Every finding on record at Hillside Manor Rehab & Extended Care Center

Based on observations, record reviews, and staff interviews conducted during an Abbreviated Survey (NY00385241), the facility failed to ensure that a resident's Advance Directives for Do Not Resuscitate were followed. This was evident for one (1) out of ten (10) residents sampled. Specifically, Resident #1 had a signed Medical Order for Life Sustaining Treatment indicating Do Not Resuscitate. Resident #1 was observed not breathing and without vital signs on [DATE] at 8:30 AM and staff performed Cardiopulmonary Resuscitation. According to several staff interviews, Resident #1 received Cardiopulmonary Resuscitation efforts until staff members learned that Resident #1 was a Do Not Resuscitate. Emergency Medical Services had previously been called, and they pronounced the resident at 8:53 AM after they learned that the resident had a Do Not Resuscitate order in place. Findings include: Facility policy and procedure titled Resident expiration with Do Not Resuscitate order in place/pronouncement of death revised [DATE] states that residents that have a physician order not to have Cardiopulmonary Resuscitation initiated will be assessed by the Registered Nurse Supervisor when they have no pulse or respirations. The procedure documented the unit nurse will contact the Registered Nurse Supervisor when a resident is noted with a change in condition. If the resident is found unresponsive the unit nurse will verify the resident's Do Not Resuscitate status to determine if a STAT code should be called. If the resident is Do Not Resuscitate, the Registered Nurse Supervisor will complete an assessment of the resident for clinical signs of death when a physician is not available. Resident #1 was admitted to the facility with diagnoses of Hypertension, Diabetes Mellitus, and Atherosclerotic Heart Disease. The Minimum Data Set, dated [DATE] documented Resident #1 had moderately impaired cognition. The Medical Order for Life Sustaining Treatment form dated [DATE] showed Resident #1 was re-admitted to the facility on [DATE] with a signed Medical Order for Life Sustaining Treatment form which documented Do Not Resuscitate. An Advanced Directive Care Plan dated [DATE] documented that Resident #1 had a Do Not Resuscitate order. A Nursing Note by Registered Nurse Supervisor #1 dated [DATE] at 11:20 AM documented that on [DATE] Registered Nurse #1 called them to Resident #1's room due to the resident not responding. Upon entering the room at approximately 8:10 AM Resident #1 was in bed breathing from their abdominal muscle, unresponsive, no pulse, and blood pressure 80/60. Oxygen saturation level was undetectable. Oxygen was administered via a nonrebreather mask. Physician's Assistant #1 was notified and gave a telephone order to start intravenous fluids. Intravenous fluid started and 911 was called at 8:30 AM. Resident #1 stopped breathing and vital signs were undetectable. An Accident/Incident Report dated [DATE] documented that on [DATE] at 8:20 AM Registered Nurse Supervisor #1 was called by Registered Nurse #1 because Resident #1 was not responding. Resident #1's vital signs were checked but was undetectable. There was no oxygen saturation recording. Resident #1's blood pressure reading was 80/60. During a telephone interview on [DATE] at 11:05 AM, Registered Nurse #1, who was first responder to Resident #1's room, stated that they did not check Resident #1's arm band to verify the resident's code status. Registered Nurse #1 stated that they checked the Electronic Medical Record and did not see the Do Not Resuscitate order because they were hurrying. Registered Nurse #1 stated that when Registered Nurse Supervisor #1 arrived on the unit they informed them that Resident #1 was a full code. Registered Nurse #1 stated that they initiated chest compressions when they were unable to obtain vital signs, but stopped when they were told Resident #1 has a Do Not Resuscitate order. Registered Nurse #1 stated that Registered Nurse Supervisor #2 informed them that Resident #1 had a Do Not Resuscitate order. Registered Nurse #1 stated after they were told Resident #1 was a Do Not Resuscitate went back and check the Electronic Medical Record and saw the order, they checked Resident #1's wrists and the resident was wearing a yellow wrist band (indicating Do Not Resuscitate) on their left wrist. Registered Nurse #1 stated this was their first code. During a telephone interview on [DATE] at 8:44 AM, Registered Nurse Supervisor #1 stated that they were notified by Registered Nurse #1 at approximately 8:20 AM that Resident #1 was not responding. Registered Nurse Supervisor #1 stated that they assessed Resident #1 who was not breathing, had no pulse, no respiration, and blood pressure 80/60. Registered Nurse Supervisor #1 stated that they were unable to get an oxygen saturation reading so they administered oxygen by a nonrebreather mask. Registered Nurse Supervisor #1 stated that Registered Nurse #1 informed them that Resident #1 was a full code. Registered Nurse Supervisor #1 stated that they left the room to call 911 and when they returned to the room Registered Nurse #1 was performing chest compressions while Certified Nursing Assistant #1 performed rescue breathing. Registered Nurse Supervisor #1 stated that they took over and continued with the chest compressions. Registered Nurse Supervisor #1 stated that the Emergency Medical Service team arrived on the unit, and they (Registered Nurse Supervisor #1) left the room to check the Electronic Medical Record and found that Resident #1 had a Do Not Resuscitate order in their profile. Registered Nurse Supervisor #1 stated that Registered Nurse Supervisor #2, some of the Emergency Medical team, and them went to Resident #1's room and notified the others that Resident #1 had a Do No Resuscitate order. Registered Nurse Supervisor #1 stated that Cardiopulmonary Resuscitation was stopped (unsure of time) after they became aware of Resident #1's code status. During a telephone interview on [DATE] at 5:25 PM, Physician Assistant #1 stated that Registered Nurse Supervisor #1 called them at 8:30 AM on [DATE] and informed them that Resident #1 was found unresponsive and that they initiated chest compressions. Physician Assistant #1 stated that they asked Registered Nurse Supervisor #1 if Resident #1 was a full code and Registered Nurse Supervisor #1 said yes. Physician's Assistant #1 stated that they instructed Registered Nurse Supervisor #1 to call 911 and continue with cardiopulmonary resuscitation. Physician Assistant #1 stated that Registered Nurse Supervisor #1 informed them that Resident #1's blood pressure was 80/60 and they told them start an intravenous fluid. During an interview on [DATE] at 2:20 PM, the Director of Nursing stated that the facility's protocol when a resident is found unresponsive is for staff to assess the resident and check the resident's wrist for their yellow wrist band (that would indicate Do Not Resuscitate), followed by checking the Electronic Medical Record for the Advance Directives to verify the residents code status. The Director of Nursing stated that the staff should have called a code, notified Registered Nurse Supervisor, and initiated cardiopulmonary resuscitation if the resident is full code. The Director of Nursing stated that Resident #1 was wearing a yellow wrist band indicating Do Not Resuscitate order. The Director of Nursing stated that chest compressions should not have been performed on Resident #1. During a telephone interview on [DATE] at 2:03 PM, the Administrator stated that the Director of Nursing notified them of the incident on [DATE] at approximately 10:00 AM. The Administrator stated that Registered Nurse #1 stated that they checked the Electronic Medical Order but did not see the order for Do Not Resuscitate. The Administrator stated that Registered Nurse #1 stated that they did not check Resident #1's wrist to see if the resident was wearing a yellow wrist band. Based on the following corrective actions taken, there were sufficient evidence that the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement prior to and during the time of this survey. A Plan of Correction is not required for this citation. The facility took immediate corrective actions and was found to be incompliance on [DATE], prior to Surveyors' entrance on [DATE]. The facility took immediate corrective actions. Facility reviewed Policies/Procedures on Advance Directives and Cardiopulmonary Resuscitation. No changes were made. Quality Assurance Performance Improvement meeting held on [DATE]. Another meeting scheduled for [DATE] and [DATE]. Meetings are ongoing. On [DATE] - Lesson Plan: Advance Directives - Do Not Resuscitate - target audience - nursing staff (nurses and Certified Nursing Assistants). Ongoing. On [DATE]- Registered Nurse #1 was removed and terminated on [DATE] for failure to check resident's wrist for an identifier (yellow wrist band) and for not following Resident #1's wishes. On [DATE]- Certified Nursing Assistant #1 was removed from schedule for three days for providing rescue breaths to Resident #1. Re-in-service was provided on [DATE]. On [DATE] - Lesson Plan: Advance Directive - All nursing staff. Ongoing. On [DATE] - an Audit tool for Identification of Advance Directives Residents. [DATE] audits on Do Not Resuscitate initiated and will continue to complete audits upon admission/readmission. Ten residents will be audited weekly times four weeks and then 10 residents' monthly times 3 months and then 10 residents quarterly. On [DATE] - Lesson Plan: Assessment and Treatment of a Resident that is Unresponsive - Target audience - All nursing staff. In-service ongoing On [DATE], [DATE], & [DATE] - STAT Code Drill/Competency On [DATE] - Staff Audits initiated. Audit Tool: F578 and F678 Advance Directive/CPR. 10 staff members monthly times 3 months, and 10 staff members Quarterly Findings will be presented monthly at Quality Assurance Performance Improvement meeting. 53 out of 61 Registered Nurses 91.38% in-serviced. 29 out of 36 Licensed Practical Nurses 93.55% in-serviced. 171 out of 192 Certified Nursing Assistants 92.93% in-serviced. 10NYCCR415.3e(2)(iii)

Based on observation, record review, and interview during the Recertification Survey conducted from 03/24/2025 to 03/31/2025, the facility did not develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet each resident's medical, nursing, mental, and psychosocial needs. This was evident in 2 of 2 residents reviewed out of 35 total sampled residents. Specifically, 1.) Resident #27, who was on palliative care and had been receiving pain medications, had no care plan developed to address pain management and palliative care. 2.) Resident #123, who had a diagnosis of Diabetes Mellitus and had been receiving medications to help control their blood sugar level, had no care plan developed for diabetes. The findings are : The facility policy titled Comprehensive Care Plan with a revision date of 12/2023 documented it is the policy of the facility that all residents will have a comprehensive care plan completed in accordance with Federal and State requirements. The comprehensive care plan include measurable objectives and timetable to meet the resident's medical, nursing, and psychosocial needs that are identified from the comprehensive assessment, it will be started immediately upon admission and completed within seven days after the completion of the comprehensive assessment. Care plan will be reviewed and revised as needed by a team of qualified persons and minimally after each assessment or reassessment. 1. Resident #27 had diagnoses of Metabolic Encephalopathy, Dementia, and Severe Sepsis. The Minimum Data Set assessment dated [DATE] documented Resident #27 had severely impaired cognition, unable to walk, and was completely dependent on staff for dressing, transfer, bed mobility, and was spoon fed by staff during meals. During an observation on 03/25/2025 at 12:05 PM, Resident #27 stated they have pain. The physician's order dated 01/09/2025 and 03/03/2025 documented Resident #27 was on Palliative Care, on Tylenol 325 milligram 2 tablets every 6 hours as needed for low back pain and to apply Voltaren 1% gel twice a day and as needed for low back pain. A medical note dated 03/05/2025 documented that Resident #27 was seen for monthly assessment and physical examination, resident was on Tylenol and Voltaren gel for pain to both knee. A palliative care visit note dated 03/31/2025 documented Resident #27 was seen on 03/21/2025 with no complaint of pain or discomfort, consumed lunch with a fair appetite. Will visit the resident again on the next palliative care visit. A review of Resident #27's comprehensive care plans had no documented evidence that care plans for palliative care and pain management was developed. 2. Resident #123 had diagnoses of Anemia, Heart Failure, and Diabetes Mellitus. The Minimum Data Set assessment dated [DATE] documented Resident #123 had intact cognition and required maximal assistance in dressing, eating, transfer, and toileting. A physician's order dated 03/23/2025 documented orders for Humalog KwikPen Insulin, Jardiance 10 milligram tablet, and Lantus Insulin for diabetes mellitus. A review of Resident #123's comprehensive care plans had no documented evidence that a care plan to address Resident #123's diagnosis of Diabetes Mellitus was developed. On 03/31/2025, Registered Nurse #4 was interviewed and stated it is the nurse supervisors' responsibility to initiate the care plans on admission. They stated it is the Registered Nurses' responsibility to update the care plans. On 03/28/2025 at 12:30 PM, Registered Nurse #5, who was the nursing supervisor, was interviewed and stated they checked the medical record and found no care plans developed for Resident #27 on pain management and palliative care. Registered Nurse #5 stated Resident #123 had no care plan developed for diabetes. They stated care plans are initiated by the admitting Registered Nurse and that it is every nurse's responsibility to initiate and complete the care plans. 10 NYCRR 415.11(c)(1)

