Every finding on record at Friedwald Center For Rehab And Nursing, L L C

Based on record review and interviews during an abbreviated survey (NY00374854/801166), the facility did not ensure that all participants in the assessment process have the requisite knowledge to complete an accurate assessment. For 4 out of 4 residents (Resident #3, Resident #6, Resident #7, Resident #8) reviewed for assessments. Specifically, (1) Resident #3 who had severe cognitive impairment and was unable to be interviewed had eight trauma informed care assessments completed by the facility Social Worker with a score of zero indicating no evidence of trauma; (2) Resident #6 who had severe cognitive impairment and was unable to be interviewed had eight trauma informed care assessments completed by the facility Social Worker with a score of zero on two assessments and a score of one on six assessment indicating no evidence of trauma; (3) Resident #7 had who had severe cognitive impairment and was unable to be interviewed had twelve trauma informed care assessments completed by the facility Social Worker, with a score of zero indicating no evidence of trauma; (4) Resident #8 who had cognitive impairment and was unable to be interviewed had five trauma informed care assessments completed by the facility Social Worker with a score of zero indicating no evidence of trauma. The completed assessments score did not accurately reflect the residents' trauma exposure or any lingering effects from traumaThe findings are: The facilities Trauma Informed Care policy dated 12/01/2022 documented it is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as their cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI), admission assessment, the history of and physical, the social history/assessment, and others. Resident #3 had diagnoses including but not limited to Alzheimer's disease, Primary Generalized Osteoarthritis and Chronic Kidney Disease. An Annual Minimum Data Set, dated [DATE] documented Resident #3 had severe cognitive impairment. The resident had impairment on both sides to the upper and lower extremities and required a wheelchair for locomotion. The resident required maximal assistance with eating and was dependent for toileting, bed mobility and transfers.Review of an impaired cognition care plan initiated 06/02/2024 documented Resident #3 had cognitive impairment due to Alzheimer's disease and Dementia. Interventions listed included ask yes/no questions in order to determine the resident's needs. Review of the facilities trauma informed assessment revealed it is a resident question-based assessment conducted by the facility Social Worker. Review of Resident #3's chart revealed they had Trauma Informed Care Assessments completed including the following dates: 08/30/2024, 11/27/2024, 02/27/2025, 05/26/2025 and 08/25/2025. The score noted on all assessments reflected 0, indicating there was no evidence of trauma reported by the resident. 2) Resident #6 had diagnoses including but not limited to Multiple Sclerosis, Cerebral Palsy and Aphasia. A Comprehensive Minimum Data Set assessment dated [DATE] documented Resident #6 had severe cognitive impairment. The resident had impairment to the lower extremities on both sides and was dependent for eating, toileting, bed mobility and transfers. Review of an impaired thought process care plan initiated 05/02/2024 documented Resident #6 had disorientation and an inability to follow. Interventions listed included to note cyclic changes in mentation and behavior. Review of Resident #6's chart revealed they had Trauma Informed Care Assessments completed on the following dates: 01/26/2024, 04/19/2024, 07/22/2024, 10/20/2024, 01/18/2024, 02/15/2025, 04/21/2025 and 07/22/2025. 3) Resident #7 had diagnoses including but not limited to Dementia, Cognitive Communication Deficit and End Stage Renal Disease. A Part A Prospective Payment System Discharge Minimum Data Set assessment dated [DATE] documented Resident #7 had severe cognitive impairment. The resident had a gastrostomy tube for nutrition and was dependent for toileting, bed mobility and transfers. Review of an impaired though process care plan dated 04/15/2025 documented Resident #7 had an impaired thought process related to disorientation and an inability to follow. Interventions listed included assess the full physical status and psychiatric symptoms first and institute plan of care to combat those first. Any change in resident Level of Consciousness indicates area of focus that must be investigated. Review of Resident #7's chart revealed they had Trauma Informed Care Assessments completed on the following dates: 01/14/2024, 01/25/2024, 03/30/2024, 06/28/2024, 08/27/2024, 10/11/2024, 12/27/2024, 03/05/2025, 04/19/2025, 06/15/2025, 07/18/2025 and 08/21/2025. The score noted on all assessments reflected 0, indicating there was no evidence of trauma reported by the resident. 4) Resident #8 had diagnoses including but not limited to Unspecified Sequelae of Cerebral Infarction, Osteoarthritis and Peripheral Vascular Disease. A Quarterly Minimum Data Set, dated [DATE] documented Resident #8 had severe cognitive impairment. The resident had impairment to their upper and lower extremities on both sides. The resident had a gastrostomy tube and was dependent for toileting, bed mobility and transfers. Review of an impaired though process care plan dated 04/13/2024 documented Resident #8 had an impaired thought process related to disorientation and an inability to follow. Interventions listed included assess the full physical status and psychiatric symptoms first and institute plan of care to combat those first and if any change in resident level of consciousness indicates area of focus that must be investigated. Review of Resident #8's chart revealed they had Trauma Informed Care Assessments completed on the following dates: 06/21/2024, 09/13/2024, 12/15/2024, 03/16/2025 and 06/20/2025. The score noted on all assessments reflected 0, indicating there was no evidence of trauma reported by the resident. During an interview on 09/05/2025 at 11:38 AM, the Social Worker stated to when they complete a Trauma Informed Care Assessment, the resident is interviewed on traumatic experiences in their life, they provide a description of possible traumatic events a resident could have experienced, which can prompt the resident to expand on any instances. The Social Worker stated Resident #3 was not able to be interviewed Trauma informed assessment has been completed for multiple residents who are not able to be interviewed. The Social Worker stated they base the assessment on information obtained from interviewing staff and family and from knowing the resident. The Social Worker provided a list of three additional residents (Resident #6, Resident #7, Resident #8) they recently completed the Trauma Informed Care assessments that they were all unable to be interviewed. During an interview on 09/08/2025 at 10:36 AM, the Administrator stated the trauma informed care policy and procedure was revised on 09/05/2025 to include that due to the nature of questions asked, it is only recommended for residents capable of answering the questions. The Administrator stated they provided an in-service to the social services department on 09/05/2025 on the policy update.Review of the facilities Trauma Informed Care policy revealed it was revised on 09/05/2025 to include the following: Due to the questions asked during the Trauma Informed Care Assessment, the assessment should only be completed for residents that are cognitively capable of properly answering the questions on the assessment.10 NYCRR 415.11(b)

Based on record review and interviews during an abbreviated survey (NY00368065, NY00356980) the facility did not ensure a comprehensive person-centered care plan was implemented for 2 out of 4 residents (Resident #1, Resident #5) reviewed for care planning. Specifically, (1) Resident #1 with a known behavior of refusing care and being non-compliant, had documented refusals of care on three occasions. Review of Resident #1's care plans revealed they did not have a care plan initiated to reflect their refusal behaviors. (2) Resident #5 had a Stage 4 sacral pressure ulcer which resolved on 07/31/2024, the resident was hospitalized on [DATE] and was readmitted to the facility on [DATE] with the Stage 4 sacral pressure ulcer reopened. There was no documented evidence of Resident #5's pressure ulcer care plan being reactivated on readmission. The findings are: The facility Comprehensive Care Plan policy dated 09/24/2024 documented it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that incudes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident comprehensive assessment. 1)Resident #1 admitted to the facility on [DATE] with diagnoses including but not limited to Hepatic Encephalopathy, Essential Hypertension and Osteoarthritis. A Medicare 5-day Minimum Data assessment dated [DATE] documented Resident #1 was cognitively intact. The resident required supervision with eating, maximal assistance with bed mobility and dependent for toileting and transfers. The resident was frequently incontinent of bladder and bowels. Review of Resident #1's nursing progress notes revealed the resident refused care on 01/03/2025, 01/27/2025 and 02/17/2025. Review of Resident #1's care plans revealed the resident did not have a care plan initiated to reflect their refusal of care behavior. During an interview on 09/04/2025 at 1:53 PM Licensed Practical Nurse #1 stated Resident #1 would resist care, and they are not able to force the residents to do anything. Licensed Practical Nurse #1 stated the behavior, and the non-compliance care plans could reflect this behavior. Licensed Practical Nurse #1 stated Resident #1's behavior should have been captured on the behavior care plan the care plans are updated by the nurse manager on the unit. During an interview on 09/08/2025 at 2:10 PM the Director of Nursing stated there should have been a behavior care plan implemented for Resident #1 due to their behaviors. The Director of Nursing stated Resident #1 had refusals of care and this should have been reflected in the resident's care plan. The Director of Nursing stated they are now doing a facility audit of residents' care plans to ensure that if a resident refuses care, then a refusal of care plan is appropriately documented in the resident chart. During a telephone interview on 09/15/2025 at 8:52 AM Registered Nurse #1 stated Resident #1 was non-compliant with a lot of their cares. Registered Nurse #1 stated Resident #1 was their non-compliant resident and many mornings they had to go into the resident's room and encourage/empower the resident to participate in their care and treatment plans. Registered Nurse #1 stated they did not implement a non-compliance care plan for Resident #1 because they did not know that was something they needed to do but they did know of Resident #1's non-compliance. Registered Nurse #1 stated they do not recall the facility having a non-compliance care plan, but Resident #1's non-compliance could have been reflected on a refusal of care or refusal of activities of daily living care plan which was not implemented. 2) Resident #5 admitted to the facility on [DATE] with diagnoses including but not limited to Type 2 Diabetes Mellitus, End Stage Renal Disease and Chronic Obstructive Pulmonary Disease. An Annual Minimum Data Set, dated [DATE] documented Resident #5 had moderate cognitive impairment. The resident requires a wheelchair for locomotion. The resident required moderate assistance with eating, maximal assistance with bed mobility, and dependent for toileting and transfers. The resident was at risk of developing pressure ulcers/injuries and had unhealed pressure ulcers/injuries. The resident had one stage 4 pressure ulcer. Review of a pressure ulcer care plan initiated 03/02/2024 documented Resident #5 had a Stage 4 pressure ulcer or potential for pressure ulcer development related to immobility. Interventions listed included administer treatments as ordered and monitor for effectiveness, assess/record/monitor wound healing weekly, educate resident/family/caregiver as to cause of skin breakdown, inform the resident/family/caregivers of any new areas of skin breakdown. Further review of the pressure ulcer care plan revealed it was resolved as of 07/31/2024. Resident #5 was readmitted to the facility following a hospitalization on 08/21/2024 with the Stage 4 sacral pressure ulcer reopened. There was no documented evidence of a pressure ulcer care plan being initiated for Resident #5's Stage 4 sacral pressure ulcer on readmission to the facility on [DATE]. During an interview on 09/08/2025 at 2:10 PM the Director of Nursing stated the wound care team documented on their weekly rounds under the weekly wound evaluation in Point Click Care (the electronic medical record) under the assessment section. Care plans should also be updated with the wound round information if a treatment resolves or if there is something new. 10 NYCRR 415.11(c)(1)

