Supervisor #3. The Assistant Director of Nursing stated it was an injury of unknown origin because they do not know how the fracture happened. The Assistant Director of Nursing stated they reviewed the video footage and looked back three days discovering three Certified Nursing Assistants (#7, #8, and #9) transferred Resident #3 by themselves. They did not follow the resident plan of care. The Assistant Director of Nursing stated that they suspended the three staff members pending investigation outcome. The Assistant Director of Nursing stated the Law Enforcement was notified and responded. During a telephone interview on [DATE] at 12:49 PM, Medical Doctor #2 stated they were not familiar with Resident #3, however, they examined Resident #3 who had a purplish discoloration on their left inner thigh. Medical Doctor #2 stated they ordered an x-ray of the left hip and femur. Medical Doctor #2 stated they received report about the result of the x-ray and ordered Resident #3 to be transferred to the hospital. Medical Doctor #2 stated they did not receive any reports of a fall or trauma and that they do not know how Resident #3 sustained the fracture. 10NYCRR 415.12(h)(2)

Based on observation, record review, and interviews during an abbreviated survey, (NY00368833), the facility did not ensure the residents' right to be free from physical abuse. This was evidence for one out of six residents reviewed (Resident #1). Specifically, on 01/13/2025 at 07:18 PM, Licensed Practical Nurse #1 reported to Registered Nurse Supervisor #1, Certified Nursing Assistant #1 threw a cup of melted ice cream on Resident #1's. Registered Nurse Supervisor #1 assessed Resident #1 and observed a wet stain on the top of Resident #1's clothes. The findings are: The facility's Policy and Procedure entitled Abuse Prevention, dated 10/2022, documented it is the policy of the organization to ensure that all residents are free from abuse, neglect, misappropriation of resident property, and exploitation. The facility prohibits verbal, mental, sexual, and physical abuse and corporal punishment or involuntary seclusion by any staff, volunteer, or other resident. Resident #1 was admitted to the facility on [DATE], with the diagnosis of Dementia with behavior, Anxiety, and Major Depression. The Minimum Data Set (assessment tool), dated 11/27/2024, documented Resident #1 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) score of eight out of 15, indicating Resident #1 was moderately cognitive impaired. A Care Plan for Victimization was initiated on 04/03/2022, last updated on 09/14/2024, with interventions to involve Resident #1 in social activities, identifying triggers for behavior, and to use a calm approach by talking in a soothing manner to Resident #1. A Nursing Note dated 01/13/2025 at 9:07 PM, written by Registered Nurse Supervisor #1 documented was informed at 7:18 PM, by Licensed Practical Nurse #1 Certified Nurse Assistant #1 threw melted ice cream into Resident #1's face. The Camera footage was reviewed, Resident #1 was seen at 7:06 PM taking a cup of melted ice cream off the medication cart. Certified Nursing Assistant #1 approached Resident #1, and Resident #1 threw the cup of melted ice cream at Certified Nursing Assistant #1. Certified Nursing Assistant #1 grabbed the cup and threw it into Resident #1's face. Certified Nursing Assistant #1 was removed from the floor. Resident #1 was assessed, denied pain, and no visible injuries were noted. Resident #1 denied emotional distress. The Assistant Director of Nursing was notified at 7:20 PM. The New York City Police were called at 7:55 PM. The Medical Doctor was made aware. Resident #1's family was notified. A psychiatry consultation was ordered. The facility's Investigative Summary dated 01/14/2024, documented on 01/13/2025 at 7:18 PM, Licensed Practical Nurse #1 reported that Certified Nursing Assistant #1 threw ice cream at Resident #1's face. Registered Nurse Supervisor #1 reviewed the video footage, and it was conformed that Certified Nursing Assistant #1 threw ice cream at Resident #1. Certified Nursing Assistant #1 was removed from the unit and was interviewed by the Assistant Director of Nursing over the phone with Registered Nurse Supervisor #1 present. Certified Nursing Assistant #1 stated Resident #1 called them racial words and threw ice cream in their face, and they threw it back at Resident #1. Certified Nursing Assistant #1 answered a repeated question, stating, Yes, I threw it back at Resident #1. It was a natural reaction. Certified Nursing Assistant #1 was suspended. The New York City Police were called at 7:55 PM and interviewed Resident #1, who could not recall the incident. The facility investigated and concluded that there is evidence to believe abuse regarding Resident #1 had occurred. A Tracking Quality Data for Improving Patient Safety dated 01/13/2025, documented on 01/13/2025 at 7:07 PM, Registered Nurse Supervisor #1 was notified by Licensed Practical Nurse #1 that Certified Nursing Assistant #1 threw melted ice cream into Resident #1's face. Surveillance video on the 6th Floor Nursing Station, dated 01/13/2025 at 7:07 PM, was reviewed with the Assistant Director of Nursing on 01/02/2025 at 10:45 AM. The video was recorded in real-time (military time) and revealed the following: On 01/13/2025 at 7:07 PM, Resident #1 approached the medication cart that was near the nursing station and took a covered orange cup from the cart and held the cup in their right hand. Certified Nurse Assistant #1 walked up close to Resident #1 with their back to the camera, and splashes of orange liquid got on Certified Nurse Assistant #1's left shoulder. Certified Nurse Assistant #1 raised their right hand, and splashes of orange liquid went toward Resident #1's neck area as Resident #1's head moved to the side. Resident #1 and Certified Nurse Assistant #1 went in opposite directions. Certified Nurse Assistant #2 and Certified Nurse Assistant #3 were in the hallway as the camera footage ended. During a telephone interview on 01/21/2025 at 12:50 PM, Certified Nursing Assistant #1 stated on 01/13/2025, after dinner, at around 7:00 PM, Resident #1 took an 8-ounce ice cream cup from the medication cart in front of the nursing station. Certified Nursing Assistant #1 stated they approached and told Resident #1 they cannot have the ice cream. Resident #1 used profanity and threw the cup with melted ice cream on their face, chest, and uniform. Certified Nursing Assistant #1 did not throw the ice cream back on Resident #1 but went away to clean their clothes. During a telephone interview on 01/21/2025 at 1:21 PM, Licensed Practical Nurse #1 stated they were sitting at the nursing station on 01/13/2025 after 7:00 PM (could not recall the exact time), Resident #1 was seen coming to the medication cart to get something. Licensed Practical Nurse #1 stated they told Resident #1 that they could not touch the nursing cart but Resident #1 ignored them. Licensed Practical Nurse #1 stated they saw Certified Nursing Assistant #1 approach Resident #1 and told Resident #1 that they could not touch the medication cart. Resident #1 grabbed the ice cream and threw it at Certified Nursing Assistant #1's chest, and it splashed on Certified Nursing Assistant #1's face and top. Licensed Practical Nurse #1 stated Certified Nursing Assistant #1 caught the cup on their chest and threw it at Resident #1, and Certified Nursing Assistant #1's right hand contacted Resident #1 upper shoulder. Licensed Practical Nurse #1 stated Certified Nursing Assistant #1 walked away quickly to the bathroom. Licensed Practical Nurse #1 stated Resident #1 walked away in the opposite direction. Licensed Practical Nurse #1 stated they yelled at Certified Nursing Assistant #1 that they could not do that and grabbed the phone to call Registered Nurse Supervisor #1, but Registered Nurse Supervisor #1 was coming out of the elevator, and they reported to them. Licensed Practical Nurse #1 stated Certified Nursing Assistant #1 was sent home. Licensed Practical Nurse #1 stated the police came to the facility, but they did not interview them. During telephone interviews on 01/21/2025 at 11:17 AM and 11:51 AM, Certified Nursing Assistant #2 and Certified Nursing Assistant #3 both stated they saw Resident #1 throw ice cream at Certified Nursing Assistant #1 but did not see if Certified Nursing Assistant 1 threw ice cream back at Resident #1 because they were behind Certified Nursing Assistant #1. During an in-person interview on 01/21/2025 at 3:28 PM, Registered Nurse Supervisor #1 stated on 01/13/2025 between 7:15 PM and 7:20 PM, Licensed Practical Nurse #1 informed them they observed Resident #1 taking ice cream from the medication cart and threw it at Certified Nursing Assistant #1 and Certified Nursing Assistant #1 grabbed the same cup and threw at Resident's #1 chest. Registered Nurse Supervisor #1 instructed Licensed Practical Nurse #1 to keep Certified Nursing Assistant #1 at the nursing station. Registered Nurse Supervisor #1 stated they assessed Resident #1 in their room and observed a wet stain on Resident #1's top. A full body assessment was done, and there was no redness or bruises. Resident #1 denied any pain or discomfort. Resident #1 had no recollection of the incident. Registered Nurse Supervisor #1 stated they called another Registered Nurse Supervisor #2 to safeguard Certified Nursing Assistant #1 in the nursing station while they went to call the Assistant Director of Nursing at 7:20 PM. Registered Nurse Supervisor #1 stated they went and took Certified Nursing Assistant #1 to the nursing office, and they were interviewed by the Assistant Director of Nursing. Registered Nurse Supervisor #1 stated Certified Nursing Assistant #1 admitted that they threw ice cream at Resident #1 as a reflex instinct reaction. Registered Nurse Supervisor #1 stated Certified Nursing Assistant #1 was suspended and escorted out of the facility. Registered Nurse Supervisor #1 stated the New York City Police were called at 7:55 PM, on arrival, Resident #1 was interviewed, and the police said that the report would be harassment. Registered Nurse Supervisor #1 stated that a Medical Doctor was called. Resident #1's the family was notified, and a Psychiatric consultation was ordered and done on the same day. During an in-person interview on 01/21/2025 at 2:17 PM, the Assistant Director of Nursing stated they investigated the incident and concluded abuse occurred. The Assistant Director of Nursing stated Certified Nursing Assistant #1 did not write in their statement that they threw ice cream at Resident #1, but when they spoke with them over the phone on 01/13/2025 at 7:40 PM, with Registered Nurse Supervisor #1 presence, Certified Nursing Assistant #1 stated that it was their instinct and reaction to throw the ice cream at Resident #1. The Assistant Director of Nursing also stated they reviewed the surveillance video, and it was confirmed, Certified Nursing Assistant #1 threw a cup with ice cream at Resident #1. The Assistant Director of Nursing stated Certified Nursing Assistant #1 was suspended immediately and terminated as of 01/13/2025. During an in-person interview on 01/22/2025 at 4:18 PM, the Administrator stated the Assistant Director informed them on 01/13/2025 at 7:46 PM that Certified Nursing Assistant #1 threw ice cream on Resident #1 and that it was witnessed by License Practical Nurse #1. The Administrator stated after the camera was reviewed, they agreed with Assistant Director of Nursing there was evidence that abuse occurred. The Administrator stated Certified Nursing Assistant #1 was suspended immediately and terminated as of 01/13/2024. 10 NYCRR 415.4(b)(1)(i)

