Every finding on record at Holliswood Center for Rehabilitation and Healthcar

Based on observation, record review, and interviews conducted during a survey, the facility failed to ensure that a resident was able to exercise their autonomy regarding choices that are important to their life. This is evident in one out of seven residents sampled. Specifically, on 02/15/2026 at 5:00 PM, Resident #1 who was alert and oriented times three, attempted to leave the dining room and Certified Nursing Assistant #1 stood in front of their wheelchair and placed both their hands on the armrests of the wheelchair preventing Resident #1 from leaving the dining room.The findings are:The facility's Policy titled Resident Rights dated 05/28/2024 states that healthcare personnel shall treat all residents with kindness, respect and dignity. Also documented resident's right to self-determination; exercise his or her rights as a resident of the facility and as a resident or citizen of the United States; be supported by the facility in exercising his or her rights.Resident #1 was admitted to the facility with diagnoses including Anxiety, Cerebral Infraction (stroke) with Hemiparesis ( weakness on one side of the body, affecting the face, arm, and leg) and Hemiplegia (a medical condition causing total or partial paralysis on one side of the body, typically affecting the face, arm, and leg, and resulting from brain or spinal cord damage)The Minimum Data Set (a resident assessment tool) dated 02/04/2026 documented Resident #1 had intact cognitions.A Comprehensive Care Plan Resident is ablet to make leisure Preferences known dated 07/29/2025, interests include watching television, reading, and listening to music.A summary of investigation dated 02/20/2026 documented on 02/15/2026 at 5:00 PM Resident #1's family reported to Registered Nurse Supervisor #1 that Resident #1 stated they were hit on the right chest and right knee by Certified Nursing Assistant #1. Resident #1 was assessed with no discoloration, no redness, swelling or injuries. Certified Nursing Assistant #1 stated they were monitoring the dining room when Resident #1 approached the exit door to leave the dining room. Resident #1 was instructed to stay in the dining room because they were at risk of falling and were being monitored. Resident #1 refused to go back to the dining room and Certified Nursing Assistant #1 reported that they positioned themself in front of Resident #1 wheelchair, placed their hands on the wheelchair armrests and explained to Resident #1 why they should be in the dining room and that was when Resident #1 struck them in their chest and kicked them. Certified Nursing Assistant #1 stated they touched Resident #1 on their right knee during the interaction to get Resident #1's attention. Certified Nursing Assistant #1 was suspended pending outcome of the investigation. The facility conclusion documented there is no evidence of abuse, neglect, or mistreatment.A Nursing Progress Note by Registered Nurse #3 dated 02/15/2026 at 11:35 PM, documented Resident #1's family reported that a staff member hit Resident #1 on their right chest and their right knee. Body assessment revealed no redness and no bruises. 911 called and four Police Officers responded to the facility. Resident #1 was transferred to hospital for chest pain. A late entry progress note by Registered Nurse #2 dated 02/17/2026 at 5:37 documented writer and social worker met with Resident #1 and Resident #1 reported that they asked the staff to put them back in their bed because they were sitting long in the chair and it hurts my hips and legs. They said they would put them back in bed, but a tall lady said no. One lady grabbed them and pushed them back in their chair very hard. Resident #1 was asked if they hit the staff member and Resident #1 stated I cannot hardly lift their arms how can they hit the staff. Resident #1 declined room change offer. Resident #1 call bell within reach, bed in lowest position. Resident #1 was asked if there are anything else they can do to make them comfortable and Resident #1 said no.A Physician's Progress Note dated 02/18/2026 documented that Resident #1 was seen and examined with no acute changes reported and no acute distress. Stable clinically at baseline.A Psychiatric Progress Note dated 02/21/2026 at 7:04 AM documented Resident #1 alleged that while in dining room they were getting uncomfortable sitting in their wheelchair, they were raising up to change their position, and a staff pushed them back in their wheelchair. Resident #1 did not present traumatized by the incident although Resident #1 reported some residual chest/muscular pain.During an interview on 07/09/2026 at 3:30 PM, Resident #1 stated they have no complaints and that they do not recall the incident.During an interview on 07/29/2026 at 1:35 PM, Certified Nursing Assistant #1 stated on 02/15/2026 (unsure of time) they were assigned to monitor the dining room. Certified Nursing Assistant #1 stated they were instructed to ensure residents do not fall. Certified Nursing Assistant #1 stated Resident #1 who has had a recent fall was in the dining room for monitoring. Certified Nursing Assistant #1 stated while they were sitting at the dining room entrance Resident #1 wheeled their wheelchair towards them, stating they needed to go. Certified Nursing Assistant #1 stated they asked from another Certified Nursing Assistant (unsure of name) if Resident #1 had to go somewhere and was told no. Certified Nursing Assistant #1 stated they redirected Resident #1 to go back to where they were sitting but Resident #1 refused and continued wheeling themself towards them. Certified Nursing Assistant #1 stated they positioned themself in front of Resident #1's wheelchair and placed both hands on the armrests of the wheelchair while explaining to Resident #1 why they should remain in the dining room. Certified Nursing Assistant #1 stated while they were in front of the wheelchair, hands on the armrests pushing the chair back in the dining room, Resident #1 hit and kicked them in the chest area. Certified Nursing Assistant #1 stated that the residents have a right to move about freely, however, they were just focusing on keeping Resident #1 from falling. Certified Nursing Assistant #1 stated they were just trying to keep Resident #1 in the dining room until their family came.During an interview on 07/29/2026 at 2:00 PM, Assistant Director of Nursing stated that all staff members received prior in-service on resident rights. Assistant Director of Nursing #1 stated while they were conducting the investigation they interviewed Certified Nursing Assistant #1 who explained to them that they were not blocking Resident #1, they were trying to keep Resident #1 engaged in the dining room until their family came because Resident #1 had recently fallen into their room. Assistant Director of Nursing stated that the facility is Resident #1's home and staff members are aware the residents have the right to move about freely. Assistant Director of Nursing stated Certified Nursing Assistant #1 was not preventing Resident #1 from moving about freely.10 New York Codes, Rules and Regulations 415.5(a)

Based on observation, record review, and interviews conducted during a Survey (2804872), the facility failed to provide adequate supervision to a resident to prevent an accident. This was evident in one out of two residents (Resident #2) sampled for accidents. Specifically, Resident #2 was left unsupervised in the shower room by Certified Nursing Assistant #2 on 03/15/2026 at 4:20 AM. Resident #2 sustained a raised area on the right side of their forehead with active bleeding. Pain medication was administered, and the resident was transferred to the hospital on [DATE] at 5:40 Am and returned to the facility same day at 12:05 PM. The findings are:The facility Policy and Procedure for Accident and Incident Reporting dated 06/01/2024 documented it is the policy of the facility to monitor and evaluated all occurrences of accidents or incidents or adverse events occurring on the facility's premises which is not consistent with the routine operation of the facility or care of a particular resident. These occurrence must be evaluated and investigated. An incident is any occurrence not consistent with the routine operation of the center, normal care of the residents a happening involving visitors, malfunctioning equipment, or observation of a condition which might be a safety hazard. The occurrence may be a fall, skin tear, bruise, new pressure ulcer and may involve abuse , neglect, and mistreatment or an injury of unknown origin. The incident may be a theft of misappropriation of resident property.The facility Policy and Procedure for Abuse Reported dated 07/18/2025 documented the facility prohibits the mistreatment, neglect and abuse of residents/patients and misappropriation of resident/patient property by anyone including but not limited to staff, family, friends and residents of the facility. The facility prohibits any exploitation of the mentally and physically disabled resident in the facility. The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property.Resident #2 was admitted to the facility with diagnoses including Bipolar Disorder, Dementia and Major Depressive Disorder.The Minimum Data Set, a resident assessment tool, dated 03/12/2026 documented Resident #2 cognition was severely impaired. Resident #2 required partial/moderate assistant with shower/bath self. (Helper does less than half the effort. Helper lifts, holds, or supports trunks or limbs, but provides less than half the effort. A Fall Care Plan dated 02/11/2026 documented Resident #2 was at risk for falls. The interventions documented to anticipate and meet resident needs, check for toileting needs and provide toileting/incontinence care as neededA Care Plan for Activities of Daily Living dated 02/11/2026 documented shower/tub transfer partial assistance times one staff (Helper completes less than half of the activity. Helper uses own strength to lift or hold the resident's body, arms, or legs. The resident completes more than half of the activity using own physical strength.A Minimum Data Set Kardex Report (a document for Certified Nursing Assistants) dated 05/06/2024 documented Resident #2 required physical help in part of bathing activity with one-person physical assistance. Resident #2's shower days are Wednesday and Saturday.There were no documented instructions for staff not to leave Resident #2 in the shower/bathroom by themself.A Nursing progress note dated 03/15/2026 at 4:30 PM by Registered Nurse Supervisor #2 documented at around 4:20 AM Resident #2 was noted with bump to their right forehead. On assessment, swelling noted to right side of forehead measuring 4.0 x 5.5 centimeter and small skin opening to forehead 0.5 x 0.5 centimeter with scant amount of sanguineous drainage. Nurse Practitioner (1) was notified and ordered Resident #2 to be transferred to hospital for Computer Tomography scan (a noninvasive medical imagining procedure). A Telehealth progress note by Nurse Practitioner #1 documented that Registered Nurse Supervisor #2 asked them to assessed Resident #2 who had a raised area to their forehead. It is documented that the raised area measured 4.0x5.5 centimeters with a small opening and scant bleeding. A Physician's order dated 03/06/2026 Acetaminophen tablet 325 milligrams, give 2 tablets by mouth every 6 hours as needed for pain.Physician's order dated 03/15/2026 Bacitracin external ointment 500 unit/Gram apply to right forehead laceration topically two times a day for wound care times 10 daysA Medication Administration Record dated 03/01/2026 - 03/31/2026 revealed Resident #2 received pain medication on 03/15/2026 as per physician's order.A Treatment Administration Record dated 03/15/2026 documented Bacitracin external ointment, apply to right forehead laceration topically two times a day for wound care for 10 days.An Investigation Summary dated 03/20/2026 documented Certified Nursing Assistant #2 reported that they brought Resident #2 to the bathroom/shower suite in a shower chair (at 4:20 AM) after observing that the resident had a bowel movement. Certified Nursing Assistant #2 reported that they locked the shower chair and left Resident #2 in the shower room by themself to get soap for the soap dispenser. Before they, left Resident #2 in the shower room by themself they instructed Resident #2 to stay seated. When they returned to the shower room, they observed Resident #2 standing in front of the shower chair and a bump was observed on their forehead. Registered Nurse Supervisor #2 came and assessed Resident #2 with hematoma to the right forehead and mild bleeding. The opening measured 4.0 x 5.5 x 0.5 x 0.5 centimeters. Resident #2 denied pain and was transferred to the hospital for computer tomograph scan. The results were negative, and the residents returned to the facility with no new recommendations. The facility investigated the accident and conceded that abuse, neglect or mistreatment was not identified. Root Cause Analysis concluded it was incomplete preparation of bathing supplies before initiating shower transfer. Facility educated nursing staff and housekeeping to ensure soap is always in the shower roomDuring an interview on 07/09/2026 at 1:07 PM, Certified Nursing Assistant #2 stated on 03/15/2026 they worked on the 11:00 PM to 7:00 AM shift and were assigned to Resident #2. Certified Nursing Assistant #2 stated Resident #2 was awake and had a large bowel movement (unsure of time) so they took Resident #2 to the shower/bathroom to give them a shower. Certified Nursing Assistant #2 stated when they were about to give Resident #2 the shower, they observed that there was no soap in the dispenser. Certified Nursing Assistant #2 stated before they left the shower room, they locked Resident #2's shower chair and instructed Resident #2 not to get up. Certified Nursing Assistant #2 stated they went to the nursing station to get a new soap and when they returned to the shower room, they observed Resident #2 standing up with their hands resting on the shower room wall that divides the shower room and toilet. Certified Nursing Assistant #2 stated that Resident #2 had a raised area to the right-side to their head with blood and that Resident #2 must have hit their head on the wall dividing the shower room and toilet area. Certified Nursing Assistant #2 stated they notified Licensed Practical Nurse #2 who notified Registered Nurse Supervisor #2. Certified Nursing Assistant #2 stated they should not have left Resident #2 unsupervised in the shower room.During an interview on 07/09/2026 at 1:30 PM, Licensed Practical Nurse #2 stated on 03/15/2026 they worked on the 11:00 PM to 7:00 AM shift. Licensed Practical Nurse #2 stated they were closed by the nursing station preparing the morning medications and that certified nursing assistant #2 did not ask them for assistance. Licensed Practical Nurse #2 stated they never saw when Certified Nursing Assistant #2 took Resident #2 to the shower at 4:20AM.During an interview on 07/09/2026 at 2:00 PM, Registered Nurse Supervisor #2 stated on 03/15/2026 that a certified nursing assistant (unsure of name) informed them that certified nursing assistant #2 need them to come to the shower room. Registered Nurse Supervisor #2 stated that when they entered the shower/bathroom they observed Resident #2 sitting in the shower chair with a raised area to their right forehead. Registered Nurse Supervisor #2 stated Resident #2 reported that they hit their head on the wall. Registered Nurse Supervisor #2 stated that they conducted a body assessment and Resident #2 was observed with a raised area with a small opening and small amount of blood; no other injuries observed. Registered Nurse Supervisor #2 stated they notified Nurse Practitioner #1 who ordered Resident #2 to be transferred to the hospital for computer tomography scan. Registered Nurse Supervisor #2 stated Resident #2 was transferred to the hospital (03/15/2026 and returned to the facility later in the day 12.05 PM. Registered Nurse Supervisor #2 stated Certified Nursing Assistant #2 was in-service and aware that Resident #2 should not be left in the bathroom unsupervised.During an interview on 07/10/2026 at 10:25 AM, Nurse Practitioner #1 stated they were informed by Registered Nurse Supervisor #2 that at approximately 4:20 AM they were informed that Resident #2 was sitting in a shower chair in the shower/bathroom and had a bump on their forehead. Nurse Practitioner #2 stated Resident #2 was assessed with swelling at the right side of their forehead measured 4.0 x 4.5 x 0.5 x 0.5 centimeter opening with scan amount of blood. Nurse Practitioner #1 stated Resident #2 was sent to emergency room for further evaluation.During an interview on 07/14/2026 at 3:42 PM, the Director of Nursing stated they were made aware by Registered Nurse Supervisor #2 on 03/15/2026 (unsure of time) that Resident #2 bumped their forehead on the wall in the bathroom. The Director of Nursing stated all staff including Certified Nursing Assistant #2 were in-serviced on preparing their supplies prior to performing their tasks. The Director of Nursing stated they conducted a Root Cause Analysis, and it was identified that Certified Nursing Assistant #2 left Resident 2 unsupervised alone in the shower room. The Director of Nursing stated they identified the issues and put corrective measures in place.Based on the following corrective actions taken, there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement prior to surveyors' s onsite visit on 07/09/2026. A Plan of Correction is not required for this citation.10 New York Code, Rules and Regulations 415.12(h)(1)The facility took immediate corrective actions and was found to be in substantial compliance on 03/25/2026.On 03/15/2026, Resident #2 was assessed for injury by Registered Nurse Supervisor #2, provider and family notified.03/15/2026, Resident #2 was transferred to the emergency room for further evaluation.On 03/15/2026, Hospital Computer Tomography scan of the Head documented findings with no acute hemorrhage. No evidence of acute infarct. No hydrocephalus. No extra-axial collection or subdural hemorrhage.On 03/15/2026, Staff disciplinary action for Certified Nursing Assistant #2 reviewed.On 03/18/2026, an Ad Hoc Quality Assurance Performance Improvement meeting with signing sheet reviewed. On 03/18/2026, Policies and Procedures on Abuse Prevention, Activities of Daily Living Care and Accident/Incident Safety and Supervisor reviewed with no changes. 03/20/2026, in-service for housekeeping staff to ensure all shower rooms are stocked, reducing the likelihood of staff missing supplies mid-care.03/16/2026 - 04/13/2026 Housekeeping audit for shower room check soap and shampoos.03/18/2026 Root Cause Analysis - Resident was left unattended in the bathroom shower suite and resident sustained a bump to the head. Root Causes: Lack of soap supply in shower room.On 03/25/2026 in-service on resident high risk for falls and/or with cognitive impairment are not to be left unsupervised in the bathroom.On 03/25/2026, Facility-wide (all staff members) in-service on abuse, mistreatment and neglect.On 03/25/2026 Registered Nurse Supervisors 92 percents, Licensed Practical Nurses 91 percents and Certified Nursing Assistants 90.1 percents were in-service on abuse, mistreatment and neglect, accident/incident and shower room supply stock.