Based on observations, interviews, and record review conducted during the Recertification Survey from 03/24/2025 to 03/31/2025, the facility did not ensure that services provided meet professional standards of quality. This was evident for 1 (Resident #320) of 3 residents observed during Medication Administration. Specifically, 1) Licensed Practical Nurse #3 was observed administering the medication Janumet 50 mg-500 mg 1 tablet by mouth at 10:05 AM, however, review of the Medication Administration Record documented the medication had been administered at 7:49 AM, and 2) Licensed Practical Nurse #3 was also observed administering Centrum Silver Ultra Men's 300 mcg-60 mcg-600 mcg-300 mcg 1 tablet by mouth that was dispensed for Resident #318 to Resident #320 instead of Centrum Silver 0.4 mg-300 mcg 250 mcg 1 tablet by mouth as ordered by the physician. The findings are: Resident #320 was admitted to the facility with diagnoses which included Diabetes Mellitus, Coronary Artery Disease, and Hypertension. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #320 had intact cognition and required supervision when performing Activities of Daily Living. The Physician Orders dated 05/14/2024, last renewed on 02/13/25, documented Janumet 50 mg-500 mg tablet give 1 tablet by oral route once daily at 08:00 AM and Centrum Silver 0.4 mg-300 mcg 250 mcg tablet, give 1 tablet by oral route once daily at 10:00 AM. On 03/26/2025 at 10:05 AM, during the Medication Administration task, Licensed Practical Nurse #3 administered Janumet 50 mg-500 mg tablet 1 tablet by mouth and Centrum Silver Ultra Men's 300 mcg-60 mcg-600mcg-300 mcg 1 tablet by mouth to Resident #320. The Medication Administration Record for Resident #320 was immediately reviewed and revealed that Licensed Practical Nurse #1 had already signed off for administration of the Janumet 50 mg-500 mg tablet give 1 tablet by oral route once daily at 08:00 AM at 7:49 AM. Review of the Physician orders revealed that Resident #320 was prescribed Centrum Silver 0.4 mg-300 mcg 250 mcg tablet,1 tablet by oral route once daily at 10:00 AM but received Centrum Silver Ultra Men's 300 mcg-60 mcg-600-mcg-300 mcg 1 tablet by mouth instead. On 03/26/2025 at 10:15 AM, an interview was conducted with Licensed Practical Nurse #3 who stated that they signed for Janumet 50 mg-500 mg tablet 1 tablet by oral route for Resident #320 when they started work this morning around 7:00 AM but they did not administer it at that time. Licensed Practical Nurse #3 also stated that they sometimes sign off medications early and hope to administer them later as many residents receive their medication at 10:00 AM and prefer to receive them all at the same time. Licensed Practical Nurse #3 further stated that they wanted to give Resident #320 all their medications together. During a follow-up interview on 03/26/2025 at 10:30 AM, Licensed Practical Nurse #3 stated that, during the Medication Administration, they did not see the medication Centrum Silver 0.4 mg-300 mcg-250 mcg dispensed for Resident #320, so they went to look for it among the extra medications located at the bottom of the medication cart. Licensed Practical Nurse #3 also stated that they just selected another Centrum medication, but they did not realize that the Centrum blister pack they picked belonged to another resident (Resident #318). On 03/31/25 10:10 AM, an interview was conducted with Registered Nurse #5, a unit supervisor who stated that all medication nurses are taught the five rights of medication administration. Registered Nurse #5 also stated that the Centrum for Resident #320 was in the medication cabinet but is listed under another name which Licensed Practical Nurse #3 was not familiar with. Registered Nurse #5 further stated that signing for a medication that had not yet been administered to the resident is not acceptable practice On 03/31/25 at 11:00 AM, an interview was conducted with the Medical Director who stated that the Janumet could be administered at any time during the morning. The Medical Director also stated that they believed the Janumet being entered for administration at 8:00 AM was an error because the medication would not have any interaction with other medications if administered at 10:00 AM. The Medical Director concluded that the nursing staff should not sign off medication they have not administered. On 03/31/25 at 11:30 AM, a further interview was conducted with the Medical Director who stated that the facility has a standard Centrum preparation that they use for residents. The Medical Director also stated that sometimes residents come from the hospital with a different order, or their respective provider required a different dosage of Centrum, so an individual order would be written, and the pharmacy would supply them individually because of the different strengths. On 03/31/25 at 12:00 PM, an interview was conducted with the Director of Nursing who stated that all nursing staff were in-serviced annually and as needed for medication administration competency. The Director of Nursing stated that the Licensed Practical Nurse #3 had received medication administration competency training, and there were no concerns with their performance at that time. 10 NYCRR 415.11(c)(3)(i)

Based on observations, record review, and interviews conducted during the Recertification survey from 03/24/2025 to 03/31/2025, the facility did not ensure that the medication error rate was not less than 5 percent. This was evident for 2 of 28 medications given during the Medication Administration task. Specifically, 1) Licensed Practical Nurse #3 was observed administering the medication Janumet 50 mg-500 mg 1 tablet by mouth at 10:05 AM, however, review of the Medication Administration Record documented the medication had been administered at 7:49 AM, and 2) Licensed Practical Nurse #3 was also observed administering Centrum Silver Ultra Men's 300 mcg-60 mcg-600 mcg-300 mcg 1 tablet by mouth that was dispensed for Resident #318 to Resident #320 instead of Centrum Silver 0.4 mg-300 mcg 250 mcg 1 tablet by mouth as ordered by the physician which resulted in a medication error rate of 7.14%. The findings are: The facility policy titled Medication Administration, dated 01/2019 documented the following that it is the policy of the facility to ensure that nurses administer medications correctly and on a timely manner. The policy also documented that medication administered shall be charted immediately after administration. The policy further documented that the medication supplied for one resident shall not be administered to another resident. Borrowing one resident's medication for another resident is not permitted. Resident #320 was admitted to the facility with diagnoses which included Diabetes Mellitus, Coronary Artery Disease, and Hypertension. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #320 had intact cognition and required supervision when performing Activities of Daily Living. The Physician Orders dated 05/14/2024, last renewed on 02/13/25, documented Janumet 50 mg-500 mg tablet give 1 tablet by oral route once daily at 08:00 AM and Centrum Silver 0.4 mg-300 mcg 250 mcg tablet, give 1 tablet by oral route once daily at 10:00 AM. On 03/26/2025 at 10:05 AM, during the Medication Administration task, Licensed Practical Nurse #3 administered Janumet 50 mg-500 mg tablet 1 tablet by mouth and Centrum Silver Ultra Men's 300 mcg-60 mcg-600mcg-300 mcg 1 tablet by mouth to Resident #320. The Medication Administration Record for Resident #320 was immediately reviewed and revealed that Licensed Practical Nurse #1 had already signed off for administration of the Janumet 50 mg-500 mg tablet give 1 tablet by oral route once daily at 08:00 AM at 7:49 AM. Review of the Physician orders revealed that Resident #320 was prescribed Centrum Silver 0.4 mg-300 mcg 250 mcg tablet,1 tablet by oral route once daily at 10:00 AM but received Centrum Silver Ultra Men's 300 mcg-60 mcg-600-mcg-300 mcg 1 tablet by mouth instead. This resulted in an error rate of 7.14%. On 03/26/2025 at 10:15 AM, an interview was conducted with Licensed Practical Nurse #3 who stated that they signed for Janumet 50 mg-500 mg tablet 1 tablet by oral route for Resident #320 when they started work this morning around 7:00 AM but they did not administer it at that time. Licensed Practical Nurse #3 also stated that they sometimes sign off medications early and hope to administer them later as many residents receive their medication at 10:00 AM and prefer to receive them all at the same time. Licensed Practical Nurse #3 further stated that they wanted to give Resident #320 all their medications together. During a follow-up interview on 03/26/2025 at 10:30 AM, Licensed Practical Nurse #3 stated that, during the Medication Administration, they did not see Centrum Silver 0.4 mg-300 mcg-250 mcg dispensed for Resident #320, so they went to look for it among the extra medications located at the bottom of the medication cart. Licensed Practical Nurse #3 also stated that they just selected another Centrum medication, but they did not realize that the Centrum blister pack they picked belonged to another resident (Resident #318). On 03/31/25 10:10 AM, an interview was conducted with Registered Nurse #5, a unit supervisor who stated that all medication nurses are taught the five rights of medication administration. Registered Nurse #5 also stated that the Centrum for Resident #320 was in the medication cabinet but is listed under another name which Licensed Practical Nurse #3 was not familiar with. Registered Nurse #5 further stated that signing for a medication that had not yet been administered to the resident is not acceptable practice On 03/31/25 at 11:00 AM, an interview was conducted with the Medical Director who stated that the Janumet could be administered at any time during the morning. The Medical Director also stated that they believed the Janumet being entered for administration at 8:00 AM was an error because the medication would not have any interaction with other medications if administered at 10:00 AM. The Medical Director concluded that the nursing staff should not sign off medication they have not administered. On 03/31/25 at 11:30 AM, a further interview was conducted with the Medical Director who stated that the facility has a standard Centrum preparation that they use for residents. The Medical Director also stated that sometimes residents come from the hospital with a different order, or their respective provider required a different dosage of Centrum, so an individual order would be written, and the pharmacy would supply them individually because of the different strengths. On 03/31/25 at 12:00 PM, an interview was conducted with the Director of Nursing who stated that all nursing staff were in-serviced annually and as needed for medication administration competency. The Director of Nursing stated that the Licensed Practical Nurse #3 had received medication administration competency training, and there were no concerns with their performance at that time. 10 NYCRR 415.12(m)(1)

Based on record review and interviews during the Recertification and Abbreviated Survey (NY00342691) conducted from 03/24/2025 to 03/31/2025, the facility did not ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation is made to the New York State Department of Health. This was evident in 1 (Resident #230) of 3 residents reviewed for Abuse. Specifically, Resident #230 had an unwitnessed incident on 05/17/2024 at approximately 4:00 AM, when the resident was observed sitting on the floor gym mat on the left side of their bed. Hospital x-ray report showed right pelvic fracture. Resident #230 was unable to explain the occurrence. This incident was not reported to the New York State Department of Health. The findings are: The facility policy titled Abuse Prevention with a revised date of 09/26/2024 documented the facility will report any incident and/or violation where abuse, neglect, or mistreatment is suspected to the New York State Department of Health according to all federal and state regulations. Resident #230 had diagnoses of Unspecified Dementia, Mood Affective Disorder, and Chronic Kidney Disease. The quarterly Minimum Data Set assessment dated [DATE] documented Resident #230 had severe cognitive impairment. A nurse progress note dated 05/17/2024 at 12:59 PM by Registered Nurse #1 documented late entry note, on 05/17/2024 at 4:00 AM, Registered Nurse #1 was called by the charge nurse to assess Resident #230 who was sitting on a gym mat next to their bed. Body check revealed no injuries were noted. A nurse progress note dated 05/17/2024 at 10:33 AM documented Resident #230 complained of pain to the right hip. The resident was noted with mild swelling and bluish discoloration on the right hip. The physician was notified and ordered hospital transfer. Resident #230 left the facility at 8:45 AM. The Nurse's Investigation Statement form dated 05/17/2024 completed by Licensed Practical Nurse #2 documented on 05/17/2024 at 4:00 AM, Resident #230 was observed in their room, sitting in a gym mat on the left side of their bed. The form documented Resident #230 had dementia, confused, and forgetful. There was no documented resident statement of occurrence. A review of the employee written statements revealed no one had witnessed the incident. During an interview with Certified Nurse Aide #3 on 03/27/2025 at 10:04 AM, they stated they were on duty on 05/17/2024 from 11:00 PM to 7:00 AM. They stated they found Resident #230 sitting on the floor gym mat, and they called for help and the nurse came. During an interview on 03/27/2025 at 9:46 AM, Registered Nurse #1, who was the Nursing Supervisor, stated they were on duty on 05/17/2025 from 11:00 AM to 7:30 AM. They stated they cannot recall when they received a call in the early morning about Resident #230 being found on the floor sitting on the gym mat. Registered Nurse #1 stated they assessed Resident #230, and the resident seemed alright. Registered Nurse #1 stated they did not consider the incident as a fall because Resident #230 was sitting on the gym mat. During an interview on 03/28/2025 at 7:55 AM, the Director of Nursing stated this incident was not reported to the New York State Department of Health because Resident #230 was observed on the gym mat and that was the basis of Resident #230's injury. They stated there was no unknown factor and that they concluded in their investigation that abuse was not determined. The Director of Nursing stated , because the fall was unwitnessed, the incident should have been reported to the New York State Department of Health. 10 NYCRR 415.4(b)(2)

