Every finding on record at Fort Tryon Center for Rehabilitation and Nursing

Based on observation, record review, and interviews, the facility failed to ensure that a resident was treated with respect and dignity and cared for each resident in a manner and in an environment that promotes maintenance or enhancement of their quality of life, recognizing each resident's individuality. This was evident for two (2) (Residents #42 and #9) of three (3) residents reviewed for Dignity out of 35 total sampled residents. Specifically, Residents #42 and #9 were observed wearing hospital patient gowns on multiple occasions.The findings are: The facility's policy titled Residents Rights: Dignity dated 12/01/2025 documented that it is the policy of the facility to ensure that all residents are treated with respect and dignity, including the right to retain and use personal possessions, including furnishings, and clothing as space permits. 1. Resident #42 was admitted to the facility with diagnoses which included Cerebral Infarction, Hemiplegia, Hypertensive Heart Disease and Chronic Atrial Fibrillation. The Minimum Data Set (a resident assessment tool) dated 07/21/25 documented that the resident was severely impaired and was dependent on staff for all activity of the daily living. From 12/11/2025 through 12/18/2025, Resident #42 was observed on several occasions wearing hospital patient gowns. On 12/16/2025 at 11:18 AM, Registered Nurse #9 was interviewed and stated that Resident #42's clothes were sent to the laundry. On 12/16/2025 at 2:17 PM, Registered Nurse #8 was interviewed and stated that Resident #42 had no family member who can bring them clothes. 2. Resident #9 had diagnoses of Non-Alzheimer's Dementia and Coronary Artery Disease. The Minimum Data Set, dated [DATE] documented that Resident #9 had severe impairment in cognition, with no triggered behaviors. Preferences for Customary Routine and Activities (Section F) documented, somewhat important to choose clothes to wear. On 12/11/2025 at 10:50 AM, Resident #9 was observed in the dining room wearing two (2) hospital patient gowns covering their front and back. On 12/15/2025 at 11:23 AM, Resident #9 was observed in the dining room wearing hospital patient gown. On 12/17/2025 at 11:00 AM, Resident #9 was observed in bed wearing hospital patient gown. On 12/17/2025 at 11:10 AM Certified Nurse Aide #5 was interviewed and stated that they had never seen clothes in Resident #9's closet and that they always see Resident #9 wearing hospital patient gown. They stated they put 2 gowns together to cover the resident's front and back. On 12/18/2025 at 7:45 AM, the Director of Nursing was interviewed and stated if residents need clothes, the staff should contact the Social Worker and the Housekeeping Department for clothes donation. They stated they rely on the Certified Nursing Assistants to report the need for residents' clothes and hat nursing supervisors are to ensure that residents are properly dressed when their making rounds. 10 NYCRR 415.5 (a)

Based on observation, record review, and interviews, the facility failed to ensure that necessary housekeeping and maintenance services were provided to maintain a safe, clean, comfortable and homelike environment for residents. This was evident for one (1) (3rd Floor) of five (5) resident units observed. Specifically, accumulation of dust, dirt, and stains were noted on bedside tables, intravenous poles, feeding pumps, oxygen concentrators and suction machines; and torn arm rests and soiled wheelchairs were observed in resident rooms on the 3rd Floor. The findings include:The facility policy titled Environmental Policy and Procedure, Subject: Safe, Clean, Comfortable and Home-Like Environment documented that housekeeping and maintenance services are provided to maintain a sanitary, orderly, and comfortable interior. The following were observed from 12/11/2025 through 12/16/2025:1.) room [ROOM NUMBER]B:a. The wheelchair's front and back end of both arms rests were torn, exposing portions of the inner material. The wheelchair seat cushion was soiled and stained. b. The oxygen concentrator had layered dust and dirt.c. The feeding pump had brownish stains and streaks.d. The intravenous pole had brownish stains and streaks. The floor had stains underneath the pole. e. The bedside table was layered with dust and debris.f. The suction machine and nebulizer on the bedside table had accumulated dust and debris. 2. room [ROOM NUMBER]A and 310B:a. The wheelchairs had accumulated dirt and dust, the wheels, brake handle and metal attachments had debris. 3. room [ROOM NUMBER]A:a. The feeding pump had brownish stains and streaks.b. The oxygen concentrator had had layers of accumulated dirt and dust. c. The bedside table had accumulated dirt and dust. d. The suction machine had layers of dust and debris.On 12/18/2025 at 10:30 AM, the Director of Housekeeping Services was interviewed and stated that the housekeepers are responsible for the upkeep of the unit and that they make rounds to ensure that the housekeeping staff are performing their duties. The Director stated that the housekeepers are responsible for daily wiping and disinfecting the equipment such as feeding pumps, intravenous poles, and bedside tables, oxygen concentrators, suction machines, and nebulizers. They stated that there are two (2) porters in the evening that are responsible for cleaning the wheelchairs. On 12/18/2025 at 12:50 PM, the Director of Maintenance was interviewed and stated that there is a logbook in each unit where staff can log what needs to be repaired. They stated that they and their staff check this logbook several times a day. They stated that the staff calls them if there is a need for an urgent repair and that it is immediately addressed. 10 NYCRR 415.5(h)(2)

Based on observation, record review, and interviews, the facility failed to ensure that a comprehensive care plan was developed to address a resident's sleep pattern disturbance. This was evident for one (1) (Resident #187) of 38 sampled residents. Specifically, Resident #187 who was receiving Ambien for Insomnia had no care plan developed and implemented to address the resident's ongoing difficulty staying asleep. The findings include:The facility's policy titled Care Plan Development with a last reviewed date of 12/12/2024 documented the facility shall develop, implement, and maintain a comprehensive, person-centered care plan for each resident. It also documented the care plan shall address the resident's medical, nursing, psychosocial, functional, and safety needs; promote dignity and quality of life; and reflect the resident's goals, preferences, strengths, and choices.Resident #187 had diagnoses of Insomnia, Generalized anxiety disorder, and Depression.The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #187 was cognitively intact, had diagnosis of Primary insomnia, and took hypnotic medication. It also documented Resident #187, and their representative participated in the assessment. The physician's order dated 04/16/2025 and was last renewed on 12/09/2025 documented that Resident #187 was ordered to receive one (1) tablet of Ambien 10 mg by oral daily at bedtime for Primary insomnia. The psychiatry consult dated 09/13/2025, 10/03/2025, and 10/24/2025 documented Resident #187 reported ongoing difficulties with sleep and continued Ambien 10 mg by oral daily at bedtime for Primary insomnia. The Resident Medication Administration Record for November 2025 documented 1 tablet of Ambien 10 mg was administered to Resident #187 at 9:00 PM every day. There was no documented evidence that a comprehensive care plan related to sleep pattern disturbance was developed and implemented for Resident #187. On 12/17/2025 at 9:58 AM, Registered Nurse #3 was interviewed and stated they are responsible for initiating and updating the care plans in Resident #187's unit. Registered Nurse #3 stated Resident #187 had care plan for the use of psychoactive medications but had no care plan related to sleep pattern disturbance. On 12/17/2025 at 10:32 AM, the Director of Nursing was interviewed and stated that the Registered Nurse Supervisors are responsible for developing and reviewing the residents' care plans. The Director of Nursing reviewed Resident #187's care plan and stated that there was a care plan for psychoactive medication use documenting that Ambien is for insomnia, however, there was no non-pharmacological interventions to address Resident #187's difficulty sleeping. The Director of Nursing further stated Resident #187 should have a care plan related to sleep pattern disturbance with both pharmacological and non-pharmacological interventions.10 NYCRR 415.11(c)(1)

Based on observation, record review, and interview the facility failed to ensure each resident's comprehensive care plans were reviewed and revised after each assessment to reflect the resident's changing needs. This was evident for one (1) (Resident #4) of five (5) residents reviewed for unnecessary medications. Specifically, Resident #4's comprehensive care plan for psychoactive drug use, Diabetes Mellitus, and bleeding potential were not reviewed and revised quarterly after each assessment. The findings include:The facility's policy titled Care Plan Development, Implementation, and Review which was last revised on 08/06/2024 documented that the purpose of the policy is to ensure compliance with the New York State Department of Health and Centers for Medicare and Medicaid Services requirements by establishing a standardized process for the comprehensive, person-centered development, implementation and ongoing review of each resident. The policy further documented for ongoing review and revision, the interdisciplinary team will monitor the resident response to care plan interventions, and the care plans shall be updated promptly to reflect changes in condition, new diagnosis, resident preference changes, and effectiveness or in effectiveness of the interventions. Resident #4 was admitted to the facility with diagnoses which included Alzheimer's Dementia, Depression, Bipolar disorder, Diabetes Mellitus, History of Embolism and Thrombus, and Hypertension. The quarterly Minimum Data Set assessment dated [DATE] documented that Resident #4 was moderately impaired in cognition and had diagnoses of Diabetes Mellitus; Bipolar Disorder; personal history of other venous thrombosis and embolism; and received insulin injections, antipsychotic, and anticoagulant medications. The Comprehensive Care Plan titled Psychoactive Medication use of any drug that affects brain activities associated with mental process and behavior was dated effective 11/04/2024 and was last reviewed on 07/16/2025. There was no documented evidence that the care plan was reviewed and revised after the quarterly assessment on 10/08/2025.The Comprehensive Care Plan titled bleeding potential/anticoagulant/antiplatelet, etiology: resident was at risk for bleeding secondary to the use of anticoagulant as evidenced by history of rectal bleeding, history of hematoma was dated effective 11/04/2024 and was last reviewed on 07/16/2025. There was no documented evidence that the care plan was reviewed and revised after the quarterly assessment on 10/08/2025.The Comprehensive care Plan titled Diabetes Mellitus related to diagnosis of Diabetes and non-compliant with diet dated effective 05/30/2019 and was last reviewed on 03/17/2025. There was no documented evidence that the care plan was reviewed and revised after the quarterly assessments on 05/05/2025, 07/09/2025, and 10/08/2025.On 12/16/2025 at 12:31 PM, Registered Nurse #1, who was the supervisor for Unit 3, was interviewed and stated they are responsible for reviewing and revising Resident #4's comprehensive care plan. They stated they are not sure if the comprehensive care plan was updated at least every quarter. On 12/17/2025 at 11:07 AM, the Director of Nursing was interviewed and stated the nursing supervisors are responsible for creating and updating the care plans and that they are aware that the care plans were not being updated. 10NYCRR 415.11(c)

