Every finding on record at Franklin Center for Rehabilitation and Nursing

Based on observations, interviews, and record review, the facility failed to ensure the residents' right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. This was evident for one (1) of six (6) residents reviewed for Activities of Daily Living out of a total of 38 sampled residents. Specifically, Resident #238 was observed to have their call bell out of reach on multiple occasions.The findings include:The facility policy titled Call Bell - Nurse Call System, with an approval date of 06/11/2025 stated that the facility is committed to maintaining a functional and accessible call bell system in all resident rooms, bathrooms, and common areas, in compliance with federal regulations. The policy also stated that all residents' rooms, bathrooms, and bathing areas must have accessible call devices within reach of the resident, including when lying on the floor. Resident #238 was admitted to the facility with diagnoses including osteomyelitis (a bone infection), diabetes mellitus (a chronic condition that occurs when the body cannot properly use blood sugar), and hypertension (high blood pressure). The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #238 had intact cognition and had functional impairment on both sides of both upper and lower extremities. On 05/13/2026 at 11:06 AM, Resident #238 was observed in bed. Resident's call bell was observed to be wound up and hanging on the wall, out of reach of the resident. Resident #238 was interviewed and stated very often they do not know where their call bell is. Resident #238 also stated that they are able to use the call bell and have used the call bell when it has been available but has resorted to just calling out for the nurses when they need help. On 05/14/2026 at 11:16 AM, Resident #238 was observed in bed. Resident's wheelchair was noted to be placed next to the bed, facing the wall. The call bell was observed to be on the floor, under the wheelchair and out of reach of the resident. On 05/19/2026 at 12:37 PM, Certified Nursing Assistant #9 was interviewed and stated that it is the responsibility of the certified nursing assistants to ensure the call bell is within reach of the resident after giving care or changing the sheets. On 05/19/2026 at 12:40 PM, Registered Nurse #7 was interviewed and stated that Resident #238 used to use their call bell more often when they had a private room but now tends to call out for the registered nurses by name. Registered Nurse #7 was unsure if resident was calling out as a preference of because the call bell was not available. Registered Nurse #7 stated that when Resident #238 calls out, they answer and assist the resident, but they do not always check that the call bell is within reach. On 05/20/2026 at 10:03 AM, the Director of Nursing was interviewed and stated call bells should be within the reach of the resident, and all nursing staff are responsible for ensuring the call bell is within reach of the resident. 10 New York Code, Rules and Regulations 415.5 (e)(1)

Based on record review, observations, and interviews, the facility to ensure it promoted and facilitated resident self-determination through support of resident choice. This was evident for two (2) residents (Resident #13 and #188) of six (6) residents reviewed for Activities of Daily Living out of 38 total sampled residents. Specifically, Resident #13's and Resident #188's bathing preferences were not honored. The findings include:The facility policy titled Activities of Daily Living with an approval date of 02/20/2026 stated the facility will ensure that bathing and showering practices, including frequency, method, timing, and assistance, are individualized, clinically appropriate, and aligned with each resident's preferences and needs. 1.Resident #13 had diagnoses which included paraplegia (paralysis or severe weakness of the lower half of the body), hypertension (high blood pressure), and peripheral vascular disease (blood vessels outside the heart and brain become narrowed or blocked). The Significant Change Minimum Data Set assessment (a resident assessment tool) dated 11/05/2025, documented it is somewhat important for Resident #13 to choose between a tub bath, shower, or sponge bath. The Quarterly Minimum Data Set Assessment (a resident assessment tool) dated 05/02/2026, documented Resident #13's cognition was intact, and resident required moderate assistance from staff for showering. On 05/13/2026 at 9:36 AM, Resident #13 was interviewed and stated they prefer a shower every day and they are only allowed a shower once a week. Resident #13 also stated they spoke to the nursing supervisor and Director of Nursing, and they were told they can only take a shower once a week. A comprehensive care plan for Activities of Daily Living with a last reviewed date of 04/23/2026 documented that Resident #13 required moderate assistance from staff for bathing/showering. The Resident Nursing Instructions dated 04/01/2026 to 05/19/2026 documented Resident #13's bathing type was shower, and the bathing schedule was every week on Friday during the 3:00 PM to 11:00 PM shift. The Resident Certified Nursing Assistant Documentation Record dated 04/01/2026 to 05/19/2026, documented Resident #13 received a shower once per week. Review of progress notes dated 04/01/2026 to 05/16/2026 revealed no documented evidence that Resident #13's shower preference was addressed. On 05/15/2026 at 3:16 PM, Certified Nursing Assistant #8 who works the 3:00 PM to 11:00 PM shift was interviewed and stated Resident #13 is scheduled for showers every Friday on the 3:00 PM to 11:00 PM shift. Certified Nursing Assistant #8 also stated all residents are scheduled showers one time a week either on the day or evening shift. Certified Nursing Assistant #8 further stated if a resident needs an extra shower, the family member has to speak to the nursing supervisor so they can schedule the shower and inform the staff. If the resident is alert, they could give them a shower anytime they request but it all depends on timing. Certified Nursing Assistant #8 stated every resident on the assignment has a shower scheduled so the shower would have to be squeezed in as long as it is not during another resident's scheduled shower. On 05/15/2026 at 3:27 PM, Licensed Practical Nurse #4 who works the 3:00 PM to 11:00 PM shift was interviewed and stated residents are scheduled showers once a week. If a resident wants to take a shower every day and they require one (1) staff to assist them, then they can take a shower every day. Licensed Practical Nurse #4 also stated if the resident requires total care and they repeatedly ask for a shower every day, they can have a shower more often, but they do not know how often. Licensed Practical Nurse #4 further stated if the resident looks like they need a shower their aide will give them a shower. 2. Resident #188 had diagnoses of Alzheimer's disease (progressive brain disease that damages memory and thinking), cerebral infarction (blood flow to part of brain is blocked), and hypertension (high blood pressure). The Quarterly Minimum Data Set Assessment (a resident assessment tool) dated 04/27/2025 documented Resident #188's cognition was severely impaired, and they were dependent on staff for showering. On 05/18/2026 at 3:02 PM, Resident #188's Representative was interviewed and stated Resident #188 receives a shower one (1) day a week. Resident #188's Representative also stated they requested more showers when Resident #188 was admitted , and the nursing supervisor stated Resident #188 can only have a shower one (1) time per week. Resident #188's Representative further stated they wish that Resident #188 could have more showers, so they can feel more comfortable. A comprehensive care plan for Activities of Daily Living with a last reviewed date of 04/27/2026 documented that Resident #188 was dependent on staff for bathing/showering. The Resident Nursing Instructions dated 04/01/2026 to 05/19/2026 documented Resident #188's bathing type was shower, and the bathing schedule was every week on Sunday during the 7:00 AM to 3:00 PM shift. The Resident Certified Nursing Assistant Documentation Record dated 04/01/2026 to 05/19/2026, documented Resident #188 received a shower once per week. Review of progress notes dated 04/01/2026 to 05/16/2026 revealed no documented evidence that Resident #13's shower preference was addressed. On 05/19/2026 at 10:26 AM, Certified Nursing Assistant #6 was interviewed and stated Resident #188 has a scheduled shower day on Sundays. Certified Nursing Assistant #6 also stated If necessary and a resident is really messed up, then they will receive a shower. Certified Nursing Assistant #6 further stated they were unaware that Resident #188's family preferred more than one (1) shower a week. On 05/19/2026 at 10:40 AM, Licensed Practical Nurse #3 was interviewed and stated Resident #188 is scheduled for showers on Sunday mornings. Licensed Practical Nurse #3 also stated Resident #188 receives a shower one (1) time a week and in between they receive bed baths each shift. Licensed Practical Nurse #3 further stated all residents receive showers one (1) time a week, and there are some residents who request more showers, and they will fit the shower into the schedule. Licensed Practical Nurse #3 stated they were unaware Resident #188's family member requested extra showers. On 05/19/2026 at 11:31 AM, Registered Nurse #5, who is also the supervisor, was interviewed and stated all residents receive showers one (1) time per week and Resident #188's shower day is Sunday morning. Registered Nurse #5 also stated Certified Nursing Assistants also give showers as needed. On 05/19/2026 at 3:09 PM, the Director of Nursing was interviewed and stated residents are scheduled one (1) shower a week and as needed. The Director of Nursing also stated if the resident or a resident's family request a shower, the aide has to give the shower. The Director of Nursing further stated they were unaware residents were not receiving extra showers when they were requested. 10 New York Codes, Rules and Regulations 415.5(b)(1-3)

Based on record review, observations, and interviews, the facility failed to ensure that a resident is free from physical restraints imposed for discipline or staff convenience and not required to treat the resident's medical symptoms. This was evident for two (2) residents (Resident #109 and Resident #184) of two (2) residents reviewed for Physical Restraints out of 38 sampled residents. Specifically, 1). Resident #184 was observed on several occasions, lying on a perimeter mattress and, 2). Resident #109 was observed on two occasions, lying on a perimeter mattress with an armchair and pillow wedged on the left side of the bed, in between the upper part of resident's bed and the window area. The findings include: The facility's policy titled Use of Restraints with an approval date of 03/06/2026 stated that a restraint is any physical or mechanical device or intervention that restricts a resident's freedom of movement or access to his/her body. The policy also stated that interventions/devices that may be considered restraints include but are not limited to chairs that prevent movement and cushions used to restrict mobility. The policy further stated devices that do not restrict purposeful movement and instead provide protective positioning or sensory/tactile cues are not considered restraints. These include but are not limited to perimeter mattresses. 1. Resident #184 had diagnoses which included Cerebrovascular Accident (a sudden disruption in blood flow to the brain which can lead to complications) , Aphasia (language condition that affects the ability to communicate effectively), Hemiplegia (paralysis or weakness affecting one side of the body), and Seizure Disorder. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #184 had severely impaired cognition, required dependent assistance of staff for personal hygiene and transfer, and had limited range of motion on one side of upper extremity and both sides of lower extremity. On 05/13/2026 at 11:40 AM, Resident #184 was observed in bed, alert and awake. Resident #184 appeared confused, was unable to make verbal or nonverbal communication when called by their name. Resident #184 was observed with a perimeter mattress on top of bed, which was raised along both sides, the top and the bottom of the mattress. The mattress also appeared to have built-in side bolsters, while the middle surface is flat. On 05/14/2026 at 09:55 AM, Resident #184 was again observed in bed with a perimeter mattress. Review of physician orders revealed there was no order for the use of a perimeter mattress. The Restraint/Device Assessment Evaluation dated 12/06/2024 document that Resident #184 was unable to understand and recall purpose and safe use of device, and why alternatives were inappropriate or ineffective to prevent use of restraint, and resident continues to slide to the edge of the bed without the perimeter. There was no further assessment completed for Resident #184. The Comprehensive Care Plan titled Occurrence and at Risk for Occurrence with effective date of 02/29/2021, and last revised on 01/01/2026, documented the Resident become frail, experience weakness of limbs, loss of muscle strength or coordination; may also be unable to think, understands as clearly as once could ,unable to adapt to new environment/ limited functional status & performance; has adverse effect of medication, this put the resident at risk for fall and injury. Interventions and measures are placed to monitor resident to minimize the risk of occurrence and injury. Interventions include, provide resident a concave/scoop mattress or perimeter mattress cover. On 05/15/2026, at 11:57 AM, an interview was conducted with Certified Nursing Assistant #1 who stated Resident #184 is confused and cannot follow simple instruction. Certified Nursing Assistant #1 also stated Resident #184 is totally dependent on staff and transferred with a Hoyer lift. Certified Nursing Assistant #1 further stated Resident #184 had been on perimeter mattress for a long time, and they believed it was to prevent fall. Certified Nursing Assistant #1 monitoring the use of a perimeter mattress is not included in their daily tasks in the electronic medical record. On 05/15/2026 at 12:01 PM, an interview was conducted with Licensed Practical Nurse #1 who stated Resident #184 is confused and cannot make their needs known to staff. Licensed Practical Nurse #1 also stated Resident #184 had no awareness of their surroundings and sometimes moves their legs to the side of bed, attempting to get off bed, so the perimeter mattress is used to protect them. On 05/15/2026 at 12:30 PM, an interview was conducted with Registered Nurse #1, the Charge Nurse, who stated that resident is confused, stated Resident #184 is nonverbal, is transferred with a mechanical lift with two staff and has had no recent falls. Registered Nurse #1 also stated Resident #184 uses a perimeter mattress for fall safety, and they are not responsible for the ongoing assessment of use of the perimeter mattress. On 05/18/2026 at 12:24 PM, an interview was conducted with Registered Nurse #2, the Nursing Supervisor, who stated that the purpose of the mattress is to prevent falls. Registered Nurse #2 also stated Resident 184 had a diagnosis of seizures, was confused and had weakness of their body, and they could fall. Registered Nurse #2 further stated they reviewed Resident #184's chart and realized that the last Restraint/Device Assessment Evaluation was completed on 12/06/2024. Registered Nurse #2 concluded that there should have been assessments completed every quarter, and the facility usually does not have physician orders for a perimeter mattress. On 05/18/2026 at 01:14 PM, an interview was conducted with Registered Nurse #3, the Nurse Educator, who stated that the perimeter mattress is a sensory mattress, which alerts the resident and provides sensory feedback for the edges of the bed to prevent them from getting out of bed. Registered Nurse #3 also stated that once the resident pulls to the side of the bed and their body touches the mattress, it gives them a sensation and will prevent them from coming out of the bed. Registered Nurse #3 further stated that a restraint/device assessment is needed every quarter and annually, but they could not explain why there was no ongoing assessment since 2024. Registered Nurse #3 stated that the facility do not have physician's order for the use of perimeter mattress. On 05/20/2026 at 11:50 AM, an interview was conducted with the Director of Nursing who stated that perimeter mattresses were never identified as a restraint, the mattress is there for safety awareness and as a bed boundary. The Director of Nursing also stated that an ongoing restraint/device assessment should be conducted every quarter and annually, but they could not explain why the assessment was missed. 2. Resident #109 had diagnoses which included quadriplegia (paralysis or severe weakness in all four limbs), neuropathic pain (burning, tingling, shooting, or electric shock sensations caused by damage or problems in the nerves), and muscle spasticity (muscles move in an involuntary, sometimes jerky way). On 05/13/2026 at 10:18 AM and on 05/15/2026 at 9:40 AM, Resident #109 was observed lying on a perimeter mattress with an armchair and pillow wedged on the left side of the bed, in between upper part of the resident's bed and the window. The Significant Change Minimum Data Set assessment (a resident assessment tool) dated 03/27/2026 documented Resident #109 had intact cognition, was dependent on staff for bed mobility and transfers, and no restraints used. What was documented for ROM? The Restraint/Device Assessment Evaluation dated 02/17/2026 documented Resident #109 had been assessed, and the purpose of the perimeter mattress would be to provide sensory feedback for edges of bed. Resident #109 was able to understand and recall purpose for and safe use of device. The device was not considered a restraint because it does not prevent purposeful exit from and entry to bed, does not restrict access to body, and does not restrict purposeful movement. A comprehensive care plan titled Occurrence and at risk for occurrence with a last reviewed date of 02/20/2026 documented Resident #109 had a fall out of bed on 02/17/2026 with no injury. Interventions included provide Resident #109 with a perimeter mattress cover to maintain bed boundaries, floor mats on both sides of bed, and bed at lowest position. Review of the progress notes did not reveal any education provided to Resident #109's spouse regarding the unsafe practice of wedging the chair and pillows in between bed and window area. There was no documented evidence of a Physician's order for the use of a perimeter mattress and of the medical necessity for use of the perimeter mattress. On 05/14/2026 at 11:34 AM, Resident #109's spouse was interviewed and stated they visit Resident #109 every day until about 11:00 PM when Resident #109 falls asleep. Resident #109's spouse also stated Resident #109 fell out of bed in the past and they are afraid Resident #109 will have another fall. Resident #109's spouse further stated they set up the chair before they leave at night, so the back of the chair is against the bed to prevent Resident #109 from falling. Resident #109's spouse further stated a staff member on the second floor showed them how to set up the chair like that and they do not know their name. On 05/15/2026 at 11:35 AM, Certified Nursing Assistant #2 was interviewed and stated Resident #109's spouse is scared Resident #109 will fall and therefore places the chair against the bed to prevent Resident #109 from falling. Certified Nursing Assistant #2 stated they think Resident #109 needs side rails instead of the mattress pillows. On 05/15/2026 at 12:09 PM, Licensed Practical Nurse #2 was interviewed and stated Resident #109 does not try and get out of bed. Licensed Practical Nurse #2 also stated Resident #109's spouse wedges the armchair in between the bed and the window area and informed them they put the chair there to feel better when they leave. Licensed Practical Nurse #2 further stated they told Resident #109's spouse to position the chair so they can reach the resident to administer medications. Resident #109 has not had a fall on this floor. On 05/15/2026 at 2:49 PM, Registered Nurse #2, who is the supervisor, was interviewed and stated they thought Resident #109's spouse moved the chair by the bed for space when they were visiting. Registered Nurse #2 also stated Resident #109 could hurt themself on the wedged chair if they fell out of the bed. Registered Nurse #2 further stated Resident #109 has a perimeter mattress for sensory feedback, so if they roll it will alert them, and the perimeter mattress does not prevent Resident #109 from getting out of bed. Registered Nurse #2 stated there is no doctor's order in Resident #109's medical record for the perimeter mattress, and there is an assessment for the perimeter mattress dated 02/17/2026 that documents Resident #109 will continue to slide to edge of bed without the mattress. Registered Nurse #2 also stated the perimeter mattress is not considered a restraint because it does not restrict purposeful movement and does not prevent exit or entry to bed. On 05/19/2026 at 2:58 PM, the Director of Nursing was interviewed and stated the chair is not supposed to be against the bed because there is an injury risk. The Director of Nursing also stated the perimeter mattress is not a restraint because Resident #109 can get over the mattress since it is not high. The Director of Nursing also stated the perimeter mattress is for Resident #109 to feel and realize that they are at the edge of the bed, and they have a bedside mat and very low bed for safety as well. 10 New York Codes, Rules, and Regulations 415.4(a) (2-7)

