Every finding on record at Coler Rehabilitation and Nursing Care Center

Based on observation, interview, and record review, the facility failed to ensure ensure that a resident was free of any physical restraint not required to treat the resident's medical symptom and that there was documented ongoing reevaluation of the need for the restraint. This was evident in one (1) (Resident #216) of two (2) residents reviewed for physical restraints out of 40 total sampled residents. Specifically, Resident #216 was observed lying in bed between two (2) large body-sized pillows which were positioned between the mattress and bed sheet that could not be removed without removing the bed sheet. There was no documented evidence of a physician's order to use the two (2) large body-sized pillows under the bedsheet or ongoing reevaluations of the use of the pillows. The findings include: The facility policy titled, Side Rails/Bed Rails, dated 07/23/2025, documented that physical restraints include any manual method, physical, or mechanical device, material, or equipment that is attached to or positioned adjacent to a resident's body, which the individual cannot easily remove, and that restricts their freedom of movement or access to their own body. The facility policy titled, Side Rails/Bed Rails, did not discuss the procedure for the use of potential restraint devices other than siderails/bedrails. No other policy addressing physical restraints was provided by the facility. Resident #216 had diagnoses including Alzheimer's Disease and Depression. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #216 had severe cognitive impairments, displayed daily physical behavioral symptoms towards others and other daily behavioral symptoms not directed towards others. It also documented that Resident #216 did not have upper or lower extremity impairments but required dependent-level assistance for rolling left and right in bed and for transfers from the bed to chair. The assessment also documented that Resident #216 did not use any restraints while in bed. On 04/01/2026 at 09:32 AM, Resident #216 was observed awake in bed with upper half side rails raised on both sides of the bed. Two (2) large body-sized pillows were observed with one (1) on each side of Resident #216 secured under the bed sheet, between the bed sheet and the mattress; the pillows could not be removed by the resident while in bed. The pillows extended in length from Resident #216's head to their ankles. The Rehabilitation Referral Form dated 02/20/2025 documented that Resident #216 was referred to Physical Therapy because the resident's family requested the use of long pillows related to non-purposeful leg movements while in bed. The form listed the need for referral to be for consideration of a positioning device such as a long pillow or body aligner while the resident was in bed. The recommendation listed a body aligner for additional positioning and pressure relief when in bed. The form addressed one (1) pillow provided by the family to be used for comfort as safe. The referral form did not document that the placement of the pillow to be secured under the bed sheet was addressed and evaluated for appropriateness or safety. The Comprehensive Care Plan related to Behavior initiated 06/08/2023 documented that Resident #216 had a behavior problem/dementia-related behavior symptoms related to cognitive impairment with mood symptoms, including banging their legs on their bed rails seeking attention, and banging their feet and arms on the surfaces. The Comprehensive Care Plan did not reference the use of the two (2) large body-sized pillows secured under the bed sheet as an intervention. The Comprehensive Care Plan did not address the resident moving to the side of the bed as a behavior. The Comprehensive Care Plan related to Activities of Daily Living, initiated on 06/08/2023, documented that Resident #216 had a self-care performance deficit and required total assistance in activities of daily living. The specific placement of two (2) large body-sized pillows to be secured in a manner not removable by the resident was not addressed in the care plan. The care plan did not reference the long pillows in any intervention/task prior to 04/01/2026. The care plan also documented the intervention last revised on 01/01/2026 for the resident to roll left and right with substantial/maximal assistance with one-person physical assist with the use of 2 upper side rails for bed mobility and positioning. The intervention did not address the bilateral pillows positioned between the resident and the upper side rails in reference to bed mobility and positioning. The Nursing Progress Note dated 06/30/2025 documented that Resident #216 experienced behaviors of yelling, screaming, and banging their hands and legs on their side rails at night. The Nursing Progress Note dated 12/12/2025 documented that Resident #216 was noted banging their right leg against the side rail and screaming throughout the night. On 04/01/2026 at 09:47 AM, Registered Nurse #3 observed Resident #216 in bed with the surveyor while Resident #216 was awake in bed with the two (2) large body-sized pillows on each side of the resident. Registered Nurse #3 stated that Resident #216 had a history of attempting to get out of bed at night and that Resident #216's family had requested full bilateral side rails be used to prevent the resident from getting out of bed at night. Registered Nurse #3 stated that Resident #216 then began to bang on the side rails, so the facility began to use the pillows to protect the resident from being injured while banging on the side rails. Registered Nurse #3 stated that they believed the order for the pillows had been placed on 06/09/2023 under an order for a wedge cushion, and stated that the order should have specified where to place the wedge cushion, that two (2) cushions were in use instead of one (1), and what the indication of use was for the wedge cushions. On 04/01/2026 at 10:01 AM, Registered Nurse #4, who is the Head Nurse on Resident #216's unit, was interviewed after observing Resident #216 awake in bed with the two (2) large body-sized pillows on each side of the resident with the surveyor. Registered Nurse #4 stated that the two (2) large body-sized pillows on each side of the resident under the bedsheet was considered to be a potential restraint, and that there should have been a physician's order in Resident #216's medical chart indicating why the pillows were being used, how many pillows were ordered to be used, and where the pillows were to be positioned. Registered Nurse #4 also stated that a comprehensive care plan should have been created to address the use of the pillows by the nurse on duty when the pillows were first utilized. Registered Nurse #4 stated that they had transferred to this unit after Resident #216 began using the bilateral large body-sized pillows but that they should have realized that the accurate order and care plan was not in place and added it at that time. Registered Nurse #4 stated that the rehabilitation department was responsible for completing quarterly assessments on the two (2) large body-sized pillows. On 04/01/2026 at 12:05 PM, the Deputy Director of Nursing was interviewed and stated that Resident #216 had a behavior of moving to the side of the bed, so Resident #216 utilized wedge pillows as positioning devices, which were first ordered on 06/09/2023. The Deputy Director of Nursing stated that the order stated apply wedge cushion while in bed but did not include an indication for use or a location for where staff should apply the wedges, both of which should have been included in the order. The Deputy Director of Nursing stated that there should have been quarterly assessments for the use of the wedge cushions, and that a comprehensive care plan should have been created and updated quarterly by the Nurse Supervisor on the unit. The Deputy Director of Nursing stated that they were not sure why the order specifications, quarterly assessments, and care plan were not completed. On 04/01/2026 at 11:38 AM, the Director of Rehabilitation was interviewed and stated that the rehabilitation department did not issue large body-sized pillows to Resident #216 and that they were not sure if the pillows in use were related to the wedge device order from 2023. The Director of Rehabilitation stated that the Rehabilitation Department manages bed mobility devices, and the Nursing Department is responsible for assessing and managing devices related to resident behaviors. On 04/02/2026 at 09:59 AM, Certified Nursing Assistant #1 was interviewed and stated that Resident #216 requires total care with all tasks. Certified Nursing Assistant #1 stated that Resident #216's family had brought the two (2) large body-sized pillows for Resident #216 to use in bed for comfort on an unknown date. Certified Nursing Assistant #1 stated that Resident #216 is unable to remove the pillows while in bed because they are positioned under the bedsheet to ensure they remain in place. Certified Nursing Assistant #1 stated that Resident #216 had previously utilized full bedrails but currently used upper half bedrails and that Resident #216 was able to hold onto the bedrails while turning during incontinence care. On 04/02/2026 at 10:27 AM, Registered Nurse #4 was reinterviewed and stated that on 02/15/2025, Resident #216's family had brought in a pillow for the resident to use for comfort, and that the pillow had been assessed by the Rehabilitation Department as being safe for Resident #216 to use on 02/20/2025. Registered Nurse #4 stated that there had been a lapse in communication between them and the former Head Nurse on the unit, and that was why the facility failed to continue to complete quarterly assessments to ensure that the use of the pillow continued to be safe for the resident to use. Registered Nurse #4 stated that they did not know if the assessment on 02/20/2025 had also assessed the safety of a second pillow being used, or if it assessed the safety of the pillows being used under the bedsheet. On 04/02/2026 at 12:07 PM, the Deputy Director of Nursing was reinterviewed and stated that they reviewed Resident #216's chart again and found that in February 2025, the Rehabilitation Department assessed the use of a body pillow for comfort as being safe for Resident #216 after their family brought a pillow in. The Deputy Director of Nursing stated that they were not sure if the assessment was for the use of one (1) or two (2) large body-sized pillows, and that they were not sure when the use of the second pillow was implemented. The Deputy Director of Nursing stated that the nursing department should have continued to assess the use of the two (2) large body-sized pillows on a quarterly basis because it was a potential restraint, and that a care plan should have been created for the use of the pillows. The Deputy Director of Nursing stated they were not sure why the assessments and care planning did not occur. On 04/06/2026 at 11:22 AM, Medical Doctor #2 was interviewed and stated that Resident #216 had previously utilized bed rails for mobility and positioning but Resident #216's family wanted a more comfortable alternative for the resident, so the family brought in a body-sized pillow for Resident #216 to use in bed. Medical Doctor #2 stated that they were not sure when the second body-sized pillow was added or if Resident #216 had been assessed to ensure that it was safe to use both large body-sized pillows at once while the resident was in bed. Medical Doctor #2 stated that they were not aware that an order was needed for the use of the two (2) large body-sized pillows under the bedsheet while the resident was in bed, and that they were not the covering doctor when the first pillow was implemented in February 2025. On 04/06/2026 at 11:42 AM, the Director of Rehabilitation was interviewed and stated that the Physical Therapy assessment dated [DATE] assessed the safety of the use of one (1) long pillow, not two (2) long pillows. The Director of Rehabilitation stated that they did not know when the second pillow was added and that the nursing department should have sent a referral to the physical therapy department to have Resident #216 reevaluated for the use of the second pillow. The Director of Rehabilitation stated that the assessment completed 02/20/2025 did not document if it was safe for the pillows to be secured underneath the bedsheet. On 04/06/2026 at 11:46 AM, the Physical Therapist Supervisor was interviewed and stated that the Physical Therapy assessment dated [DATE] was related to the use of one (1) pillow that Resident #216's family brought in for comfort. The Physical Therapy Supervisor explained that when a device is considered appropriate, it means that the assessor determined the device would not cause skin issues and would not be a risk for entrapment. The Physical Therapist Supervisor stated that the use of two (2) pillows would require a separate assessment, and that nursing would have had to put in a referral for physical therapy to be made aware of the additional pillow and the need to assess it. The Physical Therapist added that assessment for the risk of entrapment and care planning should be conducted quarterly. On 04/06/2026 at 12:05 PM, the Medical Director was interviewed and stated that after the family brought in the second pillow, the nursing department should have placed a referral for the rehabilitation department to assess the safety of the use of both pillows. The Medical Director stated that they did not know why the use of the second pillow had not been assessed, why there was not an order for the use of both pillows, and why there was no ongoing reevaluation or care plan related to the two (2) large body-sized pillows. On 04/06/2026 at 02:47 PM, the Director of Quality Management stated that the facility did not have a policy that addressed physical restraints other than the policy titled Side Rails/Bed Rails dated 07/23/2025. 10 New York Codes, Rules and Regulations 415.4(a)(2-7)

Based on record review and interview conducted during the abbreviated survey (# 2619467), 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 for one (1) of three (3) residents (Resident #1) sampled. Specifically, on 09/09/2025 at 7:30 AM, Resident #1 had an unwitnessed fall and sustained a left femoral fracture (break in bone of the upper leg between the hip and knee) which the facility did not report to the New York State Department of Health until 09/16/2025 at 02:54 PM. The findings are: The facility policy titled 'Abuse Prevention and Reporting and Management of Other Reportable Incidents' dated 11/01/2022 documented Risk Management is responsible for assessing and ensuring the reporting of eligible incidents per regulatory requirements. The policy also documented federal and state regulations require that all allegations of abuse be reported immediately, but not later than 2 hours if events or allegation resulted in serious bodily injury. Resident #1 had diagnoses including Dementia, Alzheimer's Disease, Hypertension, and Arthritis. A review of the Minimum Data Set (a resident assessment tool) dated 06/11/2025 documented Resident #1 had severe cognitive impairment, and they required supervision when lying to sitting on side of bed, sit to stand and moderate assistive during ambulation. The Facility Report of Investigation dated 09/22/2025 documented Resident #1 was observed on the floor by staff near their bed in pain and holding their left thigh. Resident #1 reported to staff that they rolled off their bed and fell. Resident #1 was sent to the hospital on [DATE] and returned to the facility on [DATE] with a diagnosis of left femoral fracture. The Nurses Note dated 09/15/2025 at 08:50 PM, documented Resident #1 was readmitted to facility from the hospital around 4 PM and was unable to put pressure on their left leg due to closed fracture of the left hip. The New York State Department of Health Nursing Home Facility Incident Report revealed the incident was submitted to the Department of Health on 09/16/2025 at 02:54 PM. On 10/31/2025 at 02:28 PM, an interview was conducted with the Director of Quality Management who stated they reviewed the incident to ensure compliance however, the Director of Risk Management reported the incident to the New York State. The Director of Quality Management also stated Resident #1 was observed on the floor by a Certified Nursing Assistant on 09/09/2025 around 7:30 AM, was complaining of pain and was sent to the hospital for further evaluation. The Director of Quality Management further stated it was only after Resident #1 returned from the hospital that they learned about the fracture. The Director of Quality Management concluded by saying an injury of unknown origin should be reported with 2 (two) hours after the facility was first made aware. On 10/31/2025 at 02:37 PM, an interview was conducted with the Director of Risk Management who stated they are part of the team and other Nursing Supervisors who can also report an incident to the New York State Department of Health. The Director of Risk Management also stated an injury of unknown origin or alleged abuse incident should be reported immediately once the facility has found out about it. The Director of Risk Management further stated Resident #1 returned to the facility on the evening of 09/15/2025, and the incident was reported the next on 09/16/2025 at 02:54 PM. The Director of Risk Management stated they reported the incident when they got the confirmation of injury. 10 NYCRR 415.4(b)(2)