Based on observation, record review, and interviews conducted during a survey, the facility failed to ensure that residents are free from physical abuse. This was evident for one of seven residents (Resident #1) sampled for abuse. Specifically, on 04/08/2026, Resident #7 reported to Registered Nurse Supervisor #7 that because they refused to take their medications, Licensed Practical Nurse #7 pushed them in their chest causing them to fall on the floor on 04/08/2026 at approximately 5:15 AM. Resident #7 was assessed by Registered Nurse Supervisor #7 with no visible injuries.The findings are:Resident #7 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease, speech disturbances and dysphagia {difficulty swallowing.The Minimum Data Set (an assessment tool) dated 03/18/2026 documented Resident #7 had intact cognition. A care plan, titled at Risk for Misappropriation, Neglect, Abuse and/or Exploitation dated 03/28/2026. Interventions included provide support and ensure that resident is free from abuse. Assess resident for signs/symptoms of abuse or neglect and report to appropriate resources.A Nursing Progress Note by Registered Nurse #7 dated 04/08/2026 documented that Resident #7 reported they were hit in the chest by Licensed Practical Nurse #7 during morning medication administration. No bruising or injuries noted. Nurse Practitioner #7 and Resident #7's family notified.A Medical Progress Note by Nurse Practitioner #7 dated 04/08/2026 documented during their examination of Resident #7, the resident reported that Licensed Practical Nurse #7 hit them in the chest during medication administration. No bruising, swelling or visible injury noted. Psychology and psychiatrist referral.The facility's investigation dated 04/13/2026 documented Resident #7 reported that Licensed Practical Nurse #7 pushed them in the chest because they refused to take their medications. Resident #7 was assessed and there were no visible injuries. Resident #7 was visibly upset while they were reporting (the incident). Licensed Practical Nurse #7 denied the allegation. The facility investigated the allegation and concluded there was some form of contact between Resident #7 and Licensed Practical Nurse #7. The facility concluded there was no evidence of abuse, neglect, exploitation or mistreatment. A progress note, by Psychiatrist #7 dated 04/18/2026 documented that they examined Resident #7 due to allegation of being hit in the chest by a staff. They asked Resident #7 about the incident, but Resident #7 waved their hands indicating it was over. No need for psychotropic medication. Supportive counseling is recommended.During an interview on 07/10/2026 at 10:00 AM, Resident #7 communicated in writing and hand gestures due to history of laryngectomy (removal of larynx). They wrote/gestured that they told Licensed Practical Nurse #7 to leave their room and Licensed Practical Nurse #7 pushed them in their chest and they fell on the floor. Resident #7 wrote they were fine and comfortable with the staff on the unit. The interview ended by Resident #7. During an interview with Licensed Practical Nurse #7 on 07/20/2026 at 3:30 PM, they stated they were terminated from the facility by the Director of Nursing for having an altercation with a staff prior to Resident #7's allegation. Licensed Practical Nurse #7 stated they have been a nurse for 14 years and had worked at the facility for two years. Licensed Practical Nurse #7 stated it was their first time being assigned on Resident #7's unit (on 04/08/2026 on the night shift) and that they went to Resident #7's room to administer their medications on 04/08/2026 at around 5:30 AM. Licensed Practical Nurse #7 stated when they entered Resident #7's room, the resident was sitting on their bed and communicated to them angrily, using hand gestures, to leave the room. Licensed Practical Nurse #7 stated they were holding a medication cup and a cup with water in their hands and while they were walking out of Resident #7's room, they were not aware Resident #7 was walking closely behind them and when they turned around their left shoulder accidentally touched Resident #7's chest. Licensed Practical Nurse #7 stated that when their shoulder touched Resident #7's chest, the resident stumbled but did not fall. Licensed Practical Nurse #7 stated that they met with the Director of Nursing for counselling and was terminated from the facility for unrelated performance issues. Licensed Practical Nurse #7 stated they did not punch or push Resident #7. A review of a statement written by Licensed Practical Nurse #7 to the facility on [DATE] at 5:00 AM documented that they entered Resident #7's room to administer medication; Resident #7 stood up and used both hands to push them out of their room. They stopped short and turned to ask Resident #7 if they wanted the medication, Resident #7's chest bumped into their back and Resident #7 took a few steps backward. A review of Licensed Practical interview on 07/20/2026 and their written statement to the facility provided contradictory tales of the incident.During an interview with Registered Nurse Supervisor #7 on 07/20/2026 at 2:10 PM. They stated they are no longer working at the facility. Registered Nurse Supervisor #7 stated on 04/08/2026 (unsure of time), but it was early morning while they were in the nursing office on the first floor, Resident #7 came to see them and wrote a note stating that Licensed Practical Nurse #7 pushed them in the chest and that they fell on the floor and got up by themself. Registered Nurse Supervisor #7 stated they accompanied Resident #7 to their room and performed a head-to- toe assessment that revealed no visible injuries. Registered Nurse Supervisor #7 stated that Resident #7 was visibly upset. Registered Nurse Supervisor #7 stated that Licensed Practical Nurse #7 reported they went into Resident #7's room to give medication and Resident #7 pushed them to leave the room. They stated that they turned around and Resident #7's chest accidentally touched their back. Registered Nurse Supervisor #7 stated that Licensed Practical Nurse #7 was dismissed from duty. Registered Nurse Supervisor #7 stated they called the Director of Nursing and notified Resident 7's physician and emergency contact. Registered Nurse Supervisor #7 stated Law enforcement was notified, and Police Officers came and interviewed Resident #7 and Licensed Practical Nurse #7 but did not file a report. During an interview with Nurse Practitioner #7 on 07/202026 at 3:00PM. They stated that on 04/08/2026 Registered Nurse Supervisor #7 notified them about the allegation and the need to assess Resident #7. Nurse Practitioner #7 stated they visited Resident #7 in their room and they reported that Licensed Practical Nurse #7 pushed them in their chest. They stated that Resident #7 denied pain and refused to continue the interview. Nurse Practitioner #7 stated they ordered laboratory testing for complete blood count, metabolic panel and urine analysis/culture and sensitivity. They stated that laboratory values were normal and psychology/psychiatric consults were ordered.During an interview on 07/10/2026 at 4:00 PM, the Director of Nursing stated on 04/08/2026 (unsure of time) Registered nurse supervisor #7 notified them of an incident that occurred between Resident #7 and Licensed Practical Nurse #7 on the 11:00 PM-7:00 AM shift. They stated that Resident #7 angrily reported an allegation of abuse to Nursing Supervisor #7. The Director of Nursing stated that they interviewed Resident #7 and Licensed Practical Nurse #7 and Resident #7 reported that Licensed Practical Nurse #7 pushed them in the chest when they refused to take their medication. Licensed Practical Nurse #7 reported that they went to Resident #7's room to administer their medication and Resident #7, who was sitting on their bed, suddenly got up and signaled for them to leave the room. Licensed Practical Nurse #7 said they had medication and a cup of water in their hands and as they walked towards the door they turned back and encountered Resident #7 close behind them resulting in Licensed Practical Nurse #7 accidentally connecting with Resident #7's chest. The Director of Nursing stated a head-to-toe assessment was done and Resident #7 did not sustain any visible injuries. The Director of Nursing stated they met with Licensed Practical Nurse #7 for suspension counseling and during the meeting, they were not receptive of the counseling and was terminated. During a follow-up interview on 07/29/2026 at 2:45 PM, the Director of Nursing stated they determined that Resident #7's chest connecting with Licensed Practical Nurse #7's body was accidental and there was no evidence of abuse. Additionally, Resident #7 was inconsistent reporting a fall during the incident.10 New York Codes, Rules and Regulations 415.4(b)(1)(i)

44864 Based on observation, record review, and interviews conducted during the Recertification survey from 04/17/2024 to 04/24/2024, the facility did not ensure that infection control prevention practices and procedures were maintained. This was evident for 2 (Resident #276 and #127) of 38 total sampled residents. Specifically, 1) Enhanced Barrier Precautions were not maintained during Foley catheter care for Resident #276, and 2) Enhanced Barrier Precautions were not maintained for gastrostomy tube medication administrations for Resident #127. The findings are: The facility policy titled Clinical Operations dated 5/18/2023 documented Enhanced Barrier Precautions are applicable for residents with infection or colonization of a multidrug-resistant organisms and indwelling medical devices (central line, urinary catheter, feeding tube, tracheostomy/ventilator). 1) Resident #276 had a diagnosis of obstructive uropathy and non-Alzheimer's dementia. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #276 was severely cognitively impaired and had an indwelling catheter. On 04/19/2024 at 09:56 AM, Licensed Practical Nurse #7 was observed entering Resident #276's room to provide Foley catheter care. Licensed Practical Nurse #7 did not don a gown prior to providing Foley catheter care to Resident #276. On 04/19/2024 at 09:58 AM, Licensed Practical Nurse #7 was interviewed and stated they were not aware they needed to wear a gown for Enhanced Barrier Precautions when providing Foley catheter care to residents. They were just inserviced regarding this infection control requirement today. 2) Resident #127 had diagnoses of dysphagia and gastrostomy status. The Physician's Order dated 1/5/2024 documented Resident #127 received Metformin 500 milligrams via gastrostomy tube twice daily. The Physician's Order dated 3/8/2024 documented Resident #127 received Enulose solution 30 milliliters via gastrostomy Tube once daily every Monday, Wednesday, and Friday. On 04/19/2024 at 09:38 AM, Licensed Practical Nurse #8 was observed entering Resident #127's room to administer medication to Resident #127 via gastrostomy tube. Licensed Practical Nurse #8 checked for patency, administered the medications via gastrostomy tube, and flushed the gastrostomy tube. Licensed Practical Nurse #8 did not don a gown prior to administering medication to Resident #127 via their gastrostomy tube. On 04/19/2024 at 09:45am, Licensed Practical Nurse #8 was interviewed and stated they were not aware of Enhanced Barrier Precautions and did not know they were supposed to don a gown prior to administering medications to residents with a gastrostomy tube. On 04/19/2024 at 10:06 AM, Registered Nurse #4 was interviewed and stated inservices regarding Enhanced Barrier Precautions were currently being provided and they were not aware that Enhanced Barrier Precaution were in effect. On 04/19/2024 at 11:27 AM, the Assistant Director of Nursing was interviewed and stated they were newly hired as the Infection Preventionist and realized the facility had not initiated Enhanced Barrier Precautions. They were in the process of inservicing staff to ensure they followed Enhanced Barrier Precautions protocol. On 04/23/2024 at 12:19 PM, the Director of Nursing was interviewed and stated Enhanced Barrier Precautions were actively being implemented but the facility was awaiting the delivery of some supplies to fully implement the protocol. 415.19(b)(4)

Based on record review and interviews conducted during the Recertification and Abbreviated (NY00331574) survey from 4/17/2024 to 4/24/2024, the facility did not ensure licensed nurses had the competencies and skills necessary to care for a resident's needs. This was evident for 1 (Resident #266) of 38 total sampled residents. Specifically, Resident #266 did not receive assessment by a qualified Registered Nurse following an injury of unknown origin and a fall. The findings are: The facility's policy titled Injuries of Unknown Etiology dated 11/2023 documented the Licensed Nurse on duty must report incidents and injuries to the on-duty Supervisor. Resident # 266 had diagnoses of Parkinson's disease and dementia. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #266 was moderately cognitively impaired and had 2 or more falls since their prior assessment. A Nursing Evaluation dated 4/14/2024 at 12:00 AM documented Licensed Practical Nurse #6 was called to the unit by the charge nurse. Resident #266 had swelling and discoloration to their left-hand 4th and 5th fingers of unknown origin. Licensed Practical Nurse #6 assessed Resident #266 and informed the Nurse Practitioner. A Nursing Evaluation Note dated 1/14/2024 at 4:10 AM documented Licensed Practical Nurse #6 was called to the unit by the charge nurse due to Resident #266 was found lying on the floor in the doorway of their room. Licensed Practical Nurse #6 assessed Resident #266, had them transferred to the wheelchair, and informed the Nurse Practitioner. The New York State Office Professions Registrations for Licensed Practical Nurse #6 documented they were registered until 6/2026. There was no documented evidence Resident #266 received an assessment from a qualified and competent Registered Nurse following an injury of unknown origin and fall on 1/14/2024. On 04/22/2024 at 04:33 PM, Licensed Practical Nurse #4 was interviewed and stated they were the charge nurse on Resident #266's unit when the resident had an injury of unknown origin and fall on 1/14/2024. Licensed Practical Nurse #4 called and reported the incidents to the Supervisor for that shift, Licensed Practical Nurse #6. On 04/23/2024 at 07:27 AM and 03:29 PM, Licensed Practical Nurse #6 was interviewed and stated they were the Supervisor in the building on 1/14/2024 when Resident #266 had discoloration to their left hand and a fall. Licensed Practical Nurse #6 assessed the resident, contacted the Nurse Practitioner, initiated an incident report, and ordered an x-ray. Licensed Practical Nurse #6 stated they failed the Registered Nurse licensing exam and was not approved for a permit to practice as a Registered Nurse in New York State. Licensed Practical Nurse #6 stated they were designated as a Supervisor and practicing the capacity of Registered Nurse on 1/14/2024 when Resident #266 had their incidents. On 04/23/2024 at 12:10 PM, the Director of Nursing was interviewed and stated the nurse on the unit was responsible for assessing residents when incidents occur. Licensed Practical Nurse #6 was the Registered Nurse Supervisor for the building on 1/14/2024 on the 11PM to 7AM shift. The Director of Nursing stated they believed the Licensed Practical Nurse #6 could practice in the capacity as a Registered Nurse because they held degree in Associate's in Nursing meeting the education requirements of a Registered Nurse. The Director of Nursing did not know whether Licensed Practical Nurse #6 had a permit to practice as a Registered Nurse in New York State. 10 NYCRR 415.13(a-b)

Based on observation, record review, and interviews conducted during the recertification survey from 4/17/2024 to 4/24/2024, the facility did not ensure a resident received adequate supervision to prevent accident hazards. This was evident for 1 (Resident #104) of 38 total sampled residents. Specifically, Resident #104's comprehensive care plan related to falls was not reviewed and revised to include supervision to prevent further accidents. The findings are: The facility's policy titled Falls Management and Prevention dated 1/2024 documented assessment and prevention of falls included staff reviewing and revising the interdisciplinary care plan after a fall event. Goals and interventions will be implemented based on the resident's individual needs. Resident #104 had diagnoses of schizophrenia and acute kidney failure. The Minimum Date Set 3.0 assessment dated [DATE] documented Resident #104 had moderately impaired cognition and 2 falls with no injury since the last assessment. The Comprehensive Care Plan created 6/16/2021 and last revised 1/5/2024 documented Resident #104 was at risk for falls due to psychoactive drug use, tremors, history of falls, and unsafe attempts to sefl-trasnfer. Interventions included provide urinal at resident bedside, toileting every 2 hours and as needed, bed in the lowest position, non-skid socks, floor mats, and resident education on safety. The Nursing Note dated 1/20/2024 documented at 7:45 PM, Resident #104 was observed laying supine on floor in the hallway bathroom close to nursing station. Occupational and physical therapy evaluation were initiated as interventions to decrease risk for falls. The Nursing Note dated 1/21/2024 documented at 8:30 AM, Resident #104 was noted sitting on the floor of the room in front of the bathroom with wheelchair unlocked. Non-skid socks were initiated to decrease risk for falls. There was no documented evidence Resident #104 was evaluated for and provided with supervision and interventions to prevent further fall occurrences. There was no documented evidence Resident #104's care plan related to falls was reviewed and revised after 1/5/2024. To address falls on 1/20/2024 and 1/21/2024. On 4/23/2024 at 11:46 AM, Registered Nurse #3 was interviewed and stated the Registered Nurse on duty was responsible for ensuring the resident's incident report and fall care plan were updated after a resident's fall. Registered Nurse #3 did not know whether interventions were reviewed and revised upon Resident #104's falls on 1/20/2024 and 1/21/2024. The care plan related to falls was not updated. On 4/24/2024 at 12:08 PM, the Director of Nursing was interviewed and stated comprehensive care plans were reviewed and revised after each fall. Preventative interventions were initiated by nursing and implemented immediately to ensure the resident does not have any more falls. In addition, the interdisciplinary team reviewed interventions for their effectiveness and revised the care plan accordingly. The Director of Nursing was not able to explain why Resident #104's fall care plan was not reviewed or revised following falls on 1/20/2024 and 1/21/2024. 10 NYCRR 415.12(h)(2)