Based on observation, record review, and interviews conducted during an Abbreviated and Partial Extended Survey (NY00354577), the facility failed to protect the residents' right to be free from physical abuse. This was evident for one out of six residents reviewed (Resident #1) for abuse. Specifically, on 09/16/2024 at 7:20 PM, Licensed Practical Nurse #1 did not intervene or remove Certified Nursing Assistant #1 from providing care to Resident #1 or any other residents assigned to Certified Nursing Assistant #1 when on 1) 09/16/2024 at around 7:20 PM, Licensed Practical Nurse #1 witnessed Certified Nursing Assistant #1 physically force Resident #1 to sit in a chair in the hallway; 2) between 8:15 PM - 8:30 PM Licensed Practical Nurse #1 and Certified Nursing Assistant #2 both witnessed Certified Nursing Assistant #1 grab and push Resident #1 to sit in a wheelchair and then wheel Resident #1 into their room; and 3) shortly after 8:30 PM, Licensed Practical Nurse #1 heard noises coming from Resident #1's room, entered the room and observed Certified Nursing Assistant #1 hitting Resident #1 multiple times on their right thigh with a closed fist. Licensed Practical Nurse #1 approached Resident #1 briefly and then exited the room closing the door behind them. This resulted in actual harm to Resident #1 with the potential for serious injury, serious harm, serious impairment, or death to all residents on the unit, which was Immediate Jeopardy and Substandard Quality of Care. The findings are: The facility's Policy and Procedure entitled Abuse Prevention, with revision date 11/07/2022, documented that residents will be protected from Abuse, Neglect, Mistreatment, Exploitation, or Misappropriation of resident property in accordance with State and Federal Regulations. Resident #1 was admitted to the facility on [DATE] with diagnoses including Osteoarthritis (Inflammation of one or more joints), Osteoporosis (a condition when bone strength weakens and is susceptible to fracture), and Metabolic Encephalopathy (change in how your brain functions due to an underlying condition). The Minimum Data Set (an assessment tool), dated 08/13/2024, documented Resident #1 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) and scored 10 out of 15, indicating moderately impaired cognition. A Behavior/Victimization Care Plan dated 02/06/2024 documented interventions that included separate resident from others as needed, calm approach, talk to resident in soothing manner and orient resident to environment. The Accident/Incident Occurrence Report dated 09/16/2024 documented time of the occurrence as 8:15 PM. Licensed Practical Nurse #1 reported they witnessed, in the hallway, Certified Nursing Assistant #1 forcefully pull and guide Resident #1 by their right arm to sit in the wheelchair despite Resident #1 not wanting to sit down. Certified Nursing Assistant #1 made Resident #1 sit in the wheelchair and wheeled them to their room. Licensed Practical Nurse #1 continued to hear noises from Resident #1's room and went into the room. Licensed Practical Nurse #1 observed Resident #1 being resistive and not wanting to stay in bed. Resident #1 was agitated. Certified Nursing Assistant #1 tried to change Resident #1's pull-up while Resident #1 was being resistive and kicking. Licensed Practical Nurse #1 observed Certified Nursing Assistant #1 hit Resident #1 on the thigh. Licensed Practical Nurse #1 called the Registered Nurse Supervisor #1 immediately. Tylenol and Ice Compress were given for pain. The facility concluded the alleged abuse probably occurred, as evidenced by the report of Licensed Practical Nurse #1, who corroborated with Resident #1. A Police Incident Information Slip dated 09/25/2024 documented occurrence date 09/16/2024. Crime: Assault 2. The facility's surveillance video recording system was reviewed by the Surveyor, only captured the portion of the unit near the nursing station. It did not capture the entrance to Resident #1's room. A Nursing Incident Note dated 09/17/2024 at 1:37AM, written by Registered Nurse Supervisor #1, documented that License Practical Nurse #1 reported an incident that occurred around 8:15 PM - 8:30 PM. Registered Nurse Supervisor #1 met Resident #1 in the hallway crying, stating that a big, black lady beat them on their right shoulder and right upper thigh - right hip. Resident #1 also stated they were in so much pain. On assessment, bruising and redness were observed on Resident #1's right arm, with some skin scratch, bleeding, a slight bluish discoloration on the right hip area that was tender to the touch, and an ecchymosis (bruise) at Resident #1's left temple. Licensed Practical Nurse #1 reported they witnessed Certified Nursing Assistant #1 beating Resident #1. Certified Nursing Assistant #1 grabbed Resident #1 and forcefully dragged Resident #1 into a wheelchair. Resident #1 was resisting, but Certified Nursing Assistant #1 still brought Resident #1 to their room, where Certified Nursing Assistant #1 beat Resident #1. Tylenol was given for pain, and a cold compress was applied to the bruises. A Medical Note dated 09/17/2024 at 6:14 PM, written by the Nurse Practitioner #1, documented Resident #1 was seen and noted with small areas of ecchymosis on the left side of their forehead, a small area of ecchymosis on the middle of their right upper arm and forearm, ecchymosis of their right hand, and fading yellowish discoloration on the side of their right thigh. Resident #1 complained of pain to the right shoulder with Range of Motion (movement). Observation on the 5th Unit was conducted on 09/25/2024 between 10:30 AM and 11:30 AM. Resident #1 was observed in the hallway sitting on a regular chair. Resident #1 was observed with yellow and dark discolorations on their right hand, right forearm, and upper forearm. There was a healing scratch on Resident #1's right upper arm. A Psychologist's note dated 09/27/2024 at 5:12 PM documented Resident #1 reported they were dragged in a chair and was taken to their room by a staff member. Resident #1 reported the staff member kept hitting their arm and hips. Psychotherapy was recommended to reduce emotional symptoms. During an interview on 09/25/2024 at 10:30 AM, Resident #1 stated Certified Nursing Assistant #1 hit them on their right arm and tried to break their right arm. Resident #1 reported their arm still hurts when they raise their arm up. During an interview on 09/25/2024 at 11:10 AM, Resident #2, who had intact cognition, stated on 09/16/2024 (in the evening) they were in the hallway close to Resident #1. Resident #2 stated they observed Certified Nursing Assistant #1 grab Resident #1 by their shoulders and forcefully push Resident #1 to sit in the wheelchair. Then, Certified Nursing Assistant #1 wheeled Resident #1 to their room while Resident #1 was resisting and kicking. During a phone interview on 09/25/2024 at 12:40 PM, Certified Nursing Assistant #1 stated they were assigned to Resident #1 on 09/16/2024 on the 3:00 PM to 11:00 PM shift. Certified Nursing Assistant #1 stated they observed Resident #1 entering another resident's room at around 8:00 PM and they tried to redirect Resident #1 to their room. Certified Nursing Assistant #1 stated Resident #1 was irritated and mad and tried to hit them and did not want to go to their room. Certified Nursing Assistant #1 stated Resident #1 threw the walker on the floor and lost their balance. Certified Nursing Assistant #1 stated they prevented Resident #1 from falling by holding on to Resident #1's right arm while grabbing a wheelchair. Certified Nursing Assistant #1 stated they held Resident #1 at their waist, with their hands, from behind and made Resident #1 sit in the wheelchair. Certified Nursing Assistant #1 stated a Licensed Practical Nurse #1 spoke with Resident #1 and Resident #1 calmed down a bit. Certified Nursing Assistant #1 stated they took Resident #1 to their room and Resident #1 sat on the bed and then laid down. Certified Nursing Assistant #1 stated they pulled off Resident #1's pull-ups while Resident #1 was being resistive and did not want to be touched. Certified Nursing Assistant #1 stated they did not hit Resident #1 at any point. During an interview on 9/25/2024 at 1:10 PM, Licensed Practical Nurse #1 stated at around 7:20 PM, they observed Certified Nursing Assistant #1 grab Resident #1's right upper arm and roughly put Resident #1 in a regular chair in the hallway while Resident #1 was resisting. Licensed Practical Nurse #1 stated they felt it was abuse and they did not intervene, but gave Certified Nursing Assistant #1 a look, and Certified Nursing Assistant #1 went to care for other residents. Licensed Practical Nurse #1 stated at around 8:15 PM - 8:30 PM, they observed Certified Nursing Assistant #1 suddenly grab Resident #1's upper right arm, then Certified Nursing Assistant #1 reached over to a wheelchair and tried to forcefully get Resident #1 into the wheelchair. Licensed Practical Nurse #1 stated Resident #1 was still holding onto their rolling walker and did not want to sit in the wheelchair. Licensed Practical Nurse #1 stated Certified Nursing Assistant #1 forcefully repositioned Resident #1 in the wheelchair and wheeled Resident #1 to their room. Licensed Practical Nurse #1 stated they did not intervene because they were in shock. Licensed Practical Nurse #1 stated they returned to their medication cart that was by Resident #1's room and heard noise and a tapping (twice) body sound coming from Resident #1's room. Licensed Practical Nurse #1 stated they went into Resident #1's room and observed Resident #1 sitting on their bed while Certified Nursing Assistant #1 was holding both hands of Resident #1 and was pushing Resident #1 to lie down. Licensed Practical Nurse #1 stated Resident #1 continued to resist lying down. Licensed Practical Nurse #1 stated they instructed Certified Nursing Assistant #1 to stop, but Certified Nursing Assistant #1 continued pushing Resident #1 to lie down. Licensed Practical Nurse #1 stated they stood in Resident #1's room trying to calm Resident #1, but Resident #1 was not listening. Licensed Practical Nurse #1 stated Certified Nursing Assistant #1 ripped the pull-ups off Resident #1 and hit Resident #1 with closed fist twice on their right upper thigh. Licensed Practical Nurse #1 stated they replaced Resident #1's pull-ups and left the room. Licensed Practical Nurse #1 stated they left Certified Nursing Assistant #1 in the room with Resident #1 and closed the door. Licensed Practical Nurse #1 stated Certified Nursing Assistant #1 exited the room in 30 seconds to 1 minute. Licensed Practical Nurse #1 stated after 5 minutes not knowing what to do, they reported the incident to Registered Nurse Supervisor #1. During an interview on 09/25/2024 at 2:40 PM, Certified Nursing Assistant #2 stated after supper time (they didn't recall the exact time), they were by the nursing station and observed Certified Nursing Assistant #1 roughly force Resident #1 to sit in a wheelchair in the hallway while Resident #1 was resisting. Certified Nursing Assistant #2 stated Licensed Practical Nurse #1 was with Resident #1 and Certified Nursing Assistant #1. During an interview on 09/25/24 at 5:02 PM, Registered Nurse Supervisor #1 stated they were notified by License Practical Nurse #1 at approximately 9:00 PM that between 8:15 PM and 8:30 PM, Licensed Practical Nurse #1 stated they observed Certified Nursing Assistant #1 beating Resident #1. Registered Nurse Supervisor #1 stated Licensed Practical Nurse #1 also reported they stopped Certified Nursing Assistant #1 and assisted in providing care to Resident #1. Registered Nurse Supervisor #1 stated Licensed Practical Nurse #1 reported they were afraid, confused, hesitant, and did not know what to do. Registered Nurse Supervisor #1 stated Licensed Practical Nurse #1 also reported shortly after 7:20 PM they saw Certified Nursing Assistant #1 forcefully drag Resident #1 out of the wrong room and Resident #1 was fighting back with Certified Nursing Assistant #1. Registered Nurse Supervisor #1 stated they assessed Resident #1 and notified the Medical Doctor and notified the Director of Nursing at 9:30 PM. Registered Nurse Supervisor #1 stated Licensed Practical Nurse #1 should have reported the first encounter. During an interview on 9/26/2024 at 10:51 PM, the Director of Nursing stated they were notified about an abuse incident between 9:30 PM and 10:00 PM by Registered Nurse Supervisor #1. The Director of Nursing stated they directed Registered Nurse Supervisor #1 to call the police and send Certified Nursing Assistant #1 home. The Director of Nursing stated they did not conduct a body assessment on the confused residents that were assigned to Certified Nursing Assistant #1's assignment. The Director of Nursing stated Certified Nursing Assistant #1 stated they did not hit Resident #1, but they made Resident #1 go to their room while Resident #1 was being resistive. The Director of Nursing stated Licensed Practical Nurse #1 did not intervene. The Director of Nursing stated Licensed Practical Nurse #1 should have separated Certified Nursing Assistant #1 when they first observed rough handling in the hallway. The Director of Nursing also stated Certified Nursing Assistant #2 could have stepped in and taken over for Certified Nursing Assistant #1. The Director of Nursing stated they have concluded it was possible abuse happened based on Licensed Practical Nurse #1's interview. The Director of Nursing stated the charge nurses on the unit and supervisors are responsible for monitoring the units to ensure the residents are free from abuse. During an interview on 09/26/2024 at 12:36 PM, the Administrator stated they were notified about the allegation of abuse at 11:46 PM by The Director of Nursing. The Administrator stated the police were called at 10:06 PM and responded, but they are not aware if an arrest was made. The Administrator stated police officers returned to the facility on [DATE] and notified them the incident was an Assault in the second degree. The Administrator stated it is a serious charge. The Administrator stated they were part of the investigation and concluded that abuse occurred. During an interview on 09/27/2024 at 4:50 PM, Attending Physician #1 stated Registered Nurse Supervisor #1 called them on 09/16/2024 at around 11:00 PM and reported Certified Nursing Assistant #1 hit Resident #1 and gave them a report of their assessment findings. Attending Physician #1 stated Resident #1 was complaining, moaning, and crying from pain in their right shoulder, which was scored as moderate to severe pain (5-6 out of 10). Attending Physician #1 stated a STAT (immediate) x-ray was ordered to rule out fracture, Tylenol for pain, and an Ice Pack. During an interview on 09/26/2024 at 1:54 PM, the Medical Director stated they were notified two days after Resident #1 was hit by Certified Nursing Assistant #1. The Medical Doctor stated they reviewed Resident #1's medical chart and discussed the incident with covering Attending Physician #1 and Nurse Practitioner #1, who evaluated Resident #1, and, in their professional opinion, Resident #1 sustained a minor injury that was managed successfully with Tylenol and Ice Pack. The Medical Director further stated there was no reason to transfer Resident #1 to the hospital. _______________________________________________________________________________ On 09/26/2024 at 06:25 PM, Immediate Jeopardy was identified and declared. The facility's Administrator and the Director of Nursing were notified. On 09/26/2024 at 10:48 PM, the facility presented a removal plan which listed the immediate action the facility would take to prevent serious harm from occurring or recurring. The removal plan was accepted. Based on observation, interview, and record review, as of 09/30/2024 at 3:15 PM, the removal plan was implemented, and Immediate Jeopardy was lifted based on the following corrective actions taken by the facility: Certified Nursing Assistant #1 was removed from the unit, relieved of duty on 09/16/2024 at 10:00 PM, and was terminated on 09/20/2024. 911 Police were called on 09/16/2024 at 10:06 PM. On 09/17/2024, a Quality Assurance Performance Improvement meeting was held. The abuse incident and actions to be taken were discussed. 0n 09/26/2024, all 12 residents on Certified Nursing Assistant #1's assignment were assessed for bruising by a Registered Nurse #1. There were no negative findings. Licensed Practical Nurse #1 was counseled on abuse prevention and reporting immediately. Licensed Practical Nurse #1 was suspended on 09/26/2024 post counseling. Certified Nursing Assistant #2 was counseled on abuse prevention and reporting immediately and was suspended on 09/26/2024. A Psychiatrist evaluated Resident #1 on 09/27/2024 and documented Resident #1 did not sustain any psychosocial harm. A Psychologist evaluated Resident #1 on 09/27/2024 at 5:12 PM, and recommendations were made for individual Psychotherapy to reduce emotional symptoms. The facility revised its policy on abuse prevention on 09/26/2024 to include a Registered Nurse/supervisor complete a full body assessment of the resident to determine injuries. The facility will monitor trends and/or patterns of occurrence via the Quality Assurance Committee to identify any potential incidents of abuse. The facility conducted all house in-service (classroom and via phone) from 09/26/2024 to 09/30/2024 on Abuse for F600 and F610 with 98% active staff in-serviced. Staff members who are furloughed will be in-serviced before returning to their shift. Interviews were done with several staff members: nurses, Certified Nursing Assistants, housekeeping/environmental staff, security staff, recreation staff, physical/occupational therapist, social workers, dietary staff, and administrative staff, and all were knowledgeable on the abuse prevention protocol, what do if they observe abuse, when to report, and who they should report to. 10 NYCRR 415.4(b)(1)(i)