Based on record review and interview conducted during the Recertification Survey from 07/31/2024 to 08/07/2024, the facility did not ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the New York State Department of Health. This was evident in 1 (Resident #132) of 6 residents reviewed for accidents, out of 38 total sampled residents. Specifically, the facility did not report to the New York State Department of Health an unwitnessed incident on 07/21/2024 when Resident #132 was observed on the floor with lacerations to the forehead and nose bridge. The findings are: The facility policy titled Identification, Investigation Protection and Reporting Physical Abuse, Mistreatment and Neglect of Residents with a revision date of 06/2024 documented that it is the facility's policy to make all employees aware of their responsibility to identify and report resident abuse. The purpose of the policy was to provide directions for identifying, reporting and investigating cases or suspected cases of resident physical abuse, mistreatment, neglect or misappropriation of resident property. The policy stated that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of Resident property, are reported immediately, but not later than 2 hours after the allegation is made. Resident #132 had diagnoses of Atrial Fibrillation, Heart Failure, and Benign Prostatic Hyperplasia. The Minimum Data Set assessment dated [DATE] documented that Resident #132 had moderately cognitive impairment. Resident #132 can independently roll left and right in bed, independently sit on side of bed to lie flat in bed, independently move from lying on the back to sit on the side of the bed with no back support, requires supervision with sit to stand and transfers. The 24 Hour Report- Falls dated 07/21/2024 at 4:22 AM completed by the Registered Nurse documented Resident #132 had an unwitnessed fall. Resident was found lying on their left side on the floor beside their bed. Resident stated they do not remember how they end up on the floor. Laceration was noted on the center of Resident's forehead and nose bridge. The facility form titled Tracking Quality Data for Improving Patient Safety documented that Resident #132 was observed on the floor by the nurse, unwitnessed, on 07/21/2024 at 4:00 AM. Resident was found with laceration to the center of their forehead and nose bridge, there was no change in level of consciousness. Staff written statements documented that Resident #132 was last toileted at 2:30 AM and was last seen by staff sleeping in bed at 3:00 AM. Resident #132 was sent to the emergency department for evaluation. The facility's summary of investigation concluded that the investigation revealed there was no cause to believe an alleged resident abuse, mistreatment, or neglect had occurred. The Hospital Patient Information and Transfer form dated 07/23/2024 documented Resident #132's primary diagnosis was status post fall, nasal bone fracture, forehead and nasal lacerations repaired. There was no documented evidence the facility reported Resident #132's unwitnessed fall incident, resulting in nasal bone fracture and lacerations, to the New York State Department of Health. During an interview on 08/02/2024 at 10:30 AM, Registered Nurse #1 stated Resident #132 was found on the floor with injury sustained to the head. They stated they believe that the injury was from the fall. During an interview on 08/05/2024 at 11:02 AM, the Director of Nursing stated that the incident was not reported to the New York State Department of Health because the investigation revealed that there was a fall even though it was not witnessed by the staff. They stated that any allegation of abuse or injury of unknown origin have to be reported within 2 hours to the New York State Department of Health. 10 NYCRR 415.4(b)(2)

Based on record review and interview conducted during the Recertification Survey from 07/31/2024 to 08/07/2024, the facility failed to ensure that a Significant Change in Status Assessment was completed within 14 days after a determination had been made in the resident's status from baseline occurred. This was evident in 1 (Resident # 167) of 1 resident reviewed for pressure ulcer / injury out of 35 total sampled residents. Specifically, on 06/30/2024, Resident #167 was identified with an unstageable pressure injury to the sacrum and deep tissue pressure injury to the left heel. The facility did not have a Significant Change in Status Assessment completed after the change in condition was identified. The findings are: The facility policy titled Minimum Data Set Completion with a revised date of 10/2023 stated that the Minimum Data Set is completed on all residents according to a mandated assessment schedule. The purpose of the policy was to ensure all Minimum Data Set assessments are completed in a timely manner and transmitted to the Centers for Medicare & Medicaid Services. The policy documented that the Minimum Data Set Coordinator determines if a resident has a significant change in condition. If the resident meets the criteria for a change in condition, the Minimum Data Set Coordinator notifies the team of the change in assessment and proceeds with a Significant Change assessment. The Coordinator ensures all assessments are submitted to the Centers for Medicare and Medicaid Services within 14 days of completion. Resident #167 was admitted to the facility on with diagnoses including Stroke, Hypertension, and Diabetes Mellitus. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #167 had severely impaired cognition. The assessment documented that Resident #167 had no pressure ulcers/injuries and had no venous or arterial ulcers present. The wound / skin assessment note dated 06/30/2024 documented Resident #167 had unstageable pressure injury to the sacrum and deep tissue pressure injury to the left heel. The medical record lacked documented evidence that a Significant Change in Status Assessment was completed within 14 days after Resident #167's pressure ulcers / injuries were identified. During an interview on 08/05/2024 at 10:15 AM, the Minimum Data Set Coordinator stated that a significant change Minimum Data Set assessment must be completed if there was a significant change in a resident's condition. They stated they do not know why Resident #167's significant change assessment was overlooked. The Coordinator stated they have not received the wound tracker report from the Wound Care Nurse. 415.11(a)(3)(ii)

Based on observation, record review, and interview conducted during the Recertification Survey from [DATE] to [DATE], the facility did not ensure that food was stored, prepared, and distributed in accordance with professional standards for food service safety. This was evident during the Kitchen Task observation. Specifically, 1.) 2 boxes containing 20 (14 ounces) packages of bratwurst in the kitchen refrigerator and the freezer in the emergency food area were stored beyond the best by date, and 2.) potentially hazardous food were not maintained at an acceptable temperature to limit the growth of pathogen. The findings are: The facility's policy on Food and Supply Storage with a revised date of ,d+[DATE] documented all food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Most, but not all, products contain an expiration date. The words sell by, best by, enjoy -by or use-by should precede the date. Foods past the use-by, sell-by, best-by, or enjoy by date should be discarded. The facility's policy on Food Handling Guidelines with a revised date of ,d+[DATE] documented that temperature of food shall be monitored using accurate thermometers. The cold food preparation documented that prior to preparation, chill potentially hazardous ingredients to 41 degrees Fahrenheit for food that will be eaten without further cooking. Examples include salads, sandwiches, cut leafy greens and produce and reconstituted food. Products are chilled again after preparation to 41 degrees Fahrenheit before being served. 1.) On [DATE] between 9:20 AM and 10:05 AM, during the tour of the main kitchen and emergency food storage area with the Food Service Director, a box containing 10 (14-ounce) packages of smoked bratwurst with a best by date of [DATE] were in the kitchen meat refrigerator. During the tour of the emergency food storage area and freezer with Patient Food Services Utility Worker #1, a box of frozen smoked bratwurst with a best by date of [DATE] were in the meat refrigerator. During an interview on [DATE] at 10:11 AM, Patient Food Services Utility Worker #1 stated that the food's best by date is the expiration date. They stated they must get rid of food items that are expired. During an interview on [DATE] at 10:12 PM, The Chef Manager stated they are usually in the kitchen at 5:30- 6:00AM in the morning and had not noticed any items out of date. During an interview on [DATE] at 11:14 AM, the Food Service Director stated rounds were done daily in the kitchen which includes checking for expired food items. These checks were done daily on the units and the main kitchen. 2). During an observation on the 2nd floor with the Chef Manager on [DATE] from 11:26 AM to 11:28 AM, temperature of 2 egg salad sandwiches were taken. The first sandwich had a temperature of 62.2 degrees Fahrenheit, and the 2nd sandwich had a temperature of 57.9 degrees Fahrenheit. On [DATE] from 12:18 PM to 12:25 PM, an observation of the 6th floor unit refrigerator with the Chef Manager revealed the following: the unit refrigerator had a temperature of 40 degrees Fahrenheit, an egg salad sandwich had a temperature of 66 degrees Fahrenheit, and a tuna sandwich had a temperature of 66.6 degrees Fahrenheit. The egg salad sandwiches were stamped Prepared food, not reheated. Prepared [DATE] at 10:24 AM. During an interview on [DATE] at 11:29 AM, Patient Food Services Utility Worker #3 stated they made the sandwiches and placed them in the freezer at 9:00 AM. They stated they had never taken the temperature of the sandwiches. During an interview on [DATE] at 11:28AM, the Chef Manager stated that the sandwiches should be below 41 degrees Fahrenheit. They stated that the sandwiches were made earlier at 10:24 AM. During an interview on [DATE] at 11:19AM, the Food Service Director stated that sandwiches are made daily and are wrapped and placed in the freezer to get the temperature below 41 degrees Fahrenheit. They stated that sandwiches are brought up the last minute after lunches are brought to the units. They stated they have not noticed any problems with the temperature. 10 NYCRR 415.14(h)

Based on record review and interview conducted during the Recertification Survey from 07/31/2024 to 08/07/2024, the facility did not ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the New York State Department of Health. This was evident in 1 (Resident #132) of 6 residents reviewed for accidents, out of 38 total sampled residents. Specifically, the facility did not report to the New York State Department of Health an unwitnessed incident on 07/21/2024 when Resident #132 was observed on the floor with lacerations to the forehead and nose bridge. The findings are: The facility policy titled Identification, Investigation Protection and Reporting Physical Abuse, Mistreatment and Neglect of Residents with a revision date of 06/2024 documented that it is the facility's policy to make all employees aware of their responsibility to identify and report resident abuse. The purpose of the policy was to provide directions for identifying, reporting and investigating cases or suspected cases of resident physical abuse, mistreatment, neglect or misappropriation of resident property. The policy stated that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of Resident property, are reported immediately, but not later than 2 hours after the allegation is made. Resident #132 had diagnoses of Atrial Fibrillation, Heart Failure, and Benign Prostatic Hyperplasia. The Minimum Data Set assessment dated [DATE] documented that Resident #132 had moderately cognitive impairment. Resident #132 can independently roll left and right in bed, independently sit on side of bed to lie flat in bed, independently move from lying on the back to sit on the side of the bed with no back support, requires supervision with sit to stand and transfers. The 24 Hour Report- Falls dated 07/21/2024 at 4:22 AM completed by the Registered Nurse documented Resident #132 had an unwitnessed fall. Resident was found lying on their left side on the floor beside their bed. Resident stated they do not remember how they end up on the floor. Laceration was noted on the center of Resident's forehead and nose bridge. The facility form titled Tracking Quality Data for Improving Patient Safety documented that Resident #132 was observed on the floor by the nurse, unwitnessed, on 07/21/2024 at 4:00 AM. Resident was found with laceration to the center of their forehead and nose bridge, there was no change in level of consciousness. Staff written statements documented that Resident #132 was last toileted at 2:30 AM and was last seen by staff sleeping in bed at 3:00 AM. Resident #132 was sent to the emergency department for evaluation. The facility's summary of investigation concluded that the investigation revealed there was no cause to believe an alleged resident abuse, mistreatment, or neglect had occurred. The Hospital Patient Information and Transfer form dated 07/23/2024 documented Resident #132's primary diagnosis was status post fall, nasal bone fracture, forehead and nasal lacerations repaired. There was no documented evidence the facility reported Resident #132's unwitnessed fall incident, resulting in nasal bone fracture and lacerations, to the New York State Department of Health. During an interview on 08/02/2024 at 10:30 AM, Registered Nurse #1 stated Resident #132 was found on the floor with injury sustained to the head. They stated they believe that the injury was from the fall. During an interview on 08/05/2024 at 11:02 AM, the Director of Nursing stated that the incident was not reported to the New York State Department of Health because the investigation revealed that there was a fall even though it was not witnessed by the staff. They stated that any allegation of abuse or injury of unknown origin have to be reported within 2 hours to the New York State Department of Health. 10 NYCRR 415.4(b)(2)