Based on record review and interviews, the facility failed to ensure that residents comprehensive care plans were reviewed and revised to reflect the resident's status after each assessment. This was evident for one (1) resident (Resident #68) of two (2) residents reviewed for Activities, and one (1) resident (Resident #4) of two (2) residents reviewed for Urinary Catheter, out of 38 sampled residents. Specifically, 1). the comprehensive care plan for Activities for Resident #68, and 2). the comprehensive care plan for bladder care for Resident #4 were not revised after each assessment. The findings include but were not limited to: The facility policy titled Care Planning-Conferences with an approval date of 03/05/2026 documented the facility shall develop, implement, maintain, and timely update a comprehensive, interdisciplinary, and person-centered care plan for each resident based on thorough assessment of the resident's clinical needs, functional status, and individual preferences, to ensure the provision of care and services necessary for each resident to attain or maintain their highest practicable physical, mental, and psychosocial well-being, with active participation of the resident and/or their representative, and ongoing review and revision on Admission, Quarterly, Annually, and whenever there is a significant change in condition, resident preferences, or effectiveness of interventions. 1.Resident #68 had diagnoses of cerebral vascular accident (brain cells damaged due to blocked blood flow or burst blood vessel), vascular dementia (memory loss and thinking decline caused by reduced blood flow to the brain), and dysphagia (difficulty swallowing). The Quarterly Minimum Data Set assessment (a resident assessment tool) dated 02/10/2026 documented Resident #68 was severely cognitively impaired. The Care Plan with focus Activities was effective on 03/18/2024 and the last review note was dated 11/20/2024. There was no documented evidence that the Activities Care Plan had been reviewed and revised since the Annual assessment on 12/04/2024. On 05/20/2026 at 10:08 AM, the Director of Therapeutic Recreation was interviewed and stated that usually care plans are updated or reviewed quarterly and on an as needed basis. The assigned recreation leader is responsible to update and review the care plans, but they were out for a while. The Director of Therapeutic Recreation also stated they have been completing the activity assessments timely but got sidetracked. The Director of Therapeutic Recreation further stated they are responsible to check to make sure the activities care plans are updated or reviewed. 2. Resident #4 was admitted to the facility with diagnoses including diabetes mellitus (a condition where the body cannot properly use blood glucose), and hypertension (high blood pressure). The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #4 was severely cognitively impaired and dependent on staff for toileting hygiene. A physician's order dated 05/12/2026 documented Amoxicillin/Clavulanate 875/125 milligrams, give 1 tablet every 12 hours by oral route for 10 days for urinary tract infection. The care plan titled, Bladder elimination/indwelling catheter/genitourinary status was initiated on 12/21/2021. The last update/review note for the care plan was dated 12/2/2024. There was no documented evidence that the care plan was reviewed or revised after each assessment On 05/19/2026 at 10:12 AM, Registered Nurse #7 was interviewed and stated that care plans are initiated for recurring conditions, such as skin conditions or recurring infections. Registered Nurse #7 also stated that the nursing supervisors are responsible for updating the care plans, but that care plans should be updated quarterly. Registered Nurse #7 further stated that given Resident #4 had a urinary tract infection, the care plan should have been updated since December 2024. On 05/19/2026 at 12:19 PM, Registered Nurse #10, who is the nursing supervisor, was interviewed and stated it is their responsibility to update care plans. Registered Nurse #10 also stated that care planning meetings involve the resident and/or the resident's representative, as well as the interdisciplinary team including nursing, rehabilitation, dietitian, and social worker. Registered Nurse #10 further stated that any updates to care, including monitoring and evaluation of interventions should be documented in the care plan. Registered Nurse #10 stated they had not reviewed and/or updated the care plans as often as they would have liked to. Registered Nurse #10 reviewed the electronic medical record and stated that the care plan for bladder elimination should have been updated, especially since Resident #4 recently had a urinary tract infection. On 05/20/2026 at 10:03 AM, the Director of Nursing was interviewed and stated that care plans should be updated quarterly, or if there is a significant change in the resident's condition. The Director of Nursing further stated that the nurses and the nursing supervisors may update the care plans. The Director of Nursing further expressed disappointment that care plans had not been updated in a timely manner. 10 New York Codes, Rules and Regulations 415.11(c)(1)

Based on observation, interviews, and record review, the facility failed to ensure that services provided meet professional standards of quality. This was evident for two (2) residents (Residents #7 and #28) observed during Medication Administration. Specifically, 1) Registered Nurse #8 was observed administering intravenous medications without flushing the access line, and 2) Registered Nurse #7 was observed administering multiple medications via gastrostomy tube without flushing the tube with water before and after each medication. The findings include:The standard of practice for maintaining the patency of intravenous catheters, as defined by the Infusion Therapy Standards of practice published by the Infusion Nurses Society in 2024, dictates the administration of antibiotics via the sequence of, saline-administer-heparin-saline, is a standardized flushing sequence designed to maintain vascular access patency, prevent occlusion, and ensure safe medication administration. The standard of practice for preparing and administering medications via enteral tube, as defined by the American Society of Parenteral and Enteral Nutrition, in conjunction with the Institute of Safe Medication Practices' publication in 2022, is that the tube must be manually flushed with at least 15 milliliters of purified water before and after each medication. Medications should not be mixed together in order to prevent drug-drug interactions which can interfere with the intended therapeutic response or form precipitates that may clog the feeding tube. The facility policy titled, Intravenous Therapy, with an approval and implementation date of 11/2008, documented that the licensed nurse will observe all resident's safety and infection control principles in intravenous insertion and administration of intravenous infusion and medications. The administration of intravenous medication procedure detailed in the policy did not provide documented guidance to flush the access line to ensure the line remains clear with proper catheter function for safe medication delivery and for reduced risk of infection. The facility policy title, Feeding Tubes Enteral - Nutrition and Medication, with an approval date of 09/29/2025, documented that the facility will ensure that a resident who is fed by enteral feeding tube shall receive the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, significant regurgitation, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers, and to restore, if possible, normal feeding function. The Medications via Gastrostomy Tube: Guidelines for Administration, procedure detailed in the policy documented the administration procedure begins with thirty to fifty (30-50) milliliters of water flush. Then using a sufficient volume of fluid (which will depend on the individual medication), mix each medication with water, and pour into tube. Flush in between each medication with minimum ten to fifteen (10-15) milliliters of water. After last medication is administered, flush with thirty to fifty (30-50) milliliters of water. 1.Resident #7 was admitted to the facility with diagnoses including chronic lung disease, respiratory failure, and atrial fibrillation.The doctor's order with start date 05/10/2026 instructs midline flush using SASH (saline, antibiotic, saline, heparin) before and after administration of medication until complete and to schedule frequency as per antibiotic order. The physician's order with a start date of 04/26/2026 documented piperacillin-tazobactam 3.375-gram intravenous solution to be infused every six (6) hours for six (6) weeks. On 05/18/2026 at 11:30 AM, Registered Nurse #8 was observed preparing and administering piperacillin-tazobactam 3.375-gram in normal saline intravenously to Resident #7. Registered Nurse #8 mixed and prepared the medication and placed medication, two saline flushes, one heparin flush, one tubing set, and alcohol pads in a cleaned tray and proceeded to enter Resident #7's room. Registered Nurse #8 failed to flush the midline with saline prior to attaching the primed line of antibiotic. After administering the medication, Registered Nurse #7 threw away the supplies left on the tray and cleaned the tray. On 05/18/2026 at 4:34 PM, Registered Nurse #8 was interviewed and stated that they performed the SASH order in the morning to check the patency of the midline. The further stated they forgot to flush the midline with saline prior to administering the intravenous antibiotic. On 05/19/2026 at 3:10 PM, Registered Nurse #11, the nursing supervisor for Unit Two (2), was interviewed and stated SASH order must be performed to ensure the patency of the midline, and it should be performed for each antibiotic administration. 2. Resident #28 was admitted to the facility with diagnoses including seizure disorder, malnutrition, and gastroesophageal reflux disease. On 05/19/2026 at 8:47 AM, Registered Nurse #7 was observed performing medication administration for Resident #28. Registered Nurse #7 was observed to appropriately prepare ten medications for administration. When initiating administration via gastrostomy tube, Registered Nurse #7 stopped the tube feed and administered approximately fifteen (15) milliliters of water. Then Registered Nurse #7 proceeded to administer each medication via gastrostomy tube one after the other, failing to flush the tube with water after each medication. After all medications were administered, Registered Nurse #7 poured approximately fifty (50) milliliters of water into the tube, then an additional forty (40) milliliters before restarting the tube feeding. On 05/19/2026 at 10:09 AM, Registered Nurse #7 was interviewed and stated that usually the gastrostomy tube would be flushed with water, then medications would be administered one by one, and finally the tube would be flushed with water at the end. They admitted that flushing between medications is done sometimes but admitted they did not flush between medications for Resident #28 because the resident was receiving a lot of medications. On 05/19/2026 at 12:19 PM, Registered Nurse #10, who is the nursing supervisor for Unit Three (3) was interviewed and stated that when administering medications via gastrostomy tube, first the tube would be flushed with at least thirty (30) milliliters of water, the medications may be administered, and then the tube would be flushed again with at least thirty to fifty (30-50) milliliters of water. They also stated that water should be flushed between medications to ensure that there is no residual medication is in the tube. They further stated that the facility's policy states that water flushed should be performed between medications. On 05/20/2026 at 10:30 AM, Registered Nurse #6 was interviewed and stated that water flushes between medications during medication administration does not require an order because it is part of the facility's protocol. On 05/20/2026 at 10:03 AM, the Director of Nursing was interviewed and stated SASH order must be performed for every antibiotic administered intravenously. The Director of Nursing stated that for gastrostomy tube medication administration, thirty (30) milliliters of water should be used to initially flush the tube, then medications may be administered one at a time with water flushes in between. If there is noticeable medication left in administration cup, then more water should be used to dissolve the medication, and it should be administered. This should be done to ensure that the full intended dose has been administered. After medications are given, the tube should be flushed again with water. They also stated that gastrostomy tube medication administration had recently been in-serviced for nursing staff about a month ago. On 05/20/2026 at 1:16 PM, Nurse Practitioner #2 was interviewed and stated that they know gastrostomy tubes must be flushed with water before and after medications and that orders are written for flushes to be done daily. They stated there is no specific order for flushes to be done in between medications but that it is protocol. 10 New York Code Rules and Regulations 415.11 (c)(3)(i)