Based on record review and interviews conducted during the Recertification Survey from 06/13/24 to 6/21/24 the facility did not ensure that a resident's Minimum Data Set assessment accurately reflected the resident's status. This was evident for 1 resident reviewed for Communication/sensory, out of 38 sampled residents (Resident #42). Specifically, the Minimum Data Set assessment inaccurately documented that Resident #42 who had vision impairment (blind) was assessed to have no vision impairment. The finding is: Resident #42 had diagnoses which include Diabetes and Hypertension. The most recent annual Minimum Data Set assessment dated [DATE] documented that the resident's vision is adequate - able to sees fine detail, such as regular print in newspapers/books. A review of the Optometry evaluation dated 11/2023 documented that the resident is legally blind. On 06/14/24 at 12:15 PM, an interview was conducted with the Certified Nursing Assistant #3 who stated, Resident #42 is blind, they cannot walk alone, and we must instruct them on what to do. The Certified Nursing Assistant #3 further stated that the resident is able to follow directions and has an intact memory. On 06/17/24 at 12:01 PM, an interview was conducted with Resident #42 (the MDS Coordinator was also present at this time). Resident #42 stated, that they are blind and cannot see anyone while standing in front of them. The resident stated that he cannot see with his right eye. On 06/17/24 at 12:55 PM, an interview was conducted with the MDS Coordinator who stated that the assessment was an error. They stated that most of the time, they review medical records offsite, and then if clarification is needed then they see the resident. They concluded that it was an oversight. I missed it. 10 NYCRR 415.11(b)

Based on observation, record review and interview conducted during a Recertification Survey and Complaint Survey (NY00334169) from 06/13/2024 to 06/21/2024, the facility did not ensure that it maintained an effective pest control program. Specifically, 1) room [ROOM NUMBER] was observed with vermin excrement in the resident room on the ledge, wall border, shared bathroom, and residents closet. 2) Resident in room [ROOM NUMBER] stated, they noted a cockroach in their room and informed staff. 3) Resident in room [ROOM NUMBER] stated that they have observed vermin in the building (mice in rehabilitation and roaches in their room). This concern was evident for 2 (2nd floor and 5th floor) out of 5 floors observed for the Environment. The findings are: The facility policy and procedure dated 10/01/2021 titled Pest Control documented that the facility adopted this integrated pest management plan. The plan outlines procedures to be followed to protect the health and safety of staff, residents and visitors from pest and pesticide hazards. The objective of the plan includes elimination of significant threats caused by pests to the health and safety of residents, staff, the public and prevention of loss or damage to structures or property by pests. Protection of environmental quality inside and outside buildings. The licensed exterminator conducts weekly facility rounds and inspects areas of special need as directed. When staff observes signs of pests, staff shall notify the Director of Housekeeping and record their observation in the unit exterminator communication log on each floor. The Director of Housekeeping shall maintain a record of the exterminator's findings and initiate corrective action to prevent recurrence as needed. The Director of Housekeeping or designee shall be the facility integrated pest management coordinator, be responsible to implement the integrated pest management plan and to coordinate pest management related communication between the facility, service providers, staff, and residents. The Pest Control log for the 2nd to 6th floor was reviewed from January 2024 to June 2024 and documented the following: 2nd floor - Roaches in room [ROOM NUMBER] on 1/1/2024. Mice in room [ROOM NUMBER] on 3/6/2024. Mice in room [ROOM NUMBER] on 5/15/2024. Roaches in room [ROOM NUMBER] on 6/5/2024. 3rd floor - room [ROOM NUMBER] roaches on 1/3/2024, room [ROOM NUMBER] roaches on 1/24/2024. Mice in room [ROOM NUMBER] on 3/7/2024. Roaches in room [ROOM NUMBER] on 5/1/2024. 4th floor - room [ROOM NUMBER] cockroaches on 1/17/2024 and ants in room [ROOM NUMBER] on 5/16/2024. 5th floor - room [ROOM NUMBER] mice on 2/13/2024. room [ROOM NUMBER] roaches on 3/12/2024. room [ROOM NUMBER] roaches on 4/1/2024. room [ROOM NUMBER] roaches on 4/17/2024. room [ROOM NUMBER] mice on 5/8/2024. room [ROOM NUMBER] roaches on 5/24/2024. room [ROOM NUMBER] ants on 6/12/2024. 6th floor - room [ROOM NUMBER] mice on 1/5/2024. room [ROOM NUMBER] roaches on 1/25/2024. room [ROOM NUMBER] mice on 5/8/2024. room [ROOM NUMBER] ants on 6/6/2024. The Pest Control service report slips were reviewed for the 2nd and 5th floor. On 1/8/2024 room [ROOM NUMBER] treated for roaches. On 1/15/2024 documented room [ROOM NUMBER] was treated. On 02/16/2024 room [ROOM NUMBER] treated for mice. On 03/11/2024 documented room [ROOM NUMBER] was treated for mice and on 03/18/2024 room [ROOM NUMBER] treated for roaches. On 04/5/2024 room [ROOM NUMBER] treated for roaches. On 04/22/2024 room [ROOM NUMBER] treated for roaches. On 5/10/2024 room [ROOM NUMBER] treated for mice. On 5/17/2024 room [ROOM NUMBER] treated for mice. On 05/27/2024 room [ROOM NUMBER] was treated for roaches. On 06/10/2024 room [ROOM NUMBER] treated for roaches. On 6/11/2024 room [ROOM NUMBER] treated for ants. On 06/18/2024 at 12:11PM, room [ROOM NUMBER] was observed to contain black colored droppings on the floor of the bathroom on the left, right and behind the toilet. Along the wall edge there were black colored droppings on the floor behind stored personal property bags. The closet was observed with a noted musty smell and multiple small black colored dropping on the closet floor. On 06/18/2024 at 12:13PM, Resident who resided in room [ROOM NUMBER] stated they have a purple bag with paper and the mice ate thru it. The bag was noted torn resting on top of boxes on floor. On 06/18/2024 at 12:24PM, room [ROOM NUMBER] was observed. On 06/18/2024 at 12:26PM, the Resident who resided in room [ROOM NUMBER] was interviewed and stated they reported seeing a cockroach on the wall of their room and informed an unspecified Certified Nursing Assistant, Housekeeping and a Nurse as well as anyone who would listen. On 06/18/2024 at 12:47PM, the Resident who resides in room [ROOM NUMBER] was interviewed and stated that they noticed a mouse in the rehabilitation department and noticed a mouse in the dining room on the 2nd floor last week. They have also noticed a mouse in their room and in the hallway past the nurse's station. This is New York City; this is an old building, and you can't kill them all. On 06/20/2024 at 03:23PM, room [ROOM NUMBER] was observed with multiple brown and black colored approximately 1/4 to 1/2 inch in length excrement noted on the windowsill and the edges of the bathroom wall. On 06/20/2024 at 03:25PM, the Resident who resides in room [ROOM NUMBER] was interviewed and stated that there are mice in the dining room not just on this floor. They are all over the place. On 06/21/2024 at 11:27AM, room [ROOM NUMBER] was observed again and noted with multiple brown and black colored mice droppings on the windowsill, black colored droppings on the floor behind their personal belongings against the wall. An interview was conducted on 06/20/2024 at 03:34PM with Certified Nursing Assistant # 2 who stated that they have not noticed any rodents or roaches or any signs in Resident #238's room. They stated that they do not know where the droppings on the ledge came from and the residents rooms need to be free of vermin for infection control. An interview was conducted on 06/20/2024 at 03:43PM, with Licensed Practical Nurse # 1 who stated the residents can get sick from mouse droppings. This is no good and it is not healthy for Resident #238 who has breathing problems. An interview was conducted on 06/20/2024 at 04:00PM, with the Registered Nurse Supervisor #1 who stated they have not noticed any vermin or vermin droppings in room [ROOM NUMBER]. If droppings are present, it would mean that we have pests here presently and we need to do pest control. An interview was conducted on 06/20/2024 at 04:18PM, with the Administrator who stated that the resident in room [ROOM NUMBER] reported that they saw something in their room. I am not sure if there were mouse droppings and they were notified in the last month. Vermin droppings are unsanitary, and it needs to be taken care of for infection control. They have had internal conversations with the Director of Housekeeping, Director of Social Work and the prior Social Worker and Director of Nursing in relation to room [ROOM NUMBER]. Pest control comes to the facility three times a week, they don't review the pest control reports, but they are aware of pest control reports. There was a report of a pest issue on the 6th floor but I can't recall specific the time frame. There have been no pest concerns that have been brought up in resident council meeting. An interview was conducted on 06/21/2024 at 10:34AM, with the Pest Control representative who stated, pest control services are provided to the facility twice a week. They ask staff if they notice any pests and look for signs of pests and mice activity. They have not noticed any droppings. They review the unit logbook for reported sightings or concerns, put out traps in nurses' station and resident rooms with vermin activity and most rooms are clean with no pest activity. They look at rooms for clutter. Items in the room have to be moved to treat the room in order to prevent it from having any activity. Residents live here and you don't want any pests to come in the facility. They further stated they caught 1 mouse on the 6th floor but cannot recall when this was. They have caught more mice outside. They treat mostly for ants and roaches which they treat with roach gel, ant gel and mice glue box traps which they place throughout the building. An interview was conducted on 06/21/2024 at 11:08AM, with the Director of Housekeeping who stated they do rounds in the building twice daily looking for dirty, dusty areas, resident closets, windowsills, and bedside table. They did rounds on the 5th floor this morning. Sometimes we have droppings from mice in resident closets and they document it in the pest control log notes. Residents have complained about pest issues yesterday and prior but could not recall when exactly. The exterminator comes two times a week and the pest control representative told them they could only use traps. They are not aware if anything was caught in room [ROOM NUMBER]. Families don't want their family members to live somewhere that has pests. Residents eat in the dining tables, and they don't want residents to be affected by rodents and pests. An interview was conducted on 06/21/2024 at 01:52PM, with the Chief Operating Officer who stated that we know we have mice and roaches, and it is a constant battle. We are in the city, and we are on top of a hill. Exterminating service was increased from once a week to twice a week since we were not happy with the pest control services. When they visit the facility, we discuss the pest problem and the pest issues have escalated in the past few years. The facility was using the current company prior to the pest issue starting. They further stated that they don't trust the extermination company and there should not be any mice or roaches in the facility. The facility should provide a safe and sanitary environment for residents. If they had mice in their house, they would move out. They look at the pest control logs and they believe the control company was not being aggressive with the pest control treatment regimen and we have a new pest control company that will start services on 7/1/2024. 10 NYCRR 415.(5)(h)(1)

