Every finding on record at Elizabeth Seton Children's Center

Based on observation, interview, and record review conducted during the recertification and abbreviated surveys (NY00381153/462978) from 7/31/25 to 8/7/25, the facility did not ensure each resident received adequate supervision and assistance to prevent accidents for one of two residents (Resident #119) reviewed for accidents. Specifically, staff did not perform a time out to double check if all strap eyelets were secured on the mechanical lift hooks prior to raising the lift up and Resident #119 slid out of the sling and dropped to the floor.Findings include:Resident #119 had diagnoses including cerebral palsy, seizure disorder, dependence on respirator, tracheostomy, and gastrostomy. The 12/31/20 Falls Care Plan documented the resident was at risk for falls related to lack of safety awareness, cognitive impairment, impaired balance, lack of voluntary extremity movements, spastic quadriplegia, and psychoactive drug use. The 2/21/25 Annual Minimum Data Set assessment documented Resident #119 had severely impaired cognition, was rarely/never understood, and was dependent on staff for all activities of daily living.The 5/16/25 Fall Assessment documented the resident scored a 12 (moderate risk for falls). The 5/19/25 Investigative Summary documented statements were obtained from Certified Nursing Aides #1 and #2, who were assisting with the transfer involving Resident #119 at the time of the fall. According to their reports, the hook mechanism securing the sling to the mechanical lift became detached from the sling eyelets while the lift was being raised from the wheelchair. Due to the resident's weight distribution, the staff members were unable to prevent the resident from sliding to the floor. The resident's care plan was updated with this occurrence; Re-education, and counseling was provided to both Certified Nurse Aides prior to returning to work; re-education was provided to all direct staff to reinforce the proper use of mechanical lift during transfers; house wide inspection was completed on all mechanical lifts and all were in working order; workflow review for all residents using a mechanical lift transfer while on a mechanical ventilator to have a Registered Nurse or Respiratory Therapy in direct oversight to further support a safe transfer; and transfer audits to be monitored for 60 days. The 5/19/25 Medical Note documented they were called, and it was reported that the resident fell on the floor. On exam noted no bruise or swelling or redness thus far. Clear breathing sound and no increased work of breathing. There was no facial grimacing. Placed cervical collar, then secured the resident's position.The 5/19/25 Hospital Paperwork documented the resident was seen in the emergency department and x-rays and CAT scan were done and both were negative for fracture.The 5/19/25 Employee Statement from Certified Nurse Aide #2 documented that at around 6:05 PM, Certified Nurse Aide #1 and Certified Nurse Aide #2 went to Resident #119's room. Resident #119 was seated in their wheelchair, connected to pulse ox and their feeding. Certified Nurse Aide # 2 documented they disconnected the resident from their pulse ox and feeding. After they were disconnected, they moved the resident's wheelchair and vent alongside the shower bed. Certified Nurse Aide #1 and Certified Nurse Aide #2 communicated to each other to ensure there was enough space for the lift next to the resident's wheelchair. They locked the wheels on the wheelchair and stretcher. They turned on the lift, moved it in position of the other side of resident's wheelchair and began to lower it. Once it was low enough, they attached each of the sling eyelets to the hooks. Certified Nurse Aide #2 was in control of the lift, while Certified Nurse Aide #1 was on the other side of the resident's chair. Once the resident was high enough, Certified Nurse Aide #1 locked the wheelchair on their side, and Certified Nurse Aide #2 unlocked their side. Certified Nurse Aide #1 then pulled out the wheelchair, Certified Nurse Aide #2 continued to lift the resident. Certified Nurse Aide #2 noticed the resident appeared to be sliding out of the sling and called out to Certified Nurse Aide #1 for help. Certified Nurse Aide #1 then pushed the wheelchair and stretcher out of the way to run across the room to the resident. It happened so quickly, and the main thing they can remember is seeing Resident #119's tubing through the sling. It disconnected as Registered Nurse #6, and 2 certified nurse aides came to assist.The 5/20/25 Care Plan Note documented Resident #119 had a fall during transfer from the wheelchair to bed via use of the mechanical lift on 5/19/25 and was sent out to the hospital for evaluation to rule out fracture or bleed. X-ray and CAT scan were negative, and the resident returned to the facility. The 5/20/25 Medical Note documented emergency room visit, status post fall. X-ray of chest, pelvis, bilateral elbow, femur forearm, humerus, knees, as well as CAT scan of brain, head and cervical spine without contract done in the emergency department and were unremarkable.The 5/20/25 In-service and education on mechanical lift transfers documented time out when the staff are to double check all sling eyelets are secured onto the hooks of the mechanical lift. The staff will then count 1,2,3 ready and then will start to raise the resident up in the Arjo Lift. During an interview on 8/04/2025 at 2:18 PM, Certified Nurse Aide #1 stated they followed the transfer protocol. They took off the pulse ox machine and the extension to feeding tube. They further stated they locked the shower bed wheels. When they transferred Resident #119 via mechanical lift the wheels were locked. Certified Nurse Aide #1 stated while the resident was raised up in the lift pad sling, a sling eyelet was not secured from coming off the hook while they were lifting resident in mechanical lift. It appeared the resident tilted to right side and the resident was sliding out. Certified Nurse Aide #1 stated they could not pull the shower bed over to catch the resident quickly because it was locked. Certified Nurse Aide #1 stated they were able to break the resident's fall although they were unable to catch the resident. During an interview on 08/04/2025 at 2:30 PM, Certified Nurse Aide #2 stated Resident #119's wheelchair was positioned toward the bottom of the shower bed and vent toward the top. Certified Nurse Aide #2 was standing by the shower bed and Certified Nurse Aide #1 was standing by the wheelchair. They attached the sling eyelets to the hooks but they did not realize at the time that an eyelet came loose. Then the resident slid through the sling and fell. They called for help verbally yelling out, and pressed call button. Certified Nurse Aide #2 stated when one side of the sling was tightened it made the eyelet on the other side loosen and come off the hook. Certified Nurse Aide #2 stated when the re-education was provided the educator stressed ensuring the sling eyelets were on the hooks and wheel locks were secured in place prior to lifting a resident in a sling. During an interview on 8/04/2025 at 3:05 PM, Registered Nurse #6 stated Resident #119 was being transferred from wheelchair to shower bed by two (2) certified nurse aides. Registered Nurse #6 stated they heard a commotion and somebody calling for help, so they ran over to assist. Registered Nurse # 6 stated Resident #119 had fallen out of the sling and when they ran over the resident was on the floor and Certified Nurse Aide #1 was holding the resident's upper body and head. Registered Nurse #6 stated the mechanical lift sling has eyelets which get latched onto hooks, and they believe something happened with an eyelet and hook to cause the accident. Registered Nurse #6 stated Resident #119 had no injury. During an interview on 8/04/2025 at 3:16 PM, Registered Nurse/Unit Manager #7 stated one of the eyelets came off the hook during the transfer and resident fell to the floor. Registered Nurse/Unit Manager #7 stated the resident did not sustain any injuries. Registered Nurse/Unit Manager #7 stated they observed the sling after the incident and the sling and the mechanical lift were in good condition. Registered Nurse/Unit Manager #7 stated the BioMed Department assessed the mechanical lift and said it was working fine. Registered Nurse/Unit Manager #7 stated that prior to the incident, they were given in-services about how to connect the sling eyelets properly onto the hooks and were also re-educated on ensuring the sling eyelets are secured on the hooks. Registered Nurse/Unit Manager #7 stated both Certified Nurse Aide #1 and #2 were given written disciplinary action.During a follow up interview on 8/07/2025 at 10:42 AM, Certified Nurse Aide #1 stated they were educated prior to the incident on transfers using mechanical lifts. Certified Nurse Aide #1 stated they realized that they did not do the time out process, which is part of the instructions where they all stop to ensure the sling eyelets are secured to the hooks. Certified Nurse Aide #1 stated after the incident the facility stressed heavily using time out before proceeding with lifting the resident. Certified Nurse Aide #1 stated they were given a disciplinary write up after the incident.During a follow up interview on 8/07/2025 at 12:38 PM, Certified Nurse Aide #2 stated they did not call time out during the incident. They stated they were not sure if they checked everything they should have the day of the incident. Certified Nurse Aide #2 stated they were given transfer training education on the mechanical lift prior to the incident. Certified Nurse Aide #2 stated they were re-educated to call time out, to check that the sling eyelets were secured on the hooks, and that all cords and tubing are in safe position and all count 1,2,3 together before they lift the resident up. 10NYCRR 415.12(h)(2)

Based on observation, record review and interviews during the recertification survey from 7/31/25 to 8/7/25, the facility did not ensure that staff maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #72) reviewed for infection control. Specifically, Resident #72 was on contact precautions until 8/1/25 and a housekeeper was observed doing a terminal cleaning of Resident #72's room and did not use the proper personal protective equipment while removing a privacy/cubicle curtain. Findings include:The Terminal Room Cleaning Policy dated 12/2012 documented when a room comes off isolation or when a resident is discharged , terminal cleaning will occur. The purpose is to provide residents, staff, and visitors with a sanitary and comfortable environment and endeavor to prevent the development and transmission of infection. It further documented in the procedures to make sure to wear personal protective equipment (gowns, gloves and masks), remove all privacy/cubicle curtains and send to laundry for washing. Resident #72 was admitted to facility with diagnoses including thyroid disorder, diabetes insipidus, and unspecified lack of expected normal physiological development in childhood. The 7/22/25 Annual Minimum Data Set assessment documented the resident had severe cognitive deficits. Resident #72 was able to eat with substantial to maximal assist and was dependent on staff for all other areas of activities of daily living. The 7/24/25 Physician Order documented Resident #72 was put on contact precautions which was discontinued on 8/1/25.During an observation on 7/31/25 at 10:12 AM Resident #72 was in their room with a contact precaution sign on the door. During an interview on 8/1/25 at 10:25 AM Registered Nurse #4 stated the resident was taken off contact precautions today at 7:22 AM. They stated the resident had been on contact precautions for positive Rhino-Entero virus.During an observation on 8/1/25 at 10:33 AM, Housekeeper #3 was doing a terminal cleaning of Resident #72's room and was removing privacy/cubicle curtain. Housekeeper #3 was wearing only gloves and a mask. During an interview on 8/1/25 at 10:35 AM, Housekeeper #3 stated when they do a terminal cleaning after contact precaution was discontinued, they were only instructed to use gloves and a mask. During an interview on 8/01/2025 at 11:05 AM, the Infection Preventionist stated Resident #72 was on contact precautions for 7 days that ended on 8/1/25. The Infection Preventionist stated during a terminal cleaning staff clean all surfaces, including privacy/cubicle curtains. The Infection Preventionist stated when removing a privacy curtain, staff should wear the proper personal protective equipment including a gown. During an interview on 8/07/2025 at 11:15 AM, the Director of Environmental Services and Security stated when they did a terminal cleaning after contact precautions were discontinued, the staff was required to wear personal protective equipment including a gown, gloves, and a mask. Privacy/cubicle curtains were removed, washed and returned to the room the same day. The Director of Environmental Services and Security stated Housekeeper #3 was trained by them or the environmental supervisor for use of personal protective equipment, terminal cleaning and infection control. The Director of Environmental Services and Security stated Housekeeper #3 was last trained on terminal cleaning and infection control in March of 2025. 10NYCRR 415.19(a)(1-3)(b)(2)

