Every finding on record at Hudson Pointe at Riverdale Center for Nursing and

Based on record review and staff interview, conducted during the abbreviated survey (#2651294) the facility did not ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the New York State Department of Health. This was evident for one (1) of four (4) residents (Resident #1) sampled. Specifically, on 10/12/2025 Resident #1 had an unwitnessed fall out of bed and sustained discoloration of the left eye which the facility did not report. The findings are: The facility policy titled 'Abuse' last reviewed on 03/11/2024 documented it is the policy of facility that each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion and misappropriation of funds. The policy also documented federal and state regulations require the reporting of alleged violations of abuse, mistreatment and neglect , including injuries of unknown origin, immediately to the facility administrator. The policy further stated federal regulations require that the facility must ensure all alleged violations involving mistreatment, neglect and abuse are reported immediately to the administrator of the facility and to other officials in accordance with State law.Resident # 1 was admitted to the facility with diagnoses that included Coronary Artery Disease, Diabetes Mellitus, and Non-Alzheimer's Dementia. A review of the Minimum Data Set (a resident assessment tool) dated 08/31/2025 documented Resident #1 was moderately cognitively impaired, they were dependent on staff for most activities of daily living, including transfer, and they used a wheelchair for mobility. The Physician's progress note dated 10/12/2025 documented Resident #1 had an unwitnessed fall early this morning sustaining injury to left eye. From staff, mentation is the same, Ice pack has been applied, Patient is able to open their eye, neuro check every 8 hours. Ice compress to left eye hematoma. Tylenol for pains as needed. Transfer to hospital emergency room for evaluation. The nursing progress note dated 10/12/2025 at 5:03 AM documented they were called to assess Resident #1 who was noted on the floor next to their bed which is at its lowest position. Swelling noted around left eye. Resident #1 was unable to explain incident. Nursing Supervisor was informed, Physician was informed, ice pack applied. Resident was transferred to the hospital for further evaluation.The Accident/Incident report summary dated 10/12/2025 documented Resident #1 was alert but confused, required extensive assistance with activities of daily living including transfer, and was observed on the floor near their bed. Resident #1 was unable to provide an account of what happened. Resident #1 was noted with hematoma of left eye, no loss of consciousness, no change in mental status. On 10/27/2025 at 1:20 PM, the Director of Nursing was interviewed and stated Resident #1 was found on the floor with an injury to the left eye and was sent to the hospital. The Director of Nursing also stated it was an unwitnessed fall, and there was no abuse involved. The Director of Nursing further stated Resident #1 was last seen by staff between 4:30 AM and 4:45 AM, and the incident was not reported to the Department of Health, because Resident #1 was sent to the hospital for treatment and the facility did what it needed to do.On 10/27/2025 at 2:00 PM, the Administrator was interviewed and stated the Director of Nursing did not report the incident to the Department of Health because there was no suspicion of any abuse, and Resident #1 was sent to the hospital. 10 NYCRR 415.4(b)(2)

Based on observations, record reviews and interviews conducted during the Recertification survey, the facility did not ensure that Minimum Data Set (MDS) 3.0 assessments accurately reflected the residents' status. Specifically, the most recent Minimum Data Set (MDS) 3.0 assessments did not reflect that wander/elopement alarms were used for 2 residents. This was evident for 2 of 2 residents reviewed for Elopement Risk out of a sample of 38 residents. (Resident # 103 and #135). The findings are: 1.) Resident #103 was admitted to the facility with diagnoses which include Dementia, Depression, and Psychotic Disorder. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the resident had impaired cognition and was dependent in performing activities of daily living. Also documented in the Section P0200-Alarm that Wander/Elopement Alarm was not used. On 07/22/24 at 12:15 PM Resident #103 was observed with a wander guard device on the right wrist. Elopement Risk assessment dated [DATE] documented that if the resident scored 3 or more negative responses, notify MD, initiate use of Wander guard and follow facility protocol/guidelines, create/update Care plan for Elopement, Update CNA Instructions. The Physician Order's dated 12/07/2022, last revised on 07/17/24 documented the following: Wander Guard-Check Q Shift for Placement. The Comprehensive Care Plan for Behavior Symptoms: Wandering/Elopement risk dated 3/18/24, revised 6/27/24 documented interventions which included: check ID bracelet is on wrist, WG to Right Wrist, and maintain safety. The Medication Administration Record (MAR) dated 07/1/24 to 07/22/24 documented the observation of the wander guard device every shift daily (7:00 AM, 3:00 PM, and 11:00 PM). 2.) Resident #135 was admitted to the facility with diagnoses which include Dementia, Anxiety and Depression. The Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the resident had impaired cognition and was dependent in performing activities of daily living. Also documented in the Section P0200-Alarm that Wander/Elopement Alarm was not used. Elopement Risk assessment dated [DATE] documented that the resident scored 3 or more negative response notify MD, initiate use of Wander guard and follow facility protocol/guidelines, create/update Care plan for Elopement, Update CNA Instructions. The Medication Administration Record (MAR) dated 07/1/24 to 07/22/24 documented the observation of the wander guard device every shift daily (7:00 AM, 3:00 PM, and 11:00 PM). The Comprehensive Care Plan for Behavior Symptoms: Wandering/Elopement risk dated 02/26/24 revised 06/21/24 documented interventions which included check ID bracelet is on wrist, WG to Right Wrist, and maintain safety. The Physician Order's dated 12/07/2022, last revised on 07/17/24 documented the following: Wander Guard-Check Q Shift for Placement. On 07/23/24 at 10:52 AM , an interview was conducted with the MDS Supervisor who stated that the MDS assessor performs physical assessment and review records and intervening staff when completing MDS assessments. They also stated that they should not solely rely on medical records, and they have to see the residents. The MDS supervisor stated that they have just completed a review of all residents on wander guards and they discovered that these 2 residents were not coded accurately. They concluded by saying It could have been an oversight for these 2 residents captured. 415.11 (b)

Based on interviews, observations and record review conducted during a recertification survey (EUC311), the facility did not ensure that a resident's care plan for falls was reviewed and revised. Specifically, staff did not complete a timely review and/or revision for the care plan for a resident who had an identified history of falls with injury. This was evident in 1 of 31 residents reviewed for care plans (Resident #52). The findings are: The facility's policy and procedure entitled Care Plan, Comprehensive, last updated 02/2024, states that the interdisciplinary team reviews and updates the care plans at least quarterly in conjunction with the required Minimum Data Set assessment. Resident #52 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Depression, Chronic Kidney Disease and Diabetes. The Minimum Data Set (a resident assessment tool) dated 06/03/2024 documented that the resident's cognition was severely impaired, that they wandered daily and used a Wanderguard to prevent their accessing the unit stairwells and elevators. A Falls Potential Care Plan was initiated for the resident on 01/09/2020 with interventions to check the equipment for the resident's use daily for stability, encourage the resident to ask for assistance when needed, anticipate needs, keep the call bell within reach and answer promptly, keep the resident's items within easy reach, review their medications, provide a well-lit and hazard free environment, redirect their behavior, refer to PT/OT for evaluation, provide a low bed with no side rails and toilet the resident as scheduled. A Nursing note dated 11/28/2023 at 11:27 AM stated that at 8:30 AM, staff responded to a sound in the resident's room and found Resident #52 sitting on the floor at the foot side of their bed. The resident was awake, alert and responsive but was unable to state what had happened and was attempting to get up by themselves. The resident was assisted