Based on observation, record review and interviews conducted during the Recertification from 03/10/2022 to 03/17/2022, the facility did not provide, based on the comprehensive assessment, interests, and the preferences of each resident, an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. Specifically, the facility did not provide a non-English speaking resident with television channel in their native language as per their preferences. This was evident for 1 of 3 residents reviewed for Activities out of a sample of 38 residents (Resident #104). The findings are: The facility policy and procedure titled Notification to residents regarding activities programs with effective date 10/97 documented it was the policy for the facility to provide therapeutic, meaningful, recreation based on each resident's assessed interests and capabilities. The facility policy and procedure titled Language translation with effective date 7/2013 documented it was the policy of the facility to have a means of translation for non-English speaking residents at the facility. It also documented translation was available via Language Line translation, qualified multilingual staff, or Google Translate via mobile device for non-medical translation. 1. Resident #104 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE] documented Brief Interview for Mental Status was not conducted as Resident # 104 was rarely/never understood. The MDS also documented that Resident #104 usually made self understood, and sometimes understood others. The MDS further documented that Resident # 104 did not participate but family/significant other participated in the assessment. On 03/10/22 at 11:22 AM, Resident #104 was observed sitting in the wheelchair in the room with television playing an English language channel. Resident #104 was interviewed and stated they spoke no English but Cantonese and Mandarin only and they used to watch Cantonese and Mandarin TV programs at home. Resident #104 also stated the staff did not discuss their activity preferences since their admission to the facility. Resident #104 further stated they wanted to watch the Cantonese or Mandarin TV programs at the facility. Television channels available on the television in Resident #104's room were observed to be in English and Spanish only. The Quick Reference Guide for LanguageLine Solutions was observed posted at the nursing station on the unit. On 03/11/22 at 10:12 AM, 03/14/22 at 09:14 AM and other occasions during the survey, Resident #104 was observed sitting in the wheelchair by a table alone in the dining room or in their own room with no on-going activity and television playing on an English language channel. The Comprehensive Care Plan (CCP) related to Preferences/Resident's Choice initiated 1/18/2022 documented the goal was Resident's preferences will be honored to the extent possible in the next 90 days. The interventions included to allow resident to choose activities of choices, solicit resident's preferences regarding meals and care, and allow resident/ family to make choices about the aspects of life in the facility that are important to resident. The CCP related to Activities initiated 1/23/2022 documented the goal was Resident will have their leisure needs being met. The interventions included to respect resident rights to make independent choices, provide resident with requested supplies, and anticipate resident's needs. The Initial Activity assessment dated [DATE] documented Resident # 104 spoke Cantonese and Activity preferences prior to admission was watching television at home. The cable television channels provided to the facility by Privatel Incorporated was reviewed and documented English and Spanish channels only. On 03/16/22 at 09:35 AM, Certified Nursing Assistant (CNA) #1 was interviewed. CNA #1 stated Resident #104 was alert, spoke some simple English words and was able to make needs known. CNA #1 further stated they had not observed Resident #104 watching television very often in the room and they were not sure if it was due to a language issue. On 03/16/22 at 10:19 AM, the Activities Assistant (AA) was interviewed. The AA stated they did the activity assessment for Resident #104 by calling the representative for activity preference and the representative did not know much about it. The AA also stated they did not interview Resident #104 because Resident #104 did not speak much English. The AA further stated the TV channels provided by the facility were in English and Spanish only. AA also stated they were not aware Resident # 104 preferred to watch Cantonese or Mandarin TV channels and they would have been able to offer these TV channels if they knew. The AA stated that they did not assess the resident in their native language through use of the Language Line because they did not know how to use it although the reference guide was posted in the nurse's station. On 03/16/22 at 11:38 AM, the Acting Director of Recreation (ADR) was interviewed. The ADR stated the Activities Assistant (AA) on each floor was responsible to do an activity assessment for the residents on the floor. The ADR also stated the AA interviewed the residents and sometimes asked the staff for residents' activity preferences. The ADR further stated the AA is supposed to use the language line in completing the activity assessment if the resident does not speak English and the Quick Reference Guide for using the language line is provided to all the AAs and is posted at the nursing station on each unit. The ADR stated the TV channels provided in the facility were in English and Spanish only and they had a Firestick that could be connected to internet for non-English speaking residents to watch the channels in their native languages if it was their preference. The ADR also stated they knew Resident #104 was non-English speaking. 415.5(f)(1)

Based on observation, interview, and record review conducted during the Recertification Survey from 3/10/22 - 3/17/2022, the facility failed to ensure that a resident maintained acceptable parameters of nutritional status. Specifically, resident's weights were not measured and recorded according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident #37). The findings are: The facility policy titled Resident Weights dated 11/16/2016, documented all residents admitted to the facility will be weighed according to the following schedule: day one on admission, day two, and then weekly for a month, then monthly. All residents will be weighted on a monthly basis unless otherwise ordered by the Physician or deemed necessary by the dietitian and or the interdisciplinary team. All weights will be recorded in the resident's electronic medical record. Resident #37 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Comprehensive Care Plan titled Comprehensive Nutrition/Hydration/Enteral feeding dated 12/23/2021 documented Etiology: at risk for weight changes, compromised nutritional/medical status As Evidenced By: ascites, liver [CONDITION(S)], [CONDITION(S)]. Interventions included monitor resident's weight as ordered. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nutrition assessment dated [DATE] documented weight trend may fluctuate due to resident's fluid shifts but will monitor. Weight is from hospital, as resident refuses to be weighed at this time. Will continue to monitor weight trend. Dietary progress notes dated 12/24/21, 1/13/22 and 1/31/22 documented will continue to monitor weight trend, weight may fluctuate with changes in fluid status. Will continue to monitor. Nursing Admission note dated 12/24/2021 states Standing Monitoring Orders (As of 12/24/2021) Admission/Readmission weight: Initial weight on admission, then 2nd weight on day 2, then weekly times 2 weeks, then monthly. Medical Record documented weight of 257 lbs on 12/24/2021 and 264.2 lbs on 1/10/2022. There was no documented evidence the resident was weighed as per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 3/15/22 at 10:40 AM, an interview was conducted with Certified Nursing Assistant (CNA) #2, who stated weights are taken from the 1st through the 5th of the month and some residents are weighed weekly. CNA #2 also stated the nurse will tell staff during morning report who is on weekly weights and the weights are written in a weight binder. CNA #2 also stated that if a resident refuses to be weighed, they tell the nurse. The Nurse reviews and enters the weight into the medical record. On 3/15/22 at 10:44 AM, an interview was conducted with Licensed Practical Nurse (LPN) #1 who stated that weights are taken monthly by the CNA. The Charge Nurse enters the weight into the medical record and compares it with the previous weight. LPN # 1 also stated that if a resident refuses weights, they let the doctor know. LPN #1 further stated they were not aware that there were no weights for Resident #37 for February and March. LPN #1 opened the weight binder and noted the resident's weight sheet was blank and reported that the weight record in the Electronic Medical Record (EMR) was also blank for February and March 2022. On 3/15/22 at 10:55 AM, an interview was conducted with the Registered Nurse Supervisor (RNS) #1 who stated that weights are taken monthly. The Nurse will enter the weight into the EMR and review. The RNS stated that if a resident refuses to be weighed, they educate the resident on the need to take the weight, inform the dietitian, nursing administration, and document in the medical record. The RNS #1 further stated that if the nurse does not see documentation of weight, they should tell the supervisor so they can follow up as to why weights were not entered. On 3/15/22 at 12:01 PM, an interview was conducted with the Registered Dietitian (RD) #1. RD #1 stated weights are reviewed at least every month. If a weight is missing, it is requested from the main nurse on the unit, the RN Supervisor and sometimes from the Director of Nursing. RD #1 also stated they will leave a list of weights that the unit needs at the nursing station. Based on the order, if the weight is not there when they do an assessment, they request it. RD #1 reviewed the EMR and stated in the first few weeks with multiple weights, it is possible that the weight was not recorded properly in the EMR. RD #1 further stated the weight should be recorded in the monitoring section of the EMR and upon review RD #1 noted that weights had not been entered as ordered. On 3/15/22 at 02:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the policy and procedure for weights is that on admission resident has to be weighed and weighed again the next day, then weighed every week for 4 weeks then monthly. The DON also stated that the nurses are responsible for ensuring that the CNA takes the weights and the nurse then enters it into the EMR. The DON further stated that dietary does weight audits and the dietitians usually follow up and seek out the nursing supervisor if they do not see weights recorded for a resident. 415.12(i)(1)