Based on observations, record reviews and interviews completed during an abbreviated survey (NY00349237), the facility did not ensure that a resident received treatment and care in accordance with their comprehensive person-centered care plan. Specifically Resident #1 had a care plan in place, that documented that they required 2 staff members to provide all care. On 7/23/2024 a single Certified Nurse Aide provided care singlehandedly to Resident #1. The finding is: The facility policy titled Lifting and transferring a Child revised on 11/2024 documents that all lifting, and transfers are conducted by trained direct care staff and or clinical staff and or trained family members. It further documened that once the transfer designation is established in the care plan it must be followed at all times within the facility by all direct caregivers. Resident #1 originally admitted on [DATE], readmitted on [DATE] with diagnoses including, but not limited to, spastic cerebral palsy with quadriparesis, epilepsy, disorder of bone density and structure, and congenital partial dislocation of her right hip. Resident #1 annual minimum data set, a resident assessment and screening tool, dated 7/18/2024 indicates that Resident #1 had an absence of spoken words, they could sometimes make their needs or wants to be known, and sometimes understand others, they were wheelchair bound, the resident was dependent on others for all cares, bilaterally impaired on upper and lower extremities, and moderately impaired for decisions regarding tasks of daily living. The facility also evaluated residents with their own fracture risk assessment tool, and Resident #1 scored a 13, a score of 10 or more indicates that the resident may be at risk for significant bone fragility and may merit further evaluation. The two items that increased this resident's score are chronic immobilization and use of anticonvulsant medication Depakote. The internal investigative summary revealed that on 7/24/2024 at 9:30am it was noted that Resident #1 was showing signs of discomfort after they had been transferred to their wheelchair. The resident was assessed and noted to have swelling to their left thigh, and it was noted to be larger than the right thigh. Resident was transferred to the hospital to rule out fracture. There was a statement made by Certified Nurse Aide #1 that indicated they provided care alone, they wrote in the internal investigation that they pulled the chuck up because the resident was mostly on their side, a little on their back, and this moved the resident so that they faced the wall. The investigative summary documented a review of the video surveillance. It revealed that Certified Nurse Aide #1 went into Resident #1's space, they closed the curtain, so their actions are not in view. The summary documented the statement given by Certified Nurse Aide #1. They stated that they they were alone, and they moved the resident by themselves. Review of care plans revealed that resident #1 was identified at risk for abuse. The goal was that Resident will remain free from abuse, neglect exploitation and mistreatment this plan was last reviewed on 8/6/2024. Another care plan for for bed mobility was last reviewed on reviewed on 10/02/2023, it documented that there are to be 2+ person physical assist, once caregiver supporting Resident's leg and trunk and one caregiver on the side of the bed for peri care. Registered Nurse # 3 wrote a note on 7/24/2024 that documented Resident #1 was received in bed at 7:30am, vitals were taken and within normal range. Morning medications were given as ordered. Upon assessment, resident had a bowel movement and voided. Resident was not crying but upon movement of lower extremities they seemed generally uncomfortable Certified Nurse Aides to bedside to perform cares secondary to large bowel movement. Certified Nurse aides performed cares and then transferred resident to their chair. Physical therapist went to Registered Nurse #3 secondary to suspected continued discomfort medical provider informed, Resident #1 noted with possible left leg swelling. Resident #1 transferred back to bed and measurements were made of legs, confirming left thigh larger than right. Resident #1 to be transferred to hospital for full assessment and mother made aware. The disciplinary Action form for Certified Nurse Aide #1 documented that during an investigational camera review/look back for a fracture on a Resident #1, Certified Nurse Aide #1 was noted as having repositioned the resident using a chuck without a second person this occurred and could be seen on video surveillance on 7/23/2024. Resident #1 is ordered for 2-person transfer/ADL/bed mobility. The corrective action was that the Certified Nurse Aide #1 will provide ALL care to ALL residents according to the care plan. Any future violation will result in termination. Certified Nurse Aide #1 was suspended for 5 days as a result of their action. During an interview on 3/4/25 at 12:50pm Registered Nurse #3, stated that they were s a care provider for Resident #1 at least 3xs a week. In the interview Registered Nurse #3 stated that the resident was a 2-person transfer- 2 person ADL care. 2 people always provided care. 10NYCRR 415.12

Based on record review and interviews conducted during an abbreviated survey (NY00345276) on 6/20/24, the facility did not ensure residents rights to be free from physical for 1 (Resident #1) of 3 residents reviewed for abuse. Specifically, on 6/12/24, two facility staff (Certified Nurse Aide #1 and Speech Therapist #2) witnessed an alleged staff to resident abuse involving Registered Nurse #7 and Resident #1. Registered Nurse #7 was witnessed screaming 25year olds don't behave this way-cut it out and holding Resident #1's hands down in their lap with closed hands over forearms. In an interview with Certified Nurse Aide #1 they stated they heard raised voices and saw Registered Nurse #7 loudly saying stop, are you a baby? Both witnesses did not report the incident on 6/12/24. The Speech Therapist #2 reported the incident to the administration on 6/13/24. Video surveillance revealed Registered Nurse #7 restraining Resident #1 by closing their hands on Resident #1 forearms and saw Registered Nurse #7 pointing a finger close to Resident #1's face. Findings include: The facility policy, 'Prohibition and Prevention of Resident Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property' revised 12/11/23 documented the facility provides on-going oversight and monitoring to ensure that Staff provides care to residents in a safe environment and to ensure that each resident's right to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of property of property is maintained. This includes but is not limited to freedom from any physical or chemical restraint imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms. Resident #1 was admitted with diagnoses which included Lennox-Gastaut syndrome, neurogenic bladder, and G-tube placement. The quarterly minimum data set (resident assessment tool) dated 5/7/24 documented moderately impaired cognition, other behavioral symptoms not directed towards others such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily waste, or verbal vocal symptoms like screaming, disruptive sounds. The resident required substantial/maximal assistance with eating and bed mobility was dependent with all other activities of daily living. The resident had impairments to upper and lower extremities on both sides and required supervision or touching assistance with locomotion in manual wheelchair. Impaired Communication dated 11/23/20 updated 6/18/24 documented the Resident will remain free from abuse, neglect exploitation and mistreatment. Interventions included to anticipate and meet resident's needs. Observe and assess for changes in behavior and physical signs that may be indicative of abuse, neglect, exploitation, or mistreatment, provide gestures, visual, auditory, and tactile prompting, and cueing, recognize resident frustration and provide support for communication. Behavioral Symptoms dated 11/23/20 updated 6/18/24 documented Neurological Impairment, Medications, Impaired relationship(s), Frustration in response to condition, Trauma, Environmental factors as evidenced by a danger to self and others, verbal expression, resists ADLs. Aggressive and resistant behaviors will occur during the morning hours and if schedule plan is interrupted due to ADL's. Interventions included maintain least restrictive environment, redirect behaviors, encourage ventilation of negative emotions using an empathetic, supportive approach. Psychologist note dated 6/11/24 documented the psychologist met with charge nurse and nurse manager regarding recent escalation of behavioral issues. It was discussed that small group in-services would be provided to staff to review strategies on behavioral management of Resident #1. Will also work with Resident #1 on restarting his positive reinforcement program to increase his motivation to improve negative moods and behavior. A review of surveillance footage was completed during the onsite visit on 6/20/24 at 12:16 PM. Registered Nurse #7 is observed in the Unit Common Area. Resident #1 is seen wheeling themselves to the Common Area close to Registered Nurse #7. A verbal interaction is observed between them. Resident #1 is seen swinging their arms and hitting their head. Registered Nurse #7 is observed standing up and saying something to the resident and held their arms down with closed hands. Resident #1 is observed rolling backwards in their wheelchair with Registered Nurse #7 continuing to hold Resident #1's arms. Registered Nurse #7 is seen releasing the resident's arms and pointing their index finger close to the resident's face. The completed facility occurrence report dated 6/13/24 concluded that there was reasonable cause to believe abuse occurred. On 6/20/24 at 9:55 AM during an interview, Certified Nurse Aide #1 stated they were in the shower room down the hall from the Common Area when they heard Resident #1 and Registered Nurse #7 using raised voices, they stepped out of the shower room and went toward the common area and from the right side of Resident #1 they saw Registered Nurse #7 standing in front of Resident #1 and holding Resident #1 hands or upper arms, and Registered Nurse #7 loudly saying, 'Stop, are you a baby?' Certified Nurse Aide #1 stated they saw the Speech Therapist approaching Registered Nurse #7 and Resident #1. Certified Nurse Aide #1 stated that the Speech Therapist has a very good relationship with Resident #1 and frequently manages Resident #1 behavioral outbursts, and they were therefore not concerned, so they went back to the shower room. During an interview on 6/20/24 at 10:22 AM, the Speech Therapist #2 stated they were in another resident's room across the hall from the Common Area when they heard very loud voices, coming from the common area. They stated they saw Resident #1 sitting in their wheelchair yelling and Registered Nurse #7 standing over Resident #1 holding Resident #1 forearms down in their lap with their hands closed and screaming in a loud voice at Resident #1 saying [AGE] year-olds don't behave this way, cut it out! The Speech Therapist #2 stated they walked towards Resident #1 and Registered Nurse #7 to assist, and Registered Nurse #7 stepped back and removed their hands from Resident #1. The Speech Therapist #2 stated they prompted Resident #1 to take deep breaths and brought Resident #1 to their room to calm down. The Speech Therapist #2 stated they asked Resident #1 what had happened, and Resident #1 informed them that they had called their parents and neither of them picked up the phone. Resident #1 was very emotional and was crying when they explained not been able to reach their parents. The Speech Therapist #2 stated they told Registered Nurse#7 that yelling at residents is unacceptable, but they were unsure if holding down Resident #1's hands was inappropriate, because they could not see if the Registered Nurse #7 was holding down Resident #1's hands with force or if the Registered Nurse #7 was preventing Resident #1 from hurting themselves. The Speech Therapist #2 stated they were trained on abuse prohibition and reporting. During an interview on 6/20/24 at 11:12 AM, Nurse Manager #3 stated that on 6/13/24 at approximately 9:00 AM, the Speech Therapist #2 reported Resident #1's behavioral event and had a concern regarding whether Registered Nurse #7 managed Resident #1's behaviors appropriately. Nurse Manager #3 stated their initial reaction was not one of abuse because Resident #1 has been having more behavioral outbursts lately and the Speech Therapist #2 has preferences as to how Resident #1's behaviors should be managed. Nurse Manager #3 stated that at approximately 1:00 PM, they performed a camera audit to see what had triggered Resident #1 behavioral event and they observed Registered Nurse #7 closing their hands on Resident #1 forearms. Nurse Manager #3 stated the facility policy is to use open-handed gentle touching, and closed hand was unacceptable. Nurse Manager #3 stated they then reported the incident to the Director of Nursing. During an interview on 6/20/24 at 11:55 AM, the Director of Nursing #5 stated they were informed by Nurse Manager #3 on 6/13/24 about the incident that occurred on 6/12/24. The Director of Nursing stated after they viewed the camera footage, they felt concerned because they observed Registered Nurse #7 not addressing Resident #1's behavior in the manner they are taught in the facility. They stated that Registered Nurse #7 was observed on the surveillance holding Resident #1 hands down in a restraining manner, and the facility does not allow restraining residents. Actions to prevent self-injurious behaviors include removing the resident from any potentially harmful objects and from other residents, and if necessary, staff may block a resident from potentially harming themselves using an open hand only, no closed hands or holding or restraining is allowed. During an interview on 6/20/24 at 11:40 AM, facility Administrator stated the incident was reported to them on 6/13/24. When they reviewed the surveillance footage, they felt uncomfortable with Registered Nurse #7's actions towards Resident #1, which included finger pointing and holding Resident #1 forearms with closed hands which are unacceptable interventions. The Administrator stated the police was called on 6/13/24 at 3:23pm. They stated that Registered Nurse #7 is currently suspended, and the facility has yet to determine if they will be terminated. On 6/20/24 at 12:06 PM during an interview, Chief Nursing Officer stated that when they reviewed the surveillance footage, they felt concerned because they observed Registered Nurse #7 not addressing Resident #1 behavior in a manner that was acceptable at their facility. They stated that Registered Nurse #7 was observed holding Resident #1 hands down and restraining Resident #1, and the facility does not allow restraining of residents. The Chief Nursing officer stated that no closed hand holding is allowed. During an interview on 6/20/24 at 3:14 PM, Registered Nurse #7 stated that at approximately 6:20 PM on 6/12/24, Resident #1 came to the nurse's desk to ask who their night nurse would be. Registered Nurse #7 stated as they were checking the schedule, Resident #1 repeatedly asked who the night nurse would be. Resident #1 was upset stated, Want a piece of me? Registered Nurse#7 stated they told Resident #1 to back away and Resident #1 started to scream and began hitting themself in the face and the head. Registered Nurse #7 stated they grabbed Resident #1 wrists and held Resident #1 arms down by their belly to prevent Resident #1 from injuring themself. Registered Nurse #7 stated they were talking in a loud voice over Resident #1 yelling to remind Resident #1 that they are not a child and told Resident #1 You are a [AGE] year-old man. 10 NYRCC 415.4(b)(1)(i)