Based on record review and interviews conducted during the Recertification and Abbreviated (NY00331574) survey from 4/17/2024 to 4/24/2024, the facility did not ensure that a resident received quality of care. This was evident for 1 (Resident #266) of 38 total sampled residents. Specifically, Resident #266 did not receive assessment by a qualified Registered Nurse following an injury of unknown origin and a fall. The findings are: The facility's policy titled Injuries of Unknown Etiology dated 11/2023 documented the Licensed Nurse on duty must report incidents and injuries to the on-duty Supervisor. Resident # 266 had diagnoses of Parkinson's disease and dementia. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #266 was moderately cognitively impaired and had 2 or more falls since their prior assessment. A Nursing Evaluation dated 4/14/2024 at 12:00 AM documented Licensed Practical Nurse #6 was called to the unit by the charge nurse. Resident #266 had swelling and discoloration to their left-hand 4th and 5th fingers of unknown origin. Licensed Practical Nurse #6 assessed Resident #266 and informed the Nurse Practitioner. A Nursing Evaluation Note dated 1/14/2024 at 4:10 AM documented Licensed Practical Nurse #6 was called to the unit by the charge nurse due to Resident #266 was found lying on the floor in the doorway of their room. Licensed Practical Nurse #6 assessed Resident #266, had them transferred to the wheelchair, and informed the Nurse Practitioner. The New York State Office Professions Registrations for Licensed Practical Nurse #6 documented they were registered until 6/2026. There was no documented evidence Resident #266 received quality of care and was adequately assessed by a Registered Nurse following an injury of unknown origin and fall on 1/14/2024. On 04/22/2024 at 04:33 PM, Licensed Practical Nurse #4 was interviewed and stated they were the charge nurse on Resident #266's unit when the resident had an injury of unknown origin and fall on 1/14/2024. Licensed Practical Nurse #4 called and reported the incidents to the Supervisor for that shift, Licensed Practical Nurse #6. On 04/23/2024 at 07:27 AM and 03:29 PM, Licensed Practical Nurse #6 was interviewed and stated they were the Supervisor in the building on 1/14/2024 when Resident #266 had discoloration to their left hand and a fall. Licensed Practical Nurse #6 assessed the resident, contacted the Nurse Practitioner, initiated an incident report, and ordered an x-ray. Licensed Practical Nurse #6 stated they failed the Registered Nurse licensing exam and was not approved for a permit to practice as a Registered Nurse in New York State. Licensed Practical Nurse #6 stated they were designated as a Supervisor and practicing the capacity of Registered Nurse on 1/14/2024 when Resident #266 had their incidents. On 04/23/2024 at 12:10 PM, the Director of Nursing was interviewed and stated the nurse on the unit was responsible for assessing residents when incidents occur. Licensed Practical Nurse #6 was the Registered Nurse Supervisor for the building on 1/14/2024 on the 11PM to 7AM shift. The Director of Nursing stated they believed the Licensed Practical Nurse #6 could practice in the capacity as a Registered Nurse because they held degree in Associate's in Nursing meeting the education requirements of a Registered Nurse. The Director of Nursing did not know whether Licensed Practical Nurse #6 had a permit to practice as a Registered Nurse in New York State. 10 NYCRR 415.12

Based on observations, interviews, and record review conducted during the recertification survey from on 04/17/2024 to 04/24/2024, the facility did not ensure the resident's right to a safe, clean, comfortable, and homelike environment. This was evident for 1 (Unit 4) of 5 resident units. Specifically, Unit 4 was observed with 1.) furniture heavily worn and in disrepair. 2.) torn and/or stained window curtains. 3.) stained privacy curtains. 4.) broken and chipped ceiling plaster. Torn room wallpaper. 5.) frame of room light fixture in disrepair. 6.) holes in walls/bathroom door. 7.) heavily stained and dirty toilet bowel. 8.) heavily stained, rusty, and dirty room commode. 9.) wheelchair with torn right-side armrest and layered dirt to the metal parts and wheel spokes. 10.) thick, orange-colored streaks of rust stains in the shower room stall. The ceiling tile surround the light fixture with rust stains. 11.) nurse front desk area layered with dirt/dust. 12.) loose rusty worn faucet handles. The findings are: On 04/17/2024 at 10:37 AM, the following observations were made on Unit 4: a.) room [ROOM NUMBER] had cracked/peeling ceiling plaster above the sink, light fixture above the sink in disrepair, torn and stained window curtains, toilet bowl stained with black grime, a rusty and dirty bathroom commode in disrepair, a wheelchair with torn armrest leather on the right side, and loose rusty faucet handles at the sink. b.) room [ROOM NUMBER] had a heavily worn dresser with inner corking exposed at the corners, stained privacy curtains and stained window curtains, holes in the wall near and above the closet, torn wallpaper above the headboard, slanted headboard in disrepairs, tape used to hold the footboard of the bed together. c.) 1 Hoyer lift in the hallway that was heavily worn on the metal frame, rusty, and layered with dirt and debris. d.) room [ROOM NUMBER] had ripped and stained window curtains, hole in the wall near the bathroom doorknob, and stained privacy curtains. e.) room [ROOM NUMBER] had loose and rusty faucet handles at the sink and stained privacy curtains. f.) room [ROOM NUMBER] had stained, dusty, torn window curtains and clothing hampers embedded with dirt. g.) The Shower Room across room [ROOM NUMBER] with rust stains beneath the grab bars and rust stains on the ceiling tiles in the shower stall, around the sink, and by the light fixtures. h.) The Dining Room had moldings with worn, tattered decorations and in disrepair with inner metal exposed, wobbly tables, walls and ceilings with multiple holes from tack marks and staples, a table with a rusty metal frame and inner corking exposed, a chair with the vinyl seat cover torn and wooden frame heavily worn, rusty wall vent, and the kitchenette area with a broken drawer handle. i.) The Nursing Station floor was covered with dirt, dust, and grime and a bundle of wires under the desk was covered in dirt and dust. On 04/24/2024 at 10:53 AM, Housekeeper # 1 was interviewed and stated they were assigned to Unit 4 and their daily routine was to clean the resident rooms, bathrooms, and dining room. Housekeeper #1 called the [NAME] when window curtains and privacy curtains needed to be replaced. Any issues with repairs were reported to the Maintenance Department. All staff were responsible for reporting concerns regarding cleanliness and repair of resident equipment. On 04/24/2024 at 12:00 PM, the Director of Housekeeping was interviewed and stated they made environmental rounds daily throughout the entire facility to ensure that staff were performing their job responsibilities and to check for cleanliness and safety concerns. The Director of Housekeeping stated they also checked for dirt, debris, and stains. Maintenance Department issues were referred using an electronic ticket system. Housekeeping staff made the Director of Housekeeping aware of emergent issues by calling them directly. Resident equipment was washed and cleaned according to a devised schedule. 10 NYCRR 415.5(h)(4)

Based on observation, record review, and interviews during an abbreviated survey (NY 029), the facility failed to ensure that the resident environment remains as free from accident hazards as is possible, and each resident receives adequate supervision to prevent accidents. This was evident for 1 of 4 residents sampled (Resident #1). Specifically, on 09/09/2022, Resident # 1 was accidentally hit on their left forehead with a wheelchair footrest. Resident # 2 had a wheelchair footrest in their hand which was detached from Resident # 3's wheelchair. When Resident # 2 turn around the footrest accidentally hit Resident #1, resulting in a one centimeter (cm) laceration with bleeding and four cm redness with mild swelling to Resident #1's left forehead. Resident #1 was transferred to the emergency room (ER) for an evaluation and Derma Glue was applied to the laceration. The findings are: The facility's Policy and Procedure entitled Accidents-Incidents last reviewed in 07/2020, documented that it is the policy of the facility to monitor and evaluate all occurrences of accidents or incidents or adverse events occurring on the facility's premises which is not consistent with the routine operation of the facility or care of a particular resident. These occurrences must be evaluated and investigated. An incident is any occurrence not consistent with the routine operation of the center, normal care of the resident, a happening involving visitors, malfunctioning equipment or observation of a condition which might be a safety hazard. The occurrence may be a fall, skin tear, bruise, new pressure ulcer and may involve abuse, neglect, and mistreatment or an injury of unknown origin. Resident #1 was admitted to the facility with diagnoses including Dementia with Behavioral Disturbance, [CONDITION(S)] and [CONDITION(S)]. The Minimum Data Set (MDS) assessment dated [DATE], documented that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #1 required limited assistance of one person for most Activities of Daily Living (ADL) tasks. There were no behavior problems documented on the MDS. A Care Plan (CP) for Risk of Abuse, Neglect, Misappropriation and or Exploitation initiated on 12/21/2021, documented: interventions for staff to assess Resident # 1 for signs/symptoms of abuse and or neglect, and report to appropriate resources, investigate all allegations of abuse promptly and provide support and ensure that the resident was free from abuse. The care plan was updated with new interventions on 09/10/2022 and documented that Resident #1 was accidentally hit with a wheelchair leg rest on his/her head on 09/09/2022. The Facility's Investigation Form dated 09/13/2022, documented that on 09/09/2022 at approximately 7:15 PM, Resident #1 was observed sitting outside their room in their wheelchair when they called the Certified Nursing Assistance #1 (CNA #1) for assistance. Resident #1 was observed by CNA #1 with some blood on the left side of Resident # 1's forehead. Resident #1 stated that Resident # 2 came into Resident #1's room and tried to fix Resident #1's bed. Resident #1 stated that Resident # 2 had Resident #1's roommate's (Resident #3's) wheelchair footrest in his/her hand. Resident #1 went to Resident # 2 to tell him/her that he/she did not have to make the bed; Resident #2 turned around and the wheelchair footrest in Resident #2's hand hit Resident #1 in Resident #1's head. Resident #1 stated that Resident # 2 hit him/her accidentally. Resident #1 had a 1 cm open area to the left forehead with bleeding and surrounding redness of approximately 4 cm. First aid was administered to Resident #1 and the Nurse Practitioner (NP) ordered that Resident #1 was transferred to the emergency room (ER) for evaluation. Resident #1 returned to the facility with Derma Glue to the open area and a negative Computed Tomography (CT) scan of the head. Resident # 2 was transferred to hospital for Psychiatric evaluation and returned to the facility for follow up with Psychiatry. The facility investigation concluded that there was no evidence of abuse, neglect, or mistreatment. A Skilled Nursing Facility/ Nursing Facility (SNF/NF) to Hospital Transfer Form dated 09/09/2022 at 7:15 PM, documented: Reason for Transfer was Hematoma and Laceration. A Telehealth Nurse Practitioner's (NP) Progress Note dated 09/09/2022 at 7:24 PM, documented that Resident #1 was seen due to swelling and small bleeding cut to the head by peer. Resident #1 is on [MEDICATION(S)], and ordered to send Resident #1 to the emergency room for further evaluation. A Physician's Order dated 09/09/2022 at 7:30 PM documented: Tylenol oral tablets 325 mg, give 2 tablets orally one time only for Pain for 1 day. A Nursing Evaluation/Documentation dated 09/09/2022 at 7:38 PM, written by the Registered Nurse Supervisor #1 (RNS # 1) documented that the type of event was a cut to the forehead with a raised bump, the License Practical Nurse #1 (LPN # 1) reported that CNA #1 responded to Resident #1's call. Resident #1 was observed sitting in their wheelchair in the hallway outside of their room door with a raised bump on their left forehead, and a small open area with blood on their face. Resident # 1 stated that Resident # 2 was trying to make up Resident # 1's bed. Resident # 2 had a footrest in his/her hand and when Resident # 1 told Resident # 2 that the bed was already made up, Resident # 2 turned around and the footrest hit Resident # 1 on their head. On assessment by RNS #1, the open area measured 1 cm and the hematoma was 4 cm. Ice compress was applied, and Resident #1 denied pain. The NP was notified, and Tylenol 325 mg, 2 tablets was given. A Neurological check was done. There were no changes in mental status. The order was to transfer Resident #1 to the ER for an evaluation. A Nursing Progress Note dated 09/09/2022 at 11:46 PM, written by LPN #1 documented that Resident #1 was transferred to the hospital for evaluation and CT scan due to resident altercation with hematoma to their left forehead. Neuro check was started. A Nursing Progress Note by LPN # 4 dated 09/10/2022 at 5:10 AM, documented that Resident #1 returned from hospital with a laceration to left side of head that was closed with Derma Glue. The diagnosis: Laceration of scalp without foreign body. The NP was notified and there was no new recommendation. Resident #1 received [MEDICATION(S)], [CONDITION(S)] and [MEDICATION(S)] Vaccine in the ER. A NP Progress note dated 09/10/2022 at 10:30 AM, documented that Resident # 1 was seen due to swelling and small bleeding cut to the head, is on [MEDICATION(S)]. Resident #1 was seen status post (S/P) ER return, now noted to be stable with Derma Glue, denies pain. Vital signs (Blood Pressure) B/P 119/65 (Pulse) P 83 (Temperature) T 97.5 Respiration (R) 18 Oxygen Saturation (SP 02) 97%, neurological checks ordered. A Nursing Progress Note written by LPN #5 dated 09/10/2022 at 3:51 PM, documented that Resident #1 was post resident altercation with hematoma to their left forehead. The resident was noted with dressing on their head. No complaint of pain. Neuro check in progress. A Hospital after Visit Summary dated 09/10/2022, documented that Resident #1's reason for the visit was a Laceration. Diagnosis Laceration of scalp without foreign body, The Laceration was repaired. A Computed Tomography (CT) scan of the head without contrast was done, there were no abnormal findings. Resident # 2 was admitted to the facility with diagnoses including Dementia with Behavioral Disturbance, Major Depressive Disorder and Hypertension. The MDS assessment dated [DATE], documented that Resident # 2 had a BIMS score of 02/15, indicating severely impaired cognition. Resident # 2 required supervision with ambulation and most other areas of his/her Activities of Daily Living (ADL) tasks. A CP titled Risk for Abuse, Neglect, Misappropriation and or Exploitation initiated on 08/31/2021, documented: interventions for staff to assess the resident for signs/symptoms of abuse and or neglect and report to appropriate resources, offer the resident food and or activities of interest while wandering, to help keep the resident occupied. The CP was updated to reflect on the incident of 09/09/2022 with new intervention to keep Resident #2 separated from Resident #1. A CP titled Resident exhibits behaviors of Paranoia, Wandering and Agitation due to Dementia initiated on 10/21/2021 documented: interventions for staff to administer [CONDITION(S)] meds as ordered, determine cause of behavior, and remove resident, distract resident with activities of interest and modify the environment to reduce episodes of negative behavior. A Psychiatry Consult dated 08/17/2022 at 7:53 PM, documented that the Resident # 2 was baseline confused, occasionally got paranoid, or even disinhibited, for example giggle for no reason. Resident # 2 was treated with psychoactive medication [MEDICATION(S)] in the hospital which was discontinued. Resident # 2 had physical altercation with peers in the past, the last event was 11/07/2021. Psychoactive medication is [MEDICATION(S)] 10 mg tablet daily for Depression. A Nursing Progress Note by RNS #1 dated 09/09/2022 at 7:15 PM documented that Resident#1 reported that Resident #2 was in Resident #1's room trying to fix the bed. Resident #2 had a footrest in his/her hand. Resident #1 went to Resident #2 and told Resident #2 that he/she didn't need to fix the bed. Resident #2 turned around and the footrest hit Resident #1 on his/her head. The NP was notified and ordered Completed Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Urinalysis (UA) and Urine Culture (UC) and to transfer Resident #2 to Hospital for Psychiatric evaluation. A nursing home to Hospital Transfer Form dated 09/09/2022 at 7:15 PM, documented that Resident # 2 was being transferred to the hospital for causing an injury to another resident. A NP Telehealth Progress Note dated 09/09/2022 at 8:10 PM, documented that Resident # 2 was assessed for to hitting his/ her peer in the head causing injury and was transfer to Psychiatric ER for further evaluation. A NP Progress Note dated 09/10/2022 at 11:00 AM, documented that Resident # 2 with diagnosis of Dementia and Behaviors was seen due to hitting peer (Resident #1) in the head causing injury. The resident was transferred to Hospital for Psychiatric evaluation. Resident # 2 was seen after returning from the ER, there were no new recommendations and Resident # 2 will resume current care. A RN Assessment Note dated 09/10/2022 at 1:14 PM, written by RN #1 documented that Resident # 2 returned from the hospital at 8:39 AM. Resident # 2 was alert and verbally responsive, pleasant, no behavior observed. T 97.6 B/P 126/74 P 82 R 20 SPO2 97% on room air. No apparent distress noted. During an interview on 09/13/2022 at 11:10 AM, Resident #1 stated that the incident with Resident # 2 was an accident. Resident #1 stated that Resident # 2 went into Resident #1's room on 09/09/2022 at around 8:00 PM. Resident #1 stated that he/she was sitting in his/her wheelchair in his/her room between the two beds, towards the foot of the bed. Resident # 1 stated that he/she observed Resident # 2 tried to get into Resident #1's bed. Resident # 1 stated that he/she stood up from his/her wheelchair and tried to stop Resident # 2 from going into Resident # 1's bed. Resident # 1 stated that Resident # 2 then pushed him/her, and Resident #1 fell on the floor on his/her buttock near the foot of the beds. Resident #1 stated that he/she held unto his/her bed and stood up. Resident # 1 stated that Resident # 2 then grabbed Resident # 1's roommate's (Resident #3's) wheelchair footrest which was inside the roommate's wheelchair and hit Resident # 1 on his/her forehead. Resident # 1 then said he/she didn't want to talk anymore, he/she was tired talking about what happened. During an interview on 09/13/2022 at 11:20 AM, Licensed Practical Nurse #2 (LPN # 2) stated that he/she was not on duty when the incident occurred. LPN # 2 stated that upon return to work, on 9/10/2022, Resident # 1 informed him/her that Resident # 2 pushed Resident #1 on the floor and hit Resident #1 with the wheelchair footrest on Resident #1's forehead because Resident #1 tried to stop Resident # 2 from going into Resident #1's bed. During an interview on 09/13/2022 at 3:00 PM, Certified Nursing Assistant # 2 (CNA #2) stated that he/she was assigned to Resident # 2. CNA # 2 stated that prior to the incident on 9/9/2022, he/she last saw Resident # 2 at 7:00 PM, lying in bed. CNA # 2 said he/she had just completed hallway watch at 7:00 PM. CNA # 2 stated that he/she then went to take care of another resident. CNA # 2 stated that Resident # 2 often wandered, and he/she redirected Resident # 2 as needed. CNA # 2 stated that he/she received in-service on keeping wheelchair footrests attached to wheelchairs or in residents' closets. During an interview on 09/13/2022 at 3:15 PM, CNA #1 stated that on 9/9/2022 around 7:15 PM, Resident # 1 called him/her when they came off the elevator. Resident # 1 was sitting in their wheelchair in the hallway, near their room. CNA # 1 stated that he/she observed Resident # 1 holding their head and some blood was coming from Resident # 1's left side forehead. CNA # 1 stated that Resident #1 informed him/her that Resident # 2 hit them with the wheelchair footrest. CNA #1 stated that he/she called LPN #1 and reported what Resident # 1 told him/her. CNA # 1 stated that he/she applied pressure to the wound with a towel. CNA #1 was assigned to Resident # 1 and stated that he/she had last seen Resident # 1 at 5:30 PM when he/she gave Resident # 1 their dinner tray. CNA # 1 stated that he/she went on his/her break at 6:15 PM, and returned around 7:15 PM. CNA # 1 stated that Resident # 1 usually sat quietly in the hallway and was able to get up from their wheelchair and wheel themselves independently. CNA # 1 stated that he/she received in-service on keeping wheelchair footrests attached to wheelchairs or in residents' closets. During an interview on 09/13/2022 at 5:10 PM, LPN # 1 stated that on 09/09/2022 at around 7:15 PM, CNA # 1 shouted for him/her to check Resident #1. LPN # 1 observed Resident #1 with bleeding from their forehead wound and started first aid treatment with applying pressure and ice. LPN # 1 stated that Resident # 1 stated that Resident # 2 hit him/her with the wheelchair leg rest. LPN # 1 stated that Resident #1 stated that Resident #2 was making up Resident #1's bed and then hit Resident with the footrest when Resident # 2 turned around. LPN # 1 stated that he/she observed Resident # 2 standing near Resident # 1. During an interview on 09/13/2022 at 5:20 PM, Registered Nurse Supervisor # 1(RNS #1) stated that he/she was called to the residents' unit shortly after 7:00 PM. RNS # 1 stated that Resident #1 had a bump and an approximately 1 cm laceration on their left forehead. RNS # 1 stated that the bleeding had subsided. RNS # 1 stated that Resident # 1 stated that Resident # 2 went into Resident #1's room. Resident # 2 wanted to make Resident #1's bed, Resident # 2 had a wheelchair footrest in his/her hand and the footrest hit Resident # 1 when Resident # 2 turned. RNS # 1 stated that cold compress was applied to Resident #1's forehead and Resident # 1 was transferred to the hospital. RNS # 1 stated that Resident #1 stated that it was an accident. During an interview on 09/13/2022 at 5:45 PM, CNA # 3 stated that on 09/09/2022, he/she was assigned to hallway watch from 6:00 PM-7:00 PM. CNA # 3 stated that he/she had seen Resident # 2 in their room earlier (could not recall the time) but did not see when Resident # 2 came out of their room and went into Resident # 1's room. CNA # 3 stated that he/she received in-service on keeping wheelchair footrests attached to the wheelchairs or placing them in closets. During an interview on 09/14/2022 at 9:45 AM, the Director of Nursing (DON) stated that RNS # 1 made him/her aware of the incident involving Resident # 1 and Resident # 2 on 09/09/2022 around 7:35 PM. The DON stated that he/she was informed that the incident was accidental and without intent. The DON stated that he/she spoke with Resident # 1 on 09/12/2022 and 09/13/2022 but Resident # 1 did not say much. The DON stated that Resident # 1 stated it was an accident and Resident # 2 was their friend. The DON stated that staff were in-serviced on keeping residents' wheelchair footrest attached to the wheelchairs or placing them in the residents' closets. The DON stated that residents are monitored 24 hours around the clock daily with staff assigned to hallway monitoring. The DON stated that staff took turns to monitor the residents for half hour periods. During an interview on 09/14/2022 at 11:35 AM, the Nurse Practitioner (NP) stated that he/she was called on 09/09/2022 around 7:15 PM and saw Resident #1 by Telemedicine visit. The NP stated that he/she saw mild to moderate bleeding from an open area on Resident #1's forehead. The NP stated that Resident #1 stated that he/she (Resident #2) hit them on their head. The NP stated that Resident #1 stated that he/she had no pain. The NP stated that he/she gave orders to send Resident #1 to the ER. During a follow up telephone interview on 09/19/2022 at 12:10 PM, CNA #1 stated that when he/she responded to Resident #1 call on 09/09/2022, he/she observed Resident # 2 standing at Resident # 1's bedside holding on to Resident # 1's bedsheet and Resident # 3's wheelchair footrest was on the floor next to Resident # 2. CNA # 1 stated that Resident # 2 usually wandered around the unit and into other residents' rooms. CNA #1 stated that he/she and the unit staff redirected Resident # 2 as needed. During a follow up interview on 09/19/2022 at 11:38 AM, the NP stated that during the Telemedicine visit on 09/09/2022, he/she also observed Resident # 1 with mild swelling on their left forehead around the open area. The NP stated that the swelling was not a hematoma. 10 NYCRR 415.12(h)(2)