Based on record review and interview conducted during the Recertification Survey from 07/31/2024 to 08/07/2024, the facility failed to ensure that a Significant Change in Status Assessment was completed within 14 days after a determination had been made in the resident's status from baseline occurred. This was evident in 1 (Resident # 167) of 1 resident reviewed for pressure ulcer / injury out of 35 total sampled residents. Specifically, on 06/30/2024, Resident #167 was identified with an unstageable pressure injury to the sacrum and deep tissue pressure injury to the left heel. The facility did not have a Significant Change in Status Assessment completed after the change in condition was identified. The findings are: The facility policy titled Minimum Data Set Completion with a revised date of 10/2023 stated that the Minimum Data Set is completed on all residents according to a mandated assessment schedule. The purpose of the policy was to ensure all Minimum Data Set assessments are completed in a timely manner and transmitted to the Centers for Medicare & Medicaid Services. The policy documented that the Minimum Data Set Coordinator determines if a resident has a significant change in condition. If the resident meets the criteria for a change in condition, the Minimum Data Set Coordinator notifies the team of the change in assessment and proceeds with a Significant Change assessment. The Coordinator ensures all assessments are submitted to the Centers for Medicare and Medicaid Services within 14 days of completion. Resident #167 was admitted to the facility on with diagnoses including Stroke, Hypertension, and Diabetes Mellitus. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #167 had severely impaired cognition. The assessment documented that Resident #167 had no pressure ulcers/injuries and had no venous or arterial ulcers present. The wound / skin assessment note dated 06/30/2024 documented Resident #167 had unstageable pressure injury to the sacrum and deep tissue pressure injury to the left heel. The medical record lacked documented evidence that a Significant Change in Status Assessment was completed within 14 days after Resident #167's pressure ulcers / injuries were identified. During an interview on 08/05/2024 at 10:15 AM, the Minimum Data Set Coordinator stated that a significant change Minimum Data Set assessment must be completed if there was a significant change in a resident's condition. They stated they do not know why Resident #167's significant change assessment was overlooked. The Coordinator stated they have not received the wound tracker report from the Wound Care Nurse. 415.11(a)(3)(ii)

Based on observation, record review, and interview conducted during the Recertification Survey from [DATE] to [DATE], the facility did not ensure that food was stored, prepared, and distributed in accordance with professional standards for food service safety. This was evident during the Kitchen Task observation. Specifically, 1.) 2 boxes containing 20 (14 ounces) packages of bratwurst in the kitchen refrigerator and the freezer in the emergency food area were stored beyond the best by date, and 2.) potentially hazardous food were not maintained at an acceptable temperature to limit the growth of pathogen. The findings are: The facility's policy on Food and Supply Storage with a revised date of ,d+[DATE] documented all food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Most, but not all, products contain an expiration date. The words sell by, best by, enjoy -by or use-by should precede the date. Foods past the use-by, sell-by, best-by, or enjoy by date should be discarded. The facility's policy on Food Handling Guidelines with a revised date of ,d+[DATE] documented that temperature of food shall be monitored using accurate thermometers. The cold food preparation documented that prior to preparation, chill potentially hazardous ingredients to 41 degrees Fahrenheit for food that will be eaten without further cooking. Examples include salads, sandwiches, cut leafy greens and produce and reconstituted food. Products are chilled again after preparation to 41 degrees Fahrenheit before being served. 1.) On [DATE] between 9:20 AM and 10:05 AM, during the tour of the main kitchen and emergency food storage area with the Food Service Director, a box containing 10 (14-ounce) packages of smoked bratwurst with a best by date of [DATE] were in the kitchen meat refrigerator. During the tour of the emergency food storage area and freezer with Patient Food Services Utility Worker #1, a box of frozen smoked bratwurst with a best by date of [DATE] were in the meat refrigerator. During an interview on [DATE] at 10:11 AM, Patient Food Services Utility Worker #1 stated that the food's best by date is the expiration date. They stated they must get rid of food items that are expired. During an interview on [DATE] at 10:12 PM, The Chef Manager stated they are usually in the kitchen at 5:30- 6:00AM in the morning and had not noticed any items out of date. During an interview on [DATE] at 11:14 AM, the Food Service Director stated rounds were done daily in the kitchen which includes checking for expired food items. These checks were done daily on the units and the main kitchen. 2). During an observation on the 2nd floor with the Chef Manager on [DATE] from 11:26 AM to 11:28 AM, temperature of 2 egg salad sandwiches were taken. The first sandwich had a temperature of 62.2 degrees Fahrenheit, and the 2nd sandwich had a temperature of 57.9 degrees Fahrenheit. On [DATE] from 12:18 PM to 12:25 PM, an observation of the 6th floor unit refrigerator with the Chef Manager revealed the following: the unit refrigerator had a temperature of 40 degrees Fahrenheit, an egg salad sandwich had a temperature of 66 degrees Fahrenheit, and a tuna sandwich had a temperature of 66.6 degrees Fahrenheit. The egg salad sandwiches were stamped Prepared food, not reheated. Prepared [DATE] at 10:24 AM. During an interview on [DATE] at 11:29 AM, Patient Food Services Utility Worker #3 stated they made the sandwiches and placed them in the freezer at 9:00 AM. They stated they had never taken the temperature of the sandwiches. During an interview on [DATE] at 11:28AM, the Chef Manager stated that the sandwiches should be below 41 degrees Fahrenheit. They stated that the sandwiches were made earlier at 10:24 AM. During an interview on [DATE] at 11:19AM, the Food Service Director stated that sandwiches are made daily and are wrapped and placed in the freezer to get the temperature below 41 degrees Fahrenheit. They stated that sandwiches are brought up the last minute after lunches are brought to the units. They stated they have not noticed any problems with the temperature. 10 NYCRR 415.14(h)