Based on observation, interviews, and record review, the facility failed to ensure that residents receive the appropriate treatment and services to prevent complications of enteral feeding. This was evident for two (2) residents observed during Medication Administration. Specifically, 1). Registered Nurse #8 did not check for patency and placement of the Resident #7's gastrostomy tube (a surgically placed tube that delivers nutrition, fluids, and medications directly into the stomach) prior to administering medications, and 2). Registered Nurse #9 checked for patency and placement of Resident #28's gastrostomy tube by auscultation (listening to sounds with a stethoscope).The findings include:The facility's policy titled Feeding Tubes Enteral - Nutrition and Medication, approved 09/29/2025 stated the facility will ensure that a resident who is fed by enteral feeding tube shall receive the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, significant regurgitation, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers and to restore, if possible, normal feeding function. The policy also stated in the procedure titled, Meds via Gastrostomy Tube: Guidelines for Administration, that the gastrostomy tube must be checked for placement and patency before administering medications. The policy detailed the procedure to check for placement and patency as follows: A) Review and ensure that the resident is positioned properly to allow flow thru the tube and limit potential for possible crimping; B) if feeding in progress, stop the feeling flow and rinse the tube with 30-50cc of water; C) check the length of the tube outside the body remains constant and the suture intact, then by attaching a syringe, aspirate a small amount of stomach contents; D) if aspiration of stomach contents any way indicated that the placement of the tube is incorrect, stop. Contact a nursing supervisor immediately for assistance. If tube is determined to be placed correctly, then the policy instructs to proceed with medication administration procedures. 1. Resident #7 was admitted to the facility with diagnoses including chronic lung disease (a progressive lung disease characterized persistent airflow limitation), respiratory failure (difficulty breathing), and atrial fibrillation (irregular heart rhythm).On 05/18/2026 at 4:07 PM, Registered Nurse #8 was observed performing medication administration for Resident #7. Registered Nurse #8 did not check the patency and placement of the resident's gastrostomy tube prior to administering medication through the tube. On 05/18/2026 at 4:38 PM, Registered Nurse #8 was interviewed and stated that they checked the patency of Resident #7's gastrostomy tube in the morning at the beginning of their shift. Registered Nurse #8 also stated that the patency of the tube should have been verified prior to medication administration and that they had forgotten to do it when they were observed. On 05/19/2026 at 3:15 PM, Registered Nurse #11, who is a Nurse Supervisor, was interviewed and stated that for gastrostomy tube medication administration, the patency of the tube may be checked by auscultation. Registered Nurse #11 also stated that auscultation was the method they had learned and was not aware that it was no longer the recommended method of checking patency and placement. 2. Resident #28 was admitted to the facility with diagnoses including seizure disorder (unprovoked seizures caused by abnormal brain activity), malnutrition (imbalance of nutrients the body needs and obtains), and gastroesophageal reflux disease (a chronic condition where stomach acid flows back into the esophagus). On 05/18/2026 at 3:44 PM, Registered Nurse #9 was observed performing medication administration for Resident #28. Registered Nurse #9 checked the patency and placement of the resident's gastrostomy tube via auscultation (listening for sounds such as air flow with a stethoscope). After medication administration, Registered Nurse #9 was interviewed and stated that they checked for patency by auscultation and listened for air flow to ensure proper placement. Registered Nurse #9 further stated they did not know that checking for patency via auscultation was no longer recommended. On 05/19/2026 at 12:15 PM, Registered Nurse #10, who is a Nurse Supervisor for the unit, was interviewed and stated the patency of the tube must be checked prior to administering medications when giving medication by gastrostomy tube, to ensure that the tube has not been dislodged or that it is not clogged. Registered Nurse #10 also stated it is not possible to know if medications or enteral feedings are entering the stomach without checking the placement of the tube. Registered Nurse #10 further stated that the facility policy states that the placement and patency must be checked prior to medication administration and that patency may be checked by either auscultation or by measuring residual volume. On 05/20/2026 at 10:03 AM, the Director of Nursing was interviewed and stated that prior to medication administration via gastrostomy tube, the patency of the tube must be verified, which is done by aspiration and checking the residual stomach contents. If the residual contents are over 150 milliliters, then it must be reported to the medical provider. If the residual is not concerning, then the tube is patent, and medications may be administered. The Director of Nursing further stated that patency and placement should not be checked via auscultation, but rather by checking gastric residual volume. The Director of Nursing stated they were not aware that registered nurses were still performing patency and placement check via auscultation. The Director of Nursing also stated that the nursing staff had been in-serviced about a month prior on checking the patency and placement of gastrostomy tubes by the staff educator. On 05/20/2026 at 1:16 PM, Nurse Practitioner #2 was interviewed and stated that it is important for check for patency and placement of gastrostomy tubes to ensure residents are safely receiving feeds and medications. Nurse Practitioner #2 also stated that there are orders for water flushes to be done to ensure the tube is not clogged but there is not a specific order to check for patency prior to medication administration as that is the facility policy. 10 New York Code Rules and Regulations 415.12(g)(2)

Based on record review, observations, and interviews, the facility failed to ensure that drugs and biologicals were stored in locked compartments. This was evident for one (1) unit (Unit 6) of eight (8) units observed for Medication Storage. Specifically, seven (7) blister packs of medications and a bag containing several vials of unmixed antibiotics for several residents were observed in an open box in an unlocked nursing supervisor's office which was located across from the nurse's station on Unit 6.The findings include:The facility policy titled Medication Storage Guidelines with an approval date of 03/10/2026 stated all drugs and biologicals are to be stored in a secure and orderly manner under proper temperatures and are to be accessible only to licensed nursing and pharmacy personnel.On 05/13/2026 at approximately 12:30 PM, the New York State Department of Health Life Safety Surveyor reported to the State Surveyor that they observed medications in a box in the Unit 6 nursing supervisor's office.On 05/13/2026 at 12:53 PM, Registered Nurse #5, who is the supervisor, was observed exiting the Unit 6 nursing supervisor's office and then returned to the office at 12:55 PM. The office was left unlocked, there was no staff present, and medications were left unattended, not supervised by staff. During this period staff had passed by the nurse's station area intermittently. On 05/13/2026 at 1:24 PM, Registered Nurse #4 was observed in the Unit nursing supervisor's office. There were several blister packs of medications for Residents #26, #59, and #253 including Omeprazole, Famotidine, Icosapent, Escitalopram, and Amlodipine and a bag with several vials of unmixed antibiotics for Resident #47 consisting of [NAME]/Tazobactam (Zosyn) in a cardboard box in the corner of the office. Registered Nurse #4 was interviewed immediately and stated these medications were supposed to be brought down to the nursing supervisors office on the main level to be returned to the pharmacy. Registered Nurse #4 also stated the Unit 6 nursing supervisor's office door is kept unlocked throughout their shift because nurses come and go.On 05/13/2026 at 1:29 PM, Registered Nurse #4 was observed exiting the Unit 6 nursing supervisor's office and then returned to the office at 1:33 PM. The office was left unlocked, with no staff present, and medications were left unattended, not supervised by staff. During this period had staff passed by the nurse's station area intermittently. On 05/15/2026 at approximately 12:40 PM, Registered Nurse #5 was interviewed and stated the nurses had collected all discontinued and expired medications on the unit and placed them in the Unit 6 nursing supervisor's office to be brought down by the night shift to the nursing office on the main floor. Registered Nurse #5 also stated the Unit 6 nursing supervisor's office door is always locked, and the Certified Nursing Assistants keep their personal belongings in there as well. Registered Nurse #5 was unable to explain why the State Surveyor observed the office door unlocked on more than one occasion with medications unattended inside.On 05/20/2026 at 12:51 PM, the Director of Nursing was interviewed and stated the nurses are instructed to bag the discontinued and expired medications and then bring them downstairs to the nursing office so they can be returned to the pharmacy. The Director of Nursing also stated medications are not supposed to be kept in the unit nursing supervisor's office. The Director of Nursing further stated if there was an emergency and they had to place the medications in the unit nursing supervisor's office, then they should lock the door.10 New York Codes, Rules and Regulations 415.18(e) (1-4)

Based on observation, interviews, and record review, the facility failed to maintain medical records that are accurately documented. This was evident for one (1) out of three (3) residents (Resident #28) reviewed for Tube Feeding out of a total of 38 sampled residents. Specifically, Resident #28's medication orders inaccurately documented to be given by oral route when medications were being given by gastrostomy tube (a flexible tube placed in the stomach for feeding, hydration and medication administration). The findings include: The facility policy titled Physicians Orders, with an implementation date of 05/07/2012 and approval date of 04/05/2026 stated that the facility will ensure that physician orders are timely and accurately carried out. The policy also stated the physician should provide clear medication orders to avoid misinterpretation and potential medication errors. The facility further stated that it is the physician's responsibility to review, enter and approve orders into the electronic medical record and that the nurse's responsibility is to pick up the order which transcribes the order into the medication and/or treatment administration record. Resident #28 was admitted to the facility with diagnoses including hypothyroidism (a condition where the thyroid gland does not produce enough thyroid hormone), and seizure disorder (unprovoked seizures caused by abnormal brain activity), and malnutrition (imbalance of nutrients the body needs and obtains).A physician's order dated 04/07/2026 documented Levothyroxine 150 microgram tablet, give one tablet by oral route every day. A physician's order dated 05/05/2026 documented Keppra 100 milligram per milliliter oral solution, give one (1) milliliter by oral route three times a day. On 05/19/2026 at 8:55 AM, Registered Nurse #7 was observed preparing and administering medications for Resident #28. Levothyroxine 150 microgram tablet was crushed and administered via gastrostomy tube. On 5/19/2026 at 11:04 AM, Registered Nurse #7 was interviewed and stated that the medication administration process included identifying the patient and ensuring the medication order is for the right patient, right medication, right dose, right time, and right route. Upon review of physician orders, Registered Nurse #7 stated that they did not notice the route documented for medication orders of levothyroxine tablets and Keppra oral solution was documented to be oral instead of gastrostomy tube. Registered Nurse #7 further stated that they have been giving all medications for Resident #28 via gastrostomy tube. Registered Nurse #7 stated that it is the nurse's responsibility to update the nursing supervisor, or the medical provider that the medication was ordered incorrectly. On 05/19/2026 at 12:19 PM, Registered Nurse #11, who is the nursing supervisor, was interviewed and stated that it is the nurses' and the nursing supervisor's responsibility to note and update medication orders if the route is incorrect. Registered Nurse #11 also stated that at times the medical provider may not realize that the route of administration was entered incorrectly. On 05/20/2026 at 1:16 PM, Nurse Practitioner #2 was interviewed and stated that nursing supervisors place orders, and the nurse practitioners and doctors review orders and sign them. Nurse Practitioner #2 also stated that the nurses or nursing supervisors can let the medical providers know when a change in the order needs to be made. Nurse Practitioner #2 further stated that since Resident #28 did not have a gastrostomy tube on a previous admission to the facility, it is possible that the provider who put in the order and/or signed the order did not remember that the gastrostomy tube was in place and ordered medications via oral route. On 05/20/2026 at 10:03 AM, the Director of Nursing was interviewed and stated that when administering medications, the first step is to check the medication order and ensure that it is for the right patient, the right medication, the right dose, the right route and the right time. The Director of Nursing also stated that nurses and nursing supervisors can identify that a medication order was written for the wrong route and can make the provider aware that it needs to be changed. 10 New York Codes, Rules and Regulations 415.3.(e)(1)