Based on record review and interviews during an abbreviated survey (NY00345276), the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than two hours to the New York State Department of Health, and the results of the 5-day investigation to the New York State Department of Health in accordance with state law within 5 working days of the incident. This was identified for 1 (Resident #1) of 3 residents reviewed for abuse. Specifically, on 6/12/24, two facility staff (Certified Nurse Aide #1 and Speech Therapist) witnessed an alleged staff to resident abuse involving Registered Nurse #7 and Resident #1, which was not reported to the facility administration until 6/13/24. Certified Nurse Aide #1 did not report the incident on 6/12/24. The Speech Therapist reported the incident to the administration on 6/13/24. The result of the facility 5-day investigation was not submitted to New York State Department of Health until 6/21/24. Finding include: The facility policy, 'Prohibition and Prevention of Resident Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property' revised 12/11/23 documented the facility requires all staff to immediately report incidents or allegations of abuse, neglect, exploitation, mistreatment, and misappropriation to resident property to the [NAME] President of Operations/Administrator. Resident #1 was admitted with diagnoses which included Lennox-Gastaut syndrome, neurogenic bladder, and G-tube placement. The quarterly minimum data set (resident assessment tool) dated 5/7/24 documented moderately impaired cognition, other behavioral symptoms not directed towards others such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily waste, or verbal vocal symptoms like screaming, disruptive sounds. The resident required substantial/maximal assistance with eating and bed mobility was dependent with all other activities of daily living. The resident had impairments to upper and lower extremities on both sides and required supervision or touching assistance with locomotion in manual wheelchair. A review of the facility surveillance video was conducted by the surveyor during the onsite visit on 6/20/24 at 12:16 PM. The footage showed Registered Nurse #7 in the Common Area at the desk. Observed Resident #1 wheel themself to the Common Area. Registered Nurse #7 and Resident #1 are seen having a verbal interaction. Resident #1 is seen swinging their arms and hitting their head. Registered Nurse #7 is observed standing up and saying something to Resident #1. Registered Nurse #7 is seen holding Resident #1 forearms down with closed hands. Resident #1 is observed in their wheel chair rolling backwards, and Registered Nurse #7 continuing to hold Resident #1 arms. Registered Nurse #7 is observed releasing their hands off Resident #1 forearms and pointing their index finger close to Resident #1 face. The completed facility occurrence report dated 6/13/24 concluded that there was reasonable cause to believe abuse occurred. The facility submitted a report to the New York State Department of Health on 6/13/24 for a witnessed staff to resident abuse allegation which occurred on 6/12/24. The facility submitted their 5-day investigative report to the New York State Department of Health on 6/21/24 for an incident that occurred on 6/12/24. On 6/20/24 at 9:55 AM during an interview, Certified nurse aide #1 stated they were in the shower room down the hall from the Common Area and they heard Resident #1 and Registered Nurse#7 using raised voices, they stepped out of the shower room and went toward the common area and from the right side of Resident #1 they saw Registered Nurse #7 standing in front of Resident #1 and holding Resident #1 hands or upper arms, and heard Staff #7 (Registered Nurse) loudly saying, 'Stop, are you a baby?' Certified Nurse Aide #1 stated they saw the Speech Therapist at the nurse's station with Registered Nurse #7 and Resident #1. Certified Nurse aide #1 stated that Speech Therapist had a very good relationship with Resident #1 and frequently manages Resident #1 behavioral outbursts, and they were therefore not concerned, so they went back to the shower room. On 6/20/24 at 10:22 AM during an interview, Staff #2 (Speech Therapist) stated they were in another resident's room across the hall from the Common Area when they heard very loud voices, coming from the common area. They stated they saw Resident #1 sitting in their wheelchair yelling and Registered Nurse #7 standing over Resident #1 holding Resident #1 forearms down in their lap with their hands closed and screaming in a loud voice at Resident #1 saying [AGE] year-olds don't behave this way, cut it out! The Speech Therapist stated they walked towards Resident #1 and Registered Nurse #7 to assist, and Registered Nurse #7 stepped back and removed their hands from Resident #1. The Speech therapist stated they prompted Resident #1 to take deep breaths and brought Resident #1 to their room to calm down. The Speech Therapist stated they asked Resident #1 what had happened, and Resident #1 informed them that they had called their parents and neither of them picked up the phone. Resident #1 was very emotional and was crying when they explained not been able to reach their parents. The Speech Therapist stated they told Registered Nurse#7 that yelling at residents is unacceptable, but they were unsure if holding down Resident #1's hands was inappropriate, because they could not see it the Registered Nurse #7 was holding down Resident #1's hands with force or the Registered Nurse was preventing Resident #1 from hurting themselves. The Speech Therapist stated they were trained on abuse prohibition and reporting. On 6/20/24 at 11:12 AM during an interview with Nurse Manager for the common area (Staff #3), they stated that on 6/13/24 at approximately 9:00 AM, the Speech Therapist reported Resident #1 behavioral event and had a concern regarding whether Registered Nurse #7 managed the Resident #1's behaviors appropriately. Nurse Manager #3 stated that at approximately 1:00 PM, they performed a camera audit to see what had triggered Resident #1 behavior event and when they performed the audit, they observed Registered Nurse #7 closing their hands on Resident #1 forearms. The facility policy is only open-handed gentle touching of residents is acceptable. Nurse manager #3 stated they reported the incident to the Director of Nursing. On 6/20/24 at 11:40 AM during an interview, facility Administrator stated the incident was reported to them on 6/13/24. When they reviewed the camera footage, they felt uncomfortable with the alleged perpetrator's actions towards Resident #1 which included finger pointing and holding Resident #1 forearms with closed hands which are unacceptable interventions. The Administrator stated the police was called on 6/13/24 at 3:23pm. They stated that the alleged perpetrator is currently suspended, and the facility has yet to determine if the staff will be terminated. 10NYRCC 415.4(b)(1)(i)

Based on record review and interviews conducted during an abbreviated survey (NY00327790), the facility did not ensure that 1 of 21 sampled residents (Resident #1) was free from physical, verbal, and emotional abuse. Specifically, Certified Nurse Aide (CNA#3) witnessed CNA#1 slap Resident #1 on the face on 11/06/2023 while providing care and witnessed CNA#1 being rough in handling some of the residents in their unit. In addition, CNA#2 reported they witnessed CNA#1 being rough in handling some of the residents on their unit. The findings are: The Facility Policy on the Prohibition and Prevention of Resident Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property last revised on 06/2023 documented that it is the facility policy to honor all resident rights and treat each resident with respect and compassion in full recognition of the person's dignity and individuality. Resident #1 had diagnoses that included Lennox Gastaut Syndrome (A severe condition characterized by repeated seizures/epilepsy), Spastic Cerebral Palsy (A developmental disorder caused by damage to the brain before birth, during delivery, or within first few years of life), Hydrocephalus (Fluid in the brain), and Osteopenia. The Quarterly Minimum Data Set (MDS, an assessment tool) dated 10/05/2023 documented short term and long-term memory problems. Resident #1 was totally dependent and required one-person physical assistance for transfer, and two-person physical assistance for all cares. A review of the facility investigation report dated 11/08/2023 documented that on the morning of 11/08/2023 Certified Nursing Assistant (CNA #2) reported to Nurse Manager (NM #1) concerns of rough handling by CNA #1 with some of the residents. CNA #2 also indicated that CNA #3 had a similar experience with CNA #1. Facility Interview with CNA #3 on 11/08/2023 revealed that on 11/06/2023, while CNA #3 and CNA #1 were performing Activities of Daily Living (ADL) care, CNA #3 witnessed CNA # 1 slap the upper part of Resident #1's face and told them to stop crying. CNA #3 informed CNA #1 not to touch Resident #1 and CNA #3 provided the hands-on care to Resident #1. CNA #3 also stated that CNA #1 was rough and handled other residents forcefully when turning them. During a telephone interview conducted with the accused CNA (CNA #1) on 11/16/2023 at 1:20 PM, CNA #1 denied the allegation that they hit Resident #1 and that they were rough with any of the residents on the unit. CNA #1 stated that they (CNA #2 & #3) probably were not happy with them, so they made up some stories about them. CNA #1 stated that they were in-serviced on abuse prevention before. CNA #1 stated that the facility terminated them. During an interview conducted with CNA #2 on 11/16/2023 at 3:28 PM, CNA #2 stated that they had observed some residents crying whenever CNA #1 took care them. CNA #2 stated they discussed the concern with CNA #3 who stated they have also observed the same. CNA #2 stated during the discussion was when CNA#2 found out from CNA #3 that CNA #1 had slapped Resident #1. CNA #2 stated that they did not report CNA #1 in the past because they were not sure of what they saw. CNA #2 stated they assumed that probably CNA#1 might have held them wrong, and they will tell CNA #1 to stop and to be careful with the kids and CNA #1 would follow. CNA #2 stated that on 11/08/2023 they observed CNA #1 being rough with the kids again, so they decided to finally report to the Nurse Manager (NM #1). CNA #2 stated that they immediately started investigating and sent CNA #1 home. CNA #2 stated that they also had to go to Human Resources (HR) the same day, they were disciplined and re-inserviced on abuse prevention and that any suspicion of abuse they had to immediately report. CNA #2 denied observing any changes to any of the kid's behavior after CNA #1's rough handling. During an interview conducted with CNA #3 on 11/16/2023 11:03 AM, CNA #3 stated that on 11/06/2023 morning, the two of them (CNA #1 and #3) went to Resident #1 where they got the clothes and CNA #1 got the morning care supplies. CNA #3 stated Resident #1 was crying so they were trying to talk to them to make them stop crying. CNA #3 stated Resident #1 do not cry loud because they had a trachea at the time, suddenly CNA #1 slapped them. CNA #3 stated they told CNA #1 don't touch her, I'll do her, so CNA #1 just stood there assisting as they completed the care. CNA #3 stated Resident #1 got more hysterical after the slap. CNA #3 stated they did not report it, it was horrible since it was their first time to be in a situation like that and does not know how to handle it. CNA #3 stated they did not know why they did not report it, probably because they don't want anyone to lose their job. CNA #3 stated they talk to CNA #2 all the time and realized they also observed how CNA #1 was to the children. CNA #3 stated that they were trained to be gentle with the children since most of them are fragile, so they recognized that how CNA #1 handle the children are rough. CNA #3 stated that they spoke to CNA #1 to stop, and they were thinking that they will listen and stop but they didn't. CNA #3 stated they were disciplined and will be on probation for 1 year. CNA #3 denied observing any changes to any of the kid's behavior after CNA #1's rough handling. During an interview conducted with the Nurse Manager (NM #1) on 11/16/2023 at 3:07 PM, NM #1 stated that CNA #2 came to their office on 11/08/2023 at around 10 AM (before their clinical status report at 10:30 AM that day) to report CNA #1 of being rough with handling some residents, rough combing their hair, and rough moving the residents. NM #1 stated that CNA #2 informed them that they do not want to work with CNA #1 anymore basically criticizing their technique in providing care and shared the information about an incident with Resident #1 getting slapped. CNA#2 stated they heard about the incident but did not witness it themselves. NM #1 stated that they informed the Director of Nursing (DON) around 10:20 AM and they immediately removed CNA #1 from the floor and initiated their investigation. NM #1 stated that Resident #1 was immediately seen by the medical team and the other residents on the unit were all assessed and there were no concerns. NM #1 stated that the re-education of all staff was also started on the same day 11/08/2023. 415.4(b)(I)(i)