Based on observation, record review and interviews conducted during the Recertification and abbreviated survey (NY# 493) from 02/23/2022 through 03/03/2022, the facility did not ensure that each resident remained free from physical restraints not required to treat the resident's medical symptoms. This was evident for 11 of 12 residents sampled for Physical Restraints (Resident #s 199, 260, 113, 191, 126, 110, 55, 295, 63, 503, and 157). Specifically, Resident #260 and Resident #113 had bilateral half SR ordered as enablers. The residents had severely impaired cognition, required extensive assistance with bed mobility and transfers, and the half SR were not identified as a restraint. There was no medical justification, restraint assessment, care plan, or evidence of alternatives attempted before using the bilateral half SR. Resident #s 191, 126, 110, 55, 295, 63, 503, and 157 had impaired cognition and required extensive assistance for bed mobility and transfers. They all had bilateral half siderails as an enabler, but they were unable to release the side rails to independently get in and out of bed. These side rails were not identified as a restraint and had no medical justification, family/resident education regarding the risks and benefits of restraint use, or restraint assessment. Resident #199, diagnosed with Dementia and severely impaired cognition, was found to have a swollen left eye on 01/09/2022. The Certified Nursing Assistant (CNA #13) reported that Resident #199 was observed with their face against the side rails (SR) with their legs on the floor. The facility investigated the incident and failed to identify the side rails as a restraint. The interdisciplinary team (IDT) met and determined the side rails were still appropriate to promote independence for the resident. On 02/19/2022, Resident #199 was found kneeling on the floor mat with head between the side rail and the bed. A facility team meeting note dated 02/21/2022 documented that the side rails were identified as a potential restraint. The team discussed risk and benefits of the rails and decided to remove the rails and replace them with a concave mattress. There was no documented evidence in the medical record that there is a medical justification for the use of the concave mattress, a restraint assessment, care plan, or alternatives prior the use of the Concave Mattress. This resulted in Immediate Jeopardy with the likelihood for serious, injury, serious harm, serious impairment, or death to all residents using side rails other devices that were potential restraints. Immediate Jeopardy (IJ) was identified and declared. IJ began on 2/19/2022 and was called on 02/23/2022 at 7:04PM. The facility submitted an IJ removal plan on 2/23/2022 with a revision on 2/24/2022. IJ was removed on 02/28/2022 at 6:38PM. The findings include but are not limited to: The Policy and Procedure for Restraints dated 09/2021 documented: Residents have the right to be free from physical or mental abuse, corporal punishment, involuntary seclusion and any physical or chemical restraint imposed for purposes of discipline or staff convenience and not required to treat the resident's medical symptoms. The Policy and Procedure for Side Rails dated 09/2019 documented: It is the policy of this facility to ensure residents attain and maintain their highest practicable level of well-being and be free of restraints. Each resident will be assessed for functional status on admission, readmission, and quarterly, for any significant change and as needed. Side rails will only be used by a resident to assist with his or her bed mobility. Side rails will not interfere with the resident's ability to egress from the bed surface. Side rails will be analyzed for safety and prevention of entrapment. The Policy and Procedure for Concave/Perimeter Mattress Use dated 09/2021 documented that the facility may choose to add a concave/perimeter mattress to improve a resident's safety and or comfort while sleeping in bed. 1) The Facility's Investigation dated 02/22/2022 documented on 02/19/2022, Resident #199 was observed kneeling on the floor mat on the right side of the bed. Staff noted that her/his head was between the siderail and the mattress. The nurse was notified, and the resident was removed from the kneeling position and the siderail. Resident #199 was assessed and noted with a reddened area, measuring 1.5 cm (centimeters) by 0.5 cm, to the forehead. Resident #199 did not display any signs or symptoms of pain and denied pain. The CNA demonstrated the position in which the resident was found. The resident's face was in the downward position and the siderail was noted to be against the resident's left temple area. The resident's airway was clear, and the resident was alert with vital signs within normal limits. The resident was unable to dislodge herself/himself, however, the position in which the resident was found did not indicate there was an imminent threat of significant or life-altering injury. The resident was assessed the month prior, and the SR were deemed non-restraint and appropriate to facilitate bed mobility. The facility side rail monitoring for entrapment risk was reviewed, and the resident's SR met state and federal guidelines. The investigation concluded the incident was unpredictable and unavoidable due to the resident's poor safety awareness, and there was no evidence to support that any abuse, neglect, mistreatment, or misappropriation may have occurred. Resident #199 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #199 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severely impaired cognition. The MDS documented Resident #199 required extensive assist of two or more staff for bed mobility and needed to be transferred using a Hoyer lift. Physical restraints and bedrails were not used for the resident. On 2/23/22 at 5:21PM, Resident #199 was observed in bed sleeping with a concave mattress in place. The bed was in the lowest position with bilateral floor mats in place. The Comprehensive Care Plan (CCP) for Risk for falls dated 11/21/2018 documented Resident #199 was at high risk for falls. The CCP for Non-restraint SR dated 12/21/2018, revised 08/04/2021, documented Resident #199 used SR for increased independence and mobility. Interventions included: Educate resident on how to safely move in bed with assist of SR; Offer resident assistance with position change and bed mobility often during the shift; and Orient resident to call light and safety measures. The CCP for Activities of Daily Living (ADLs) dated 05/13/2021 documented Resident #199 required extensive assist of 2 staff for bed mobility, dressing, personal hygiene, toilet use and transfers. The SR assessments dated 03/10/2021, 06/02/2021 and 09/09/2021, documented Resident #199 used the SR as an enabler. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This was the only side rail order entered for the resident. A Physical Therapy (PT) note dated 12/16/2021 at 5:00 PM documented Resident #199 was unable to safely perform sit-to-stand or bed-to-wheelchair transfers without total assistance due to confusion. Resident #199 was unable to follow instructions. The CNA Assignment Tasks dated 01/01/2022 documented Resident #199 was totally dependent (unable to participate in the activity) and required two staff members for bed mobility and transfers with Hoyer lift. Resident #199 could not assist with rolling on/off the lift sheet. There was no documented evidence that other devices were used for enablers prior to the use of half SR. There was no evidence the resident was observed using the half SR as an enabler. The bilateral half SR were not identified as a restraint. A Nurse's note, by Licensed Practical Nurse (LPN) #2, dated 01/09/2022 at 7:47AM documented Resident #199 was observed in bed with swelling to the left eye. As per the Certified Nursing Assistant (CNA #13), Resident #199 was observed with their face against the SR with their legs on the floor. An Incident report dated 01/09/2022, documented by the RN Supervisor (RNS #1), revealed that RNS #1 was called to the 5th floor because Resident #199 had left eye swelling. RNS #1 was told that the left side of Resident #199's upper body was against the siderails, and the resident's legs were on the floor. Resident #199 was trying to slide to the floor. A cold compress was applied. The Facility's investigation, completed by the Director of Nursing (DON), dated 01/09/2022 documented that Resident #199 was noted with discoloration and ecchymosis to the left eye. Upon discovery, Resident #199's left side was leaning on the side rail with the side of the resident's face against the siderail. Resident #199 was trying to slide to the floor. The investigation concluded the injury was not a consequence of having the side rails, rather incidental due to the resident's attempt to place self on the floor. The Interdisciplinary team (IDT) met to determine if Resident #199 still required side rails and decided side rails were still appropriate to promote independence for Resident #199. The half side rails were continued and not identified as a restraint. There was no documented evidence the facility assessed the resident to determine if the resident could demonstrate the ability to release the side rails and use the half side rails as an enabler. A Nurse's note, by LPN #7, dated 02/19/2022 at 3:58AM documented Resident #199 was observed kneeling on the floor mat with their head between the SR and the bed. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nurse's note, by Director of Nursing (DON) dated 02/21/2022 at 4:25PM documented Resident #199 was status post [MEDICAL RECORD OR PHYSICIAN ORDER] . The assist rails were removed for trial basis. Floor mats continued for safety to prevent injury. There was no documented evidence in the medical record that there was a medial justification for the use of the concave mattress, a restraint assessment, care plan, or alternatives attempted prior to the use of the concave mattress. During an interview on 02/28/2022 at 8:37AM, CNA#13 reported that he/she worked on the 5th floor on 02/19/2022 and observed Resident #199 kneeling on the floor mat at approximately 3:30AM. CNA #13 stated the resident's head was stuck facedown between the mattress and side rails. CNA #13 stated that while he/she was waiting for RNS #2, the resident was restless and moving around. CNA #13 assisted the resident back to bed as the resident was not staying still on the floor. CNA #13 stated that he/she never observed the resident using the side rails independently to move around in bed. CNA #13 reported was not aware that half side rails can be a potential restraint. CNA#13's re-enactment of how Resident #199 was found, revealed the resident's knees were on the floor and his/her head was face down, stuck between the siderail and mattress. During an interview on 02/26/2022 at 10:10AM, LPN #7 reported that he/she worked on the 11-7 shift on 02/19/2022. LPN #7 stated that CNA #13 made rounds at 3:30AM and observed Resident #199 kneeling on the floor. LPN #7 stated that he/she observed the resident's knees on the floor mat and the resident's face between the mattress and side rail. LPN #7 stated that he/she and CNA #13 repositioned the resident on the floor mat and called the Registered Nurse Supervisor (RNS #2). LPN #7 stated the resident used the SR to move up and down in the bed, but LPN #7 never observed Resident #199 using the SR to move or turn and position self in bed. LPN #7 stated the resident could not release the SR or move the SR up and down. On 02/26/2022 at 10:10 AM, LPN #7 re-enacted the position they found Resident #199 in prior to RNS #2's arrival, demonstrating the knees were on the floor mat with the head stuck face down between the side rails and the mattress. During an interview on 02/24/2022 at 9:40AM, LPN #3 stated Resident #199 could hold onto the SR during care when prompted by staff. LPN #3 stated Resident #199 kept sliding out of the bed, and the half SR were put in place to prevent the resident from falling out of bed. During an interview on 02/24/2022 at 10:24AM, RNS #2 stated LPN #7 called him/her to the unit on 2/19/2022. When he/she entered Resident #199's room, Resident #199 was in bed. RNS #2 stated LPN #7 and CNA #13 reported that the resident's head was between the side rail and mattress, and the knees were on the floor mat. RNS #2 stated that LPN #7 reported that LPN #7 put the resident back in bed for safety reasons. RNS #2 stated the resident was assessed and observed with a discoloration to the right side of the forehead. RNS #2 reported he/she was aware that the siderails can be used a restraint, but the SR were considered enablers. During an interview on 02/24/2022 at 10:35AM, the Medical Director (MD #4) stated that he/she was aware that Resident #199's cognition was impaired. MD #4 stated that Resident #199 was assessed by the Physical Therapist (PT #1) and the Occupational Therapist (OT #1) upon admission, and Physical Therapy (PT) and Occupational Therapy (OT) demonstrated how to use the side rails with Resident #199. MD #4 stated that some residents with impaired cognition, who ambulate without assistance from staff, used the SR as an enabler for bed mobility to assist in pulling themselves up in bed and for turning and position. MD #4 stated that Resident #199 used the SR as an enabler. MD #4 reported he/she never saw Resident #199 used the siderails to pull themselves up or turn and position. MD #4 reported he/she did not consider the half side rails a potential restraint. During an interview on 03/03/2022 at 9:40AM, the MDS Coordinator (MDSC # 9) stated a restraint is any object that restricts the resident's movement. The MDS manual dated October 2019 documents if a resident is immobile and cannot voluntarily get out because of physical limitation or because proper assistive devices were not present, the bedrail does not meet the definition of physical restraint. The MDSC stated there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDSC stated that he/she never saw the resident use the side rails to turn and position in bed. MDSC did not consider the siderails as a potential restraint until they were in-service on the topic after the IJ was called. During an interview on 03/03/2022 at 10:00AM, the Physical Therapist (PT #1) stated that the resident was assessed for bed mobility and would benefit from using the siderails to turn and position self in bed. PT #1 stated Resident #199 could hold onto the siderails independently. PT #1 stated that he/she did not assess the resident's ability to release the side rails or move the SR up and down because the resident was not able to follow commands and staff provided total care for bed mobility. PT #1 stated that they did not consider the siderails as a potential restraint until they were in-service on it after the IJ was called. During an interview on 02/28/2022 at 4:23PM, the Director of Nursing (DON) stated upon admission all residents are assessed by physical therapy for bed mobility. The DON stated if residents can benefit from side rails to aid in their bed mobility, then PT will recommend side rails as an enabler. The DON stated that the Interdisciplinary team (IDT) meets after every fall to discuss appropriate interventions and involve the resident and resident representative. The DON stated the IDT considers the resident's mental status, ADL status, and the risk and benefits prior to the initiation of any type of restraint. The DON stated after the IDT meeting and discussion with the Nurse Practitioner (NP), it was decided that Resident #199 would benefit from side rails to assist with bed mobility. The DON stated Resident #199 requires 2-person assist with bed mobility. The SR were used for Resident #199 to hold onto during care and for safety and security. The DON stated Resident #199 is totally dependent and cannot rise on their own without staff assist. The DON stated that the facility did not view the side rails as a restraint because it did not restrict Resident #199's freedom of movement. Resident #199 was able to grab onto the siderail to assist in turning and positioning. The DON stated after the incident with the side rails on 02/19/2022 the IDT met and decided they would place Resident #199 on a concave mattress on a trial basis for safety and security after Resident #199 had several falls within a three-month period. 2) Resident #260 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #260 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating severely impaired cognition. Resident #260 required extensive assist of two or more persons for bed mobility and extensive assist of one person for transfers. The Care Plan for Non-restraint Side rails dated 02/23/2022, revised 02/24/2022, documented Resident #260 used side rails for increased independence and mobility. Interventions included: educate resident on how to safely move in bed with assist of side rails, offer resident assistance with position change and bed mobility often during the shift, orient resident to call light and safety measures, and reevaluate side rail use quarterly and as needed. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented evidence Resident #260 was assessed for side rails used as a restraint. There was no documented evidence the resident was educated on how or demonstrated the ability to use the SR for bed mobility or release the SR to get in and out of bed. There was no documented evidence that Resident #260's designated representative was educated about the risks and benefits of side rails used as a potential restraint. 3) Resident #113 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that Resident #113 had a Brief Interview for Mental Status (BIMS) score of 2 out of 15, indicating severely impaired cognition. The resident required extensive assist of one staff for bed mobility and transfers. The Care Plan for Non-restraint Side rails dated 09/18/2021, revised 02/24/2022, documented Resident #113 used side rails for increased independence and mobility. Interventions included: educate resident on how to safely move in bed with assist of side rails, offer resident assistance with position change and bed mobility often during the shift and orient resident to call light and safety measure, reevaluate side rail use quarterly and as needed. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented evidence Resident #113 was assessed for restraints or bedrails prior to 2/23/22. There was no documented evidence the resident was educated on how or demonstrated the ability to use the SR for bed mobility or release the SR to get in and out of bed. There was no documented evidence that Resident #113's designated representative was educated about the risks and benefits of side rails used as a potential restraint. Immediate Jeopardy (IJ) was identified and declared. The facility Administrator and Director of Nursing were notified on 02/23/2022 at 7:04PM. The facility submitted a removal plan that was reviewed and accepted by NYS DOH on 02/23/2022 at 9:43 PM. The removal plan was revised on 02/24/2022 at 5:32PM after the initial plan due to continued issues. On 02/28/2022 at 6:38PM, the survey team declared the IJ was removed based on the following corrective actions taken by the facility: · Observations were conducted on all floors from 02/25/2022 to 02/28/2022. There were no observed concerns related to side rail use or other restraints. · The facility re-evaluated all residents who had side rails in use. The facility completed a side rails assessment, rehab assessment, medical assessment, IDT meeting, and family/resident notification. On 02/23/2022, the day IJ was called, the facility had 51 side rails in place. By 02/28/2022, the facility removed 49 side rails, leaving only 2 residents with side rails in use. · Resident #199 record review and observation completed to confirm immediate corrections. Resident re-assessed and concave mattress discontinued. CCP updated. · Additional sampled residents also reviewed to confirm all assessments, revised orders, updated care plans, IDT, and resident/family notification was completed. · Reviewed revised policies and procedures for Physical Restraint Use and Side Rails. · Reviewed in-service lesson plans and sign-in sheets to confirm the following staff were in-serviced on restraints/side rails: Activities/Recreation 8/8 = 100%; Administration/Finance/Human resource/staffing/Medical Records/Security 16/16= 100%; CNAs 113/125 = 90%; Dietary/dietary 23/24 = 96%; LPN 38/46 = 83%, Housekeeping/maintenance 24/25 =96%, Nurse Practitioner/MD 5/5 = 100%, Nursing Supervisors 16/21 = 76%, Social Worker 4/4 = 100%, Therapy 28/35 = 80%. · Interviews were conducted with the following staff: DON, Administrator, 25 CNAs, 8 LPNs, 4 RNs, 6 Housekeepers, 3 Occupational Therapists, 4 Physical Therapists, 1 Speech Therapist, 1 Nurse Practitioner, 1 Social Worker, 2 dietary Aides, 2 maintenance workers. All staff were in-serviced and knowledgeable on Restraints and Side Rails. Based on observations, interviews and record review conducted on 02/28/2022, the facility fully implemented the revised Immediate Jeopardy Removal Plan, and the Immediate Jeopardy was removed as of 02/28/2022 at 6:38PM. 415.4(a)(2-7)