back to bed and was seen by the Nurse Practitioner, who noted a small raised area on their forehead with slight redness but no bleeding and ordered a skull x-ray, which was negative. The Nurse Practitioner also ordered a Physical Therapy evaluation, and the resident's next of kin was made aware. The Falls Care Plan was reviewed and updated with a note reflecting the fall. Resident #52's Minimum Data Sets were reviewed and noted that the resident had two quarterly assessments so far in 2024, in March and in June, but their Falls Care Plan had no reviews noted at any point in 2024. On 07/26/2024, Registered Nurse #4 was interviewed and stated that at the time of their fall, Resident #52 was able to ambulate independently but was confused. After their fall, more frequent rounding on all rooms was made. The Nurse Manager stated that they are responsible for reviewing and updating care plans with issues that take place during the day shift; they updated the Falls Care Plan in December 2023 as well as all the resident's other care plans. The Nurse Manager was unable to explain why the Falls Care Plan was not updated in 2024. On 07/26/2024 at 10:53 AM, Registered Nurse #1 was interviewed and stated that they were the Nurse Supervisor covering Resident #52's unit at the time of their fall. However, the Nurse Manager was the person responsible for updating all care plans, and although they were supervising the Nurse Manager on 11/28/2023, they were covering the resident's unit only. The Nurse Supervisor stated that Resident #52 was recently hospitalized and returned to the second floor. On 07/26/2024 at 12:07 PM, Licensed Practical Nurse #1 on the second floor was interviewed and stated that Resident #52 had been on this unit for about ten days and had had no falls during that time. However, the resident is currently not ambulatory. The nurse stated that the resident now spends their day in rehab or in the unit day room, where they participate in activities and have constant staff supervision. The nurse stated that the resident will have their readmission assessment in a few days and their care plans will be updated, including the Falls Care Plan. 483.21(b)(2)(i-iii)

Based on observations, record review, and interviews conducted during the Recertification survey from 07/21/2024 to 07/26/2024, the facility did not ensure that it promoted and facilitated resident self-determination by supporting resident choice. Specifically, residents' bathing preferences were not honored. This was evident for 2 of the 4 residents reviewed for Choices out of 38 sampled residents. (Resident #88, and #46). The findings are: The facility policy and procedures titled ADL-Shower with the last revised date February 2024 documented that it is the policy of the facility to shower residents, to cleanse, and refresh resident, observe the skin and to provide increased circulation. Place resident in a shower chair and drape with a bath blanket or other form of cover. 1. Resident #88 was admitted to the facility with diagnoses that included Peripheral Vascular Diseases and Depression. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #88 as cognitively intact and dependent on staff for Activities of Daily Living (ADLs). No rejection of care was documented. The Annual Minimum Data Set assessment dated [DATE] documented that it is very important for Resident #88 to choose between a tub bath, shower, or sponge bath. On 07/22/2024 at 9:58 AM, Resident # 88 was observed out of bed in a Geri chair in their room. The resident was interviewed and stated that I would like to get a shower, but I have not had a shower since I came to the facility. They wipe me down. The Resident Nursing Instructions dated 05/19/2023 documented that Resident #88 is scheduled for bathing on Mondays and Thursdays during the 3:00 PM to 11:00 PM shift. Bathing types documented include bed bath, shower, and sponge bath. The instructions did not specify Resident #88's preference. The Resident CNA Documentation History Detail Report dated 01/01/2024 to 07/22/2024 documented tasks performed bathing type bed bath. There was no documented evidence that a shower was provided. Progress notes dated 07/01/2024 to 07/24/2024 contained no documented evidence that Resident #88 had been offered and/or refused showers. On 07/24/2024 at 11:19 AM, Certified Nursing Assistant #1 was interviewed and stated that Resident #88 gets showers during the evening shift. Certified Nursing Assistant #1 