Based on observation, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This was evident for one (1) resident observed during Medication Administration. Specifically, Registered Nurse #8 was observed changing gloves multiple times during medication administration without performing hand hygiene between glove changes. The findings include: The facility policy titled Hand Hygiene, effective 12/07/2021 and last revised 03/05/2026, stated that all members of the healthcare team will comply with current Centers for Disease Control and Prevention hand hygiene guidelines as effective hand hygiene reduces the incidence of healthcare associated infections. The indications for handwashing and hand rubbing listed in the policy both include after glove removal as a clinical situation where hand hygiene is appropriate. The policy also stated that the use of gloves does not eliminate the need for hand hygiene and hands should be decontaminated after removing gloves. The policy further stated that during medication preparation and administration, after gloves are removed, hand hygiene is to be performed before moving on to the next task or resident. 1. Resident #7 was admitted to the facility with diagnoses including chronic lung disease (a progressive lung disease characterized persistent airflow limitation), respiratory failure (difficulty breathing), and atrial fibrillation (irregular heart rhythm). On 05/18/2026 at 4:10 PM, Registered Nurse #8 was observed administering three medications via gastrostomy tube (a tube inserted into the stomach to provide direct access for feeding, hydration or medication administration) for Resident #7. Registered Nurse #8 was observed performing three (3) glove changes during the medication administration and did not perform hand hygiene between any glove change. On 05/18/2026 at 4:34 PM, Registered Nurse #8 was interviewed and stated that hand hygiene should be performed between glove changes. Registered Nurse #8 also stated they were rushing and were nervous during medication administration observation and so forgot to perform hand hygiene. The document titled Hand-Washing Competency for Registered Nurse #8 dated 06/06/2026 documented the observation was satisfactory. On 05/19/2026 at 3:15 PM, Registered Nurse #11, who is the nursing supervisor, was interviewed and stated that hand hygiene should be performed before entering and after exiting the resident's room, before medication preparation and administration, and before and after gloves are worn. On 05/20/2026 at 10:03 AM, the Director of Nursing was interviewed and stated that hand hygiene should be performed prior to entering a resident's room, prior to preparing medications, and between glove changes. The Director of Nursing also stated that if handwashing cannot be performed, alcohol-based hand sanitizer is available on every medication cart. On 05/20/2026 at 1:10 PM, Registered Nurse #3, who is also the Infection Preventionist, was interviewed and stated that hands must be washed prior to medication preparation and that after about five uses of hand sanitizer. Registered Nurse #3 also stated that after gloves are removed, hand hygiene must be performed before a new set of gloves can be put on. 10 New York Code Rules and Regulations 415.19 (b)(4)

Based on observation, record reviews, and interviews, conducted during a survey, the facility failed to ensure that a resident was free from physical abuse. This was evident for one (1) out of seven (7) residents (Resident #1) sampled for abuse. Specifically, on 05/01/2026, Licensed Practical Nurse #1 was giving Resident #1 pain medication. Resident #1 refused the medication by putting their hand over their mouth. Licensed Practical Nurse #1 removed Resident #1's hand and placed the medication in Resident #1's mouth. Resident #1 spit the medication out and Licensed Practical Nurse #1 picked up the medication and gave it to Resident #1. Certified Nursing Assistant #1 who was present stated Resident #1 was refusing their medication.The findings are:The facility's Policy titled Abuse, Neglect, Mistreatment and Exploitation Prohibition dated 03/16/2026, documented that the facility shall not use or permit verbal, mental, sexual or physical abuse, including corporal punishment and involuntary seclusion of residents/patients, or other mistreatment or neglect. This can be directly or through electronic means such as using photographs or recordings in any manner that would demean or humiliate a resident(s), including, distribution of images, personal information photographs and recordings through any media including print, text and online social media. This prohibition extends to abuse by anyone, including, but not limited to, other residents, staff, consultants, volunteers, staff of other agencies serving the residents, family members, legal guardians, friends, or other individuals. Incidents where the facility determines upon review there is a reasonable cause an abuse occurred must be reported to the New York State Department of Health. All allegations of abuse must be immediately reported to the Administrator and no later than 2 hours to other officials (including to the State Survey Agency) after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury. The alleged violations must be reported no later than 24 hours to the State Survey Agency if the events that caused the allegation to not involve abuse and do not result in serious bodily injury.Resident #1 was admitted to the facility with diagnoses of acquired absence of left leg below knee (removal of leg), major depressive disorder (mood changes) and falls.The quarterly Minimum Data Set (a resident assessment tool) dated 04/21/2026, documented Resident #1 had severe cognitive impairment. Resident #1 required partial/moderate assistance with personal care.A care plan titled Abuse Prevention, dated 11/18/2025, with interventions that included offer recreational activities as directed by choices made by the resident and the family.The facility's Occurrence Report Summary dated 05/07/2026, documented on 05/01/2026 at approximately 11:20 PM, Resident #1 was observed on the floor. Registered Nurse Supervisor #1 was notified. Body assessment revealed a small scratch mark to the lower lip with minimal bleeding. Tylenol was administered for pain, initially Resident #1 covered their mouth and Licensed Practical Nurse #1 gently removed Resident #1's hand from their mouth and gave the medication. Facility investigated the alleged incident and concluded that there is no indication of abuse or neglect.A Nursing progress note dated 05/02/2026 at 3:33 PM, by Licensed Practical Nurse #3 documented Resident #1 noted to be bleeding from the lip. Nurse Practitioner made aware. Site cleaned and bacitracin applied.A Physician's progress note dated 05/02/2026 at 1:11 PM, documented post fall, skin cut on the chin or lower lips. Per nursing report, they found resident on the floor mat last night. Observed little skin scratch to lower lips. Resident #1 had before probably after shaving, scratch clean with normal saline and apply bacitracin. On examination no visible injury or trauma noted.Daily Staffing Sheet dated 05/01/2026 shows Licensed Practical Nurse #1 and Certified Nursing Assistant #1 was working on the 11:00 PM - 7:00 AM shift. Licensed Practical Nurse #1 was allowed to continue working their schedule from 05/01/2026 through 05/04/2026.During an interview on 05/07/2026 at 10:19 AM, Certified Nursing Assistant #1 stated on 05/01/2026 at approximately 11:20 PM, Resident #1 was observed on the floor. Certified Nursing Assistant #1 stated they picked up Resident #1 and put them back in bed, then informed Licensed Practical Nurse #1.During an interview on 05/07/2026 at 11:42 AM, Licensed Practical Nurse #1 stated on 05/01/2026 Certified Nursing Assistant #1 reported to them that Resident #1 had pain. Licensed Practical Nurse #1 stated they attempted to give Resident #1 pain medication and Resident #1 covered their mouth refusing the medication. Licensed Practical Nurse #1 stated they removed Resident #1's hand from their mouth to give them their medication.During an interview on 05/07/2026 at 11:30 PM, Registered Nurse Supervisor #1 stated that on 05/01/2026 Licensed Practical Nurse #1 reported to them that Resident #1 was on the floor. Registered Nurse Supervisor #1 stated when they got to Resident #1's room, Resident #1 was already in bed. Registered Nurse Supervisor #1 stated they performed body assessment and observed a scratch on Resident #1's lower lip with minimal dry blood. Licensed Practical Nurse #1 informed them Resident #1 covered their mouth refusing the medication and they removed Resident #1's hand to give them their medication. Registered Nurse Supervisor #1 stated they did not see this as abuse, but Licensed Practical Nurse #1 encouraged Resident #1 to take the medication. Licensed Practical Nurse #1 remained on the unit and continued to work through their shift.During an interview on 05/07/2026 at 12:35 PM, Director of Nursing stated they did not think Licensed Practical Nurse #1 abused Resident #1. Licensed Practical Nurse #1 was encouraging Resident #1 to take their medication. The Director of Nursing stated they never suspended Licensed Practical Nurse #1, and they never called local law enforcement or reported it to the State Department of Health.During an interview on 05/07/2026 at 4:46 PM Licensed Practical Nurse #2 stated on 05/01/2026 they worked on the 3:00 PM - 11:00 PM shift and was still on the unit. Licensed Practical Nurse #2 stated approximately 11:25 PM Licensed Practical Nurse #1 asked them to assist in giving Resident #1 their medication. Licensed Practical Nurse #2 stated when they went into Resident #1's room they observed Resident #1 covering their mouth. Licensed Practical Nurse #2 stated they explained to Resident #1 about the medication. Licensed Practical Nurse #2 stated they observed blood on Resident #1's lower lip. Licensed Practical Nurse #2 stated during their shift they did not observe any scratch or blood on Resident #1's lower lip.During an interview on 05/11/2026 at 1:22 PM, the Administrator stated on 05/04/2026 they become aware that Resident #1 had a fall on 05/01/2026 on the 11:00 PM - 7:00 AM shift in their room without injury. The Administrator stated they were not aware of any alleged incident related to Licensed Practical Nurse #1 forcefully give Resident #1's pain medication. The Administrator stated the facility's policy when a suspicion of a crime with serious injury occurred it must be reported to local law enforcement and the New York State Department of Health within 2 hours; and if there is no injury within 24 hours. The Administrator stated after reviewing and getting additional information inorder to be in compliance with the regulation, the alleged allegation was reported to the New York Department of Health 05/11/2026. The Administrator stated the facility did not believe abuse occurred.10 New York Codes, Rules, and Regulations 415.4(b)(1)(i)

Based on observation, record review, and interviews conducted during a survey, the facility failed to ensure that allegations of abuse were investigated thoroughly and that residents were protected from further abuse during the investigation. This was evident for one (1) out of seven (7) residents (Resident #1) sampled for abuse. Specifically, on 05/01/2026 at approximately 11:25 PM, Licensed Practical Nurse #1 was giving Resident #1 pain medication. Resident #1 refused the medication by putting their hand over their mouth. Licensed Practical Nurse #1 removed Resident #1's hand and placed the medication in their mouth. Resident #1 spit the medication out and Licensed Practical Nurse #1 picked up the medication and gave it to Resident #1. The facility failed to thoroughly investigate the allegation of abuse and remove Licensed Practical Nurse #1 from direct care and access to residents after Certified Nursing Assistant #1 reported the allegations to Registered Nurse Supervisor #1. The findings include:The facility's Policy titled Abuse, Neglect, Mistreatment, and Exploitation Prohibition dated 03/16/2026, documented that the facility shall not use or permit verbal, mental, sexual or physical abuse, including corporal punishment and involuntary seclusion of residents/patients, or other mistreatment or neglect. It was also documented if an alleged violation has been identified and reported to the administrator/Designee, the facility must immediately report it and provide protection for the identified resident(s) prior to conducting the investigation of the alleged violation. At the conclusion of the investigation, and no later than 5 working days of the incident, the facility must report the results of the investigation, and if the alleged violation is verified, take corrective action in accordance with State Regulatory Requirements.Resident #1 was admitted to the facility with diagnoses of Acquired absence of left leg below knee ( removal of a leg), major depressive disorder, and falls.The quarterly Minimum Data Set (a resident assessment tool) dated 04/21/2026, documented Resident #1 had severe cognitive impaired cognition. Resident #1 required partial/moderate assistance with personal care.The faility's Occurrence Report Summary dated 05/07/2026, documented on 05/01/2026 at approximately 11:20 PM Resident #1 was observed on the floor. Registered Nurse Supervisor #1 was notified. Body assessment revealed a small scratch mark to the lower lip with minimal bleeding. Tylenol was administered for pain, initially Resident #1 covered their mouth and Licensed Practical Nurse #1 gently removed Resident #1's hand from their mouth and gave the medication. The facility initiated an investigation into the abuse allegation on 05/07/2026. Licensed Practical Nurse #1 was removed from schedule on 05/07/2026 pending completion of investigation. During an interview on 05/07/2026 at 12:35 PM, Director of Nursing stated they were not informed that Licensed Practical Nurse #1 removed Resident #1's hand from their mouth to give Resident #1 their medication at the time when this occurred. Director of Nursing stated Licensed Practical Nurse #1 should have walked away and re-approached Resident #1 to take the medication. During an interview on 05/11/2026 at 1:22 PM, the Administrator stated they were not informed of the alleged allegation on 05/01/2026 until the Department of Health arrived in the facility. The Administrator stated after reviewing additional information and to be in compliance with the regulation, the alleged allegation was reported to the New York Department of Health 05/11/2026. The Administrator stated the facility did not believe abuse occurred. 10 New York Codes, Rules, and Regulations 415.4(b)(3)

Based on observation, record review, and interviews conducted during a survey, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents. This was evident for one (1) out of two (2) residents (Resident #1) sampled for fall. Specifically, Resident #1 who has acquired bilateral below knees amputation was observed on the floor in their room on 05/01/2026. Certified Nursing Assistant #1 went into the room picked up Resident #1 and placed them back into the bed before Resident #1 was assessed by Registered Nurse Supervisor #1. On assessment Resident #1 was observed with a small scratch on their lower lip.The findings are:The facility's Policy title Resident Occurrences, dated 03/07/2023, documented all resident occurrences must be reported and investigated. Plans of correction will be developed in an attempt to prevent re-occurrence and unsafe conditions. Unusual and/or serious events will be brought to the attention of administration, in addition to following the routine procedure. Root Cause Analyses will be conducted by an interdisciplinary quality improvement team for sentinel events or more severe adverse events.Resident #1 was admitted to the facility with diagnoses of acquired absence of left leg below knee (removal of a leg), major depressive disorder and falls.The quarterly Minimum Data Set (a resident assessment tool) dated 04/21/2026 documented Resident #1 had severely impaired cognition. Resident #1 required partial/moderate assistance with personal care.The facility's investigation report dated 04/28/2026 at 3:20 PM, documented Resident #1 on the floor mat in their room. Body assessment revealed no visible injury.A Fall/Injury Risk Evaluation dated 04/28/2026, documented Resident #1 score high risk for falls.T he facility's Occurrence Report Summary dated 05/07/2026, documented on 05/01/2026 at approximately 11:20 PM, Resident #1 was observed on the floor. Registered Nurse Supervisor #1 was notified. Body assessment revealed a small scratch mark to the lower lip with minimal bleeding. Tylenol was administered for pain, initially Resident #1 covered their mouth and Licensed Practical Nurse #1 gently removed Resident #1's hand from their mouth and gave the medication. Facility investigated the alleged incident and concluded that there is no indication of abuse or neglect.Nursing progress note dated 04/28/2026 at 4:19 PM by Registered Nurse Supervisor #2 documented at approximately 3:20 PM Resident #1 was observed on the floormat on floor in their room. On assessment Resident #1 had no visible injury. Resident #1 was transferred to the hospital for Computer Tomography Scan. Computer Tomography Scan dated 04/28/2026 showed no fractures.A Physician's progress note dated 05/02/2026 at 1:11 PM documented post fall, skin cut on the chin or lower lips. Per nursing report, found Resident #1 on the floor mat last night. Observed little skin scratch to lower lips. Resident #1 had before probably after shaving, scratch clean with normal saline and apply bacitracin. On examination no visible injury or trauma noted.A Nursing progress note dated 05/02/2026 at 3:33 PM by Licensed Practical Nurse #3 documented Resident #1 noted to be bleeding from the lip. Nurse Practitioner made aware, and anticoagulants placed on hold. Site cleaned and bacitracin applied.The Activity Monitoring Record dated 05/01/2026 documented Resident #1 was on 30 minutes monitoring.During an interview on 05/07/2026 at 10:19 AM, Certified Nursing Assistant #1 stated on 05/01/2026 at approximately 11:20 PM, Resident #1 was observed on the floor. Certified Nursing Assistant #1 stated they picked up Resident #1 and put them back in bed, then informed Licensed Practical Nurse #1.During an interview on 05/07/2026 at 11:30 PM, Registered Nurse Supervisor #1 stated that on 05/01/2026 Licensed Practical Nurse #1 reported to them that Resident #1 was on the floor. Registered Nurse Supervisor #1 stated when they got to Resident #1's room, Resident #1 was already in bed. Registered Nurse Supervisor #1 stated they performed body assessment and observed a scratch on Resident #1's lower lip with minimal dry blood.During an interview on 05/07/2026 at 12:35 PM, Director of Nursing stated Resident #1 was observed on the floor on 05/01/2026 at approximately 11:20PM. Director of Nursing stated Certified Nursing Assistant #1 picked up Resident #1 before Resident #1 was assessed by Registered Nurse Supervisor #1. Director of Nursing stated that when residents are found on the floor, residents must be assessed by a Registered Nurse Supervisor before placing them back into bed. 10 New York Codes, Rules, and Regulations 415.12(h)(2)