Based on record review and interviews conducted during an abbreviated survey (NY00327790), the facility did not ensure an alleged violation involving abuse was reported to the New York State Department of Health (NYS DOH) within 2 hours of occurrence. This was evident for 1 out of 21 residents (Resident #1) reviewed for abuse and mistreatment. Specifically, the facility reported a staff-to-resident abuse that occurred on 11/06/2023 to the NYSDOH on 11/09/2023. The findings are: The Facility Policy on Reporting and Investigation of Abuse, Neglect, Exploitation, Mistreatment, Misappropriation of Resident Property and Other Incidents effective 11/2022, revised on 06/2023 documented that all staff reports all reportable incidents immediately to the manager/supervisor or to the [NAME] President of Operations/Administrator. The facility immediately conducts a preliminary investigation and, if warranted, reports to the New York State Department of Health (NYS DOH), other agencies and law enforcement as specified in law and regulation within required timeframes. Resident #1 had diagnoses that included Lennox Gastaut Syndrome (A severe condition characterized by repeated seizures/epilepsy), Spastic Cerebral Palsy (A developmental disorder caused by damage to the brain before birth, during delivery, or within first few years of life), Hydrocephalus (Fluid in the brain), and Osteopenia. The Quarterly Minimum Data Set (MDS, an assessment tool) dated 10/05/2023 documented Resident #1 had short term and long-term memory problems. Resident #1 was totally dependent and required one-person physical assistance for transfer, and two-person physical assistance for all cares. A review of the facility investigation report dated 11/08/2023 documented that on the morning of 11/08/2023 Certified Nursing Assistant (CNA #2) reported to Nurse Manager (NM #1) concerns of rough handling by CNA #1 with some of the residents. CNA #2 also indicated that CNA #3 had a similar experience with CNA #1. Facility Interview with CNA #3 on 11/08/2023 revealed that on 11/06/2023, while CNA #3 and CNA #1 were performing Activities of Daily Living (ADL) care, CNA #3 witnessed CNA # 1 slap the upper part of Resident #1's face and told them to stop crying. CNA #3 informed CNA #1 not to touch Resident #1 and CNA #3 provided the hands-on care to Resident #1. CNA #3 also stated that CNA #1 was rough and handled other residents forcefully when turning them. During an interview conducted with CNA #2 on 11/16/2023 at 3:28 PM, CNA #2 stated that they had observed some residents crying when CNA #1 provided care to them. CNA #2 stated that they did not report CNA #1 because they were not sure of what they saw. CNA #2 stated they were informed by CNA# 3 that CNA #1 slapped Resident #1. CNA #2 stated that on 11/08/2023 they observed CNA #1 being rough with some of the residents, so they reported to the Nurse Manager (NM #1), and an investigation was initiated. CNA #1 was sent home. CNA #2 stated that they were called to Human Resources (HR) the same day, they were disciplined and re-in serviced on abuse prevention and to report any suspicion of abuse immediately. During an interview conducted with CNA #3 on 11/16/2023 11:03 AM, CNA #3 stated they did not report it, it was horrible since it was their first time to be in a situation like that and does not know how to handle it. CNA #3 stated they did not know why they did not report it, probably because they don't want anyone to lose their job. CNA #3 stated that they were trained to be gentle with the children since most of them are fragile, so they recognized that how CNA #1 handle the children are rough. During an interview conducted with the Nurse Manager (NM #1) on 11/16/2023 at 3:07 PM, NM #1 stated that CNA #2 came to their office on 11/08/2023 at around 10 AM (before their clinical status report at 10:30 AM that day) to report CNA #1 of been rough with handling the residents, rough combing their hair, and rough moving the residents. NM #1 stated that CNA #2 informed them that they do not want to work with CNA #1 anymore basically criticizing their technique in providing care and shared the information of Resident #1 getting slapped which they heard and did not witness it themselves. NM #1 stated that they informed the Director of Nursing (DON) around 10:20 AM and they immediately removed CNA #1 from the floor and started the investigation process. NM #1 stated that Resident #1 was immediately seen by the medical team and the other residents on the unit were also assessed, and there were no concerns. NM #1 stated that the re-education of all staff was also initiated the same day 11/08/2023. 415.4(b)(2)

Based upon observation, interview, and record review conducted during the recertification survey on 7/31/2023 - 8/4/2023, the facility did not ensure that foods were stored, prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, 1. unwrapped, uncooked ground beef was stored in a walk-in refrigerator, 2. an unsecured chest freezer located in a hallway near the kitchen contained foods intended for consumption by residents which were not labeled with expiration dates or use by dates, and 3. A dietary staff member was observed checking food temperatures prior to meal service and did not properly sanitize the thermometer. The findings are: During the initial and follow up tours of the kitchen on 7/31/2023 at 9:33 AM and on 8/2/2023 at 10:55 am the following were observed: 1. Observation on 7/31/23 at 9:57 AM revealed approximately one pound of ground beef stored in a walk in refrigerator. The ground beef was not adequately wrapped, and one side of the beef was open to the air and to contamination. In an interview conducted at that time the Food Service Supervisor (FSS) stated that the ground beef should have been fully covered so that it did not drip into other foods, so other foods do not fall into it, and to prevent cross contamination. 2. Observation on 8/02/23 at 10:55 AM revealed a large chest freezer was found located in the hallway near the kitchen. Signage on the chest freezer documented: Emergency Kitchen Supply: Please do not touch/open. The chest freezer was unsecured and easily accessible. In an interview on 8/02/23 12:29 PM the Food Service Director stated that the food service supervisor was responsible for: a. the use of the chest freezer, and b. for managing the contents of the chest freezer. At that time the contents of the chest freezer which were intended for use by residents were checked and revealed the following: a. Thirty-six (36) 4-6 oz. containers of kosher puree chicken with a received date of 7/13/2023 were not labeled with a use by or expiration date. b. Thirty-six (36) 4-6 oz. containers of kosher puree chicken with a received date of 7/26/2023 were not labeled with a use by or expiration date. In an interview on 8/2/2023 at 12:32 PM the FSS stated that the chest freezer is currently being used for freezer overflow and contained some kosher foods used for the residents in that building. The FSS stated that the unit is not locked and should be locked to prevent anyone from tampering with the food. The FSS stated they did not have any documented monitoring of the freezer to ensure it is secured against tampering. The FSS stated that they are responsible to ensure all foods in the freezer are labeled with the date the food item was received, name of the food item, and the expiration date/discard date of the item. In an interview on 8/2/2023 at 1:12 PM the FSD stated that they need to do a better job of determining expiration dates, and discard the items on that date. 3. A facility policy and procedure dated 12/2022 and titled Food temperature documented Method for measuring temperatures: a clean, rinsed, sanitized and air-dried thermometer .is needed. Observation on 8/04/23 at 11:57 AM revealed the Dietary Aide checking food temperatures prior to meal service for the six (6) residents receiving meals. The Dietary Aide was observed dipping the probe tip of the thermometer into a cup of water and wiping the probe dry with a paper napkin. Surveyor stopped the Dietary Aide before they could proceed to insert the probe into the food. In an interview at that time the Dietary Aide stated that they dip the thermometer into the warm water to kill the bacteria, and then wipe with a paper napkin to wipe the water or excess food from the thermometer. 415,14(h)