Based on record review and interviews during an abbreviated survey (NY00368065/801164), the facility did not ensure a comprehensive person-centered care plan was implemented for 1 out of 4 residents (Resident #1) reviewed for care planning. Specifically, Resident #1 with a known behavior of refusing care and being non-compliant, had documented refusals of care on three occasions. Review of Resident #1's care plans revealed they did not have a care plan initiated to reflect their refusal behaviors and noncompliance. The findings are:The facility Comprehensive Care Plan policy dated 09/24/2024 documented it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that incudes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident comprehensive assessment. 1)Resident #1 had diagnoses including but not limited to Hepatic Encephalopathy, Essential Hypertension and Osteoarthritis.A Medicare 5-day Minimum Data assessment dated [DATE] documented Resident #1 was cognitively intact. The resident required supervision with eating, maximal assistance with bed mobility and dependent for toileting and transfers. The resident was frequently incontinent of bladder and bowels.Review of Resident #1's nursing progress notes revealed the resident refused care on 01/03/2025, 01/27/2025 and 02/17/2025.Review of Resident #1's care plans revealed the resident did not have a care plan initiated to reflect their refusal of care behavior.During an interview on 09/04/2025 at 1:53 PM, Licensed Practical Nurse #1 stated Resident #1 would resist care, and they are not able to force the residents to do anything. Licensed Practical Nurse #1 stated the behavior, and the non-compliance care plans could reflect this behavior. Licensed Practical Nurse #1 stated Resident #1's behavior should have been captured on the behavior care plan and the nurse manager on the unit is responsible for updating the residents care plans. During an interview on 09/08/2025 at 2:10 PM, the Director of Nursing stated there should have been a behavior care plan implemented for Resident #1 due to their behaviors. The Director of Nursing stated Resident #1 had refusals of care and this should have been reflected in the resident's care plan. The Director of Nursing stated they are now doing a facility audit of the resident's care plans to ensure that if a resident refuses care, then a refusal of care, care plan is appropriately documented in the resident chart. During a telephone interview on 09/15/2025 at 8:52 AM, Registered Nurse #1 stated Resident #1 was non-compliant with a lot of their cares. Registered Nurse #1 stated Resident #1 was their non-compliant resident and many mornings they had to go into the resident's room and encourage/empower the resident to participate in their treatment plans. Registered Nurse #1 stated they did not implement a non-compliance care plan for Resident #1 because they did not know that was something they needed to do. Registered Nurse #1 stated they did not implement the care plan, but they did know of Resident #1's non-compliance. Registered Nurse #1 stated they do not recall the facility having a non-compliance care plan, but Resident #1's non-compliance could have been reflected on a refusal of care or refusal of activities of daily living care plan, and they did not implement these care plans either.10 NYCRR 415.11(c)(1)

Based on record review and interviews during an abbreviated survey (NY00368065, NY00374854), the facility did not ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming and personal hygiene for 3 out of 3 residents (Resident #1, Resident #3, Resident #4) reviewed for quality of care. Specifically, (1) Resident #1's representative reported they found Resident #1 covered in urine and feces on multiple occasions. Resident #1 was incontinent and dependent on staff for toileting. Review of Resident #1's certified nurse aide accountability revealed within a 2-month period, there were no signatures indicating toilet use was provided by direct care staff on 37 occasions; (2) Resident #3 is incontinent and dependent on staff for toileting. Review of Resident #3's certified nurse aide accountability record revealed within a 2-month period, there were no signatures indicating toilet use was provided by direct care staff on 26 occasions; (3) Resident #4 was incontinent and dependent on direct care staff for toileting. Review of Resident #4's certified nurse aide accountability record revealed within a 2-month period, there were no signatures indicating toilet use was provided by direct care staff on 16 occasions.The findings are:The facility Activities of Daily Living (ADL) Documentation policy last revised 05/2016 documented the activity of daily living documentation is completed on each shift by the certified nurse aide giving direct care. Toileting is provided as per individual needs of the resident, typically every two to four hours and as needed as the basic standard of care. Certified nurse aides will document whether the resident was continent or incontinent during their shift.1) Resident #1 was admitted with diagnoses including but not limited to Hepatic Encephalopathy, Essential Hypertension and Osteoarthritis.A Medicare 5-day Minimum Data assessment dated [DATE] documented Resident #1 was cognitively intact. The resident required supervision with eating, maximal assistance with bed mobility and dependent for toileting and transfers. The resident was frequently incontinent of bladder and bowels.Review of an activities of daily living care plan initiated 12/20/2024 documented Resident #1 needed assistance with all tasks. Interventions listed included allow sufficient time to complete each task, assess the ability to bathe, dress, eat and perform toileting activity, assist with toileting and encourage self-care.Review of an incontinence care plan initiated on 01/09/2025 documented Resident #1 was incontinent of bladder and bowel. Interventions listed included observe skin for sign of redness, provide dignity and privacy in management of incontinent episodes, provide emotional support, render perineal skin care as needed and utilize incontinence aids.Review of Resident #1's certified nurse aide accountability for January 2025 revealed toilet use was not signed as being performed on the following dates and times: 7 AM - 3 PM shift: 01/07/2025, 01/12/2025; 3 PM - 11 PM shift: 01/04/2025, 01/05/2025, 01/06/2025, 01/07/2025, 01/11/2025, 01/12/2025, 01/17/2025, 01/19/2025, 01/20/2025, 01/22/2025, 01/25/2025, 01/26/2025, 01/28/2025. Review of Resident #1's certified nurse aide accountability for February 2025 revealed toilet use was not signed as being performed on the following dates and times: 3 PM - 11 PM shift: 02/03/2025, 02/06/2025, 02/08/2025, 02/09/2025, 02/10/2025, 02/16/2025, 02/22/2025, 02/23/2025, 02/24/2025, 02/27/2025.Review of Resident #1's certified nurse aide accountability for March 2025 revealed toilet use was not signed as being performed on the following dates and times: 7 AM - 3 PM shift: 03/13/2025, 03/22/2025; 3 PM - 11 PM shift: 03/03/2025, 03/04/2025, 03/08/2025, 03/13/2025, 03/14/2025, 03/16/2025, 03/18/2025, 03/22/2025, 03/23/2025, 03/24/2025.Further review of Resident #1's certified nurse aide accountability revealed Certified Nurse Aide #1 was assigned Resident #1 on 11 out of the 37 occasions when no signature was documented indicating the toilet use task was performed.During an interview on 09/04/2025 at 2:37 PM, Certified Nurse Aide #1 stated Resident #1 was incontinent at times, but there were times if they were out sitting in the wheelchair they would go to the bathroom and use the toilet. Certified Nurse Aide #1 stated Resident #1 required a one person assist to use the bathroom and sometimes when they arrived on the unit for work, Resident #1 would be soaked in urine, but not feces. Certified Nurse Aide #1 stated they were assigned to Resident #1 on the 11 dates that are missing a signature in the certified nurse aide accountability. Certified Nurse Aide #1 stated if there is no signature in a box on the certified nurse aide accountability, that means the task was not done. Certified Nurse Aide #1 stated sometimes they work short staffed on the units, and they are not able to complete their certified nurse aide accountability and even when they have staff sometimes, they just do not have enough time to complete the accountability. During an interview on 9/5/2025 at 3:24 PM Certified Nurse Aide #4 stated when they arrive for their shift, they would find Resident #1 soaked in urine, but the resident would let them know if they were wet, and the resident used adult incontinence briefs. Certified Nurse Aide #4 stated an empty box on the certified nurse aide accountability means that they either did not do the task or forgot to go back and document for the task. Certified Nurse Aide #4 stated they possibly got caught up doing something else and did not go back and document for Resident #1.2) Resident #3 was admitted with diagnoses including but not limited to Alzheimer's disease, Primary Generalized Osteoarthritis and Chronic Kidney Disease.An Annual Minimum Data Set, dated [DATE] documented Resident #3 had severe cognitive impairment. The resident had impairment on both sides of the upper and lower extremities and required a wheelchair for locomotion. The resident required maximal assistance with eating and was dependent for toileting, bed mobility and transfers.Review of an incontinence care plan initiated 06/02/2024 documented Resident #3 was incontinent of bladder and bowel related to cognitive deficit and lack of sphincter control. Interventions listed included observe skin for redness, provide dignity and privacy in management of incontinence episodes, render perineal and skin care as needed, toilet/change resident every three hours and as needed and utilize incontinence aids.Review of an activities of daily living care plan initiated 06/02/2024 documented Resident #3 required assistance with toileting. Interventions listed included assist with toileting as necessary to promote continence and provide privacy at all times.Review of Resident #3's certified nurse aide accountability for February 2025 revealed toilet use was not signed as being performed on the following dates and times: 7 AM-3 PM shift: 02/03/2025, 02/04/2025, 02/05/2025, 02/06/2025, 02/11/2025, 02/17/2025, 02/23/2025; 3 PM-11PM shift: 02/12/2025, 02/13/2025, 02/18/2025, 02/22/2025; 11 PM-7 AM shift: 02/13/2025, 02/18/2025, 02/21/2025, 02/23/2025.Review of Resident #3's certified nurse aide accountability for March 2025 revealed toilet use was not signed as being performed on the following dates and times: 7 AM-3 PM shift: 03/11/2025, 03/12/2025, 03/26/2025; 3 PM-11 PM shift: 03/02/2025, 03/12/2025, 03/22/2025, 03/30/2025; 11 PM-7 PM shift: 03/23/2025, 03/24/2025, 03/26/2025, 03/30/2025.During an interview on 09/05/2025 at 2:48 PM, Certified Nurse Aide #2 stated they always do their documentation, but about a week ago they were not able to access the documentation on the computer. Certified Nurse Aide #2 stated they did not have a password to enter the computer and document their task completion in point click care (an electronic medical record) before and the Director of Nursing just reset it. Certified Nurse Aide #2 stated this was why they did not sign the certified nurse aide accountability in the computer, but Resident #3 is always their resident. Certified Nurse Aide #2 stated their password was reset and they were able to do their documentation in the computer yesterday. Certified Nurse Aide #2 stated if there is no signature in a box on the certified nurse aide accountability then this means that the task was not done. 3) Resident #4 was admitted with diagnoses including but not limited to Bipolar Disorder, Schizoaffective Disorder and Difficulty Walking.A Modification of Quarterly Minimum Data Set, dated [DATE] documented Resident #4 had moderate cognitive impairment. The resident exhibited verbal behavioral symptoms directed towards others. The resident had impairment to their lower extremity on one side and used a wheelchair for locomotion. The resident required supervision for eating, moderate assistance for bed mobility and dependent for toileting and transfers. The resident was always incontinent of bladder and bowel.Review of an incontinence care plan initiated 03/26/2024 documented Resident #4 was incontinent of bladder and bowel related to cognitive deficit, lack of sphincter control and a neurological condition that results in the inability to perceive the need to void. Interventions listed included observe skin for redness, provide dignity and privacy in management of incontinence episodes, render perineal and skin care as needed, toilet/change resident every three hours and as needed and utilize incontinence aids.Review of Resident #4's certified nurse aide accountability for February 2025 revealed toilet use was not signed as being performed by direct care staff on the following dates and times: 7 AM-3 PM shift: 02/03/2025, 02/04/2025, 02/05/2025, 02/08/2025, 02/12/2025, 02/17/2025, 02/27/2025; 3 PM-11 PM shift: 02/11/2025; 11 PM-7 AM shift: 02/13/2025, 02/18/2025, 02/21/2025, 02/23/2025.Review of Resident #4's certified nurse aide accountability for March 2025 revealed toilet use was not signed as being performed by direct care staff on the following dates and times: 7 AM-3 PM shift: 03/06/2025, 03/07/2025, 03/13/2025; 3 PM-11 PM shift: 03/11/2025.Resident #4 was discharged from the facility on 03/14/2025.During an interview on 09/05/2025 at 3:08 PM, Certified Nurse Aide #3 stated they have been working in the facility for fifteen years now. Certified Nurse Aide #3 stated they recall Resident #4, and they were incontinent and transferred to the wheelchair. Certified Nurse Aide #3 stated if a box is blank with no signature, then the task was not completed. Certified Nurse Aide #3 stated the computer probably was not working at the time when they did not sign for Resident #4's toileting and they always complete their documentation before they leave the building. Certified Nurse Aide #3 stated they do receive in-services regularly on documentation in the facility.During an interview on 09/04/2025 at 12:05 PM, the Director of Nursing stated the certified nurse aide accountability documents all the task the certified nurse aide provides each shift. The Director of Nursing stated each task should be documented every shift and if the task was not completed then there is an option to select not applicable or activity did not occur. The Director of Nursing stated for the shifts, if there is nothing in the box, then that means the certified nurse aide did not document on the accountability. The Director of Nursing stated if the certified nurse aide does not document then the task was not done.During an interview on 09/04/2025 at 1:53 PM, Licensed Practical Nurse #1 stated if the certified nurse aide documentation has a blank or is not signed, then that means the task was not completed. Licensed Practical Nurse #1 stated the nurses on the unit are responsible for reviewing the certified nurse aid accountability documentation, but sometimes they do not have time to check the documentation. Licensed Practical Nurse #1 stated prior they had a designated person that would review the certified nurse aide accountability documentation, printout any omissions and give it to the certified nurse aide to correct. 10 NYCRR 415.12 (a)(3)