Based on observation, record review, and interview during an Abbreviated and Partial Extended Survey (NY00354577), the facility failed to remove Certified Nursing Assistant #1 from resident care after witnessed abuse. This was evident for one out of six residents reviewed (Resident #1) for abuse. Specifically, 1) On 09/16/2024 at around 7:20 PM, Licensed Practical Nurse #1 witnessed Certified Nursing Assistant #1 physically force Resident #1 to sit in a chair in the hallway; 2) between 8:15 PM - 8:30 PM Licensed Practical Nurse #1 and Certified Nursing Assistant #2 both witnessed Certified Nursing Assistant #1 grab and push Resident #1 to sit in a wheelchair and then wheel Resident #1 into their room; and 3) shortly afterwards Licensed Practical Nurse #1 heard noises coming from Resident #1's room, entered the room and observed Certified Nursing Assistant #1 hitting Resident #1 multiple times on their right thigh with a closed fist. Licensed Practical Nurse #1 did not intervene or remove Certified Nursing Assistant #1 from providing care to Resident #1 or to any other residents assigned to Certified Nursing Assistant #1. This resulted in actual harm to Resident #1 and the potential for serious injury, serious harm, serious impairment, or death to all residents on the unit, which was Immediate Jeopardy and Substandard Quality of Care. The findings are: The facility's Policy and Procedure entitled Abuse Prevention, with revision date 11/07/2022 states the facility will protect all residents during any abuse investigation by removing staff from direct care and/or removing them from schedule pending conclusion. The facility will provide counseling and support for residents as needed. Resident #1 was admitted to the facility on [DATE] with diagnoses including Osteoarthritis (Inflammation of one or more joints), Osteoporosis (a condition when bone strength weakens and is susceptible to fracture), and Metabolic Encephalopathy (change in how your brain functions due to an underlying condition). The Minimum Data Set (an assessment tool), dated 08/13/2024, documented Resident #1 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) and scored 10 out of 15, indicating moderately impaired cognition. A Nursing Incident Note dated 09/17/2024 at 1:37 AM, written by Registered Nurse Supervisor #1, documented that License Practical Nurse #1 reported an incident that occurred around 8:15 PM - 8:30 PM. Registered Nurse Supervisor #1 met Resident #1 in the hallway crying, stating a big, black lady beat them on their right shoulder and right upper thigh - right hip. Resident #1 also stated (bruise they were in so much pain. On assessment, bruising and redness were observed on Resident #1's right arm, with some skin scratch, bleeding, a slight bluish discoloration on the right hip area that was tender to the touch, and an ecchymosis (bruise with discolored skin) at Resident #1's left temple. Licensed Practical Nurse #1 reported that they witnessed Certified Nursing Assistant #1 beating Resident #1. Certified Nursing Assistant #1 grabbed Resident #1 and forcefully dragged Resident #1 into a wheelchair. Resident #1 was resisting, but Certified Nursing Assistant #1 still brought Resident #1 to their room, where Certified Nursing Assistant #1 beat Resident #1. Tylenol was given for pain, and a cold compress was applied to the bruises. The Employee timecard (KRONS) dated 09/16/2024 showed Certified Nursing Assistant #1 clocked out at 10:00 PM. A Police Incident Information Slip dated 09/25/2024 documented occurrence date 09/16/2024. Crime: Assault 2. During an interview on 09/25/2024 at 10:30 AM, Resident #1 stated Certified Nursing Nurse #1 hit them on their right arm and tried to break their right arm. Resident #1 reported their arm still hurts when they raise their arm up. During an interview on 9/25/2024 at 01:10 PM, Licensed Practical Nurse #1 stated at around 7:20 PM, they observed Certified Nursing Assistant #1 grab Resident #1's right upper arm and roughly put Resident #1 in a regular chair in the hallway while Resident #1 was resisting. Licensed Practical Nurse #1 stated they felt it was abuse and they did not intervene, but gave Certified Nursing Assistant #1 a look, and Certified Nursing Assistant #1 went to care for other residents. Licensed Practical Nurse #1 stated at around 8:15 PM - 8:30 PM, they observed Certified Nursing Assistant #1 suddenly grab Resident #1's upper right arm, then Certified Nursing Assistant #1 reached over to a wheelchair and tried to forcefully get Resident #1 into the wheelchair. Licensed Practical Nurse #1 stated Resident #1 was still holding onto their rolling walker and did not want to sit in the wheelchair. Licensed Practical Nurse #1 stated Certified Nursing Assistant #1 forcefully repositioned Resident #1 in the wheelchair and wheeled Resident #1 to their room. Licensed Practical Nurse #1 stated they did not intervene because they were in shock. Licensed Practical Nurse #1 stated they returned to their medication cart that was by Resident #1's room and heard noise and a tapping (twice) sounds coming from Resident #1's room. Licensed Practical Nurse #1 stated they went into Resident #1's room and observed Resident #1 sitting on their bed while Certified Nursing Assistant #1 was holding both hands of Resident #1 and was pushing Resident #1 to lie down. Licensed Practical Nurse #1 stated Resident #1 continued to resist lying down. Licensed Practical Nurse #1 stated they instructed Certified Nursing Assistant #1 to stop, but Certified Nursing Assistant #1 continued pushing Resident #1 to lie down. Licensed Practical Nurse #1 stated they stood in Resident #1's room trying to calm Resident #1, but Resident #1 was not listening. Licensed Practical Nurse #1 stated Certified Nursing Assistant #1 ripped the pull-ups off Resident #1 and hit Resident #1 with a closed fist twice on their right upper thigh. Licensed Practical Nurse #1 stated they adjusted Resident #1's pull-ups and left the room. Licensed Practical Nurse #1 stated they left Certified Nursing Assistant #1 in the room with Resident #1 and closed the door. Licensed Practical Nurse #1 stated Certified Nursing Assistant #1 exited the room in 30 seconds to 1 minute. Licensed Practical Nurse #1 stated after 5 minutes not knowing what to do, they reported the incident to Registered Nurse Supervisor #1. During an interview on 09/25/2024 at 5:02 PM, Registered Nurse Supervisor #1 stated they were notified by Licensed Practical Nurse #1 at approximately 9:00 pm that between 8:15 PM and 8:30 PM, Licensed Practical Nurse #1 observed Certified Nursing Assistant #1 beating Resident #1. Registered Nurse Supervisor #1 stated Licensed Practical Nurse #1 also reported they stopped Certified Nursing Assistant #1 and assisted in providing care to Resident #1. Registered Nurse Supervisor #1 stated Licensed Practical Nurse #1 reported they were afraid, confused, hesitant, and did not know what to do. Registered Nurse Supervisor #1 stated Licensed Practical Nurse #1 also reported that earlier (7:20 PM) they saw Certified Nursing Assistant #1 forcefully drag Resident #1 out of the wrong room and Resident #1 was fighting back with Certified Nursing Assistant #1. Registered Nurse Supervisor #1 stated Licensed Practical Nurse #1 should have reported the first encounter. During an interview on 9/26/2024 at 10:51 PM, the Director of Nursing stated they were notified about an abuse incident between 9:30 PM and 10:00 PM by Registered Nurse Supervisor #1. The Director of Nursing stated they directed Registered Nurse Supervisor #1 to call the police and send Certified Nursing Assistant #1 home. The Director of Nursing stated Licensed Practical Nurse #1 did not intervene. The Director of Nursing stated Licensed Practical Nurse #1 should have separated Certified Nursing Assistant #1 when they first observed rough handling in the hallway. The Director of Nursing also stated Certified Nursing Assistant #2 could have stepped in and taken over for Certified Nursing Assistant #1. The Director of Nursing stated the charge nurses on the unit and supervisors are responsible for monitoring the units to ensure the residents are free from abuse. ___________________________________________________________________________ On 09/26/2024 at 06:25 PM, Immediate Jeopardy was identified and declared. The facility's Administrator and the Director of Nursing were notified. On 09/26/2024 at 10:48 PM, the facility presented a removal plan which listed the immediate action the facility would take to prevent serious harm from occurring or recurring. The removal plan was accepted. Based on observation, interview, and record review, as of 09/30/2024 at 3:15 PM, the removal plan was implemented, and Immediate Jeopardy was lifted based on the following corrective actions taken by the facility: Certified Nursing Assistant #1 was removed from the unit, relieved of duty on 09/16/2024 at 10:00 PM, and was terminated on 09/20/2024. 911 Police were called on 09/16/2024 at 10:06 PM. On 09/17/2024, a Quality Assurance Performance Improvement meeting was held. The abuse incident and actions to be taken were discussed. 0n 09/26/2024, all 12 residents on Certified Nursing Assistant #1's assignment were assessed for bruising by a Registered Nurse #1. There were no negative findings. Licensed Practical Nurse #1 was counseled on abuse prevention and reporting immediately. Licensed Practical Nurse #1 was suspended on 09/26/2024 post counseling. Certified Nursing Assistant #2 was counseled on abuse prevention and reporting immediately and was suspended on 09/26/2024. A Psychiatrist evaluated Resident #1 on 09/27/2024 and documented Resident #1 did not sustain any psychosocial harm. A Psychologist evaluated Resident #1 on 09/27/2024 at 5:12 PM, and recommendations were made for individual Psychotherapy to reduce emotional symptoms. The facility revised its policy on abuse prevention on 09/26/2024 to include a Registered Nurse/supervisor complete a full body assessment of the resident to determine injuries. The facility will monitor trends and/or patterns of occurrence via the Quality Assurance Committee to identify any potential incidents of abuse. The facility conducted all house in-service (classroom and via phone) from 09/26/2024 to 09/30/2024 on Abuse for F600 and F610 with 98% active staff in-serviced. Staff members who are furloughed will be in-serviced before returning to their shift. Interviews were done with several staff members: nurses, Certified Nursing Assistants, housekeeping/environmental staff, security staff, recreation staff, physical/occupational therapist, social workers, dietary staff, and administrative staff, and all were knowledgeable on the abuse prevention protocol, what do if they observe abuse, when to report, and who they should report to. 10 NYCRR 415.4 (b)(3)