Based on observation, record review, and interviews during an abbreviated survey (NY00362797, the facility did not ensure that each resident received adequate supervision to prevent accidents. This was evident in one out six residents (Resident #1) sampled. Specifically, Resident #1 was observed on the floor in their room next to their bed at approximately 8:00 PM on 12/02/2024 by Certified Nursing Assistant #1. A Nursing Progress Note, by Registered Nurse #1, dated 12/02/2024 at 8:18 PM documented Resident #1 was assessed with a bruise around their right eye, a skin abrasion about 0.5 centimeter, and minimal bleeding below the right eye. The Hospital Discharge Summary dated 12/05/2024 documented Resident #1 had a laceration to their right maxillary process for which derma bond was applied. Resident #1's medical record revealed Resident #1 was observed on the floor in their room on 02/08/2024, 03/11/2024, 08/01/2024, and 12/02/2024. The Care Plan dated 02/08/2024 documented purposeful rounding every 2 hours and as needed. Resident #1 remained on two hours monitoring from 03/11/2024 through 12/02/2024. The findings include: The facility's Policy and Procedure titled Fall Reduction and Injury Prevention Program dated 06/27/2024 documented it is the policy of this facility to take appropriate measures to provide a safe environment and minimize the risk of resident injuries resulting from a fall. All residents will be assessed and reassessed to determine their risk for a fall. Based on the assessment findings, an individualized plan of care is developed, revised, or modified to reduce the risk of falls and falls with injuries. Resident #1 was admitted to the facility with diagnoses including Bipolar Disorder, Cerebrovascular Disease with Hemiplegia and Hemiparesis. The Minimum Data Set (an assessment tool) dated 09/11/2024 documented Resident #1 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) score of 03 associated with severe impairment. An Actual Fall Care Plan dated 02/08/2024 at 2:40 PM documented Resident #1 was observed sitting on the floor close to their bed. The interventions documented monitoring for pain and discomfort, and purposeful rounding every 2 hours and as needed. The updated Fall Care Plan dated 03/11/2024 at 7:45 AM documented Resident #1's roommate notified staff that Resident #1 fell while they were trying to get out of the bed. The interventions documented call bell within reach and to remind the resident to use call bell. Transfer Resident #1 closer to the nursing station. The updated Fall Care Plan dated 08/01/2024 documented Resident #1 was observed sitting on the floor next to their bed at 7:20 PM. The interventions documented movie Resident #1 to another room with less air conditioner use. The updated Fall Care Plan dated 12/03/2024 documented Resident #1 had a fall on 12/02/2024 (no time documented). The interventions documented Resident #1 to be transferred to the memory unit for residents with Dementia. There was no documented evidence of monitoring modification to care plans dated 03/11/2024, 08/01/2024, and 12/03/2024. A Documentation Survey Report (for Certified Nursing Assistants) dated from 10/01/2024 to 12/02/2024 documented purposeful rounding was being conducted every 2 hours while Resident #1 was awake. There was no documented evidence of monitoring modification on the Documentation Survey Report. A Nursing Progress note dated 12/02/2024 at 8:18 PM, by Registered Nurse #1, documented Certified Nursing Assistant #1 informed them Resident #1 fell on the ground. Resident #1 was noted with a bruise around their right eye and a skin abrasion (about 0.5cm) with minimal bleeding below the right eye. The Medical Doctor was notified and ordered for Resident #1 to be transferred to the hospital. An Unwitnessed Fall Report (Incident) and Summary of Report dated 12/02/2024 at 8:00 PM documented at around 8:00 PM Certified Nursing Assistant #1 reported Resident #1 was found lying on the floor in a supine position next to their bed. Body assessment revealed a bruise around Resident #1's right eye and a skin abrasion with minimal bleeding below the right eye. Resident #1 was transferred to the hospital. The investigation concluded that neglect did not occur. During an interview on 12/09/2024 at 1:00 PM, Certified Nursing Assistant #2 stated they were assigned to Resident #1 on 12/02/2024 from 3:00 PM - 11:00 PM. Certified Nursing Assistant #2 stated at approximately 7:00 PM Certified Nursing Assistant #1 assisted them in providing care to Resident #1. Certified Nursing Assistant #2 stated before leaving Resident #1's room, they positioned Resident #1 in the middle of the bed, call bell within reach, and the bed in the lowest position. Certified Nursing Assistant #2 stated 30 minutes after leaving Resident #1's room, they were informed by another staff member (don't recall name) Resident #1 was not in their bed. Certified Nursing Assistant #2 stated they went to Resident #1's room and observed Resident #1 on the floor next to their bed. Certified Nursing Assistant #2 stated Resident #1 was on the floor on the side of the bed away from the door. During an interview on 12/10/2024 at 11:16 AM, Registered Nurse #1 stated while they were making rounds on 12/02/2024 on the 3:00 PM to 11:00 PM (don't recall exact time), they did not see Resident #1 in their bed and asked Certified Nursing Assistant #1 for Resident #1. Registered Nurse #1 stated Certified Nursing Assistant #1 went to Resident #1's room and observed Resident #1 on the floor. Registered Nurse #1 stated they conducted a body assessment and Resident #1 was observed with a skin abrasion below their right eye. Registered Nurse #1 stated they notified the Medical Doctor who ordered Resident #1 to be transferred to the hospital for further evaluation. During an interview on 12/10/2024 at 2:53 PM, Medical Doctor #1 stated they and Resident #1 speak the same language (Hindi). Medical Doctor #1 stated Resident #1 has severe cognitive impairment/Dementia and that they encouraged Resident #1 to stay in bed to prevent them from falling and Resident #1 said they did not fall. Medical Doctor #1 stated Resident #1 has short-term memory problems and easily forgets. Medical Doctor #1 stated, Resident #1 was transferred to the memory unit where there are more activities to keep Resident #1 engaged. During an interview on 12/11/2024 at 12:00 PM, Associate Director of Nursing #1 stated Resident #1 was being monitored every 2 hours at the time of the fall. Associate Director of Nursing #1 stated Registered Nurse #1 was on duty at the time of the incident and updated Resident #1's care plan. Associate Director of Nursing stated modification to the monitoring should have been updated to 30 minutes, but it was not done. 10NYCRR415.12(h)(1)

Based on record review and interviews during an abbreviated survey (NY00318982, NY00315258), the facility failed to protect a resident's right to be free from physical restraint. This was evident in 1 (Resident #2) of 3 residents reviewed for abuse. Specifically, on 06/26/2023 during medication administration, Registered Nurse #3 held Resident #2's right arm firmly as they disconnected the syringe from the gastric tube. Resident #2 sustained a scratch mark on the right hand. The findings are: The facility's Policy and Procedure titled Abuse Prevention and Reporting and Management of other reportable incidents with a revised date of 11/01/2022 documented that facility residents have the right to freedom from verbal, sexual, physical, and mental abuse, corporal punishment, neglect, exploitation, mistreatment, involuntary seclusion and from misappropriation of their property and other crimes. The facility's Policy and Procedure titled Use of Restraints with a revised date of 12/23/2019 documented restraints shall only be used to treat resident's medical symptoms and never for discipline or staff convenience or for the prevention of fall. The policy defined physical restraints as any manual method attached or adjacent to a resident's body that an individual cannot remove easily which restricts freedom of movement or restricts normal access to one's body. Resident #2 was admitted to the facility with diagnoses of Epilepsy, Traumatic Brain Injury, and Chronic Respiratory Failure. The Minimum Data Set, dated dated dated [DATE] documented that Resident #2 had moderate impairment in cognition. The Minimum Data Set documented Resident #2 had a feeding tube. A Plan of Care Note dated 06/26/2023 at 4:53 pm documented Resident #2 pulled their gastric tube. Resident was calm and cooperative during gastric tube insertion by the physician. The note documented Resident #2 stated that the medication nurse tied them after they said no to medication. Resident #2 was noted with a faint discoloration on the right arm. A physician progress note dated 06/26/2023 at 11:20 am documented Resident #2 pulled their gastric tube and was reinserted. Resident #2 claimed they did not want to take their medications and the nurse gave medications by holding their wrist. The physician note documented a faint scratch mark on the right hand during examination. The facility's Accident/Incident report dated 06/26/2023 documented Resident #2 stated that the nurse came to their room to give them unnecessary medication, Resident #2 refused but the nurse insisted. The nurse took a plastic bag, rolled it up, tied their arm to the bedrail and gave Resident #2 the medication. The written statement by Registered Nurse #3 dated 06/26/2023 documented after administering Resident #2's medication and while the gastric tube syringe was still attached to Resident #2's gastric tube, Resident #2 swung their right arm and hit Registered Nurse #3 forcefully. This prompted Registered Nurse #3 to hold Resident #2's right arm down firmly until they were able to disconnect the syringe from the feeding tube. The Risk Management Summary Report documented the incident date as 06/26/2023, investigation completion date of 07/03/2023. The report documented the Risk Manager interviewed the accused nurse and the nurse stated that after administering the medications through Resident #2's gastric tube, the Resident struck the nurse on their arm. To prevent the Resident from striking the nurse again, the nurse took a plastic bag from their pocket and placed it on the resident's arm and held the arm firmly as they disconnected the syringe from the gastric tube. During an interview on 10/03/2023 at 1:21 pm, Resident #2 stated they did not remember the nurse's name, but the nurse twisted up a plastic bag and tied their arm to the rail. Resident #2 stated that the nurse tied them because Resident #2 was refusing their medication. During an interview on 10/06/2023 at 2:40 pm, Registered Nurse #3 stated they administered morning medication via gastrostomy tube to Resident #2 when the Resident hit them while the syringe was still attached to the gastrostomy tube. Registered Nurse #3 stated they held Resident #2's right hand down to protect themselves and Resident #2. Registered Nurse #3 stated they had a bag in their pocket when they entered Resident #2's room but they did not use the bag to tie Resident #2. During an interview on 10/18/23 at 12:19 pm, Risk Manager #1 stated that Registered Nurse #3 mentioned in their interview that they used a bag to hold onto Resident #2's arm. Risk Manager #1 stated they concluded that abuse was undetermined because there was not enough evidence to support the allegation and there was no witness. During an interview on 01/18/2024 at 1:43 pm, the Administrator stated they were made aware of the abuse allegation and that the outcome of the investigation was not substantiated because the incident was not observed. 10 NYCRR 415.4(a)(2-7)

Based on record review and interviews during an Abbreviated Survey (NY00315258, NY00318982), the facility failed to ensure that a resident's care plan was reviewed and revised by the interdisciplinary team following an allegation of abuse. This was evident in 1 (Resident #1) of 3 residents reviewed for abuse. Specifically, on 04/21/2023, Resident #1 alleged that Food Service Aide #1 hit their leg with a food truck. Resident #1's Comprehensive Care Plan was not reviewed and revised to reflect the allegation. The findings are: The facility's Policy and Procedure titled: Abuse Prevention and Reporting and Management of other reportable incidents with a revised date of 11/01/2022 documented that every resident of the facility is assessed by the interdisciplinary team for risk of abuse or for a risk of abusing others. This assessment is conducted upon admission, quarterly, and annually; or as indicated by a change in resident's status or behavior. Following assessment, the team develops an individualized abuse care plan based on the assessment findings. In the event of an incident of abuse, the team reviews, revises, and updates the care plan on the basis of the abuse incident. The facility's Policy and Procedure titled Care Plans, Comprehensive Person-Centered with a revised date of 12/2016, documented that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. Resident #1 was admitted to the facility with diagnoses of Paraplegia, Chronic Pain, and Diabetes Mellitus. The Minimum Data Set, dated dated dated [DATE] documented that Resident #1 was cognitively intact. A nurse's note by Registered Nurse #1 dated 04/21/2023 at 8:44 PM documented at around 5:15 pm, Resident #1 stated they asked Food Service Aide #1 not to leave their food tray by the window, but they did it anyway. Resident #1 stated they approached Food Service Aide #1 to talk to them and Food Service Aide #1 ran them over with the food cart causing their wheelchair and leg to collide with the food cart. The Risk Management Summary Report documented the incident occurred on 04/21/2023, investigation completion date of 04/26/2023. The investigative findings documented that Registered Nurse #1 heard Resident #1 yelling and cursing at Food Service Aide #1. Resident #1 was blocking Food Service Aide #1 from removing the food truck from the unit. Resident # stated that Food Service Aide #1 left their food tray by the window. When they approached Food Service Aide #1 to talk, Food Service Aide #1 ran them over with the food truck striking their leg and their wheelchair. Food Service Aide #1 documented in their statement that they placed Resident #1's food tray on the heater after asking Resident #1 twice where to place it. Resident #1 became agitated and pursued Food Service Aide #1 on their wheelchair, threatened to strike the Food Service Aide, and blocked the food truck with their motorized wheelchair. Food Service Aide #1 asked Resident #1 to make way for them to exit, but Resident #1 banged their wheelchair into the food truck. A Certified Nursing Assistant witnessed the incident. The facility concluded that the available evidence did not support the allegation of staff to resident abuse. A Comprehensive Care Plan for at risk for being abused and at risk of verbal/physical/sexual abuse by others related to diagnosis of paraplegia and self-care deficit was initiated on 12/18/2019. There was no documented evidence that care plan was reviewed after the alleged incident on 04/21/2023. A Comprehensive Care Plan for Behavior was initiated on 12/21/2019. The care plan documented that Resident #1 had behavior problem related to diagnosis of personality disorder and verbal and physical abuse with others. There was no documented evidence that the care plan was reviewed after the alleged incident on 04/21/2023. During an interview on 10/05/2023 at 12:11 PM, Registered Nurse #1 stated it was not their responsibility to update a care plan after the incident on 04/21/2023. It was the Head Nurse's responsibility to update the care plan. During an interview on 10/05/2023 at 1:30 PM, Registered Nurse #2 stated that whoever initiated the incident report was supposed to review and update the care plan. Registered Nurse #2 stated Registered Nurse #1 should have reviewed and revised Resident #1's care plan after the alleged incident on 04/21/2023. During an interview on 10/04/2023 at 11:30 AM, the Deputy Director of Nursing stated that the Staff Nurse or Head Nurse on the unit is responsible for reviewing the Comprehensive Care Plan. The Staff Nurse should put a new intervention after each incident to prevent recurrence. The Deputy Director of Nursing stated the Assistant Director of Nursing is responsible for overseeing the care planning and updating of interventions. During an interview on 01/18/2024 at 12:30 PM, the Director of Nursing stated that when an incident happens, the Registered Nurse is supposed to update the Comprehensive Care Plan with new interventions. When there is an allegation of abuse, the care plan on abuse is supposed to be reviewed and updated. The Director of Nursing stated that if the incident was related to resident's behavior, the behavior care plan must be reviewed and updated. The Director of Nursing stated that it was the Assistant Director of Nursing's responsibility to ensure that Resident #1's Comprehensive Care Plan was reviewed and interventions revised after the incident on 04/21/2023, which was not done. 10 NYCRR 415.11(c)(2)(i-iii)