Based on observation, record review and interview conducted during a Recertification survey, the facility did not ensure a clean, comfortable and homelike environment and maintenance and housekeeping services to maintain an orderly and comfortable interior were provided. Specifically, 1)dining tables had rust on the bottom and leg areas, 2) holes in the walls, and 3) resident rooms were observed with missing and peeling wallpaper, unfinished plaster, dirty walls and radiator covers. This was evident for 3 out of 6 floors observed for the Environment (Floors 2, 5, and 6). The findings are: Multiple requests were made for the Environmental Services Policy. The facility did not provide a copy of the requested environmental policy. 1) On 02/28/22 12:12 PM to 12:37PM and on 03/02/2022 at 12:09 PM residents were observed in the dining room awaiting lunch meal. The moveable resident table being used by staff to feed residents in lunchroom on 2nd floor was noted with a rusted foot pedal, rust on the bottom 6 inches, and food stains in two areas on the dining table. On 02/28/2022 at 12:55 PM, Resident #186 was noted sitting between room 229 and 231 and white colored stains on metal on bedside dining table on both sides of feet area while resident eating lunch meal. CNA staff, LPN and Director of Dietetics present assistance with lunch meal. On 02/28/2022 at 04:59 PM, on 03/01/2022 at 12:27 PM, on 03/02/2022 at 12:23 PM, on 03/03/22 10:52 AM, on 03/03/22 10:54 AM, on 03/03/2022 at 10:59 AM, and on 03/03/2022 at 11:01 AM residents were observed being served a meal from tables with rust and food stains. During an interview on 03/02/2022 at 12:11 PM, a 2nd floor Certified Nursing Assistant (CNA) #7 stated that they did not notice the rust on the tables. CNA #7 stated the dining room should be presentable and the table should not be rusty. On 03/02/2022 at 12:18PM, an interview was conducted a 2nd Floor Licensed Practical Nurse (LPN) # 4 (on the 2nd Floor) who stated the dining tables are old, but they are cleaned daily. On 03/02/2022 at 12:29 PM, an interview was conducted with LPN #6 who stated that they did not notice the rust on the tables before, but the rust should be cleaned. LPN #6 stated the tables were new and received a few weeks ago. Maybe the table should be changed, and the rust may be due to storage. LPN #6 stated the tables should be presentable. On 03/02/2022 at 12:24PM, an interview was conducted with the 2nd floor Housekeeper (HK#1) who stated the clean twice daily in the morning and afternoon. They clean and disinfect the tables to reduce germs. On 03/02/2022 at 12:48PM, an interview was conducted with Maintenance Worker (MW#1) who stated that they take care of the dining tables and bedside tables. MW#1 stated they do rounds daily on the units and the maintenance supervisor does weekly rounds on the units. MW#1 stated they inspect the dining tables to make sure they roll properly and ensure the top is not damaged. MW #1 stated maintenance staff will check all tables today and clean them up. MW #1 stated residents should have a nice environment. On 03/03/2022 at 12:05 PM, an interview was conducted with the Director of Housekeeping (DOHK) who stated they were informed of the concern related to the resident tables. The DOHK stated they ordered new tables, but there is a delayed delivery. The DOHK stated Housekeeping staff clean the tables to make them presentable. The bedside tables should be presentable because the residents must feel comfortable, as this is their home. The DOHK stated the tables will be replaced. On 03/03/2022 at 3:36PM, an interview was conducted with the Director of Nursing (DON) who stated the facility plans to renovate the 2nd and 3rd floors. Environmental rounds are done by the DON and administration on a weekly basis, and they make note of things that need to be corrected and fixed. The notes are given to maintenance and housekeeping and prioritized on what needs to be done first. 2) On 02/23/22 at 10:06 AM, in room 510, five holes approximately the size of dimes were observed in the wall next to the paper towel dispenser. On 02/24/22 at 08:41 AM, 02/28/22 at 11:31 AM, 03/01/22 at 09:44 AM, and 03/02/22 at 09:37 AM the same was observed. On 03/02/22 at 12:47 PM, the Maintenance Worker (MW) # 1 was interviewed. MW #1 stated they were not regularly assigned to the 5th floor. The MW assigned to the floor will make daily rounds and report back to the supervisor with any issues. MW #1 stated the supervisor makes rounds on all the units once a week. The State Agent (SA) showed MW #1 the holes in the wall in room #510. MW #1 was not aware of the holes in the wall in room #510. MW #1 stated the soap dispenser was missing from the wall. MW #1 stated they will replace the soap dispenser. On 03/02/22 at 01:07 PM, MW #1 followed up with the maintenance supervisor. MW #1 stated the supervisor stated the resident continuously rips the soap dispenser out of the wall and the facility keeps replacing it. On 03/03/22 at 10:50 AM the Director of Maintenance (DOM) was interviewed. The DOM stated the goal is to keep the facility safe and with a homelike environment for the residents. The DOM stated every morning the maintenance department workers meet and discuss situations in the building and what has to be done during the day. The DOM stated they check maintenance books and create a schedule for the day. The DOM reported in room 510 the resident ripped the soap and paper towel dispenser out of the wall approximately one week ago. The DOM reported they replaced both items and the resident ripper the soap dispenser out of the wall again. The DOM reported the 5th and 6th floors have behavioral issues and they constantly have to replace items and fix things. 3) Room 607 Bed A was observed on 2/23/22 at 9:37 AM. The window wall baseboard is off, and the wall is not painted toward the bottom. The wall opposite the bed has paneling that is detached at the seam, and the vent cover needs painting. Room 607 Bed B was observed on 3/03/22 at 12:14 PM with wallpaper seam open to the left of bed. Wallpaper was missing toward the bottom of the wall. There were phone numbers written on the wallpaper for 2 people (aunt and cousin) to the left of the bed. The corner bead on the television wall, right side, was missing a cap. Room 608 was observed on 2/23/22 at 9:51 AM with the plastic corner bead cap missing and a broken piece hanging from the right side at the top. The soffit above the television was dirty with brown spots. The wall behind the closet and behind the room door is missing paint. Room 610 was observed on 2/23/22 at 9:53 AM and 3/03/22 12:30 PM. There is a hole in the wall to the left of the closet. Next to the hole is a bracket and the wall is cracked. The wallpaper is mismatched to the left of the bed. Room 612 Bed B was observed on 2/23/22 at 10:00 AM. The wallpaper behind the bed was missing. Room 613 Bed A and B were observed on 3/03/22 at 12:09 PM. The beds were not aligned with the overbed lights on the wall so that the resident did not have access to the pull-string to turn the light on or off. The window wall was patched / plastered and missing wallpaper. To the right of the radiator, the bottom section of wall was cracked with bubbled paint. Room 623 Bed A was observed on 2/23/22 at 10:16 AM. There was some missing wallpaper behind the bed and brown spots on the wallpaper that was in place. The overbed light frame had rusty edges. On 3/03/22 at 12:18 PM, 623 Bed B was observed with the wall plates over the bed rusted. To the left of Bed B, wallpaper was missing toward the bottom of the wall. During both observations of Room 623, the radiator was dirty with brown spots, and the wall to right of radiator was also dirty with brown residue. Room 626 Bed A was observed on 2/23/22 at 10:43 am and 3/3/22 at 12:25 pm with wallpaper torn at the foot of the bed as well as the wall being cracked next to the electrical outlet. The room walls had scratched up paint. Room 626 Bed C was observed on 2/23/22 at 10:39 AM, 2/24/22 at 9:26 AM and 3/3/22 at 12:25 PM. The wallpaper was torn with broken plaster showing to the right of the bed and behind the bed. The walls were dirty all around the room, including the radiator cover with brownish color spots. There was a hole in the wall to the right of the bed. There was wallpaper peeling behind the bed and an unfinished patch of plaster below the overbed light. The sink wall had unpainted plaster patches. An interview was conducted on 03/03/22 at 12:35 PM with the Director of Housekeeping (DH). The DH stated Houskeeping has a schedule for detailed room cleaning, which include walls, mattress, and bed frame. The windowsill is cleaned every day along with the sink and toilet. Each room is detailed twice a month. DH stated they do audits once a month per unit, to look to see if the rooms are clean, including vents and bathrooms. An interview was conducted on 03/03/22 at12:40 PM with the Director of Maintenance (DM) with regard to repairs on resident units. The DM stated for repairs upstairs, there is a maintenance log book on each unit accessible to everyone to write in. Nurses, housekeepers, and even visitors can document concerns in the log. People can also call the maintenance office to report concerns. The DM stated their goal is safety and homelike environment with a comprehensive maintenance program. In the morning, they have a meeting with their staff to discuss the previous day and what has to be done today. The DM assigns one person who checks the log book every day. They note what has to be done. If there are too many things, another guy is added. The other staff with more work like electrical construction, plumbing. The DM stated they make rounds every day, checking 3 rooms from the building. There is a detailed check list for rounds. The DM stated they went to room 610 on February 15, 2022. At that time, the findings were a couple of scratches on the wall, the light did not have a pull string, but everything else was okay. At the time, there was no hole in the wall. The wallpaper, etc. is a work in progress. The 5th and 6th floors are psychological floors, and they are constantly working on the constant problems on those units. 415.5(h)(2)