Based on observation, record review, and interview during an Abbreviated and Partial Extended Survey (NY00354577), the facility's administration failed to ensure that the facility was operated in a manner that use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was evident in one out of six residents sampled (Resident #1). Specifically, on 09/16/2024, the facility did not intervene or remove Certified Nursing Assistant #1 from the unit resulting in further abuse to Resident #1. Administration failed to ensure in-service lesson plans provided guidance to facility staff on how to protect residents from suspected or witnessed abuse. The findings are: The facility's Policy and Procedure entitled, Abuse Prevention, with revision date 11/07/2022, documented residents will be protected from Abuse, Neglect, Mistreatment, Exploitation, or Misappropriation of resident property in accordance with State and Federal Regulations. The facility's in-service Lesson Plan on tips (14) for managing aggressive behavior did not include what staff should do or how staff should respond when resident abuse was witnessed. Resident #1 was admitted to the facility on [DATE] with diagnoses including Osteoarthritis (Inflammation of one or more joints), Osteoporosis (a condition when bone strength weakens and is susceptible to fracture), and Metabolic Encephalopathy (change in how your brain works due to an underlying condition). The Minimum Data Set (assessment tool), dated 08/13/2024, documented that Resident #1 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) and scored 10 out of 15, indicating moderately impaired cognition. A review of the Accident/Incident Occurrence Report dated 09/16/2024, documented time of occurrence 8:15 PM. Licensed Practical Nurse #1 reported that they witnessed in the hallway Certified Nursing Assistant #1 forcefully pull and guide Resident #1 by their right arm to sit in the wheelchair despite Resident #1 not wanting to sit down. Certified Nursing Assistant #1 made Resident #1 to sit in the wheelchair and wheeled them to their room. Licensed Practical Nurse #1 continued to hear noises from Resident #1's room and went into the room. Licensed Practical Nurse #1 observed that Resident #1 continued to resist Certified Nursing Assistant #1, did not want to stay into the bed, and was agitated. Certified Nursing Assistant #1 tried to change Resident #1's pull-up while Resident #1 resisted and kicked. Then, Licensed Practical Nurse #1 observed the Certified Nursing assistant hit Resident #1 on the thigh. Licensed Practical Nurse #1 called the Registered Nursing Supervisor #1. During interviews conducted from 09/25/2025 to 09/26/2024, multiple staff including Licensed Practical Nurse #1, stated that they did not know that they had to separate the victim from the abuser. During an interview on 9/26/2024 at 10:51 AM, The Director of Nursing stated Licensed Practical Nurse #1 should have separated Certified Nursing Assistant #1 when they first observed rough handling in the hallway. The Director of Nursing stated all staff received in-service on abuse prevention before the incident. The Director of Nursing stated that the charge nurses on the unit and supervisors are responsible for monitoring residents to prevent abuse. During an interview on 09/26/2024 at 12:13 PM,, the In-service Coordinator #1, stated the lesson plan did not include how facility staff would protect residents from suspected or witnessed abuse. The In-service Coordinator stated they'll do another in-service to address abuse and what staff should do when they suspect or witness residents' abuse. During an interview on 09/26/24 at 12:36 PM, the Administrator stated that all staff received mandatory in-service training regarding abuse prevention prior to the incident. The Administrator stated that nurses on the units, supervisors, and heads of departments are responsible for monitoring residents for abuse. The Administrator stated that Licensed Practical Nurse #1 acted appropriately in reporting abuse, but they should not have left Certified Nurse Assistant #1 in the room with Resident #1. The Administrator also stated that it was poor judgment from Licensed Practical Nurse #1 not to remove Certified Nursing Assistant #1 from Resident #1 in the hallway, which would have prevented abuse in Resident #1's room. 10NYCRR 415.26

Based on observations, record review, and interviews conducted during the recertification survey from 12/6/2023 to 12/13/2023, the facility did not ensure separately locked, permanently affixed compartments for storage of controlled drugs. This was evident for 1 (5th Floor) of 5 units observed for medication storage. Specifically, the Controlled Medications (CM) cabinet on the 5th Floor was observed with 1 lock that was not functional. The findings are: The undated facility policy titled Management of Current CM Records documented proper storage of CM is in a double door, double locked, double keyed, steel, wall mounted, cabinet. On 12/8/2023 at 10:33 AM, the medication storage room on the 5th Floor was observed in the presence of Licensed Practical Nurse (LPN) #2. The CM cabinet affixed to the wall had 1 locked closed inner door and 1 unlocked outer door that was ajar. LPN #2 attempted and was unable to lock the outer door of the CM cabinet. LPN #2 stated the lock on the CM cabinet was broken. The inner compartment of the CM cabinet contained 1 medication blister pack with 24 capsules of Pregabalin (25mg). LPN #2 was interviewed on 12/8/2023 at 10:50 AM and stated the lock on the CM cabinet had been broken since 12/7/2023 and provided a maintenance request /work order dated 12/7/2023 that documented the first door of the CM cabinet was not functional. On 12/8/2023 at 1:00PM, the Director of Nursing (DON) was interviewed and stated the lock was fixed 12/8/2023. 10 NYCRR 415.18(d)

Based on observations, interviews, and record review conducted during the recertification survey from 12/6/2023 to 12/13/2023, the facility did not ensure food was stored according to professional standards for food safety. This was evident for 1 (5th Floor) of 10 floor unit pantries observed during Kitchen review. Specifically, the pantry refrigerator was above 41 degrees Fahrenheit (F) and contained undated and unlabeled food. The findings are: The undated facility policy titled Floor Pantry Refrigeration documented that for optimal conditions of refrigeration, the temperature should be maintained between 36-40 degrees. All foods/snacks will be identified with the residents ' name, room number, labeled content, date, and covered before being refrigerated. Nursing staff will check refrigerators daily to remove any leftover food items, snacks, etc. that are more than 24 hours. On 12/8/2023 at 12:00 PM, the 5th floor pantry refrigerator was observed in the presence of Registered Nurse Supervisor (RNS) #1. The internal temperature of the refrigerator was 56 F. The refrigerator contained 1 unlabeled and undated container of ribs and rice. On 12/8/2023 at 12:15PM, RNS #1 was observed completing a maintenance request/work documenting the pantry refrigerator temperature was 56 F. On 12/11/2023 at 11:03 AM, RNS #1 was interviewed and stated the pantry refrigerator had been replaced. On 12/8/2023 at 1:00PM, the Director of Nursing (DON) was interviewed and provided a copy of the maintenance request/work order that the pantry refrigerator was replaced 12/11/2023. 10 NYCRR 415.14(h)

Based on observation, interview, and record review conducted during the recertification survey from 12/6/2023 to 12/13/2023, the facility did not ensure that each resident was treated with respect and dignity. This was evident for 1 (Resident #256) of 38 total sampled residents. Specifically, Licensed Practical Nurse (LPN) #2 and Certified Nursing Assistant (CNA) #1 were observed standing over Resident #256 while feeding them. The findings are: The facility policy titled Feeding the Resident dated 10/2023 documented staff should be sitting down facing the resident while feeding. On 12/6/2023 at 12:02 PM, LPN #2 was observed in the 5th Floor dining room standing over Resident #256 while feeding them during the lunch meal service. On 12/8/2023 at 12:00PM, CNA #1 was observed in the 5th Floor dining room standing over Resident #256 while feeding them during the lunch meal service. On 12/8/2023 at 12:15PM, CNA #1 was interviewed and stated they stood over the residents for a short time while feeding them to see if the resident likes the food. Then CNA #1 would sit down to feed the resident. On 12/11/2023 at 10:45AM, LPN #2 was interviewed and stated they stood over Resident #256 while feeding them because it was uncomfortable to feed Resident #256 since the resident was in a high-back wheelchair. On 12/11/2023 at 10:58 AM, Registered Nurse Supervisor (RNS) #1 was interviewed and stated they educated CNA #1 regarding being seated while feeding residents. 10 NYCRR 415.3(d)(1)(i)