Based on record review and interviews conducted during an abbreviated survey (NY00349754, NY00348426) the facility did not ensure that nursing staff were in serviced in behavioral health care needs of residents for 1 of 4 residents. Specifically, the facility was unable to provide documented evidence that they provided education on behavioral health to Licensed Practical Nurse #1 before they were assigned to the dementia unit on 7/30/2024. Licensed Practical Nurse #1 engaged in a verbal altercation with Resident #1 with known verbal/physical aggressive behavior, and Licensed Practical Nurse #1 threw a pitcher of water at the resident during the verbal exchange. Finding include: A review of the Behavioral Health Policy dated 9/1/2022 documented it is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning. All facility staff, including contracted staff and volunteers, shall receive education to ensure appropriate competencies and skill sets for meeting the behavioral health needs of residents. Education shall be based on the role of the staff member and resident needs identified through the facility assessment. Review of a course completion list dated 8/7/2024 with completion dates 2/7/2024-8/7/2024 for caring for residents with cognitive impairment and management of behavioral challenges documented out of 85 employees, only 9 facility staff had completed both the cognitive and behavioral portions of the curriculum.38 employees had completed the behavioral portion and 38 employees had completed the cognitive portion of the training. Resident # 1 was admitted to the facility on [DATE] and last readmitted on [DATE] with diagnoses including Bipolar disorder, Depression and Chronic Pain Syndrome. A Quarterly Minimum Data Set, dated dated dated [DATE] documented that Resident # 1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 15, associated with intact cognition. No behaviors noted. Resident #1 required set up assistance for meals, supervision for bed mobility and moderate assistance for transferring and maximal assistance for toileting. Review of a behavior care plan initially dated 4/24/2024 and revised 8/5/2024 documented Resident #1 used abusive language, resistant to activities for daily living, and exhibits aggressive behaviors. The goal is Resident #1 will display no negative behaviors through the review date. Interventions listed included provide a safe environment and psychological consult and follow up as needed. Review of a risk for abuse care plan initially dated 2/21/2024 and revised on 5/22/2024 documented Resident #1 is at risk for potential abuse related to aggressive behavior, verbally abusive towards staff and a diagnosis of bipolar disorder. The goal is Resident #1 will be kept safe and free from abuse through the next review date. Interventions listed included create a home like environment as much as possible and encourage diversion activities. Review of behavior symptoms: physical abuse care plan dated 6/4/24 documented Resident #1 exhibits physically aggressive behavior towards staff and others. The goal is Resident #1 will show a decrease in the number of episodes of physically aggressive behavior. Interventions listed included to administer medications as ordered by physician, allow time to de-escalate when agitated, notify and report behavior changes to the physician, redirect negative behaviors. During a telephone interview on 8/6/2024 at 2:10 PM Licensed Practical Nurse #1 stated they have had dementia training from a previous employer but Resident #1 was upset and wanted their pain medications to be given right away. Licensed Practical Nurse #1 stated they were warned about Resident #1 before the beginning of their shift that Resident #1 can be aggressive. The Registered Nurse Unit Manager told them that the North side of the unit had a lot more psychiatric residents than dementia. Licensed Practical Nurse #1 stated the facility may give an orientation on combative residents or residents with behaviors, but they had not received the training before their assignment to the 3rd floor North unit. During an interview on 8/6/2024 at 2:55 PM, the Director of Nursing stated they have been working in the facility since July 22, 2024. The Director of Nursing stated the behavior training is conducted during the general orientation. If new staff start on a day that the general orientation is not held, they will not receive the training. There is now a new onboarding process where new staff are now receiving abuse, resident rights, Corporate Compliance, HIPPA, Fire Safety and Evacuation Plan and Emergency Codes Behavioral/Cognitive trainings. During an interview on 8/06/2024 at 3:30 PM the Registered Nurse Staff Development Coordinator stated they started working in the facility at the end of June 2024. Stated In orientation all staff are trained on how to handle combative residents and residents with behaviors. The Registered Nurse Staff Coordinator stated the last orientation was completed August 1, 2024, and the last mandatory training was completed before they arrived in the facility. Abuse In-service after the incident with Resident #1 is still ongoing and they have to come in on off hours to complete the abuse in service with the other shifts. During an interview on 8/7/2024 at 9:20 AM the Administrator stated the incident that occurred on 7/30/2024 revealed that there was a systematic failure. A new systemic process since the incident has been put in place. New orientation in service packets during on boarding for nurses now include all mandatory trainings which include the cognitive and behavioral trainings. Licensed Practical Nurse #1 had not received their training and was scheduled for the training two days after the incident occurred. The Administrator stated that even if the nurse had received abuse training prior to the incident they are not sure it would have prevented the nurse from losing their cool. During an interview on 8/7/2024 at 5:20 PM Licensed Practical Nurse #2 stated the facility does not train them on dealing with residents and their behaviors. Licensed Practical Nurse #2 stated the unit manager would just inform the assigned nurse that the resident is drug seeker. Stated the facility does not do an official training for agency nurses in the facility 10 NYCRR 415.4(g)(2)