F760 Based on interviews and record review during an abbreviated survey (Case # NY00275054), on 05/13/2021, the facility did not ensure its residents were free from any significant medication errors. Specifically, (Resident #1, #2, and #3), were ordered to take nothing by mouth (NPO), however the physician ordered medications to be administered by mouth. The findings were: Review of the facility policy titled Medication Administration, revised 01/20/2021 documented that medications are to be given as ordered, if there is any question in regard to dose, route of administration or medication form, the person in doubt is not to give the medication until verification is received from the physician. Resident #1 was admitted to the facility on [DATE], with a diagnosis of cerebral infarction, hemiplegia and hemiparesis, and dysphagia. The Minimum Data Set (MDS) dated [DATE], identified that the resident #1 had a Brief Interview of Mental Status (BIMS) score of 12/15. Resident #1 required total assistance with activities of daily living (ADLs). Resident #2 was admitted to the facility on [DATE], with a diagnosis of cerebral ataxia and dysphagia. The MDS dated [DATE], identified that Resident #2 was unable to participate in the BIMS assessment. Resident # 2 required total assistance with ADLs. Resident #3 was admitted to the facility on [DATE], with a diagnosis of dysphagia, acute respiratory failure, and acute kidney failure. The MDS dated [DATE], identified that Resident #3, was unable to have a BIMS assessment. Resident #3 required total assistance with ADLs. Review of Resident #1's Physician orders dated 03/25/2021, documented orders, to give Nothing by Mouth (NPO). There are three medications identified to be given orally. An order originally dated 4/12/2021 and renewed on 4/19/2021 for Oxycodone 5 mg capsule with instructions to give 1 capsule (5 mg) by oral route every 12 hours. A second order originally dated 04/09/2021, documented on 04/19/2021, Tylenol Extra Strength 500 mg tablet give 2 tablets (1000 mg) by oral route every 8 hours. A third order originally dated 04/09/2021 and discontinued (D/C) on 04/14/2021 for Pepto-Bismol 262 mg/15 mL with instructions to give 30 milliliters by oral route 3 times per day for 5 days. Review of The Medication Administration Record (MAR) for Resident #1 documented in April 2021 that Oxycodone 5 mg was administered by oral route on 04/12/2021 at 10:45 AM and an additional 15 times between 04/13/2021 and 04/21/2021. Pepto-Bismol 262 mg/15 milliliters (mL) was administered by oral route 15 times between 04/09/2021 and 04/14/2021. Tylenol Extra Strength 500 mg was administered by oral route 31 times between 04/10/2021 and 04/21/2021. Review of the Speech Therapy evaluation for Resident #1, dated 04/02/2021 revealed that the Medication will be given via the feeding tube. Review of Resident #2's physician orders revealed that there was an order dated 05/12/2021 for NPO. On 05/11/2021, Atorvastatin 40 mg tablet was ordered to be given by oral route once daily at bedtime. On 05/11/2021, Metoprolol tartrate 25 mg tablet give 0.5 tablet (12.5 mg) by oral route 2 times per day. On 05/11/2021, Tylenol Extra Strength 500 mg tablet give 2 tablets (1000 mg) were ordered to be given by oral route 3 times per day as needed. Review of MAR for Resident #2 revealed that Atorvastatin 40 mg tablet was administered by oral route on 05/12/2021 at 09:00 PM, Metoprolol Tartrate 25 mg tablet was administered by oral route on 05/12/2021 at 09:00 AM and 05:00 PM. A review of the Speech Therapy evaluation for Resident #2 dated 04/06/2021, revealed that the medications will be given via a feeding tube. A review of Resident #3's Comprehensive Nutrition/Hydration/Enteral Feeding care plan dated 05/07/2021, documented interventions for nothing by mouth as an aspiration precautions due to difficulty swallowing (dysphagia). A review of Resident #3's physician orders dated 05/10/2021, documented nothing by mouth. An order dated 05/10/2021, documented Tylenol 325 mg, 3 tablets (975 mg) orally. An order dated 05/10/2021, for Ibuprofen 200 mg tablet 4 tablets (800 mg) given by oral route as one dose. On 05/12/2021, Nephro-Vite 0.8 mg tablet, give 1 tablet by oral route once daily. A review of The MAR for Resident #3 revealed that Ibuprofen 200 mg tablet was administered by oral route on 05/10/2021 at 08:00 PM and Tylenol 325 mg was administered by oral route on 05/11/2021 at 12:00 AM. A review of Resident #3's progress notes documented: Speech Therapy note dated 05/07/2021, documented that Resident #3, presented as non-responsive, non-verbal and is getting nothing by mouth. During an interview on 05/13/2021 at 02:49 PM, The Registered Nurse (RN) #1 stated that Resident #1 only received medications by peg feeding tube, never by mouth due to NPO status. RN #1 denied giving Resident #1 medications by mouth. RN #1 stated they check the orders and route prior to administering. RN #1 stated that if they notice the wrong route, they immediately contact the prescriber and verify the orders and change them if needed. When informed that Resident #1 had orders for two medications to be given by mouth and that there were documentation that the two medications were given by mouth. RN #1 stated that they have never given Resident #1 anything by mouth. RN #1 stated they would never give an NPO resident anything by mouth. During an interview on 05/13/2021 at 03:20 PM with Registered Nurse Supervisor (RNS) #1 they denied giving Resident #1 anything by mouth, including medications. During the interview, RNS #1 had a laptop open with the medical record open and verified that there are three medication orders that are indicated as oral route and that they documented two of the medications were administered. RNS #1 acknowledged the documentation and stated that they have never given any medications by oral route as Resident #1 is considered NPO. RNS #1 stated that when they see an order with the incorrect route, they must call and clarify the order. RNS #1 could not recall whether these orders were clarified. During an interview on 05/13/2021 at 04:35 PM, The Medical Doctor (MD) stated that the medication orders that state by oral route for residents that have NPO orders in place are most likely a typographical error. MD #1 stated that these are questions for nursing. MD stated that for Residents #1, #2 and #3 all medications should be given via peg feeding tube and not by mouth. MD stated that as a part of their responsibilities are to sign orders. MD stated that when signing off on medications, they glance at them and quickly sign off on them. MD stated they must have over-looked the orders for Residents #1, #2, and #3 that state oral route. During an interview on 06/03/2021 at 02:57 PM, the Director of Nursing (DON) stated that when a resident has an order for NPO, they are not able to receive any medications by mouth. The DON stated that prior to the complaint investigation conducted on-site on 05/13/2021, they were not aware that there were any residents which had orders for NPO in combination with medications ordered to be administered by oral route. The DON stated that they were not aware that residents wth orders for NPO status had documentation in the MAR for medications administered by oral route. The DON stated that when orders are entered into the Electronic Medical Record/Order Entry System (EMR), the person entering the orders have an option to select the route of administration. The DON stated that there are supposed to be three checks to ensure that orders and route are correct. The DON stated that there is also a pop-up window that comes up during the order entry to ensure the order is correct. The DON stated that when medication orders have errors, specifically the route, the nurses are required to reach out to the MD or Nurse Practitioner (NP) to clarify and correct the orders. The DON stated that if a nurse documents that an oral medication was given to a resident with NPO status, the nurse would have to be educated and in-serviced. The DON stated that medications ordered by oral route and documented as administered are not necessarily medication errors if the nurse administered them by the correct route. The DON stated that it would not be possible to verify the actual route of administration for the medications ordered by oral route for residents #1, #2, and #3. The DON stated that when a mediation error is identified, the nurse that made the error is provided with an in-service. The DON stated that Residents #1, #2, and #3 had NPO orders. 415.12(m)(2)

Based on observation, record review, and staff interviews during a fifth Focused Infection Control COVID-19 Survey conducted on 01/07/2021, the facility did not ensure infection control surveillance designed to help prevent the development and transmission of COVID-19. Specifically, the COVID-19 staff screening completed upon entry did not include screening questions to confirm if staff members had signs and symptoms of COVID-19. The finding is: The Centers for Medicare and Medicaid Services (CMS) released a memo titled, Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in nursing homes, Ref: QSO-20-14-NH (dated 03/04/2020 and revised 09/28/2020). This memo, as revised, documented that facilities should screen all staff at the beginning of their shift for fever and respiratory symptoms, actively take their temperature and document absence of shortness of breath, new or change in cough, and sore throat. The New York State Department of Health (NYSDOH) Health Advisory, COVID-19 Cases in Nursing Homes and Adult Care Facilities, (dated 03/13/2020 and revised 07/10/2020), documented that nursing homes must: Immediately implement health checks for all HCP (health care personnel) and other facility staff at the beginning of each shift. This includes all personnel entering the facility regardless of whether they are providing direct patient care. Facility staff performing health checks must wear facemasks. HCP and other facility staff with symptoms or with T (greater than or equal to) 100.0 F should be sent home, and HCP and other facility staff who develop symptoms or fever while in the facility should immediately go home. The NYSDOH Dear Administrator Letter to Nursing Home Administrators (dated 04/29/2020), documented the following directive: Requiring all staff to be checked for COVID-19 symptoms (e.g., fever, cough, difficulty breathing, or other respiratory symptoms), including temperature checks upon the start of each shift and every 12 hours while on duty. The policy and procedure titled, Staff Assessment for Coronavirus (COVID-19) (Dated 03/11/2020) documented that staff will be screened and monitored for symptoms of acute respiratory illness before entering the facility. The policy indicated the employees will complete a onetime screen and a daily screen before the beginning of shift. This screening includes a temperature check documented on a tracking log form and identifying if they have any current signs or symptoms of COVID-19. On 01/07/2021 at 08:10 AM, employee screening was observed in the lobby. There was one staff member behind the security desk, and an unmanned screening table was set up to the right of the entrance across from the security desk. A thermal reading thermometer was affixed to the wall across from security, by the screening table. Two staff members walked into the building, sanitized their hands, independently took their temperatures, and documented their temperature in a black binder. The black binder contained an employee temperature log, and there were no screening questions regarding COVID-19 symptoms. However, a separate questionnaire that was clipped to a brown clipboard contained the screening questions for vendors, but not for staff. The facility Employee Temperature log dated 01/03/2021 to 01/09/2021 documented a listing of employee names and temperatures taken. The facility did not have a daily screening form for employees asking about presence of signs and symptoms of COVID-19. On 01/07/2021 at 09:45 AM, a Certified Nursing Aide (CNA #1) was interviewed and stated employee screening process consists of sanitizing hands, taking your temperature, recording it in a log, and donning a fresh mask. She further stated there are no screening questions. On 01/07/2021 at 09:40 AM, a Housekeeper was interviewed and stated employee screening occurs at the front desk where he takes and records his temperature and puts on a new mask. He further stated there are no screening questions. On 01/07/2021 at 09:30 AM, a Licensed Practical Nurse (LPN #1) was interviewed and stated employee screening consists of sanitizing hands, donning a fresh mask, and a temperature check. She stated there are no screening questions. On 01/07/2021 at 02:49 PM, the Director of Nursing (DON)/Infection Preventionist (IP) was interviewed and stated staff take their temperature and record it on a log against their name. The staff does not complete a questionnaire regarding symptoms of COVID-19. The staff only answers the questionnaire when they come back from vacation. She said that vendors and consultants answer questionnaires upon entrance to the facility. She stressed that the staff who work daily do not have to answer the screening questions. On 01/07/2021 at 12:55 PM, the Administrator was interviewed and stated that staff screening is completed via temperature check, and it is logged. The staff does not complete a questionnaire regarding signs and symptoms. He further stated he will start having staff complete a questionnaire today. 415.19(a)(1-2), 400.2