Based on record review and interviews conducted during the Recertification survey from 02/21/2024 to 02/28/2024, the facility did not ensure that a resident and/or resident's representative were offered the opportunity to participate in the revision and/or review of the comprehensive care plan. This was evident for 3 residents (Resident #31, #142, and #165) reviewed for Care Planning out of 38 total sampled residents. Specifically, 1) Resident #31 and/or their designated representative were not invited to their care plan meeting, 2) Resident #142 and/or their designated representative were not invited to their care plan meeting, and 3) Resident # 165 was not invited to their care plan meeting. The findings are: The facility policy and Procedure titled Care Planning - Conferences with approval date 04/17/2021 documented the resident had the right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process. It also documented the Comprehensive Care Meetings are scheduled on Admission, for Significant Change, Annually, and a Quarterly review. The resident/representative is invited to attend the annual, significant change and admission meetings. 1. Resident #31 was admitted to the facility with diagnoses of Hypertension, Respiratory Failure, Tracheostomy Status, Diabetes, Pressure Ulcer and Major Depressive Disorder. The quarterly Minimum Data Set assessment dated [DATE] documented Resident #31 was moderately cognitively impaired and participated in the assessment. The social services notes from 07/28/2023 to 01/31/2024 were reviewed. There was no documented evidence that Resident #31 and/or their designated representative, or family were invited to any quarterly care plan meetings. The care plan meeting reports dated 10/27/2023 and 01/19/2024 documented these were quarterly care plan meetings. The reports did not document Resident #31 and/or their designated representative or Family were invited to the care plan meetings nor attended these meetings. There was no documented evidence in the medical record that Resident #31 and/or their designated representative, and or family participated in the review and revision of quarterly comprehensive care plans or attended the quarterly care plan meetings scheduled on 10/27/2024 and 01/19/2024. 44843 2. Resident #142 had diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction, Aphasia, and Other Seizures. The annual Minimum Data Set assessment dated [DATE] documented Resident #142 was cognitively impaired and only the representative participated in the assessment. The social services notes from 01/01/2023 to 02/22/2024 were reviewed. There was no documented evidence that Resident #142 and/or their designated representative were invited to any care plan meeting. The care plan meeting reports dated 04/20/2023, 07/13/2023, and 09/28/2023 documented these were quarterly care plan meetings. The reports did not document Resident #142 and/or their designated representative were invited to the care plan meetings nor attended these meetings. There was no documented evidence in the medical record that Resident #142 and/or their designated representative participated in the review and revision of comprehensive care plans or attended the care plan meetings scheduled on 04/20/2023, 07/13/2023, and 09/28/2023. 3. Resident #165 had diagnoses of Major Depressive Disorder, Bipolar Disorder, and Unspecified Fracture of the Right Femur. The quarterly Minimum Data Set assessment dated [DATE] documented Resident #165 was cognitively intact and had no rejection of care. It documented only Resident # 165 participated in the assessment. On 02/21/2024 at 09:45 AM, Resident #165 was interviewed and stated they make their own decisions. Resident #165 stated they did not recall being invited to any care plan meeting for a long time. The social services notes from 01/01/2023 to 02/22/2024 were reviewed. There was no documented evidence that Resident #142 and/or their designated representative were invited to any care plan meeting. The care plan meeting reports dated 01/12/2023, 07/13/2023, 10/12/2023 and 01/18/2024 documented these were quarterly care plan meetings. The reports did not document Resident #165 and/or their designated representative were invited to the care plan meetings nor attended these care plan meetings. There was no documented evidence in the medical record that Resident #165 and/or their designated representative participated in the review and revision of comprehensive care plans or attended the care plan meetings scheduled on 01/12/2023, 07/13/2023, 10/12/2023 and 01/18/2024. On 02/21/2024 at 10:57 AM, Resident #142's representative was interviewed and stated they made decisions for Resident #142. The representative also stated they were never invited to any care plan meeting. On 02/26/2024 at 02:14 PM, Social Worker #1 stated during the interview they received training from the Social Work Director and stated they only invite residents and/or their designated representative to the initial, annual, and significant change care plan meetings. Social Worker #1 stated they were told by the Social Work Director that they do not have to invite residents and/or their designated representative to the quarterly care plan meetings. On 02/26/24 at 02:31 PM, the Social Work Director was interviewed and stated they were trained by the previous two Social Work Directors that they were not required to invite the residents and/or their designated representative to participate in the quarterly care plan meetings. The Social Work Director stated they were not aware the Centers for Medicare & Medicaid Services regulation requires the residents' participation in the care plan meetings. 10 NYCRR 415.11(c)(2)(i-iii)

Based on record review and interviews conducted during the Recertification Survey from 02/21/2024 to 02/28/2024, the facility did not ensure that residents were provided a safe and homelike environment and that residents received care and services safely and does not pose a safety risk. This was evident for 1 (Resident #5) of 3 residents investigated for Respiratory care out of an investigative sample of 38 residents. Specifically, on 02/22/2024, a Maintenance staff was observed cleaning the air conditioning unit while Resident #5 was in bed sleeping in their room. The findings are: The facility's policy titled Entry of Engineers and Repair Workers dated 03/03/2023 stated that before entering a resident's room, engineers and repair workers must first check in with the nurse on duty in that unit. They should provide details about the nature of the work, estimated duration, and any potential disturbances. The purpose is to ensure the safety, privacy, and dignity of our residents when engineers and repair workers need to enter their rooms for maintenance or repair work. On 02/22/2024 at 10:24 AM, the State Surveyor observed two Maintenance Staff in Resident #5's room. One Maintenance Staff was vacuuming the air conditioning unit while the other Maintenance Staff was standing next to them. Resident #5 was observed in bed sleeping with oxygen via nasal canula. The State Surveyor observed dust coming from the vacuum and blowing inside the room. Resident #5 was admitted to the facility with diagnoses of Schizoaffective Disorder, Panic Disorder with Agoraphobia, and Sleep Apnea. The Significant Minimum Data Set, dated dated dated [DATE], documented Resident #5's cognition was intact, independent for bed mobility, dependent for transfer and toilet use, and uses Oxygen therapy. A Comprehensive Care Plan for Respiratory: Oxygen Use was initiated on 01/11/2024. The care plan documented that resident requires use of oxygen due to episodes of shortness of breath. The interventions included providing oxygen as ordered by the physician and to assess for discomfort with breathing. 02/28/2024 10:19 AM, the Inservice Coordinator was interviewed and stated that Maintenance staff must notify the charge nurse when work will be done in a resident's room and that residents must be taken out of the room. The Inservice Coordinator stated they were not notified that Maintenance will be working in Resident #5's room on 02/22/2024. On 02/28/2024 at 01:39 PM, the Maintenance Assistant was interviewed and stated they forgot to let the nurse know that they will be working on Resident #5's room on 02/22/2024. On 02/28/2024 at 01:42 PM, the Director of Maintenance was interviewed and stated that they are responsible for scheduling the maintenance works. They stated they usually notifies the nurse about the type of work and the nurse would either let the resident know or have the resident move out of the room. The Director of Maintenance stated that on 02/22/2024, the Maintenance Assistant forgot to tell the nurse that they were going to work on Resident #5's room. 415.5(h)(2)

Based on record review and interviews conducted during the Recertification and Abbreviated (NY00330116) Survey from 02/21/2024 to 02/28/2024, the facility failed to ensure that all alleged violations involving abuse and injuries of unknown source were reported immediately but not later than 2 hours after the allegation was made to the New York State Department of Health. This was evident for 3 (Resident #655, #203, and #97) of 38 total sampled residents. Specifically, 1) On 02/12/2024, Resident #655 sustained a laceration to their right eyebrow. The injury was not witnessed, and the source of injury could not be explained by the Resident. The injury was not reported to the New York State Department of Health, and 2) On 12/18/2023 at approximately 5:45 AM, Residents #203 and #97 were involved in a resident-to-resident altercation. The alleged incident was not reported to the New York State Department of Health within 2 hours after the allegation was made. The findings are: The facility policy titled Abuse, Neglect, Mistreatment, Exploitation Prohibition dated 09/26/2022 documented the facility shall ensure that alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, are reported immediately to the Administrator of the facility or his/her designee. When required by law or regulation, the facility shall ensure timely notification to the Department of Health. 1) Resident #655 had diagnoses of Diabetes Mellitus, Coronary Artery Disease, and Heart failure. The Minimum Data Set assessment dated [DATE] documented Resident #655 had severely impaired cognition. A Nurses' Notes dated 02/12/2024 at 9:10 AM documented Resident #655 was observed in bed with a small cut to their right eyebrow with moderate amount of bleeding. Resident was unable to give account of what happened. The facility's Occurrence Investigative Risk Management Summary Report dated 02/12/2024 documented Resident #655 was observed lying in bed with a small cut close to their eyebrow. The facility concluded that Resident #655's head may have come in contact with the call bell clip during movement and that their investigation has not revealed cause to believe an alleged exploitation, abuse, mistreatment, or neglect had occurred. A review of Occurrence Reports and Employee Statements did not indicate any witness to how Resident #655 sustained the eyebrow laceration. There was no documented evidence that Resident #655's eyebrow laceration was reported to the New York State Department of Health. 2. Resident #203 had diagnoses of Nontraumatic Intracerebral Hemorrhage and Cerebrovascular Accident. The Minimum Data Set assessment dated [DATE] documented Resident #203 had intact cognition. Resident #97 had diagnoses of Cerebrovascular Accident and Mood disorder. The Minimum Data Set assessment dated [DATE] documented Resident #97 had intact cognition. A Nurses' Notes dated 12/18/2023 at 6:57 AM documented that Resident #97 called Resident #203 N*gger. Resident #203 told Resident #97 to stop. Resident #97 refused to stop; Resident #203 started to hit Resident #97 with a stick. A Nurses' Notes dated 12/18/2023 at 3:07 PM documented that at 5:45 AM, was called by the Charge Nurse and stated that Resident #97 was poked by their roommate with a stick. Resident #97 was noted with scratch marks on the right forearm. The facility's Investigation Report dated 12/19/2023 documented that during interview Resident #97 stated they wanted to turn down the heat in their room. Resident #203 told them to stop yelling and go back to sleep. Resident #97 told Resident #203 Shut up N*gger. A verbal exchange continued, Resident #203 approached Resident #97 and poked them with a reacher bar. Resident #97 sustained superficial scratch to their right forearm. The facility concluded there was no evidence of abuse, neglect, or mistreatment by the facility. Resident #97 provoked Resident #203 when they called them N*gger. The Nursing Home Facility Incident Report documented that the staff was first made aware of the incident on 12/18/2023 at 5:45 AM. The report documented that the facility Administrator submitted the incident report to the New York State Department of Health on 12/18/2023 at 6:04 PM. On 02/22/2024 at 11:50 AM, Resident #203 was interviewed and stated that the other resident he had an altercation with would not call for the nurse but would holler. Resident #203 stated one night they got into it and that they jumped them. Resident #203 stated they were moved to a different floor. On 2/28/2024 at 10:22 AM, the Director of Nursing was interviewed and stated they did not report Resident #655's laceration because it was explainable. The Director of Nursing stated that they did an investigation and that it was unsubstantiated since there was evidence of blood stain on the clip and that was how they knew the injury was self-inflicted. On 02/28/2024 at 10:28 AM, the Director of Nursing stated during the interview that the incident between Residents #203 and #97 occurred at 12/18/2023 at 5:45 AM and was submitted to the New York State Department of Health on 12/18/2023 at 6:04 PM. The Director of Nursing stated it should have been reported to the New York State Department of Health within 2 hours. They added that they need to gather all information that was why it takes a while for them to report. On 2/28/24 at 12:17 PM, the Administrator was interviewed and stated the facility policy on abuse reporting stated that reporting is to be done within 24 hours or within 2 hours if there is an obvious injury. The Administrator further stated name calling does not constitute abuse. 10 NYCRR 415.4(b)