Based on record review, observations and interviews conducted during an abbreviated survey (NY00349754, NY00348426) the facility did not ensure that each resident was free from abuse for 1 of 4 residents (Resident #1) reviewed for abuse. Specifically, on 7/30/2024 Licensed Practical Nurse #1 was seen on surveillance video picking up a water pitcher with water off their medication cart and throw the pitcher and water in Resident #1's direction. Licensed Practical Nurse #1 then threw a small water bottle at Resident #1. An assessment of Resident #1 was conducted, and no injuries were identified. Findings include: The facility Abuse, Neglect and Exploitation policy dated 6/1/2021 and last reviewed/revised 10/1/2023 documented it is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, causing physical harm, pain or mental anguish includes verbal abuse, physical abuse, and mental abuse. Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including but not limited to Bipolar disorder, Depression and Chronic Pain Syndrome. A Quarterly Minimum Data Set, dated dated dated [DATE] documented Resident #1 had a BIMS score of 15. No behaviors noted. The resident required set up assistance for meals, supervision for bed mobility and required maximal assistance for toileting. The resident had lower extremity impairment on one side, used a wheelchair for locomotion and needed moderate assistance for transfer. Review of a risk for abuse care plan dated 2/21/24 and revised on 5/22/24 documented Resident #1 was at risk for potential abuse related to aggressive behavior. Resident #1 was verbally abusive towards staff and the goal was, Resident #1 will be kept safe and free from abuse through the next review date. Interventions included to create a home like environment as much as possible and encourage diversion activities, refer to psychologist and psychiatrist as needed. Review of a behavior care plan dated 4/24/24 and revised 8/5/24 documented Resident #1 uses abusive verbal language, is resistant to activities for daily living, and exhibits aggressive behaviors. The goal was for Resident #1 to display no negative behaviors through the review date. Interventions included to provide a safe environment, psychological consult and follow up as needed. Review of a behavior symptoms physical abuse care plan dated 6/4/24 documented Resident #1 exhibits physically aggressive behavior towards staff and others. The goal was Resident #1 will show a decrease in the number of episodes of physically aggressive behavior. Interventions included to administer medications as ordered by physician, allow time to de-escalate when agitated, assess/evaluate comfort level and medicate as necessary, document in medical record the intensity, duration or frequency of behavior, notify and report behavior changes to the physician, redirect negative behaviors, , remove from situation triggering behavior and social service evaluation and follow up as needed. A Review of the surveillance video dated 7/30/2024 with no audio was completed during the onsite visit. Resident #1 is seen in the dining room seated around a table with Resident #2 and Resident #3. Licensed Practical Nurse #1 is seen at the medication cart in the doorway between the dining room and the hallway. Licensed Practical Nurse #1 walked over to Resident #1 and handed them a pill cup with medication. Resident #1 took the medication. There is an inaudible dialogue back and forth between Resident #1 and Licensed Practical Nurse #1. Resident #1 is seen throwing water from their cup in Licensed Practical Nurse #1's direction, landing on Resident #3. Licensed Practical Nurse #1 then proceeded to walk towards Resident #1, and the dialogue continues. Licensed Practical Nurse #1 was seen leaning towards Resident #1 and say something. Resident #1 jerked back in their wheelchair at what was said to them and is seen throwing water at Licensed Practical Nurse #1. Licensed Practical Nurse #1 was seen going to the medication cart, take a bottle of water and [NAME] the water towards Resident #1 and threw the empty bottle at the resident. Licensed Practical Nurse #1 was seen at their medication cart, picking up the water pitcher with water off their medication cart and [NAME] the entire pitcher and water in Resident #1's direction. Licensed Practical Nurse #1 was seen throwing the top of the pitcher in Resident #1's direction. Resident #1 left and headed towards their room. Certified Nurse Assistant #1 appears on the scene and is seen speaking to Resident #1 as they enter their room. Licensed Practical Nurse #1 is seen exiting the video. Review of Accident/Incident Report dated 7/30/2024 documented the incident that occurred on 7/30/2024 at 6:00 PM. Licensed Practical Nurse #1 threw water and a small plastic water bottle at Resident # 1 after Resident # 1 threw water at Licensed Practical Nurse #1. Resident #1 with no injury noted at the time of the incident. Physician notified at 6:30 PM. Licensed Practical Nurse # 1 was terminated to prevent recurrence. Review of a Resident #2' s (witness) statement dated 7/30/2024 documented they saw Licensed Practical Nurse #1 and Resident #1 throwing water at each other. The statement documented the incident got more intense and the anger intensified, and Licensed Practical Nurse #1 threw the pitcher at Resident #1, and it broke. Resident #1 also threw water at the Licensed Practical Nurse. Resident #3 had hearing impairment and was not interview able. Review of Registered Nurse Supervisor #1's note dated 7/30/2024 at 9PM documented Resident #1 stated they did not sustain any injury from the confrontation. However, Resident #1 stated they felt very anxious and nervous as a result. Therapeutic communication was applied to calm Resident #1 and assure them of their safety. The Incident/Accident report conclusion dated 8/1/2024 documented statements were obtained from all residents present at the time of the incident as well as staff assigned to the unit. Video of the incident was obtained from the facility camera system. After review of the statements and video, the facility concluded the complaint was verified, the employee was immediately terminated, a professional discipline complaint form was filed by the facility with New York State office of the professions. During an interview on 8/6/2024 at 12:24PM Resident #1 stated they have been in the facility for 5 years. Stated they were due for a pain medication, and they asked Licensed Practical Nurse #1 for it, and they stated they were not ready to give it to them yet. Stated Licensed Practical Nurse #1 came and spoke with Resident #2 and Resident #3 and was giving them their pain medications which they are not supposed to get until bedtime, and it was about 6:00 PM. Resident #1 stated they then told Licensed Practical Nurse #1 that they cannot do that, and they stated, do not tell them what to do, I do what I want. Licensed Practical Nurse #1 got in their face and stated, they do what they want to do bitch faggot and if they want to give others their medications now, they will, and Resident #1 will wait. Resident #1 stated they had a little cup of water, and they threw it at Licensed Practical Nurse #1. Resident #1 stated Licensed Practical Nurse #1 then went back to their medication cart and grabbed the water pitcher and threw it at Resident #1 and it shattered against the wall and broke into pieces. Resident #1 stated they had a little water bottle on the table in front of them and they threw that at Licensed Practical Nurse #1 and Licensed Practical Nurse #1 started charging towards them and the certified nurse assistant held Licensed Practical Nurse #1 back and told them to go back to their room. Resident #1 stated they were scared and shaking. Resident #1 stated Licensed Practical Nurse #1 lost it and was out of control. Resident #1 stated Licensed Practical Nurse #1 told them they do not need this job and that they will kill Resident #1, and you could see it in their eyes. Resident #1 stated they have had arguments with staff prior, but no one had ever threatened them before. Resident #1 stated they were very nervous following the incident and they felt as if they could not defend themself in the wheelchair. they would kill them, and they believed it and could see it in their eyes. During an interview on 8/6/2024 at 1:20 PM, the Administrator stated they were informed about the incident on 7/30/24. They reviewed the surveillance video and Resident #1 pushed Licensed Practical Nurse #1's buttons and they lost it. Licensed Practical Nurse #1 exited the building, and they could not speak with them. The Administrator stated they tried to contact Licensed Practical Nurse #1 via telephone but have not been to reach them. The Administrator Stated Licensed Practical Nurse #1 was an agency employee who started in the facility on 7/25/2024. The day of the incident was Licensed Practical Nurse #1's first day on the floor and they had only worked 3 shifts prior. During a telephone interview on 8/6/2024 at 2:10 PM Licensed Practical Nurse #1 stated they had only been working in the facility for a couple of days and it was their first time on the unit. Licensed Practical Nurse #1 stated they were switched from the south side to work on the north side where Resident #1 resides. Resident #1 asked them for their pain medication. Licensed Practical Nurse #1 stated the outgoing nurse reported that d just given Resident #1 their medication at 3:00 PM and they informed Resident #1 of that. Resident #1 stated they can have the medication 1 hour early, and they informed Resident #1 that it does not apply to nonscheduled (as needed) medications. Resident #1 was told that the last time they were given the pain medication was at 3:00 PM and when they could only receive their medication at 6PM. Licensed Practical Nurse #1 stated Resident #1 stated Resident #1 called them a piece of shit because they will not give them their meds before the due time. Other nurses on the unit told them they do not deal with Resident #1 and that no one does. Licensed Practical Nurse #1 stated Resident #1 stated insisted to be given their medication when they were administering medications to other residents. Licensed Practical Nurse #1 stated Resident #1 started to try to stand up, and they stepped away from Resident #1 towards their cart. Resident #1 continued talking while they administered medications to others. Licensed Practical Nurse #1 stated Resident #1 had a pitcher of water and they spit in the pitcher and threw it at them. Licensed Practical Nurse #1 stated they had a pitcher of water and threw it back at Resident #1. Licensed Practical Nurse #1 stated they engaged in the back and forth with Resident #. For Resident #1 to spit in the water and throw it at them triggered them. During an interview on 8/7/2024 at 5:00 PM, Resident #2 stated they have been in the facility for a year. Resident #2 stated they were in their room, and they heard screaming and cursing. They went out and saw Licensed Practical Nurse #1 in Resident #1's face. Resident #2 stated Licensed Practical Nurse #1 stated they do not need this fucking job and they would kill Resident #1. Resident #2 stated Licensed Practical Nurse #1 went and got their water pitcher and threw it at Resident #1 and some of the water got on them. Resident #2 stated Resident #1 wanted their medications and they did not want to wait for it. Resident #1 saw Licensed Practical Nurse #1 give them their medications and Resident #1 asked why Resident #2 is receiving their meds and not them. Licensed Practical Nurse #1 told Resident #1 it was not time for their medications. Resident #2 stated the facility has a lot of new staff. Resident #2 stated Resident #1 is always in excruciating pain and they get irate at times. Stated Resident #1 cries like a baby at times asking for her pain med and the nurses will tell them, you have 3 minutes left before you can receive your medications. 10NYCRR 415.4(b)(1)(i)

Based on record review and interviews conducted during an abbreviated survey (NY00349754, NY00348426) the facility did not ensure that the comprehensive care plan was reviewed and revised timely for 2 out of 4 residents (Resident #1, Resident #4) reviewed for abuse. Specifically, (1) Resident # 1 with a history of known behaviors, had an incident on 7/30/2024 with Licensed Practical Nurse #1 and the risk for abuse, behavioral symptoms care plans were not updated to reflect the 7/30/2024 incident. (2) Resident # 4 reported to the Director of Social Services on 7/16/2024 that Registered Nurse # 1 had cursed at them and called them a name. Resident #4's risk for abuse care plan was not updated to reflect the allegation. Findings include: The facility's undated as comprehensive care plan policy documented it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Resident # 1 was admitted to the facility with diagnoses including but not limited to Bipolar disorder, Depression and Chronic Pain Syndrome. A Quarterly Minimum Data Set, dated dated dated [DATE] documented that Resident # 1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 15/15 (associated with intact cognition). No behaviors noted. The resident required set up assistance for meals, maximal assistance for toileting, supervision for bed mobility and moderate assistance for transferring. Resident #1 had lower extremity impairment on one side and used a wheelchair for locomotion. Review of a behavior care plan dated 4/24/2024 and revised 8/5/2024 documented Resident #1 uses abusive verbal language, is resistant to activities of daily living, and exhibits aggressive behaviors. The goal was Resident #1 will display no negative behaviors through the review date. Interventions listed included provide a safe environment and psychological consult and follow up as needed. Review of a risk for abuse care plan dated 2/21/2024 and revised on 5/22/2024 documented Resident #1 is at risk for potential abuse related to aggressive behavior, verbally abusive towards staff and a diagnosis of bipolar disorder. The goal was Resident #1 will be kept safe and free from abuse through the next review date. Interventions listed included create a home like environment as much as possible and encourage diversion activities, refer to psychologist and psychiatrist as needed, staff to ensure that Resident #1 understands what constitutes resident abuse such as verbal, physical, emotional, and sexual abuse. Review of a behavior symptoms: physical abuse care plan dated 6/4/2024 documented Resident #1 exhibits physically aggressive behavior towards staff and others. The goal was Resident #1 will show a decrease in the number of episodes of physically aggressive behavior. There were no revisions/interventions documented after the incident on 7/30/2024. Review of the surveillance video dated 7/30/2024 revealed Resident #1 having a verbal altercation with Licensed Practical Nurse #1 back and forth. Resident #1 throws water from their cup in the direction of Licensed Practical Nurse #1, which landed on 2 other residents. Licensed Practical Nurse #1 while at their medication cart picked up the pitcher of water from the medication cart and flung the entire pitcher and water in Resident #1's direction. Licensed Practical Nurse #1 then threw the top to the pitcher in Resident #1's direction. Licensed Practical Nurse #1 picks up a water bottle and flings it at the resident and throws the empty bottle towards Resident #1 A review of the at risk for Abuse Care Plan initiated on 02/21/2024 and last revised on 5/22/2024 revealed no updates/revisions after the occurrence on 7/30/2024. There was no documented evidence of the risk for abuse, behavior or behavior symptoms care plans being updated to reflect the incident that occurred on 7/30/2024. 2)Resident # 4 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to Chronic Obstructive Pulmonary Disease, End Stage Renal Disease, and Muscle Weakness. A Quarterly Minimum Data Set, dated dated dated [DATE] documented Resident # 4 has a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of score of 12/15, associated with moderate cognitive impairment with no behaviors present. Resident #4 had limited range of motion to both lower extremities. The resident required supervision with eating, needed partial /moderate assist with bed mobility and required maximal assistance with transfers. Resident #4 was dependent with toileting and uses the wheelchair for locomotion. A review of at risk for abuse care plan dated 1/20/2024 documented Resident #4 is at risk for potential abuse related to the dependence of staff for assistance of activities of daily living. The goal was Resident #4 will be kept safe and free from abuse through the next review date. Review of a grievance form dated 7/16/2024 documented Resident #4 self-reported to the Director of Social Services that Registered Nurse #1 verbally abused them. The Administrator was made aware and was responsible for investigating and following up with the issue. Resident #4 was interviewed by the Administrator, and an abuse investigation was initiated. The form documented the corrective action taken was Registered Nurse #1 was re-assigned to prevent further interaction with the resident and that Resident #4 was happy with the resolution. The form also indicated that a follow up was done on 7/19/2024 with the concerned party. Attached to the grievance form were statements from the Director of Social Services, three other alert and oriented residents from the same unit and Registered Nurse #1. There was no documented /update/revision to the risk for abuse care plan. During an interview on 8/7/2024, the Registered Nurse Unit Manager of the 3rd floor stated they are responsible for updating the residents care plans. The Registered Nurse Manager stated on 7/30/2024 when the incident occurred between Resident # 1 and Licensed Practical Nurse #1, they were not in the building. Registered Nurse Unit Manager of the 3rd floor stated the abuse care plan should have been updated and any negative psychological indications would be updated. Registered Nurse Unit Manager 3rd floor acknowledged that they did not update the care plans for Resident #1 and Resident #4 because when the incident occurred, they were not in the building, but they should have completed the updates to the care plan upon return. 10 NYCRR 415.11 (c)(2)(ii)