Based on observation, record review, and interviews during an abbreviated survey (NY00304945), the facility fail to ensure that all alleged violations involving abuse were reported immediately, but no later than two hours after the allegation was made, or not later than 24 hours, if the event that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administration of the facility, and to the New York State Department of Health (NYSDOH). This was evident in one out of three residents reviewed for abuse (Resident #1). Specifically, on 11/3/22, an allegation of staff-to-resident abuse occurred. The alleged abuse was reported to NYSDOH and the Facility's administrator on 11/5/22. The findings are: The facility's Policy and Procedure titled: Identification, Investigation, Protection, and reporting of Physical Abuse, Mistreatment, and neglect of Residents last revised 9/2022, stated that all alleged violations, involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and mis appropriation of resident's property must be reported immediately, but no later than two hours after the allegation is made. All cases of abuse, mistreatment or neglect, misappropriation of resident's funds, or physical injury must be reported to the police. The badge number, date, and time of response must be entered on the Accident and Incident Report. Resident #1 with diagnoses which included Alzheimers' Disease, Anxiety, and Gait Abnormality Disorder. The Minimum Data Set (MDS, a resident assessment tool) dated 10/02/22, documented a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of two. Resident #1 was cognitively impaired and required extensive assistance of one person for hygiene, toileting, turning, positioning, and activities of daily living. Resident #1 was wheelchair bound. A Care Plan for victimization dated 04/05/22, documented that Resident #1 was at risk to be harmed by others due to cognitive impairment related to Dementia. The Interventions were to identify triggers for behaviors, provide a calm approach and recognize that resident's cognitive status may inhibit understanding. Orientate resident to the environment and do visual checks. A Behavior Monitoring Tracking Log dated from 11/5/22 to 11/7/22, documented that Resident #1 was monitored for changes in behavior and that Resident #1 remained calm. The facility's occurrence report dated 11/5/22 at 2:45 PM, documented that on 11/5/22 at 2:45 PM, Certified Nursing Assistant #2 (CNA #2) reported that on 11/3/22 during the 2 PM-10 PM shift, CNA #1pounded on Resident #1's right hand two to three times. CNA #2 did not report the incident until 11/5/22. Resident #1 had a full body check by RNS, there were no evidence of bruising, swelling, discoloration, or trauma. The Medical Doctor (MD), the facility administrator, the Director of Nursing (DNS), the police, and the next-of-kin were informed on 11/5/22. The Physician examined Resident #1 and ordered X-ray of the right hand. The X-ray results were negative for fractures. Resident #1 was unable to give statement due to severe cognitive impairment. CNA #1 was interviewed over the phone and denied the allegation of abuse. CNA #2 was interviewed by RNS #1 and Police Officers. All staff working on the unit were interviewed, and they denied having witnessed CNA #1 abuse Resident #1, or any other residents. The Facility Investigation Summary dated 11/5/22 at 2:45 PM, documented that CNA #2 presented a written statement to the RNS #1. The statement documented that on 11/3/22, while providing care, CNA #2 witnessed CNA #1 physically and verbally abuse Resident #1. The Facility's immediate action included body assessment of Resident #1. Resident seemed emotionally intact. The MD was informed and conducted a physical assessment of the resident, ordered X-ray of right hand, and X- ray result showed no evidence of fracture or dislocation. The MD also ordered psychiatric/psychologic evaluation of the resident. Resident #1 was assessed for pain, did not appear to be distressed. Resident #1 was placed on monitoring for changes in behavior. The next-of-kin/ family and NYPD were notified. On 11/5/22 at 8:05 PM, two officers arrived at the facility. The alleged perpetrator (CNA #1) was not in facility when the officers arrived. The Police Officers interviewed CNA #2, and the resident's family. The facility's corrective actions included: Revision of Resident #1's Comprehensive Care Plans (CCP) for victimization, re-education of facility's staff on safe resident handling, verbal, physical abuse, and timely reporting. CNA #1 was suspended following the outcome of the investigation. CNA #2 was suspended for delayed reporting of alleged abuse. The facility concluded there was no care plan violation, and no physical evidence to suggest that abuse, mistreatment, or neglect had occurred. The resident was unable to recall the event due to impaired cognition. A Nursing Note, written by Register Nurse #1(RN #1), dated 11/5/22 at 9:23 PM, documented that the resident was examined for alleged physical abuse. The right hand was examined, there were no visible injuries, no swelling, no pain to touch, no discoloration on Resident #1's right hand or anywhere on the body. Then Nurse Supervisor (RNS) called the emergency number (911) and reported the allegation of abuse. Two Police Officers arrived at 8:05 PM and gave their badge numbers. The Officers interviewed CNA #2 and the resident's family. No arrest were made. A Physician Visit Summary dated 11/6/22 at 1:12 PM, documented that Resident #1 was examined, and is awake, alert, and confused. There was no swelling, no pain during passive range of motion. The Physician ordered x-ray of right hand and the X-ray revealed no fractures. The pain level was assessment as 0 out of 10 on the pain scale. During an interview on 11/8/22 at 1:20 PM, the Director of Nursing (DON) stated that on 11/5/22, CNA #2 submitted a written statement that on 11/3/22 during the 2 PM-10 PM shift, they witnessed CNA #1 strike Resident #1 several times on the hand. DON stated the CNA #2 did not report the incident, but during interview claimed they had a severe migraine headache after the incident and went home. CNA #1 sent an e-mail to the facility, stated that they did not abuse Resident #1 or any other resident. The DON stated that both CNAs were currently on suspension, and facility immediately began to in - service all facility staff on abuse, immediate reporting of abuse, abuse prevention, and caring for residents with dementia. The allegation was reported to NYSDOH and local precinct. During an attempted interview on 11/8/22, Resident #1 is not answering questions due to dementia. Resident #1 only responded to questions with a smile and a wave of hands. During an interview on 11/8/22 at 3 PM with the 2 PM to 10PM shift, CNA #3 stated they have never seen CNA #1 act out, angry, or abusive to residents or co-workers. CAN #3 stated that CNA #1 always have a joke to tell but was never rude or exhibit any bizarre behavior. CNA #3 stated that they had received In-service on abuse, reporting, keeping residents' information safe, care of residents with dementia yearly as part of the mandatories. During interview on 11/8/22 at 3:30 PM, the Interim facility Administrator (IFA) stated that they were unaware of the alleged abuse incident until CNA #2 came to work on 11/5/2022 at 2:45 PM and handed RNS a written statement of having witnessed a staff abuse Resident #1 on 11/3/2022 during care. IFA stated they questioned CNA #2 why incident was not reported to unit nurse or the supervisor on the day of occurrence, that CNA #2 said they had a terrible headache on the day and was only focusing on going home to rest. IFA stated that CNA #2 left unit in the middle of the shift, came to RNS office requesting to go home because of a headache. IFA said CNA #2 had ample opportunity to tell the supervisor what they had witnessed, that instead came to work three days later and presented a statement dated 11/4/2022 to supervisor. The IFA said the incident was immediately reported to NYSDOH and law enforcement on 11/5/2022. CNA #2 was interviewed by the police officers and placed on suspension for failure to report the allegation timely. During interview on 11/8/22 at 4:32 PM, Registered Nurse #1 (RN #1), stated that they worked 2 PM to 10 PM on 11/3/22 and CNA #1 was assigned to Resident #1. RN #1 stated that they were not aware of any incident and that CNA #2 did not report that the resident was abused by the CNA #1 during care. RN said at approximately 6:30 PM on 11/3/22, CNA #2 came to the nurses' station, very anxious, erratic, crying and wanting to go home in the middle of the shift. CNA #2 left and did not return to unit. RN #1 stated the CNA #1 have never been abusive to any resident, takes good care of residents that are assigned, and works well with staff. RN #1 stated that at no time did CNA #2 said that CNA #1 mistreated or abuse Resident #1during the shift. RN #1 stated that they had received in-services on abuse after the incident, and it is part of the mandatories as a refresher every year. During a telephone interview on 11/8/22 at 6:50 PM, CNA #2 stated that they were not assigned to Resident #1 but was asked by CNA #1 to help put Resident #1 on toilet. CNA #2 stated that as soon as the resident was wheeled into the room, the CNA #1 went into a rant, cursing, yelling, talking off key, and acting bizarre. CNA #2 said attempt to calm CNA #1 down but was unsuccessful. CNA #2 stated they did not report it to anyone, did not press resident's call bell to alert other staff, and was just trying to help with the transfer and be done with. CNA #2 said they both transferred the resident onto the toilet and waited for the resident to finish, that CNA #1 washed the resident, the resident was holding on to the safety bar while CNA #1 pulled up the resident's pants. CNA #2 said as resident was holding on to the safety bar, CNA #1 pounded on Resident #1's right hand two to three times, but Resident #1 did not scream or yell out in pain. Resident #1 was calm. CNA #2 stated that they both transferred Resident #1 back to the wheelchair and CNA #1 wheeled the resident out of the bathroom to the dining room. CNA #2 stated that the resident was fine, was not in pain, did not scream and just forgot the whole episode because they could sense a severe migraine headache coming on. CNA #2 said they were focused on the headache and left the unit to sit in the car to cool off. They went to the Nurse Supervisor's office and requested to be excused from duty but did not tell the Nursing Supervisor that CNA #1 pound on Resident #1's right hand, cursing, yelling, talking off key, or acting bizarre in front of the resident. CNA #2 were not on schedule the next day and while at home, they relived the whole scenario, wrote a statement of the alleged abuse, and handed it to the evening supervisor on 11/5/22 at approximately 2:40 PM. CNA #2 said they were trained in abuse recognition, abuse reporting, and knows well that any staff can report abuse to the department of health and 911. CNA #2 said they understood abuse must be reported immediately and had it in mind to report it next time they were on duty. CNA #2 states the resident seemed okay at the time, was not crying, the hand was not red or swollen. CNA #2 said they were interviewed by the police on 11/5/2022 and have been suspended since. CNA #2 said they regretted not following the protocol and it will never happen again, that they regularly received in services on care of the elderly, abuse, neglect, and not sharing resident's information with anyone. During interview on 11/9/22 at 3 PM, Registered Nurse Supervisor (RNS) stated on 11/5/22, CNA #2 handed them a written statement stating they witnessed CNA #1 physically abuse Resident #1 during care on 11/3/22. CNA #2 was asked why they did not report the incident immediately. CNA #2 avoided the question and was just berating CNA #1 by saying that CNA #1 was controlling and always telling people what to do. RNS stated that CNA #2 do not mentioned the type of abuse that the resident received. RNS stated CNA #1 was asked many times to describe what they saw, so CNA #2 was given a statement form and told to write down the statement. RNS said the CNA #2 was again asked to describe the incident, and why she/he did not report the incident right away but was evasive and said they failed to report it then but was reporting it now, they are aware it should have been reported right away and was in-service on abuse. During a telephone interview on 11/9/22 at 4:35 PM, CNA #1 stated that said they have been employed by the facility as a CNA for [AGE] years and had spent two years working on the Resident #1's unit. CNA #1 stated that Resident #1 was regularly assigned to them. CNA #1 stated that they cared for the Resident #1 on 11/3/22 and 11/4/22. CNA #1 stated that they had asked CNA #2 to assist in transferring Resident #1 on to the toilet at approximately 5:00 PM. CNA #1 stated that CNA #2 wanted to take Resident #1 off the toilet a few minutes after the resident sat on the toilet. CNA #2 stated that it was too soon and that the resident likes to stay longer on the toilet, and they should give them time. CNA #2 became very anxious, complaining about the assignment and don't want to waste time waiting on the resident, CNA #1 said they told CNA #2 to calm down, as it is the nature of the job, and they should let the resident finish and not abruptly remove the resident off the toilet. CNA #1 said CNA #2 kept complaining and insisting they should have put the resident on the bed to toilet the resident, which is faster, and could have been done with it. CNA #1 said they insisted CNA #2 stop fidgeting as it is making the resident nervous. CNA #1 stated that they washed Resident #1 asked CNA #2 to help put the resident back on to the wheelchair. CNA #1 said that CNA #2 was still complaining, anxious throughout the care and would not calm down. CNA #1 denied Resident #1 would not let go of safety rail and at no time pounded on the resident's hand and would never abuse Resident #1 or any other resident. CNA #1 stated that she/he tried to calm CNA #2 down as the resident was also becoming anxious. CNA #1 said they reassured Resident #1 and wheeled Resident #1 to the dining room for dinner after providing care. CNA #1 said that CNA #2 screaming, yelling at the nurses' station then burst into tears wanting to go home, saying I got to go, I have anxiety, I have a headache left the unit and never returned. CNA #1 stated they have yearly in-services on abuse, knows to report any abuse to the nurse, and to the supervisor if necessary. CNA #1 stated that the Director of Nursing called on 11/5/2022 and placed them on suspension for abusing Resident #1. CNA #1 denied ever abusing any resident. CNA #1 stated that they have not been contacted by the police or visited by one. During interview on 11/9/22 at 5:30 PM, Interim Facility Administrator stated that they contacted the 122nd Precinct to obtain a copy of the police report for the incident, the police officer on duty stated that the detective assigned to the case was working on the report and that CNA #1 was not contacted by the police and no arrest have been made. 10 NYCRR415.4 (b).(2).