Based on interview, record review, and review of video evidence during the recertification survey and abbreviated survey (NY00296893) from 7/31/2023 to 8/4/2023, it could not be ensured that the facility provided the necessary care and treatment in accordance with professional standards of practice and the resident's patient centered comprehensive care plan. This was evident for 2 (Resident #64 and #319) of 5 residents reviewed for injury of unknown origin. Specifically, 1. video evidence revealed that on the evening of 6/1/2022 staff did not follow facility transfer protocol resulting in Resident #64 being transferred improperly and 2. a 6/18/2022 video revealed Resident #319 entering Resident #64's room and moving about the room freely, without indication of supervision or redirection for a time frame greater than one hour. The findings are: 1. Resident #64 was admitted with Lennox-Gastaut syndrome, congenital malformations of corpus callosum, disorders of bone density and structure, and dislocation of left hip. The resident's annual minimum data set (MDS: an assessment tool) dated 3/7/2022 documented the resident was totally dependent and received assist of 2 persons for transfers. The resident's cognition was severely impaired. The resident had no falls since admission/entry or reentry, was receiving physical therapy and occupational therapy since 1/29/2020 ongoing and did not have any pain presence. A 10/19/2020 care plan was in place related to the resident's risk for pathological fracture related to (r/t) osteopenia with history of prior fractures. Goals included: will be free from fracture, will have a reduction in risk factors. Care plan notes dated 3/10/2022 documented goals and intervention were appropriate at that time and continue plan of care x 90 days. A 10/25/2020 care plan was in place for falls and injury related to lack of safety awareness, cognitive impairment, impaired balance, and lack of voluntary extremity movements. Interventions included to provide gentle handling in all activities of daily living (ADL) care, ongoing assessment of risk factors, and 2 persons assist or more with transfer. Care plan notes dated 3/10/2022 documented goals and interventions were appropriate and would be continued x 90 days. A 10/26/2020 care plan was in place for ADL/Habilitation/Rehabilitation related to the resident having difficulty with mobility, and impaired mobility to perform age-appropriate ADLs. Goals included to provide transfers between surfaces, assistance in accordance with resident's needs, provide safety training to staff for transfers and mobility, provide transfer support with 2+ persons physical assist, lift manually, and lift with 2-person manual transfer. A Notation documented: 2-person maxi-slide sheet transfer may be used between level surfaces. A 10/29/2020 physician order documented out of bed daily. A 6/1/2022 nursing progress note documented at approximately 5:40 PM called by Certified Nursing Assistant (CNA) that the resident's right thigh with swelling and the resident was crying. Immediately called the charge nurse, supervisor, and the Nurse Practitioner (NP). NP assessed and ordered 1 time ibuprofen. Charge nurse called the parents. Resident shifted to the hospital via ambulance at 6:50 PM. A 6/1/2022 Nurse Practitioner (NP) progress note documented found swelling to right thigh without visible trauma in this evening. On exam lying in bed crying and looking uncomfortable. Started crying and shaking on exam of right leg. Transfer to hospital for further exam and intervention. A Disciplinary Action Form dated 6/6/2023 documented that on 5/31/22 and 6/1/22, Certified Nurse Aide (CNA) #1 was observed performing transfers that were in violation of the transfer policy with regard to hand placement and gentle handling. Surveyor video review of the 6/1/2022 transfer revealed a transfer with 2 persons. CNA #1 did not wait until the resident's full body was resting on the bed prior to releasing their hold on the resident's lower body, which resulted in the resident leaning to the right and her left leg was bent at the knee. In an interview on 8/04/23 at 11:00 AM the Director of Nursing (DON) stated that the CNA's are taught that transfers should never be conducted by lifting under the arms or lifting under the knees. DON stated that the resident's care plan was not violated as it was a transfer of 2, but the transfer was not optimal, it was not what they teach the staff, and they did not think their actions were intentional. DON stated that the 2 CNAs should have communicated better, they should have transferred according to education guidance which included a demonstration of transfer and return demonstration by staff, and they should have been more mindful during the transfer. In an interview on 8/04/23 at 1:22 PM CNA #2 stated that on 6/1/2022 they and another CNA transferred Resident # 64 into the bed, (they could not recall the part of body they were holding during the transfer), and then they left to do other cares. CNA #2 stated they thought they were communicating with the other aide during the transfer, but they could not be sure what happened as it was so long ago. In an interview on 8/04/23 at 3:19 PM CNA #1 stated that on 6/1/2022 they and another CNA transferred the resident from the wheelchair to their bed, they transferred the lower part of the resident's body, and the other CNA transferred the upper part of the resident's body. CNA #1 stated that they put their hands under the resident's upper thighs, and then with other CNA they transferred Resident #64 into their bed. CNA #1 stated that to their knowledge there was no problem with the transfer. 2. Resident #64 was admitted with Lennox-Gastaut syndrome, congenital malformations of corpus callosum, disorders of bone density and structure, and dislocation of the left hip. The resident's annual minimum data set (MDS: an assessment tool) dated 3/7/2022 documented the resident was totally dependent with assist of 1 person for bed mobility, and 2 persons for transfers. The resident's cognition was severely impaired. A 10/19/2020 care plan related to the resident's risk for pathological fracture related to (r/t) Osteopenia with history of prior fractures 3/17/2013 of the Right femur and humerus, and non-weight bearing/non-ambulatory status. Goals included: will be free from fracture, will have a reduction in risk factors. Care plan notes dated 3/10/2022 documented goals and intervention were appropriate at that time and continue plan of care x 90 days. Resident #319 was admitted on [DATE] with diagnoses including autistic disorder, congenital scoliosis, and coarctation of the aorta. The Quarterly Minimum Data Set, dated dated dated [DATE] for Resident # 319 documented: cognition was moderately impaired for decision making, functional status included walk in room and corridor supervision (oversight, encouragement, or cueing). Active diagnoses included Autistic disorder, congenital scoliosis, and coarctation of aorta. A wander/elopement alarm was being were used daily. Residents overall goal was to be discharged to another facility/institution, and active discharge planning was already in progress for the resident to return to the community. A care plan for Behavioral symptoms for Resident # 319; documented Autistic behavior dated 11/22/2020 and updated on 5/28/2022 documented etiology: neurological impairment, a danger to herself and others. Additional detail: Behaviors, hitting/kicking staff, head banging, throwing things, yelling/screaming. Interventions included: reinforce calm, appropriate behaviors with praise and individual attention; offer activities such as outdoor activities, music and books, space voyage room, and water toys; allow to exercise control of television viewing/remote in the common area for limited period of time in early evening; Provide quiet space in the common area when fewer residents are present; offer verbal/tactile support as needed to assist with emotional regulation; monitor and track behaviors including possible triggers for maladaptive behaviors and frequency of occurrences; To the extent possible staff will take turns supervising resident in the common area, and reduce time spent in the playpen area of her room. A Care plan progress note dated June 13, 2022, documented that on 6/13/2022 Resident # 319 entered another resident room, climbed into the bed and remained in the bed for approximately 2 minutes watching TV. Residents wandering has been increasing. The video evidence of the 6/18/2022 occurrence was viewed by surveyor on 8/3/2023 and the following were noted: At 10:32:29 AM Resident #64 was sleeping in their bed and Resident #319 entered Resident #64's room and began twirling around, touching TV, turning TV off and on, and pulling the TV forward and back on its extending arm multiple times. Resident #319 remained in Resident #64's room through 11:34:24 AM, at which time Resident #319 climbed onto Resident #64's bed and kneeled over Resident #64. In an interview on 08/04/23 10:41 AM the Director of Nursing (DON) stated that at the time of the incident Resident #319 was allowed to come out of their room, to walk about the hallways of their unit, use the common area, attend activities as desired, they were not supposed to go into residents' rooms, they had not had a history of going into other residents' rooms, and there was no anticipation that Resident #319 would enter another residents room, and 1:1 observation was not in effect at that time. DON stated that Certified Nurse Aide (CNA) #1 was seen on video 6/18/2022 redirecting Resident #319 and when questioned if they had seen any other resident in Resident #64's room, CNA #1 responded that they had seen Resident #319 sitting on the foot of Resident #64's bed watching TV. In an interview 8/04/23 04:26 PM Registered Nurse Unit Manager (RNUM) #2 stated they verbally reported Resident #319 had increased wandering on 6/13/2023, and the occurrence would have been discussed at the weekly meeting with the Medical Director, Director of Quality, Director of Nursing, Director of Rehabilitation, Administration, and Nurse Managers. RNUM #2 stated they recalled the meeting on this occurrence, and there was a discussion of initiating 1:1 supervision of the resident at that time but they think they decided not to make the resident a 1:1 supervision. RNUM #2 stated that at that time they made all staff aware of what occurred, put it in the nursing report, and advised staff to keep a close eye on the resident as they had never gone into another resident's bed before. 415.12

Based upon observation, record review, and interviews conducted during the recertification survey on 7/31/2023 - 8/4/2023, the facility did not ensure that the garbage storage area was maintained in a sanitary condition. Specifically, the ground under the loading dock located near the door to the trash compactor was heavily littered with solid debris including two (2) treatment items labeled with personal health information. The findings are: An Environmental Services (ES) policy and procedure dated 12/2008 and titled Non-Hazardous Waste Removal documented the policy is To remove all trash from the facility in a safe and sanitary condition., and the purpose is To provide residents, staff, and visitors with a sanitary and comfortable environment and endeavor to prevent the development and transmission of infection. Procedures included that assigned housekeeping staff collect trash per schedule removing and sealing the clear plastic liners from each wastebasket, each sealed plastic liner is placed in a large trash bin on wheels, the trash is wheeled to/emptied into a dumpster at least twice each day and more frequently as indicated, and the dumpster is removed/replaced every 10-14 days. Observation on 8/02/2023 at 11:39 AM revealed that the ground area under the the loading dock located near the door to the trash compactor was heavily littered with solid debris inclusive of: a. 13 oral syringes in a variety of sizes ranging from 4 milliliters to 20 milliliters which had been used as evidenced by no substance observed in the oral syringes and the black stopper was at the top of the syringes. b. One approximately 12 inch length of clear tubing with a white connector attached. c. One approximately 24 inch length of red tubing with a green connector attached. d. An opened plastic bag labeled Piston enteral feeding syringe which was labeled with personal health information (residents' name) e. One empty 50 ml bottle of sodium bicarbonate injection without a stopper. f. One empty 2 oz. tube of desitin labeled with personal health information (residents' name) g. One capped 100 ml, half filled bottle of sterile saline. h. A variety of snack food wrappers and plastic utensils. During interviews on 8/02/2023 at 11:52 AM and 12:21 PM, the Director of Environmental Services (ES) stated that none of the debris should have been on the ground, the ES department was responsible for checking and cleaning up after themselves each time staff get rid of garbage, it is everyone's job, and there were no scheduled rounds or logs for monitoring the trash compactor area for cleanliness. During an interview on 8/02/23 at 11:59 AM the Lead Environmental Worker stated that they were responsible to check the compactor area daily by 9AM, and today when they checked they did not look at the the area under the loading dock. During an interview on 8/2/2023 at 1:25 PM the Director of Nursing (DON) stated that the red tubing and clear tubing are suctioning catheters which are used either orally, through the tracheostomy tube, or nasally, and the tubing should be discarded in the regular garbage. DON stated that housekeeping is responsible to tie the bags of garbage, and the tubing may have been on the ground if the bag was not closed properly. DON stated that any medication or treatment items labeled with identifying resident information should have a de-identifier label sticker, which will obliterate the personal information, before being discarded in the regular garbage. 415.14(h)