Based on observation, interview, and record review conducted during the recertification survey from 7/9/2024 to 7/16/2024, the facility did not ensure the resident's right to a clean, comfortable, and homelike environment. This was evident for 1 (3rd Floor) of 3 resident units. Specifically, the 3rd Floor ad peeling wallpaper in the hallway and a dayroom with walls that were stained and damaged, missing and mismatched wallpaper, and with misshapen and bent window blinds. The findings are: The undated facility policy titled Cleaning and Disinfection documented routine cleaning will be performed in resident common areas and wall cleaning will be conducted when visibly soiled. On 07/09/2024 at 09:39 AM, the 3rd Floor dayroom was observed with window blinds containing several misshapen and bent slates, a quarter-sized hole in the wall next to the television that was crumbling and exposing white dusty plaster beneath, several areas along the wall with remnants of thick white tape, a missing section of wallpaper near the television, and dried food splatters and black scuff along the perimeter of the room on the bottom half of the wall. The hallway to the left of the elevator door had approximately 6 inches of wallpaper near the ceiling that had peeled away from and was hanging off the wall. On 07/16/2024 at 10:45 AM, Housekeeper #20 was interviewed and stated they were responsible for daily dayroom cleaning that included wiping down the walls with cleaning solution. After observing the stains and splatters on the wall, Housekeeper #20 stated they miss cleaning some spots along the wall because the tables, chairs, and residents are sometimes in the way. Resident wheelchairs caused the black scuff marks along the walls, and they were not easily removed by using a cleaning solution. On 07/16/2024 at 10:29 AM, the Director of Maintenance was interviewed and stated renovations of the resident units were ongoing. The 1st and 2nd Floors have already been completed. The facility planned to start renovating the 2nd Floor within the next few months. Soap and water were used to clean the stains and splattered food off the walls in the dayroom. The staff verbally reported to the Director of Maintenance when there were repair needs on the units. The damage to the walls and wallpaper were not repaired because the impending renovation would ensure all those issues were addressed. 10 NYCRR 415.5(h)(2)

Based on observation, record review and interview conducted during a recertification survey conducted from 7/9/24-7/16/24, the facility did not ensure infection control prevention including proper use of personal protective equipment and enhanced barrier precautions were maintained to help prevent the development and transmission of communicable diseases and infections for 2 of 32 residents (#130 and #72). Specifically, 1) contact precautions were not followed when Activity Aide #9 touched an overbed table in Resident #130's room and 2) enhanced barrier precautions were not implemented when Certified Nurse Assistant #10 and Certified Nurse Assistant #11 transferred Resident #72 into bed by Hoyer lift. Findings include: The undated facility policy for enhanced barrier precautions documented precautions were an infection control intervention designed to reduce transmission of multi drug resistant organisms that employed targeted gown and glove use during high contact resident care activities. High contact care activities include transfer from chair to bed. 1) Resident #130 was admitted with diagnoses including Diabetes Mellitus, End Stage Renal Disease, and Clostridium Difficile infection. The Quarterly Minimum Data Set (an assessment tool) dated 5/22/24 documented the resident had intact cognition and was totally dependent on staff for toileting, and transfers. The Physician Order dated 7/5/24 documented contact isolation for clostridium difficile infection and vancomycin 50 mg/cc 5 milliliters by mouth four times a day. During observation on 7/10/24 at 10:15 AM a sign documenting contact precautions: put on gloves and a gown before entering the room was outside Resident #130's room. During a short interview at that time Licensed Practical Nurse #15 was asked why the resident was on contact isolation and stated it was because the resident had a clostridium difficile infection. During observation on 7/10/24 at 10:25 AM Recreation Aide #9 entered Resident #130's room without donning gloves and a gown and was observed touching the residents overbed table. During an interview with Recreation Aide #9 on 7/10/24 at 10:25 AM they stated they usually brought the activity schedule to the resident and arranged the room activities for the resident. Recreation Aide #9 stated they were told by the nursing staff the yellow contact signs meant they did not need a gown when dropping things off and were told to wash their hands with antibacterial hand sanitizer when they exited the room. During an interview on 7/12/24 at 9:18 AM Licensed Practical Nurse #19 stated clostridium infection was highly transmissible and could stay on surfaces longer. Licensed Practical Nurse # 19 stated the recreation aide had it all wrong and should have looked at the door and ask nursing staff before entering the room. Licensed Practical Nurse # 19 stated staff could not use antibacterial hand sanitizer for clostridium difficile and must wash hands with soap and water. 2) Resident #73 had diagnoses including Alzheimer Disease, Atrial Fibrillation, and Dysphagia. The Quarterly Minimum Data Set (an assessment tool) dated 4/25/24 documented the resident had severe cognitive impairment and was dependent on staff for all care. The resident had an indwelling feeding tube. The Physician Order dated 3/27/24 documented enhanced barrier precautions for gastrostomy tube. During observation on 7/9/24 at 3:23 PM a sign documenting enhanced barrier precautions everyone must wear gloves and gown for the following high contact resident care activities dressing, bathing, transferring, changing linens, providing hygiene, changing briefs, and assist with toileting outside was outside Resident #72's room . During observation 07/09/24 at 3:23 PM Certified Nurse Assistant #10 and Certified Nurse Assistant #11 were observed transferring Resident #72 into their bed from their chair with their clothing coming in contact the rails on the residents bed Both Certified Nurses Assistant #10 and Certified Nurses Assistant#11 were not wearing a gown as indicated on the enhanced barrier precaution signage. During an interview on 7/9/24 at 3:23 PM Certified Nurse Assistant #10 and Certified Nurse Assistant #11 stated they knew to wear gloves when touching the resident but didn't need a gown because that was only during wound dressing changes and not when getting residents back to bed. During an interview on 7/16/24 at 1:35 PM the Infection Preventionist stated they had provided in services regarding enhanced barrier precautions. The infection Preventionist stated they made rounds and corrected certified nurse assistants whenever it was needed. 10 NYCRR 415.19 (b) (4)

Based on observation, interview, and record review conducted during the recertification and abbreviated (NY00314688) survey from 7/9/2024 to 7/16/2024, the facility did not ensure all alleged violations involving abuse 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 Resident #136 reviewed for abuse out of 37 total sampled residents. Specifically, an allegation of abuse related to ecchymosis (bruising) found on Resident #136's ear was not reported to the New York State Department of Health. The findings are: The facility policy titled Abuse, Neglect, and Exploitation dated 10/1/2023 documented allegations involving abuse will be reported immediately, but not later than 2 hours after the allegation is made, to the Administrator and state agency. Resident #136 had diagnoses of dementia and metabolic encephalopathy. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #136 had severe cognitive impairment. On 07/09/2024 at 02:52 PM and 7/10/2024 at 1:07 PM, an interview was conducted with Resident #136's Designated Representative who stated Resident #136 had an ecchymotic area on their outer left ear found by nursing staff on 4/27/2024. The area was red and swollen. The facility nursing staff explained that the redness was from anticoagulant therapy. Resident #136's Designated Representative had the resident evaluated by the Dermatologist on 5/1/2024. The Dermatologist determined Resident #136 had trauma to their ear and contacted Adult Protective Service to support a suspicion of abuse. A meeting was held with the facility staff and Ombudsman because the Designated Representative was not satisfied with the facility's explanation of Resident #136's ear ecchymosis. The Administrator stated they would not report the alleged traumatic physical injury to the New York State Department of Health. The Accident/Incident Investigation Form dated 4/27/2024 documented Resident #136 was found with a discoloration to their outer ear at 11:45 PM. A dermatology Consult dated 5/1/2024 was included in the facility's investigation. The Investigation Form was signed on 4/28/2024 and recommended a Psychiatry Consult. Dermatology Consult dated 5/1/2024 documented Resident #136 was evaluated for ecchymotic area to their left outer ear. Trauma was suspected and the Dermatologist contacted the Adult Protective Services to report alleged abuse. The Investigation Form dated 5/10/2024 documented Resident #136's Designated Representative alleged physical trauma was the cause of Resident #136's left ear discoloration. The investigation revealed no evidence to support abuse. There was no documented evidence the facility reported Resident #136's left outer ear ecchymosis to the New York State Department of Health upon allegations of abuse by the Designated Representative and Dermatologist. On 07/16/2024 on 03:23 PM, the Administrator was interviewed and stated that the former Director of Nursing was responsible for the investigation into Resident #136's left ear discoloration. An investigation to rule out abuse was conducted. No abuse occurred. By the time the Administrator learned of the occurrence, it was past the 2 hour timeframe to report to the New York State Department of Health and the Administrator decided not to make a report. 10 NYCRR 415.4(b)(2)

Based on observation, interview, and record review during the recertification survey from 7/9/24 through 7/16/24, the facility did not ensure drugs and biologicals were stored in accordance with currently accepted professional standards for 2 of 26 residents (Resident #378 and #425) reviewed for medication storage and labeling . Specifically, 1. Nystatin-Triamcinolone cream with a 6/14/24 -6/28/24 administration date was observed on Resident # 378's bedside table and 2. Fluticasone and Albuterol metered dose inhalers were observed on Resident # 425's bedside table. The findings are: The undated policy titled Resident Self-Administration of Medication documented all nurses and nurse aides were required to report any medication found at the residents' bedside to the charge nurse. 1. Resident # 378 was admitted to the facility with diagnoses including Diabetes, Chronic Kidney Disease and Peripheral Vascular Disease. The Minimum Data Set (an assessment tool) dated 5/9/24 documented Resident #378 was cognitively intact. Observation on 07/09/24 at 12:23 PM, 07/09/24 at 03:50 PM, 7/10/24 at 10:06 AM, 7/11/24 at 10:02 AM, and 7/12/24 at 8:43 AM revealed a tube of Nystatin-Triamcinolone cream was on Resident #378's bed side table. During an interview on 7/12/24 at 8:54 AM, Licensed Practical Nurse #27 stated Resident #378 did not currently have a physician order for the application of Nystatin-Triamcinolone cream. During an interview on 7/12/24 at 9:00AM, Licensed Practical Nurse # 13 stated the resident had redness to the perineal area and needed the Nystatin-Triamcinolone cream, but, there was no longer an order for the administration of the cream. Licensed Practical Nurse #13 stated medicated creams should not have been left at the bedside. 2. Resident # 425 was admitted to the facility with diagnoses including Asthma, Hypertension, and Hypothyroidism. The Minimum Data Set (an assessment tool) dated 7/5/2024 documented Resident # 425 was cognitively intact. During observation on 7/9/24 at 12:10 PM, 7/10/24 at 9:10 AM, and 7/12/2024 at 9:28 AM a plastic storage bag containing Fluticasone and Albuterol meter dose inhalers were noted on Resident #425's bedside table. During an interview on 7/12/24 at 9:24 AM, Certified Nurse Aide #27 stated they had seen the resident's inhalers on the bedside table, and did not report it to the nurse. During an interview on 7/12/24 at 9:29 AM, Resident #425 stated the inhalers at the bedside were labeled with another facility's name. During an interview on 7/12/24 at 9:36 AM, Licensed Practical Charge Nurse #15 stated they found the medication/s in the resident's room at the bedside. Licensed Practical Nurse #15 stated the inhalers at the resident's bedside were from the hospital and should not have been left at the bedside. Licensed Practical Charge Nurse #15 stated they did not know the resident had their own medication at the bedside. 10 NYCRR 415.18 (d)