Based on observation, record review, and interviews during an abbreviated survey (NY 00 298102), the facility failed to protect resident's right to be free from physical abuse. This was evident for two out of four Residents sampled (Residents #1 and Resident #2). Specifically, on 6/25/2022 between 7:00 PM and 8:00 PM, a Temporary Nursing Aid, (TNA #1) who was employed for three months, heard yelling coming from an adjacent bedroom and did not respond or report to the Charge Nurse. TNA #1 went home at the end of the double shift without reporting what was heard. On 6/26/22, at 1:20 PM, TNA #1 observed Resident #1 with discoloration on the left cheek and a small laceration to the lower lip and reported what was heard the night before to the Charge Nurse (RN #1). Resident #1 identified Resident #2 as a person who came to their room on 6/25/2022 at night and hit them in their face. The findings are: The Facility's Policy and Procedure entitled Identification, Investigation, Protection, and Reporting Physical Abuse, Mistreatment, and Neglect of Residents with revision date 4/2022, documented that it is the facility's policy to make all employees aware of their responsibility to identify and report resident abuse in compliance with the Office of Primary Care and Health System Management. The facility's surveillance camera was reviewed with the Assistant Director of Nursing (ADNS) on 7/14/2022 at 2:18 PM. The surveillance camera footage was recorded in real-time. Camera on the Fourth floor D -2 (D wing): 8:00 PM, a Certified Nurse Assistant (CNA#1) was seen walking on the unit. TNA #1 standing at the doorway of room [ROOM NUMBER] B which is next to Resident #1's room (room [ROOM NUMBER]). TNA #2 and CNA #1 were seen walking in the hallway. Both staff members went into other residents' rooms. TNA #1 went into the resident's room that is next to Resident #1's room. 8:06 PM, Resident #2 was seen walking with a rolling walker (RW), and entered their room (room [ROOM NUMBER]). 8:07 PM, Resident #2 exited their room with RW, walked down the hallway and look into another resident's room but did not enter. Resident #2 kept walking slowly in the hallway, then entered Resident #1's room. 8:10 PM, Resident #2 came out of Resident #1 room and proceed in the hallway toward their room. Resident #2 stood at the doorway for a moment, touched their right wrist, and looked back toward Resident #1 room. Resident #2 walked toward the nursing station. 8:11 PM, Resident #2 returned to their room. Resident #2 was seen going in and out of their room a few times. 8:24 TNA #1 exited the room that was next to Resident #1's room and walked toward the nursing station. There were three staff members, (CNA #1, CNA #2, and TNA #3) walking in the hallway. Camera on the Fourth floor D - 1: 8:22 PM, Resident #2 was observed sitting in a chair next to the nursing station, talking to another resident who was sitting next to Resident #2. 8:25 CNA #1, TNA #1, and CNA #2, were walking in the hallway. A review of the Facility's undated Summary of Investigation of 6/25/2022, documented that on 6/26/2022 the Nursing Supervisor, (RNS#1) informed the Assistant Director of Nursing (ADNS) that Resident #1 reported that a resident with white hair entered their bedroom and punched them in the face multiple times. The Video surveillance from 10:00 PM to 6:AM was reviewed and did not reveal anybody entering Resident #1's room. On 6/27/2022, in the morning, Resident #1 pointed at Resident #2 and said that Resident #2 was the one who hit Resident #1. Video surveillance footage was reviewed using different times frame and revealed that on 6/25/2022 at 8:08 PM, Resident #2 went into Resident #1's room and came out at 8:10 PM. The Police were notified and interviewed Resident #1. Resident #2 was transferred to the hospital for psychiatric evaluation. Upon return Resident # 2 was placed on 1:1 monitoring. The team discussed changing rooms for Resident #2 but decided that it will destabilize Resident #2. Resident #1 did not want their room change. The Medical Doctor evaluated Resident #1 and observed a bruise and redness on the Resident #1's face and a small scratch/cut to the lower lip. Resident #1 denied emotional trauma and being fearful of Resident #2. The facility concluded that Resident to Resident abuse had occurred. Resident #1 was admitted to the facility with diagnoses including Hypertension, Renal insufficiency, and Diabetes Mellitus. A Quarterly Minimum Data Set (MDS, a resident assessment tool) assessment dated [DATE] documented, that Resident #1 had a Brief Interview of Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 11, indicating that Resident #1 had moderately impaired cognition. A review of the Nursing Note dated 6/26/2022 at 3:10 PM, written by RNS #1, documented that Resident #1 was assessed for redness and petechia-like spotting on his/her face. No open areas were noted. Resident #1 stated that the lady with white hair came to his/her room last night, and maybe he/she did it. Resident #1 was wheeled on the unit but was not able to identify a lady with white hair saying that he/she did not remember. The roommate denied seeing anybody in their room. The camera surveillance was reviewed for 6/25/2022 from 10:00 PM to 6:00 AM, and no one was seen entering Resident #1's room. The family was called, and a voice message was left. The ADNS was informed. A review of the Medical Doctor's (M.D.) Note dated 6/27/2022 at 7:11 AM, documented that Resident #1 was seen and examined for skin discoloration of the face after Resident #1 stated that he/she was struck in the face a few days ago by another resident. There was ecchymosis and petechia on the left side of the face around the cheekbone area. No swelling was noted. There was also a small laceration to the left side lower lip, no bleeding was noted. Resident #2 was admitted to the with diagnoses including Dementia, Schizophrenia, Anxiety disorder, and Depression. Resident #2's BIMS score was 7, which indicated that Resident #2 was severely cognitively impaired. Resident #2 required limited assistance of one-person for bed mobility, and transfers. Resident #2 ambulates with a rolling walker. A review of the Behavior Care Plan dated 10/27/2021, documented that Resident # 2 needed ongoing redirection, monitoring, and structured activities for being Psychically Abusive with another resident and displayed wandering behavior. A review of the Medical Record from 6/1/2022 to 6/25/2022, revealed that Resident # 2 was wandering to other residents' rooms and was not on any scheduled visual monitoring. A review of the Nursing Note dated 6/27/2022 at 10:02 AM, written by Unit Manager /Registered Nurse #1, (RN #1), documented that Resident #1 complained that Resident #2 struck them in the face a few days ago. Resident #1 pointed to Resident #2 in the hallway. A video surveillance footage reviewed showed that on 6/25/2022 at 8:08 PM, Resident # 2 entered Resident #1's room for approximately two minutes. The family was made aware. The M.D. ordered to send Resident #2 to the emergency room for psychiatric evaluation. 911 was called. Emergency medical services and the Police arrived. Resident #2 left the unit at 9:05 AM. A review of the M.D. Order dated 6/27/2022, documented, transfer Resident #2 to the Hospital for psychiatric evaluation due to a physical altercation, Psychology consultation, and Psychiatry consultation. A review of the Nursing Home to Emergency Department (ED) Transfer Sheet dated 6/27/2022, documented that Resident #2 had a physical altercation with another resident. Resident #2 punched another resident in the face. Resident #2 need Psychiatric evaluation. A review of Nursing Note dated 6/27/2022 at 2:06 PM, written by RN #1, documented that Resident #2 returned from the hospital and was placed on 1:1 monitoring until further notice. Psychiatric and Psychology services were ordered. A review of the Hospital Discharge Summary dated 6/27/2022, documented that Resident #2 was evaluated for Neurocognition Disorder and Xanax 0.5 mg was given by mouth. A review of the Unsafe Wandering Tracking Log dated 7/14/2022, documented that Resident #2 was on every 15 minutes monitoring. A review of the ADL Fact Sheet dated as of 7/15/2022, documented instruction to redirect Resident #2 when observed wandering into other residents' rooms. During an interview on 7/14/2022 at 11:17 AM, Resident #1 stated that he/she remember that a resident with white hair came to their room and hit them many times on the cheeks. Resident #1 stated that they were asleep and woke up because Resident #2 was hitting them. Resident #1 stated that the next day while they were going to take a shower, they saw Resident # 2 sitting in the hallway, and was able to recognize Resident #2 and told the Doctor that Resident #2 was the person who hit them. Resident #1 stated that Resident #2 comes into their room sometimes and tries to go into their drawers. Resident #1 stated that after the incident, Resident #2 has not come back to their room and that they are not afraid of Resident #2. During an interview on 7/14/2022 at 11:35 AM, Resident #2 stated that they do not sleep well at night. Resident #2 stated that they go to other residents' rooms and give residents extra blankets if they are cold. Resident #2 stated that residents like the blankets. During an interview on 7/14/2022 at 1:23, TNA #1 stated he/she was employed for three months and on 6/25/2022, worked a double shift from 6 AM to 8:30 PM. TNA #1 stated that approximately between 7-8 PM, he/she was assisting another resident in the bathroom that was connected to Resident #1's room. TNA #1 stated that they heard yelling coming from Resident #1's room. The person was saying, stop you hurting me, stop pulling my hair. TNA #1 stated that the bathroom door that was connected to Resident #1's room was closed. TNA #1 stated that he/she could not leave the resident on the toilet and that a wheelchair was blocking the way to Resident #1's room. TNA #1 stated that after he/she completed care for the other resident, he/she went in the hallway, look up and down, and did not see anybody. TNA #1 stated that he/she did not go to Resident #1's room and did not look in the room to see if anybody was there. TNA #1 stated that he/she was looking for the nurse but did not see anyone. TNA #1 stated that he/she did not find a nurse or CNA. TNA #1 stated that he/she did not know who else to report the suspected abuse. TNA #1 stated that he/she clocked out and left the unit at 8:30 PM. TNA #1 stated that the following morning on 6/26/2022, he/she was working from 6 AM-2 PM (was not assigned to Resident #1). Stated that he/she observed Resident #1 in the hallway (does not recall the time) in the wheelchair. TNA #1 stated that he/she saw Resident #1's face with blue and black discoloration and a little bruise on the bridge of the nose. Resident #1' face was not swollen or bleeding. TNA #1 stated that he/she told the nurse on duty what he/she heard the night before. During an interview on 7/14/2022 at 12:00 PM, CNA #1 stated that he/she was assigned to Resident #1 on 6/26/22, 6-2 shift. CNA #1 stated providing care to the Resident #1 at approximately 6:10 AM. Resident #1 does their face by themselves. Then CNA #1 was changing Resident #1 he/she observed unusual red cheeks. The color of the cheeks was very bright with a lot of spots like a rash. CNA #1 stated that he/she asked Resident #1 what happen. Resident #1 stated that a resident came to their room at night and hit them in the face. CNA #1 stated that there were no marks on the nose, just the cheeks. After breakfast, CNA #1 observed that Resident #1 had a deep scratch on the left side of the face. CNA #1 stated that he/she reported to the nurse at around 6:30 AM but cannot recall which nurse. During an interview on 7/14/22 at 12:30 PM, Registered Nurse #1 (RN #1), stated that Resident #2 was alert and oriented x 1. Stated that Resident #2 ambulates with an RW and had a behavior of wandering to other residents' rooms, covering residents with blankets, and attempting to bring the bed up if it was low. Resident #2 was not on any scheduled monitoring before the incident, it is the team's effort to monitor and redirect Resident # 2. The staff encouraged Resident #2 to join daily activity, but the Resident #2 does not like activity and does not participate. During the day, Resident #2 likes to sit next to the nursing station and other residents. The staff stated that Resident # 2's wandering behavior only occurs in the evening and night. RN #1 stated that on 6/27/2022, MD came to evaluate Resident #1 due to the incident. RN #1 stated that he/she observed Resident # 1 with scattered petechia on both cheeks and one spot on the nose. Also, Resident #1 had the tendency to rest their head on rolled sheet on the bedside table while sitting in the wheelchair. RN #1 stated that Resident #2 was calm at the time of the transfer but became agitated because they did not understand why they had to go to the hospital, and that they did not do anything wrong. Resident #2 was sent to the hospital as per facility protocol, due to a resident-to-resident altercation, for evaluation. Resident #2 was placed on 1:1 for 24 hours and was discontinued because Resident #2 was more agitated. Resident #2 was placed on 15-minute monitoring, then 30 minutes, and then the monitoring was discontinued. RN #1 stated that on 7/14/2022, Resident #1 complained that Resident #2 was passing by Resident #1's room. RN #1 stated that Resident #2 was put on every 15 minutes monitoring. Resident #1 was offered a room change but Resident #1 refused to move. During an interview on 7/15/22 at 10:00 AM, ADNS stated that RNS #1 notified him/her on 6/26/2022 at around 1:30 PM that Resident #1 verbalized that a resident with white hair came into their room last night and hit them in the face. Resident #1 was observed with red spots, petechia-like on his/her face with no black and blue discoloration. The RNS #1 reviewed the video of 6/25/2022 from 10:00 pm to 6:00 PM and did not see no described person entering Resident #1 room. The next morning on 6/27/2022, Resident #1 was going to take a shower and MD who came to evaluate Resident #1 was walking with Resident #1. Resident #1 saw Resident #2 in the hallway and pointed at Resident #2 stating, that is the one who hit me. There was no line up of residents. MD ordered to send Resident #2 to ER and 911 was called as per protocol. The resident's family were notified. The family of Resident #2 was present and accompanied Resident #2 to the emergency room . Resident #2's family member was upset because Resident #2 was brought to the psychiatric unit. ADNS stated that the facility has no control over where 911 takes the residents. The facility usually transfers residents to a regular ER for evaluation if an in-house Psychiatrist is not available within a reasonable time. During an interview on 7/15/2022 at 11:00 AM, MD #1 stated that he/she evaluated Resident #1 and observed a bruise on the left cheek that was black and blue and consistent with trauma. MD #1 does not recall seeing a bruise on the nose. MD #1 stated that after he/she evaluated Resident #1, he/she was conducting rounds and Resident #1 was going to the shower room. MD #1 stated that Resident #1 saw Resident #2 in the hallway and pointed at Resident #2 stating that's the one who hit me. MD #1 stated that Resident #2 denied the allegation and was calm. The facility watched the video and observed Resident #2 going to Resident #1 room. Resident #2 was sent to the hospital for psych evaluation because an in-house Physiatrist was not immediately available. During an telephone interview on 7/18/22 at 3:41 PM, RN # 2 who worked on the 6/25/22, during the six to two shift stated that TNA #1 reported to them at around 1:00 PM, that Resident #1 was observed with redness to the face. RN #2 assessed Resident #1 and observed redness to both cheeks. RN #2 stated that it looks like an allergic reaction. RN #2 asked Resident #1 what happen, and Resident #1 answered that they do not know. Resident #1 did not complain that somebody hit them and did not verbalize any pain. RN stated that he/she did round in the morning but Resident #1 was very persistent with wearing a mask and had a mask on the face at almost all times. RN #1 stated that he/she called the RNS #1 immediately to assess Resident #1. RN #2 stated that it was TNA #1 who reported. CNA #1 did not report any change in Resident #1's condition. During a telephone interview on 7/18/2022 at 12:00 PM, ADNS stated that they discussed resident's safety with Resident #2's family and the family agreed to relocate Resident #2 to another wing. Resident #2 agreed and was transferred to another wing on the same unit on 7/16/2022. Resident #2 tolerated the new room change well. During a telephone interview on 7/22/2022 at 11:18 AM, the Director of Nursing (DNS) stated that he/she became aware of the incident on 6/27/2022 and implemented interventions to prevent re-occurrence. TNA #1 and CNA #1 were counseled on timely reporting. All staff received in-service on behavior management, abuse identification, investigation, and reporting timely. The Police were called, and Resident #2 was transferred to the hospital for an evaluation. Resident #2 returned to the facility and was placed on 1:1. Staff monitoring. Resident #2 did not display any adverse behavior and the scheduled monitoring was discontinued. DNS stated the camera was reviewed to see if Resident #2 was disturbing other residents on the unit and none was identified. 10 NYCRR: 415.4(b)(1)(i)