Based on observation, record review and interview conducted during an abbreviated survey (NY00287557), the facility failed to ensure that a resident received adequate supervision and assistance to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents. Specifically, Resident #1 who was totally dependent with bed mobility and required two-person transfer via mechanical lift, rolled out of bed and fell face down on the floor when Certified Nursing Assistance (CNA #1) turned their back from the residents' bedside to retrieve a suction equipment; (2) After the fall, CNA #1 and CNA #2 transferred the resident back into their bed without being assessed and did not utilize a mechanical lift for the transfer as indicated on Resident #1's care plan. Resident #1 sustained a contusion to the face including swelling and erythema to the right side of the face, a hematoma to the right distal conjunctiva, nasal bleeding from bilateral nares, and swelling of the nasal bridge with no fractures. The findings are: The Facility policy and procedure on Lifting and Transferring a Child effective 09/1988, revised 02/2021 documented that all residents are to be handled, lifted, and transported in a safe, gently, and comfortable manner based on the child's neuromuscular and developmental needs as documented in the care plan. The Facility policy and procedure on Falls (Witnessed or Unwitnessed) Care of the Resident effective 03/2015, revised 02/2021 documented that a resident who sustains a fall / head injury will be promptly assessed and monitored. Responsible staff actions documented to attempt to keep resident on the surface where they fell , to acquire assistance, and to notify the charge nurse/designee who will notify the Medical Doctor (MD) / Nurse Practitioner (NP) immediately. Resident #1 had diagnoses that included Spastic Quadriplegic Cerebral Palsy, Lennox - Gas taut Syndrome and Tracheostomy Status. The Minimum Data Set (MDS, an assessment tool) dated 09/16/2021 documented that Resident #1 had short-term and long-term memory problems. Resident #1 required total dependence two-person assistance for transfer via Hoyer lift, bed mobility, dressing, toilet use and personal hygiene. The Nursing Fall Risk assessment dated [DATE] documented that the resident scored a 13 (Low Risk: greater or equal to 10; Moderate Risk: 11-15; High risk: greater than 16) indicating Moderate Risk for Fall. The Fall and Injury Care Plan initiated on 06/14/2021 documented that Resident #1 was at risk for falls and injury due to medical conditions of Epilepsy, Cerebral Palsy, Encephalopathy, and as evidenced by Developmental Delay, Presence of High-Risk Factors for Osteopenia, Presence of High Risk for bleeding and bruising related to lack of safety awareness, cognitive impairment, impaired balance, lack of extremity movements and psychoactive drugs. The goal was for Resident #1 to be free from falls and injury. Interventions included assess judgement/mental status/physical status and provide supervision in accordance with needs; provide gentle handling in all aspects of ADL care; provide education to family/staff on transfer and positioning, accident prevention and resident specific precautions. The Resident Nursing Instructions dated 06/14/2021 documented that Resident #1 was totally dependent with Activities of Daily Living (ADLs) and required two-person physical assistance for bathing, bed mobility, dressing, personal hygiene, and toilet use. On 06/15/2021, the instructions also documented that Resident #1 required 2-person for transfer via mechanical lift. The Facility video footage timeline review dated 12/05/2021 documented the following events: at 9:54 PM, CNA #2 was seen at the bedside and checks Resident #1's diaper, then begins to gather supplies from their cabinet. CNA #1 enters and was seen at the bedside of Resident #1shortly after; at 9:55 PM, the curtain was drawn so they can provide ADL care; at 9:56 PM, CNA #1 leaves the bedside briefly but returns seconds later; at 9:58 PM, the curtains are slightly parted, and it does not appear that the resident was in the bed; at 10:04 PM, the curtain was pulled back and CNA #1 leaves the bedside. Resident #1 was in the bed at this time. CNA #2 was seen wiping Resident #1's face and body and adjusting the oxygen tubing. The Facility Occurrence Report dated 12/05/2021 documented that on 12/05/2021 at approximately 9:55 PM, CNA #1 & #2 drew the curtain around Resident #1's bed to perform a diaper change. According to their statements, during the ADL care the resident rolled off the bed and onto the floor when CNA #1 turned away to retrieve an item. Resident #1 fell face down on the vinyl floor and the two CNAs proceeded to place Resident #1 back into bed. Resident #1 had some visible injuries which included swelling and redness to the right side of their face and a hematoma to the right proximal conjunctiva. Resident #1 was also bleeding from both nares with redness to the bridge of their nose and some redness to their left knee. The CNAs informed RN #1 who then informed the Nurse Practitioner (NP0. The NP ordered to transfer Resident #1 to the hospital emergency room (ER) for further evaluation. During an interview conducted with CNA #2 (Accused #2) on 01/11/2022 at 12:19 PM, CNA #2 stated that at the time of the incident they were not assigned to Resident #1 but was assisting with Resident #1's diaper change. CNA #2 stated that they were on the right side of the bed and was providing care to the lower portion of Resident #1's body while CNA #1 was on the left side and was providing care to the upper portion. CNA #2 stated that they heard CNA #1 say something about Resident #1 having a lot of spit in the mouth and next thing they knew Resident #1 fell . CNA #2 stated that they both placed Resident #1 back to bed without calling the nurse and without using a Hoyer lift. During a telephone interview conducted with CNA #1, on 07/24/2023 at 1:44 PM, the CNA#1 stated that they were assigned to Resident #1 and CNA #2 was assisting them to provide care. CAN #1 stated that they were providing care to the upper portion of Resident #1 and CNA #2 was doing the lower portion. They noticed Resident #1 had a lot of mucus coming from their mouth. CNA #1 stated that they asked CNA #2 to hold Resident #1 while they grab the suction thing. CNA #1 stated that the siderail was down, but they did not move away from the bedside and only turned to get the suction but when they turned back, they saw Resident #1 on the floor. CNA #1 stated they were not able to catch the resident, Resident #1 just fell . CNA #1 stated that they got nervous and together with CNA #2 they picked up Resident#1 from the floor and placed them back into the bed without using a Hoyer lift and without waiting for a nurse to assess the resident. The facility trained them over and spoke to them, and they had to do a competency. During a telephone interview conducted with the Director of Nursing (DON) on 07/27/2023 at 2:40 PM, the DON stated that the Resident transfer instructions are documented in the care plans and CNA nursing instructions and CNAs are required to review/ follow so they know how to apply the appropriate transfer technique whether one person, two-person, manual transfer, or mechanical transfer. The CNAs undergo safe transfer in-service competency at least once a year. The side rails should be down when CNAs are actively providing care and when not providing care side rails need to be up. CNA #1 and CNA #2 had no previous discipline, they both underwent prior in-services, had a reenactment of the incident, and were re-educated. CNA #1 and CNA #2 were not disciplined because the decision was that they did not have any infraction, it was an honest mistake since they were trying to get a piece of equipment (suction) that was by the bedside to assist the resident (remove secretions from the mouth). The DON stated that they train staff to report a witnessed fall immediately. However, in this case, the DON stated that the CNAs stated that they panicked and picked up Resident#1 and placed them back to bed before calling the nurse. The DON stated that the CNAs did not have any discipline to date from after the incident. 483.25(d)(1)(2)

Based on observation, record review and interviews conducted during an abbreviated survey (NY00285051), the facility did not ensure that residents are free of significant medication errors. This was evident for 2 of 4 residents sampled for Medication Administration (Residents #1, and Resident #2). Specifically, on 10/14/2021 at 3:20 PM Registered Nurse (RN #1 - accused) administered medication prescribed for Resident #3 to Resident #1. Resident #1 was evaluated by the Nurse Practitioner (NP) and stomach contents were aspirated on 10/14/2021 at 5:57 PM. Resident #1 was transferred to the emergency room (ER) for further evaluation and a higher level of care. Also, on 10/17/2021 at 5:29 PM, RN #1 administered the wrong tube feeding formula to Resident #2. Resident #2 developed urticaria on their torso (front and back), and redness and swelling on both eyes and lips. Resident#2 was evaluated by the Nurse Practitioner(NP) and adminstered benadryl and prednisone which resulted in the decrease in their symptoms and eventually a rerurn to baseline level. The findings are: The Facility Policy and Procedures on Medication Administration effective 02/2021 documented that it is the policy of the facility that all medications are administered in accordance with proper procedure, all state and federal laws, and within proper nursing practice guidelines, which include the 6 rights of medication administration (right person, right medication, right dose, right time, right route, right documentation). The Facility Policy and Procedures on Medication Administration Enteral Tube revised on 04/2019 documented that it is the facility policy to administer medications via an enteral tube safely and appropriately. If the resident has a gastric tube, medications and feedings should be administered via the tube specified in the physician / practitioner order. Resident#1 Resident #1 had diagnoses that included Congenital subglottic stenosis, Gastrostomy Status, and Spastic Diplegic Cerebral Palsy. The Minimum Data Set (MDS, an assessment tool) dated 07/21/2021 documented that Resident #1 had short term and long-term memory problems and had severe cognitive skills impairment for daily decision making. Resident #1 is totally dependent and required one-person total assistance for transfer via Hoyer (mechanical lift), dressing, eating, toilet use and personal hygiene. Section K documented that the resident had a gastrostomy tube (GT). The Facility Investigation of Medication Error dated 10/14/2021 documented that Resident #1 was administered medications that belonged to Resident #3. RN #1 did not follow proper medication administration procedure. Review of the Medical Note dated 10/14/2021 documented that the Resident #1 inadvertently received Clobazam 20 mg (a controlled substance sedative) via GT at 3:20 PM. Aspirated stomach contents immediately via GT for 300 ml of formula, unable to assess if any of the medication was removed. Resident #1 was transferred to the emergency room for further evaluation and higher level of care. The Medication Error Report Form dated 10/15/2021 documented that Resident #1 was administered Clobazam 20 mg tablet, Ceravite Antioxidant 18 mg-400 mcg tablet, and Cholecalciferol (Vitamin D3) 25 mcg (1000 unit) tablet on 10/14/2021 at 3:20 PM but none of the medications were prescribed for Resident #1. An attached statement from RN #1 documented that they administered medication prescribed for Resident #3 to Resident #1. Review of RN #1's written statement dated 10/15/2021 documented that on 10/14/2021, they inadvertently administered Resident #3's medications to Resident #1 via GT. RN #1 stated that they realized this after they returned to their workstation on wheels (WOW) to pick up Resident #3's medications. They immediately informed the NP who assessed Resident#1. Resident #2 Resident #2 had diagnoses that included Cranial Nerve Disorder, Epilepsy, Tracheostomy Status, Encephalopathy, and Gastrostomy Status. The Minimum Data Set (MDS, an assessment tool) dated 08/31/2021 documented that Resident#2 had short term and long-term memory problems. Resident#2 required total dependence two-person assistance for transfer via Hoyer lift, dressing, toilet use, and personal hygiene, total dependence one-person assistance for eating. Section K documented that the resident had a GT. The Investigation Summary dated 10/17/2021 documented that Resident # 2 was administered the wrong formula by RN #1 (Accused) who was assigned to Resident#2 on 10/17/2021. Shortly after the administration of this GT feeding, Resident #2 became symptomatic with redness and hives to their torso and redness and swelling to their lips and eyes. Resident # 2 was immediately evaluated and administered 25 mg of Benadryl followed by a second dose of Benadryl 25 mg. Gastric contents were aspirated via GT. Resident # 2 received additional doses of Benadryl (25mg and then 50mg) and 50 mg of Prednisone in an effort to decrease thier symptoms, and Resident # 2 was later noted to return to baseline level of activity It was the determination of the medical team not to transfer Resident # 2 to the hospital for further evaluation. The Incident Camera Footage (Video) Timeline dated 10/17/2021 reviewed by the facility documented that at 5:29 PM RN #1 was seen pouring the Complete Pediatric Formula into Resident #2's feeding bag. Resident#2's ID band was not scanned prior to administration. At 6:14 PM, Resident # 2 was seen rubbing their abdomen repeatedly with their left hand. At 6:16 PM, Resident # 2 appeared more agitated and began squirming and rocking their body in their wheelchair and was observed thrashing around uncomfortably. Review of RN # 1's documentation in the progress notes revealed an account of the event that occurred on 10/17/2021. RN #1 documented that they started Resident #2's GT feed and 10 minutes later, Resident # 2 began to rub their GT. I then noticed it was very tight and I attempted to remove some fluid from the g-tube balloon. I was unable to draw any fluid. I then called the charge nurse to assist as resident#2 was becoming agitated. Resident#2 was transferred into bed and began to wiggle in bed and his torso and legs were becoming red and hives were noted on their body. Attempts to call RN #1 (the accused) on 01/11/2022 at 10:30 AM, and on 07/28/2023 at 11:38 AM were not successful. No message During an interview conducted with RN #2 on 01/11/2022 at 11:40 AM, RN # 2 stated that the nurses in the facility are trained to use the Omnicell System that dispenses the medications for the residents. The RN stated that it ensures that the right medication is administered to the right patient. RN # 2 stated that they are supposed to scan the residents identification (ID) band then the medication and it will alert them if that medication is not for that resident. RN#2 also stated that they follow the 6 rights of medication administration (right person, right medication, right dose, right time, right route, right documentation) and that they undergo med pass in-service and competency at least once a year. During an interview conducted with the RN Manager (RNM) on 01/11/2022 at 12:15 PM, the RNM stated that they were made aware of the incident as soon as RN #1 realized the medication error on 10/14/2021. The RNM stated that they responded to assist with Resident #1 together with the Nurse Practitioner that day. The RNM stated that RN #1 had no prior discipline and they counselled and reeducated RN #1 after the incident. During a telephone interview conducted with the Director of Nursing (DON) on 07/27/2023 at 2:50 PM, the DON stated that besides following the 6 rights of medication administration, the protocol is that the nurses must scan the residents ID band and then the medication before they administer medications to residents. All nurses are educated on this, and it is part of their med pass competency which is done annually. The DON stated that all nurses completed their med pass annual competency for the year 2021, and 2022, and med pass competency for 2023 will begin next week. The DON stated RN #1 had no prior medication error and was not suspended after the incident when they gave the wrong medication to Resident #1. RN #1 was counselled and re-educated by the RNM instead. The DON stated that RN #1 was suspended after the incident where RN #1 administered the wrong feeding formula to Resident #2. The DON stated in addition to annual med pass competencies, the facility performs random med pass audit quarterly to prevent incidents like this from reoccurring. 415.12(m)(2)