Based on observation, interview, and record review conducted during the Focused Infection Control COVID-19 survey (NY 295) on 9/1/20, the facility did not ensure that infection control practices designed to help prevent the development and transmission of communicable diseases and infections were followed. Specifically, multiple staff members were observed wearing a surgical mask incorrectly while in the facility. This was evident for 5 staff members observed on 1 of 5 resident units (5th Floor) and an additional observation in the Lobby. The findings are: The facility policy and procedure titled Personal Protective Equipment (PPE) Training was undated and documented each employee shall be trained to know how to properly don and doff PPE. The Centers for Disease Control (CDC) guidance titled Preparing for COVID-19 in Nursing Homes, updated 6/25/20, documents: HCP (Health Care Provider) should wear a facemask at all times while they are in the facility. The CDC guidance titled Using Personal Protective Equipment (PPE), updated 8/19/20, documents: Respirator/facemask should be extended under chin. Both your mouth and nose should be protected. Do not wear respirator/facemask under your chin or store in scrubs pocket between patients. On 9/1/20 at 11:00 AM, Housekeeper #1 was observed in the hallway near the elevator on the 5th floor. His face mask was under his chin and not covering his mouth and nose. He was heard talking with a resident who was also in the hallway at a social distance (at least 6 feet). As rounds were continued on the unit, Licensed Practical Nurse (LPN #3) was observed sitting behind the nursing station wearing her surgical mask underneath the chin, exposing her nose and mouth. On 9/1/20 at 11:30 AM, a Certified Nursing Assistant (CNA #4) was observed in the 5th floor hallway speaking with a resident in a wheelchair near a clothing rack. CNA #4 was wearing a surgical mask underneath her chin, exposing her mouth and nose. She was approximately 2 feet from the resident, and the resident was also wearing a surgical mask underneath the chin, exposing the nose and mouth. On 9/1/20 at 12:15 PM, LPN #4 was observed standing at the medication cart in the hallway on the 5th floor. She was wearing a surgical mask underneath her chin, exposing her mouth and nose. LPN #4 was immediately interviewed upon being observed. She stated she is wearing her mask improperly because there are no residents around, and she is not currently dispensing medication. The mask becomes uncomfortable at times. She has been in-serviced that masks should be worn at all times when in the facility. An interview was conducted with CNA #4 on 9/1/20 at 12:20PM. She stated she is aware that a mask should be worn, covering the face at all times when in the facility. She pulled it down because she felt dizzy and knows that is an improper way to wear a mask. An interview was conducted with LPN #3 on 9/1/20 at 12:26 PM. She stated that she had her surgical mask pulled down under her chin because she was behind the nursing station and away from residents. In-services have been provided regarding proper donning of surgical masks and she is aware that masks are supposed to be worn covering the mouth and nose. On 9/1/20 at 1:18 PM, an interview was conducted with Housekeeper #1. He stated his mask was pulled down because he was in the middle of cleaning the bathroom and the bleach fumes were overwhelming. He has been in-serviced on how to properly wear surgical masks, and he knows that he was not wearing his mask properly. An interview was conducted with the Director of Nursing (DNS) on 9/1/20 at 2:57 PM. She stated that all staff were in-serviced, and they are expected to wear masks the moment they step into the facility. The staff can take it down if they are going to a private area such as a bathroom, or they can take it down for a moment if they cannot breathe. They must put the mask back right away. Staff on the units should not be removing their mask just because they are at the nursing station or medication cart. Staff should not be removing the mask for any reason prior to leaving the facility. During the interview with the DNS, a staff member in scrubs was observed getting off of the elevator alone with a cloth mask pulled under her chin, exposing her mouth and nose. The staff member proceeded to walk across the lobby, passed the Surveyor and DNS, and proceeded behind the front desk to the time clock. As the employee walked back towards the DNS, she pulled her mask up and apologized to the DNS stating, Sorry, I know I should have my mask up right now. The DNS continued the interview with the Surveyor and stated the staff member who just passed by should have had their mask worn over her mouth and nose. All staff have been in-serviced regarding this. 415.19(a)(1-3)

Based on record review and staff interview conducted during the Infection Control Focus Survey and Abbreviated Survey (NY 253), the facility did not ensure that a resident was free from verbal abuse. Resident #1 reported that he was verbally abused by the night shift RN supervisor (RNS) in the lobby on 8/29/20. Two Front Desk Receptionists witnessed the incident and reported that the RNS yelled and cursed at the resident. This was evident for 1 of 3 residents reviewed for Abuse/Neglect (Resident #1). The finding is: The facility's policy titled Abuse Prohibition, dated 2/23/17, documented: Alleged violations involving mistreatment, neglect, or abuse, including injuries of an unknown source, are reported to the Administrator of the facility or his or her designee and other officials, in accordance with State law or regulations. The facility shall ensure timely notification to the Department of Health. Abuse falling under the category of a crime must be reported to the NYSDOH and local law enforcement agency within 2 hours after forming the suspicion if the suspected crime results in serious bodily injury. If there are no serious bodily injuries, the facility must report the suspicion of a crime no later than 24 hours after forming the suspicion. Resident #1 was admitted with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS used to determine attention, orientation, and ability to recall information) score of 15 out of 15, indicating intact cognition. The Resident required extensive assistance of 1 person for bed mobility, transfer, and toilet use. On 9/1/2020 at 10:33 AM, Resident #1 was interviewed. Resident #1 stated that on 8/29/2020, at around 8 AM, when they attempted to go out on pass to go to the ATM, the nurse informed him that he was not allowed to go due to his high blood pressure. The resident stated they refused to take the medication, and they know they have the right to refuse. The resident started to go to the elevator. The elevator opened, and he saw the RNS. The RNS suddenly shoved him and pushed him on his wheelchair. The RNS was very aggressive, and they argued. After the argument, the resident went down to the lobby, and later, he saw the RNS coming out of the nursing office. The RNS started pointing his fingers at the resident, and he was shouting and cursing towards the resident, not allowing him to go out on pass. Both the Resident and RNS continued to argue and curse at each other. The resident added that there were two front desk receptionists and a couple of lobby surveillance cameras that could prove that the RNS was hostile and aggressive towards him. The resident stated that he reported the incident on 8/31/2020, in the morning, to the Executive Assistant. The 5th floor surveillance camera footage from 8/29/2020 between the hours of 8:00 AM and 8:30 AM for the 5th floor was viewed. The resident interaction with the RNS was not visible from any of the cameras on the unit. The lobby surveillance camera footage from 8/29/20 at 8:09 AM was viewed, and the RNS was observed pointing his finger and walking towards the resident near the front desk. The Comprehensive Care Plan (CCP) titled, At risk for abuse due to physical limitation and residing in the long-term care unit, effective date 5/23/19, documented that the Resident will be free from abuse. Interventions included assessing residents' needs and providing interventions, monitoring for potential situations that may trigger abuse or the potential to abuse others and intervene. The Nursing Progress note dated 08/29/2020 at 7:45 AM documented that the resident had high blood pressure, and the Nurse Practitioner (NP) ordered the nurse to give antihypertensive medication. The resident refused and verbalized they were going out. The NP instructed the nurse not to allow the resident to go out on pass unless blood pressure parameters were met. The RN asked the Nurse supervisor (RNS) to see the Resident and follow up with the NP instructions. The Medical Progress note dated 8/29/2020 at 8:15 AM documented that the resident's blood pressure (162/81) was high, and the resident was advised to wait until their blood pressure returned to normal before going out on pass. Despite the education provided, the resident was noncompliant with taking his blood pressure medication and, against medical advice, left the facility to withdraw money from the ATM and returned to the facility afterwards. There was no documentation in the medical record regarding the incident that occurred between the resident and RNS on 8/29/20. There was no documented evidence that the incident was reported or investigated. The RN Supervisor personnel file documented that the RNS received an abuse prohibition Inservice on 8/21/2020. On 8/11/2020, the RNS received a written warning and a two-day suspension due to poor job performance, insubordination, and unprofessional behavior. The Written notice documented that the RNS was observed hostile, and his tone was aggressive and stuck out a clipboard in the Assistant Director of Nursing's (ADON) direction with the verbal warning documents attached. On 8/12/2020, a written letter from RNS documented that he denied his hostile behavior towards the ADON and that ADON claims that he was screaming but maybe because of his voice that was high as a male. On 9/1/2020 at 3:15 PM, an interview with the RNS was conducted. The RNS stated that the charge nurse informed him that the resident refused to take their medication and was going out on pass. The RNS immediately went to the unit, and as soon as the elevator opened, the RNS saw the resident and tried to talk to the Resident. The RNS observed that the Resident was already upset but continued to encourage the resident to take the medication before going on out on pass. The RNS denied pushing the resident and stated that he only touched the resident's back. The RNS added that after a few minutes, while he was already at the nurses' office, the resident started yelling at him from across the lobby, saying do not put your hands on me, never do that again, and began to curse at the RNS. The RNS denied cursing back and stated that he did not push nor hurt the resident. On 9/1/2020 at 12:10 PM, an interview with the Front Desk Receptionist #1 was conducted. Receptionist #1 stated that he heard an argument take place between the Resident and RNS on 8/29/20 in the front lobby. The RN Supervisor yelled and cursed back at the Resident. The front desk personnel did not report the incident to anyone until 8/31/20 when he told the Executive Assistant. On 9/1/2020 at 3:14 PM, an interview with the Front Desk Receptionist #2 was conducted. Receptionist #2 stated that she heard Resident #1 stating, Don't put your hands on me. Never do that again. You are not supposed to put your hands on me. Both Resident #1 and RNS were observed arguing in the lobby. Receptionist #2 stated that she did not report the incident since it was more like a misunderstanding, and the resident was talking to the RNS. The receptionist felt that the situation was handled because, after the argument, the resident was able to leave out on pass. On 9/1/2020 at 12:47 PM, an interview with the Executive Assistant (EA) was conducted. The EA stated that the Resident informed her of the incident, and she informed the Administrator of the incident around 8/31/2020 at 3 PM inside the Administrators office. The EA added that she did not investigate further since she reported the incident to the Administrator at 3 PM. On 9/1/2020 at 10:15 AM, the Administrator was interviewed and stated that no one reported the incident to him prior to the Department of Health bringing it to his attention. On 9/1/2020 at 1:40 PM, the Assistant Director of Nursing was interviewed and stated that she was working from 8/31/2020 to 9/1/2020, and no one informed her of the incident. On 9/1/2020 at 1:45 PM, the Director of Nursing (DON) was interviewed and stated that she was off from 8/28/2020 to 8/31/2020. The DON stated that no one reported the incident to her. 415.4(b)(1)( i )