Based on record review and interviews conducted during an Abbreviated Survey (NY00 298102), the facility failed to implement policies and procedures to ensure that an alleged violation involving abuse was reported to the New_York State Department of Health (NYSDOH) within two hours after the allegation was made. Specifically, on 6/25/2022 between 7:00 PM and 8:00 PM, a Temporary Nursing Aid, (TNA #1), heard yelling coming from the adjacent bedroom and did not respond or report to the charge nurse but went home at the end of the double shift. On 6/26/22, at 1:20 PM, TNA #1 observed Resident #1 with discoloration on the left cheek and a small laceration to the lower lip and reported what was heard the night before to the charge nurse. The facility reported the incident to NYSDOH on 06/27/2022 at 08:44 AM. The findings are: The facility's Policy and Procedure entitled Identification, Investigation, Protection, and Reporting Physical Abuse, Mistreatment, and Neglect of Residents with revision date 4/2022, documented that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of Resident's property, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and other officials. A review of the facility's undated Summary of Investigation documented that the occurrence happened on 6/25/2022. On 6/26/2022 the Nursing Supervisor (RNS#1) reported to Assistant Director of Nursing (ADNS) that Resident #1 reported that a resident with white hair entered their room and punched them in the face multiple times. A Video surveillance on 06/26/2022, from 10:00 PM to 6:AM, was reviewed and did not reveal anyone entering Resident #1's room. On 6/27/2022, in the morning, Resident #1 pointed at Resident #2 and said that Resident #2 was the one who hit Resident #1. A Video surveillance footage was reviewed using different times frame and revealed that on 6/25/2022 at 8:08 PM, Resident #2 went into Resident #1's room and came out at 8:10 PM. The Medical Doctor evaluated Resident #1 and observed a bruise and redness on the resident's face and a small scratch/cut to their lower lip. The Police were notified, responded, and interviewed Resident #1. Resident #2 was transferred to the hospital for a psychiatric evaluation. Resident #1 returned to the facility and was placed on 1:1 monitoring. The team discussed changing rooms for Resident #2 but decided that it will destabilize Resident #2. Resident #1 declined to have their room changed. Resident #1 denied emotional trauma and being fearful of Resident #2. The facility concluded that alleged resident abuse had occurred. Resident #1 was admitted to the facility with diagnoses including Hypertension, Renal insufficiency, and Diabetes Mellitus The Quarterly Minimum Data Set (MDS, a resident assessment tool) dated 5/29/2022, documented that Resident #1 had a Brief Interview of Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) and scored 11, indicating that Resident #1 had moderately impaired cognition. A review of the Nursing Note dated 6/26/2022 at 3:10 PM, written by RN #3 documented that Resident #1 was assessed for redness and petechia-like spotting on his/her face. No open area was noted. Resident #1 stated that a resident with white hair came to his/her room last night, and maybe he/she did it. The roommate denied seeing anyone in their room. The camera surveillance was reviewed from 6/25/22 from 10:00 PM to 6:00 AM, and no one entered Resident #1's room. The family was called, and a voice message was left. The Assistant Director of Nursing (ADNS #1) was informed. A review of the Medical Doctor Note dated 6/27/2022 at 7:11 AM, documented Resident #1 was seen and examined for skin discoloration of the face after Resident #1 stated that he/she was struck in the face a few days ago by another resident. There was ecchymosis and petechia on the left side of the face around the cheekbone area. No swelling was noted, and no open area. No tender to palpitation. There was also a small laceration to the left side lower lip with surrounding petechia, no bleeding was noted. Observation for future swelling was ongoing. Resident #2 was admitted with diagnoses including Dementia, Schizophrenia, Anxiety disorder, and Depression. Resident #2's BIMS score was 7, which indicated that Resident #2 was severely cognitively impaired. Resident #2 ambulates with a rolling walker and required limited assistance of one-person for bed mobility, and transfers. A review of the Nursing Note dated 6/27/2022 at 10:02 AM, written by Unit Manager /Registered Nurse #1, (RN#1), documented Resident #1 complained that Resident #2 struck them in the face a few days ago. Resident #1 pointed to Resident #2 in the hallway. A Video surveillance footage was reviewed, and Resident #2 was seen entering Resident #1's room for approximately 2 minutes on 6/25/2022 at 8:08 PM. The family was made aware. The Medical Doctor (M.D.), ordered to send Resident #2 out for a psychiatric evaluation. Emergency Medical services was called, and the Police arrived. At 9:05 AM, Resident #2 was transferred to the emergency room . During an interview on 7/15/22 at 10:00 AM, ADNS #1 stated that RNS #1, notified him/her on 6/26/2022 at around 1:30 PM, that Resident #1 said that a resident with white hair came into their room last night and hit them in the face. Resident #1 was observed with red spots, petechia-like on his/her face with no black and blue discoloration. ADNS #1 stated that DNS and two ADNSs are responsible for reporting the incidents to NYSDOH within 2 hours. ADNS #1 was on call that weekend and was responsible for investigating and reporting the incident. ADNS #1 stated that they reported the incident on 6/27/2022 after Resident #1 pointed out Resident #2 as the aggressor and they reviewed a video surveillance with a time frame dated 6/25/2022 during the 2-10 PM shift, that confirmed that Resident #2 entered Resident #1's room at around 8:00 PM. ADNS #1 stated that he/she notified the DNS on 6/27/2022. ADNS #1 stated that the Administrator was notified on 6/27/22, during the morning report. ADNS #1 stated that he/she was not aware that the facility should report the incident after Resident #1 verbalized abuse on 6/26/2022. During an interview on 7/22/2022 at 11:18 AM, the Director of Nursing (DNS), stated that he/she became aware of the incident on 6/27/2022. ADNS #1 was reviewing the camera in the morning and informed the DNS of the occurrence. The DNS stated that any allegations of abuse, neglect, or mistreatment should be reported within 2 hours to NYSDOH. ADNS #1 was on call and had full autonomy of investigating incidents and reporting to NYSDOH. The ADNS did not report on 7/27/2022 because they were not sure is the discoloration on Resident #1 was a bruise or a rash. During an interview on 7/22/2022 at 11:45 AM, the Administrator stated that he/she became aware of the incident on 6/27/2022. The Administrator stated that if there are an allegation of abuse, the DNS and the Administrator should be made aware as soon as possible. All incidents that involve abuse should be reported within 2 hours to NYSDOH. 10 NYCRR: 415.4(b)(1)(i)

Based on interviews and record reviews conducted during the Recertification and Complaint (#NY 077) Survey from 61/2022 to 6/ , the facility did not ensure a resident's Comprehensive Care Plan (CCP) was reviewed and revised to reflect a change in the resident's status. This was evident for 1 (Resident #535) of 7 residents reviewed for accidents out of 38 sampled residents. Specifically, Resident #535's CCP related to wandering and elopement was not revised to address the resident's repeated attempts to elope from the facility. The findings are: The facility's policy titled CCP revised 11/2021 documented the CCP shall be reviewed and revised quarterly, annually, whenever there is a change in resident's medical condition, functional status, and as needed. Resident #535 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Minimum Data Set (MDS 3.0) assessment dated [DATE] documented Resident #535 had moderately impaired cognition and had a wander guard. The CCP related to behavior symptoms dated 10/5/21 documented Resident #535 had exit-seeking behavior, wandered, attempted to elope, and removed their wander guard. Interventions included providing psychiatry/psychology consult, providing [CONDITION(S)] medication as ordered, and ensuring proper placement and function of wander guard. The Elopement assessment dated [DATE], 1/5/22, and 1/13/22 documented that Resident #535 was at high risk for elopement as evidenced by wandering and verbalizing wanting to go home. Interventions included personal safety alarm devices, keep behavior logs, review medications, identification bracelet, utilization or check in/out log, recreational activities, personalization of room, photograph on wander list, and staff aware of resident's wander risk. Nursing Notes dated 10/17/21, 10/19/21, 10/20/21, 10/22/21, 10/27/21, 11/10/21, 11/23/21, 12/5/21, 12/22/21, 12/23/21, 12/24/21, 12/25/21, 12/26/21, 12/27/21, 1/3/22, 1/5/22, 1/19/22, and 1/21/22 documented Resident #535 attempted to board the elevator or exit the unit through the staircase. The Accident Incident (AI) report dated 1/5/22 documented Resident #535 attempted to exit the unit using the stairwell and was redirected by staff back to the unit. Preventative measures included frequently monitoring the resident, notifying the Medical Doctor (MD), and ordering a psychiatry consult. The Care Plan Meeting (CPM) note dated 1/5/22 documented an interdisciplinary team (IDT) meeting was held and the action plan included ensuring Resident #535's wander guard was in place, elopement precautions, frequent monitoring, and redirection. The AI report dated 1/19/22 documented Resident #535 was wandering with intent to leave the unit multiple times by using the elevator and stairwell and became increasingly agitated. Resident #535 was able to board the elevator and the elevator doors closed. Preventative measures included to continue monitoring and redirection. The AI report dated 1/20/22 documented Resident #535 removed their wander guard, used the elevator to leave the floor, and went to main lobby desk. Preventative measures included one-to-one safety monitoring and application of a new wander guard. The CPM note dated 1/20/22 documented the IDT met and determined Resident #535 did not have their wander guard in place when they attempted to leave the unit and elevator doors closed. The action plan included one-to-one monitoring and application of another wander guard. There was no documented evidence Resident #535's CCP related to wandering and elopement behavior was revised following the resident's attempts to elope from the unit and facility. On 6/9/22 at 11:30 AM, Registered Nurse (RN #6) was interviewed and stated CCPs should be reviewed and revised each time a resident attempt to elope from facility and could not explain the lack of revision to Resident #535's CCP. On 6/9/22 at 12:06 PM, RN #5 was interviewed and stated the nursing supervisor on duty is responsible for updating a resident's CCP when they exhibit behavior. Resident #535's CCP was initiated 10/5/21 but was not revised after Resident #535 had multiple attempts of eloping from the unit and facility. 415.11(c)(2)(iii)