Based on observations, record review, and interviews conducted during the Recertification Survey from 1/5/23 to 1/13/23, the facility did not ensure residents remained free from physical restraints. This was evident for 3 of 3 residents reviewed for Restraints of 42 total sampled residents (Resident #s 47, 18, 68). Specifically, 1) siderails (SR) were not used with Resident #47, #18, and #68 in accordance with Medical Doctor Order (MDO). The findings are: The facility policy titled Use of Restraints dated 12/23/19 documented restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. 1) Resident # 47 had diagnoses of traumatic brain injury (TBI) and post-traumatic seizures. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident # 47 had severely impaired cognition, was totally dependent on two persons for bed mobility and transfer, and did not use physical restraints. Between 01/05/23 at 11:20 AM and 01/10/23 at 09:39 AM, there were multiple observations of Resident #47 lying in bed with 4 SRs raised. MDO initiated 12/10/2020 documented Resident #47 was ordered to use 2 upper SRs for positioning, per air mattress manufacturer's recommendation, and for diagnoses of TBI, seizure, hemiplegia, and pressure injury prevention. The SR assessment dated [DATE] documented bilateral upper SRs were used with Resident #47 for safety and episodically during care. The call button and lights were incorporated into the SRs. Resident #47 had a history of falling out of bed due to sliding, poor trunk control, no sense of bed boundary, and unpredictable restlessness and agitation. On 01/10/23 at 10:12 AM, Certified Nurse Aide (CNA) # 2 was interviewed and stated Resident # 47 was alert and disoriented in bed. Resident #47 was quiet and did not move a lot. The 4 SRs are raised to protect Resident #47 from falling out of bed. CNA #2 receives report on residents from the head nurse daily at the start of their shift and recalls the head nurse reporting Resident #47 has 4 SRs raised while in bed. On 01/10/23 at 11:05 AM, Head Nurse (HN) # 2 was interviewed and stated the MDO is for Resident # 47 to have 2 upper SRs raised because the resident had no sense of bed boundaries. HN #2 gives resident report to the CNAs in the morning and the CNA should know Resident #47 has an MDO for 2 upper SRs. Resident #47 should not have 4 SRs raised while in bed. During the interview, HN #2 observed Resident #47 in bed with 4 SRs raised and was unable to provide an explanation for 2 lower SRs being raised. HN #2 stated they make rounds on the unit paid attention to positioning when the resident is in bed. It is considered a physical restraint when 4 SRs are raised. On 01/13/23 at 11:17 AM, the Director of Nursing (DON) was interviewed and stated they considered all 4 raised SRs as a physical restraint if the resident was not able to lower them or get out of bed. The DON rounds daily on some units and did not observe Resident #47 with 4 raised SRs. 45988 2) Resident #18 had diagnoses of traumatic brain injury (TBI) and vascular dementia. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #18 had severely impaired cognition, was totally dependent on staff to perform activities of daily living, and did not use physical restraints. On 01/05/23 at 09:49 AM and 02:55 PM and 01/06/23 at 10:14 AM, Resident #18 was observed in bed with 4 SRs raised. On 01/09/23 at 10:28 AM, Resident #18 was observed in bed with 3 (2 upper and 1 lower SR on resident's right side) out of 4 SRs raised. The Comprehensive Care Plan (CCP) related to SR use was initiated on 3/16/20 and last reviewed 10/18/22 documented Resident #18 had 2 upper SR raised due to diagnosis of dementia, impaired cognition, and seizures. MDO dated 10/23/20 documented Resident #18 was ordered 2 upper SRs while in bed for positioning due to diagnosis of seizures, dementia, impaired cognition, and no boundary awareness. The SR assessment dated [DATE] documented raising 2 upper SRs for positioning and turning of Resident #18. The SRs were not restricting Resident #18's movements and were not used as a restraint. On 01/11/23 at 03:40 PM, Certified Nursing Assistant (CNA) #5 was interviewed and stated Resident #18 holds on to the 2 raised upper SRs when turning in bed and the lower SRs are kept in the lowered position. A CNA on another shift possibly raised the lower SRs for Resident #18's protection. 3) Resident #68 had diagnoses of traumatic brain injury (TBI) and dementia. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #68 had severely impaired cognition, was totally dependent on staff for activities of daily living (ADL), and did not use restraints. On 01/05/23 at 09:53 AM and on 01/09/23 at 10:27 AM, Resident #68 was observed in bed with 3 (2 upper and 1 lower SR on resident's left) of 4 SRs raised. On 01/06/23 at 10:17 AM, Resident #68 was observed in bed with all 4 SRs raised. A Comprehensive Care Plan (CCP) related to SR use initiated 3/17/20 and last revised 11/22/22 documented Resident #68 had 2 upper SRs for positioning and ADL support. MDO dated 1/20/22 documented order for Resident #68 to have 2 upper SRs raised for positioning, ADL support, and diagnosis of seizure disorder. The SR assessment dated [DATE] documented recommendation for Resident #68 to have 2 upper SRs for positioning due to diagnosis of dementia, impaired cognition, and no sense of boundary awareness. SRs were not used as a restraint. On 01/11/23 at 03:32 PM, Certified Nursing Assistant (CNA) #6 was interviewed and stated Resident #68 uses 2 upper SRs for bed boundaries and to grab during care. The CNAs raise the lower SRs sometimes to prevent falls because Resident #68 tends to slide down in bed. On 01/13/23 at 10:12 AM, Registered Nurse (RN) #4 was interviewed and stated most residents use 2 upper SRs for mobility and to grab during care. Sometimes, the CNAs raise the lower SRs during care even though the CNAs know they are not supposed to raise all 4 SRs. RN #4 periodically spot-checks the SRs and lowers the SRs that were not supposed to be raised. On 01/13/23 at 10:37 AM, associate director of nursing #2 was interviewed and stated SRs are used as enablers during care and it is physical restraint when 4 SRs are raised. Residents #18 and #68 were not supposed to have their lower SRs raised. The CNAs were trained on proper SR use. The beds are manufactured with 4 SRs attached and cannot be modified. The lower siderails cannot be detached or disabled. On 01/13/23 at 02:15 PM, the Director of Nursing (DON) was interviewed and stated SRs are not used for staff convenience or as a physical restraint. The DON was not sure whether CNAs raise the lower SRs during care. 415.4(a)(2-7)

Based on interviews and record review conducted during the Recertification and Complaint survey (NY00284350, NY00303282, and NY00276114) from 01/05/2023 to 01/13/2023, the facility did not ensure violations involving abuse were reported to the New York State Department of Health (NYSDOH) immediately, but not later than 2 hours after the allegations were 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. This was evident for 6 of 6 residents reviewed for Abuse out of 42 total sampled residents (Resident #s 278, 285, 170, 347, 245, and 251). Specifically, 1.) the facility reported resident-to-resident altercations involving Resident #278, #285, and #170 to the NYSDOH more than 2 hours after occurrence, 2.) the facility reported a resident-to-resident altercation involving Resident #347 and #245 to the NYSDOH more than 2 hours after occurrence, and 3.) the facility reported Resident #251's second-degree cigarette burns to the NYSDOH more than 24 hours after occurrence. The findings are: The facility policy titled Abuse Prevention and Reporting and Management of Other Reportable Incidents dated 11/01/2022 documented Risk Management is responsible for assessing and ensuring the reporting of eligible incidents per regulatory requirements. Accidents resulting in second-degree burns must be reported to the NYSDOH. Incidents that do not involve serious bodily injury are to be reported to the NYSDOH no later than 24 hours after forming the suspicion. 1.) Resident #278 had diagnoses of non-Alzheimer's dementia and traumatic brain injury. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #278 was moderately cognitively impaired. Resident #285 had diagnoses of non-Alzheimer's dementia and seizure disorder. The MDS dated [DATE] documented Resident #285 was cognitively intact. Resident #170 had diagnoses of coronary artery disease (CAD) and depression. The MDS dated [DATE] documented Resident #170 was moderately cognitively impaired. Nursing Note dated 10/06/2021 documented Resident #285 hit Resident #278 with a cane and Resident #278 sustained a left eye hematoma and left wrist abrasion. Health Emergency Reporting Data System (HERDS) report (NY00284350) dated 10/06/2021 at 3:42 PM documented a facility report the resident-to-resident altercation involving Resident #285 and Resident #278 occurred on 10/06/2021 at on 10/06/2021 at 5:15 AM, more than 2 hours prior to the facility report. Nursing Note dated 02/21/2022 documented the nurse resolved a dispute over headphones between Resident #278 and Resident #170. The nurse later responded to a noise in the bathroom and found Resident #278 kicking Resident #170. The HERDS report (NY00284350) dated 02/21/2022 at 10:57 PM documented a facility report of an altercation between Resident #278 and Resident #170 that took place on 02/21/2022 at 6:00 PM, more than 2 hours prior to the facility report. 42101 2.) Resident #245 had diagnoses of dementia and mood disorder. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented resident #245 was severely cognitively impaired. Resident #347 had diagnoses of dementia and dysphagia. The MDS dated [DATE] documented Resident #347 the resident was moderately cognitively impaired and displayed physically, verbally, and other inappropriate behavior. A Nursing Note dated 10/4/2022 documented Resident #347 punched Resident #245 leaving a scratch mark on Resident #245's face on 10/04/2022 at 6:15 AM. The Aspen Complaint Tracking System (ACTS) intake (NY00303282) documented the facility reported the altercation between Resident #347 and #245 to the NYSDOH on 10/04/2022 at 2:18 PM, more than 2 hours after occurrence. On 01/13/2023 at 01:57 PM, the Risk Manager (RM) stated they were made aware of the incident involving Resident #347 and #245 on 10/04/2022 at 7:47 AM via email. The RM is unable to access the system to file facility reports with the NYSDOH from home. The RM and the Registered Nurse (RN) working during the incident on 10/04/2022 have access to NYSDOH reporting through the Health Commerce System (HCS). The facility was not reporting allegations of abuse to the NYSDOH within the 2-hour timeframe. Instead, the facility reported allegations of abuse to the NYSDOH within 12 hours of occurrence. 44843 3.) Resident # 251 had diagnoses of cerebral infarction and left hemiparesis. (NY00276114) The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident # 251 was cognitively intact. The Incident Report dated 5/22/2021 documented Resident #251 was observed with blisters on their chest and stated they burned themselves while smoking a cigarette at their bedside. The Health Emergency Reporting Data System (HERDS) report dated 5/24/2021 at 11:16 AM documented facility reported Resident #251's chest burns incident occurred on 5/22/2021 at 5:00 PM, more than 24 hours prior to facility's report to the NYSDOH. Nursing Note dated 6/22/2021 documented Resident # 251 was discovered with a second-degree burn to their abdomen. The HERDS report dated 6/25/2021 at 3:32 PM documented Resident #251's abdominal burn occurred on 6/22/2021 at 10:37 AM, more than 24 hours prior to the facility's report to the NYSDOH. On 01/09/23 at 03:31 PM, Associate Director of Nursing (ADON) # 1 was interviewed and stated the Resident #251's burn incidents on 5/22/21 and 6/22/21 should have been reported to the NYSDOH within 24 hours of occurrence. The charge nurse reports any incident to the ADON immediately. The ADON discusses the incidents with the Risk Manager (RM) and the Director of Nursing (DNS) to determine whether incidents are reportable to the NYSDOH. ADON # 1, the RM, and the DNS have access to the Health Commerce System (HCS) to report allegations of abuse and other reportable incidents to the NYSDOH. On 01/09/23 at 03:48 PM and 01/13/23 at 2:17 PM, Director of Risk Management (DORM) was interviewed and stated they were responsible for reporting allegations of abuse and other reportable incidents to NYSDOH through the HCS. The incidents involving Resident #251 should have been reported to the NYSDOH within 24 hours of occurrence and the DORM was unable to recall the reason reporting was delayed. The DORM previously believed all allegations of abuse had to be reported within 24 hours of occurrence. The DORM is now aware allegations of abuse should be reported no later than 2 hours after occurrence. On 01/13/23 at 02:21 PM and 03:28 PM, the DNS was interviewed and stated allegations of abuse, including resident-to-resident altercations are supposed to be reported to the NYSDOH within 2 hours of occurrence. The RM reports during the day and the ADON is responsible for reporting on the night shift. The DNS was trained on the HERDS procedure and was unaware there were facility reported incidents that were not reported to the NYSDOH within the acceptable timeframe. 415.4 (b)(1-2)