Based on observation, record review and interview conducted during a complaint investigation on 03/06/2020 and revisit on 08/03/2020 (NY 424), the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, a Registered Nurse (RN) failed to apply a pulse oximeter, for 1(Resident #1) of 3 residents who was on continuous pulse oximetry while in bed. Subsequently, Resident #1 was left unmonitored, resulting in there being no audible alarm and causing a delay in staff initiating lifesaving interventions. The findings are: The Facility Policy on Pulse Oximetry updated on 08/2019 documented that pulse oximetry will be ordered as continuous when the resident is in the room or when the resident is asleep. Resident #1 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS, an assessment tool) dated 12/23/2019 documented that the resident had severe cognitive impairment. The resident required one-person total dependence on all areas of activities of daily living (ADL). The Pulmonary Care Plan initiated on 08/22/2017 and active as of 03/01/2020 documented that the resident is at risk for change in respiratory status due to ineffective airway clearance as evidenced by decrease in oxygen saturation, course breath sounds and cyanosis. The goal of the care plan documented that the resident will maintain optimal oxygenation as per physician order, be free of evidence of respiratory distress and maintain patent airway. Interventions included monitor oxygen saturation as ordered, maintain patent airway, administer oxygen when indicated, provide airway humidity, administer medications and monitor effects. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Facility Occurrence Report dated 03/01/2020 at 12:16 PM documented that Registered Nurse #2 (RN) was performing safety rounds after RN #1 took a break. RN #2 observed Resident #1 unresponsive with medium emesis around the mouth. RN #2 documented that Resident #1 was not connected to pulse oximetry and upon assessment, Resident #1 was pulseless. RN #2 documented that she immediately pulled the emergency cord, began chest compressions, and code protocol was followed. The summary report documented that Resident #1's pulse oximeter was disconnected at 9:40 AM and was discovered not connected at 12:16 PM during RN #2's safety rounds. A code blue was initiated at 12:19 PM. Review of the respiratory notes on 03/01/2020 at 12:46 PM documented that a cord-out (code blue) was initiated around 12:20 PM, upon arrival Resident #1 was being bagged (manual ventilation) by an RN. The writer took over the bagging at approximately 12:22 PM, compression was initiated prior to arrival. Pulse was absent, compression resumed along with manual ventilation. Pulse returned around 12:40ish, Resident #1's SPO2 (peripheral capillary oxygen saturation, the percentage of oxygenated hemoglobin in the blood) now 100%, Heart Rate (HR) 88%, sent (Resident #1) out with Emergency Medical Services (EMS) to the hospital. Review of RN #1s statement dated 03/01/2020 documented that she completed medication administration and assessment on the resident at 8:45 AM and resident care at 10:30 AM on the day of the incident. RN #1 stated that she must not have put back Resident #1's pulse oximeter after the care. RN #1 stayed in the 4 bedded room charting until she left for break at 12:00 PM. RN #1 stated that she did tube feeding for the 3 other residents in the room but did not go directly to Resident #1 before she left the room. Review of RN #2's statement dated 03/01/2020 documented that during safety rounds on the day of the incident at approximately 12:16 PM she noted Resident #1 was not connected to the pulse oximeter, had a medium emesis around the mouth, was unresponsive and pulseless. RN #2 immediately pulled the emergency cord and started chest compressions. An interview was conducted with the Administrator and Director of Nursing on 03/06/2020 at 2:30 PM. They stated that after the incident they have increased the frequency of their safety rounds to hourly. They stated that the facility will increase visual audits to ensure that monitoring compliance is being done. They also stated that at the time of any hands off, such as, during change of shift or break times, the incoming and outgoing nurse will do a visual handoff at bedside with documentation in the progress notes. During an observation on 08/03/2020 at 10:45 AM, Resident #1 was supine in bed with eyes open, responded to their name spoken in a normal tone with extension of arms and grimace. Resident #1 was ventilated via [CONDITION(S)], supported with individualized support equipment. During the interview on 09/15/2020 at 12:01 PM, the Medical Doctor (MD) stated that he ordered continuous pulse oximetry monitoring while the Resident#1 is in their room, and parameters for monitoring included pulse oximetry settings of heart rate low at 60 and heart rate high at 180, parameters also include % oxygen saturation low setting at 90 and % oxygen saturation high setting at 100. The MD stated that if the pulse oximeter was attached to the resident, it would have triggered an alarm if the resident's heart rate and oxygen saturation was lower or higher than the set parameters. The staff would have been alerted and would have provided immediate interventions that would have given the resident a better outcome. However, he stated that he cannot say if that would have avoided a prolonged resuscitation, because the resident was found with vomit on their face. The resident could have aspirated, and aspiration could do damage to the lungs that could require longer resuscitation (resident was treated with antibiotics for presumptive aspiration pneumonia in the hospital). 415.4(b)(I)(i)

Based on observation, interview and record review conducted during the recertification survey, the facility did not ensure that food brought in from the outside was handled according to professional standards of practice. Specifically, food items found in the refrigerators on resident units were either outdated or not labeled and dated. This was evident on 2 of 8 resident units (Bryant Park and Marine Park). The findings are: Leftovers and Food Safety Often when we cook at home or eat in a restaurant, we have leftovers. To ensure that leftovers are safe to eat, make sure the food is cooked to a safe temperature and refrigerate the leftovers promptly. Not cooking food to a safe temperature and leaving food out at an unsafe temperature are the two main causes of foodborne illness. Safe handling of leftovers is very important in reducing foodborne illness. Follow the USDA Food Safety and Inspection Service's recommendations for handling leftovers safely. Store Leftovers Safely Leftovers can be kept in the refrigerator for 3 to 4 days or frozen for 3 to 4 months. Although safe indefinitely, frozen leftovers can lose moisture and flavor when stored for longer times in the freezer. https://www.fsis.usda.gov/wps/portal/fsis/topics/food-safety-education/get-answers/food-safety-fact-sheets/safe-food-handling/leftovers-and-food-safety/ct_index Refrigerators on resident units were checked on 9/23/19 between 1:30 and 2:00PM. On the[NAME]Park unit a container of homemade soup was dated 9/16/19 (7 days old). The RN unit manager was interviewed at that time. He stated food from the outside can be kept for about a week. When asked about the policy for keeping food from the outside he produced a Policy and Procedure - Food from Outside that indicated the following; All food/homemade tube feeds in refrigerator will be discarded after 5 days by Environmental Services. In an interview with the Director of Environmental services at that time he stated his staff are aware of how long food can be kept but they do not discard any of the food. He stated they are instructed to bring it to the attention of the nursing staff. The refrigerator on the Marine Park unit was checked on 9/23/19 at 2:00PM. Two containers of food brought in from home for a resident were not dated. The resident's father was present at the time and stated he thought the food had been brought in over the previous weekend. In an interview with the Food Service Supervisor on 9/23/19 at 2:15PM she stated that food should be labeled and dated and discarded after 3 days. In an interview with the Director of Nutrition Services on 9/23/19 at 2:30PM she stated there have been a lot of issues related to food brought in by families that was discarded by nursing staff when outdated. The policy was updated to have Environmental Services discard the food to avoid conflict with the families. She was unaware that this was not being done. 415.14(h)

Based on record review and interview conducted during the recertification survey, the facility did not ensure that the Ombudsman was being notified of resident transfers. This was evident for 2 residents reviewed for hospitalization (Resident #19 and #156). The findings are: 1. A Nursing Progress Note dated 7/21/19 indicated Resident #19 was sent to the hospital with an elevated heart rate and fever. The Nursing Progress Note dated 7/25/19 indicated the resident returned to the facility with a [DIAGNOSES REDACTED]. 2. A Nursing Progress Note dated 7/19/19 indicated Resident #156 was vomiting coffee ground material and was transferred to the hospital. The Nursing Progress Note dated 8/28/19 indicated the resident returned to the facility following hospitalization where a G/J Tube (Gastrostomy/Jejunostomy - required for feeding and administration of medications) was placed. There was no documented evidence in the medical records of both residents that the Ombudsman was notified of either transfer. In an interview with the Director of Social Work on 9/19/19 at 10:26 AM, regarding notification to the Ombudsman, she stated she only sends notification to the Ombudsman if the resident is discharged from the facility to home or to another facility. 415.3(h)(1)(iv)(a-e)

Based on observation, interview and record review conducted during the recertification survey, the facility did not ensure that the plan of care was implemented as written for one of two residents reviewed for tube feeding (Resident #79) and for one of three residents reviewed for the use of restraints (Resident #147). Specifically; 1) a care plan intervention that addressed monitoring and recording of meal consumption, necessary to assess adequacy of meal intake, was not consistently implemented for Resident #79; and 2) the plan of care regarding the use of mittens to prevent self injurious behavior was not implemented for Resident #147 when observed on two consecutive days. This had the potential for more than minimal harm that was not immediate jeopardy. THIS IS A REPEAT DEFICIENCY for the issue cited in example #2. The findings are: 1. Resident #79 is a 4 year old who is developmentally delayed and receives supplemental feedings via a gastrostomy tube (GT). A goal for the resident to gain 4-10 grams of weight daily was identified in the resident's plan of care, dated 9/3/13. Interventions to achieve this goal included monitoring/recording of intake, assessing appetite and nutritional adequacy of the resident's diet, a pureed diet. According to records of the resident's daily consumption for the months of April, May and June 2014, the amount of food consumed by the resident at breakfast was not recorded at least 75% of the time. These records were signed each shift by a nurse. The Team Leader/Registered Nurse (RN #3) reviewed these records on 6/12/14 in the afternoon. RN #3 stated that entering information about the resident's food consumption was supposed to be completed by the Certified Nurse Aides. The resident was observed being fed by RN #5 during breakfast on 6/13/14. The resident was served rice cereal with coconut milk, applesauce, thickened juice and water. While being fed by RN #5, the resident repeatedly pushed away the spoon before RN #5 was able to place it in his mouth. The resident consumed 1 oz of the cereal and all the applesauce. He refused all the fluids. At that time, RN #5 stated that the resident's intake at meal times depended on his mood. Following completion of the meal, RN #5 reviewed the June 2014 records of the resident's intake. RN #5 stated that RNs fed the resident and were responsible for recording the amounts consumed. The Registered Dietitian was interviewed on 6/13/14 at 10:28 AM and identified that the records of daily consumption were one of the sources the Registered Dietitian used to evaluate the adequacy of the resident's food intake. 2. Resident #147 is a 3 month old who was admitted to the facility with [DIAGNOSES REDACTED]. According to progress notes entries from 5/6/14 to 6/11/14, the resident exhibited irritability during care and jerky movements and violent shaking of the arms, especially upon waking up, on multiple occasions. The resident's care plan for "Physical Restraints / Safety and Positioning Devices" of 5/13/14 and the Resident Care Flow Book for June 2014 identified the use of bilateral soft hand mitts. The physician's orders [REDACTED]." The resident was observed in bed on 6/12/14 at 8:00 AM, 1:00 PM and at 2:00 PM without any hand mitts in place. During the 2:00 PM observation, the resident was awake and was moving his hands. No care was being provided at this time and no unit staff member was observed to have direct view of the resident. The resident was again observed with no hand mitts in place on 6/13/14 at 7:15 AM. The resident was awake and was moving his arms. Upon further observation, a slight redness was noted on the right side of the resident's face. RN #1, a unit Registered Nurse assigned to the resident's care, was interviewed on 6/13/14 at 7:25 AM and stated that the resident must have hand mitts in place to prevent him from accidentally scratching his face. RN #1 stated that the resident gets agitated during care with jerky or shaking motions of the hands. RN #1 stated that she was unaware that the hand mitts had been removed "probably from the resident's hand movements." RN #2 was interviewed on 6/13/14 at 10:40 AM. RN #2 stated that the resident usually gets agitated and has jerky movements of his hands that can cause accidental scratching of the resident's face. RN #2 further stated that prior to this interview, she observed the resident with three superficial abrasions on the right side of his face "which were possibly from scratches caused by the unprotected hands". 415.11 (c) (3) (ii)