does not know if the resident gets the shower. On 07/24/2024 at 3:23 PM, Certified Nursing Assistant #2 was interviewed and stated that Resident # 88 gets showers on Mondays and Thursdays during the evening shift. The resident is taken out of bed and taken to the shower room for the shower. At times, the resident will say they do not want to go to the shower room because they have pains. Resident #88 cannot sit in the shower chair, so I gave the resident a shower in the Geri chair, but I documented it as a bed bath. The administration is unaware that the resident cannot sit in the shower chair. I gave the resident a bed bath on Monday. I documented it in the kiosk and clicked bed bath. On 07/24/2024 at 3:36 PM, Certified Nursing Assistant #3 was interviewed and stated that they worked the evening shift and had not seen Resident #88 getting a shower before. They document the shower in the kiosk. If the resident receives a shower, I will click shower, I click bed bath when a resident gets a bed bath. On 07/25/2024 at 11:47 AM, the Unit Manager was interviewed and stated that the Certified Nursing Assistant documents care provided in the kiosk. The assigned charge nurse and the supervisors monitor and ensure care is provided. The Licensed Practical Nurse on the day and the evening shift ensures that residents are getting showers on each shift. There has not been any report that the staff needs a special shower chair to give Resident #88 a shower. We do not use Geri-chairs for showers. On 07/25/2024 at 12:10 PM, the Director of Nursing was interviewed and stated that they offer residents shower two times a week, as needed, as requested, and per the resident's preference. Resident #88's accountability record shows the task was performed, and the bathing type was documented as a bed bath. This is the first time I have heard that Resident #88 does not get a shower. I have not heard that the resident cannot sit in the shower chair. If a problem arises, we will refer the resident to rehab and provide the proper care and equipment. If Resident #88 cannot sit in the shower chair, the resident will need a a special shower chair. The resident can use a reclining shower chair in one of the units. If a resident refuses to shower, it should be documented in the accountability record. We do not use Geri-chair for showers. 48876 2) Resident #46 was admitted to the facility with diagnoses that included Coronary Artery Disease and Diabetes Mellitus. The Quarterly Minimum Data Set (MDS) assessment dated [DATE], identified Resident #46 as cognitively intact, dependent on staff for all surface transfers and requiring moderate assistance with showers and bathing. On 07/25/24 at 12:18 PM, Resident #46 was observed in bed. An interview was conducted when Resident #46 stated that they are not offered showers and that the Certified Nursing Assistant just gives me a bed bath. The Care Plan Activity Report last updated 04/01/2024, documented that Resident #46 is scheduled to be showered on Tuesdays and Saturdays during the 7:00 AM to 3:00 PM shift. Bathing type documented is shower with instructions to inform the nurse if the resident is refusing showers. There is no documented evidence that Resident #46 was refusing showers. The Resident CNA Documentation History Detail Report dated 06/01/2024 to 07/23/2024 documented task performed - bathing, type - bed bath. There was no documented evidence that Resident #46 was offered or received a shower. The Resident Certified Nursing Assistant Documentation History Detail Report, dated 06/01/2024 to 07/23/2024, documented that Resident #46 did not resist care. There was no documented evidence that Resident #46 refused showers. On 07/25/24 at 09:28 AM, an interview was conducted with Certified Nursing Assistant #6 who stated that every resident should be offered a shower twice a week and bed baths should be performed on the other days, resident #46 is scheduled to be showered on Tuesdays and Saturdays but usually gets a bed bath. Certified Nursing Assistant #6 also stated that all the Certified Nursing Assistants document daily in the computer system whether a shower or bath is given. Certified Nursing Assistant #6 further stated that if a resident refuses care, the nurse should be notified. On 07/25/2024, Registered Nurse #3, the floor supervisor, was interviewed and stated that Resident #46 should have been provided all the Activity of Daily Living Care which included a shower twice a week, and if the resident refused it should have been reported by the Certified Nursing assistant and documented by the charge nurse. Registered Nurse #3 further stated that they were unable to locate any documentation that Resident #46 was offered or refused showers. On 07/25/2024, The Director of Nursing was interviewed and stated that they were informed by Registered Nurse #3 that there was no documentation that Resident #46 refused to be showered. The Director of Nursing then confirmed that there was also no documentation found that Resident #46 had been offered or refused showers. 415.5(b) (1-3)