Based on interviews and record review conducted during the Recertification and Complaint (#NY 077) Survey from 6/1/22 to 6/9/22, the facility did not ensure a resident was free from accidents. This was evident for 1 (Resident #535) of 7 residents reviewed for accidents. Specifically, Resident #535 was identified as an elopement risk and did not receive adequate supervision to prevent actual elopement from the facility by walking through the lobby front door. The findings are: The policy titled Elopement Risk Assessment and Procedure dated 12/21 documented residents will be assessed for elopement and a plan of care developed to address elopement risk and initiate interventions to ensure their safety. Resident #535 was admitted to the facility with diagnosis of dementia and hypertension. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #535 had moderately impaired cognition and a wander guard in place. The Behavior Symptoms Comprehensive Care Plan (CCP) dated 10/5/21 documented that resident with exit Seeking Behavior, wanders, attempt to elope, removes wander. Interventions include to provide psychiatry/psychology consult as ordered by medical provider, provide [CONDITION(S)] medication if ordered, ensure proper placement and function of wander tag, wander alert bracelet. There was no documented evidence that the CCP was updated post multiple elopement attempts. The Elopement assessment dated [DATE], 1/5/22, and 1/13/22 documented that Resident #535 was at high risk for elopement as evidenced by wandering and verbalizing wanting to go home. Interventions included personal safety alarm devices, keep behavior logs, review medications, identification bracelet, utilization or check in/out log, recreational activities, personalization of room, photographs on wander list, staff aware of resident's wander risk. It did not document any supervision. Physician's Orders dated 10/22/21 documented order for wander guard to Resident #535's left wrist to be checked every shift. Nursing Notes dated 10/17/21, 10/19/21, 10/20/21, 10/22/21, 10/27/21, 11/10/21, 11/23/21, 12/5/21, 12/22/21, 12/23/21, 12/24/21, 12/25/21, 12/26/21, 12/27/21, 1/3/22, 1/5/22, 1/19/22, and 1/21/22 documented Resident #535 attempted to board the elevator or exit the unit through the staircase. The Accident Incident (AI) report dated 1/5/22 documented Resident #535 attempted to exit the unit using the stairwell and was redirected by staff back to the unit. Preventative measures included frequently monitoring the resident, notifying the Medical Doctor (MD), and ordering a psychiatry consult. The Care Plan Meeting (CPM) note dated 1/5/22 documented an interdisciplinary team (IDT) meeting was held and the action plan included ensuring Resident #535's wander guard was in place, elopement precautions, frequent monitoring, and redirection. The AI report dated 1/19/22 documented Resident #535 was wandering with intent to leave the unit multiple times by using the elevator and stairwell and became increasingly agitated. Resident #535 was able to board the elevator and the elevator doors closed. Preventative measures included to continue monitoring and redirection. The AI report dated 1/20/22 documented Resident #535 removed their wander guard, used the elevator to leave the floor, and went to main lobby desk. Preventative measures included one-to-one safety monitoring and application of a new wander guard. The CPM note dated 1/20/22 documented the IDT met and determined Resident #535 did not have their wander guard in place when they attempted to leave the unit and elevator doors closed. The action plan included one-to-one monitoring and application of another wander guard. The Summary of Investigation dated 1/24/22 documented video surveillance showed Resident #535 walking past a security guard at the front desk and out the facility desk. The security guard received a phone call from a facility worker who saw Resident #535 on the street walking away from the facility. Resident #535 was redirected back to the facility and was found to have no wander guard in place. Treatment Administration Record (TAR) from October 2021 to January 2022 did not document wander guard check for Resident #535 in 23 shifts in October 2021, 18 shifts in November 2021, 15 shifts in December 2021, and 20 shifts in January 2021. On 6/7/22 at 2:52PM, the Administrator was interviewed and stated prior to Resident #535's elopement, the unit manager was closely monitoring the resident because the resident had a history of removing their wander guard and attempting to leave the unit. The facility was unable to determine when Resident #535 removed their wander guard in order to board the elevator without the alarms sounding. After the incident occurred, Resident #535 was placed highly visible on the unit, near by the nursing station, the front entrance door was locked, and the side door was used as an entrance. Resident was placed on one-to-one monitoring and a larger picture of Resident #535 was placed at the front entrance. Resident #535 was then discharged to a more appropriate setting. On 6/8/21 at 10:24 AM, Certified Nursing Assistant #2 was interviewed and stated Resident #535 had wandering behavior, was known to remove their wander guard, and was supervised closely with 15-minute checks. There is no documented record of the 15-minute checks. On 6/9/22 at 12:06 PM, Registered Nurse (RN) #5 was interviewed and stated staff closely monitored and frequently check on Resident #535, including during medication pass or regular rounds on the unit. Resident #535 was also checked by staff every 15 minutes. On 6/9/22 at 1:29PM, the Director of Nursing was interviewed and stated Resident #535 removed their wander guard and the nursing staff were supposed to check placement of the wander guard every shift. Resident #535 was also closely monitored on the unit because of their frequent attempts to leave the unit. Resident #535 was observed talking to the RN just prior to their elopement, was able to board the elevator shortly after talking with the RN because Resident #535 had removed their wander guard and was able to walk past security because Resident #535 was wearing a hat and mask. The elevator alarm sounds only if a resident is wearing their wander guard. The DON was unable to provide documented evidence of frequent checks or 15-minute monitoring. On 6/9/22 at 3:51 PM, RN #3 was interviewed and stated they were the last person to see Resident #535 prior to their elopement from the facility on 1/24/22. Resident #535 had a known behavior of wandering and attempting to elope and would remove their wander guard. Resident #535 had multiple incidents of being able to board he elevator because of the removal of their wander guard. 415.12(h)(1)(2) The facility was cited with a past non-compliance and the following Plan of Correction was implemented: For Resident #535: -One-to-one monitoring until resident was transferred to a locked unit completed 1/26/22. -Conducted elopement/Code 500 drill with door alarm drill on 1/24/22 at 4:45PM. -CCP related to wandering and elopement was reviewed and revised on 1/25/22 -Entrance and exit sliding doors were locked and alternate door was made accessible with close 24-hour monitoring and surveillance on 1/25/22 -Security guards were re-educated on Elopement Policy and Procedure and awareness of individuals entering and exiting the building on 1/25/22 -Staff were educated on Elopement Policy and Procedure/Code 500 protocol and behavior monitoring effort on 1/25/22. For all residents: -all residents with wander guards were checked immediately for placement and all wander guards were in place. -any residents noted to remove bracelets will be placed on high alert with Q15 minute checks and/or one-to-one monitoring depending on their ambulation status. System Changes to prevent re-occurrence: -monthly Quality Assurance Performance Improvement (QAPI) review of a random sample of 15 residents who triggered 5 or greater on the elopement assessment -frequency of elopement QAPI reviews were increased from quarterly to monthly. -frequency of door alarm/elopement drills increased too monthly. Monitoring Efforts to prevent re-occurrence: -any resident identified with exit seeking/wandering behaviors, are placed on safety watch for 15 minutes checks/one-to-one monitoring based on ambulation status/wheelchair mobility.