Based on observations, record review, and staff interviews conducted during the Recertification and Complaint survey, the facility did not ensure procured food was stored, prepared, distributed, and served in accordance with professional standards of food service safety. Specifically, expired thickened apple juice stored in the kitchen storeroom was not discarded on or before the expiration date. This was evident during the Kitchen Observation facility task. The findings are: 1) The facility policy and procedure titled, Food Storage Policy revised /,d+[DATE] documented all stock must be rotated with each new order received. Rotating sock is essential to assure the freshness and highest quality of all foods. Old stock is always used first (first in-first out method). Supervise the person designated to put away to make sure it is rotated properly. The policy Thickened Liquids revised ,d+[DATE] documented the food service department must serve pre-thickened and/or thickened all beverages and soups to residents on modified fluid consistencies prior to delivery on units. Alterations to the consistency of food and fluid presented to the individual is made in accordance with the recommendation of a speech and language pathologist and is implemented according to the order of the persons primary care provider/doctor. Pre-thickened liquids are available in all consistencies from commercial food service supplier. On [DATE] at 08:55 AM expired boxes of thick and easy clear thickened apple juice were observed in the Kitchen storeroom on a tier metal shelf. There was 1 box with an expiration date of [DATE], 2 boxes with expiration dates of [DATE], 4 boxes with expiration dates of [DATE], 2 boxes with expiration dates of [DATE] and 1 box with expiration date of [DATE]. On [DATE] at 9:20 AM, an interview was conducted with the Dietary Aide (DA#1). The DA#1 stated they are the primary person in charge of the storeroom. Deliveries come in on Thursdays and these items got away from them. We get ,d+[DATE] trucks in 1 day of food items that we put away in storage. These are small boxes. I usually check the stickers. I last checked the stickers 2 weeks ago. It can cause resident danger if it is expired. Use by date means you have to use before the time they expire. On [DATE] at 09:25 AM, an interview was conducted with the Food Service Director (FSD) who stated, I check the storeroom 2 times a week. Most of the time look for expired items and items with upcoming expiration dates. Because expired items are a potential to get a resident sick. There are two staff responsible for setting up trays and they check the expiration dates of items before they use them. On [DATE] at 09:30 AM, an interview was conducted with Dietary Aide #2 (DA#2) who stated they check the dates. I sometimes forget to tell the storeroom person or supervisor that we have expired thickened juice. If item is past the expire date, it should be thrown out and I won't use past the date on item. Use by means you have to use by a certain time. On [DATE] at 09:42AM, an interview was conducted with Dietary Aide #3 (DA#3) who stated I am in charge of putting thickened water and juice on trays. I check expiration dates to make surewe are using the right one. I have been in-serviced about First in First Out (FIFO) training. When I notice expired items I tell the director or the storeroom person. If we give residenst something that is expired and the resident get sick it will fall back on me. As I am are the one who set it up. Residents can get sick eating expired items. A Resident eating expired stuff would be resident abuse. This is their home and have to treat them like you want to treat your family. Sometimes I have to ask myself, will you eat an expired item, so why give it to them. On [DATE] at 3:36PM, an interview was conducted with the Director of Nursing (DON)/Infection Preventionist who stated, I have not heard of any issues with expired foods going upstairs. We do random audits and more of quality control. Audits happen every ,d+[DATE] months in the kitchen. There have never been any issues. Anything with shelf life needs to be rotated. 415.14 (h)

Based on observation, record review, and interviews conducted during the recertification survey the facility did not ensure a quality assurance and performance improvement (QAPI) program that put forth good faith attempts to identify and correct quality deficiencies. Specifically, the facility had repeat deficiencies from the previous recertification surveys (May 2019 & December 2017) in the areas of right to be free from physical restraints (F604) and care plan timing and revision (657). There was no evidence there was a QAPI plan in place to meet the specific needs of the facility. Findings include: The facility Policy & Procedure titled, Quality Assurance and Performance Improvement Plan dated 1/1/2021 documented the facility will develop, implement, and maintain an ongoing, facility-wide QAPI plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems. The policy further documented it will provide structure and processes to correct identified quality and/or safety deficiencies, establish and implement plans to correct deficiencies, and to monitor the effects of the action plans on resident outcome. On 03/03/22 at 03:32 PM the Director of Nursing (DON) was interviewed. The DON reported the QAPI team will identify any issues during daily routines such as morning report, rounds, staff identified issues, family concerns, resident counsel, etc. The QAPI team meets monthly to discuss issues, see identified issues are improving, and discuss if any areas are not improving how the facility can adjust the plan. The facility will conduct audits, get feedback from whoever it is effecting to see what is working and what is not working, review and collect report. Once issues are identified the facility will set a target for an acceptable goal. When the target is reached the facility will revisit the issue to see if the improvement is there. The DON reported the goal is long term improvement. The DON was asked why the QAPI team did not identify side rails as restraints for residents with limited mobility and cognitively impairment. The DON reported restraints are reviewed every 3 months and episodically. Up until this point side rails did not fall under the category of something the facility considered a restraint. The DON reported after an incident involving side rails the facility will look at side rails to rule out the possibly of entrapment. If the team can identify another intervention they will implement it. After Immediate Jeopardy was determined the facility did education on identification of rails as a potential restraint. The DON reported the facility reviewed all residents with side rails in the building to identify whether they were able to raise and lower the side rail, obtained rehab evaluations for every resident with side rails, did a reduction on all of those who fit the criteria to be a restraint. In regards to care planning timing and revision the DON reported it is a constant evolving and changing system. The DON reported in morning report the facility is looking at care plans as they discuss residents. The goal is during the review is that all the care plans are reviewed so if we miss anything on the day to day so by the quarterly review we make the changes to reflect. At the quarterly we comprehensively review and final update. The DON reported the care planning process is something the facility is constantly looking into. 10NYCRR 415.27 (a-c)

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. Specifically, (1) multiple residents were not offered hand hygiene before lunch and dinner meals on the 2nd Floor unit. (2) Multiple residents receiving oxygen therapy were noted with oxygen tubing touching the floor on multiple occasions and oxygen tubing was observed being stored without a plastic covering wrapped around the top of the oxygen concentrator on the 4th floor. This was evident for the dining observations on the 2nd floor and a random infection control observations on 2 out of 6 resident units. (Unit 2 and Unit 4) The findings are: 1) The facility policy and procedure titled Hand washing reviewed Handwashing reviewed 1/ 021 documented the facility considers hand hygiene primary means to prevent the spread of infections and provide a high quality of care to its residents. Wash hands with soap (antimicrobial and non-antimicrobial) and water for the following situations before and after eating. During the lunch meal on 02/28/2022 at 12:12 PM there were 20 residents in the dining room awaiting the arrival of lunch. Lunch meals service began at 12:38PM. The following residents were observed not being offered hand hygiene before meal service and consumption #152, #271, #24, #57, #84, #33, #119, #70, #81, #144, #255, #554, #212. During the dinner meal on 02/28/2022 at 5:14 PM residents were observed eating dinner in the dining room. The following residents were observed in the dining room and not offered hand hygiene prior to their meal; #554, #57, #271, #205, #99, #212, #70, # 121, # 24, #81. During the lunch meal on 03/01/2022 at 12:17PM - 12:45PM, the following residents were not offered hand hygiene prior to their meal; #57, #152, #3, #554, #271 and #121. On 03/01/2022 at 03:16 PM, Certified Nursing Assistant (CNA) #9 was interviewed. CNA #9 stated that some residents like to eat in their rooms and residents are asked where they want to eat before the meal. CNA #9 stated they give wash cloths to residents if the facility provides them, then the nurse gives the meal tray, and provides dinner. CNA # 9 stated residents always use wash cloths for hands before meal service. Residents are also offered hand sanitizer before meals too. CNA #9 stated they did not know why the residents were not offered a wash cloth or hand sanitizer before their meal. On 03/01/2022 at 04:01 PM CNA #10 was interviewed. CNA #10 stated they take residents to the dining room, clean their hands, and prep for dinner using hand sanitizing wipes. CNA #10 stated residents get hand sanitizer wipes before dinner is served. CNA #10 stated they noticed residents did not get wipes to clean their hands before dinner. On 03/01/2022 at 4:12 PM, Certified Nursing Assistant (CNA) #12 was interviewed. CNA #12 stated they were in the dining room yesterday, 2/28/22. CNA #12 stated there is nothing special before meal done before meals. On 03/02/2022 at 12:18 PM, the Licensed Practical Nurse (LPN #4) was interviewed. LPN #4 stated hand hygiene should be done before and be after meals. Hand hygiene is to make sure not getting any bacteria in food because some residenst use hands to eat. On 03/03/2022 at 03:32 PM, the Director of Nursing (DON) Infection Preventionist was interviewed during the QA meeting and stated staff are educated constantly on hand hygiene and we recently installed multiple hand sanitizers thru out the building to promote hand hygiene. Increased the number of stations to make it readily available. Hand hygiene should be offered before and after meals. 2. The facility policy titled Oxygen Therapy with revision dated 1/2020 documented, The administration of supplemental oxygen is an essential element of appropriate management for a wide range of clinical conditions. However, oxygen should be regarded as a drug and therefore requires prescribing in all but emergency situations. The policy did not specify the care of the oxygen tubing in the prevention of infection. It documented tubing change weekly and prn. During the initial tour of the facility Fourth Floor unit (4th Fl ) the following rooms were observed with residents' using oxygen by nasal cannula (NC) with the tubing laying on the floor running from the oxygen concentrator connection port to the resident. These observations were made on two (2) consecutive days 02/23/2022 and 02/24/2022 for Resident #227, #280, #91 and #175 room [ROOM NUMBER] B , Resident # 227 has physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] room [ROOM NUMBER] A, Resident # 280 has physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident's oxygen tubing was observed with no plastic covering wrapped around the top of the oxygen concentrator. room [ROOM NUMBER] D Resident # 91 with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . room [ROOM NUMBER] A --Resident # 175 with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/28/2022 at 2:00 PM,the Registered Nurse Supervisor # 1 was interviewed and shown Resident # 426B with the oxygen tubing touching the floor. They stated, It is every staff responsibility to see to it that oxygen tubing are not touching the floor and when not in use, must be covered with a plastic bag. On 02/8/2022 at 2;45 PM , Certified Nursing Assistant on the unit (CNA) # 4 was interviewed on what is their responsibilities on residents' with use of oxygen and stated, I have to see to it that the oxygen tank is not empty. I check if the nasal cannula is properly used by the resident and to see to it that the tubing is not touching the floor, because that is an infection control issue. On 03/03/2022 at 11:20 AM the assigned Certified Nursing Assistant (CNA) # 5 to resident # 280 and #91 was interviewed and stated, I know I have to cover the tubing with a plastic bag and that the tubing should not be touching the floor. 415.19 (b) (4)

Based on observations, interview, and record review conducted during the recertification survey, the facility did not ensure that a resident's designated representative was informed of a change in medication. Specifically, an antipsychotic medication was initiated, discontinued, and restarted without documented evidence the family was made aware. This was evident for 1 of 1 residents reviewed for Notification of Change (Resident #272). The finding is: The facility policy for notification dated 4/2019 documented: except in a medical emergency, the facility must consult with the resident immediately if the resident is competent and notify the residents physician and designated representative when there is: a need to alter treatment significantly (to commence a new form of treatment). Significant change in treatment a) nurse will promptly notify the resident and/or representative of any changes in resident care and treatment initiated by nursing measure or physician order, b) examples of alteration in treatment- change in medication Resident #272 was [AGE] years old and was admitted to the facility on [DATE]. As per the admission Minimum Data Set (MDS) 3.0 dated 2/3/22, the resident was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] further documented that the resident's cognitive status was cognitively intact. The MDS documented the resident received an antipsychotic medication 7/7 days. A review of the Patient Review Instrument (PRI) dated 1/11/22 documented primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented evidence the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Social Services note dated 1/28/22 documented the resident does not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Psychiatry note dated 2/9/22 documented patient evaluated earlier today. She tells everyone they are lying about her. Full note to follow Psychiatry MD Evaluation note dated 2/13/22 documented the resident is status post [MEDICAL RECORD OR PHYSICIAN ORDER] . I was asked to evaluate for decline in cognitive abilities with episodes of confusion and [CONDITION(S)]. I visited the resident on 2/9/22. The resident is alert, but forgetful and mixes up her thought. The resident says everyone is lying about me. The resident feels on edge and has trouble relaxing. I spoke with the nurse and got a report. I went over the chart and asked about the residents medicines. No adverse drug reactions. The resident was started on [MEDICATION(S)] prior to admission. The resident was also treated with [MEDICATION(S)] at the hospital due to agitation requiring restraints. The resident takes off their wander guard. Memory loss is present. BIMS score is pending. The resident triggers for depression on a mood assessment. The resident denies past history of [CONDITION(S)] or mental illness. PMH: AMS, Dementia with Behavioral Disturbances, Unspecified [CONDITION(S)], and Wandering. Daughter and granddaughter main contacts. Perception: paranoid thoughts others are lying against her, no specified delusions, observed talking to themselves. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Psychoactive meds: [MEDICATION(S)] 25 MG QD, [MEDICATION(S)] Discontinued, risk vs benefits weighed. [MEDICATION(S)] is a boxed warning drug, antipsychotics are medically necessary for short term use in individuals with acute [CONDITION(S)] and agitated [CONDITION(S)]. Revisit in 3 months or prn earlier if asked. [MEDICATION(S)] unable to reduce at this time. Monthly Medication Review dated 2/13/22 documented [MEDICATION(S)] indicated for [CONDITION(S)] however, [CONDITION(S)] not listed on admission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Can [MEDICATION(S)] 25 MD QD be discontinued if no long hx of [CONDITION(S)] at age 79? Physician noted dated 2/15/22 documented resident was seen s/p pharmacy review and agree with the recommendation for discontinuing [MEDICATION(S)]. The psychiatrist saw by 2/09 and agree the recommendation. Will discontinue [MEDICATION(S)] per recommendation. Physician note dated 2/22/22 documented resident seen wandering on the unit with episodes of confusion and [CONDITION(S)]. Psych was seen on 2/13/22 and diagnosed with [CONDITION(S)], recommend [MEDICATION(S)] 25 MG HS. Will order [MEDICATION(S)] as per psych recommendations Physicians Orders documented [MEDICATION(S)] 25 mg at bedtime for [CONDITION(S)] order date 2/22/22. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The [MEDICATION(S)] 25 MG for [CONDITION(S)] was discontinued on 2/16/22 and reordered on 2/22/22. The resident received [MEDICATION(S)] 25 MG for [CONDITION(S)] 2/23/22-3/2/22. On 3/3/22 at 10:29 AM RN #3 was interviewed. RN #3 reported if residents have capacity new medications are discussed with them and if they don't have capacity the medication is discussed with their guardian. RN #3 reported they were unsure who spoke to the resident's representative about the antipsychotic medication. RN #3 reported nursing or social work should reach out to the family about a change in medication or condition and document it in the medical record. State Agent (SA) asked for documentation the resident or representative were notified of the initiation of the antipsychotic medication [MEDICATION(S)]. None was provided. On 03/02/22 at 11:02 AM RN #4 was interviewed. RN #4 reported the resident is a fairly new resident. RN #4 reported when a resident is admitted on antipsychotic medications, they follow the order for two weeks. RN #4 reported after the resident is seen by the psychiatrist and they talk to them about the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RN # 4 reported they agreed the resident is not psychotic and does not have a FDA approved diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #4 reported the psychiatrist diagnosed the resident as [CONDITION(S)]. RN #4 reported the [MEDICATION(S)] was discontinued after the pharmacy review recommended it. [MEDICATION(S)] was reordered after the psychiatrist saw the resident and gave them the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #4 reported the resident denies [CONDITION(S)]. RN #4 stated the Nurse Practitioner that sees the resident should discuss the medication with the resident and the family. RN# 4 reported there should be a note in the chart about discussing the antipsychotic medication with the resident or the representative. On 03/03/22 at 11:05 AM the Medical Director was interviewed. The Medical director reported when a new medication is started the physicians notify the family and there is a discussion between multiple providers. The Medical Director reported there should be a notes in the medical record if the family was notified about any changes in medication. There was no documented evidence the resident and or their representative was notified of the initiation of the antipsychotic medication [MEDICATION(S)] 25 mg HS, when it was discontinued, and when it was initiated again. 415.3(e)(2)(ii)(a)