Based on record review and staff interview conducted during the Recertification survey from 12/6/2023 to 12/13/2023, the facility did not ensure Minimum Data Set 3.0 (MDS) assessments were electronically transmitted to the Centers of Medicare/Medicaid Services Data System (CMSDS) within 14 days of completion. This was evident for 1 (Resident #138) of 17 residents reviewed for resident assessment out of 38 total sampled residents. Specifically, Resident #138's MDS assessment was not transmitted within 14 days of completion. The findings are: The facility policy titled MDS dated ,d+[DATE] documented all MDS assessments must be transmitted in a timely manner. The MDS assessment for Resident #138 with completion date of 3/21/2023 was not transmitted to CMSDS until 4/7/2023, more than 14 days after completion. On 12/11/2023 at 10:43 AM, the MDS Coordinator (MDSC) was interviewed and stated they were the only staff member responsible for submitting MDS assessments to the CMSDS. The MDSC checked the dashboard of the electronic medical record (EMR) every day to monitor if any MDS assessments were for completion and submission. Completed MDS assessments were submitted 3 times weekly even when the MDSC went on vacation. The MDSC stated they were unable to recall the reason Resident #138's MDS assessment from 3/2023 was not submitted timely. On 12/11/2023 at 11:09 AM, the Administrator was interviewed and stated the MDSC reported to the Administrator if there were concerns with completing and submitting the MDS timely. The Administrator was not aware of any late submissions of MDS assessments. 10 NYCRR 415.11(a)(5)

Based on record review and interview conducted during the recertification survey from 12/06/2023 to 12/13/2023, the facility did not ensure that the Minimum Data Set 3.0 (MDS) assessment accurately reflect the resident status. This was evident for 2 (Resident # 342 and # 80) of 38 total sampled residents. Specifically, 1) the MDS assessment for Resident # 342 did not accurately capture their discharge to the community, and 2) the MDS assessment for Resident # 80 did not accurately capture behaviors of refusal and rejection of care and treatment. The findings are: 1.) Resident # 342 had diagnoses of Diabetes Mellitus and Malignant Neoplasm of Bronchus and Lung. The MDS assessment dated [DATE] documented Resident #342 had an anticipated planned discharge to the hospital. Social Work Note dated 10/09/2023 documented Resident #342 wa discharged to their home in the community on 10/9/2023. The Discharge Summary dated 10/30/2023 documented Resident #342 was prepared for discharge home with their family on 10/9/2023. There was no documented evidence Resident #342's discharge MDS assessment accurately documented the resident's discharge status to the community. 2.) Resident # 80 had diagnoses of renal insufficiency and hemodialysis. The MDS assessment dated [DATE] documented Resident #80 was cognitively intact and did not reject care. The Medication Administration Record (MAR) dated 10/28/2023 to 11/03/2023 documented Resident #80 refused medication administration 4 times on 10/28/2023, 4 times on 10/29/2023, and 2 times on 11/01/2023. Nursing Note dated 10/28/2023 documented Resident #80 refused to go to hemodialysis treatment that morning. There is no documented evidence Resident #80's refusal of care was accurately documented on the MDS assessment dated [DATE]. An interview was conducted on 12/12/2023 at 11:21 AM with MDS Assessor #1 who stated they review 7 days of notes and MAR prior to the assessment reference date of an MDS assessment to accurately capture a resident's behavior. Resident #80's refusal of care should have been captured on their MDS assessment. The MDS Coordinator was interviewed on 12/08/2023 at 11:43 AM and stated they reviewed medical records and spoke with staff to ensure MDS assessment accuracy. The electronic medical record had a pop-up window signaling when a resident was discharged and the MDS Coordinator cross referenced the dates and disposition with gathered information. The MDS Coordinator stated it was important for a resident's status to be accurately reflected in the assessment. 10 NYCRR 415.11(b)

Based on observation and interview, during the recertification survey, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety to prevent foodborne illness. Specifically, staff were observed not wearing hairnets appropriately while in the kitchen. This was evident during the Kitchen facility task. The findings are: On 10/14/21 at 10:54 AM, a Dietary Aide loading meal trays was observed with a hair restraint covering hair down to eye level and loose hair approximately 4 inches in length to the back of the head which was not covered by a hair restraint. On 10/14/21 at 11:05 AM, the Food Service Supervisor (FSS) was observed in the kitchen near the trayline with loose hair approximately 3 inches in length which was not covered by a hair restraint. On 10/14/21 at 11:29 AM, Dietary Aide #1 was observed entering the kitchen and walking through the kitchen while not wearing a hair restraint. On 10/19/21 at 11:05 AM, Dietary Aide (DA) #1 an interview was conducted with DA #1. DA #1 stated that their responsibilities included serving lunch to staff and to residents when they eat in the lunch room. DA #1 also stated that staff will need to wear hairnet when coming into the kitchen. DA #1 further stated that hairnets are not always available in the hairnet dispenser located on the wall by the main entrance, and that it may be stored in the storage room which is located on the other side of the kitchen. DA #1 stated they received in-service on hairnets a week ago. On 10/19/21 at 11:10 AM, the Food Service Supervisor (FSS) was interviewed. The FSS stated their responsibilities include supervision of the dietary staff and ensuring that they are wearing appropriate uniforms and hairnets. The FSS also stated their own hair probably fell out of the hairnet so now they are using a ponytail. The FSS also stated that the dietary aide was provided a ponytail holder to contain their hair. The FSS further stated that staff have been provided monthly in-service on wearing hairnets in the kitchen and stated that the last in-service was provided a month or two ago. On 10/19/21 at 11:25 AM, the Food Service Director (FSD) was interviewed. The FSD stated that all new staff are provided with an orientation including infection control, handwashing, hairnet/hats. The FSD also stated that hair should always be covered when in the kitchen and DA #1 is aware of the hair restraint policy and the location of the hair restraints in the kitchen. The FSD stated that it is the responsibility of the supervisor to make sure all hairnets are in place. 415.14 (h)

Based on record review and interviews conducted during the Recertification survey, the facility did not ensure that a resident/resident representative was invited to participate in care plan meeting. Specifically, residents/representatives were not invited to the quarterly care plan meeting. This was evident for 3 out of 4 residents reviewed for Care Planning out of an investigative sample of 38 residents (Residents #176, #247, & #285) The findings are: The facility policy & procedure titled Invitation to Resident or Family-Comprehensive Care Plan Meeting revised 11/16/2018 documented that it is the policy of Hillside Manor Rehabilitation and Extended Care center that when any competent resident, is scheduled to be discussed at CCP for initial, annually or when a significant change occurs, they will be invited to the meeting. For residents who are unable to represent themselves, appropriate family member or significant other must be invited to that meeting. 1. Resident #176 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS dated [DATE] documented that Resident #176 had intact cognition and did not reject care. The MDS also documented Resident # 176 participated in assessment and has no guardian or legally authorized representative. On 10/12/21 at 02:05 PM, an interview was conducted with Resident #176. Resident # 176 stated they were not invited to any care plan meeting since their admission to the facility on [DATE]. Resident #176 also stated that they made decision for themselves. The Social Worker note for Admission/CCP (Comprehensive Care Plan) Adjustment Note on 7/21/21 documented family and resident were invited to participate in the care plan meeting over the phone. The Social Worker note for Significant Change care plan meeting on 8/25/21 documented family was invited to participate in meeting. The Social Worker note for Quarterly Review of Comprehensive Care Plan on 10/6/21 did not document that Resident #176 or a representative had been invited to participate in the CCP meeting. The Team Meeting Members' Signature/Meeting table contained no signature for either Resident #176 or their representative for CCP meeting held on 10/6/21. On 10/14/21 at 11:55 AM, an interview was conducted with Registered Nurse Supervisor (RN) #4. RN #4 stated that residents and/or representatives and interdisciplinary team (IDT) including nurse, rehab staff, dietitian, social worker (SW), recreation staff were invited to the initial, significant change, and annual care plan meetings. RN #4 also stated they were not sure if resident and/or representatives were invited to quarterly care plan meetings. RN #4 further stated the Social Worker notifies the residents and/or representatives about the care plan meeting. RN #4 stated Resident #176 was cognitively intact and able to make decision, and cognitively intact residents are invited to care plan meetings. 2. Resident #285 was admitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented that the resident'had moderate cognitive impairment. On 10/13/2021 at 11:25 AM, Resident #285 was interviewed. Resident #285 stated that they nor their family had been invited to any meeting to discuss the resident's care. Quarterly Care Plan meetings dated 03/27/2020,06/20/2020, 06/25/2021 and 09/24/2021 documented that the family was not invited to this meeting and the family was not in attendance at this meeting. The CCP dated 12/24/2020 (annual meeting) documented that the family or the legal representative was invited to this meeting. There were no documented evidence the resident or their representative participated in the meeting. On 10/14/2021 at 12:14 PM, Social Worker (SW #2) was interviewed. SW #2 stated that care plan meetings were held quarterly, annually, and for significant changes. SW #2 also stated that the families were only invited to the annual, the significant change, the admission meetings and not the quarterly meetings. 3. Resident # 247 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) dated [DATE] documented that resident was moderately cognitively impaired and resident and family/significant other participated in assessment. On 10/13/2021 at 1:02 PM, Resident #247 was interviewed and stated that they had not been invited to participate in care planning meetings. The document titled Haven Manor Rehabilitation and Extended Care Team Related Activities documented Comprehensive Care Plan (CCP) meetings were held on 1/04/2021, 4/5/2021, 6/28/2021 and 9/20/2021. The form documented that the resident/designated representative were invited to participate in the meeting on 4/5/2021, 09/20/2021 and did not attend the meeting. There was no documented evidence that resident or their resident representative was invited to participate in either the 1/4/2021 or the 6/28/21 care plan meeting. On 10/14/21 at 03:49 PM, the Social Worker (SW) #1 was interviewed. SW #1 stated that care plan meetings were held for admission, quarterly, significant change and annually. SW #1 also stated that interdisciplinary team members (IDT) attended all the care plan meetings and residents and/or representatives were only invited to initial, significant change, and annual care plan meeting as attendance at quarterly meetings was not mandatory. On 10/15/21 at 09:45 AM, the Director of Social Services (DSS) was interviewed. The DSS stated that residents and/or representatives were invited to attend initial, significant change and annual care plan meetings. The DSS also stated the facility did not invite residents and/or representatives to quarterly care plan meeting as it was not mandatory to do so. The DSS further stated only the IDT were invited to the quarterly care plan meeting. DSS stated the residents and/or representatives could request the care plan meeting anytime if they wanted it. On 10/18/2021 at 04:09 PM, an interview was conducted with the Registered Nurse Supervisor (RNS) #2. RNS #2 stated that for the quarterly assessments the team meets without the resident or family. 415.11(c)(2) (i-iii)