Based on observation, record review, and interviews conducted during the Recertification and Complaint survey (NY00305646, NY00276114) from 01/05/2023 through 01/13/2023, the facility did not ensure residents were adequately supervised to prevent smoking accidents. Specifically, the facility failed to provide adequate supervision and interventions to address unsafe smoking incidents in undesignated areas. Additionally, incidents of unsafe smoking were not investigated to determine adequate interventions to prevent a recurrence. This was evident for 2 of 6 residents reviewed for smoking out of 42 sampled residents. (Resident #s 314 and 78) The findings include but not limited to: The facility's policy and procedure titled Smoking Control, with the last revised date 10/05/2022, documented that Smoking is prohibited in all facility vehicles, on the facility grounds, and within the building- except in designated resident smoking areas. A smoking area has been designated. Residents are permitted to smoke only in this designated smoking area. The policy further documented that the purpose is to advise residents of the conditions of their privilege to smoke and their responsibilities to smoke in a safe manner and only in designated areas. The non-compliant smoker shall have their cigarettes, lighters, and other ignition sources confiscated by the Hospital Police and may be issued a summons. The resident shall no longer be allowed to maintain cigarettes at the bedside and be informed that they will be subject to random environmental searches from the beside area conducted by Hospital police. 1) Resident #78 was readmitted on [DATE] at 12:43 AM post amputation of the left second digit with diagnoses that include Chronic Kidney Disease, Peripheral Vascular Disease, Diabetes Mellitus, and Blindness in one eye. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident # 78 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The Comprehensive Care Plan for Smoking, initiated on 11/13/2019 and updated on 11/17/2022, documented the resident was an unsafe smoker due to smoking in undesignated areas. The smoking safety assessment dated [DATE], completed upon readmission, identified the resident had no safety concerns. The Smoking Control Form dated 11/20/2022 documented Resident #78 was found smoking in the room with Resident #346 by the charge nurse. The room was searched, and no smoking materials were found. The Smoking CCP was revised on 11/23/2022, and no new interventions were added. Resident #78 did not have a Behavior Care Plan to address noncompliance with smoking per facility policy. There was no documented evidence the resident was referred to the Behavioral Management Committee to address the continued noncompliance. A Nursing Note dated 11/17/2022 at 12:58 PM documented that Resident #78 was noted with a burnt area on the dressing applied on the left-hand post left index finger amputation. The resident was noted with a closed blister 1x2cm-left-hand dorsal aspect base of the 1st digit. A facility investigation report dated 11/17/2022 documented that Resident #78 sustained a second-degree burn because of a smoking accident related to a change in functionality from the finger amputation. The investigation did not include staff statements or an attempt to determine where the accident occurred (smoking room or undesignated area). The investigation documented a new smoking evaluation was conducted and determined the resident could smoke safely. A Nursing Note dated 11/20/2022 at 9:17 PM documented that Resident #78 was smoking in the room with another resident (Resident #346). The Hospital Police were called at 9:15 PM and informed nursing staff that they could not conduct a room search because they did not see the residents smoking. On 01/09/2023 at 3:10 PM, an interview was conducted with Certified Nursing Assistant #4 (CNA #4). CNA #4 stated that Resident #78 is a smoker, and sometimes, the resident goes outside early in the morning to smoke. Resident #78 buys and keeps the smoking materials at the bedside. Resident #78 never smokes in the room. CNA #4 had never heard that the resident sustained burns while smoking. On 01/09/2023 at 3:24 PM, an interview was conducted with Head Nurse #3 (HN#3). HN #3 stated that Resident #78 is a heavy smoker and non-compliant with the smoking policy. The resident was seen smoking in the shower room. They called the Hospital police to search and searched the bedside but did not find any cigarettes at the bedside. HN #3 educated the resident not to smoke in the shower room. Resident #78 goes outside the building to smoke, but at times the resident goes to the smoking room. Resident #78 had burns to the left hand while smoking before, but it is healed. The resident admitted that the injury on 11/17/2022 occurred from smoking. On 01/11/2023 at 2:16 PM, a follow-up interview was conducted with HN #3. HN #3 stated that the smoking assessment was done upon re-admission. Resident #78 was identified as an unsafe smoker because the resident had an amputation of the index finger and was smoking in the undesignated area. The smoking assessment means that the resident is a safe smoker but is noncompliant with the smoking policy. Resident #78 was able to light a cigarette and hold a cigarette, so the resident was a safe smoker. Non -compliant residents can keep smoking materials at the bedside. They monitor the residents every two hours. On 01/10/23 at 2:57 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the nursing department oversees the residents who smoke and the smoking room. The DON is aware that Resident #78 is an unsafe smoker. The intervention is to have hospital police check the resident and orient the resident to the smoking room. They offered the resident smoking cessation, but the resident refused. The residents keep their smoking materials. Unsafe smokers are not allowed to keep smoking materials at the bedside. Safe smokers are allowed to keep smoking materials at the bedside. On 01/12/23 at 10:10 AM, a follow-up interview was conducted with the Director of Nursing (DON). The DON stated that a smoking assessment is completed upon admission and reassessed every three months. It is documented in the resident's electronic medical record. The criterion for an independent smoker is that they can hold the cigarette by themselves. The facility does not provide smoking materials to residents. The smoking materials are obtained/purchased by the residents themselves. On 01/12/2023 at 10:09 AM, an interview was conducted with the Associate Executive Director (AED). The AED stated that non-independent/unsafe smokers ambulate throughout the facility and befriend unsafe smokers. Some residents leave the facility on therapeutic leave. If we know they smoke and suspect they have smoking materials, the facility police intervene. The resident's room will be searched and confiscated if any smoking materials are found. They do not suspend the smoking privilege. Residents are not searched; therefore, they may hide cigarette materials on their bodies. They recognized an issue with unsafe smoking, and it has been challenging to control this problem. 01/12/2023 at 10:23 AM, an interview was conducted with the Administrator. The Administrator stated that the smoking issue had been brought up in the past. The smoking policy and procedure were last revised as a plan of correction for the past deficiency. It is reviewed every three months, last reviewed in October 2022. Monitoring of unsafe smokers is done by rounding by the hospital police. Psychiatry will also work with the Interdisciplinary Team (IDT) team to develop plans for those with unsafe smokers. 42101 2.) Resident #314 was readmitted [DATE] with diagnoses of Disorganized Schizophrenia, Anxiety Disorder, Nicotine Dependence Unspecified and Other Specified Peripheral Vascular Disease. The Admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #314 had intact cognition and required supervision/set up help with Activities of Daily Living (ADL). On 1/05/2023 at 10:53 AM, during the initial tour, Resident #314 opened their room door, and the resident's room smelled like smoke. On 1/09/2023 at 11:07AM, the surveyor observed staff report the smell of smoke in the Resident 314's room. The hospital campus police arrived to the room at 11:10AM to investigate. One used cigarette butt was observed under the resident's bed, and the smell of smoke was noted in the air in the resident's room and bathroom. The [NAME] Police Department Resident Call for Assistance forms documented that [NAME] Police were called to the resident's room for the smell of smoke, and cigarette or lighter were in the resident's possession. On 07/02/2022 Hospital Police (HP) did a room check after staff reported smelling smoke in Resident #314's room. On 07/22/2022 documented Resident #314 was given a lighter to smoke by another resident and upon requesting the lighter Resident #314 refused to return it and HP responded to retrieve the lighter. On 08/24/2022 documented the staff nurse reported resident smoking in their room. On 09/30/2022 documented that 11 cigarettes were confiscated and returned to Behavioral Health Associate (BHA). On 8/19/2022, 10/25/2022, 11/1/2022, 11/22/2022, 12/07/2022 documented 1 lighter was recovered and returned to Behavioral Health. On 12/14/2022 documented HP reported to the resident's room for a report that Resident #314 was smoking in their room. On 01/07/2023 documented 1 lighter was confiscated from the resident. There was no evidence of increased monitoring or new interventions implemented after these incidents. The Smoking Safety Evaluation forms done on 12/23/2020, 3/22/2021, 7/16/2021, 10/16/2021, 1/16/2022, 5/28/2022, 08/28/2022 and 12/5/2022 documented resident was a tobacco user. The Quarterly Smoking Safety Evaluation on 12/5/2022 documented the resident is a smoker, supervision will be required for all residents during designated smoking times and the resident has balance problems while sitting or standing. The smoking assessment did not state if resident #314 was identified as either a safe or unsafe smoker. The Smoking Care Plan dated 05/24/2022 documented the following interventions: , instruct resident about the facility policy on smoking: location, time, safety concerns, monitor behavior towards other residents, intervene timely when resident is agitated and call Behavioral Rapid Response Team (BRRT) when needed, orient resident with the location of the smoking room, assess/reassess ability to smoke independently and compliance with smoking policy, educate regarding smoking policy and designated smoking areas, offer smoking cessation, random environmental rounds when at bedside, instruct to report timely any injuries related to smoking, monitor compliance with smoking policy, observe clothing and skin for signs of cigarette burns, and requires supervision while smoking . On 5/29/2022 the CCP was updated with the intervention to store the resident's cigarettes in the smoking room. The CCP intervention for Behavior management staff to escort resident to smoking daily was added on 8/15/2022. On 1/07/2023, the CCP was updated with the intervention to conduct a body search and room check for posession of smoking materials by staff with hospital police and confiscate any materials found. A CCP note on 1/7/2023 at 1:12 PM documented Resident #314 was found smoking in their room. The BRRT was called, and the Hospital police did environmental check in order to confiscate lighter and cigarette. The Nurse supervisor made aware. The Progress notes for the resident on 8/19/2022 there is not documentation related to lighter being found. A Nursing note on 10/25/2022 at 3:28 PM documented a Behavioral Health Associate found a lighter in Resident #314's room and confiscated it. The Behavioral notes on 11/6/2022 and 11/11/2022 there is no documentation related to smoking. A Nursing Note dated 12/07/2022 at 10:13 AM documented a lighter was found in Resident #314's room. There are no progress notes on 11/1/2022 in relation to the lighter found for resident. A Nursing Note dated 1/7/2023 documented the Rapid Response Team (RRT) was called because the resident was found smoking in the room. The RRT reported to Resident #314's room at 1:00pm, and an environmental search was conducted by the hospital police. Resident #314 left the unit. A Nursing on 1/9/2023 at 11:29 AM documented the Tour 2 medication nurse notified the writer of the smell of cigarette smoke coming from Resident #314's room. Redirection and education were provided, and the resident was verbally abusive/threatening. Hospital police was called to assist with de-escalation. The Assistant Nurse Director (ADN) and Psychiatrist were notified of the resident's behavior. A lighter and cigarette were found in the resident's room. There was no documented evidence the facility reassessed Resident #314 for smoking after documented incidents of smoking in the room and lighters being found in the resident's possession. There was no documented evidence the facility provided adequate supervision to prevent smoking incidents after repeated noncompliance, investigated incidents of unsafe smoking, or addressed the resident's unsafe smoking with revised care plan interventions. During an interview on 01/09/2023 at 11:27 AM and 01/12/2023 at 08:50 AM, the assigned Certified Nursing Assistant (CNA #7) stated they smell smoke coming from Resident #314's 2-3 times per week. CNA #7 stated smoking has been an ongoing issue on the unit, and they are constantly calling campus police to look at Resident #314's room. Anytime we smell smoke, we do room checks, and we can smell the smoke while the door is closed. CNA #7 stated they have never seen burn marks on Resident #314's clothing. The Social Worker keeps Resident #314's smoking materials, and staff will offer soda in exchange for smoking materials. CNA #7 stated if they smell smoke, they report it to the nurse who reports it to the ADN and hopsital police. The hospital police serach the resident's room for smoking materials. Resident #314 is taken to smoke at 10AM and 2PM by staff, but the resident does not follow the rules and will also smoke in their room. CNA #7 stated they can smell the cigarette smoke through their N95 mask. On 01/09/2023 at 05:24 PM, an interview was conducted with CNA #8, a smoke room monitor. CNA #8 stated Resident #314 smokes at 5PM. Resident #314 is provided with a cigarette to smoke, and they are not given a lighter. On 01/10/2023 at 09:58 AM and 01/12/2023 at 09:14 AM, an interview was conducted with CNA #9, a smoke room monitor. CNA #9 stated Resident #314 comes with an escort to smoke. Resident #314's cigarettes are provided to the smoke room monitor daily by behavioral health. Resident #314 is not allowed to have a lighter. CNA #9 stated unsafe smokers are not allowed to hold their smoking materials and are on watch. CNA #9 stated the smoke room is locked outside of the designated hours. The room is open at 10AM, 11AM, and 2PM. On 01/11/2023 at 08:56 AM, an interview was conducted with LPN #1 who stated resident #314 smoking in their room and smoking cigarette smoke noted from room and when resident out check and always find smoke smell. Resident #314 goes to different floors. Resident goes with another staff to go smoke. Resident #314 went out 9 AM this morning but not sure if resident went to smoke. when noticed smoke smell they did not notify anyone. The Behavior Health Associates came to check on resident #314 as part of the psychiatry team. If smell cigarette reports, it and resident clothes smell like smoking. Resident #314 does not want anyone close to them and curses staff. Resident #314 is accompanied by psych team when they want to smoke. They have not noticed cigarette butts or lighters when cleaning resident room. No burns in resident clothing noted. Rounding is done at 9AM, 10AM, 12PM, 2PM and have Plan of Care (POC) where it is documented. Call the nurse in charge if they note any smoking behavior. They have had in-service on fire in 2022. They stated in 2021 that they noticed a lighter in the middle area of the resident's door and they threw it in the garbage and did not report this. There are no other smokers on the unit that they are aware of. and discriminatory words. On 1/11/2023 at 03:10 PM, the Licensed Practical Nurse (LPN #1) was interviewed and stated most of the time when CNA assigned next door and active to look at resident so when walk and smell cigarette call doctor and contact the police to search resident. LPN #1 stated they were instructed not to go inside without consent resident alert, with schizophrenia and confused sometimes. LPN #1 document behavior and if resident #314 is smoking in their room in nursing progress notes and resident #314 is not allowed to hold cigarette. They have scheduled smoking times in smoking room [ROOM NUMBER]AM and 2PM and they don't know where resident gets cigarette. When staff gave resident shower found a lighter on resident wheelchair. We cannot talk to the resident, and they curse staff. If there is an incident and they are working, they make note. We have a behavioral tracking for resident and if documented behaviors it would take up the whole chart. There is a smoke room in the facility and the smoke room provides the materials for the resident. LPN #2 stated that prior to October 15, 2022, they documented in progress notes any smoking behavior. LPN #1 stated that they were just informed on Monday resident smoked again. They have to call the police and can't go inside resident room and when reporting when searching could not find cigarettes and only the police can search the resident. Resident #314 is considered unsafe smoker resident smoked on unit and not sure how resident dispose of cigarette butt and when smell will call police right away and this behavior may cause a fire. We cannot notice lighter, or cigarettes resident #314 will hide it and was not holding anything and resident is prohibited from smoking in here and not sure how the resident gets the cigarette. On 01/11/2023 at 03:38PM, an interview was conducted with RN #5 who stated that they noticed the resident #314 smoked in their room and they were caught 2 times in the last few days. They normally deescalate situation if smell it knock on room smell smoke and if can come in 9 out of 10 times and deny smoking in their room and if verbally aggressive call hospital police and confiscate, They may have found a lighter and cigarette recently. Resident #314 is escorted to smoke, and they are not sure if this is done by the CNA or psychiatry team. Resident #314 is educated on smoking, and they call the psych to further educate and redirect resident. Resident #314 refused to sign smoking contract and they are not sure how long-ago contract done. Rounding every 1 hour for the resident when they are working on this unit. If any smoking incident and the [NAME] smoking form is filled out. Not sure if focused meetings for resident had behavior meeting and no meeting related to smoking, they are aware of. On 01/09/2023 at 11:12 AM, the Campus Police Officer (CPO) was interviewed and stated they are responding to a report of Resident #314 smoking in their room. The CPO stated a used cigarette butt was found under the bed. The CPO stated Resident #314 could not be searched because they left the unit. On 01/09/2023 at 11:24 AM, the Housekeeper was interviewed and stated that they clean the resident's room when the resident leaves due to resident being aggressive and they don't let anyone into their room, and they smell smoke in the room every time they clean the resident room. The Housekeeper stated that they have found cigarette butts and ashes in the resident's sink a couple of times while cleaning the room. They report this to the charge nurse on the unit. The Houskeeper stated they did not receive recent education on smoking or the smoking policy. On 01/11/23 at 03:01 PM, an interview was conducted with CNA #11 who stated that Resident #314 goes with another staff to go smoke. The BHA's come to check on resident and escort the resident to smoke. CNA #11 also stated that if they smell cigarette smoke, they report it and they have noticed the resident's clothes smelled like cigarette smoke. Resident #314 does not want anyone close to them and curses staff. CNA #11 further stated they have not noticed any cigarette butts or lighters when cleaning resident room and no burns in resident's clothing was noted. Rounding is done at 9AM, 10AM, 12PM, and 2PM and it is documented on the behavioral health monitoring sheet and they notify the nurses if they notice any smoking behavior. In 2021 they noticed a cigarette lighter in the resident's doorway and they threw it in the garbage. Resident #314 was smoking in their room and smell of cigarette smoke noted from room. CNA #11 stated they notify the doctor and call campus police to search the resident when they smell smoke from their room. Resident #314 goes to different floors, and they are escorted to smoke. On 01/11/2023 at 3:10 PM, an interview was conducted with Licensed Practical Nurse (LPN) #1 who stated Resident #314 is alert and confused sometimes. If Resident #314 is smoking in their room it is documented in the nursing progress notes. Resident #314 is not allowed to hold their own cigarettes, have designated smoke time at 9 AM and 2 PM in the smoke room where smoking materials are provided for the resident, and they did not know where resident obtained cigarettes. When giving Resident #314 a shower, staff reported that they found a lighter on the resident's wheelchair. LPN #1 also stated it is difficult to communicate with Resident #314 due to their cursing behavior. Prior to October 15, 2022, any smoking behavior was documented in the progress notes. LPN #1 stated that they were just informed on Monday resident smoked again. When they did a search for Resident #314, they could not find cigarettes. Resident #314 is considered an unsafe smoker, smokes on unit and they are not sure how resident disposes of cigarette butt, but when they smell cigarette smoke will call police right away as this behavior may cause a fire. Resident #314 will hide the lighter or cigarettes, and materials cannot be visualized by staff. On 01/11/2023 at 03:38 PM, an interview was conducted with Registered Nurse (RN) #5 who stated that they noticed Resident #314 smoked in their room and they were caught two times in the last few days. They normally deescalate situation if they smell smoke in the resident's room, they knock on room door and resident will deny smoking in their room and if verbally aggressive call hospital police who will confiscate the smoking materials. Resident #314 is escorted to smoke. Resident #314 is educated on smoking, and they call the psych to further educate and redirect resident. Resident #314 refused to sign smoking contract and they are not sure how long ago the contract was done. If there is a smoking-related incident, the [NAME] smoking form is filled out. RN #5 also stated that they were not aware of any care plan meeting related to smoking. On 01/11/2023 at 03:47 PM, the Behavioral Health Associate (BHA) #1 was interviewed and stated that Resident #314 is an unsafe smoker due to their diagnosis and they are not allowed to keep own cigarettes so they take Resident #314 to smoke at 9 AM. They come to the unit to get Resident #314 if they are not already in the smoke room, and then escort them back to the unit. We always keep lighter, and we walk with Resident #314 in the morning and light cigarette for resident. Resident #314 may get a lighter from other residents and we educate other residents not to give Resident #314 cigarette or lighters. BHA #1 also stated we make sure we do a weekly search on Resident #314 and have found a lighter on the resident between one and five times but have not found any cigarettes. Resident #314 was educated on smoking and advised not to smoke in their room as this was not safe and they are only allowed to smoke in the smoke room. Resident #314 is taken outside to smoke anytime they want to by the Behavioral Health Supervisor. Smoking materials are purchased for Resident #314, provided to the resident and then behavioral health keeps the remaining cigarettes. On 01/11/2023 at 03:59 PM, an interview was conducted with Associate Director of Mental Health Services (ADMHS) who stated Resident #314 is an active smoker and they have tried ways to curb and control the resident's smoking habit. Resident #314 cannot keep cigarette and lighter due to delusions and is an unsafe smoker due to smoking in undesignated areas. Smoking is used to prevent emotional distress and to get Resident #314 to comply with taking medications, ADL care and injections. We have to monitor Resident #314 room in relation to smoking. The concern is keeping resident safe and others safe ongoing issues. The ADMHS also stated the smoking contract needs to be revisited for resident and they understand that the resident is the most watched case. The ADMHS further stated there is a smoking committee and smoking cessation is offered to residents. A smoking cessation program for smokers was offered during quarantine. On 01/11/2023 at 4:12 PM, the Behavioral Health Associate (BHA #2 was interviewed and stated they also escort Resident #314 to smoke at times. BHA #2 also stated they have not found cigarettes only lighters and since 2021 to present they have found 4-5 lighters on resident. BHA #2 further stated they have some documentation in a notebook in their office but they do not document their findings in the resident's electronic medical record. BHA #2 stated after finishing room cleaning, they write down observations and were not told that they needed to document as the hospital police and nursing do the documentation so we will have evidence as to what was found in the resident's room during cleaning. On 01/12/2023 at 10:28 AM, an interview was conducted with the Administrator who stated that residents who smoke may obtain smoking materials by purchasing in the community, or family or peers may provide. The Administrator also stated that they may need to look at their ability to do room searches and bag checks to monitor the process and be more vigilant about what is brought back into the facility. We have to look at how to safely store and distribute smoking paraphernalia. The smoking policy was put in place a long time ago in the past Plan of Correction (POC). We are monitoring in smoking in bathroom and psychiatry is included in problem solving related to smoking. On 01/12/2023 at 10:28 AM, an interview was conducted with Director of Nursing (DON) who stated for unsafe smokers, smoking materials are not provided and some may go outside to get smoking materials unless there is an order for them not to go outside of the facility. A resident can be an unsafe smoker and can navigate community. We assume residents are buying paraphernalia and we are dealing with a challenging population and some residents put cigarettes in their underclothing so we have to look to see how stringent we can be with process and rules about smoking and not take away their rights. There is a logbook for when residents depart and enter the facility. There is no identification band for smokers. In relation to smoking materials- some residents go out great lengths to keep on their body; high risk residents smoking materials are provided by the BHA's. There is an opportunity to look at the smoking policy. The Hospital Police also do rounds. The DON also stated the smoking contract is offered and currently there are no rules for the violation of the criteria for smoking privileges. When cigarettes are taken away BHA is informed and care planning and Behavioral Rapid Response Team (BRRT) assist the clinical team to deal with behaviors and attempt to remove items as it may be become difficult to manage. BHAs are on unit and do rounds and develop relationships with residents so they can have discussions. BHA is an integral part of process in place and included in the management of challenging residents. 415.4(a)(2-7) sues. Investigation comple 45988