Based on record review and staff interview conducted during the Infection Control Focus Survey and Abbreviated Survey (NY 253), the facility did not ensure that abuse policies and procedures were implemented. Specifically, two Front desk receptionists who witnessed a verbal altercation between a resident and a nurse supervisor (RNS) did not report the incident timely. There was no investigation initiated after the resident informed the Executive Assistant of the allegation. The Administrator alleged that they were not informed of the incident, and the RNS continued to work in the facility after the incident for two days. This was evident for 1 of 3 residents reviewed for Abuse/Neglect (Resident #1). The finding is: The Facility's policy titled Abuse Prohibition dated 2/23/17 documented: Alleged violations involving mistreatment, neglect, or abuse, including injuries of an unknown source, are reported to the Administrator of the facility or his or her designee and other officials. In accordance with State law or regulation, the facility shall ensure timely notification to the Department of Health. Abuse falling under the category of a crime must be reported to the NYSDOH and local law enforcement agency within 2 hours after forming the suspicion if the suspected crime results in serious bodily injury. If there are no serious bodily injuries, the facility must report the suspicion of a crime no later than 24 hours after forming the suspicion. The facility policy further documented that mandatory training shall include identification of possible incidents or allegations that need investigation. The training will inlcude identification of residents at risk for abuse and emphasize to staff and volunteers that they have an obligation to report their knowledge related to allegations without fear or reprisal, and it will describe the process for reporting and investigation of allegations as outlined in the policy. All residents and staff members will be protected from harm during the course of an investigation. The actions taken to protect the resident may differ depending on the person against whom the allegation of abuse is made and may include but are not limited to staff, including companions and volunteers, will be reassigned from the unit or relieved of duty pending the outcome of invetisgation. Resident #1 was admitted with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS used to determine attention, orientation, and ability to recall information) score of 15 out of 15, indicating intact cognition. The Resident required extensive assistance of 1 person for bed mobility, transfer, and toilet use. On 9/1/2020 at 10:33 AM, Resident #1 was interviewed and stated that on 8/29/2020 at around 8 AM, the Night Shift Supervisor shoved and pushed the resident. A few minutes later, when the resident was in the lobby, the resident saw the RNS coming out from the nursing office and started pointing his fingers, shouting, and cursing towards the resident while not allowing the resident to go out on pass. Resident #1 added that the front desk receptionists and the lobby surveillance camera would prove that the RNS was rough on him. The 5th floor surveillance camera footage from 8/29/2020 between the hours of 8:00 AM and 8:30 AM for the 5th floor was viewed. The resident interaction with the RNS was not visible from any of the cameras on the unit. The lobby surveillance camera footage from 8/29/20 at 8:09 AM was viewed, and the RNS was observed pointing his finger and walking towards the resident near the front desk. The Facility Nursing Staff Schedule dated 8/30/2020 and 8/31/2020 documented that RNS was worked at the facility as the 11 PM to 7 AM nightshift nurse supervisor. The RNS was also scheduled to work for the night shift on 9/1/2020. There was no documented evidence that the incident was reported or investigated. On 9/1/2020 at 3:15 PM, the RNS was interviewed and stated that while he was working at the nursing office, Resident #1 was shouting towards him from across the lobby, stating, You should not touch me. You should not push me, and you know you are wrong. The RNS immediately got up from the chair and started approaching the resident. The RNS denied an argument occurred. He stated that he kept apologizing to the resident, and he told the resident he can go out on pass. Then, the RNS walked away and went back to the nursing office. The RNS denied raising his voice or cursing towards the resident. On 9/1/2020 at 12:10 PM, Front Desk Receptionist #1 was interviewed and stated that he heard an argument take place between the Resident and RNS on 8/29/20 in the front lobby. The RNS yelled and cursed back at the Resident. The front desk personnel did not report the incident to anyone until 8/31/20 when he told the Executive Assistant. On 9/1/2020 at 3:14 PM, Front Desk Receptionist #2 was interviewed and stated that she heard Resident #1 stating, Don't put your hands on me, Never do that again, you are not supposed to put your hands on me. Resident #1 and the RNS were observed arguing in the lobby. Receptionist #2 stated that she did not report the incident since it was more like a misunderstanding, and the resident was talking to the RNS. The receptionist felt that the situation was handled because, after the argument, the resident was able to leave out on pass. Receptionist #2 stated that all alleged abuse should be reported to the next chain of command, and if no one responded to her report, she should call 911 herself and report the incident. On 9/1/2020 at 12:47 PM, the Executive Assistant (EA) was interviewed and stated that staff did not report the incident to her. The resident informed her of the incident stating that Resident #1 and the RNS had an altercation on the 5th floor and in lobby. Resident #1 informed the EA that they will report it to the Department of Health. The EA informed the Administrator of the incident around 8/31/2020 at 3 PM inside his office. The EA did not follow-up further after reporting the incident to the Administrator. On 9/1/2020 at 10:15 AM, the Administrator was interviewed and stated that no one reported the incident to him. If he knew about the incident, he and the Nursing Director would have started the investigation. On 9/1/2020 at 12:24 PM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were interviewed and stated no one reported the incident to them. It should have been reported. The staff involved would have been suspended pending investigation, and an immediate investigation would have taken place. 415.4 (b)

Based on observations, record review, and interviews during the second Focused Infection Control Survey (FICS) and Abbreviated Survey (Complaint # NY 253), the facility did not ensure alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, to the Administrator and State Survey Agency. Specifically, a witnessed incident of verbal abuse that occurred 8/29/20 between a resident and the nursing supervisor was not reported to the Administrator and State Survey Agency within 2 hours. This was evident for 1 of 3 residents reviewed for Abuse (Resident #1). The finding is: The facility policy titled Abuse Prohibition dated 2/23/17 documented: Alleged violations involving mistreatment, neglect, or abuse, including injuries of an unknown source, are reported to the Administrator of the facility or his or her designee and other officials. In accordance with State law or regulation, the facility shall ensure timely notification to the Department of Health. Abuse falling under the category of a crime must be reported to the NYSDOH and local law enforcement agency within 2 hours after forming the suspicion if the suspected crime results in serious bodily injury. If there are no serious bodily injuries, the facility must report the suspicion of a crime no later than 24 hours after forming the suspicion. Resident #1 was admitted with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS used to determine attention, orientation, and ability to recall information) score of 15 out of 15, indicating intact cognition. The Resident required extensive assistance of 1 person for bed mobility, transfer, and toilet use. On 9/1/2020 at 10:33 AM, Resident #1 was interviewed and stated that on 8/29/2020, at around 8 AM/8:30AM, there was an altercation that occurrent between him and the Night Shift Nurse Supervisor (RNS) and that he is going to report it to the Department of Health. The resident stated that there are two front desk receptionist and lobby camera to prove of the verbal altercation. The resident added that he reported the incident to the facility executive assistant on 8/31/2020. The NYSDOH intake information Form dated 08/31/2020 documented that there are no facility report. There was no documented evidence the Administrator and NYS DOH was informed about the incident of verbal abuse. There was no documented evidence that an investigation was initiated. On 9/1/2020 at 12:10 PM, Front Desk Receptionist #1 was interviewed and stated that he heard an argument take place between the Resident and RNS on 8/29/20 in the front lobby. The RNS yelled and cursed back at the Resident. The front desk personnel did not report the incident to anyone until 8/31/20 when he told the Executive Assistant. On 9/1/2020 at 3:14 PM, Front Desk Receptionist #2 was interviewed and stated that she heard Resident #1 stating, Don't put your hands on me. Never do that again; you are not supposed to put your hands on me. Resident #1 and the RNS were observed arguing in the lobby. Receptionist #2 stated that she did not report the incident since it was more like a misunderstanding, and the resident was talking to the RNS. The receptionist felt that the situation was handled because, after the argument, the resident was able to leave out on pass. Receptionist #2 stated that all alleged abuse should be reported to the next chain of command, and if no one responded to her report, she should call 911 herself and report the incident. On 9/1/2020 at 12:47 PM, the Executive Assistant (EA) was interviewed and stated that staff did not report the incident to her. The resident informed her of the incident stating that Resident #1 and the RNS had an altercation on the 5th floor and in lobby. Resident #1 told the EA that they will report it to the Department of Health. The EA informed the Administrator of the incident at 8/31/2020 at 3 PM inside his office. The EA did not follow-up further after reporting the incident to the Administrator. On 9/1/2020 at 10:15 AM, the Administrator was interviewed and stated that no one reported the incident to him. If he knew about the incident, he and the Nursing Director would have started the investigation. On 9/1/2020 at 12:24 PM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were interviewed and stated no one reported the incident to them. It should have been reported. The staff involved would have been suspended pending investigation, and an immediate investigation would have taken place. 415.4(b)(2)