Based on observation, interview, conducted during the recertification survey from 7/9/2024 to 7/16/2024, the facility did not ensure a resident's right to refuse a room transfer solely for the convenience of staff. This was evident for 1 (Resident #132) of 37 total sampled residents. Specifically, Resident #132 was transferred from the 2nd Floor to the 3rd Floor after a staff member reported they were uncomfortable providing the resident care. The findings are: The undated facility policy titled Change of Room or Roommate documented the facility reserves the right to make resident room changes when found the facility deems it necessary. A resident has the right to refuse a transfer to another room. Resident #132 had diagnoses of a right femur fracture and end stage renal disease. The Minimum Data Set 3.0 dated 6/6/2024 documented Resident #132 was cognitively intact. During an interview on 07/10/2024 at 12:11 PM, Resident #132 stated that Certified Nursing Assistant #28 reported to the former Director of Nursing and the current Director of Social Work that Resident #132 displayed inappropriate behavior during care. Resident #132 stated they were moved from a room they were comfortable in on the 2nd Floor to the 3rd Floor in 3/2024 to make the Certified Nursing Assistant feel better. Resident #132 denied any inappropriate interaction took place and stated their room was changed after they requested the Certified Nursing Assistant be removed from their assignment. Resident #132 did not recall being interviewed by staff regarding accusations they were inappropriate with the Certified Nursing Assistant. Resident #132 did not feel compatible with the resident population on the 3rd Floor and spent most of their time on the 2nd Floor dayroom to engage with more cognitively intact residents and more stimulating activities. Resident #132 stated facility staff did not follow up after the room change to determine whether they had adjusted to the room and floor change. The Comprehensive Care Plan related to adjustment dated 2/1/2024 documented Resident #132 was at risk for adjustment issues related to their recent hospitalization and admission to the facility. Interventions included honoring Resident #132's preferences and routines. The Comprehensive Care Plan related to being newly admitted to the facility dated 2/1/2024 documented Resident #132 would be introduced to their roommate and co-residents on the unit, oriented to their new environment, and a relationship with Resident #132 should be developed. There was no documented evidence the Comprehensive Care Plans related to adjustment and new facility admission were reviewed and revised to address Resident #132's risk for adjustment difficulties. A Psychiatry Consult dated 3/28/2024 documented nursing staff reported Resident #132 was inappropriate during care and encouraged to ask for privacy if needed. Resident #132 reported the Certified Nursing Assistants became upset when Resident #132 washed certain parts of their body while staff assisted with their bathing routine. It was a delicate issue. The Room Change assessment dated [DATE] documented Resident #132 was moved from the 2nd Floor to a more appropriate bed on the 3rd Floor. Resident #132 was made aware of the room change. The Nursing Note dated 3/29/2024 documented Resident #132 was transferred to the 3rd Floor with all their belongings as per Social Worker #4. The Nursing Note dated 3/30/2024 documented Resident #132 was adjusting well 1 day post room and unit transfer. There was no documented evidence Resident #132 was provided with an opportunity to refuse a room transfer from the 2nd to 3rd Floor based on a staff member's discomfort with providing the resident with bathing assistance. During an interview on 07/16/2024 at 11:28 AM, Social Worker #4 stated they were Resident #132's social worker prior to the move from the 2nd to 3rd Floor. In 3/2024, Certified Nursing Assistant #28 the resident was sexually inappropriate while they provided them with bathing assistance. Resident #132 was cognitively intact, had no psychiatric diagnosis, and had no history of sexually inappropriate behavior during care. Certified Nursing Assistant #28 reported the incident to the former Director of Nursing and the Director of Social Work. Social Worker #4, the Director of Social Work, the Director of Nursing, Resident #132, and the resident's family member made a collective decision to move Resident #132 from the 2nd Floor to the 3rd Floor to separate them from the Certified Nursing Assistant #28. Social Worker #4 stated they did not counsel Resident #132 regarding their alleged sexually inappropriate behavior or document the incident in the resident's medical record. Social Worker #4 said that they should have documented and counseled the resident. Social Worker #4 did not recall whether Resident #132 was introduced to the 3rd Floor and their prospective roommate prior to having their room changed. Social Worker #4 stated the Room Change Assessment should have been more detailed regarding the reason for Resident #132's room change. There was no documentation that Resident #132 agreed with the room change. The social workers did not develop care plans with interventions to address room change adjustment risk. The nursing staff and social workers collectively checked in with residents following room changes to ensure the residents were adjusting well but did not document this in the medical record. During an interview on 07/16/2024 at 11:42 AM, Social Worker #3 stated they were assigned to Resident #132 after the resident moved to the 3rd Floor. Resident #132 was involved in an incident with their assigned Certified Nursing Assistant on the 2nd Floor. The interdisciplinary team addressed the incident by moving Resident #132. Since their move to the 3rd Floor, Resident #132 has interacted well with staff and did not display sexually inappropriate behavior. Resident #132 was also moved to the 3rd Floor because their discharge planning was delayed due to a pending Medicaid application and the 2nd Floor was intended for shorter-term residents. Social Worker #3 stated they checked in on Resident #132 following their room change but did not document the interaction in the medical record and did not develop a care plan with interventions to address potential room change adjustment issues. During interviews on 07/15/2024 at 04:59 PM and 07/16/2024 at 02:30 PM, the Director of Social Work stated social workers were responsible for discussing and obtaining a resident consent for room changes. The Room Change Assessment should detail the reason was moved. But social workers did not document whether the resident agreed to change rooms. The Director of Social Work stated the former Director of Nursing was informed after Certified Nursing Assistant #28 reported that the resident displayed sexually inappropriate behavior during care. The interdisciplinary team met and decided to move Resident #132 off the unit to address Certified Nursing Assistant #28 discomfort. The Director of Social Work did not interview Resident #132 or obtain their statement. The incident was not documented in the resident's medical record and was not investigated by the facility. 10 NYCRR 415.3(d)(2)(ii)(a)

Based on staff interview and review of facility records during the recertification survey from 7/9/24 through 7/16/24, the facility did not ensure certified nurse aide performance reviews were completed at least once every 12 months. Specifically, five of seven certified nurse aides did not have performance reviews documented at least once every 12 months. Findings include: Review of Certified Nurse Aide #7, #17, #24, #25, and #26 hire dates revealed they had been working at the facility for more than one year. The review of performance evaluations for Certified Nurse Aide #7 and #17 revealed their last performance evaluations were completed on 8/4/08 and 3/15/10 respectively. There was no documented evidence that performance evaluations were completed for Certified Nurse Aide #24, #25 and #26. During an interview on 07/15/2024 at 11:22 AM, the Human Resources Director stated the annual performance evaluations for the Certified Nurse Aides were not done, the facility was in the process of getting them done with the new administrator on board. During an interview on 7/15/2024 at 12:06 PM, the Director of Nursing stated yearly certified nurse aide performance assessments were once done by the previous Director of Nursing and the facility was currently in the process of bringing back the yearly evaluation assessments for the certified nurse aide and nurses. During an interview on 7/16/2024 at 9:16 AM, Certified Nurse Aide #17 stated they could not recall when they last had a performance evaluation done. During an interview on 7/16/2024 at 9:18 AM, Certified Nurse Aide #18 stated the facility did in-services with the certified nurse aides but not performance evaluations. During an interview on 7/16/2024 at 9:23 AM Certified Nurse Aide #19 stated they did not have a recent performance evaluation done. 10NYCRR 415.26(c)(1)(IV)

Based on observations, interviews, and record review during a recertification survey conducted from 7/9/24-7/16/24, the facility did not ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 2 of 8 residents (Resident #21 and #98) reviewed for positioning and mobility. Specifically, the staff did not ensure 1) Resident # 21's bilateral hand splints were worn throughout the day as ordered and care planned and 2) Resident #98's right-hand splint was worn as per physician order. The finding is: A Policy and Procedure dated 2/21 titled Rehabilitation Positioning Devices, documented ensure residents were proper position and body alignment with appropriate positioning devices as needed. 1) Resident #21 was admitted with diagnosis of Multiple Sclerosis, Functional Quadriplegia and Type 2 Diabetes. The Quarterly Minimum Data Set (an assessment tool) dated 4/18/2024 documented Resident #21 was cognitively intact and was dependent with all activities of daily living. The 3/20/2024 care plan titled Rehabilitation Positioning Device documented bilateral hand splints throughout the day for prevention of further contracture. Perform hygiene care and skin checks to ensure no skin breakdown/discomfort pre and post use. The 3/20/24 physician order documented bilateral hand splints throughout the day for prevention of further contracture. There was no documented evidence in the electronic medical record prior to 7/12/24 to indicate the hand splints were applied. During an observation on 07/09/24 at 10:43 AM Resident # 21 was in bed, both hands were contracted. Hand splints were not in place as per physician order and were noted on the bedside table. During an observation on 07/10/24 at 8:45 AM Resident #21 was in bed. Hand splints were not in place as per physician order. During an observation on 07/10/24 at 12:13 PM and 2:10 PM Resident #21 was out of bed in the wheelchair. Hand splints were not in place as per physician order. During interview on 7/12/24 at 8:29 AM Certified Nurse Aide #7 stated they usually applied splints on both hands after AM care/s. Certified Nurse Aide # 7 stated they were aware the resident should wear the splints on their hands throughout the day and the splints should be removed after PM care/s. During interview on 7/12/24 at 8:31 AM Licensed Practical Nurse #6 stated they put the splints on the resident after AM care. Licensed Practical Nurse # 6 stated the physician order referencing throughout the day indicated the splints should be applied after AM care and should be worn until PM care. During interview on 7/12/24 at 9:15 AM the Director of Nursing stated the certified nurse aides should put the resident's splints on and the nurses were responsible for checking to ensure the splints were in place and should sign off in the treatment administration record. The Director of Nursing stated when the physician order was put in place the order did not carry over to the treatment administration record, therefore the nurses were not able to sign off that they were monitoring the application of the splints. 50816 2) Resident #98 was admitted with diagnosis including right hemiplegia and hemiparesis following cerebral infarction The 4/18/22 Annual Minimum Data Set (an assessment tool) documented Resident # 98 had severe cognitive impairment, functional limitation in range of motion of the upper extremity and was dependent with all activities of daily living. The 3/20/24 physician order documented Resident #98 was to wear a right-hand grip II splint throughout the day for prevention of further contracture. The 3/20/24 care plan titled Positioning Device documented resting hand splint throughout the day for prevention of further contracture. During observation on 7/09/2024 at 12:52 PM, Resident #98 was in bed, their right hand was clenched closed, the hand splint was on the right arm and not on the right hand as per physician order. During observation on 7/10/24 at 8:54 AM and 7/11/24 at 12:08 PM Resident #98 was in bed, their right hand was clenched closed. The right-hand splint was not on the right hand as per physician order. During interview on 7/11/2024 at 12:08 PM, Certified Nursing Assistant #1 stated the resident's right hand splint was not in place. Certified Nursing Assistant #1 stated they were aware that Resident #98 was supposed to wear the right-hand splint, but the resident refused to wear it. Certified Nursing Assistant #1 stated they reported resident refusal to the nurse and the therapist and had been told to put the splint back on. During interview on 7/11/24 at 1:18 PM Registered Nurse/Charge Nurse # 2 stated the certified nurse assistants were responsible for putting the splint on and the nurses were responsible for checking that the splint had been applied. During the interview Registered Nurse/Charge Nurse # 2 stated the resident care plan documented the splint was to be worn throughout the day and indicated it should be on during the 7-3 shift. During interview on 7/11/2024 at 1:18 PM Registered Nurse/Charge Nurse # 2 stated the nurses were responsible for creating and updating care plans. Registered Nurse/Charge Nurse # 2 stated the care plan did not indicate the resident refused cares or the use of the right-hand splint. Registered Nurse/Charge Nurse # 2 stated a plan should be in place if the resident was removing the right-hand splint. Registered Nurse/Charge Nurse # 2 stated the nurses were responsible for supervising the certified nurse assistants and were responsible for documenting the use of the right-hand splint in the medication or treatment administration record. Upon checking Registered Nurse/Charge Nurse # 2 stated there was not a directive in the administration record for the use of the right-hand splint. Registered Nurse/Charge Nurse # 2 stated the resident should have the splint in place to prevent contracture of the right hand. 10NYCRR 415.12