Based on observation, record review, and interviews conducted during the Recertification and Complaint survey from 01/05/2023 through 01/13/2023, the facility did not ensure that residents are informed and provided written information concerning their right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. This includes a written description of the facility's policies to implement advance directives and applicable State law. This was evident for 1 of 2 residents reviewed for Advance directive out of a total sample of 42 residents (Resident #481). Specifically, the facility failed to discuss and provide information concerning the resident's right and option to formulate an advance directive for Resident #481 upon admission. The findings are: The facility Policy and Procedures titled Advance Directives and Health Care Decision making dated August 26, 2014, last revised 08/27/12, documented that the facility will provide all newly admitted adult residents and/or family members following information concerning their right to execute advance directives: a) The New York State Department of Health (NYSDOH) form entitled planning in Advance for your Medical Treatment .Acknowledgement Form signed by the resident/family member attesting to the receipt of the above mentioned information is to be placed in the Advance Directives section of the medical record. Resident #481 was admitted to the facility on [DATE] with diagnoses that included Hypertension, Peripheral Vascular Disease (PVD), Acquired Absence of Right and Left Leg above knee. The Admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition. The MDS also documented Resident #481 participated in the assessment and goal setting. On 01/05/23 at 11:22 AM, during the initial pool, Resident #481 was interviewed. Resident #481 stated that he/she has been in the facility about a month, and no one has had any discussion with them regarding Advance Directives. During the initial record review process on 01/05/23 at 03:24 PM, there was no documented evidence of advance directives in the Electronic Health Record (EHR) and on hard chart. The Nurses Note - New admitted d 12/01/2022 documented Resident #481 was received by nursing staff with their belongings. The Physician (MD) and Assistant Director of Nursing were informed of the admission. The Social Worker Initial assessment dated [DATE] documented Resident #481 was alert and oriented, pleasant, cooperative, and had no viable discharge plan. The resident stated they would like to stay at the facility for long term care. Progress note Social Worker Plan of Care Note dated 12/14/2022 documented that Resident has friend listed in personal care section, resident has not listed any family members, if any changes occur, they will be made to the profile. No documented evidence that Advance directive was discussed. The Multidisciplinary Care Conference Social Work Summary dated 12/15/2022 documented Resident #481 had intact cognition, was new to the facility, and acclimating to the environment. There was no documented evidence in the medical record that advance directives were discussed with the resident or that information regarding advance directives was provided. There was no Comprehensive Care Plan (CCP) initiated for Advance Directives in the medical record. On 01/10/23 at 11:59 AM, an interview was conducted with the Registered Nurse/Head Nurse (HN #1). HN #1 stated that Resident #481 was newly admitted to the unit, and it is the Social Worker that is responsible for discussing and initiating Resident's Advance directive for new admission residents. HN #1 also stated that they don't actually know anything about the new residents' advance directive. On 01/10/23 at 12:15 PM, an interview was conducted with the Social Worker (SW #1). SW #1 stated that they usually have a conversation with the residents upon admission. SW #1 stated that if new residents have no Advance Directives, sometimes they need to educate them and explain the meaning and importance of Advance Directives to the resident and invite them for the meeting to discuss the details. SW #1 stated that they have not yet scheduled any meeting to discuss advance with Resident #481, but they are now going to meet with the resident to complete a Medical Orders for Life-Sustaining Treatment (MOLST) form. On 01/11/23 at 02:45 PM, an interview was conducted with the Director of Social Work (DSW). The DSW stated that upon admission, the person that does the admission usually discusses Advance Directives with the resident, which could be the nurse or the doctor. The Social Worker will discuss advance directives as soon as possible if the resident wishes to formulate one and ensures it is in place as per the resident's wishes. The DSW also stated that they believe there is a section in the SW assessment where the discussion and implementation of advance directives should be documented. The DSW stated they did not know why this was not done. On 01/13/23 at 02:28 PM, an interview was conducted with the Director of Nursing (DON). The DON stated upon admission, if a resident comes with an advance directive, the doctor will be notified so orders can be put in place. If the resident does not have an advance directive upon admission, the doctor and social worker will discuss advance directives with the resident or family. 415.3 (e) (2)(iii).

Based on the record review and interviews conducted during a Recertification and Abbreviated (NY00293582) Survey, from 01/05/2023 to 01/13/2023, the facility did not ensure all alleged violations of abuse were thoroughly investigated. This was evident for 2 (Resident #199 and #357) of 10 residents reviewed for Abuse of 42 total sampled residents. Specifically, the investigation of resident-to-resident altercation involving Resident #199 and Resident #357 did not contain statements from staff witnesses. The findings are: The facility policy titled Abuse Prevention and Reporting and Management of Other Reportable Incidents last revised 11/01/2022 documented allegations must be investigated promptly. The supervisor immediately takes statements or ensures that statements are taken from all staff present in the unit at the time of the incident or allegation. Resident # 199 had diagnoses of chronic obstructive pulmonary disease and bipolar disorder. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident # 199 was moderately cognitively impaired. The Accident Report dated 04/01/2022 documented Resident # 199 reported an abrasion to the right wrist after Resident #357 hit Resident #199 with their cane. Resident # 199 punched Resident #357 in the face. Housekeeping saw Resident #357 near the elevator and informed the head nurse. The Behavior Rapid Response Team was initiated by staff at 8:45 AM. The primary doctor, the psychiatrist, and the hospital police responded to the unit. Resident # 357 had diagnoses of dementia and hemiplegia. The MDS assessment dated [DATE] documented that Resident # 357 was moderately cognitively impaired and required supervision and cueing. The Accident Report dated 04/01/2022 documented Resident #357 was observed in the hallway at 8:48 AM bleeding on the right side of their face. Resident # 357 had a lacerated wound and bleeding on the right lower eyelid, bruise on the forehead, nose, cheek bridge, and scratch marks on the right and left upper arms. Several metallic rings on Resident #199's fingers aggravated Resident #357's injuries. The Risk Management Summary Report dated 04/01/2022 documented the facility concluded a resident-to-resident physical altercation between Resident #199 and Resident #357 occurred. There was no documented evidence the facility gathered statements from direct witnesses (housekeeping staff, nursing staff, and Resident #199) when investigating the resident-to-resident altercation between Resident #199 and Resident #357. On 01/11/2023 at 9:02 AM, an interview was conducted with the Housekeeping Staff (HS) #1 who stated that they saw Resident # 357 with blood in the eye and called the nurse. The nurse asked HK #1 what happened, but HS #1 was not asked to write a statement. On 01/11/2023 at 9:33 AM, an interview was conducted with the Certified Nursing Assistant # 3 (CNA # 3). CNA #3 was not there when the incident occurred. The residents were on the same unit, but they were not roommate. CNA # 3 heard that the residents had arguments before the fight. The residents had no verbal or physical altercation before the incident. Resident # 199 had no history of aggressive behavior. CNA # 3 was not asked to write a statement. On 01/12/2023 at 9:00 AM, an interview was conducted with the Head Nurse (HN) #1 and stated they observed Resident #357 sitting in their wheelchair in the hallway bleeding from their right eye. The resident was alone in the hallway and was aphasic but was able to motion that someone punched them in the eye. Resident #199 admitted to punching Resident #357 in the eye. HN #1 did not write a statement re: the incident. An interview was conducted on 01/12/23 at 9:09 AM, with Registered Nurse (RN) who stated RN #3 initiated the Accident Report. The Risk Manager followed through and completed the investigation. RN #3 did not write a statement. On 01/11/2023 at 3:39 PM, an interview was conducted with the Risk Manager (RM) who stated the RM reviewed the Accident Report to determine whether the incident between Resident #199 and Resident #357 was reportable to the New York State Department of Health (NYSDOH). The facility practice is not to collect statements, but it depends upon the type of incident. Resident-to-resident altercations are not treated as abuse allegations and the RM does not collect witness statements. The Accident Report, progress notes, and hospital police documentation is used to complete the RM's investigation. On 01/13/23 at 9:52 AM, an interview was conducted with the Director of Nursing (DNS) who stated the RM is supposed to complete the Risk Management Summary Report with statements from staff. Even if an incident is unwitnessed, the staff involved should have their statements included in the investigation. 415.4(b)(3)

Based on record review and interviews conducted during the Recertification Survey from 01/05/23 to 01/13/23, the facility did not ensure a resident and their representative were provided with a written summary of the baseline care plan (BCP). This was evident for 1 (Resident #481) of 42 total sampled residents. Specifically, Resident #481 did not receive a written copy of their BCP once developed and implemented. The findings are: The facility policy titled Care Plans - Baseline dated 10/012019 documented the BCP will be completed and implemented within 48 hours of a resident's admission. The Social Worker (SW) provides the resident a copy of the BCP if the resident is cognitively intact and documents in the resident's medical record. Resident #481 was admitted [DATE] with diagnoses of right above the knee amputation and peripheral vascular disease. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #481 was cognitively intact and participated in the assessment and goal setting. On 01/05/23 at 11:22 AM, Resident #481 was interviewed and stated they were admitted to the facility approximately 1 month ago and have not received their BCP in writing. BCP dated 12/05/2022 documented the Interdisciplinary Team (IDT) completed Resident #481's BCP. There was no documented evidence Resident #481 was provided with a written copy of their BCP dated 12/05/2022. On 01/10/23 at 11:59 AM, Head Nurse (HN) #1 was interviewed and stated Resident #481's BCP was completed by the IDT within 48 hours of the resident's admission. HN #1 could not recall if the resident was provided with a copy of the BCP and was unable to provide documented evidence Resident #481 received a copy of the BCP. On 01/10/23 at 12:15 PM, SW #1 was interviewed and stated the BCP was provided to residents in written form during their initial care plan meeting. SW #1 was unable to provide documented evidence Resident #481 received their BCP in writing. On 01/11/23 at 02:45 PM, the Director of SW was interviewed and stated the Nursing staff are responsible for providing residents with a copy of their BCP. On 01/13/23 at 02:28 PM, the Director of Nursing was interviewed and stated the SW is responsible for giving a written copy of BCP to residents and/or their representatives. The IDT discussed the need to provide the BCP to residents during morning meetings. 415.11 (c)

Based on record review and interviews conducted during the Recertification Survey from 1/5/23 to 1/13/23, the facility did not ensure that a comprehensive person-centered care plan (CCP) was developed and implemented to address a resident's needs. This was evident for 2 (Resident #488 and #489) of 42 total sampled residents. Specifically, 1) a CCP related to discharge planning was not developed or implemented for Resident #488 and 2) a CCP related to discharge planning was not developed or implemented for Resident #489. The findings are: The facility policy titled Interdisciplinary Care Plan Meeting dated 10/1/19 documented each discipline is responsible for completing and updating their specific sections of the resident's CCP. Social Workers (SW) are responsible for reviewing discharge plans and related impact upon resident adjustment. The facility policy titled Discharge Planning and Transfer dated 9/10/19 documented the SW, interdisciplinary team (IDT), and resident/family develop an individualized comprehensive person-centered discharge plan consistent with medical discharge recommendations and identified needs. 1) Resident #488 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus and Alzheimer's disease. and was discharged to community on 12/14/22. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #488 was severely cognitively impaired. SW Note dated 10/17/22 documented Resident #488 did not have an active discharge plan due to barriers like advanced dementia, cannot be alone due to safety issues, family unable to support and homelessness. SW Note dated 10/28/22 documented Resident #488 had no immediate plans for discharge. SW Note dated 11/21/22 documented Resident #488's family wanted the resident to be discharged home. Resident #488 will require post-discharge plan of care such as appropriate care/setting and physician clearance to ensure safe discharge. SW Notes dated 12/1/22 and 12/13/22 documented Resident #488's family continued to want the resident discharged home. SW Note dated 12/14/22 documented Resident #488's family decided to have the resident discharge Against Medical Advice (AMA) from the facility despite plan to facilitate resident's safe discharge home. On 01/13/23 at 09:20 AM, SW #2 was interviewed and stated discharge planning starts upon a resident's admission assessment. Resident #488 was admitted to the facility for long-term placement and did not have a plan for discharge. The resident's family later requested for Resident #488 to be discharged to their home. SW #2 discussed plans for discharge with the resident's family, but a CCP related to discharge planning was not developed for Resident #488. CCPs related to discharge planning are initiated when discharge is determined to be safe by the IDT. Resident #488 had discharge barriers that needed to be addressed before the resident's discharge could be determined safe. 2) Resident #489 was admitted to the facility on [DATE] with diagnoses of spinal fusion and obesity. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #489 was cognitively intact and their discharge plan included returning to the community. The Baseline Care Plan (BCP) dated 10/5/22 documented Resident #489's initial discharge goal was to return to the community. The SW Initial assessment dated [DATE] documented Resident #489 wants to return to community and has a viable discharge plan to return to the community upon completion of care. The SW Note dated 11/17/22 documented Resident #489 requested discharge to the community on 11/18/22. Resident's brother has unoccupied room and lives in an elevator building. Resident's transportation, medical appointment and medications have been confirmed for discharge instructions. The SW Note dated 11/18/22 documented Resident #489 requested discharge to their family's home until all services are in place for return to home. The Physician's Order dated 11/18/22 documented order for Resident #489 to be discharged home the same day. There is no documented evidence a CCP related to discharge planning was developed and implemented for Resident #489. On 01/13/23 at 09:37 AM, SW #3 was interviewed and stated Resident #489 was admitted for short-term rehabilitation and their discharge plan was initiated during the resident's admission assessment. Resident #489's discharge plans were documented in the SW Notes. SW #3 was unable to explain the reason a CCP related to discharge planning was not developed for Resident #489. On 01/13/23 at 10:14 AM, the SW Supervisor was interviewed and stated they are a new employee and had to consult with their Director re: the discharge planning process. The SW Supervisor stated discharge planning is initiated and developed for residents admitted to the facility for short-term rehabilitation. Discharge planning is not applicable to long-term residents of the facility. The CCP is initiated once a resident has a safe discharge plan. 415.11(c)(1)

Based on the record review and interview conducted during a Recertification survey from 01/05/2023 to 01/13/2023, the facility did not ensure a resident and their representative was invited to participate in the comprehensive care plan (CCP). This was evident in 1 (Resident #78) of 42 total sampled residents. Specifically, Resident #78 was not invited to attend CCP meetings. The findings are: The facility policy titled Interdisciplinary Care Plan (ICP) Meeting dated 10/01/2019 documented the Social Worker (SW) is responsible for inviting the resident and resident representative to the ICP meeting, with advance notice prior to the date of the ICP meeting. Resident # 78 had diagnoses of chronic kidney disease and diabetes mellitus. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that Resident # 78 was cognitively intact. On 01/05/2023 at 11:50 AM, an interview was conducted with Resident # 78 who stated that sometimes they are not invited to their CCP meetings. Care Conference Notes dated 4/13/22, 7/03/22, and 9/22/22 documented CCP meetings were held for Resident #78. The resident's attendance signature was not documented. There was no documented evidence Resident #78 was invited to attend the CCP meetings scheduled 4/13/22, 7/03/22, and 9/22/22. On 01/10/2023 at 11:21 AM and 3:17 PM, the Social Worker (SW #2) was interviewed and stated they invite Resident #78 to the CCP meetings, but the resident does not always attend. Resident # 78 is usually at dialysis treatment during the CCP meetings because the meetings are scheduled every Thursday at 11 AM. SW #2 stated they believed there was documentation in the medical record that Resident #78 was invited to all CCP meetings, but after reviewing the medical record, SW #2 stated there was no documentation Resident #78 was invited to their CCP meetings. On 01/13/2023 at 8:49 AM, an interview was conducted with the Director of Social Services (DSS) who stated residents and designated representatives are invited to all CCP meetings and Resident #78 should have been invited to their CCP meetings. 415.11(c)(1)