Based on record review, and staff interviews during the re-certification survey and abbreviated survey (NY 874), the facility did not ensure that alleged violations, including injuries of unknown origin were reported to the state survey agency within 2 hours if the allegation involves abuse or serious bodily injury. Specifically, abuse allegations with an injury of unknown origin were not reported within 2 hours. This was evident for 1 of 6 residents reviewed for abuse (Resident #199). The finding is: The facility policy and procedure titled, Abuse (Dated 03/2021) documented the following: the facility prohibits the mistreatment, neglect and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends. Resident #199 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] documented Resident # 199 has severely impaired cognition with long and short-term memory problems. The investigation report dated 08/26/2021 documented Resident #199 was observed with a large discoloration to their right arm wrist area while the Certified Nursing Assistant (CNA) #3 was providing activity of daily living (ADL) care. Resident #199 is cognitively impaired and a poor historian. An x-ray was ordered on 08/22/2021 and completed. The X-ray results dated 08/23/2022 revealed no fracture. The New York State Department of Health (NYSDOH) Health Electronic Response Data Systems (HERDS) intake documented the incident occurred on 08/22/2021 at 10:00 PM and the report was submitted to DOH on 8/24/2021 at 9:50 PM. The investigation report dated 09/24/2021 documented while the CNA# 15 was providing AM care for Resident #199, Resident #199 was observed with discoloration to the right inner hand and swelling to the pinky area. It was reported to the Registered Nurse Supervisor (RNS) #2. The registered nurse supervisor performed an assessment and notified the Nurse Practitioner (NP). The Nurse Practitioner ordered an x-ray of the right hand on 09/20/2021. The x-ray results dated 09/20/2021 revealed acute fracture involving the base of the 5th proximal phalanx. Resident #199 was sent to the hospital orthopedic for further evaluation on 9/21/21 and returned from the appointment with recommendations of activities as tolerated, no recommendation for bracing or wrapping. The facility documented there is no evidence to support that any alleged resident abuse, neglect, exploitation, or mistreatment may have occurred. The NYSDOH HERDS intake documented the incident occurred on 09/20/2021 at 11:30 AM and was submitted to DOH on 09/21/2021 at 7:56 PM. These allegations of abuse were not reported within 2 hours to NYSDOH. During an interview with the Registered Nurse Supervisor #1 on 03/04/2022 at 3:05PM, RNS #1 stated if staff observe any discoloration or witness any incidents, the CNA will report to the Licensed Practical Nurse (LPN) who will then report to the Registered Nurse Supervisor (RNS). The RNS #1 stated staff members are expected to immediately report any unknown injury so that the resident can be assessed by the RNS. The RNS then reports their findings to the Assistant Director of Nursing (ADON) or the Director of Nursing (DON). During an interview with the Director of Nursing (DON) dated 03/03/2022 at 12:00PM, the DON stated the staff are in-serviced on reporting any incidents or abuse immediately to the charge nurse. The DON stated the investigation should be completed within 24 to 48 hours. The DON stated if there is suspicion of abuse, the DON will report it to the NYSDOH within 24 hours of incident occurring. 415.4(b)(2)

Based on record reviews and staff interviews conducted during the recertification survey, the facility did not ensure person-centered care plans with measurable objectives and timeframes to meet a resident's medical and nursing needs identified in the comprehensive assessment were developed. Specifically, (1) a comprehensive care plan (CCP) was not developed and implemented to address care needs for a resident's [CONDITION(S)]/repsiratory care (Resident #451), and (2) a resident's CCP did not include interventions to address the use of a BiLevel Positive Airway Pressure ([CONDITION(S)]) machine (Resident #286). This was evident for 2 out of 2 residents reviewed for care planning out of a total of 38 residents (Resident #451 and #286). The findings are: The Comprehensive Care Plan (CCP) policy, last revised October 2019, documented the interdisciplinary team (IDT) in conjunction with the resident/family will develop and implement a comprehensive person-centered care plan for each resident. The CCP will include measurable objectives and timeframes, describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, and incorporate identified problem areas. 1) Resident # 451 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had severely impaired cognition. The resident was totally dependent on two persons form most activities of daily living. In addition, the resident received oxygen, [CONDITION(S)] care, and suctioning. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented evidence that a CCP was developed and implemented with interventions to address the resident's need for [CONDITION(S)], [CONDITION(S)] care and the use of oxygen therapy. On 03/01/22 at 03:11 PM, Liscense Practical Nurse (LPN) #2 stated that the Resident was a new admission. The resident was on the unit for two weeks. The resident was admitted with [CONDITION(S)] and needed [CONDITION(S)] care, suctioning and receives oxygen therapy. On 03/02/22 at 11:32 AM, Registered Nurse (RN) #1 stated they cover two floors. RN #1 also stated the resident has been on the unit for two weeks. The resident was admitted with a [CONDITION(S)] and received oxygen therapy and suctioning. RN #1 further stated when a patient is admitted , nursing does a full assessment. Nursing based the assessment on the Patient Review Instrument (PRI), hospital records, and a physical assessment. The Comprehensive care plan is based on the assessment. RN #1 stated the RN Supervisor is responsible for initiating care plans upon admission. A comprehensive care plan for respiratory should been initiated. RN # 1 also stated they were not sure why the respiratory care plan was not done. The supervising nurse is responsible for developing care plans. The resident should have had a care plan respiratory. On 03/02/22 at 03:49 PM, the Director of Nursing Services (DNS) stated the Care plans are supposed to be initiated upon admission by the RN supervisor. The DNS further stated that the comprehensive care plan should be developed as soon as possible. The DNS further stated that when we have an Interdisciplinary team meeting, we check to ensure all care plans are up to date and were initiated. The DNS stated they were not sure why a care plan was not developed for respiratory care for the resident. There should have been a comprehensive care plan in place for respiratory care with the appropriate interventions. 2.) Resident #286 was initally admitted on [DATE] and readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) 3.0 dated 02/07/2021 documented the resident had intact cognition. The resident was independent in most and needed supervision in some activities of daily living (ADLS). On 02/28/2022 at 9:01 AM, Resident #286 was observed in the unit at various dates and time ambulating independently. Resident's room was observed with the Licensed Practical Nurse (LPN) with the [CONDITION(S)] machine on top of the bedside table covered with plastic bag. Review of the Comprehensive Care Plan (CCP) last updated on 02/07/2022 titled Alteration in Respiratory system related to Chronic Obstructive Pulmonary Disease ([CONDITION(S)]) and sleep apnea. The goals were resident will receive effective treatments as evidenced by No Shortness of Breathe (SOB) or bronco spasm . Will receive adequate ventilation ,will verbalize and demonstrate understanding of education provided. The interventions : Administer treatments ( nebulizer ) and medications per Medical Doctor (MD) orders, observe vital signs as ordered by MD and report those not within normal limit (WNL). The CCP titled Resident exhibits behavioral symptoms such as non- complaint with oxygen, non compliant with care,diet and continues to exhibit behavior taking juices off the nurses medication cart was last updated on 02/07/2022 . The goals were Resident will not leave facility unattended, safety will be maintained,will seek out staff/ caregiver when agitation occurs. The interventions listed as follows : document all behaviors, attempt to identify pattern and target interventions, identify triggers for wandering, initiate psychiatric evaluation as needed, modify the environment to reduce episodes of negative behavior and risk for fall or injury, provide a wander guard . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . ( [CONDITION(S)] is a type of positive airway pressure that is used to maintain a consistent breathing pattern at night or during symptoms flare ups in patients with [CONDITION(S)] and also use for patient with sleep apnea ). Oxygen via nasal cannula (NC) 2-6 liter per minute (LPM) as needed to keep oxygen saturation to 90% and check oxygen saturation every shift. The CCP did not address the care needs related to the resident's [CONDITION(S)] machine use or refusal. Review of the nurses notes reveals no documented evidence that the resident used or refused to use the [CONDITION(S)] machine as ordered. On 03/02/2022 at 3:40 PM, the 3-11 tour Certified Nursing Assistant (CNA #5) assigned to the resident was interviewed and stated he/she never saw the resident use the [CONDITION(S)] machine. On 03/01/2022 at 12:00 PM the Registered Nurse Supervisor (RNS #1) was interviewed and stated he/she did not realized the resident had a [CONDITION(S)] machine prior to yesterday. The CCP should be delevoped upon admission and updated quarterly or as needed. RNS #1 stated after reviewing the CCP, he/she confired there was no CCP addressing the [CONDITION(S)] use. The RNS #1 further stated he/she did not receive any reports regarding the resident's refusal to use the [CONDITION(S)] machine. On 03/01/2022 at 4:00 PM, RNS #2 from the 3-11 tour was interviewed and stated Resident #286 is known to be non-complaint with use of the [CONDITION(S)] machine. The refusal should be documented by staff. On 03/02/2022 at 2:00 PM the DNS was interviewed and submitted an inactive CCP from the debrided medical record for the use of the [CONDITION(S)] machine dated 04/2021 with no updates since the resident's re-admission. The resident was discharged and readmitted to the facility on [DATE] and no there was no documented CCP from this admission for the [CONDITION(S)] machine. During the interview , the DNS stated CCP are completed upon admission , the basic is done and then it should be completed within 24 hours . It is the RNS who completes and sometimes myself and the ADNS. It should be reviewed quarterly and especially before any Interdisciplinary team meetings (IDT) meetings . 415.11(c) (1)

Based on observation, interview, and record review conducted during the Recertification survey, the facility did not ensure that the comprehensive care plans were reviewed and/or revised after each assessment and as needed. Specifically, multiple care plans for resident #230 were not reviewed and/or revised. This was evident for 1 of 1 reviewed for tube feeding out of a total of 36 residents investigated. The findings are: The facility policy and procedure titled Care Plans-Comprehensive created 10/2015 and last date revised 10/2019, documented A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident' physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The Interdisciplinary Team reviews and updates the care plan: at least quarterly, with scheduled quarterly MDSs. Resident #230 was admitted to the facility with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Comprehansive Care Plan titled Resident at risk for being a victim due to inability to understand her surroundings, initiated 9/21/18, last revised 4/17/20, documented: Focus: relalted to dependence on others for Activities of Daily Livings (ADL), wandering and intrusive behaviors. Goal: Resident will not be a victim. Interventions: Provide assistance with ADLs as needed. Resident to be offered food and or activities of interest while wandering to help keep resident occupied. There is no documented evidence the care plan was reviewed and revised to reflect the resident's NPO status. Comprehensive Care Plan titled, Resident exhibits behavior symptoms initiated 10/18/2918, last revised 6/17/2020 documented: Focus: socially inappropriate/verbally aggressive/abusive; Wandering Behavior; Elopement risk. Resident wanders in /out of rooms. She/he ambulates unit hallway at a rapid pace and is difficult to redirect. She/he refuses to eat her/his meals. She/he grabs the sugar from others, trays, and on the food carts. She/he is unable to follow re-direction due to cognitive impairment. Resident grabs food from the tray while being fed. Staff has to stand by her/him while being fed to prevent resident from grabbing the food off the tray. Goal: Resident will exhibit fewer or no episodes of behavioral activity. Interventions: Remove any nonfood items, small objects that she/he can swallow within her reach. Room search and remove objects that she/he can mistakenly place in her/his mouth. Check placement of wander guard each shift, Provide a wander guard. There is no documented evidence the care plan was reviewed and revised to reflect the resident's NPO status or to reflect that the resident no longer wanders and does not have a wander guard in place nor an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Comprehensive Care Plan titled Resident is at risk for bleeding initiated 2/18/2020 with no revision date documented: Goal: resident will be free of signs and symptoms (s/s) of abnormal bleeding. Interventions: administer meds as prescribed. Monitor for s/s of abnormal bleeding. Provide therapeutic diet and supplements as order. There is no docuemnted evidence the care plan was reviewed and revised to reflect the resident's NPO status. Comprehensive Care plan titled Resident uses [CONDITION(S)] medications related to [CONDITION(S)] [CONDITION(S)] Disorder (d/o) [CONDITION(S)] d/o initiated 9/24/2018 with no revision date documented; Goal: the resident will have minimal side effects or adverse reactions related to use of [CONDITION(S)] medications. Interventions: monitor/record/report to MD prn side effects and adverse reactions of psychoactive medications: [MEDICAL RECORD OR PHYSICIAN ORDER] There is no documented evidence the care plan was reviewed and revised to reflect the resident's NPO/enteral feeding status. Comprehensive Care Plan titled The resident uses physical restraints initiated 3/8/2021 with no revision date documented; abdominal binder r/t Confusion; Resident pulling on G-Tube. Goal: The resident will remain free of complications related to restraint use, including contractures, skin breakdown, altered mental status, isolation or withdrawal. Intervention: Discuss and record with the resident, family/ caregivers, the risks and benefits of the restraint, when the restraints should/will be applied, routines while restrained and any concerns or issues regarding restraint use. Ensure valid consent on chart prior to initiating restraint. Evaluate the resident's restraint use. Evaluate/record continuing risks/benefits of restraint, alternatives to restraint, need for ongoing use, and reason for restraint use. There is no documented evidence the care plan was reviewed and revised to reflect that the resident does not use an abdominal binder nor has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] An interview was conducted on 02/28/22 at 10:30 AM with Crtified Nuring Assistant (CNA) #15. CNA #15 stated the resident requires total care for ADLs. CNA #15 reported the resident did ont have an adaptive device and there was nothing arounf the residents waist to cover their PEG site. An interview was conducted on 03/02/22 at 10:43 AM with CNA #2 regarding diversional tactics for resident. CNA #2 stated that if the resident gets agitated, they try to distract the resident by singing, especially referring to her husband. CNA #2 reported before the tube feeding was placed, the resident used to get food, but now nothing to eat. An interview was conducted on 03/02/22 at 10:48 AM with CNA #3, with regard to diversional tactics for resident. CNA #3 stated the resident used to walk, but not anymore. CNA #3 stated now diversion is done by talking with the resident, cuddle them, or playing music. CNA #3 stated the resident doesn't get any more food by mouth since she starting getting the milk through her stomach. An intervierw was conducted on 03/02/22 at 11:19 AM with a Recreation Aide (RA). The RA stated that the resident loves music, especially [NAME] Brown. The RA stated they will encourage the resident to sing or ask the resident to talk about their spouse. The resident doesn't talk as much as they used to but, they respond with their eyes. The RA further stated that they will not use food or offer food to the resident if it is being served at a program. The RA is aware that resident is nothing by mouth. An interview was conducted on 03/02/22 at 11:08 AM with Registered Nurse (RN) #4. RN #4 stated that they go over care plans at weekly care plan meetings. The MDS triggers when care plans are due, for example as a quarterly, significant change, annual, or with rehab status change. Based on the MDS schedule, they review the care plans and update relevant care plans. For example, when the resident in question stopped eating, it was a significant change and would need a meeting. Upon RN #4's review of the active care plans, RN #4 stated that the care plan with the intervention of offer food should have been updated. An interview was conducted on 03/02/22 at 11:30 AM with the MDS Coordinator. Minimum Data Set (MDS) Coordinator stated they schedule care plan meeting for admission, quarterly, annual, sig change. The MDS assessors are assigned to different floors and they attend the meeting. The MDS staff include the Coordinator, then 2 full time assessors. MDS Coordinator stated the nursing managers do the care plans, but the assessors review and make recommendations for changes to care plan documentation. It is discussed daily in the morning meeting that care plans are to be updated. The MDS Coordinator stated these care plans should have been updated. 415.11(c)(2)(i-iii)