Based on record review and interviews conducted during the COVID-19 Focused Infection Control Survey and Complaint Investigation Survey (NY 977) dated [DATE] - [DATE], the facility did not ensure the Office of the State Long-Term Care Ombudsman was notified of resident discharges and transfers. Specifically, the facility did not communicate in writing to the Ombudsman's office when 34 residents were transferred to the hospital. The findings are: The facility Admission, Discharge, Transfer Activity Detail Report documented from [DATE] through [DATE], there were 91 Discharges. Of those 91 Discharges, 34 residents were discharged to the hospital, 27 residents expired, 29 residents had a planned discharge to home, and 1 resident was discharged against medical advice. The facility was unable to provide any documented evidence that they notified the Office of the State Long-Term Care Ombudsman with written communication regarding resident discharges and transfers since [DATE]. During an interview on [DATE] at 12:16 PM the Administrator stated the Admissions Director usually updates the Ombudsman's office every 30 days with all the hospital transfers and discharges. This is done via email communication. He would need to follow up with her to obtain documentation related to the last time this was done. At 3:02 PM, the Administrator confirmed the last communication with the Ombudsman's office took place on [DATE] and the Admissions Director must have been overwhelmed the last few months and has not sent any updates. He will ensure that communication is sent to the Ombudsman. 415.3(h)(1)(iii)(a-c)

Based on observation, interviews and record review conducted during an abbreviated survey (NY 871), the facility did not ensure that a resident received adequate supervision to prevent elopement. This was evident in 1 out of 4 residents sampled (Resident #1). Specifically, Resident #1 eloped from the facility on 08/18/2018 at 11:20AM and the facility staff became aware that Resident #1 was missing at 2:00PM (2 hours 40 minutes) after the resident eloped from the facility. Resident #1 returned to the facility on [DATE] at 4:55PM. The Findings Include: Review of the facility's undated Elopement Policy documented that it is the policy of the facility that residents be maintained in a safe and secure manner and to make every effort to identify residents who have the potential for elopement. Residents will be assessed on admission for the potential for elopement. If residents are identified as potential for elopement, then further assessment will be done in conjunction with the Comprehensive Care Plan team for protective devices. Residents identified as having the potential for elopement will have a care plan meeting to develop a viable interdisciplinary plan in order to protect the residents. Resident #1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 08/14/2018, documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 03/15, associated with severely impaired cognition, (00-07 severe impairment, 08-12 moderate impairment and 13-15 cognitively intact). Resident #1 required extensive assistance of one staff with wheeling and most other areas of his Activities of Daily Living (ADL) needs. Review of the Nursing Admission Record dated 08/07/2018 noted that Resident #1 was not at risk for Elopement. Review of the Nursing Progress Note dated 08/10/2018 at 11:35AM documented that Resident #1 went down to the facility's front door. Resident #1 stated that he wanted to leave the facility to go to 183rd street. Staff were able to redirect the resident to the unit. Resident #1 continued to say that he wanted to leave the facility. The Registered Nurse Supervisor (RNS) was informed and a wander-guard was applied to Resident #1's left lower leg. Review of the Social Service's Progress Note dated 08/10/2018 at 2:08 PM documented that the Social Worker (SW) went to Resident #1's room because the resident verbalized that he wanted to leave the facility. The SW conducted a cognitive Assessment and Resident #1 presented with cognitive impairment. Resident #1 stated that he had to get something, but he didn't know what. Resident #1 was informed that he could not leave on his own. Resident #1 was considered at Risk for Elopement. Review of the Elopement Care Plan initiated on 08/10/2018 documented that Resident #1 was at High risk for Elopement as evidenced by history of attempts to leave the facility's premises. Resident #1 verbalized wanting to go home. The goal was that Resident #1 would not have eloped within the next 90 days. There were no interventions to prevent elopement, documented on the care plan. Review of the Elopement Risk Assessment form from 08/10/2018 to 08/17/2018, revealed that an Elopement Risk Assessment was not updated to reflect Resident #1's attempt to elope from the facility. A physician's orders [REDACTED].#1's wander- guard for placement every shift. Review of the Resident Nursing Instructions from 08/10/2018 to 08/18/2018 at 11:20AM, revealed no instructions for wander-guard monitoring and monitoring of Resident #1's whereabouts to prevent elopement. A Nursing Progress Note dated 08/18/2018 at 4:22PM documented that Resident #1 was noted missing at 2:00PM when staff was giving out nourishment. The Registered Nurse Supervisor (RNS) was made aware and Code E (used for missing person) was activated. 911 was called and their staff members went outside to search the surrounding streets. Review of the printed images from the Facility's Surveillance Video Camera, revealed that Resident #1 was seen standing in front of the facility's front door in the lobby on 08/18/2018 at 11:19AM. The Receptionist was seen sitting behind the front desk in the lobby. The inner door was opened at 11:19AM. Resident #1 was seen walking between the inner and outer door at 11:20AM. Resident #1 was last captured walking on the street in front of the facility on 08/18/2018 at 11:20AM. A Nursing Progress Note dated 08/18/2018 at 5:24PM documented that Resident #1 returned to the facility at 4:55PM, ambulating without any assistive device. Resident #1 was evaluated and was not wearing a wander-guard. Resident #1 stated that he walked to his family member's house. Review of the Facility Occurrence Investigation documented that facility staff discovered that Resident #1 was missing on 08/19/2018 (date error) at 2:00PM. Resident #1 removed his wander-guard, walked out of the facility and went to his family's house. Resident #1 returned to the facility at 4:55PM and was assessed with [REDACTED]. CNA #3 was interviewed on 10/18/2019 at 3:00PM and stated that Resident #1 often stated that he did not want to stay in the facility. She further stated that Resident #1 had prior episodes of leaving the unit and trying to leave the facility. She also stated that Resident #1 did not have a specific monitoring schedule. CNA #3 stated that she last saw Resident #1 around 10:00AM and that he was standing in the doorway of his room. The Receptionist was interviewed on 10/18/2019 at 4:00PM and stated that she was covering the front desk when Resident #1 eloped from the facility on 08/18/2018. She further stated that Resident #1 looked like a visitor and slipped out of the facility when she opened the front door for a visitor. She went on to say that Resident #1 was not wearing a wander-guard, his name was not on the list of Residents at Risk for Elopement and that Resident #1's picture was not at the front desk. CNA #1, assigned to Resident #1 on 08/18/2018 on the 7-3 shift, was interviewed on 10/28/2019 at 3:30PM and stated that she was not familiar with Resident #1. She stated that she was not told that Resident #1 was at risk for elopement. She went on to say that she last saw Resident #1 around 9:30AM on 08/18/2018 prior to his elopement. Upon inquiry, CNA #1 stated that she left Resident #1's lunch tray in his room at around 12:00PM on 08/18/2018. She did not see Resident #1 in the room when she left the lunch tray. She documented that Resident #1 consumed 100% of his lunch. Resident #1's tray was in his room untouched when he was discovered missing. The Assistant Director of Nursing (ADON) was interviewed on 11/22/2019 at 1:13PM and stated that Resident #1 was not identified as at risk for elopement on admission. She further stated that no Elopement Risk Assessment was completed for Resident #1 between 08/08/2018 and 08/18/2018. She went on to say that Resident #1 was not on any documented monitoring prior to his elopement from the facility on 08/18/2018. In addition, no interventions were documented on Resident #1's Risk for Elopement Care Plan prior to 08/18/2018. However, Resident #1 had a wander guard which was checked for placement every shift. 415.12(h)(2)

Based on observations and interview conducted during the recertification survey, the facility did not post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent New York State Department of Health (NYSDOH) survey report and plan of correction was posted for review by residents, staff, and visitors. Specifically, the survey team did not observe survey results posted anywhere in the facility. In addition members of the Resident Council were interviewed and reported that they did not where the survey report was posted or accessible for residents to review. This deficient practice had the potential to affect the entire resident population. The findings are: A facility Policy and Procedure dated 8/25/2017 and related to the Posting of Survey Results documents that it is the policy to post the most recent Department of Health survey results, and the plan of correction, as per federal and state requirements. The results will be made available for examination in a prominent area that is readily accessible to resident, where they do not have to ask any staff member. The prominent location will be on the 1st floor near the elevator, located near the front receptionist. On 6/11/19 09:05 AM the 1st floor area where the results of the most recent survey report is supposed to be kept was observed. At the time of observation the binder was empty and did not contain the most recent survey report or plan of correction. The facility Administrator was shown the empty binder and could not explain why the survey report was missing. On 6/11/19 at 3:28 PM the facility Administrator was interviewed and stated, You showed me that loose leaf binder containing the previous NYS DOH Survey Report was empty and did not contain a copy of the survey. The previous survey is always kept in this loose leaf binder. Someone must have removed it. I don't know how this might have happened. I will immediately place a copy of our last survey in the loose leaf binder. On 06/13/19 at 02:16 PM, a resident council meeting was held with 9 members of the Resident Council including the Resident Council President. The residents that were present were unaware that they had the right to review the previous NYSDOH survey inspection results or where the survey results were posted in the facility. On 06/18/19 at 12:46 PM, an interview was conducted with the Administrator. The Administrator stated that resident's rights are reviewed annually with residents during resident council meetings. The survey results are kept at the front near the elevator on the first floor and he is unsure of how they had gone missing. 415.3(1)(c)(1)(v)