Based on observation, record review and interviews conducted during a recertification survey from 1/5/23 to 1/13/23, the facility did not ensure a resident was assisted with making appointments to maintain vision abilities. This was evident for 1 of 1 resident(s) reviewed for Communication of 42 total sampled residents (Resident #324). Specifically, optometry and ophthalmology appointments were not scheduled for Resident #324. The findings are: The facility policy titled Consultations/Specialty Referrals Processing dated 4/1/11 documented residents will receive specialty evaluations upon request by their primary care physicians. Resident #324 had diagnoses of glaucoma and diabetes mellitus. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #324 had moderately impaired cognition and highly impaired vision. On 01/05/23 at 02:55 PM, Resident #324 was interviewed and stated they have problems with their vision and their eyeglasses have been missing for years. Resident #324 was seen by the eye doctor last year but did not have a follow-up appointment scheduled. The Comprehensive Care Plan related to impaired visual function initiated 8/27/21 and last reviewed 12/8/22 documented to arrange consultation for Resident #324 with eye care practitioner as required. The Optometry Consult dated 11/9/21 documented Resident #324 had chronic glaucoma, was referred to the ophthalmologist for an evaluation, and was to return in 6 months for follow-up with the optometrist. There was no documented evidence follow-up appointments for the ophthalmologist and/or optometrist were scheduled for Resident #324 after 11/9/21. On 01/10/23 at 10:26 AM, an interview was conducted with Registered Nurse (RN) who stated Resident #342 was not seen by the optometrist or ophthalmologist since 11/9/21. On 01/10/23 at 12:05 PM, the Attending Physician was interviewed and stated Resident #324 was not scheduled for an ophthalmology evaluation after the recommendation was made by the optometrist on 11/9/21 because there was an increase in COVID-19 cases at the time and Resident #324 was at high risk for contracting COVID-19. 415.12(3)(b)

Based on observation, record review, and interviews conducted during the Recertification survey from [DATE] to [DATE], the facility did not ensure medications and biologicals in accordance with currently accepted professional principles and expiration date, if applicable. This was evident for 1 of 22 units (Unit C12). Specifically, (1) a multi-use vial of intramuscular (IM) Lorazepam was not discarded according to manufacturer recommendation. The findings are: The undated facility policy titled Storage of Medications documented when multidose injectable vial seal is broken, the vial will be dated (a) the nurse shall place a date opened sticker on the medication and enter the date opened and (b) if a vial or container is found without a date opened, the date will automatically default to the date dispensed and the expiration date will be calculated accordingly. On [DATE] at 11:14 AM, the C12 medication room refrigerator was observed with Registered Nurse (RN) #5 present and to contain an opened Lorazepam IM 20 mg/10 ml multi-use vial prescribed to Resident #412 with the following label: Rx # 77175824; Date Written: [DATE]; Electronic Repeat Dispensing ([NAME]): [DATE]; Inject 2 MG intramuscularly every 24 hours as needed for agitation 30 minutes before hemodialysis 5 days a week. The vial did not document the date it was opened or the date to be discarded. On [DATE] at 02:48 PM, Licensed Practical Nurse (LPN) # 1 was interviewed and stated the vial of Lorazepam did not contain parameters so LPN #1 called the pharmacy representative and was informed the vial of Lorazepam would expire after being opened for 90 days. On [DATE] at 12:06 PM, RN #5 was interviewed and stated the Lorazepam for Resident #412 should have been dated to prevent the resident from being given an expired medication. RN #5 contacted the facility pharmacy and was informed the vial of Lorazepam was good for up to 6 days when refrigerated. Resident #412's behavior has been stable, so the medication has not been administered recently. On [DATE] at 3:33 PM, the Director of Nursing (DON) was interviewed and stated any multi-use vial of medication should be labeled with the date it was opened. The medication should be discarded according to the pharmacy recommendations for the expiration date. On [DATE] at 04:35 PM, the Pharmacist was interviewed and stated that the multidose medication vial expires in 28 days from the date of the first puncture when kept in the refrigerator. 415.18(e)(,d+[DATE])

Based on observation, interviews, and record review during an abbreviated survey (NY 00283561), the facility did not ensure that the services provided or arranged by the facility, as outlined by the comprehensive care plan meets professional standards. This was evident in 1 out of 4 residents sampled (Resident #1). Specifically, on [DATE] at 9:00 AM, Registered Nurse #1 (RN #1) did not identify Resident #1 before administering medications. Resident #1 was given six wrong medications that were prescribed for another resident (Resident #2), resulting in a 40 millimeter of mercury (mm/hg) reduction in Resident #1's blood pressure (BP). Review of the facility's policy and procedure entitled Administering Medications, revised in [DATE] documented that only persons licensed and permitted by this state to prepare, administer, and document the administration of medications may do so. The individual administering medications must verify the resident's identity before giving the resident his/her medications. Methods of identifying the resident include checking the identification band, checking photograph attached to the medical record and if necessary, verifying the resident's identification with other facility personnel. The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Resident #1 was initially admitted to the facility with diagnoses including Dementia, Major Depressive Disorder, Hypertension and Seizure Disorder. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 03 out of 15, indicating severely impaired cognition. An undated Investigation Summary Report documented that on [DATE] at approximately 9:00 AM, as Registered Nurse #1 (RN #1) was administering medications in the Day Room, he/she checked Resident #2 identification band and prepared Resident #2's medications which included Seroquel, Metoprolol, Lisinopril, Aspirin, Docusate, B Complex Vitamins and Vitamin C. After a momentary distraction, RN #1 took the poured medications to Resident #1 without checking Resident #1's identification band. Afterwards, RN #1 drew up insulin ordered for Resident #2 and checked the dosage with RN #2. RN #1 then took the insulin to Resident #1 and the RN #2 interrupted RN #1. RN #1 then informed RN #2 that RN #1 had given Resident #1 medications prescribed for Resident #2. The Medical Doctor (MD) ordered charcoal capsules orally and normal saline intravenously (IV) at 75 mls/hr. and notify him/her if the (systolic) SBP falls below 90 or pulse below 50. IV Normal Saline was administered. Resident #1's blood pressure (B/P) baseline was approximately ,d+[DATE]. During the early afternoon Resident #1's B/P was ,d+[DATE]. The facility concluded that RN #1 did not follow the facility's policy and procedure for safe medication administration, resulting in a 40 mm/hg reduction in Resident #1's blood pressure. Standard of care was not met. The Physician Orders for [DATE], documented ordered on [DATE], Allopurinol tablet 100 milligrams (mg) give 0.5 tablet by mouth in the morning for Gout, Levetiracetam tablet 500 mg, give 1 tablet by mouth two times a day for Seizures. On [DATE], the orders were Nephro-Vite Rx 1 mg tablet, give 1 tablet by mouth 1 time a day for Supplement. The Blood Pressure Summary dated [DATE] documented at 9:20 AM, Resident #1's BP was ,d+[DATE]. At 11:00 AM, the BP was ,d+[DATE]. At 1:00 PM, the BP was ,d+[DATE]. At 2:35 PM, the BP was ,d+[DATE]. At 5:25 PM, the BP was ,d+[DATE], and on [DATE] at 4:40 AM, the BP was ,d+[DATE]. The Vital Signs Summary dated [DATE] at 9:27 AM, documented Resident #1's Pulse was 73, and at 2:35 PM, the Pulse was 51. A Physician's Progress Note dated [DATE] at 9:59 AM, documented that Resident #1 was seen after being given wrong medications. According to the staff nurse, Resident #1 was given wrong medications this morning: Seroquel 50 mg orally (po), metoprolol 50 mg po, Lisinopril 10 mg po. The resident was currently asymptomatic. BP was ,d+[DATE] P 73. Will monitor vital signs every 2 hours for 12 hours. Staff given parameters to call MD. Start intravenous fluids (IVF) with normal saline at 75 ml/hr. A Nursing Progress Note written by RN #2, dated [DATE] at 12:49 PM, documented that Resident #1 received 9:00 AM medications that belonged to another resident (Resident #2). The medications were Lisinopril, Seroquel, Metoprolol, Aspirin, Docusate Sodium, B Complex/Vitamin C tab. Resident #1 was seen by the Physician. Resident #1 observed with low BP from his/her baseline after he/she received the wrong medication. BP ,d+[DATE], ,d+[DATE], ,d+[DATE]. A Heparin lock (a device that allows access to a vein) was inserted into the left hand, and Normal Saline 75 milligrams per hour was administered for 12 hours. The resident was on vital signs and mental status monitoring every 2 hrs. for 12 hrs. A Nursing Progress Note written by RN #2, dated [DATE] at 5:06 PM, documented that at around 1:00 PM, Resident #1 was alert with no changes in baseline mental status. Resident #1's breathing was non-labored and he/she was not drowsy. Vitals signs were BP ,d+[DATE] P 56, Respiration (R)17, Oxygen saturation (O2 SAT) 98%. The Physician was made aware, and IV fluids rate was increased to 100 milliliters each hour (ml/hr.). B/P around 2:30 PM was ,d+[DATE] and the Pulse was 51. A Nursing Progress Note written by RN #2, dated [DATE] at 1:40 AM, documented that Resident #1 was alert and responsive to verbal and tactile stimuli. The resident is on IV Fluids 0.9 % Normal saline was infusing in the left hand at 100 mls/hr. There were no changes in the resident's mental status. At 12:30 AM, T 97.7, P 59 R 20 B/P ,d+[DATE] and oxygen saturation was (O2 SAT) 98%. Review of RN #1's Staff Education Record on [DATE], revealed that there was no documented evidence that the Medication Administration Observation Competency was completed prior to [DATE]. During an interview on [DATE] at 12:15 PM, RN #2 stated that RN #1 was on orientation on their unit for about a week and was buddied up with another nurse during orientation for medication administration. RN #2 also stated that he/she did some of RN #1's competencies while RN #1 was training on the unit. RN #2 stated that on [DATE], he/she was administering medications to the residents of one side of the first floor unit and RN #1 was administering medications to the residents on the other side of the first floor unit. RN #2 stated that RN #1 asked them how to use the insulin pen. RN #2 stated that shortly afterwards, he/she observed RN #1 standing over Resident #1 with the insulin pen. RN #2 stated that he/she then alerted RN #1 that Resident #1 was not prescribed insulin. RN #1 then admitted that he/she gave Resident #1 medications which belonged to Resident #2. RN #2 stated that the Physician ordered to monitor Resident #1's vital signs and administer intravenous fluids. RN #2 further stated that RN #1 was sent home and was given further orientation when he/she returned to work. This Surveyor contacted RN #1 for an interview on [DATE] at 1:00 PM, but RN #1 refused to be interviewed. RN #1 stated that he/she had retained a Legal Counsel and will speak to his/her lawyer first. RN #1 stated that he/she will get back if his/her lawyer agreed for RN #1 to give an interview, however RN #1 did not return the call. During an interview on [DATE] at 3:50 PM, the Risk Manager (RM) stated that he/she conducted the incident investigation. The RM stated that he/she became aware of the incident on [DATE], and interviewed RN #1. The RM stated that RN #1 informed him/her that RN #1 did not check Resident #1's identification band. The RM stated that resident standard of care was not met by RN #1. During an interview on [DATE] at 10:20 AM, the Physician stated that he/she examined Resident #1 after the incident when Resident #1 was given incorrect medications. The Physician stated that intravenous fluids were ordered to increase Resident #1's fluid volume and to reduce any negative effects of the wrong medications. During an interview on [DATE] at 1:27 PM, the Director of Nursing (DON) stated that he/she became aware of the medication incident with Resident #1 on [DATE] around 11:00 AM. The DON stated that he/she was informed that RN #1 had mistakenly given Resident #1 medications that were ordered for Resident #2. The DON stated that RN #1 did not check Resident #1's identification band before administering the medications. The DON stated that RN #1 had a week of orientation in the classroom and another week of orientation on the unit. The DON stated that RN #1 worked with a preceptor on the unit and competencies including medication competency were done on the unit. The DON stated that RN #1's Medication Observation Competency Checklist was completed it could not be located and the Nurse Educator at the time of the incident is currently out on leave. The DON further stated that RN #1 did not follow the rights for medication administration, however Resident #1 had no adverse reactions. The DON stated that RN #1 was given extended orientation after the incident. During a follow up telephone interview on [DATE] at 4:59 PM, the Director of Nursing (DON) acknowledged that RN #1 administered the wrong medications and did not follow the professional standards for safe medication administration. 10 NYCRR 415.11(c)(3)(i)