Based on observations and interviews conducted during the Recertification survey, the facility did not ensure that housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior were provided. Specifically, torn privacy curtain, peeling wall paper, and a soiled feeding tube pole was observed. This was evident on 2 of 8 units during Environmental rounds. (Unit 2 and Unit 3) The findings are: 1.The following observations were made on Unit 2: On 10/13/2021 at 08:46 AM, 10/14/2021 at 12:57 PM and 10/18/2021 at 10:11 AM, Room #209 was observed. The privacy curtain for the bed closest to the door contained 5 holes that were about 1 inch in length in the white netting area of the green privacy curtain; On 10/14/2021 at 01:00 PM, 10/15/2021 at 03:59 PM and 10/18/2021 at 10:54 AM, Room 212 was observed. The wallpaper under the light was observed to be peeling and was approximately 18 inches in length. In addition, on the top of the wall to the right of resident's closet, the wallpaper was observed to be peeled approximately 6 to 8 inches in length. On 10/18/2021 at 10:13AM, an interview was conducted with the Certified Nursing Aide (CNA) #6 who was providing care for the residents in Room 209. CNA #6 stated that the curtain had holes in it after it was brought back from washing when it was changed. CNA #6 also stated that they would report any concerns to the nurse. On 10/18/2021 at 10:16AM, Registered Nurse (RN) #3 was interviewed. RN #3 stated that they do rounds every 30 minutes on the unit and do an environmental check for dangers or hazards. RN #3 also stated that they look at the curtains but had not noticed this curtain. RN #3 further stated that the privacy curtain needs to be changed and they would call housekeeping for a replacement. On 10/18/2021 at 10:21AM, Housekeeper (HK) #1 was interviewed. HK#1 stated that they look at the privacy curtains once every 15 days. If they are missing hooks, they tell their supervisor. HK#1 also stated that the curtain needs to be replaced as the curtain has a hole in it. On 10/18/2021 at 10:43 AM, the Director of Housekeeping (DOH) was interviewed. The DOH stated that they do rounds daily looking for room cleanliness, uniformity, privacy curtains, trash, and ceiling tiles. The DOH also stated that sometimes, a resident will pull the curtain and it causes the problem of curtains being torn. The DOH further stated that the curtain needs to be changed due to having a hole in the net and it is an older curtain. On 10/18/2021 at 10:56AM, CNA #7 who was assigned to the resident in Room 212 was interviewed. CNA #7 stated facility staff had started changing the wallpaper in the facility a few months ago and had not gotten to the resident room yet. CNA #7 also stated that if we see something wrong, we put it in the maintenance book. On 10/18/2021 at 11:01AM, RN #3 assigned to Unit 2 was interviewed. RN #3 stated that they did not notice the wallpaper peeling off. RN #3 also stated that the facility was doing beautification on the unit in August or September this year and they were checking the walls in the hallway but nothing had been done with the wallpaper in the resident rooms. 2. The following observations were made on Unit 3: On 10/12/2021 at 09:53AM, 10/14/2021 at 03:21PM, 10/15/2021 03:48PM and 10/18/2021 at 12:43PM, Room # 312 was observed with the wall to the right of the headboard was noted with rips in the wallpaper in 3 areas with 2 holes in the wallpaper exposing the wall underneath. The enteral feeding pole legs were noted with cream colored stain on all 4 legs. On 10/18/2021 at 11:05AM, the Maintenance Worker (MW) was interviewed. The MW stated that the wallpaper is a special project and the resident needs to be out of the room. They MW also stated that they have not participated in the wallpaper project recently. The MW further stated the wallpaper is not acceptable due to tearing and being loose on wall. On 10/18/2021 at 12:47PM, RN #6 was interviewed. RN #6 stated that the evening shift nurses do the residents enteral feeding, and they look at the enteral feeding pole daily. RN #6 also stated that during rounds of the resident's room they look at the wall, air conditioning (AC) unit and resident's oxygen. RN #6 further stated they did not notice the enteral feeding pole was dirty and the pole should be cleaned daily to prevent possible infection due to resident has a [CONDITION(S)] tube. On 10/18/2021 at 12:55 PM, Housekeeper (HK) #2 assigned to Unit 3 was interviewed. HK#2 stated that they check the enteral feeding pole daily when they work, clean the room first and then they clean the pole. HK #2 also stated that they cannot leave it in that condition as it needs to be cleaned. HK #2 further stated that they have noticed the residents wall is chipped and cannot recall how long it has been that way. On 10/19/21 at 03:22 PM, the Director of Housekeeping (DOH) was interviewed. The DOH stated that their responsibility is to ensure that the facility is kept in a clean manner. The DOH also stated that they conduct rounds on every unit, every day. The DOH further stated that housekeeping staff is responsible for cleaning the feeding pump pole and pump and these should be cleaned whenever spillage is observed. The DOH stated staff are in-serviced every month or two. 415.5(h)(2)

Based on observation and staff interviews conducted during the Recertification survey, the facility did not ensure that it maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections was maintained. Specifically, (1) a resident with an indwelling catheter was noted to have the urine collection bag touching the floor or floor mat, and (2) a resident receiving oxygen therapy via nasal cannula tube was observed with tubing on the floor. This was evident for 2 random infection control observations on 2 out of 8 resident units. (Unit 2 and Unit 4) The finding is: The facility policy and procedure titled Care of Resident with Suprapubic Cystostomy Catheter effective 1/15/2003 documented the drainage tube must never be allowed to contact the urine in the collection bag. The undated facility policy and procedure titled Foley Catheter Insertion-Maintenance-Removal documented the drainage bag should be positioned below level of the bladder but never touch the floor. The facility policy and procedure titled Oxygen Therapy Using Oxygen Concentrator revised on 10/2019 documented change nasal cannula/mask every 72 hours and as needed, date when applied and keep cannula/mask in plastic bag when not in use. 1). Resident #171 was admitted to the facility with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) dated [DATE] documented Resident #171 was severely impaired and required extensive assistance of 2 persons for toileting. The MDS also documented that the resident had an indwelling catheter and was always incontinent of bowel and bladder. On 10/12/2021 at 2:30PM, 10/14/2021 at 09:17AM, 10/14/2021 at 11:46AM, 10/14/2021 at 04:54PM, 10/15/2021 at 10:36AM and 10/18/2021 at 09:17AM the urinary catheter collection bag for Resident #171 was observed touching the floor or the fall mat on the right side of the resident's body while hanging from the lower bed frame. The Comprehensive Care Plan (CCP) for indwelling catheter secondary to [CONDITION(S)] bladder [CONDITION(S)] effective 8/17/2021 documented interventions which included observe for signs of infection, maintain infection control practices such as care of catheter, tubing, and collection bag. Review of medical records documented that Resident #171 was diagnosed with urinary tract infection on 5/31/2021 and was hospitalized in 07/31/2021 with a urinary tract infection. On 10/18/2021 at 09:22 AM, Certified Nursing Assistant (CNA) #5 was interviewed. CNA #5 stated they drain the urinary drainage bag when it is full in the morning and they check again before they leave for the shift. CNA #5 also stated that they have had training on urinary catheter, and they make sure that they foley does not touch the floor and keep it clean. CNA #5 also stated that anytime they check the resident, they make sure it is not touching the floor and not spilling as the urine collection bad should not be touching the ground because of infection control. On 10/18/2021 at 11:18 AM, Registered Nurse Supervisor (RNS) #2 was interviewed. RNS #2 stated that they conduct rounds 3-4 times a day and they observe the resident's catheter placement. RNS #2 also stated the urine collection bag should not be touching floor or floor mats due to infection control infection control. RNS #2 further stated that catheter care is usually discussed in morning huddles at the beginning of the shift. On 10/19/2021 at 01:15PM, the Infection Preventionist (IP) was interviewed. The IP stated that they do rounds weekly and urine collection bags should not be touching the floor or fall mat. 2). Resident #290 was admitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS dated [DATE] documented resident #290 was moderately cognitively impaired, required total assistance with all activity of daily living with 1 to 2 persons assist and had impairment on upper and lower extremities on both sides. The MDS also documented that the resident received Oxygen therapy. On 10/12/2021 at 04:20PM and 10/18/2021 at 11:51AM, the oxygen tubing attached to the nasal cannula for Resident #290 was observed touching the floor. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/18/2021 at 02:56PM, an interview was conducted with CNA #4. CNA #4 stated the oxygen tubing should not touch the ground and they check on the oxygen tubing many times during their shift. CNA#4 also stated that they have had training in the last year for residents using oxygen. On 10/18/2021 at 03:00PM, an interview was conducted with RN #1. RN#1 stated they do rounds in the morning, at the end of their shift during shift change to see if the oxygen tubing is on the ground and check the position of the tubing when doing oxygen treatments. RN#1 also stated that during morning report they tell staff to check to make sure oxygen tubing is not on floor for infection control and patient safety. On 10/19/2021 at 03:31PM, the Director of Nursing (DON) was interviewed. The DON stated they do daily rounds and oxygen tubing should not be touching the floor at any time. The DON also stated that the Infection Preventionist participates in Quality Assurance Process Improvement checks to make sure that oxygen tubing is not on the floor and does competencies on the nurses. The DON further stated that the night supervisors do quality control of residents on oxygen and make sure the oxygen tubing is not on the floor. 415.19 (b) (4)

Based upon observation, interview, and record review, conducted during the Recertification survey, the facility did not ensure it provided an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. This was evident for 2 of 6 residents reviewed for Activities out of a sample of 38 residents. (#209 and #224) The finding is: The facility policy & procedure titled Sensory Program/Live Music Program created 1/27/21, documented the Recreation department has a sensory cart that travels from unit to unit designed specifically to work with those residents who have dementia or other condition which limits the cognitive ability. The policy also documented that the department also employees a musician who provides both group and personal music and the Recreation department will identify residents who would benefit from sensory program. The policy also documented the Recreation department will ensure that sensory cart and live music are part of the monthly programming calendar and the recreation staff will record each visit on the resident's individual participation record and ensure that sensory program/musical visits are documented on resident's ongoing assessment/care plans. The undated facility policy & procedure titled Care of Residents with Dementia, documented that it is the policy of the facility to address the needs of residents with Dementia and the behavior associated with it through a structured, interdisciplinary management plan. The policy also documented the Recreation Department will provide activities to meet the resident's individual needs. 1.Resident #209 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognitive skills for daily decision making. On 10/12/21 at 09:43 AM, 10/13/21 at 08:40 AM, 10/13/21 at 11:27 AM, 10/13/21 at 12:25 PM, 10/14/21 at 11:54 AM, 10/14/21 at 02:04 PM, 10/14/21 at 04:25 PM, 10/15/21 at 09:48 AM, 10/15/21 at 02:57 PM, and 10/19/21 at 10:05 AM, Resident #209 was observed lying in bed or in a wheelchair in the room or hallway and was not engaged in any activity. No activity calendar, radio, or indications of religious/spiritual items were observed in the resident's room. On 10/18/21 at 10:55 AM, Resident #209 was observed in the day room sitting at a table with plastic screws/bolts in a container. Recreation Leader was not observed engaging with resident or encouraging resident to participate in the activity. The Comprehensive Care Plan dated 1/8/21 for Resident is unable to make daily preferences known; information provided by resident representative documented preferences included newspapers & magazines, music, television, group programs, religious/spiritual practices and that the resident's religious affiliation was Muslim. Goals included resident will pursue religious practices, be exposed to a variety of group activities, and receive personal visits, including 1:1 cultural visits 1x a week. Interventions included provide monthly calendar of events, assist in finding programs of interest, invite/escort to activities of choice/interest: music, provide personal visits. The Recreation Department Initial assessment dated [DATE] documented the resident's interest/preferences prior to admission were television, movies, games (cards), listening to music, daily news; group activities: music, spiritual/religious programs, cultural visits. The Recreation Department Quarterly Note dated 8/30/21 documented the resident preferred activities in own room/on unit, in small groups, needed escort to/from program area, and was unable to express choices. The note also documented the resident observes, does not participate, and receives sensory visits from recreation staff. The Recreation Department Monthly Participation Record dated September 2021 documented live music attended 4 out of 30 days; personal visit 14 out of 31 days; sensory visit 4 out of 30 days. The Recreation Department Monthly Participation Record dated October 2021 documented live music with attended 1 time out of 19 days; sensory visit 2 times out of 19 days; virtual music entertainment 1 time out of 19 days. On 10/15/21 at 03:00 PM, Certified Nursing Assistant (CNA) #11 was interviewed. CNA #11 stated that Resident #209 does not understand English and just responds yes, yes when spoken to. CNA #11 also stated that the resident goes to the day room twice a week and watches what is going on but does not actively participate in activities. On 10/18/21 at 03:01 PM, Recreation Leader (RL) #1 was interviewed. RL #1 stated activities provided for Resident #209, include live music 1:1 once per week, and another recreation leader does sensory activity once a week. RL #1 also stated that other recreation leaders visit on Fridays for Indian culture visits (music, religious images, general Indian culture). RL #1 further stated that residents with dementia are provided with music the resident likes or they talk with them about the past and provide gentle touch. RL#1 stated that Resident #209 mostly receives 1:1 activities as resident does not really come out of their room and does participate in Facetime calls with family. 2. Resident # 224 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS dated [DATE] documented the resident with severely impaired cognitive skills for daily decision making. On 10/12/21 at 09:56 AM, 10/12/21 at 03:20 PM, 10/13/21 at 08:46 AM, 10/13/21 at 11:32 AM, 10/13/21 at 12:27 PM, 10/14/21 at 08:35 AM, 10/14/21 at 11:55 AM, 10/14/21 at 02:01 PM, 10/14/21 at 03:32 PM - 10/14/21 at 4:24 PM, 10/15/21 at 09:49 AM, 10/15/21 at 02:55 PM, 10/15/21 at 03:13 PM, and 10/18/21 at 10:25 AM, Resident #224 was observed lying in bed or in a wheelchair in the room or hallway and was not engaged in activities. On 10/15/21 at 10:02 AM, Recreation Leader #1 came to unit and entered the day room. No activity calendar, radio, or indications of religious/spiritual items were observed in the resident's room. The Comprehensive Care Plan for resident is unable to make daily preferences known, revised 8/27/21 documented the resident's representative stated the resident likes newspapers, magazines, music, doing things with groups of people, television, religious/spiritual practices. Goals included resident will attend programs of interest, pursue religious practice, express satisfaction with type/level of activity involvement when asked, be exposed to a variety of group activities, receive personal visits, accept, and respond to 1:1 visits 2x a week. Interventions included provide monthly calendar of events, assist resident in finding programs of interest, invite/escort to music, and provide personal visits. The Recreation Department Quarterly Update dated 8/27/21 documented resident referred activities in their own room, was unable to express preferences, does not participate/provided with scheduled visits, attends/participates in scheduled activities music live virtual and receives sensory stimulation. The resident was visited for sensory stimulation as well as escorted to music programs off unit for a change in scenery. The Recreation Department Monthly Participation Record September dated 2021 documented live music 3 days out of 30, Personal visit 17 days out of 30, sensory visit 3 days out of 30. The Recreation Department Monthly Participation Record October dated 2021 documented live music 2 days out of 19, sensory visit 2 days out of 19. On 10/18/21 at 11:38 AM, CNA #10 was interviewed. CNA #10 stated that the resident is taken out of bed after breakfast. CNA #10 also stated they they are a floater and noticed that the resident's remote control had no batteries and they reported this to the nurse. On 10/18/21 at 03:12 PM, Recreation Leader (RL) #1 was interviewed. RL #1 stated there is live music, and sensory stimulation once week. RL #1 also stated that sometimes on the weekend, an activity leader goes individually to each resident with a tablet for music and church services to ask if they want to do it. RL#1 stated Resident #224, was provided with a tablet to play music, or turn on the television but they were not sure what sensory devices were available in the resident's room. On 10/15/21 at 03:29 PM, RL #2 stated that they go to the unit for live music activity. RL #2 also stated that activities are done in the day room, and there are also room visits sometimes. On 10/19/21 at 10:12 AM, the Director of Activities (DA) was interviewed. The DA stated that the Recreation Department tried to identify residents who are isolated, have low cognitive ability, and creates a list/groups of residents who fit that category. The DA also stated that all staff are responsible for visits on their unit and some staff go unit by unit by their specialty, such as sensory or music. The DA further stated that staff use past interests for residents with dementia. For spiritual/religious needs, facility provides copies of various items, such as Jehovah Witness Watchtower and Daily Bread. On Friday during Indian Culture visits, recreation staff will make copies of images and sayings to distribute and/or use an iPad to play cultural music or services. The DA stated if the resident does not speak English and no staff member speaks the specific language, communication is through music. 415.5(f)(1)