Based on record review and interviews conducted during the recertificaiton survey, the facility did not ensure that Minimum Data Set (MDS) assessments were electronically transmitted to the Centers for Medicare and Medicaid Services (CMS) System. Specifically, 10 of 17 residents reviewed for the Resident Assessment task had MDS assessments submitted later than 14 days after completion. (Residents #1,7, 9, 14 17, 19, 21, 25, 75, 174) The findings include but are not limited to: 1) Resident #9 was admitted on [DATE]. The last quarterly assessment had an ARD(Assessment Reference Date) of 04/12/2019. At the time the State agency came for the recertification on 06/12/2019, the assessment was still incomplete and not transmitted to CMS. The following sections not completed were Section H-bowel and bladder assessment; Section I- incomplete on [DIAGNOSES REDACTED]. 2) Resident #14 was admitted to the facility on [DATE]. The most recent Annual MDS documents a Reference Date of 5/5/2019 and a Completion Due date as 5/17/2019. There was 28 days between the Completion Due date and the Submission Date. The assessment was not completed and submitted until 6/14/19 as per the documentation on the MDS. 3) Resident #21 was admitted to the facility on [DATE]. The most recent Quarterly MDS docments a Reference date of 5/1/2019 and a Completion Due date of 5/8/19. There were 37 days between the Completion Due date and the Submission date. The assessment was not completed and submitted until 6/14/2019 as per the documentation on the MDS. 4) Resident #25 was admitted to the facility on [DATE]. The most recent Quarterly MDS documents a Reference date of 5/4/1019 and a Completion Due date of 5/18/2019. There were 27 days between the Completion Due date and the Submission date. The assessment was not completed and submitted until 6/14/2019 as per the documentation on the MDS. 5) Resident #75 was admitted to the facility on [DATE]. The most recent Annual MDS documents a Reference Date of 4/19/2019 and a Completion Due date as 4/26/2019. There were 49 days between the Completion Due date and the Submission Date. The assessment was not completed and submitted until 6/14/2019 as per the documentation on the MDS. 6) Resident # 174 was admitted to the facility on [DATE]. The admission assessment has an ARD of 02/27/2019. It was completed on 03/05/2019 , with the care plan completed on 03/08/2019 . The assessment was not submitted until 06/04/2019. An interview was conducted with MDS Coordinator #1 on 06/14/19 at 12:48 PM. MDS Coordinator #1 stated that the department does not have a Director but operates under corporate supervision. She stated that there are still some MDS assessments that have been completed but have not been submitted/transmitted because the MDS Coordinators need to review the assessments first. MDS Coordinator #1 stated that she believes the assessments should have been submitted within a month of completion. There are times that they are behind in submitting. When MDS Coordinator #1 started working in the facility, there was an clerk that submitted the MDS assessments. The clerk eventually left the position and the MDS Coordinators had to take on additional tasks including submitting the MDS assessments. The MDS assessments for Resident #14 and Resident #75 have been completed but have not been reviewed or submitted as of yet. MDS Coordinator #1 stated that the MDS Department is behind in submitting MDS assessments right now and there is a backlog that is listed in the SIGMA Electronic Medical Record. The corporate director is aware that MDS assessments are delayed in being transmitted. 415.11 (a)(1-5)

Based on record review and interviews conducted during the recertification survey, the facility did not ensure that Minimum Data Set (MDS) assessments were accurate . This was evident for 2 out of 73 sampled residents reviewed. Specifically: 1. Resident #91, a resident without any recent falls was documented as having a recent fall with injury. 2. Resident # 174 who ambulates freely with supervision in and around the unit was documented on their most recent assessment as needing extensive assist with 1 person. The findings are: 1) Resident #91 was admitted to the facility on [DATE]. The most recent Quarterly MDS assessment dated [DATE] documented that the resident has severely impaired cognition and a [DIAGNOSES REDACTED]. The MDS also documented that the resident had a fall since the last MDS assessment that resulted in injury (except major) - (skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the resident to complain of pain). The Occurrence Comprehensive Care Plan (CCP) related to Falls was initiated on 2/11/18. Notes updating the CCP on 6/15/2018, 7/19/2018, 10/15/2018, 1/6/2019, and 4/07/2019 do not document that the resident had any falls since 2/11/2018. Nursing Notes and Medical Doctor Notes did not document any falls since 2/11/2018. An interview was conducted with the Director of Nursing (DNS) on 06/17/19 at 02:56 PM. The DNS stated that Resident #91 has not fallen since 2/2018. There are also no accident/incident investigations for the resident within the past year. The MDS Department fills out the portion of the MDS that documented a resident's fall status. On 06/17/19 at 03:03 PM, an interview was conducted with MDS Coordinator #2. MDS Coordinator #2 stated that she was the person who filled out the resident's MDS assessment and did complete the section related to whether the resident has had any falls. She acknowledged that this was a mistake and initiated a correction of the MDS. MDS Coordinator #2 stated that she may have been looking at the resident's fall from 2/2018 when she filled out the MDS assessment because the resident did not have a fall. She will usually review the documentation related to the resident in the SIGMA Electronic Medical Record when filling out the MDS assessment. All MDS assessments are reviewed to ensure accuracy prior to being submitted. 2. Resident #174 a [AGE] years old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 dated 2/27/2019 identified the resident as severely impaired with his cognitive skills. Activities of Daily Living (ADL) documented functional activities : needs extensive assist with one (1) person on bed mobility, transfer, walk in room and in corridor, locomotion on and off unit and personal hygiene. However, the same assessment documented that during walking the resident is not steady, but able to stabilize himself without staff assistance (section G0300 Balance during Transitions and Walking). The assessment also documented that the resident does not use any assistive or mobility devices while walking. It documented that the resident no impairment to the lower extremities. Resident #174 was observed by the State Agency Surveyor (SA) from 6/14/2019 to 6/17/2019 at various times of the day. Resident was observed several times, appropriately dressed with a Wanderguard due to his tendency of trying to leave the unit. The resident was observed ambulating independently to and from his room to the dining room at 12:00 PM. After meals, the resident was observed on 06/17/2019 at 3:30 PM ambulating independently from his room to the hallway near the elevator. The resident was then asked by a staff member to please go back to his room, which he did unassisted. On 6/18/2019 at 11:50 AM MDS Coordinator #2 from the corporate office was interviewed and stated, During the time of the MDS period, he looked at the CNA accountability and what was coded. The resident is needing supervision, extensive assist during care and ambulation on and off unit. When asked if his assessment includes observing, or if he saw the resident during care, he answered no, they review staff documentation. On 6/18/2019 at 11:49 AM CNA #2 who is assigned to the resident was interviewed. The CNA stated, the resident is able to do care mostly for himself with some supervision and is able to walk in and out of bed to the bathroom, the dining room, and around the unit by himself. He has a Wanderguard and at times, when he walks near the elevator we redirect him. The CNA accountability record for the assessment period and current, documented that the resident only requires supervision while ambulating. The Comprehensive Care Plan (CCP) for Activities of Daily Living (ADL) dated 2/20/2019 documented that the resident is ambulatory. The CCP documented that the resident required supervision and assistance and setup help for locomotion and transfers. However it does not indicate the level of assistance required as an intervention. 415.11(b)

Based on record review and interviews conducted during the recertification survey, the facility did not ensure that a resident's Comprehensive Care Plan (CCP) was reviewed and revised. Specifically, a resident with Advance Directives in place did not have this reflected on the Advance Directive CCP. This was evident for 1 out of 38 residents reviewed for Care Plans. (Resident #24) The findings are: Resident #24 was admitted to the facility on [DATE]. Her most recent Minimum Data Set ((MDS) dated [DATE] documented that the resident's cognition is intact and that the resident has a [DIAGNOSES REDACTED]. The MDS also documented that the resident's Advance Directives include Do Not Resuscitate (DNR) and Do Not Intubate (DNH). The SIGMA PHI Restriction Alert, a pop-up alert that shows on the computer screen when opening the resident's medical record, documented that the resident has a DNR, DNI, no feeding tube, and comfort measures in place. The physician's orders [REDACTED]. A Medical Orders for Life-Sustaining Treatment form (MOLST) documented that the resident initiated a DNR, DNI, comfort measures only, and no feeding tube on 1/4/19. The MOLST form was updated on 3/18/2019 and 6/4/2019 with no change. Nurse Practitioner notes from 1/6/2019 and 6/11/2019 documented that the resident has a DNR, DNI, and comfort measures in place. A Monthly physician progress notes [REDACTED]. Social Work Quarterly Assessments dated 2/28/2019 and 5/24/2019 do not document that the resident has a DNR, DNI, or comfort measures in place. A CCP related to Advance Directives and initiated on 12/22/2012 documented that the resident is Full Code. An update to the Advance Directive CCP on 4/8/2019 and 6/10/2019 documented that the Resident #24 remains Full Code with no Advance Directives in place. Residents declines to initiate advance directives, resident is full code. An interview was conducted with the Director of Social Work (DSW) on 06/18/19 at 11:31 AM. The DSW stated that he had made an error with regards to documenting the Advance Directive status of Resident #24. He stated that approximately 6 months ago, The Nurse Practitioner (NP) that works with residents covered under the Optum Network began initiating Advance Directives when she would meet with residents and discuss their Advance Directive wishes. As a result, there were some Advance Directives that were initiated that the DSW was not aware of. Prior to this, the SW Department was responsible for generating the MOLST form. The DSW stated that an audit will need to be conducted in order to identify any other discrepancies related to Advance Directive orders and Social Work documentation. The DSW has also discussion with the NP from Optum to make the NP aware that other documentation, such as CCPs, are affected by the initiation of an Advance Directive. The DSW believes that there needs to be a formal process to inform the SW Department if an NP or Medical Doctor initiatives a Advance Directive with a resident. The DSW has now reviewed Advance Directives with Resident #24 again to ensure accuracy and has updated the Advance Directive CCP. It was an oversight that the Advance Directive CCP had not been previously updated. 415.11(c)(2)(i-iii)