Based on observation, record reviews, and staff interviews during the Recertification Survey the facility did not ensure residents were free from unnecessary antipsychotic medications. Specifically, a resident who had no prior history with mental illness of [CONDITION(S)] was diagnosed and treated with the antipsychotic medication [MEDICATION(S)]. This was evident for 1 of 5 residents reviewed for Unnecessary Medications. (Resident #272). The findings are: The facility policy on [CONDITION(S)] medication use dated 9/2015, revised 11/18 documented the following: antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The attending physician will identify, evaluate, and document with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications. Resident who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for appropriateness and indications for use. The interdisciplinary team will complete PASRR, re-evaluate the use of antipsychotic medications at the time of admission and/or within two weeks to consider whether or not the medication can be reduced, tapered, or discontinued, based on assessing the resident's symptoms and overall situation. Diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident. FDA ALERT [6/16/2008]: FDA is notifying healthcare professionals that both conventional and atypical antipsychotics are associated with an increased risk of mortality in elderly patients treated for dementia related [CONDITION(S)]. In April 2005, FDA notified healthcare professionals that patients with dementia-related [CONDITION(S)] treated with atypical antipsychotic drugs are at an increased risk of death. Since issuing that notification, FDA has reviewed additional information that indicates the risk is also associated with conventional antipsychotics. Antipsychotics are not indicated for the treatment of dementia-related [CONDITION(S)]. Resident # 272 was admitted to the facility on [DATE]. As per the admission Minimum Data Set (MDS) 3.0 dated 2/3/22 , indicated that the resident was admitted with diagnoses that included Non-Alzheimer's Dementia, [CONDITION(S)], and wandering. The MDS's also indicated that the resident's cognitive status was cognitively intact, and the resident did not have any potential indicators for [CONDITION(S)]. A review of the Patient Review Instrument (PRI) dated 1/11/22 documented primary diagnosis as Dementia with Behavioral Disturbances, secondary diagnosis as AMS/[CONDITION(S)], Dementia with [CONDITION(S)]. There was no documented evidence the resident had a history of [CONDITION(S)]. On 02/23/22 at 09:35 AM Resident #272 was observed in their room sitting in a chair working on a book of puzzles. On 02/28/22 at 09:34 AM Resident #272 was observed in their room appropriately dressed, calmly putting clothes away in the dresser. On 03/01/22 at 09:50 AM Resident #272 was observed in their room calmly sitting on their bed. A review of physician order dated 1/27/22 documented the resident was admitted on [MEDICATION(S)] ([MEDICATION(S)]) Tablet 25 MG once a day for [CONDITION(S)] and [MEDICATION(S)] 10 MG at bedtime for Dementia. A review of the Medication Administration Record showed the resident received [MEDICATION(S)] 25 MG for [CONDITION(S)] 1/28/22- 2/10/22, 2/12/22-2/16/22. The [MEDICATION(S)] 25 MG for [CONDITION(S)] was discontinued on 2/16/22 and reordered on 2/22/22. The resident received [MEDICATION(S)] 25 MG for [CONDITION(S)] 2/23/22-3/2/22. Social Services note dated 1/28/22 documented the resident does not have a diagnosis of major mental illness Psychiatry note dated 2/9/22 documented patient evaluated earlier today. She tells everyone they are lying about her. Full note to follow Psychiatry MD Evaluation note dated 2/13/22 documented the resident is status post hospital stay after found outside wandering her former apartment talking to herself. I was asked to evaluate for decline in cognitive abilities with episodes of confusion and [CONDITION(S)]. I visited the resident on 2/9/22. The resident is alert, but forgetful and mixes up her thought. The resident says everyone is lying about me. The resident feels on edge and has trouble relaxing. I spoke with the nurse and got a report. I went over the chart and asked about the residents medicines. No adverse drug reactions. The resident was started on [MEDICATION(S)] prior to admission. The resident was also treated with [MEDICATION(S)] at the hospital due to agitation requiring restraints. The resident takes off their wander guard. Memory loss is present. BIMS score is pending. The resident triggers for depression on a mood assessment. The resident denies past history of [CONDITION(S)] or mental illness. PMH: AMS, Dementia with Behavioral Disturbances, Unspecified [CONDITION(S)], and Wandering. Daughter and granddaughter main contacts. Perception: paranoid thoughts others are lying against her, no specified delusions, observed talking to themselves. Diagnosis: Dementia with behavioral disturbance, Unspecified [CONDITION(S)], Other [CONDITION(S)], Restlessness with agitation. Psychoactive meds: [MEDICATION(S)] 25 MG QD, [MEDICATION(S)] Discontinued, risk vs benefits weighed. [MEDICATION(S)] is a boxed warning drug, antipsychotics are medically necessary for short term use in individuals with acute [CONDITION(S)] and agitated [CONDITION(S)]. Revisit in 3 months or prn earlier if asked. [MEDICATION(S)] unable to reduce at this time. Monthly Medication Review dated 2/13/22 documented [MEDICATION(S)] indicated for [CONDITION(S)] however, [CONDITION(S)] not listed on admission diagnosis history on profile. 2/9/22 res seen by psychiatrist with full note to follow. Can [MEDICATION(S)] 25 MD QD be discontinued if no long hx of [CONDITION(S)] at age 79? Physician noted dated 2/15/22 documented resident was seen s/p pharmacy review and agree with the recommendation for discontinuing [MEDICATION(S)]. The psychiatrist saw by 2/09 and agree the recommendation. Will discontinue [MEDICATION(S)] per recommendation. Physician note dated 2/22/22 documented resident seen wandering on the unit with episodes of confusion and [CONDITION(S)]. Psych was seen on 2/13/22 and diagnosed with [CONDITION(S)], recommend [MEDICATION(S)] 25 MG HS. Will order [MEDICATION(S)] as per psych recommendations. On 03/02/22 at 09:49 AM Certified Nursing Assistant (CNA) # 1 was interviewed. CNA # 1 reported the resident does not refuse care. CNA # 1 reported the resident has the behaviors of taking the her mattress out of their room, walking with pillow, and is resident is always looking for their grandson. The resident is always looking to go home. The resident is not aggressive either verbally or physically. CNA # 1 reported the resident is exit seeking. The resident has taken the wander guard off every time is it put on her. The resident will repeat themselves. sometimes the resident will stay in her room. On 03/02/22 10:10 at AM Licensed Practical Nurse (LPN) #3 was interviewed. LPN #3 reported the resident is confused. Yesterday the resident wanted to go home and took mattress off the bed. LPN #3 reported staff redirected the resident to their room. LPN #3 reported if needed to staff call the social worker to talk to the resident. The resident is resistive, repeats they wants to go home and will try to push the elevator button. LPN #3 reported the only issues is the resident refuses their wander guard. On 03/02/22 at 10:29 AM Registered Nurse (RN) #3 was interviewed. RN # 3 reported the resident is recent admission and has advanced Dementia. The resident wandered off from their daughters apartment. The resident is high elopement risk. The resident watches the key pad for the exit door codes. The resident gets fixated on wanting to leave and can become demanding. RN # 3 reported the resident said their grandson was decapitated and was demanding to see him. Rn # 3 reported the verbally aggressive could be physically aggressive, but has not been. The resident calls staff liars. RN #3 reported the resident is on [MEDICATION(S)] at bedtime for [CONDITION(S)]. On 03/02/22 at 11:02 AM RN #4 was interviewed. RN #4 reported the resident is a fairly new resident. RN #4 reported when a resident is admitted on antipsychotic medications, they follow the order for two weeks. RN #4 reported after the resident is seen by the psychiatrist and they talk to them about the diagnosis and dose of medication. The resident was admitted on [MEDICATION(S)] without an appropriate diagnosis, but we cannot discontinue it right away. RN # 4 reported they agreed the resident is not psychotic and does not have a FDA approved diagnosis for [MEDICATION(S)]. RN #4 reported the psychiatrist diagnosed the resident as [CONDITION(S)]. RN #4 reported the [MEDICATION(S)] was discontinued after the pharmacy review recommended it. [MEDICATION(S)] was reordered after the psychiatrist saw the resident and gave them the diagnosis of [CONDITION(S)]. RN #4 reported the resident denies [CONDITION(S)]. On 03/02/22 at 02:59 PM the Psychiatrist was interviewed. The Psychiatrist reported when a resident is admitted they take a history, evaluate the resident, consider what led the resident to the hospital, how are they feeling, inventory about symptoms, ask about psychiatric history, family history, perform mental status exam, review notes, talk to staff members, and formulate treatment plan for the resident. The Psychiatrist reported they try not to discontinue medications shortly after admission because they residents are adjusting to the facility. When asked about the monthly medication review the Psychiatrist reported the Pharmacist is not a clinician and only makes recommendations on what they reviewed in the chart. The Psychiatrist reported their impression of the resident was that they suffered from [CONDITION(S)] Spectrum Disorder. The Psychiatrist reported the resident did not meet the criteria for Dementia related [CONDITION(S)]. The Psychiatrist reported their opinion is their opinion. The Psychiatrist reported to the best of their judgement the resident was presenting with [CONDITION(S)] and not just Dementia regardless of their age and no history of mental illness. The Psychiatrist did not mention discussing the resident history of mental illness with the residents daughter or other main contact. On 03/03/22 at 11:05 AM the Medical Director was interviewed. The Medical Director reported the Psychiatrist comes in as a consultant makes recommendations. After the recommendations the Nurse Practitioner (NP) or themselves will read them and discuss. The Medical Director reported if they don't agree with the psychiatrist they will call the family and see if the history is there and notify them if there is a change to medications. The Medical Director reported the history on mental illness is not always in the hospital discharge paperwork so they cannot always go by the hospital discharge paperwork. The Medical Director reported they try to reach out to families and get the psychiatric history. The Medical Director reported they spoke to the psychiatrist at length about the resident and on presentation the resident was paranoid and was having behavior, was aggressive towards staff, both physical and verbal aggressive, does have history of being aggressive towards family. The Medical Director reported the residents family mentioned the was roaming around neighborhood paranoid talking to themselves. The Medical Director reported prior to admission the resident was in leather restraints and needed [MEDICATION(S)] in the hospital. The Medical Director reported this leads us to believe it is more than an episodic behavior or adjustment disorder. The Medical Director reported there is some psychiatric disorder that was never mentioned to family. The Medical Director reported psychiatric diagnosis can be embarrassing and families don't always know. The Medical Director reported the facility has to fill in the gaps. The Medical Director did not mention if the residents family was contacted to discuss a history of mental illness. On 03/03/22 at 09:14 AM the residents daughter was interviewed. The resident daughter reported the resident has no history of mental illness. The resident was never taking antipsychotic medication, was never hospitalized , and never had a diagnosis of [CONDITION(S)] prior to admission. 415.12(l)(2)(ii)

Based on record review and staff interviews conducted during Abbreviated Survey (NY 415), the facility did not provide and document sufficient preparation and orientation to a resident to ensure safe and orderly transfer from the facility. This was evident for 1 out of 6 residents (Resident #2). Specifically, Resident #2 was transferred to the hospital on 11/18/2020 and was transferred back to the facility on [DATE]. When Resident #1 returned to the facility on [DATE], the facility transferred Resident #1 to another facility via a taxi accompanied by Certified Nursing Assistant (CNA). There was no documented evidence that Resident #1 was aware of or requested the transfer. The findings are: The facility's Policy and Procedure titled Discharge -Transfer/Discharge Process last revised in 12/2019 documented that the facility will ensure a safe and proper discharge for all residents leaving the facility. When a resident is transferred or discharged from the facility, details of the transfer discharge will be documented in the medical record, and appropriate information will be communicated to the receiving health care facility or provider. Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Minimum Data Set (MDS, a resident assessment tool) dated 11/2/2020 documented that Resident #2 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) and scored 15/15 (00-07 severe impairment, 08-12 moderate impairment and 12-15 cognitively intact). A Discharge Status Comprehensive Care Plan (CCP) dated 10/8/2020 documented that Resident #2's placement remains appropriate at this time. Resident #2 will be re-evaluated on an ongoing basis. Interventions included to provide support and counsel regarding discharge concerns and Social Worker will meet with Resident #2 and/or designated representative to identify discharge needs. There was no documented evidence that Resident #2 requested to be transferred to another facility. A Care Plan Meeting note dated 10/12/2020 at 05:09 PM documented that an Intradisciplinary Care Plan Meeting was held for Resident #2 and Resident #2's family participated in the meeting. Resident #2's placement was appropriate at this time. There was no documented evidence that discharge to another facility was discussed with Resident #2 and family. Social Service Documentation dated 10/27/2020 at 3:19 PM documented that Resident #2 refused to comply with quarantine and mask requirements. Resident #2 was educated that they were violating the infection control requirements of the facility and must return to their room. If Resident #2 chose to disregard the requirements endangering the health of other residents and staff, Resident #2 will be asked to sign out of the facility. Resident #2 returned to the room and declined discharge. A Care Plan Meeting note dated 11/10/2020 at 11:33 AM documented that a care plan meeting was held for Resident #2's quarterly review. Resident #2's parent was included in the meeting. Resident #2's family was satisfied with the care. No changes in the plan of care. There was no documented evidence that discharge was discussed with Resident #2 and family. Physician's Progress Note dated 11/18/2020 at 7:50 PM, documented that Resident #2 was agitated, restless, and verbally and physically aggressive. Resident #2 was abusive to staff and peer and refused medication and care. Resident #2 called 911 and was taken to the Emergency Department for further management. Nurse's note dated 11/18/2020 at 11:14 PM, documented that Resident # 2 left the unit with 911 personnel. Social Service Documentation dated 11/19/2020 at 4:29 PM, documented Hospital Transfer. The social worker was made aware that Resident #2 was transferred to the hospital on 11/19/2020 after Resident #2 called 911. Resident #2's parent was called and notified. A Notice of Transfer/discharge date d 11/19/2020 documented that Resident #2 was transferred to a receiving facility. The transfer/discharge had been made in compliance with Resident #2's request. The form also documented that Resident #2 refused to sign the notice. The Patient Review Instrument (PRI) from the receiving facility dated 11/19/2020 documented that the transferring facility completed a review. Resident #2's medical record contained no documented evidence that Resident #2 requested to be transferred to another facility. There was no documentation that discharge orientation and preparation were provided to Resident #2 and the family prior to resident's transfer to another facility. There was no documented evidence that Resident #2 returned from the hospital and refused to stay in the facility. During an interview on 11/17/2021 at 2:00 PM, the Registered Nurse Supervisor (RNS) #1, who worked on the 3-11 shift, stated that Resident #2 was alert and oriented and had many complaints about everything. Resident #2 was rude, offensive toward staff, and insulted the staff. Resident #2 was causing a lot of noise and drama. RNS #1 also stated that Resident #2 made a lot of complaints about the food and care but did not want to leave the facility. During an interview on 11/17/2021 at 2:30 PM, the Director of Social Service (DSS) stated that Resident #2's Social Worker (SW) no longer works in the facility. The DSS also stated that Resident #2 was young and needed a more appropriate facility to accommodate their needs. The DSS further stated that Resident #1 wanted to go to another facility and that it should have been reflected in the discharge care plan and SW's notes in the resident medical record. The DSS could not specify when Resident #2 voiced that they wanted to go to another facility or when it was discussed with the family. During an interview on 11/17/2021 at 4:05 PM, RNS #2 stated that they were working a 3-11 shift per diem when Resident #2 returned to the facility from the hospital. RNS #2 stated that they met Resident #2 in the lobby because the resident refused to be readmitted to the facility and refused to get off the stretcher. The Administrator was called and spoke with Resident #2 and Resident #2 agreed to go to another facility. RNS #2 stated that they did not document the incident in Resident #2's medical record. During an interview on 11/17/2021 at 4:45 PM, the Administrator stated that discharge to another facility was discussed prior to Resident #2's altercation with another resident. The Administrator stated that the facility was looking for a more appropriate placement for Resident #2. The Administrator stated that Resident #2 was young and was non-compliant with medications and treatment. The Administrator also stated that Resident #2 came from the hospital on 11/19/2020 and did not want to stay in the facility and another nursing home agreed to take Resident #2. The Administrator reported that a CNA escorted Resident #2 to the receiving facility via taxi because Resident #2 did not want to wait for service transportation and was willing to go in a taxi. During an interview on 12/22/2021 at 2:00 PM, DNS #2, from the receiving facility, stated that admission to the facility was done through a centralized office. According to the Patient Review Instrument (PRI) dated 11/19/2020, Resident #2 was admitted from the transferring facility. DNS #2 stated that the facility received the PRI, Physician Orders, and referral information form on 11/19/2020. During subsequent interview on 02/01/2022 at 11:43 AM, DNS #1 stated that they were not in the facility when Resident #2 returned from the hospital on 11/19/2020. DNS #1 also stated that the nursing staff notified them that Resident #2 refused to stay in the facility and was transferred to another nursing home. DNS #1 further stated that the RNS should have documented in the resident's medical record that the resident refused to stay in the facility. 415.3(h)(1)(v)