Based on observation, record reviews, and interviews conducted during an Abbreviated Survey (NY00310328), the facility failed to ensure that a Resident was adequately supervised to prevent an accident. This was evident in 1 out of 3 residents reviewed (Resident #1). Specifically, Resident #1 was observed on the dining room floor in a sitting position by Certified Nursing Assistant (CNA) #2 on 02/05/2023 at 10:15 PM. The facility's investigation revealed that Resident #1 was left unsupervised in the dining room by CNA #1. Resident #1 did not sustain any visible injuries. The findings are: The Facility's Policy and Procedure entitle Accident/Incident Prevention with a review date of 03/2022 documented that resident of the facility will be assessed on admission, or whenever a change of condition occurs, for risk factors to prevent accident/incident. Subsequently, an individualized plan of care will be formulated in conjunction with the Interdisciplinary team that identifies risk factors and interventions for prevention of accidents/incidents. Resident #1 was admitted to the facility with diagnoses including Alzheimer's disease, Dementia with agitation, and Depression. The Minimum Data Set (MDS, a resident assessment tool) dated 01/31/2023 documented that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 02 indicating severely impaired cognition. Resident #1 required and extensive assistance by one person with transfer. Resident #1 used a wheelchair for mobility. A Brisk Fall Evaluation dated 12/26/2022 documented that Resident #1 had a score of 18 indicating a high risk for fall. A Comprehensive Care Plan (CCP) potential for falls was implemented on 10/26/2022. The interventions included an interdisciplinary team to anticipate a need and to keep the call bell within reach. The CCP was updated on 10/29/2022 with the interventions: do not leave the resident by themselves when in the dining room and encouraged the Resident to ask for assistance. A Resident Nursing Instructions dated as of 02/01/2023 documented instructions for Resident #1 to be monitored every shift for fall precautions. A review of the facility's Accident/Incident Report dated 02/05/2023 documented that on 02/05/2023 at 10:15 PM, CNA #2 informed Nurse Supervisor (NS) #1 that Resident #1 was observed sitting on the floor in the dining room near their wheelchair. Resident #1 was assessed with no visible injury observed. Resident #1 verbalized no pain. The facility concluded that there was no reasonable cause to believe any alleged resident abuse mistreatment or neglect has occurred. CNA #1's written statement dated 02/05/2023, documented that CNA #1 was doing Sigma Care, and one of the CNAs informed them that Resident #1 was on the floor. A Nursing Progress Note dated 02/05/2023 at 11:01 PM, written by NS #1, documented that at about 10:15 PM, the writer responded to a call in the 3rd-floor dining room that Resident was found sitting on the floor. Upon assessment the Resident was observed sitting on the floor in the dining room, no one witnessed the incident. During a follow-up interview on 02/10/2023 at 10:55 AM, CNA #1 stated that after they left Resident #1 alone in the dining room, they went document in Sigma on the computer located in the hallway, not far from the dining room. CNA #1 stated that they knew that they were not supposed to leave Resident #1 in the dining room unattended because they knew the Resident was at risk for a fall. CNA #1 stated that CNA #2 approached the dining room and said, look, the man on the floor. During an interview on 2/10/2023 at 11:37 AM, CNA #2 stated that they came off the elevator and approached the dining room and observed Resident #1 on the floor in a supine position, but Resident #1 sat themself up in a sitting position. CNA #2 stated that they did not look around to see if any staff was in the dining room. CNA #2 