Based on observation, interview and record review during the recertification survey, the facility did not ensure that the necessary care to increase oral intake and decrease dependency on tube feedings was provided for one of two residents reviewed for tube feeding (Resident #79). Specifically, 1) measures in place to determine the adequacy of daily oral intake were not being implemented consistently and 2) other specific measures, such as monitoring and assessing total daily oral fluid intake to reduce dependency on supplemental feedings provided via a gastrostomy tube two times daily, were not put in place. This had the potential for more than minimal harm that was not immediate jeopardy. The findings are: 1. Resident #79 is a 4 year old who is developmentally delayed and receives supplemental feedings via a gastrostomy tube (GT). The resident's plan of care, dated 9/3/13, identified a goal for the resident to maintain adequate nutrition. Interventions to achieve this goal included monitoring/recording the resident's nutritional intake, assessing appetite and nutritional adequacy of the resident's diet, a pureed diet with honey thick liquids. The amount of food or fluids consumed by the resident at breakfast was not recorded in the resident's care record for greater than 75% of the days in the April and May 2014 records. Dietary notes entries, dated 6/4/14 and 6/10/14, indicated that, since the resident continued with excellent intake and good nutritional status, a recommendation would be made to discontinue GT feedings and to provide [MEDICATION NAME] Junior (a commercially prepared formula) 120 ml orally after breakfast, lunch, dinner and at 8:00 PM. The notes further stated that, if these amounts of [MEDICATION NAME] were not taken orally, feedings should be given via GT. Physician's Interim Orders entered on 6/10/14 instructed to discontinue 240 ml tube feedings at 10:00 PM and 4:00 AM and to begin giving honey thickened [MEDICATION NAME] Junior 120 ml orally as recommended by the Registered Dietitian (RD) reflected above. There was no documented evidence that a plan was put in place to monitor the adequacy of the resident's daily oral fluid intake. There was no evidence in the dietary notes that the lack of consistent documentation of meal intake at breakfast time was identified or addressed. These notes also did not indicate how the adequacy of the resident's oral intake was determined prior to 6/4/10 or would be assessed after the GT feedings were discontinued on 6/10/14. The 6/10/14 physician's orders [REDACTED]. There was no explanation for resumption of tube feedings documented by the Physician. There was no documented evidence of communication between the dietary, nursing and medical staff regarding the resumption of GT feedings or of a plan to reduce the GT feedings again. The Physician was interviewed on 6/12/14 at 1:15 PM and revealed that the resident was not eating well after the order to stop the tube feedings was written on 6/10/14 and the Physician was concerned that the resident would become dehydrated. This interview revealed no evidence that there was a plan to determine whether the resident's inadequate intake at that time, after the 6/10/14 order was written, was isolated or that objective criteria were to be used to determine when to discontinue the GT feedings. The resident was observed being fed by RN #5 during breakfast on 6/13/14. The resident was served rice cereal with coconut milk, applesauce, thickened juice and water. While being fed by RN #5, the resident repeatedly pushed away the spoon before RN #5 was able to place it in his mouth. The resident consumed 1 oz of the cereal and all the applesauce. He refused all the fluids. At that time, RN #5 stated that the resident's intake at meal times depended on his mood. Following completion of the meal, RN #5 reviewed the June 2014 records of the resident's intake. The resident's breakfast consumption was not consistently documented. RN #5 stated that RNs fed the resident and were responsible for recording the amounts consumed. The Registered Dietitian was interviewed on 6/13/14 at 10:28 AM and revealed that there was no written plan in place to decease dependency on tube feeding and that that there should have been one. 415.12 (g) (2)

Based on observation, interview and record review, a hand mitt was not applied, as planned, to prevent injuries for a resident with self-injurious behavior. Specifically, hand mitts were recommended for the resident to prevent injuries from scratching and biting. This was evident for one of one residents (Resident #108) whose care plan was reviewed for physical restraints and resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are: Resident #108 is [AGE] years old with [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) of 4/12/13 indicated that the resident had functional limitation of range of motion of one side of the body and required total assistance from the staff to perform all aspects of her activities of daily living. The resident was observed in bed on 7/29/13 at 8:02 AM with a mitt in place on her right hand. There was no mitt on her left hand. The resident moved both upper extremities independently. Further observation of the resident in bed on 7/30/13 at 7:10 AM revealed that a mitt was again applied to the right hand and that no mitt was in place on the left hand. The resident moved both upper extremities independently when observed. The assigned 11-7 shift Certified Nursing Assistant (CNA) was interviewed on 7/30/13 at 7:15 AM and stated that the resident wore a mitt on the right hand and not the left hand. The CNA stated that the resident had always used one hand mitt. The CNA further stated that the resident used the hand mitt to prevent injury because the resident scratched herself a lot. The physician's orders [REDACTED]. The use of bilateral hand mitts with skin checks every two hours was also included in the care plan for Self-Injurious Behavior to prevent injury secondary to the resident scratching herself, dated 7/17/13, and the care plan for Physical Restraints/Safety and Positioning Devices that was initiated on 7/18/13. During an interview with the 11-7 shift assigned Licensed Practical Nurse on 7/30/13 at 7:25 AM, she stated that the resident must have bilateral hand mitts applied while in bed because the resident bites her hands. The Licensed Practical Nurse stated that the hand mitt for the resident's left hand was probably brought down to the laundry for washing. 415.11 (c) (3) (ii)

Based on interview and record review, the facility did not ensure that the medication regimen of a resident was free of an unnecessary medication. Specifically, a resident was administered an anti-anxiety medication without any indication for its ongoing use and without any attempts to reduce its dose for over a year in the absence of any symptoms. This was evident for one of ten residents (Resident #16) reviewed for unnecessary drugs. This had the potential for more than minimal harm that was not immediate jeopardy. The findings are: Resident #16 is a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the resident ' s current physician's order [REDACTED]. Nurses ' Notes for the year 2013 and the current Comprehensive Care Plan were reviewed and showed no evidence that the resident was having difficulty sleeping or exhibiting any mood/behavioral problems that interfered with his ability to sleep. Historical information in the clinical record was then reviewed to determine when this medication was initially prescribed and what symptoms the resident exhibited to justify its use. The historical information revealed the following: The resident ' s admission physician's order [REDACTED]. The resident was seen by a Neurologist on 5/19/08 who recommended that the resident should be weaned off the [MEDICATION NAME] slowly by 0.5 mg steps every two weeks. The reduction of [MEDICATION NAME] was initiated subsequent to this visit although at a slower pace. The first reduction was from 1 mg every 8 hours to 1 mg every 12 hours with the last reduction occurring on 12/21/09 to 1 mg at bed time, 8:00 PM. At that time the indication identified to continue [MEDICATION NAME] use was changed from "agitation" to "sleep disturbance." However, a review of the Nurses ' Notes for the year 2009 revealed no evidence that the resident had difficulty sleeping at nights or at any other time. Following clinical record review on 7/31/13, two Registered Nurses on the unit (the Team Leader and the nurse assigned to care for the resident), the current primary care Physician and the Physician who wrote the order on 12/21/09 to lower the dose to 1 mg daily for sleep disturbance were interviewed at 10:25 AM. The Registered Nurses stated that the resident was transferred to their unit in January 2013 and there had been no report of any problems with sleeping or any other behavioral problems. The Physician who reduced the dose stated that he made the dose reduction in December 2009 because the nurses reported that the resident was not exhibiting any behavioral symptoms on the day shift. However, the Physician stated that he continued the dose in the evenings because the nursing staff reported some problems at night. This Physician further stated that, at the time he wrote "sleep disturbance" as the indication for the use of the medication, the resident had no problems sleeping but the Physician objected to the use of the term "agitation" for children. The current primary care Physician indicated that it was not appropriate to use the term "sleep disturbance" because it provided misinformation and affected the ability of the staff to assess the resident in order to determine the effectiveness of the medication and justification for its ongoing use. This Physician also stated that she would begin to attempt to discontinue the medication by reducing the dose further. 415.12 (1)(1)

Based on interview and record review, the facility did not ensure that the Pharmacist identified an irregularity in a resident's medication regimen and reported the irregularity to a Physician when indicated. This was evident for one of ten residents (Resident #16) reviewed for unnecessary drugs and had the potential for more than minimal harm that was not immediate jeopardy. The findings are: Resident #16 is a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the resident's current physician's orders [REDACTED]. Nurses' Notes for the year 2013 and the current Comprehensive Care Plan were reviewed and showed no evidence that the resident was having difficulty sleeping or exhibiting any mood/behavioral problems that interfered with his ability to sleep. Historical information in the clinical record was then reviewed to determine when this medication was initially prescribed and what symptoms the resident exhibited to justify its use. The historical information revealed the following: The resident's admission physician's orders [REDACTED]. The resident was seen by a Neurologist on 5/19/08 who recommended that the resident should be weaned off the Ativan slowly by 0.5 mg steps every two weeks. The reduction of Ativan was initiated subsequent to this visit although at a slower pace. The first reduction was from 1 mg every 8 hours to 1 mg every 12 hours with the last reduction occurring on 12/21/09 to 1 mg at bed time, 8:00 PM. At that time the indication identified to continue Ativan use was changed from "agitation" to "sleep disturbance." However, a review of the Nurses' Notes for the year 2009 revealed no evidence that the resident had difficulty sleeping at nights or at any other time. Following a review of the medical record on 7/31/13, two Registered Nurses on the unit (the Team Leader and the nurse assigned to the resident), the primary care Physician and the Pharmacist were interviewed at 10:25 AM on 7/31/13. The Registered Nurses stated that the resident was transferred to their unit in January 2013 and there had been no report of any problems with sleeping or any other behavioral problems. The Physician stated that she would begin to attempt to discontinue the medication by reducing the dose further. The Pharmacy Monthly Reviews were presented to the Pharmacist when she was being interviewed. The reviews showed no evidence that any irregularities were identified regarding the ongoing use of Ativan for at least the past 12 months through the most recent review on 7/31/13. The Pharmacist stated that she was going to ask the physician about the need for the continued use of the Ativan. The Pharmacist provided no documented evidence to substantiate this statement. 415.18(c)(2)