Based on observation, record review and interview conducted during the COVID-19 Focused Infection Control Survey completed on 1/19/21, 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 3 out of 5 units observed for Infection Control (Units 4, 5, and 6). Specifically, a staff member was observed providing resident care without donning (applying) a gown and eye protection for a resident on quarantine (Unit 6). Additionally, residents who were in contact with COVID-19 positive staff members were not placed on quarantine (Units 4 and 5). The findings are: The Centers for Disease Control and Prevention (CDC) guidance titled Preparing for COVID-19 in Nursing Homes, updated 11/20/2020, 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. The guidance further provides: Because of the higher risk of unrecognized infection among residents, universal use of all recommended PPE (Personal Protective Equipment) 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 12/14/2020) until the HCP's COVID-19 test results are known. If the 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 12/14/2020 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 (National Institute for Occupational Safety and Health) 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 on COVID-19 System Wide Policy and Procedure titled Disease Preparedness revised 1/14/2021 documented under caring for a person either having or suspected of having COVID-19 to use standard, contact, droplet precautions along with gown, gloves and eye protection when caring for patients who are conformed or suspected of have COVID-19. Personal Protective equipment (PPE) should include facemask, gown, gloves and eye protection (goggles or face shield). Under the Disease Preparedness of the COVID-19 System Wide Policy and Procedure it was documented that the facility will conduct contact tracing to stop the spread of COVID-19. On 1/19/2021, on the 6th Floor Unit at 10:55 AM, Certified Nursing Assistant (CNA) #1 was observed in a resident's room wearing a surgical mask, gloves and personal eyeglasses. The resident's unit was on contact/droplet precautions. CNA #1 was observed trimming the resident's nails. CNA #1 did not wear an isolation gown, eye protection and N95 Mask. CNA #1 was interviewed on 1/19/2021 at 11:10 AM and stated that he was supposed to be wearing eye protection when cutting the resident's nails. CNA #1 stated that he can get additional PPE from the cart at the nursing station. An interview with the Registered Nurse Manager (RNM) on 1/19/2021 at 11:59 AM revealed that staff members must don (apply) gowns for direct resident care. The RNM said that CNA #1 should have been wearing eye goggles, face shield and gown while trimming the resident's nails. An interview with Infection Control Preventionist (ICP) on 1/19/2021 at 12:06 PM revealed that the 6th Floor was on quarantine due to staff members testing positive for COVID-19. A CNA tested positive on 1/5/2021 and a Nurse Practitioner (NP) tested positive on 1/15/2021. ICP stated, that every employee should wear full PPE (gown, gloves, eye protection and mask). An interview with the Director of Nursing (DON) on 1/19/2021 at 12:47 PM revealed that the 6th Floor is on quarantine due to COVID-19 positive exposure. The DON stated, for contact/droplet precaution, staff should wear full PPE (gown, gloves, goggles and mask) when performing direct care including trimming nails. The DON stated that daily rounds are conducted to ensure staff are wearing appropriate PPE. The Nurse Manager also performs daily and ongoing education. Review of the facility list of staff members on furlough, as of 1/19/2021, documented that a CNA was tested on [DATE] and received a positive COVID-19 test result on 1/12/2021. The CNA last worked on the 5th floor on 1/10/2021. The list also revealed that a NP staff member was tested for COVID-19 on 1/14/2021 and received a positive COVID-19 test result on 1/18/2021. The NP last worked in the facility 1/13/2021, on the 4th, 5th, and 6th floors. An observation on 1/19/2021, on the 4th Floor, at 10:15 AM revealed there was no signage posted on the unit for contact/droplet precautions. Several staff members were observed wearing surgical masks and face shields and were not wearing gowns. The Registered Nurse (RN), on the 4the Floor, was interviewed on 1/19/2021 at 10:25AM and stated there were no residents on contact/droplet precaution and that there was no COVID-19 infection on the 4th Floor. CNA #2, on the 4th Floor, was interviewed, on 1/19/2021 at 1:40PM and stated that the 4th Floor was not on quarantine. There are no residents on contact/droplet precautions. An observation on 1/19/2021, on the 5th Floor, at 10:50 AM, revealed contact/droplet precaution signs were posted on three resident rooms. There were no other contact/droplet precaution signs observed on the unit. Licensed Practical Nurse #1 (LPN #1), on the 5th Floor, was interviewed on 1/19/2021 at 10:55AM. The LPN stated that the residents in the three rooms are on contact/droplet precautions for 14 days as they are new admissions. There are no active COVID-19 infections on the unit and there are no other residents on isolation precautions. An interview with CNA #3, on the 5th Floor, on 1/19/2021 at 1:45PM. The CNA stated, the unit was not on quarantine and the staff are only required to wear a surgical mask, face shield, and gloves when caring for residents. Staff must wear gowns if they are providing direct care for residents on contact precautions. CNA #3, on the 5th Floor, was interviewed on 1/19/2021 at 1:45PM and stated the unit is not on quarantine and the staff are only required to wear a surgical mask, face shield, and gloves when caring for residents. Staff must wear gowns if they are providing direct care for residents on contact precautions. The ICP was interviewed on 1/19/2021 at 12:18PM and stated that the facility performs contact tracing starting from 48 hours prior to a staff member testing positive for COVID-19, in order to determine close contacts. The ICP stated that the NP tested positive for COVID-19 on 1/14/2021 at another facility. The ICP stated that the medical staff member reported the positive result on 1/18/2021. The ICP stated that the 4th and 5th Floors were not placed on contact/droplet precautions or quarantine. The ICP stated that it was determined that the exposed residents would be placed on the 24-hour report for monitoring of symptoms and would be tested on their regularly scheduled serial testing date. The ICP stated she is not familiar with the NYSDOH Health Advisory titled, COVID-19 Cases in Nursing Homes (NH) and Adult Care Facilities, dated 3/13/20 revised 7/10/20 or the CDC guidance titled Responding to Coronavirus (COVID-19) in Nursing Homes, dated 4/30/20. The ICP stated that the NYSDOH Epidemiologist has recommended to quarantine all units in the past. The ICP did not implement this because the facility determined that these were recommendations and they were not required to quarantine all units. The DON was interviewed on 1/19/2021 at 2:30PM and stated that staff members are required to wear full PPE, including gloves, masks, face shields, and gowns when interacting with residents on the quarantined units. If a staff member becomes symptomatic or COVID-19 positive, contact tracing is implemented and the facility determines which residents had contact with that staff member and the last time the resident was tested . The DON stated, if contact tracing revealed that units were exposed to a COVID-19 positive staff member, the ICP, DON, and Administrator discuss whether to place the exposed residents and/or units on quarantine/isolation precautions. If a resident is positive through routine testing, the resident is moved to the COVID-19 designated unit and their former unit is placed on quarantine for 14 days. The DON stated that she was not aware that a medical staff member had become symptomatic on 1/15/2021 and reported a positive COVID-19 test result on 1/18/2021. The DON stated that the guidance from the CDC and the NYSDOH is to quarantine the entire building; however, it is not a regulatory requirement and is only a recommendation. The facility follows the policy in place for addressing COVID-19 positive staff members. The corporate entity for the facility has determined that it is unnecessary to place the entire building or exposed units on quarantine. 415.19 (a)(1-2);400.2

Based on record review and staff interview conducted during the recertification survey, the facility did not ensure Minimum Data Set (MDS) 3.0 assessments were electronically transmitted to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in a timely manner. Specifically, a discharge assessment was not transmitted within 14 days after completion. This was evident for 1 of 1 resident reviewed for the Resident Assessment task. (Resident # 4). The finding is: Resident #4 was discharged from the facility on 06/22/2019. Nursing progress note dated 6/22/19 documented resident was discharged home accompanied by ambulette attendants. Medications were reviewed and discharge instruction was given. Review of the medical record revealed no documented evidence that a discharge MDS assessment had been completed. On 10/07/2019 at 11:30 AM, the State Agent (SA) requested the discharge MDS. MDS Coordinator # 2 processed and transmitted the discharge assessment on 10/07/2019. On 10/08/2019 at 10:33 AM, an interview was conducted with MDS Coordinator #1. MDS Coordinator #1 stated the discharge was inadvertently inactivated. A 30-day assessment was completed on 06/25/2019 for billing purposes, although the resident was actually discharged on [DATE]. The discharge assessment was missed. On 10/09/2019 at 2:45 PM, MDS Coordinator #2 was interviewed. MDS Coordinator #2 stated when residents are scheduled for discharge, the information is automatically populated in the Sigma Care (a type of electronic medical record) and is displayed on the dash board. When staff goes into the record pending assessments are automatically displayed. Then the discharge MDS is generated. MDS Coordinator #2 further stated that because the resident had a previous discharge and readmission, the discharge assessment opened on the wrong date and we did not catch the correct discharge date . The facility policy and procedure is that discharge assessments should be transmitted 14 days from completion. 415.11

Based on observation, record review and interview, the facility did not ensure that the Minimum Data Set 3.0 (MDS) accurately reflected the resident's status. Specifically, (1) a resident with no pressure ulcer during the assessment period was documented on the MDS as having an unhealed Stage 2 pressure ulcer and, (2) a [DIAGNOSES REDACTED]. This was evident for 2 residents reviewed out of a total investigation sample of 38 residents. (Resident # 117 and 276). The findings are: 1. Resident #117 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] documented the resident is totally dependent on two staff persons for bed mobility, transfer and toilet use. The MDS also documented that the resident had one unhealed Stage 2 pressure ulcer. The Comprehensive Care Plan (CCP) for Skin Integrity: at Risk for Skin Breakdown updated 7/24/19 documented: resident is at high risk for skin breakdown. The CCP monitoring/Evaluation note updated 10/09/19 documented: Resident has a skin breakdown as evidenced by Stage 1 to inner left gluteal fold. Review of the quarterly updates on Comprehensive Care Plan (CCP) for Skin Integrity since 01/2016 to 10/2019 contained no documentation that the resident had a Stage 2 pressure ulcer. Nursing Progress note dated 10/8/19 documented: Resident noted to have small reddened area approx. 4 cm x 2 cm irregular shaped redness. Remains incontinent of bowel and bladder. Turned and positioned. Evaluated by NP. [MEDICATION NAME] applied. Nurse Practitioner progress note dated 10/8/19 documented: Seen and examined for staff report of redness on left buttock noted this (morning) am. Has a H/O (history) of same. Exam reveals small irregular area of [DIAGNOSES REDACTED]. Skin is intact. The Matrix for Providers (CMS-822) printed 10/3/2019 contained no documentation that the resident had a pressure ulcer. There was no documented evidence that the resident had a Stage 2 pressure ulcer. On 10/08/19 at 08:46 AM, an interview was conducted with the Registered Nurse/Unit Manager (RN#4). RN #4 stated that resident has no pressure ulcer at present but only skin redness on the left buttock which was first developed on 7/27/19 and healed. RN #4 stated that the redness is noted on and off due to Moisture Associated Skin Damage (MASD) and is usually treated with ointment and cream with good effect. The present treatment is being applied every 3 days as per order. Skin is assessed on shower days and documented in the treatment section of the skin assessment progress note. Residents with PRESSURE ULCER are followed up by the wound doctor weekly to evaluate and assess the PRESSURE ULCER status and document it on the assessment progress note for other staff to know the current status. The resident is not on weekly MD wound round assessment list because she has no pressure ulcer. RN#4 also stated that resident had skin redness/excoriation that developed to stage 2 pressure ulcer long time ago but has been healed since (MONTH) this year. RN stated that the coding on the current MDS indicating stage 2 PRESSURE ULCER is an error done by the MDS assessor. On 10/09/19 at 08:15 AM, an interview was conducted with the Registered Nurse RN/ MDS Coordinator (RN #3). RN #3 stated that the tools used during the quarterly MDS review to ensure that the resident's condition is consistent with the information in the progress notes and plan of care are the weekly decubitus round notes, the care plans, the push notes, from the morning reports if there is any newly developed issues, from the dieticians' notes if there is new skin breakdown and if there is any issues unresolved. RN #3 also stated that to ensure that each portion of the assessment is accurate, everything is checked with Point Right - the weekly documentation of the wound assessment, MD orders, treatment records, and current care plans are also checked during the assessment period. RN #3 further stated that the MDS coordinator does not go through every section for accuracy, the RN or the interdisciplinary team (IDT) member that does the assessment is expected to check for the accuracy of the section completed while the MDS coordinator checks and review for the completion of the entire assessment and submit for billings. RN stated that the error noted in the resident's current MDS was not captured by the assessor and by the coordinator before final submission. RN #3 stated that the MDS will be modified and re-submitted immediately. 2. Resident #276 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set 3.0 ((MDS) dated [DATE] documented the resident had moderately impaired cognition with an active [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3.0 ((MDS) dated [DATE] and 7/15/17 documented a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3.0 ((MDS) dated [DATE] documented the resident had moderately impaired cognition and received antianxiety medication for seven days. Psychiatrist Progress note dated 9/27/19 documented the resident with a [DIAGNOSES REDACTED]. There was no documented evidence that the resident's [DIAGNOSES REDACTED]. On 10/09/19 at 08:34 AM, an interview was conducted with the MDS Coordinator who stated the [DIAGNOSES REDACTED]. The MDS Coordinator also stated the [DIAGNOSES REDACTED]. 415.11(b)