Based on record review and interviews conducted during the Recertification Survey from 02/21/2024 to 02/28/2024, the facility failed to ensure that the Minimum Data Set assessments accurately reflected the residents' status. This was evident for 2 (Resident #181 and Resident#25) of 2 residents sampled for catheter care, out of 38 sampled residents. Specifically, Resident #181's Foley catheter was not documented, and Resident #25 's use of suprapubic catheter was documented as an ostomy, instead of indwelling catheter. The findings are: The facility's policy titled Minimum Data Set Assessment and Completion with an approval date of 02/01/2022 documented that the Minimum Data Set 3.0 manual is to be utilized by all disciplines participating in the completion of the Resident Assessment Instrument and that each individual completing a portion of the assessment, signs and certifies the accuracy of that portion of the assessment. Resident #181 was admitted to the facility with diagnoses of Stroke and Cardiac Arrest. The Quarterly Minimum Data Set, dated dated dated [DATE], documented that Resident #181 was severely cognitively impaired, dependent on bed mobility, transfers, eating, and toilet use. The Minimum Data Set also documented always incontinent of urine and bowel. The Minimum Data Set did not document the use of indwelling catheter. The admission Peer Review Instrument dated 01/10/2024 documented indwelling catheter. The Physician's orders dated 01/19/2024, documented Foley Catheter, change as needed with size 16 French, 10 milliliter balloon. Irrigate Catheter with 200 milliliter sterile saline as needed for increase sediments and / or blockage of urine flow. Provide Foley care every shift and as needed, record urine output every shift and as needed. The Comprehensive Care Plan on bladder elimination/indwelling catheter/genitourinary, created on 07/28/2022, documented aging process: neurogenic bladder, as evidenced by use of a Foley catheter. Interventions include to provide Foley care every shift and as needed, observe and monitor resident's urine output. Resident #25 was admitted to the facility with diagnoses of Obstructive Uropathy, Quadriplegia, and Respiratory Failure. The Quarterly Minimum Data Set, dated dated dated [DATE] documented Resident #25's cognition was intact, had ostomy, and always incontinent of bowel. The Physician's Orders dated 12/17/2018 with renewal date of 02/22/2024 documented to irrigate suprapubic tube with 200 milliliter of normal saline solution for malfunction as needed, and suprapubic tube care every shift. The Comprehensive Care Plan titled bladder elimination/indwelling catheter/ genitourinary status, created on 01/28/2023 documented neurogenic bladder, use of a suprapubic catheter. Interventions include to observe and monitor resident's urine output color, appearance, and odor of urine; record urine output as instructed and if abnormalities were evident. On 02/28/2024 at 12:23 PM, the Minimum Data Set Assessor was interviewed and stated they are the Case Manager and also completed the Minimum Data Set. They stated that Resident #181 came back from the hospital on 01/18/2024 with a Foley catheter and it should have been documented in the Minimum Data Set. They stated they probably missed it. The Minimum Data Set Assessor stated the Assessors crosscheck each other's work to ensure that the Minimum Data Set was accurate. On 02/28/2024 at 12:04 PM, the Minimum Data Set Coordinator was interviewed and stated they completed the Minimum Data Set assessment dated [DATE] for Resident #25. They stated that the suprapubic tube should have been coded as indwelling catheter and not as ostomy. The Minimum Data Set Coordinator stated it was probably an oversight and that each staff who completed their section of the Minimum Data Set is responsible for the accuracy of their documentation. 10 NYCRR 415.11 (b)

Based on observations, interviews and record review conducted during the Recertification Survey from 02/21/2024 to 02/28/2024, the facility failed to ensure a person-centered comprehensive care plan was developed and implemented to meet residents' preferences. This was evident for 1 (Resident #116) of 38 total sampled residents. Specifically, a Comprehensive Care Plan was not developed to address Resident #116's preference not to use a urinary catheter privacy bag. The findings are: The facility policy titled Care Planning-Conferences with an approval date of 04/17/2021 stated that the facility will develop and implement a comprehensive person-centered care plan for each resident. The policy stated that the comprehensive care plan must be prepared by an interdisciplinary team and other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. Resident #116 had diagnosis of Obstructive Uropathy, Benign Prostatic Hyperplasia, and Bipolar Disorder. The Minimum Data Set assessment dated [DATE] documented that Resident #116 was cognitively intact and had an indwelling catheter. On 02/21/2024 at 12:03 PM, 02/22/2024 at 12:17 PM, and 02/23/2024 at 12:14 PM, Resident #116 was observed in the dining room sitting in their wheelchair with an exposed Foley catheter bag containing urine hanging on the arm of their wheelchair. There were other residents sitting in the dining room eating lunch at the time. The Physician's Order dated 11/04/2023 and was last renewed on 02/21/2024 documented the following: Change suprapubic catheter once a month and as needed size 24 French 10 milliliter balloon. There was no documented evidence that a Comprehensive Care Plan to address Resident #116's preference not to use a Foley privacy bag was developed. On 02/28/2024 at 1:01 PM, Resident #116 was interviewed and stated they have a black bag that covers the urine bag, but they do not want to use it. Resident #116 further stated that the nurses have asked them to cover their urine bag with the black bag in the past. On 02/27/2024 at 11:29 AM, the Assistant Director of Nursing was interviewed and stated that Resident #116 refused to use a urinary catheter privacy bag because the Resident complained that the wheel on the wheelchair rubs off on the privacy bag. The Assistant Director of Nursing stated they will update Resident #116's Comprehensive Care Plan with their preference not to use a urinary catheter privacy bag. On 02/28/2024 at 10:05 AM, the Director of Nursing was interviewed and stated that Resident #116 removed their urinary catheter privacy bag because it keeps getting caught in the wheelchair. The Director of Nursing stated that a care plan for Resident #116's refusal to use privacy bag should have been documented. 10 NYCRR 415.11(c)(1)

Based on interviews and record review conducted during a Recertification and Complaint survey (NY00295349) from 02/21/2024 to 02/28/2024, the facility failed to ensure each resident received adequate supervision to prevent elopement. This was evident for 1 (Resident #163) of 5 residents investigated for Accidents out of an investigative sample of 38 residents. Specifically, on 05/02/2022 at 7:45 PM, Resident #163 identified as at high risk for elopement, was able to exit the facility undetected through the fire exit gate on the main floor. Resident #163 was located by the New York City Police Department on 05/04/2022 at an apartment building that Resident claimed they previously lived. The findings are: The facility's policy and procedure titled Missing Persons with a review date of 05/06/2022 documented that it is the policy of the facility to ensure that conditions for security of residents and the building and the prevention of a resident from becoming a missing person is maintained at all times through environmental technology, worker surveillance, and procedural conditions. The facility's Policy titled Elopement and Unsafe Wandering, Prevention of, with a review date of 05/06/2022, documented that in order to eliminate and or control unsafe wandering and elopement behavior of residents, it is the policy of this facility to have the people , system and tools in place to do all that is reasonable to identify and prevent unsafe wandering and or elopement and to act quickly and prudently, should either occur. Resident #163 was admitted to the facility with diagnoses of Hemicraniectomy, Seizure Disorders and Anxiety Disorder. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #163's cognition as severely impaired and required supervision with set-up help for locomotion on and off the unit, and no mobility devices used. Section E of the Minimum Data Set assessment documented that Resident #163 had wandering behavior that occurred daily and had a wander/elopement alarm, used daily. The elopement risk assessment dated [DATE] documented Resident #163 was at high risk for elopement. The form documented Resident #1163 was independently mobile; elopement risk factors include exhibited wandering behavior, cognitively impaired or demonstrated impaired decision making, verbalized wanting to go home or indicated desire to leave unit/building. A Comprehensive Care Plan on Elopement/Wandering was initiated on 03/07/2022. The facility interventions included to communicate to staff resident's unsafe wandering/potential elopement status via 24-hour report; place a wander alert device on the resident, check for placement every shift and for proper functioning; place a picture of resident in the front desk/lobby. A Nurse's Note dated 05/03/2022 at 12:01 AM documented that Resident #163 stated they were waiting for their ordered food for half an hour. The writer called the operator who stated that they did not see any food for Resident #163. Resident became agitated, and at around 7:40 PM, Resident stepped in the elevator. Writer told Resident they can wait for their ordered food in the unit, but Resident did not respond. A Nurse's Note dated 05/03/2022 at 8:03 PM documented that Resident #163 walked out of the building followed by the receptionist, the Director of Nursing, Supervisor and the housekeeper and was escorted back to unit. At around 8:15 PM, a call was received from the Receptionist informing writer that Resident was not in the facility. Code E was activated, and staff searched all units and each room including the rooftop and basement. Search was done on outside area of the building and the nearby streets around the facility. The Director of Nursing and other administrative staff were informed and continued the search around the neighborhood. New York Police Department was informed. A Nurse's Note dated 05/04/2022 by the Director of Nursing documented that at around 7:06 PM, they were informed by a Police Officer that Resident #163 was found sitting in an apartment building and will be sent to the hospital for evaluation. The facility's Investigation Summary dated 05/03/2022 documented that based on the review of security camera footage, Resident #163 exited the facility on 05/02/2022 at 7:45 PM through the fire exit gate from the outdoor main floor outdoor terrace. Resident was dressed in black leather coat and black polo shirt. The summary documented that Resident #163 made an earlier attempt to leave the facility through the lobby to get food at 6:45 PM, however, the wander alert device alerted the lobby attendant and Resident was redirected back to their unit. At 7:30 PM, there was a disturbance in the lobby when a large group of visitors wanting to visit a resident were aggressively protesting the COVID-19 requirement. While the commotion was going on in the lobby, Resident #163 returned to the main floor, likely saw the melee in the lobby and used the opportunity to exit through the main floor terrace fire exit. Resident #163 exited through the side main floor terrace gate sounding the alarm at the reception desk. The alarm was not immediately heard due to disturbance caused by the visitors. Several minutes passed before the alarm was noticed and a quick check of the location did not show anyone exiting. The lobby attendant called the unit and was told that Resident #163 was there, and later on received a call confirming that Resident #163 was not in the unit. Code E was called, and search was initiated. On 02/26/2024 at 2:34 PM, Licensed Practical Nurse #3 was interviewed and stated that they worked on the evening shift on 05/02/2022. They stated that Resident #163 often goes downstairs by themselves. Licensed Practical Nurse #3 stated that they saw when Resident #163 went downstairs, and they called the operator. They stated that at round 8:30 PM, the Certified Nursing Assistant reported that Resident #163 was not back. They called the operator who stated that they did not see the Resident. Licensed Practical Nurse #3 stated they started the search and reported the incident to the supervisor. On 02/26/24 at 04:21 PM, Front Desk Receptionist #3 was interviewed and stated that on 05/02/2022, there were about 10 family members at the lobby who needed COVID-19 testing and would not allow them to respond quickly when they heard the alarm. They stated that by the time they responded to the alarm, they could not get to the door fast enough. Front Desk Receptionist #3 stated they called the unit and was told that Resident #163 was not there, they then called Code E and the search ensued. On 02/27/24 09:19 AM, the Director of Nursing was interviewed and stated that there was a commotion in the lobby. When Resident #163 saw the commotion, the Resident directed themselves out in the back door and the receptionist missed the alarm. When the commotion settled, the receptionist called the unit and found that Resident #163 was missing. The Director of Nursing stated that Resident was found the next day. The Director of Nursing stated they had a Quality Assurance Performance Improvement meeting and discussed the elopement. They re-assigned the COVID-19 testing to another staff member since it was during the time when the elopement occurred. The receptionist was involved with testing which caused the delay in answering the alarm. On 02/26/2024 at 03:15 PM, the Administrator was interviewed and did a replay of what occurred on 05/02/2022. The Administrator stated that Resident #163 had a tendency to come off the elevator frequently and to the main floor. On 05/02/2022, they reviewed the camera, and it showed that the Resident went to the right of the elevator, and walked towards the back of the main floor, to the physical therapy gym, where there is an exit door to the left of the main floor. The Administrator stated that the Resident went through both doors which lead to the side courtyard. The resident then opened the gate leading to the driveway, out to the street. The Administrator stated that the gate had an alarm which went off, but the receptionist had a delay in attending to the alarm due to the commotion in the lobby. The facility implemented corrective actions and was found to be in substantial compliance on 05/12/2022, prior to the start of the Recertification Survey on 02/21/2024. Resident #163 was located by the Police on 05/04/2022 and was sent to the hospital. Resident was readmitted to the facility on [DATE] without injury. The Comprehensive Care plan for Elopement for Resident #163 was updated Elopement prevention policy reviewed and updated. The Policy and Procedure on Elopement, Missing Persons were reviewed on 5/6/2022. An ad hoc Quality Assurance Performance Improvement meeting was held on 05/06/2022. Resident #163's elopement was discussed. The Covid testing area was relocated from lobby entrance, and a second staff were assigned to attend the duties of testing. Audits were completed for exit doors to be checked weekly to ensure functionality. Elopement drills were scheduled and were completed. All wander alert and exit door alarms in the facility were inspected and were in working condition. All fire exit panic alarms at the Reception desk were tested working as intended. A facility wide in-service on Elopement and Elopement Drills were completed on 05/12/2022, 06/06/2022, and 07/08/2022. All lobby attendants were re-educated on importance of monitoring exit alarms and make them highest priority even if other activity is present in the lobby. 415.12(h)(2)