stated that they immediately called Registered Nurse (RN) #1 who came and assessed the Resident. CNA #2 stated that Resident #1 should not be left alone in the dining room because the Resident is at risk for a fall. CNA #2 also stated that if a resident is restless after 9:30 PM, staff would take turns and monitor the resident in the dining room. During an interview on 02/09/2023 at 1:47 PM, RN #1 stated that Resident #1 was watching TV in the dining room and that Resident #1 was not restless. RN #1 stated that the CNAs alternate in the dining room to monitor the residents up to 9:30 PM. RN #1 stated that the CNAs takes turn to watch Resident #1 due to the high risk for fall. RN #1 stated that at 10:15 PM on 02/05/2023, CNA #2 informed them that Resident #1 was on the floor. RN #1 stated that they conducted a head-to-toe assessment, and the Resident had no visible signs of injuries. During an interview on 02/09/2023 at 4:45 PM, RNS #1, who worked on the 02/05/2023 on the 3:00 PM -11:00 PM shift, stated that on 02/05/2023 at about 10:15 PM, CNA #2 notified them that Resident #1 was on the floor in the dining room. RNS #1 stated that they observed Resident #1 sitting on the floor behind the wheelchair. RNS #1 stated that CNA #2 said that they just came and observed Resident #1 on the floor and there was no staff member in the dining room. RNS #1 stated that CNA #2 reported that CNA #1 was supposed to be in the dining room monitoring Resident #1. RNS #1 stated that CNA #2 said that they did not see CNA #1 dining room. RNS #1 stated that CNA #1 explained that they were in the dining room, but they left the dining room for a few seconds to grab something. RNS #1 stated that they performed a head-to-toe assessment and Resident #1 did not have any visible injury or pain. RNS #1 stated that Resident #1 was calm and did not exhibit any signs of emotional disturbance. RNS #1 stated that the Medical Doctor ordered a neuro check, and no deficits were identified. During an interview on 02/09/2023 at 12:00 PM, the Director of Nursing (DON) stated that Resident #1 sustained a fall on 02/05/2023 on the evening shift. The DON stated that they investigated the fall, and that CNA #1 should not have left the Resident in the dining room alone. 415.12(h)(1)(2)

Based on observation, interviews, and record review during an abbreviated survey (NY00301673), the facility did not ensure that a resident was free from physical restraints. This was evident in 1 out of 4 residents sampled (Resident #2). Specifically, Resident #2 was observed with a sock on their right hand and a glove tied over the sock on the Resident's right wrist on 09/01/2022 at 08:30 AM. The glove and sock were removed, and swelling was observed to the Resident's right hand and distal fingers. The findings are: The facility's policy titled Use of Restraints with review date of 09/2021 states that Restraints should only be used for the safety and wellbeing of the resident and only after other alternatives have been tried successfully. The policy defined physical restraints as any manual method or physical or mechanical device, material or equipment attached or adjacent to resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Resident #2 was admitted to the facility with diagnoses including End Stage Renal Disease (ESRD), CKD Stage 5 (Chronic Kidney Disease), Cerebrovascular Disease, and Vascular Dementia. The Minimum Data Set (MDS, resident assessment tool) with an assessment reference date of 06/21/2022 documented that Resident #2 had a Brief Interview for Mental Status (BIMS) and scored 9/15 indicating moderately impaired cognition. Section P documented restraints are not used. A Care Plan on behavior, dated 01/22/2020, documented that the Resident had behavior of digging feces from the diaper and smearing the feces, screaming without any a reason, removing the dressing, and scratching the wound. The care plan was last reviewed on 06/17/2022. The interventions included staff to redirect negative behaviors and refer to psychiatric, consult or follow up as needed. Administer medications as ordered by the physician, allow time to de-escalate and re-approach if agitated. Staff to check and changed the incontinence pad every 3-4 hours. The Resident Nursing Instructions for 08/2022 did not include instructions on what CNAs should do if the Resident was observed digging, scratching, or removing their dressing. A Nursing Progress Note dated 09/01/2022 at 11:15 AM, by