Based on observation, record review and interviews during an abbreviated survey (NY00283561), the facility did not ensure that residents are free of significant medication errors. This was evident in 1 out of 4 residents sampled (Resident #1). Specifically, on 09/19/2021 at 9:00 AM, Registered Nurse (RN #1) did not check Resident #1 identification band and administered the medications prescribed for Resident #2 to Resident #1. Resident #1 was given six medications in error resulting in a 40 millimeter of mercury (mm/hg) reduction in Resident #1's blood pressure (BP). The findings are: The facility's Policy and Procedure entitled Administering Medications, revised in December 2012, documented that only person licensed and permitted by this state to prepare, administer, and document the administration of medications may do so. The individual administering medications must verify the resident's identity before giving the resident his/her medications. Methods of identifying the resident include checking the identification band, checking photograph attached to the medical record and if necessary, verifying the resident's identification with other facility personnel. The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Resident #1 was admitted with diagnoses that included Dementia, Major Depressive Disorder, and Seizure Disorder. The Minimum Data Set (MDS, an assessment tool) dated 08/09/2021, documented a Brief Interview for Mental Status (BIMS) score of 03 out of 15, indicating that Resident #1 had severely impaired cognition. An undated Facility's Investigation Summary Report documented that on 09/19/2021, at approximately 9:00 AM, as Registered Nurse (RN) #1 was administering medications in the Day Room, he/she checked Resident #2's identification band and prepared Resident #2's medications which included Seroquel, Metoprolol, Lisinopril, Aspirin, Docusate, B Complex Vitamins and Vitamin C. After a momentary distraction, RN #1 took the poured medications to Resident #1 without checking Resident #1's identification band. Afterwards, RN #1 drew up insulin ordered for Resident #2 and checked the dosage with RN #2. RN #1 then took the insulin to Resident #1 and RN #2 interrupted RN #1. RN #1 then informed RN #2 that he/she (RN #1) had given Resident #1 the medications that were prescribed for Resident #2. The Medical Doctor (MD) ordered normal saline intravenously (IV) and to notify him/her if the systolic blood pressure falls below 90 or the pulse below 50. Resident #1's blood pressure (BP) baseline was approximately 140/80. During the early afternoon Resident #1's BP was 89/50. The facility concluded that RN #1 did not follow the facility's policy and procedure for safe medication administration, resulting in a 40 mm/hg reduction in Resident #1's BP. The standard of care was not met. A Physician Orders, dated 01/30/2021, documented that the following medications were ordered for Resident #1: Allopurinol tablet 100 milligram (mg), give 0.5 tablet by mouth in the morning for Gout, Levetiracetam tablet 500 mg, give 1 tablet by mouth two times a day for Seizures. On 02/02/21, Nephro-Vite 1 mg tablet, give 1 tablet by mouth 1 time a day for Supplement were ordered. A BP Summary for Resident #'s BP dated 09/19/2021, documented at 9:20 AM, Resident #1's BP was 141/87. At 11:00 AM, the BP was 109/68. At 1:00 PM, the BP was 89/50. At 2:35 PM, the BP was 92/61. At 5:25 PM, the BP was 106/65 and on 09/20/2021 at 4:40 AM, the BP was 122/64. The Vital Signs Summary dated 09/19/2021 at 9:27 AM, documented that Resident #1's Pulse rate was 73. At 2:35 PM, the Pulse rate was 51. A Physician's Progress Note dated 09/19/2021 at 9:59 AM, documented that Resident #1 was seen after given the wrong medications. Resident #1 was given Seroquel 50 mg orally (po), Metoprolol 50mg po, and Lisinopril 10 mg po that was not ordered for Resident #1. Resident #1 was asymptomatic with BP of 141/81 and Pulse rate of 73. Vital signs were monitored every two hours for 12 hours. Intravenous fluids (IVF) of normal saline were administered. A Nursing Progress Note written by RN #2, dated 09/19/2021 at 12:49 PM, documented that Resident #1 received the 9:00 AM medications that belonged to another resident (Resident #2). The medications were Lisinopril, Seroquel, Metoprolol, Aspirin, Docusate Sodium, and B Complex/Vitamin C tab. Resident #1 was seen by the Physician. Resident #1 was observed with low BP from his/her baseline after he/she received the wrong medication. The BP results were 141/81, 109/68, and 102/72. A Heparin lock was inserted in the left hand and Normal Saline 75 milliliters per hour for 12 hours was started. Resident #1 was on vital signs and mental status monitoring every two hours for 12 hours. A Nursing Progress Note written by RN #2 dated 09/19/2021 at 5:06 PM, documented that at around 1:00 PM, Resident #1 was alert with no changes in baseline mental status. Resident #1's breathing was non-labored and he/she was not drowsy. Vitals signs were BP 89/50 P 56, Respiration (R)17, Oxygen saturation (O2 SAT) was 98%. The Physician was made aware, and IV fluids rate was increased to 100 ml/hr. The BP around 2:30 PM was 92/61, and the P was 51. A Nursing Progress Note written by RN #2 dated 09/20/2021 at 1:40 AM, documented that Resident #1 was alert and responsive to verbal and tactile stimuli. The resident is on IV Fluids of 0.9 % normal saline infusing in the left hand at 100 mls/hr. There was no change in the resident's mental status. At 12:30 AM, Resident #1's vital signs were T 97.7, P 59 R 20 BP 105/66 and the O2 SAT was 98%. A review of RN #1's Staff Education Record on 10/06/2022, revealed no documented evidence of Medication Administration Observation Competency Checklist prior to 09/19/2021. During an interview on 10/06/2022 at 12:15 PM, RN #2 stated that RN #1 was on orientation on their unit for about a week and was budded up with another nurse during orientation for medication administration. RN #2 also did some of RN #1's competencies while RN #1 was in training on the unit. RN #2 stated that on 09/19/2021, he/she was administering medications to the residents of one side of the first-floor unit and RN #1 was administering medications to the residents on the other side of the first floor unit when RN #1 asked them how to use the insulin pen. RN #2 stated that shortly afterwards, he/she observed RN #1 standing over Resident #1 with the insulin pen, and he/she then alerted RN #1 that Resident #1 was not prescribed insulin. RN #2 stated that RN #1 then admitted that he/she gave Resident #1 the medications which were prescribed to be given to Resident #2. RN #2 stated that the Physician ordered to monitor Resident #1's vital signs, intravenous fluids, and charcoal medication. RN #2 also stated that RN #1 was sent home and was given further orientation when they returned to work. During a telephone interview on 10/06/2022 at 1:00 PM, RN #1 refused to be interviewed. RN #1 stated that he/she had retained Legal Counsel, and RN #1 will speak to his/her lawyer, and call back. RN #1 did not return the call. During an interview on 10/06/2022 at 3:50 PM, the Risk Manager (RM) stated that he/she conducted the incident investigation. The RM stated that he/she became aware of the incident on 09/20/2021. The RM stated that he/she interviewed RN #1 and RN #1 informed them that he/she did not check Resident #1's identification band. The RM stated that resident's standard of care was not met by RN #1. During an interview on 10/10/2022 at 10:20 AM, the Physician stated Resident #1 was examined after Resident #1 was given the wrong medications. The Physician stated that he/she ordered intravenous fluids to increase Resident #1's fluid volume and to reduce any negative effects of the wrong medications. During a follow up interview on 10/19/2022 at 10:43 AM, the RN #2 stated that RN #1 was on orientation on their unit for about a week and RN #1 shadowed the medication nurse. RN #2 stated that after the week, he/she observed RN #1 administered medications for six or more residents for medication administration competency. RN #2 stated that he/she did not sign a medication administration competency sheet for RN #1, and could not recall the date when the medication competency was done for RN #1. RN #1 did well with the medications administration and there were no issues at the time. During an interview on 10/19/2022 at 1:27 PM, the Director of Nursing (DON) stated that he/she became aware of the medication incident with Resident #1 on 09/19/2021 around 11:00 AM. The DON stated that he/she was informed that RN #1 had mistakenly given the medications that were ordered for Resident #2 to Resident #1. The DON stated that RN #1's Medication Observation Competency Checklist was completed but it could not be located. The DON stated that the Nurse Educator at that time was currently out on leave. The DON further stated that RN #1 did not follow the rights for medication administration; however, Resident #1 had no adverse reactions, and RN #1 was given extended orientation after the incident. 10 NYCRR 415.12(m)(2)

Based on observation, record review and interviews conducted during an abbreviated survey (NY00298599), the facility failed to ensure that a resident was free from physical abuse. This was evident for 1 out of 3 residents sampled for Abuse (Resident #1). Specifically, on 07/05/2022 at 2:46 PM, Resident #1 was observed on the Hospital Police (HP) surveillance camera recording being dragged backwards by the armpits from a small corridor into the hallway by Security Guard (SG) #1. While being dragged Resident #1 had no shoe or sock on their left foot. The findings are: The facility's Policy and Procedure entitled Abuse Prohibition dated on 09/21/2017 documented that residents of the facility have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, neglect, exploitation, mistreatment, involuntary seclusion, misappropriation of resident property, a quality-of-care concerns, a physical environment issue and/or a crime. The policy defined physical abuse as inappropriate physical contact with a resident which harms or is likely to harm the resident. Inappropriate physical contact includes, but not limited to striking, punching, verbal swearing, kicking, shoving, bumping, and sexual molestation. This Resident was admitted to the facility with diagnoses including Schizoaffective Disorder, Dementia, and anxiety disorder. The Minimum Data Set assessment dated [DATE] documented that Resident #1 had a Brief Interview of Mental Status and a score of 10/15 indicating moderately impaired cognition. Documented that Resident #1 required supervision with set up help only with ambulation. A Care Plan dated 10/02/2020 documented that Resident #1 was at Risk for Potential Verbal, Physical, and Sexual Abuse. The interventions documented that staff should assess Resident #1 for signs and symptoms of abuse such as bruises, behavior, and weight loss. Staff to investigate all allegations of abuse and neglect promptly. An Allied Security Details Job Description dated 04/22/2022 states the following guidelines apply to all residents on one to one: do not touch the resident, do not restrain residents, redirect to other areas with verbal comments, follow resident to every place they go, except into bedrooms or bathroom stalls, keep distance of 6 feet or more that he/she feels comfortable with with from residents, and report any confrontations/altercations/issues residents has with residents or staff to HP Command (number listed). A Nursing Progress Note, by Registered Nurse (RN) #1, dated 07/05/2022 documented that Risk manager (RM) #1 reported that a Hospital Police Staff (HPS) #1 reported that he/she observed, on the security camera, Resident #1 being pulled by SG #1 in front of the central supply room on 07/05/22 between 2-3 PM. Resident #1 was examined with no injury. The facility surveillance camera recording dated 07/05/2022 was viewed on 07/18/2022 at 12:00 PM. The camera recording showed on 07/05/2022 at 2:46 PM Resident #1 was being dragged backwards by the armpits from a short corridor into the long hallway by SG #1. SG #1 positioned Resident #1 to stand against the wall in the hallway. While being dragged Resident #1 had no shoe or sock on their left foot. SG #1 brought a shoe from the short corridor and threw the shoe down in front of Resident #1. Camera ended with Resident #1 walking away. The facility Summary Report dated 07/08/2022 documented that HPS #1, observed on the security camera, SG #1 held Resident #1 under their arms and dragged the resident out of a short corridor and placed the resident near a wall. Resident #1 was evaluated by the RN #1 with no signs and symptoms of injuries. The Psychiatrist evaluated Resident #1 to be at baseline. Resident #1 did not recall the incident. SG #1 was removed from the duty immediately and subsequently terminated for failure to follow protocol of inappropriately touching Resident #1 during an episode of impulsive behavior. The facility's investigation concluded that they could not find any evidence to substantiate allegation of physical abuse. During an interview on 07/18/2022 at 11:30 AM, Institutional Aide (IA) #1 stated that he/she witnessed the incident of 07/05/2022. Stated that Resident #1 entered the Central Supply Room (CSR) and SG #1 followed Resident #1. IA #1 stated that Resident #1 tried to go through the partition glass inside the CSR room and was about to fall when SG #1 grabbed Resident #1 under their arms to prevent the resident from falling. IA #1 stated that SG #1 took Resident #1 out into the corridor. During an interview on 07/18/2022 at 12:06 PM HPS #1 stated that he/she was in the Hospital Police Command Center watching the facility security camera when he/she observed Allied Security Guard (SG #1) running to the CSR. HP #1 stated that he/she rewound the video tape and saw SG #1 pulling Resident #1 out of a small corridor into a main corridor and placed the resident near a wall. HPS #1 stated that SG #1 gave Resident #1 their slipper. HPS #1 stated that he/she reported the incident to the Risk Manager. On 07/18/2022, three unsuccessful attempts were made to contact SG #1 by phone. Messages were left for SG #1 to contact surveyor. No response to date. SG #1 provided a signed handwritten statement to the facility dated 07/05/2022. SG #1 stated that Resident #1 went in the supply room on the 3rd floor. I had to drag resident out of the room because the resident was screaming nonsense. The supply personal said no resident in the area. The supply personal said take the resident out of the room. SG #1 stated that Resident #1 put up a fight. Stated Resident #1 grabbed the door for dear life. SG #1 Stated that he/she had to drag Resident #1 by the back of their arms then get the resident's slipper. During an interview on 07/18/2022 at 1:53 PM, RN #1, who worked on 07/05/2022 on the 7:30-4:00 PM shift, stated that RM #1 reported to him/her that Resident #1 was observed on the security camera being dragged by SG #1. RN #1 stated that he/she examined Resident #1 after the incident and did not find any injuries. Stated that Resident #1 did not complain of pain or discomfort. RN #1 stated that he/she informed the Medical Doctor immediately. During an interview on 07/18/2022 at 3:25 PM, RM #1 stated that he/she was notified by HPS #1 that there was an incident between SG #1 and Resident #1. RM #1 stated that he/she viewed the video and that it did not appear to be violent. Stated that SG #1 put their arms under Resident #1's arms and pulled the resident out of the supply room into the hallway. RM #1 stated that SG #1 tried to coax Resident #1 into leaving the supply room but Resident #1 did not listen. RM #1 stated that SG #1 was in a position where SG #1 could not verbally convinced Resident #1 to leave the supply room. RM #1 stated that he/she immediately removed SG #1 from duty and reported to New York State Department of Health (NYS DOH). During an interview on 08/19/2022 at 9:45 AM, the Director of Nursing (DON) stated that the protocol for SGs to perform 1:1 duty was to shadow the residents. The DON stated that SGs do not render care to the residents. The DON stated that SG #1 was educated on not to touch the residents during monitoring. Stated that if something was going on with the residents, the SGs should call the HP. The DON stated that SG #1 should have called the HP when the resident entered the CSR. 10NYCRR 483.12

Based on observation, interview and record review conducted during an abbreviated Survey (NY 732) on 12/20/2021, the facility did not ensure that a resident was free from sexual abuse. This was evident for 1 out of 3 residents sampled (Resident # 1). Specifically, Resident # 3 reported that he/she observed Resident #2 wheeled Resident #1 into the stairwell on the unit at approximately 2:00PM a month ago. Resident #3 stated that Resident #1 and Resident #2 were in the stairwell for 10-15 minutes. Resident #1 identified Resident #2 as the person who touched him/her breasts and pelvic area in the stairwell. Resident #1 stated that he/she did not consent to being touched by Resident #2. Facility staff were not aware that Resident #1 and Resident #2 were in the stairwell from 10-15minutes until Resident #3 reported it. The findings including: The Facility Policy and Procedure titled Incident Reporting within the Nursing Facility with the Abuse Prohibition Protocol dated 08/22/2017, documented that it was the policy of the facility that all residents have the right to be free from verbal, sexual, physical, and mental abuse. The policy defined Sexual Abuse as the nonconsensual sexual contact of any type with a resident that includes, but is not limited to sexual harassment, sexual coercion, or sexual assault. Resident #1 was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set, (MDS, a resident assessment tool) dated 09/07/2021 identified Resident #1 with severely impaired cognition. Resident #1 was totally dependent with Activities of Daily Living. An Abuse Care Plan dated 12/11/2019 documented interventions to assessed Resident #1 for signs and symptoms of abuse and or neglect. For example, bruises, behavior, weight loss and report to appropriate resources. Encouraged the resident to seek out staff for assistance if having difficulties with others. Investigate all allegations of abuse and neglect promptly. Resident #1 Physician's progress note dated 12/08/2021 documented that the writer was informed by the Registered Nurse that another resident touched Resident #1 inappropriately. A Psychology's progress note dated 12/08/2021 documented that Resident #1 was interviewed along with Patient Relation (PR), Hospital Police, Risk Manager, and an interpreter. Resident #1 was accepting of being interviewed by staff and cooperated fully. Resident #1 was able to show through gestures that he/she was touched by a male in specific areas: genitals, breasts (gesturing both to over shirt and under shirt) against his/her consent. Resident #1 was shown a paper with 4 male photos and Resident #1 identified Resident #2, a resident in the facility as the one who touched him/her. Resident #1 was asked if the incident happened once or more than once, and Resident #1 stated more and continued crying. An Incident Progress note dated 12/08/2021 documented that around 12:32 PM writer was informed by Patient Relations (PR) that a resident from C-building (Resident #3) reported to PR yesterday on 12/07/2021 that another resident (Resident #2) from C-building took Resident #1 into the C-building stairwell on the third floor and touched between Resident #1 ' s legs and his/her breast about a month ago. A Risk Summary Investigation Summary Report dated 12/08/2021 documented that the available evidence supported that Resident #1's allegation of sexual assault was credible. A Psychiatry Note dated 12/08/2021 documented that a consult was requested to Resident #1 for psychological distress and need for support. Resident #1 was a possible victim of sexual touching by a male peer which may have occurred about a month ago. During the interview to discuss allegation and looking at the photo of Resident #2, Resident #1 appeared shaken and disturbed during the process. Resident #1 was quickly comforted and showed no signs of persistent distress. Resident #2 (Aggressor) was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #2 had a BIMS score of 10/15, associated with moderately impaired cognition. A Behavior Care plan dated 12/01/2021 with interventions includes Provide a program of activities that is of interest and accommodates resident status. Encouraged the resident to express feelings appropriately. Anticipate and meet the resident's needs. Provide opportunity for positive interactions and attention. Stop and talk with resident as he/she is passing by. A Psychiatry note dated 12/08/2021 documented that Patient Relation informed that a male peer reported that about a month ago he/she saw Resident #2 maneuvered another peer ' s (Resident #1) power chair into a stairwell away from others' view. Resident #2 emerged back out with the peer. Through investigation the peer stated Resident #2 touched him/her against his/her wish in the chest area and pelvic area. Resident #2 was interviewed and categorically denied having ever touched anyone male or female in a sexual manner. During an interview on 12/21/2021 at 11:21 AM, Resident #1 stated that a man touched his/her breast and between his/her legs (Resident #1 pointed to the areas on his/her body). During an interview on 12/21/2021 at 12:12 PM, Resident #2 was interviewed via telephone interpreter. Resident #2 stated that he/she was friends with Resident #1 and that he/she did not touch Resident #1 inappropriately. Resident #2 stated that he/she previously gave Resident #1 a massage on Resident #1's shoulder and back. Resident #2 stated he/she did not do anything wrong and did not like staff following him/her around everywhere. During an interview on 12/21/2021 at 12:34 PM, Resident #3 stated through an interpreter that he/she reported seeing Resident #2 and Resident #1 about a month ago in a stairwell. Resident #3 stated he/she did not know what happened in the stairwell between the two residents. Resident #3 stated that he/she did not hear any screaming or yelling while residents were in the stairwell. Resident #3 stated that he/she did not report the incident because he/she did not like being involved in things or causing issues. Resident #3 stated that she agreed to be educated on reporting incident in a timely manner. During an interview on 12/21/2021 at 1:22 PM, the Director of Patient Relations (DPR) stated that Resident #3 reported to him/her on 12/07/2021 that Resident #2 took a female resident on the 3rd floor into the stairwell. Resident #3 reported the allegation happen a month ago. Resident #3 stated there were no staff and the hallway was empty outside of the three residents. Resident #3 stated the alleged incident happed around 2:00 PM in the afternoon. Resident #3 stated that he/she reported the allegation to the DPR first because he/she did not want to cause any issues. The DPR stated that Resident #3 said that he/she reported the incident because he/she heard that Resident #2 allegedly grabbed a male resident butt. Resident #3 stated that he/she did not hear any yelling but stated he/she felt Resident #2 did not go willingly because Resident #2 guided Resident #1 ' s wheelchair into the stairwell. The DPR stated that Resident #3 only knew the name of Resident #2. The DPR stated that he/she immediately reported the allegation to the Administrator and Risk Manager. The DPR stated from Resident #3 ' s description they were able to identify Resident #1. The DPR stated that the Police was notified and New York Police Department special victims' unit, who stated that they would have to get back with the facility. During an interview on 12/21/2021 at 2:30PM, the Risk Manager (RM) stated that the DPR reported the allegation regarding Resident #1 and Resident #2. The RM stated after receiving the allegations he/she immediate followed up with the DPR and Psych to get interviews done with Resident #1 and Resident #2. The RM stated that he/she attempted to review the cameras on 3rd floor however due to the incident allegedly happening a month prior to it being reported those dates were already recorded over. The RM stated that the investigation concluded that the allegation did occur due to Resident #1 ' s consistent interview and emotions regarding the allegation. RM stated that Resident #3 was educated on reporting in a timely fashion. During a follow up interview with the Risk Manager (RM) on 01/03/2022 at 1:41PM. The RM reported to receive a call this morning (01/03/2022) from the Police Department requesting to make an appointment to interview Resident #3 on Thursday. As per the RM, Resident #1 has been living at the facility for more than thirty years. Stated that Resident #1 could ride around the building with no restrictions. The RM stated that there were no staff members in the area (where the incident occurred) to monitor the resident because the area was being monitored by a close-up camera. 415.4(b)(1)(i)