Based on observation, record review, and interviews conducted during a Recertification and Abbreviated Complaint Survey (NY 497), the facility did not ensure that a resident representative was immediately notified of a significant change in the resident's clinical condition. Specifically, there was no documented evidence the Family Representative (FR) was informed when a resident exhibited symptoms and received treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The finding includes: The facility policy titled Notification to Designated Representative of a Resident Change in Status dated [DATE] documented FR will be notified of significant changes in resident's clinical health immediately. During an interview on [DATE] at 11:14 AM, the FR of Resident #404 stated the facility did not inform the FR that Resident #404 had a fever and reported the resident was doing well until Resident #404 expired on [DATE]. Resident # 404 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #404 had moderately impaired cognition. Resident #404's Face Sheet documented FR as the primary contact of Resident #404. A NN (NN) dated [DATE] Resident # 404 had an elevated temperature of 100F degrees, the nursing supervisor was notified, and Tylenol 650 mg was administered. A Medical Progress Note dated [DATE] documented Resident #404 developed fever and received Tylenol. A Nurse Practitioner's (NPPN) Progress Note dated [DATE] documented Resident #404 exhibited tiredness and fever of 100F and COVID-19 Protocol initiated. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #404 was placed on contact/droplet precautions and a portable chest x-ray for Fever was ordered. NPPN dated [DATE] documented Resident # 404 was evaluated for intermittent cough and low-grade fever. Tylenol 650 mg every 6 hours for Fever and Robitussin Sugar-Free ,d+[DATE]mg/5 ml oral syrup every 4 hours as needed. NNs dated [DATE] documented Resident # 404 had a room change and remained on contact/droplet precaution from [DATE] through [DATE] A Monthly Physician Assessment Note dated [DATE] documented that Resident # 404 is being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] There was no documented evidence the facility notified the FR that Resident #404 had changes in medical condition including a fever, was suspected of, and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 2:15 PM, the Registered Nurse Supervisor (RNS) stated Resident # 404 had a room change to the COVID-19 designated unit and the entire unit (including Resident #404) was placed on contact/droplet precautions because there was a COVID-19 infection surge at that time. After reviewing the medical record of Resident #404, RNS confirmed Resident #404 had a fever and was provided with Tylenol. RNS was unable to find documented evidence the FR was informed of these changes. During an interview on [DATE] at 1:21 PM, the Director of Nursing (DON) stated that nursing staff are responsible for notifying the FR if a resident had a fever or suspected/positive for COVID-19. The DON stated that staff should have notified the FR of the changes in condition re: Resident #404. During an interview on [DATE] at 01:45 PM, the Administrator stated FRs were notified when the resident ha a significant change in condition. At the time Resident #404 expired, the facility was notifying FRs of suspected or positive COVID-19 cases in the facility. Th FR of Resident #404 may have been notified, but it was not documented in the medical record. 415.3(e)(2)(ii)(a)

Based on observation, record review, and staff interviews conducted during Recertification survey, the facility did not ensure that each portion of the Minimum Data Set (MDS) assessment accurately reflects the resident's status. Specifically, the most recent MDS did not accurately indicate tube feeding. This was evident for 1 out of 35 sampled residents reviewed (Resident # 34). The finding is: The facility's policy and procedure titled MDS Assessment and Completion dated 12/01/2020 states that the assessment system will provide a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capabilities and assist staff in identifying health problems and care plan development. The policy further states that the assessment must reflect the resident's status, including the resident's strengths and needs, which must be addressed in an individualized care plan. Resident # 34 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Quarterly MDS assessment dated [DATE] identified Resident #34's cognition as moderately impaired. Section K of the MDS indicated that Resident # 34 is on mechanically altered diet. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] @ 237 ml each time four times a day for Dysphasia. Check placement and patency of GT before feeding, Manuel fluid flush 200 ml Q6H of flush via PEG and Elevate the head of the bed at least 30 degrees during feeding and 1/2 hour after feeding. The orders were renewed 11/30/2021. A Tube Feeding Care Plan initiated on 12/10/2016 documented that Resident # 34 is on tube feeding-related to dysphagia. The interventions include administering formula with the required amount of water, keeping the head of the bed elevated about 35-45 degrees during feeding and one hour after feeding. The revised care plan dated 10/07/2021 documented Resident # 34 is on tube feeding for nutrition and hydration. The MDS did not accurately document that Resident # 34 was on tube feeding during the review period. During an interview on 12/29/2021 at 02:27 PM, the MDS Assessor stated that the MDS Assessor completed a quarterly MDS assessment on 10/10/21. Each department conducts the required section of the MDS. Resident # 34 has been on tube feeding since 03/31/2021. There has been an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Each department signs the last section of the MDS to ensure that it is completed. During an interview on 12/29/2021 02:39 PM, the Chief Clinical Dietician stated that the dietician does the swallowing and the nutrition section of the MDS. The MDS does not indicate that Resident #34 received tube feeding. It seems that it was overlooked, and it was an oversight. During an interview on 12/29/2021 at 11:17 AM, the MDS Coordinator stated that they interview the residents, the staff, and review the chart, and then code the MDS according to the resident's condition. Each department Is responsible for reviewing each section, and then the MDS clerk submits the assessment. They check and make sure each section is complete. They do not check for accuracy. Each department is responsible for checking for the accuracy of the assessment. 415.11(b)