Based on observation, interview, and record review conducted during the recertification survey from 7/9/2024 to 7/16/2024, the facility did not ensure a resident received treatment and services in accordance with professional standards of practice and their comprehensive person-centered care plan. This was evident for 1 (Resident #65) of 37 total sampled residents. Specifically, Resident #65 was observed out of bed in a reclining back wheelchair seated on a hoyer pad and there was no documented evidence to address the level of assistance and devices required for safe bed-to-chair transfer. The findings are: Resident #65 had diagnoses of cerebral infarction and left side hemiplegia. The Minimum Data Set (assessment tool) dated 6/20/2024 documented Resident #65 had severe cognitive impairment, was dependent on staff assistance for bed-to-transfers and did not use a wheelchair or mobility device. On 07/10/2024 at 01:49 PM, 07/12/2024 at 10:20 AM, and 07/15/2024 at 12:54 PM, Resident #65 was observed out of bed in a reclining back wheelchair with a hoyer lift canvas underneath them. There was no documented evidence in the Care Plan related to activities of daily living initiated 2/1/2024 and last reviewed 6/21/2024 to address the level of assistance and devices required for safe bed-to-chair transfer. There was no documented evidence in the Occupational Therapy Discharge Note dated 4/18/2024 to address the level of assistance and devices required for safe bed-to-chair transfer. The July 2024 Certified Nursing Assistant Documentation Survey Report documented Resident #65 was totally dependent on 2 people for transfers on 12 occasions, totally dependent on 1 person for transfers on 4 occasions and required the extensive assistance of 1 person on 1 occasion. There was no documented evidence in the Certified Nursing Assistant Kardex Instruction Sheet as of 7/15/2024 to address the level of assistance and devices required for safe bed-to-chair transfer. On 07/15/2024 at 04:13 PM, Certified Nursing Assistant #23 stated they were unable to access Resident #65's instructions on the computer console. They did not know what was documented for Resident #65's transfer status and relied on verbal instruction from their coworkers. On 07/16/2024 at 01:33 PM, Certified Nursing Assistant #22 stated they were unable to access the electronic medical record on the computer console and did not know what instructions were listed for how to transfer Resident #65 from bed to wheelchair. They asked the nurse how to transfer Resident #65 out of bed and was told to use a Hoyer lift. On 07/16/2024 at 01:43 PM, Registered Nurse #12 was interviewed and stated a resident's transfer status was included in the care plan and then populated the Certified Nursing Assistant instruction sheet. A physician order should be obtained for resident requiring hoyer lift transfers. The nurse manager was responsible for checking to ensure transfer orders were in place. The rehabilitation department was responsible for checking quarterly during scheduled assessments of the residents. Resident #65 required a hoyer lift for transferring out of bed to the wheelchair. Registered Nurse #12 checked the medical record and stated there were no transfer orders documented for Resident #65. On 07/16/2024 at 12:14 PM, the Director of Rehabilitation stated they had been working at the facility for 3 months. The rehabilitation department screens residents and recommends devices for positioning and transfers. These recommendations were communicated to the nursing department either verbally or through a progress note written by the occupational therapist in the electronic medical record. The occupational therapist initiated a physician order for hoyer lift transfers and the nursing department was responsible for getting the order signed. The certified nursing Instructions were automatically pre-populated with hoyer lift instructions once a physician order was obtained. The Director of Rehabilitation confirmed there were no transfer orders for Resident #65 and there were no instructions on the resident's chart that indicated hoyer lift transfers were required. 10 NYCRR 415.12

Based on observations, interviews and record review conducted during a recertification survey and abbreviated survey (NY00322156) conducted from 7/08/24-7/16/24 , the facility did not ensure that a comprehensive person-centered care plan was developed for 1 of 1 residents (#127) reviewed for urinary tract infections. Specifically, there were no care plans in place to address prevention of reoccurring urinary tract infections for Resident #127. Findings include: The undated facility policy titled Comprehensive Care Plans documented the facility was to develop and implement a comprehensive person-centered care plan for each resident with resident rights, that included measurable objectives and timeframe's to meet a resident's medical, nursing, mental and psychosocial needs. Resident #127 was admitted with diagnoses and conditions including Dementia, Diabetes Mellitus, and history of Urinary Tract Infections. The Minimum Data Set an assessment tool dated 4/11/24 documented Resident #127 had severe cognitive impairment and was dependent on staff for all activities of daily living and was incontinent of bladder and bowel. The 5/2/24 Physician Note documented the resident presented with increased confusion. Urine analysis and culture ordered. The 5/4/24 Nursing Note documented the resident was started on Cipro 250 mg for cystitis. The 6/28/24 Nursing Note documented start on pipercillin intravenous for cystitis. The 7/2/24 Nursing Note documented intravenous antibiotics in progress, incontinent care rendered. There was no documented evidence in the electronic medical record indicating a comprehensive care plan to address urinary tract infection/s had been developed. During an interview 07/12/24 at 10:29 AM Registered Nurse #12 stated the resident was at risk for urinary tract infection/s because they were immobile, incontinent, had dementia and was dependent on staff for all cares. Registered Nurse #12 stated it was their responsibility to initiate a care plan to address concerns including antibiotic use and monitoring but, it had not been done yet. 10NYCRR 415.11(c)(1)

Based on observations, interview, and record review conducted during the recertification and abbreviated (NY00314688) survey from 7/9/2024 to 7/16/2024, the facility did not ensure all alleged violations involving abuse were thoroughly investigated. This was evident for Resident #136 reviewed for abuse out of 37 total sampled residents. Specifically, an allegation of abuse related to ecchymosis found on Resident #136's ear was not thoroughly investigated to include interviews with the Dermatologist who assessed and determined Resident #136 experienced physical trauma. The findings are: The facility policy titled Abuse, Neglect, and Exploitation dated 10/1/2023 documented allegations involving abuse will be reported immediately, but not later than 2 hours after the allegation is made, to the Administrator and state agency. Resident #136 had diagnoses of dementia and metabolic encephalopathy. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #136 was severely cognitively impaired. On 07/09/2024 at 02:52 PM and 7/10/2024 at 1:07 PM, an interview was conducted with Resident #136's Designated Representative who stated Resident #136 had an ecchymotic area on their outer left ear found by nursing staff on 4/27/2024. The area was red and swollen. The facility nursing staff explained that the redness was from anticoagulant therapy. Resident #136's Designated Representative had the resident evaluated by the Dermatologist on 5/1/2024. The Dermatologist determined Resident #136 had trauma to their ear and contacted Adult Protective Service to support a suspicion of abuse. A meeting was held the facility staff and Ombudsman because the Designated Representative was not satisfied with the facility's explanation of Resident #136's ear ecchymosis. The Accident/Incident Investigation Form dated 4/27/2024 documented Resident #136 was found with a discoloration to their outer ear at 11:45 PM. A dermatology Consult dated 5/1/2024 was included in the facility's investigation. The Investigation Form was signed on 4/28/2024 and recommended a Psychiatry Consult. Dermatology Consult dated 5/1/2024 documented Resident #136 was evaluated for ecchymotic area to their left outer ear. Trauma was suspected and the Dermatologist contacted the Adult Protective Services to report alleged abuse. The Investigation Form dated 5/10/2024 documented Resident #136's Designated Representative alleged physical trauma was the cause of Resident #136's left ear discoloration. The investigation revealed no evidence to support abuse. There was no documented evidence the facility conducted a thorough investigation into reported Resident #136's left outer ear ecchymosis to include interviews with the consulting Dermatologist related to their assessment of trauma to the Resident's ear and report to Adult Protective Services. On 07/16/2024 on 03:23 PM, the Administrator was interviewed and stated that the former Director of Nursing was responsible for the investigation into Resident #136's left ear discoloration. An investigation to rule out abuse was conducted. No abuse occurred. The Administrator was unsure if the Dermatologist was contacted by the former Director of Nursing as part of their investigation and believed that a thorough investigation was completed. 10 NYCRR 415.4(b)(3)

Based on observation, record review, and interview conducted during a recertification and abbreviated (NY00335338 and NY00341688) survey from 7/9/2024 to 7/16/2024, the facility did not ensure prompt efforts were made to resolve resident grievances for 2 of 2 residents reviewed for grievances (Resident #321 and #136). Specifically, 1) a grievance investigation was not conducted when the Designated Representatives for Resident #321 and Resident #136 expressed care concerns to facility staff. The findings are: The undated facility policy titled Grievances documented when a grievance is reported, the grievance officer and assigned social worker will be notified and an investigation will be conducted. All investigative findings will be discussed with the complainant in writing by the facility within 5 business days, 1) Resident #321 had diagnoses of Parkinson's disease and adult failure to thrive. The Minimum Data Set 3.0 assessment tool dated 4/5/2024 documented Resident #321 had moderately impaired cognition. On 7/15/2024 at 11:00 AM, Resident #321's Designated Representative was interviewed and stated they sent written correspondence to the former Administrator and former Director of Nursing in 1/2024 and 2/2024 regarding several concerns related to Resident #321's care. The Designated Representative did not receive a response from the facility and was not aware whether the facility conducted a grievance investigation to address their concerns. Email communication dated 1/16/2024 documented Resident #321's Designated Representative sent an email to the former Administrator and former Director of Nursing expressing concerns that Resident #321 did not have their clothing changed daily and that resident clothing items did not always come back from laundry. A letter from Resident #321's Designated Representative to the former Administrator and the former Director of Nursing dated 2/15/2024 documented the Designated Representative's had concerns related to staff that was assigned to Resident #321 refusing to take the resident out of bed. There was no documented evidence a grievance investigation was conducted to address clothing and care concerns communicated by Resident #321's Designated Representative to the facility staff on 1/16/2024 and 2/15/2024. On 7/15/2024 at 12:13 PM, Social Worker #3 was interviewed and stated Resident #321's Designated Representative visited daily and expressed care concerns. Social Worker #3 communicated the concerns to nursing staff and did not initiate or conduct any grievance investigations. On 7/15/2024 at 2:30 PM, Licensed Practical Nurse #6 was interviewed and stated Resident #321's Designated Representative expressed concerns related to staffing. Licensed Practical Nurse #6 was unaware of any grievance investigations conducted related to these concerns. 40686 2) Resident #136 had diagnoses of dementia and metabolic encephalopathy. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #136 was severely cognitively impaired. On 07/09/2024 at 02:52 PM and 7/10/2024 at 1:07 PM, Resident #136's Designated Representative was interviewed and stated they reported concerns related to care and supervision of Resident #136 to nursing staff on the unit, the Director of Social Work, and Social Worker #3 on several different occasions. A grievance investigation to address their concerns was not conducted. A Social Work Note dated 10/10/2023 documented Resident #136's Designated Representative expressed concerns regarding changes in Resident #136's condition and care team. Emotional support was provided by the Director of Social Work. A Nursing Note dated 5/13/2024 documented Resident #136's Designated Representative requested staff change Resident #136 because the resident's clothing was wet from lunch when liquid spilled on them. Staff attempted to change the resident and the Designated Representative expressed concern related to reddened areas on the resident's skin and fingers. A Follow-Up Meeting Note dated 5/24/2024 documented Resident #136's Designated Representative, the Ombudsman, and facility staff met to discuss concerns related to Resident #136's bruised ear. The Director of Social Work documented that emotional support was provided to the Designated Representative regarding their preferences and for care and recreational activities. There was no documented evidence a grievance investigation was conducted to address care concerns expressed by Resident #136's Designated Representative. On 07/10/2024 at 11:25 AM, the Ombudsman was interviewed and stated a meeting was held with the Administrator, Director of Nursing, Director of Social Work, Social Worker #3, and Resident #136's Designated Representative on 5/17/2024 and no grievance investigation was conducted to address the care concerns expressed by Resident #136's Designated Representative. On 07/16/2024 at 11:48 AM, Social Worker #3 was interviewed and stated Resident #136's Designated Representative visited daily and expressed concerns regarding Certified Nursing Assistants and care provided to the resident. No grievance investigation was conducted to address the Designated Representative's concerns. Social Worker #3 attempted to address the concerns in real time by verbally discussing them with the nursing staff on the unit. A grievance investigation should have been conducted to address the care concerns expressed by the Designated Representative. On 07/16/2024 at 02:36 PM, the Director of Social Work was interviewed and stated any resident or family had the right to request a grievance and receive a verbal report of the outcome of the investigation within 5 days. There were Grievance Log binders on each unit and grievances forms were accessible for investigations to be initiated at any time and with any staff member. On 07/16/2024 at 03:23 PM, the Administrator was interviewed and stated they were present at a meeting with Resident #136's Designated Representative to discuss concerns related to a an ecchymotic area on Resident #136's ear. The Administrator did not know whether Resident #136's Designated Representative was offered the opportunity to file a grievance. The Administrator stated they did not have access to the former Administrator's emails and correspondence prior to today. The Administrator stated that email correspondence from Resident #321's Designated Representative was received and in the email inbox. A grievance investigation should have been conducted to address the concerns expressed by Resident #321's Designated Representative. 10 NYCRR 415.3(d)(1)(ii)