Based on observation, record review, and interview conducted during the COVID-19 Focused Infection Control Survey completed on 01/04/21, the facility did not establish and maintain an Infection Control Program to ensure the health and safety of residents to help prevent the transmission of COVID-19. Specifically, for 1 (unit C-52) of ten units reviewed a Certified Nursing Assistant (CNA #1) was observed not donning (putting on) gown and gloves prior to performing care to the residents on contact and droplet precautions. The findings are: Centers for Disease Control guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated November 4, 2020 provides: HCP who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to Standard Precautions and use a (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 and procedures, titled Guidance and Management for COVID-19/Admission Procedure dated 11/05/20 documented the following: residents who are admitted to the facility must provide a negative COVID-19 test performed within 72 hours of their admission. In addition, the residents will be placed on a COVID-19 contact and airborne precautions for quarantine observation for 14 days. The resident will be transferred to their home units after a negative COVID-19 test confirmation. On 01/04/21 at 10:52 AM, observation on Unit C-52, a new admission unit, revealed signage on the entrance door for Resident #1 indicated droplet/contact precautions. CNA #1 was observed repositioning a resident in bed. The CNA did not don an isolation gown and gloves prior to performing resident care. CNA #1 was interviewed at the time of the observation and stated that he was aware of and had received several in-services related to COVID-19 infection control protocols on PPE. He stated he knew the proper ways to don and doff (remove) gowns, gloves, and eye protection and to wash hands as required for contact/droplet precautions. He further stated he was supposed to wear a gown and gloves when inside the resident's room especially when providing direct care to any resident. On 01/04/21 at 12:15 PM, CNA #1 was observed setting up a food tray for Resident #1. CNA #1 did not don a gown and gloves. CNA #1 then left Resident #1's room and proceeded to the food cart located at the hallway. He picked up a food tray and served another resident in the same room. CNA #1 was also observed rolling the food cart down the hallway and went into other resident rooms. CNA #1 was not wearing gloves and did not perform hand hygiene between each resident. On 01/04/21 at 1:06 PM, an interview was conducted with Registered Nurse (RN) #1: She stated that unit C52 currently houses 7 residents who were recently admitted /readmitted to the facility. She stated that the entire unit is on quarantine and each resident is being monitored for 14 days before transferring to their home unit. She further stated that all staff are supposed to don full PPE when performing care in this unit. She further stated she supervises staff and makes sure they are following infection control protocol appropriately, but she could not explain why the CNA # 1 was not following orders. On 01/04/21 at 2:23 PM, an interview was conducted with the Infection Control Preventionist (ICP). She stated that they have a designated unit for their new admissions to stay for 14 days. The residents are tested within 48 hours after admission and are quarantined for 14 days. She stated that they monitor them and observe for symptoms of COVID-19 and ensure that contact and droplet precautions are in effect. The staff are required to don full PPE. She stated that they have had many employees who test positive for COVID-19 every now and then. The ICP stated, the facility has 30 employees currently on self-quarantine and that is why they reinforce to the employees the importance of the use of full PPE. The ICP could not explain why the CNA # 1 did not follow the infection control protocols. 415.19(a)(1-2);400.2

Based on observation, record review and interview, the facility failed to ensure that a resident was free from abuse. Specifically, the facility staff did not inform other staff when a resident (Resident #33) on 1:1 (one-to-one) observation went missing for an undetermined period of time, and the resident, subsequently, had the opportunity to hurt and injure another resident (Resident #18). This was evident for 1 of 4 residents reviewed for allegations of abuse, neglect, or mistreatment(Resident #33). COMPLAINT # NY 691 The finding is : Resident #18 a [AGE] year-old, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS 3.0 (minimum data set) assessment dated [DATE] documented the resident had moderately impaired cognition and was able to verbalize wants and needs. The MDS further documented the resident required assistance and supervision with activities of daily living (ADLs). The MDS documented the resident ambulated independently with supervision. The CCP (comprehensive care plan) for ADL function and rehab potential dated 5/12/15, updated on 7/28/15, documented the resident requires intermittent supervision with set up for personal hygiene, grooming, and bathing. The CCP included the following interventions: anticipate all care needs, provide cueing and supervision as needed. The facility investigation of an incident dated 8/1/15 involving Resident #18 and Resident #33 documented the following: The incident occurred on 8/1/15 at 1:10 PM. Resident #33 from C-24 was seen hitting and punching Resident #18 from C-23 (units C-24 and C-23 are adjacent to each other). Resident #18 was lying down on the floor in the resident shower room. Resident #18 sustained a reddish bluish discoloration of the left arm, redness on the left side of her face, and pain in the left arm, left face, left leg, back and neck. There were no changes in ROM (range of motion) and no LOC (loss of consciousness). The investigation report dated 8/1/15 documented that Resident #18 was seen and evaluated by the physician with the following documentation: noted 2 cm (centimeter) linear scratch mark on left arm (superficial). No bleeding. She is able to move all extremities as before. Will monitor vital signs and Tylenol PRN (as needed) for pain. Review of the facility investigation dated 8/1/15 and statements of the staff involved in the incident revealed the following findings: Resident #33 was on 1:1 monitoring. The resident's assigned CNA (certified nursing assistant) went on break from 12:00 PM to 1:00 PM, and she was relieved by another CNA. When she came back, she took over from her relief , receiving the resident who was in the bathroom throwing his food from his tray. She took the tray from him and discarded the food with her back to the resident. When she turned around the resident was nowhere to be found. The staff saw the CNA walking around the unit, but the CNA did not inform any staff that she lost sight of the resident. The unit Registered Nurse (RN) Head Nurse was interviewed on 9/16/15 at 10:40 AM and stated (Resident #18's) established routine is to take a shower before lunch time, and she takes a long period doing that. She was set up by her assigned CNA and left for privacy with frequent monitoring. At that time, no other residents were in the vicinity of the shower room. Then we just heard her shouting and staff came to investigate and found (Resident #33) inside the shower hitting her. (Resident #33), from the time of admission, was on 1:1 monitoring because of his unpredictable behavior. We don't know how long the CNA lost sight of him. The RN Charge Nurse who responded to the cry of the resident was interviewed on 9/19/15 at 1:00PM and stated, before the resident cried, I saw the CNA standing near the door of (Resident #33) and I thought the resident was inside the room. The CNA was unavailable for interview because she is no longer employed at the facility. 415.4 (b) (1) (i)

Based on observation, record review and interview, the facility failed to implement written policies and procedures that prohibit abuse and neglect of residents. Specifically, the facility staff did not inform other staff when a resident (Resident #33) on 1:1 (one-to-one) observation went missing for an undetermined period of time, and the resident, subsequently, had the opportunity to hurt and injure another resident (Resident #18). This was evident for 1 of 4 residents reviewed for allegations of abuse, neglect, or mistreatment(Resident #33). COMPLAINT # NY 691 The finding is : Resident #18 a [AGE] year-old, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS 3.0 (minimum data set) assessment dated [DATE] documented the resident had moderately cognition and was able to verbalize wants and needs. The MDS further documented the resident required assistance and supervision with activities of daily living (ADLs). The MDS documented the resident ambulated independently with supervision. The CCP (comprehensive care plan) for ADL function and rehab potential dated 5/12/15, updated on 7/28/15, documented the resident requires intermittent supervision with set up for personal hygiene, grooming, and bathing. The CCP included the following interventions: anticipate all care needs, provide cueing and supervision as needed. The facility investigation of an incident dated 8/1/15 involving Resident #18 and Resident #33 documented the following: The incident occurred on 8/1/15 at 1:10 PM. Resident # 33 from C-24 was seen hitting and punching Resident #18 from C-23 (units C-24 and C-23 are adjacent to each other). Resident #18 was lying down on the floor in the resident shower room. Resident #18 sustained a reddish bluish discoloration of the left arm, redness on the left side of her face, and pain in the left arm, left face, left leg, back and neck. There were no changes in ROM (range of motion) and no LOC (loss of consciousness). The investigation report dated 8/1/15 documented the resident was seen and evaluated by the physician with the following documentation: noted 2 cm (centimeter) linear scratch mark on left arm (superficial). No bleeding. She is able to move all extremities as before. Will monitor vital signs and Tylenol PRN (as needed) for pain. Review of the facility investigation dated 8/1/15 and statements of the staff involved in the incident revealed the following findings: Resident #33 was on 1:1 monitoring. The resident's assigned CNA (certified nursing assistant) went on break from 12:00 PM to 1:00 PM, and she was relieved by another CNA. When she came back, she took over from her relief , receiving the resident who was in the bathroom throwing his food from his tray. She took the tray from him and discarded the food with her back to the resident. When she turned around the resident was nowhere to be found. The staff saw the CNA walking around the unit, but the CNA did not inform any staff that she lost sight of the resident. The unit Registered Nurse (RN) Head Nurse was interviewed on 9/16/15 at 10:40 AM and stated (Resident #18's) established routine is to take a shower before lunch time, and she takes a long period doing that. She was set up by her assigned CNA and left for privacy with frequent monitoring. At that time, no other residents were in the vicinity of the shower room. Then we just heard her shouting and staff came to investigate and found (Resident #33) inside the shower hitting her. (Resident # 33), from the time of admission, was on 1:1 monitoring because of his unpredictable behavior. We don't know how long the CNA lost sight of him. The RN Charge Nurse who responded to the cry of the resident was interviewed on 9/19/15 at 1:00PM and stated, before the resident cried I saw the CNA standing near the door of (Resident #33) and I thought the resident was inside the room. The CNA was unavailable for interview because she is no longer employed at the facility. 415.4(b)

Based on record review and interview, the facility did not ensure that each resident receives adequate supervision to prevent accidents. Specifically, a resident, who required two persons for care was assisted by one person, resulting in a fall with injury. This was evident for 1 of 2 residents reviewed for Accidents and Supervision out of a sample of 33 residents reviewed for Quality Care concerns. (Resident #10). The finding is : Resident #10 is a [AGE] year-old with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 assessment ((MDS) dated [DATE] documented the resident had memory problems, poor decision making and severely impaired cognition. The MDS further documented the resident required extensive to total assistance with activities of daily living. The Comprehensive Care Plan (CCP) for Behavior dated 6/16/15 documented that the resident has unpredictable aggression, resists and rejects care, and tries to hit or punch care givers. The interventions included providing assistance of two staff as needed (for agitation). The CCP for falls dated 9/7/15 documented the resident should be provided care by two staff due to unpredictable agitation. The Occurrence Report Form dated 8/30/15 documented: . Occurrence Date: 8/30/15 .Occurrence Time: 7:00 AM .resident fell from bed during care and sustained swelling and discoloration 6.5 centimeters (cm) x 5 cm on left forehead. also redness on right elbow. The Physician's Report section of this form documented: .while getting cleaned up on bed with two providers, one left the room, side rails were down and she fell from the right side of the bed. The Progress Record dated 8/30/15 documented that the resident was transferred to the hospital. On 9/17/15 at 10:40 A.M., the assigned Certified Nurse Assistant #1 (CNA #1) was interviewed and stated that while providing morning care for the resident, she asked CNA #2 to get her a towel. She further stated that CNA #2 left the resident's room to get the towel, leaving her alone in the room with the resident. CNA #1 stated that as she was applying deodorant to the resident, the resident became agitated and attempted to hit her. She stated that the resident slid from the bed onto the floor. On 9/17/15 at 10:51 A.M., CNA #2 was interviewed and stated that CNA #1 asked her for a towel, and she obtained the towel gave it to CNA #1. She further stated she left the room, and she heard screams for help coming from the room shortly afterward. CNA #2 stated that she returned to the room and observed the resident lying on the floor. On 9/17/15 at 12:20 P.M., the Assistant Director of Nursing (ADN), who was the supervisor, was interviewed stated that on 8/30/15 at 7 A.M. she was called by the Charge Nurse. She further stated the Charge Nurse told her that CNA #1 was giving morning care to the resident, and while applying the deodorant, the resident became agitated, tried to hit CNA #1, and slid from the bed to the floor. The ADN stated she instructed the Charge Nurse to have two CNAs care for the resident at all times. Attempts to reach the charge nurse by phone for interview on 9/17/15 and 9/18/15 were unsuccessful. The facility's policy on care planning dated 2/22/2011 was reviewed and documented: Our residents will be provided with the necessary care and services to attain the highest practicable, physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care 415.12(h)(1)