Based on record review and interview conducted during the re-certification and abbreviated survey, the facility did not ensure that residents were free from abuse, neglect, and exploitation. Specifically, (1) Resident #69 sustained an injury of a laceration to her right leg that required sutures in a resident-to-resident altercation (NY# 196); and (2) Resident #604 was punched in the head by another resident and suffered a headache and blurred vision (NY# 990). Both incidents involved the same aggressor (Resident #267). This was evident for 2 of 5 residents reviewed for Abuse (Resident #69 and Resident #604). This deficient practice resulted in actual harm to Resident #69. The findings are: The undated policy for Resident to Resident Abuse documents that the facility will ensure residents' right to be free from verbal and physical abuse and misappropriation of property from other residents. All forms of resident to resident abuse must be reported immediately to the nursing supervisor who will notify the physician, director of nursing, administrator and social worker. Procedures for the aggressor include developing a care plan for residents at risk of abusing other residents that have strategies and interventions to prevent occurrences, developing a behavioral care plan with interventions, and monitoring the resident for aggressive behavior. Procedures for the victim include identifying residents who may be victims of abuse, psychiatrist and/or psychologist evaluations if necessary, and providing in-service education to staff. Resident #267 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/18/19 at 8:40 AM and 7/19/19 at 11:11 AM Resident #267 was observed in his room doing activities by himself. Resident was calm. A Quarterly MDS dated [DATE] documented resident #267 is usually understood and usually understands others, cognitively intact, no delusions, mood severity score of 2, no hallucinations, no delusions, no behaviors, independent with ADLs. The resident's active [DIAGNOSES REDACTED]. The resident received antipsychotic medication daily. The CCP titled Behavior symptoms dated 1/29/18 documented wandering, resident has a history of verbally abusive/yelling/screaming, history of physically abusive throwing chairs at others, socially inappropriate, easily agitated when does not get what he wants. Interventions included allow to vent feelings, assess mental status, call resident's mother to help him calm down when agitated, monitor and document changes in behavior, provide verbal and emotional support, psychological consult and treatment as ordered, redirect as needed, remove resident from situations with increased behaviors A Nursing Note dated 1/27/18 documented Resident #267 was screaming and talking to himself at times. Emotional support was provided, and the behavior was redirected. Staff set limits with the resident and encouraged the resident to play with Play Do or color, but the interventions were not effective. The MD ordered [MEDICATION NAME] 50 mg PRN to be given. A Nursing Note dated 1/30/18 documented Resident #267 was transferred to the hospital for aggressive behavior of lifting and throwing a chair on the floor in front of other residents in the dining room because he was frustrated with his computer program running slow. Resident #267 was moved away from other residents and emotional support was provided. Resident #267 was at high risk for hurting self and others. Resident #267 was transferred to Jamaica hospital for unmanageable behaviors. The resident returned to the facility on [DATE]. There was no documented evidence in the medical record that the facility reviewed or updated the plan of care with interventions to address the resident's aggressive and unmanageable behaviors after the resident returned from the hospital. A Nursing Note dated 2/6/18 documented Resident #267 returned to the facility from an appointment and had a scheduled room change to a different unit. Subsequent nursing notes documented behaviors of screaming, yelling, and becoming upset when he cannot get his way. Resident #267 was not responsive to emotional support and redirection. 1) A nursing note dated 2/11/18 documented Resident #267 began hitting and yelling at staff and residents. The resident became agitated when his tablet was not working. Resident #267 was a danger to himself and others with no self-control. Resident #267 became aggressive in the dining room and inflicted physical harm to Resident #69 via laceration resulting in Resident #69 being transferred to the hospital for suturing. Resident # 267 was transferred to the hospital for psychiatric evaluation. A Nursing note dated 2/11/18 documented Resident #69 was transferred to the hospital at 11:50 AM. Resident had a laceration on right lower leg 7 cm x 1 cm bleeding. Resident #69 was sitting in her recliner chair and Resident #267 held her leg and scratched her causing lacerations. The resident was transferred to the hospital for suturing. A Social Work Note dated 2/11/18 documented that Resident #69 was seen after the incident. The resident was not able to recall the incident or express feelings regarding the incident. The facility Occurrence Report dated 2 /11/18 documented resident #267 is an Autistic patient who became agitated/yelling at patients and staff. Resident #267 is a danger to self and others. Resident #267 follows staff around verbally abusing them. Resident # 267 is a hostile resident with no self-control, may cause hard to self and/or others. Resident #267 got aggressive in the dining room causing another resident physical harm. Resident #267 caused a laceration on resident #69 leading to resident #69 being transferred to the hospital for suturing. Attached to the report were two separate statements from CNA #2. The statements differ in the account of events. In the first written statement dated 2/11/18, CNA #2 reported that around 11:45 AM she was in the dining room when Resident #267 came into the dining room banging his hands on the tables. Resident #267 was hostile and started following her around. Resident #69 was in her recliner chair when Resident #267 began banging her leg and then scratched it. CNA #2 stated Resident #69 was already bleeding when she was able to intervene. In the second written statement dated 2/11/18, CNA #2 reported that between 11:15-11:30 AM she was in the dining room observing the residents. CNA #2 reported resident #267 entered the dining room upset about his iPod not working. CNA #2 told the resident she could not help him, resident #267 began screaming I need You Tube and began banging his fists on the table. CNA #2 reported that resident #267 began following her while banging his fists on other tables. Resident #69 was close to resident #267. Resident #267 then spun around and banged on resident #69's leg, causing resident #69's leg to slip out of the wheelchair and start bleeding. Resident #267 moved to the other side of the room and started to pack his things asking where he was going to be sent. Shortly after this resident #267 went over and sanitized his hands. In a written statement dated 2/11/18, the Licensed Practical Nurse (LPN #1) reported she provided wound care to Resident #69 after the incident. In a written statement dated 2/11/18, the Nurse Practitioner (NP) reported they were called to evaluate Resident #69 after the incident. The NP determined Resident #69 should be transferred to the hospital for stitches since the wound was deep. The NP reported that Resident #267 was sitting in his wheelchair watching television saying he was sorry and that his tablet was not working, and he was agitated about that. The facility investigation summary of the incident dated 2/14/18 documented that on 2/11/18, around 10:30 AM, Resident #267 became upset when his iPod was not working. Certified Nursing Assistant (CNA) #2 was in the dining room when the incident occurred. CNA #2 stated resident #267 began screaming I need You Tube and started banging his fists on the table. Resident #267 followed the CNA around the room and eventually banged his fists on resident #69 leg. CNA #2 intervened and separated the residents. The nursing supervisor was notified. Resident # 267 was sent to the hospital for psychiatric evaluation, and Resident #69 was sent to the hospital for suturing of the lower right leg. The investigation concluded that there was insufficient reason to believe that resident #267 willfully tried to inflict injury on Resident #69 and stated resident #267 has a [DIAGNOSES REDACTED]. Nursing Notes dated 2/15/18 documented Resident #267 returned to the facility from the hospital. The resident was transferred to a different floor and placed on 1:1 (one-to-one) 24-hour supervision. Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #69 is sometimes understood and sometimes understands others. The resident had moderately impaired cognitive skills for daily decision making, and there were no signs and symptoms of [MEDICAL CONDITION], delusions, or hallucinations. The behavior of rejecting care occurred four to six days. The resident required extensive assistance for bed mobility and transfer. The resident was totally dependent on staff for locomotion on and off unit, dressing and toilet use. The resident had range of motion impairment on both sides of upper and lower extremities. The resident did not have any skin conditions upon admission. The Comprehensive Care Plan (CCP) titled Cognitive status, for Resident #69, dated 2/1/18 documented the resident has moderately impaired (alert and oriented X (times) 1 to self only) cognition with short- and long-term memory loss. Interventions included assessing the resident's mental status, providing an interpreter as needed, and allowing the resident to express feelings. The CCP titled Behavior Symptoms dated 2/1/18 documented the resident is verbally abusive, physically aggressive, socially inappropriate talking to herself, and resists care. Interventions included: allow resident to vent feelings, assess mental status, monitor and document changes in behavior, redirect as needed, and remove from situations where resident may have increased behaviors. The CCP titled Communication dated 2/1/18 documented the resident has impaired communication related to hearing loss and cognitive impairment, and the resident is Spanish speaking. Interventions included anticipate needs, use short and simple sentences, and non-verbal communication techniques. The resident was observed by the SA (State Agency Surveyor) on 7/16/19 at 11:54 AM and again on 7/23/19 at 9:32 AM. Both times the resident was observed, sitting in her wheelchair, in the dayroom. The resident is Spanish speaking. The resident was observed to speak louder when staff approaches to give assistance. It was observed that once staff gives resident emotional support she calms down. On 7/16/19 at 11:59 AM an interview was held with Resident #69's nephew. The resident's nephew stated he comes to visit his aunt every day to feed her during lunch time since she was admitted to the facility. Prior to the incident on 2/11/18, the resident's nephew stated his aunt never had any altercations or problems with other residents. Resident #69's nephew stated that his aunt is confused and mostly talks to herself and sometimes gets scared when staff try to provide care. The resident's nephew confirmed that his aunt was assaulted by another resident last year. He identified the resident as resident (#267). The facility called him after the incident. The resident's nephew stated his aunt was sent to the hospital and got stitches. The resident's nephew stated his aunt does not remember the incident. He stated that resident #267 was transferred to another unit and he was pleased. He stated that his aunt is confused, so he did not notice any change in his aunt after the incident. On 07/23/19 at 10:56 AM, the Director of Nursing (DON) was interviewed. The DON stated that Resident # 69 is demented and needs total assistance from staff with her Activities of Daily Living (ADL's). The DON stated that Resident #69 is out of bed in the recliner wheelchair in the dayroom and is usually very noisy. The DON stated that if you touch Resident #69 she will scream. The DON stated Resident #69 is very confused and maybe only recognizes her nephew's face. The DON also stated that Resident #267 will lash out when he does not get his way and gets upset quickly. Resident #267 gets very upset when he does not get his way. The DON stated that she was in the building at the time of the incident and became aware of the incident immediately. The DON reported that Resident #267 was upset his iPod was not working. The DON stated that staff were trying to fix his iPod and it was taking too long so resident #267 became upset and started banging on the tables before banging on Resident # 69's leg. The DON stated that the CNA assigned to the dining room separated the residents as soon as she could. The DON stated Resident #69 was sent out to the hospital for stitches after the incident and was evaluated by a psychiatrist. The DON stated that after the incident, staff monitored Resident #69 for any psychological effects from the event, and none were exhibited. Resident #69 continues to have the behavior of screaming out when she is touched, so staff try to position her correctly. The staff also move her out of the room when she gets upset to prevent other residents getting upset. The DON stated that Resident #69 has a very involved family and they did not express any concerns after Resident #267 was moved to another unit. The DON stated that after the incident there was an in-service done with direct staff. The training was done by someone who specializes in Autism. The in-service topics included how to approach a resident in a calm manner. The DON stated that staff are in-serviced on abuse upon hire and annually. Resident #267 was transferred to a different unit and put on 1:1 monitoring for 24 hours a day. The DON stated the interdisciplinary team developed a comprehensive care plan and a solo activity schedule to keep Resident #267 occupied. The DON reported the activity schedule was written on a board, so all staff members knew what Resident #267 was scheduled to be doing throughout the day. The DON reported there were scheduled times for the resident to call his mother, which was identified as a non-pharmacological intervention to calm the resident down. The DON stated that after the incident in February, the structured routine and schedule was working well for the resident, and with 1:1 supervision, the resident was doing well. The DON stated attempts were made to interview Resident #267 about the incident, but the resident would not talk about it. On 07/23/19 at 11:15 AM, an interview was held with CNA #1. CNA #1 stated Resident #267 needs a routine and structure. Since the implementation of the activity schedule, the resident's behavior has improved. CNA #1 stated that the resident can perform his ADLs with supervision. CNA #1 stated that the resident can wash, dress, brush his teeth, make the bed, and eat by himself. CNA #1 stated that Resident #267 has poor impulse control. The CNA reported that after the incident, the resident was not able to recall the incident, but he apologized afterwards. On 7/23/19 at 12:21 PM, an interview with the Registered Nurse (RN #2) was conducted. RN #2 stated that she was in the building during the incident. After the incident, Resident #69's mental status was assessed. As a result of the assessment, the staff keep constant visual contact on the resident to make sure she is safe. The RN stated that staff will monitor to see if any residents try and to get closer to Resident #69 for any reason. RN #2 stated that the resident is vulnerable, and, after the incident, staff need to make sure the resident is safe both physically and emotionally. Per the DON, CNA #2 was not available for interview because they were out on medical leave, and LPN #1 was not available. 2) The undated policy titled Special Assignment (1:1) documents one-to-one/special assignment is provided to residents that exhibit potential to harm themselves or others. A CNA will be scheduled to monitor the resident's behavior and indicate on the monitoring log form any concerns noted. Any behavioral issues will be reported to the charge nurse for intervention and follow up, and period assessment for need will be conducted. Resident #604 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly MDS assessment dated [DATE] documented the resident was understood and understands others, the resident had intact cognition. The resident did not experience any hallucinations, delusions, or symptoms of [MEDICAL CONDITION]. The resident did not display any behaviors. The resident required extensive assistance from staff for Activities of Daily Living (ADLs). The resident's [DIAGNOSES REDACTED].#604 was discharged from the facility on 12/21/18, therefore no observations were made. The Comprehensive Care Plan (CCP), for resident #604, titled Mood dated 12/22/18 documented the resident was feeling down, depressed, hopeless, feeling bad about self, and had a [DIAGNOSES REDACTED]. The facility investigation summary report dated 4/27/18 documented, prior to the incident, Resident #267 was sitting in his wheelchair in front of the nursing station asking staff to call his mother. Staff called the resident's mother four times with no answer. Resident #267 became anxious and the MD was notified. The MD instructed staff to redirect and monitor the resident with no new orders given. A CNA offered the resident juice and told the resident they were going to call his mother in a little bit. After a few minutes, the resident asked for more juice and permission to ride his wheelchair into the dining room. Around 12:45 PM resident #267 stood up from his wheelchair in the dining room asking where his mom was and became anxious. Resident #267 walked to the dining room and struck another resident (#604) in the head. Staff immediately responded and separated the residents. Resident #267 received a [MEDICATION NAME] injection per the MD order and was transferred to the hospital for agitation. Resident #604 was assessed by the nurse and the MD ordered the resident's transfer to the hospital for evaluation. The investigation concluded that there was insufficient reason to believe that resident #267 willfully tried to inflict injury on Resident #604 because Resident #267 has a [DIAGNOSES REDACTED]. In a written statement dated 4/27/18 LPN #2 reported that around 12:40 PM, on 4/27/18, resident #267 asked the nurse to call his mom and the nurse and social worker called the resident's mom four times, but the mom did not answer the phone. In the hallway by the nursing station, Resident #267 got out of his wheelchair and asked, Where is my mom? The CNA offered the resident juice, and the nurse explained she would call his mom back in a little bit. Resident # 267 asked for more juice and permission to ride his wheelchair into the dining room. In the dining room, Resident # 267 became anxious and began asking where his mom was. The staff tried to redirect him, but it was not effective. Resident #267 stood up and punched resident #604 in the head. In a written statement dated 4/27/18 CNA #3 reported around 12:40 PM she went into the dining room and noticed Resident #267 got out of his chair and was very agitated. Resident #267 turned and punched resident #604 in the head and turned away and slapped resident #604 in the head again. CNA #3 stated she tried to calm resident #267 down and the resident got angry and spit on her. Resident #267 apologized to the CNA afterwards. Nursing Notes dated 2/15/18 documented Resident #267 returned to the facility from the hospital after a resident-to-resident altercation. The resident was transferred to another floor and placed on 1:1 (one-to-one) 24-hour supervision. A Nursing Note dated 4/1/18 documented resident #267 was on 15-minute checks. The resident was observed with verbal disturbances of laughing and having conversations with himself. Subsequent Nursing Notes documented Resident #267 displayed behaviors of talking to self and yelling, disrupting other residents. Resident #267 remained on 1:1 supervision and started on [MEDICATION NAME] for [MEDICAL CONDITION]. A Social Work Note dated 4/13/18 documented a team meeting was held to discuss resident #267 plan of care. The team discussed the resident's behaviors, recreational needs, and monitoring. The plan was for structured activities and 1:1 monitoring to be continued. Social Work Notes dated 4/18/18 and 4/19/18 documented the resident was approved for a 24-hour aide and supportive services from OPWDD after discharge. The resident could return home and wait for group home placement with a tentative discharge the following week. In the meantime, Resident #267 was transferred Resident #604's unit. The Physician's (MD) note dated 4/19/18 documented Resident #267 was seen by the psychiatrist and the recommendation was made to continue 1:1 monitoring. A Social Work Note dated 4/23/18 documented extended homecare was declined because Resident #267's mother did not want to care for the resident at home. Resident #267 had to remain in the facility until appropriate placement could be obtained. There was no documentation in the record indicating whether the resident received notice or increased support regarding not being able to be discharged home to live with his mother. The (MONTH) (YEAR) progress notes were reviewed for resident #604, and there were no behavior notes documented. The MD Note dated 4/27/18 documented the MD was called to the unit to evaluate Resident #604 after she was struck by another resident (#267) around 12:45 PM. Resident #604 had mild [MEDICAL CONDITION] to the temple and cheek area. Resident #604 complained of left side facial pain and blurry vision. The MD ordered for Resident #604 to be transferred to the hospital for an evaluation. The MD documented Resident #604 had a history of [REDACTED]. A Nursing Note dated 4/27/18 documented resident #604 was transferred to the hospital status [REDACTED]. Resident #604 was the victim of abuse when she was hit/slapped in the head by another resident (#267) suddenly without reason while in the main dining room. Resident #604 complained of left side facial pain and blurry vision. An ice pack was applied to the resident's head. A Social work Note dated 4/27/18 documented Resident #604 was the victim of abuse this afternoon; the resident was hit by another resident (#267) while in the dining room. Resident #604 was expressive and appeared to be saddened about the incident. Resident #604 was counseled and expressed desire to remain on the unit at the time. Psychology follow up was requested. The CCP titled Resident to Resident Altercation dated 4/27/18 documented the resident was a victim of abuse and was hit by another resident (Resident #267). The resident also had verbally abusive behavior and was easily annoyed with a short temper. Interventions included counseling resident to assist with coping with stressful situations, monitoring resident interactions with peers, and psychological evaluation and services. A review of the Resident Status Observation Log dated 4/27/18, for Resident #267, documented the resident exhibited upset, aggressive behavior from 8:30-9:00 AM. At 9:45 AM, it was documented that the resident was repeatedly calling his mother with no answer on the other end. From 12:15-1:15 PM the CNA assigned to resident #267 was on their lunch break, the resident was no longer being monitored 1:1. It is documented that While I was out for lunch (the resident) hit a patient/spat on CN[NAME] A post incident report dated 4/27/18 documented Resident #267 returned from the hospital the same day, 4/27/18. MD ordered resident #267 to be closely monitored to prevent his autistic related behavior from injuring others. An post incident Report dated 4/27/18 documented Resident #604 returned from the hospital on the same day, 4/27/18, with a clear CT scan of head, neck and spine. Resident # 604 was referred to psychological services for emotional support and optometry for blurred vision. A Social work note dated 4/30/18 documented resident #604 was seen by the psychologist today and no recommendations made. A Social Work Note dated 4/30/18, for Resident #267, documented the Social Worker requested 1:1 companion from OPWDD until the resident can be placed into a group home. On 07/23/19 around 11:10 AM, RN #1 was interviewed. RN #1 stated she was the supervisor on the unit at the time. RN #1 stated that Resident #267 got very angry when his mom did not answer the phone and went into the dining room and slapped resident #604 in her face. RN #1 stated that resident #267 calmed down after the incident. RN#1 stated that both residents involved in the incident were sent out to the hospital. RN #1 stated that resident #267 was on 1:1 at the time of the incident, and the CNA watching him was on their lunch break. When asked about who covers the resident when staff goes on lunch break, RN #1 stated the floor staff provide coverage and monitor the resident. She stated there is no one person who relieves the CNA from 1:1 assignment when they go on break. RN #1 stated that resident #267 is allowed to be in his room alone. When questioned about impulsive behavior or unsafe behavior in the resident's room, RN #1 reported that the staff are monitoring every 30 minutes and there had been no episodes since February. RN #1 reported during lunch time, there are 5 CNAs and a nurse in the dining room, which provides enough coverage to monitor residents. RN #1 reported that resident #267 behaviors are episodic and unpredictable. RN #1 stated that the resident was supposed to be discharged that week before the incident, but the resident mother did not want to take him back home. The facility was working on getting him placement in a group home. RN #1 stated that resident #604 is alert and oriented x 3. RN #1 stated that resident # 604 was very anxious and depressed about her placement in the nursing home from the beginning. RN #1 stated that after the incident, Resident #604 was placed on psychotherapy. RN #1 stated that the resident's daughter is very involved and would take her outside and spend time with her. After the incident, RN #1 stated that resident #604 was offered a transfer to a different unit but declined at the time. The facility continued treatment for [REDACTED]. On 07/23/19 at 10:56 AM, the Director of Nursing (DON) was interviewed. The DON stated that most incidents that happen with Resident #267 involve his mother. The DON reported that the resident's mother was not working with the facility on caring for the resident. The DON reported that after this incident, the resident's mother has been more cooperative with the team and is working on getting housing where she can live with the resident at home. The DON reported that to date, Resident #267 has been declined from four group homes and they are still looking for appropriate placement. Per the DON, CNA #3 and LPN #2 were not available for interview. The facility staff did not ensure that the 1:1 supervision was provided, as recommended, in order to prevent further incidents. In addition, Resident #267 was permitted to go into the dining room with other residents without the 1:1 supervision after displaying aggressive behavior and increased anxiety. This put other residents at risk for being abused by the resident. The facility did not protect other residents from being abused by Resident #267. 415.4(b)(1)(i)