Based on record review and interviews conducted during the Recertification survey from the facility did not ensure that a resident's assessment was accurate. Specifically, the Minimum Data Set (MDS) 3.0 assessment inaccurately documented that a resident received insulin injections. This was evident for 1 out of 1 resident reviewed for Resident Assessment out of an investigative sample of 38 residents. (Resident #194) The findings are: The facility policy & procedure titled MDS 3.0 revised 10/2020 documented that it is the policy of Hillside Manor Rehabilitation and Extended Care to ensure accurate and timely completion of MDS, CAA and CCP for all residents. Resident #194 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/12/21 at 03:21 PM, Resident #194 was interviewed. Resident #194 stated they did not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS dated [DATE] documented that Resident #194 had intact cognition. The MDS did not document that Resident #194 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Reconciliation Assessment History Form dated 8/16/2021 for Resident #194 did not include insulin on the list. The Physician admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/14/21 at 02:17 PM, an interview was conducted with Registered Nurse (RN) #7. RN #7 stated they had administered medications to Resident #194 for the past 2 weeks and they had not administered an insulin injection to the resident. RN #7 also stated Resident # 194 did not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/14/21 at 02:51 PM, an interview was conducted with the MDS Assessor (MDSA). The MDSA stated they collected data for the Admission MDS assessment by reviewing the hospital discharge summary, doing resident observation, and interviewing the resident and staff. Staff # 15 stated they were responsible for completing Sections I and N in the others among others. The MDSA stated that they observed that the resident was receiving [MEDICATION(S)] injections and thought the injection in section N of MDS was referring to [MEDICATION(S)] and did realize the section referred to insulin injection. The MDSA stated that insulin injections was coded in error. On 10/18/21 at 09:15 AM, the MDS Coordinator (MDSC) was interviewed. The MDSC stated that each MDS nurse needed to do 5 to 6 MDS assessments in a day on average. The MDSC also stated that the MDS nurses review the hospital discharge summary, assess the residents, and interview residents and staff to collect data for the Admission MDS assessment. The MDSC further stated that the MDS nurses were professional registered nurses and are responsible for reviewing the accuracy of the MDS assessment after completion. The MDSC stated that they mainly check the completion and signature of MDS assessments before it is submitted. 415.11(b)

Based on interviews and record review conducted during Recertification and Complaint investigations (NY 949 & NY 625), the facility did not ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the State Survey Agency. Specifically, the facility did not report incidents of unknown origin, resulting in a fracture, to the New York State Department of Health (NYSDOH) within 2 hours. This was evident for 2 of 3 residents reviewed for Abuse out of a sample of 38 residents. (Resident #494 and Resident #395). The findings are: The facility policy and procedure titled Abuse Prevention Program revised April 9th, 2018, documented that all alleged or suspected incidents of abuse, neglect, mistreatment, exploitation, or misappropriation of resident's property will be thoroughly investigated, and findings documented in a report format. The policy also documented that any case, in which abuse, neglect, mistreatment, exploitation, or misappropriation of resident's property will be identified via the investigation, will be reported promptly to the State of New York Department of health via the Health Commerce System (HCS) for further investigation. 1.Resident # 494 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented that resident had severely impaired cognition and had no behavioral symptoms exhibited. The MDS also documented that resident had not rejected care and had not exhibited any wandering behavior. An Incident/Accident report dated 07/05/20 documented that on 07/05 20 at 1:30 PM, Registered Nurse was called by staff, to see resident who was noted with swelling and discoloration to inner and outer aspect of the left hand and complaining of (c/o) pain upon touching. Ice packs were applied and pain management in progress. The investigation findings documented that resident stated in Spanish and English, that a new girl pulled my hand', showing left hand, while in the bathroom on [NAME] (Saturday) morning, because she wants to have breakfast but also need to go to the bathroom. Resident was shown clear pictures of all assigned staff x 3 shifts but unable to point specific staff, stated that 'they are all her children'. Radiology report dated 07/06/20 of the examination of the left hand for Resident # 494, documented Comminuted Fracture of the proximal phalanx of the ring finger. The Health Electronic Response Data System (HERDS) Data Entry report documented that the incident occurred on 07/04/20 at 1:30PM and was reported on 07/06/20 2:32PM, via the Health Commerce System, 24 hours after the incident. On 10/18/21 at 10:17 AM, the Assistant Director of Nursing (ADON) was interviewed. The ADON stated they conducted an interview with the resident following the incident. The ADON also stated that the supervisor is responsible for completing the initial report, then both the ADON and the DNS would complete the facility's investigation. The ADON further stated that they are not involved in reporting to HERDS as this is done by the Director of Nursing after they complete the investigative summary. On 10/18/21 at 10:36 AM, Licensed Practical Nurse (LPN) #1 worked on 07/04/20 and 07/05/20 was interviewed. LPN #1 stated that they recalled that the resident's hand was swollen, and that the resident was in the chair and when the Certified Nurse's Assistant (CNA) called them. LPN#1 then called the supervisor because the resident had an injury, as the supervisor will then get statements from all the other staff and do the investigation. On 10/18/21 at 03:00 PM, Certified Nursing Assistant (CNA)#12 who worked on the 7-3 shift on 07/05/20 was interviewed. CNA #12 stated that initially the resident refused care, so they then went to tend to other residents and prior to going to lunch, went back to assist the resident with care. CNA #12 also stated that upon returning to the unit, they went to toilet the resident, and as they were about to hold the resident's hands, the resident said that their hands were hurting. CNA #12 observed the discoloration on the left hand and called the nurse. On 10/19/21 at 10:03 AM, CNA #3 who worked the 7-3 shift on 07/4/20 was interviewed. CNA #3 stated that when they arrived on the unit, the resident was out of bed and in the wheelchair. CNA #3 stated the resident can wheel themselves and was toileted around 9 AM and 1:15 PM and attended activities around 1:45 PM. CNA #3 stated that the resident did not voice any complaints and they did not observe any injury to the resident. 2. Resident #395 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Readmission Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented resident had severely impaired cognition with no behaviors. The MDS also documented the resident required total assistance with activity of daily living of 1 or 2 persons and was receiving Occupational and Physical Therapy. The Discharge Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #395 had severely impaired cognition with no behaviors. The resident required total assistance x1 or 2 persons. Resident required extensive assistance with activity of daily living (ADL)diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing Progress Notes dated 09/19/2019 to 02/06/2020 documented no accident/incidents for Resident #395. The Monthly physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The Accident/Incident (A/I) Report initiated on 2/14/2020 at 05:30 AM, documented the Certified Nursing Assistant (CNA) noticed during care that resident #395 had swelling, complained of pain when they were turned during morning care and this was reported to the Charge Nurse. The A/I report also documented the Registered Nurse Supervisor (RNS) saw the resident who had swelling to the right thigh with pain, area above knee was hard to touch and lower extremity was also slightly swollen with no discoloration or bruise was noted. The resident was confused and did not answer any questions when interviewed by the RNS about the circumstances of the accident/incident. The A/I report further documented that statements were obtained. The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was noted with positive right lower extremity/thigh diffuse swelling with mild warmth and general tenderness. The progress note also documented the assessment/plan included venous doppler, x-ray and laboratory testing. The Patient Transfer Form documented the resident was transferred to the hospital on 2/14/2020 at 11:20PM with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The Health Electronic Response Data System (HERDS) report dated 2/16/2020 documented the incident that occurred on 2/14/2020 at 5:30AM was reported on 2/16/2020 at 2:30PM. Review of the NYS DOH Automated Complaint Tracking System (ACTS) Complaint/Incident Investigation Report documented date/time of occurrence: 2/14/2020 at 05:30 AM. Submitted by facility: 02/16/2021 at 2:30 PM. On 10/18/2021 at 07:34 PM, the former Director of Nursing (DON #2) was interviewed. DON #2 stated that they were notified of the accident/incident with Resident #395 on the weekend. DON #2 also stated that they were informed the resident was noted with swelling on the area, x-ray was done, and a fracture was noted, and resident was sent to the hospital. DON #2 further stated the reporting time frame if there is an injury is within 24 hours and if it the accident/incident occurred on a weekend we would go in and gather staff statements before we forward the report. DON #2 stated abuse should be reported within 2 hours. During an interview on 10/19/2021 at 09:11AM, the ADON was interviewed. The ADON stated the accident/incident was reported in the morning meeting on 2/14/2020 for the 11-7 shift. The ADON also stated that accident/incident has to be reported the same day within 3 hours as soon as we know it is of unknown origin and we do the investigation at the same time. The ADON further stated they would be notified via email if an incident occurs and they are not in the facility at the time. The ADON stated the incident was reported on 2/17/2020. 415.4(b)(1)(2)