Based on observation, interviews, and record reviews conducted during a recertification survey, the facility did not ensure that each resident had the right to a dignified existence and each resident was cared for in a manner and environment that promoted maintenance or enhancement of his or her quality of life for 1 of 4 residents (#90) reviewed for dignity. Specifically, resident #90 was observed in the dining room wearing a urinary (foley) catheter drainage bag with no privacy cover. The findings are: Review of the Facility Policy and Procedure on Indwelling Urethral Catheter dated 07/17 documented to provide privacy, and leg bags may be used either for the dignity of the resident or when the drainage bags interfere with residents ambulation. There was no documentation specific to applying a cover to the foley drainage bag when the resident is out of bed and out of the room. Resident #90 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS, an assessment tool) dated 05/13/2021, documented that the resident had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation and ability to recall information) score of 10/15, associated with intact cognition (00-7 severe impairment, 08-12 moderate impairment and 13-15 cognitively intact). The resident required total dependence two-person assistance for toilet use; extensive two-person assistance for bed mobility and transfer; and extensive one-person assistance for dressing and personal hygiene. The resident had an indwelling catheter. Review of the Indwelling Foley Catheter Care Plan related to Neuromuscular Dysfunction of Bladder initiated on 09/06/2020 and updated on 05/20/2021 documented that the resident will be free from infection and complication, and patency of the catheter will be maintained. There was no documented evidence specific to applying a cover to the foley drainage bag when the resident is out of bed and out of the room. During the initial pool observation on 07/07/2021 at 12:15 PM, resident #90 was sitting in his/her wheelchair at the dining room eating lunch without any privacy cover on his/her foley catheter drainage bag. During an interview conducted with Certified Nursing Assistant (CNA #1) on 07/07/2021 at 2:20 PM, he/she stated that he/she took the resident out of bed at around 9:35 AM that morning. He/She stated that he/she did not put the cover to the foley drainage bag because he/she did not see the cover in the resident's drawer. CNA #1 further stated that he/she usually put the leg bag on when the resident is out of bed, but she also did not see a leg bag in the resident's drawer. The CNA stated that the supply is usually at the nurse's station, but he/she did not go and get it. During an interview conducted with Unit Manager Registered Nurse (UMRN) on 07/09/2021 at 9:40 AM, he/she stated that the drainage bag cover should be in place anytime the resident leaves the room and when the resident has a visitor in her room. The UMRN also stated that the assigned CNA puts the privacy cover on in the morning or when the resident is coming out of the room. The UMRN stated they have a lot of the privacy cover in stock. Three other CNAs was interviewed who all stated that a privacy cover is applied to the foley drainage bag when the resident is out of bed and when out of the room. A privacy cover is also applied when the resident is in bed and have visitors. The CNAs stated that they always have enough of this privacy cover at the nurses station. During an interview conducted with the Director of Nursing (DON) on 07/14/2021 at 02:45 PM revealed that the facility train the CNAs and Nurses to ensure that the resident's foley drainage bag is covered when the resident is out of bed and when the resident is out of the room. The DON stated that they have a lot of the foley privacy cover and the staff are aware on where to get it at the nurses station. The DON also stated that he/she is aware that their policy, their care plan, and the resident nursing instructions did not include specifics regarding the foley privacy cover, those will be included in their plan of correction. 415.5(a)

Based on record review and interview during a recertification survey and abbreviated survey (NY 488), the facility did not exercise care for the protection of resident property from loss or theft. This was evident for 2 of 2 residents (#36, #149) reviewed for personal property. Specifically, (1) resident #36's family complained that a total of 15 pairs of clothing was missing which was reported to the facility; ( 2) during the initial pool process resident #149 stated that the facility lost his/her two blankets two weeks ago which was reported to the Social Worker (SW). The findings are: Review of an Undated Facility Policy on Resident Clothing replacement of loss or damaged item documented that all clothing must be labeled with the residents name and logged on the residents personal property sheet on admission and whenever additional clothing items were obtained. Only clothing listed on the resident's personal property sheet will be replaced if lost or damaged. All lost clothing should be reported to Social Services (SS) and SS will contact Housekeeping (HK) to begin an in-house search as well as contacting the laundry service. HK will log the lost clothing items on the Missing Clothing Log. If the items are not found within three weeks, lost clothing will be replaced by the facility. Review of the Facility Policy on Resident's Clothing and Possessions dated June 2021 documented that it is the policy of the facility to safeguard the dignity of all residents by ensuring the security of their personal belongings. To minimize possible losses, family members and responsible parties will be educated upon admission to follow these procedures: All clothing that is brought in must be logged onto a Resident's Personal Possession Form which is available at the front desk and at the Nurse's Station; clothing will be labeled with the resident's name and brought back to the unit by the HK Department. In the event that clothing is lost, or personal items are lost, residents and family members will be instructed to report such loss to their Social Worker. Should the item(s) not found (within the facility or at the laundry), the facility will reimburse or replace for lost items. There was no documented evidence of a Resident Personal Belongings Form for Resident #36. There was no documented evidence of any form of communication between the complainant and the Administrator regarding the missing clothing. (1) Resident #36 was admitted to the facility on [DATE] with diagnoses that included Acute Kidney Failure, [CONDITION(S)] and Alzheimer's Disease. The Admission Minimum Data Set (MDS, an assessment tool) dated 04/15/2021, documented that the resident had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation and ability to recall information) score of 03/15, associated with intact cognition (00-7 severe impairment, 08-12 moderate impairment and 13-15 cognitively intact). The resident required extensive one-person assistance for dressing and personal hygiene. The resident's family participated in the assessment. An interview was conducted with the Administrator on 07/12/2021 at 10:10 AM who stated that the resident's family reported the missing clothing's on 05/03/2021. The Administrator stated that the Social Worker (SW#1) initiated a Grievance Investigation and the facility completed an extensive search but the clothing was not located. The Administrator requested the resident's family to compile a list of the missing items and the facility will reimburse them. The Administrator stated that the resident's family has not submitted the list, so he/she has not reimbursed them. An interview was conducted with the SW #1 on 07/13/2021 at 11:49 AM who stated that the resident does not have a personal belongings form. The SW stated that he/she saw the resident's family bring clothing on 04/10/2021 but he/she was not aware that they brought in more clothes. The SW stated that they tried to find the missing clothing's, but the resident had a lot of behaviors and his/her clothes could be anywhere. The SW stated that he/she initiated a grievance on 05/03/2021 but he/she had not communicated with the resident's family because they yell at her. The SW stated that the Administrator had been communicating with the family via text and the family was supposed to give a list of the clothing so they can reimburse them. An interview was conducted with the Receptionist on 07/14/2021 at 8:45 AM who stated that when it comes to the resident's property from admission the SW is in charge and he/she (receptionist) does not receive anything from the resident or resident's family. The receptionist stated that any family member dropping off any resident property after admission he/she provides them a Resident Personal Belonging List to fill up, he/she receives the property and puts the Property list in the same bag and he/she calls HK to pick it up. He/She stated he/she does not keep any file at the front desk and does not remember anything that was dropped even from a week ago. An interview was conducted with the Licensed Practical Nurse (LPN) Unit Manager (UM) on 07/14/2021 at 11:13 AM who stated that resident #36 does not have a Personal Property list on the chart. The LPN UM stated that they used to file the property list but not anymore because the residents on the first floor come and go. An interview conducted with the Laundry Aide #2 on 07/14/2021 at 01:09 PM revealed that there was no unaccounted clothing in the laundry room and that he/she was not aware of any missing clothing or blankets. A telephone interview was conducted with the complainant on 07/16/2021 at 11:44 AM who stated that the Administrator called him the other day about the reimbursement but they are not interested about the money. (2) Resident #149 was admitted to the facility on [DATE] with diagnoses that included Coronary Artery Disease, Diabetes Mellitus and Peripheral Vascular Disease. The Admission MDS dated [DATE], documented that the resident had a BIMS score of 15/15 denoting intact cognition. The resident required extensive one-person assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. There was no documented evidence of a Resident Personal Belongings Form for Resident #149. During the initial pool process, an interview was conducted with resident #149 on 07/07/2021 at 11:40 AM. The resident stated he/she lost two blankets that has a sentimental value two weeks ago and he/she informed the Social Worker. An interview conducted with SW#1 on 07/13/2021 at 08:25 AM revealed that the resident came back (06/11/2021) from a recent hospitalization and that was when it was noticed the blankets were missing. The SW stated that he/she knew that the blanket had a sentimental value to the resident but he/she did not initiate a grievance because he/she felt the blankets would be found. An interview conducted with the Director of Environmental Services and Laundry Aide #1 on 07/13/2021 at 12:43 PM revealed that they do not keep a personal belonging list and a missing clothing log in the laundry room. An interview was conducted with the Administrator and Director of Nursing (DON) on 07/13/2021 at 01:03 PM regarding the missing items (2 blankets) for resident #149. The Administrator and DON stated that during COVID the facility did forego completing clothing lists upon admission. 415.5(h)3