Licensed Practical Nurse (LPN) #1, documented that Resident #2 was noted with swelling to the right hand and distal fingers. Supervisor was made aware, the MD (medical doctor) to follow up. Resident went to dialysis appointment at 08:45 AM. A Nursing Progress Note dated 09/01/2022 at 09:35 PM, by Registered Nurse Supervisor (RNS #1) documented that staff reported at around 08:30 AM that Resident #1 was noted with swelling on the right hand. The Resident was assessed and was able to do full range of motion on the affected extremity. Resident #2 denied pain or discomfort. The Resident was unable to report the incident due to impaired cognition. The Accident/Incident Report documented that on 09/01/2022 at about 8:30 AM, it was reported to LPN #1 that Resident #2 was noted with swelling to the right hand and distal fingers. Resident #2 was noted with a sock placed over the right hand and a glove tied around the right wrist over sock. Upon removing the glove and sock, swelling was observed. LPN #1's written statement dated 09/01/2022, documented that on 09/01/2022 at about 08:30 AM, it was reported to LPN #1 and the RNS that during morning care, Resident #2 was noted with swelling to the right hand and distal fingers. CNA #1 further explained that Resident #2 was observed with a sock placed on the right hand and glove tied around right wrist over sock, that swelling was observed upon removing the sock and glove. CNA #1's written statement dated 08/01/2022, documented that CNA #1 was getting Resident #2 ready for an appointment with the help of CNA #2 when they saw that Resident #2 had a sock around the wrist tied with gloves. CNA #1 stated that they took the sock off and saw that the Resident's hands were swollen and looked red. CNA #1 wrote maybe it was placed on both her hands last night. CNA #2's, undated, written statement documented that on 09/01/2022 at about 8:20 AM, while assisting CNA #1 with Resident #1's morning care, they observed that a sock with glove tied around the wrist of Resident #2. CNA #2 documented that they immediately removed the glove and sock, and swelling was observed. The nurse and the supervisor were informed. CNA #3's, undated, written statement documented that on 08/31/2022 at around 10:30 PM, CNA #3 took care of Resident #2. CNA #3 wrote on the statement that Resident #2 was observed digging their sacral wound, so they decided to put the Resident's hands in gloves and socks to prevent Resident #1 from digging the wound which was already bleeding. CNA #4's, undated, written statement documented that they were assigned to Resident #2 on 08/31/2022 for the 11:00 PM - 7:00 AM shift. CNA #4 documented that as they were doing their routine rounds when they noticed that Resident #2 was wearing green socks tied with blue gloves on their both hands. CNA #4 also documented that the bed sheet was soaked with blood and feces. CNA #4 documented that they notified LPN #2 and the LPN found out that the wound was bleeding. The nurse did their dressing immediately. LPN #2's, undated and unsigned, written statement documented that at approximately 11:40 PM, CNA #4 informed LPN #2 that Resident #2's dressing needs to be changed. LPN #2 went to the room to do the dressing and observed that Resident #2 had green socks on their hands. LPN #2 cleansed and redressed the wound and left the room. At about 05:00 AM, LPN #2 redressed the wound and did fingerstick on the left hand. LPN #2 wrote that they did not see any glove tied to the socks. During a telephone interview on 02/23/2023 at 01:59 PM, CNA #2 stated that they were asked by LPN #1 to help prepare Resident #2 for dialysis and when they entered the room, they immediately noticed that Resident #2 had a sock on their right hand and a blue glove was tied over the sock. CNA #2 stated that they took off the sock immediately and showed the Resident's hand to LPN #1. During a telephone interview on 02/23/2023 at 01:49 PM, LPN #1 stated that CNA #2 asked them to check on Resident #2's hand and they observed that Resident #2's right fingers were swollen and there was slight redness to the right wrist. According to LPN #1, CNA #2 stated that there was a sock placed over Resident #2's right hand. LPN #1 stated that CNA #2 had already removed the sock when it was brought to LPN #1's attention. LPN #1 stated that they immediately notified the nursing supervisor. During a telephone interview on 02/23/2023 at 2:16 PM, RNS #1 stated that LPN #1 told them that Resident #2's hand was swollen but could not recall which hand was affected. The RNS stated that they assessed Resident #1 and noted a visible mark around the wrist like it was tied and the hand was puffy. RNS #1 stated that they notified the MD and Resident #2's family. During a telephone interview on 02/23/2023 at 03:27 PM, CNA #3 stated that they were on duty on 08/31/2022 for the 3:00 PM - 11:00 PM shift. CNA #3 stated that Resident #2 had a behavior of digging their wound in their buttocks until it bleeds. CNA #3 stated that on 08/31/2022, at about 10 to 20 minutes before the shift ended, they put the socks on both of Resident #2's hands and tied a glove over each sock to prevent Resident #2 from removing the socks. CNA #3 stated that they did not realize that socks are restraints. CNA #3 stated that they applied the socks and gloves because they felt bad for Resident #2 that the wound might get infected if they kept digging. CNA #3 further stated that this was not the first time they put socks on Resident #1's hands but could not elaborate on other dates. During a telephone interview on 02/23/2023 at 02:53 PM, CNA #4 stated that they worked on 08/31/2022 for 11:00 PM - 7:00 AM shift and Resident #1 was on their assignment. CNA #4 stated that during rounds, they observed that that Resident #2's bedsheet was soaked with blood and feces. CNA #4 stated that they also noticed that Resident #2 had socks on both hands and gloves were tied around the socks. CNA #4 stated that they should have taken the socks off but thought it was used as mittens to prevent the Resident from digging their wound and feces. During a telephone interview on 02/23/2023 at 03:18 PM, LPN #2 stated that they were aware that Resident #2 had socks on both of their hands but did not notice if it was tied with gloves. LPN #2 stated that they did not remove the socks on Resident #1's hand because Resident #2 digs her wound on their back. During an interview on 02/13/2023 at 2:41 PM, the ADON stated that they were responsible to investigate the incident that involved Resident #2 on 09/01/2022. The ADON stated that RNS #1 informed them that Resident #2's right hand was swollen, and that the staff who took care of Resident #2 found a sock worn over Resident #2's hand, and a glove tied over the sock. The ADON stated that Resident #2 was assessed by the RNS with no pain and there was no limitation in movement. Resident #2 went to dialysis after the assessment. The ADON stated that they called CNA #4 who stated that they saw the socks on Resident #2's hand at the beginning of the night shift and did not remove the sock because Resident #2 was scratching and digging their wound. The ADON stated that CNA #4 notified LPN #2, who also admitted to observing the socks on Resident #1's hands but did not remove them. The ADON stated that CNA #3 admitted to putting the socks on because Resident #1 was digging their wound. The ADON stated that the investigation concluded that the swelling on Resident #1's right hand was due to the sock and glove. The ADON stated that abuse was ruled out because there was no intention to harm Resident #2. During the interview on 02/27/2023 at 10:16 AM, the Administrator stated that they were notified about the incident on the same day that it was found on 09/01/2022. The Administrator stated that they were told that Resident #2 was picking on their wound dressing and was observed with a sock on their hand. The Administrator stated that restraints are not allowed in the facility and that the putting socks on Resident #2's hand is considered a restraint. 415.4(a) (2-7)

Based on observation, interview, and record review conducted during an abbreviated survey (NY00310328), the facility failed to ensure that a resident was free from physical abuse. This was evident in 1 out of 3 residents reviewed (Resident #1). Specifically, the facility's surveillance video recording (SVR) showed that on 02/05/2023 at 10:06 PM Certified Nurse Assistant #1 (CNA #1) approached Resident #1 who was sitting in their wheelchair in the dining room and slapped Resident #1 on the top of the head with CNA #1 's left hand. Resident #1 was assessed with no visible injuries. The findings are: The Facility's Policy and Procedure entitled Abuse with review date 9/12/2022 documented it is the policy of the facility that each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, and misappropriation of funds. Further, each resident will be treated with respect and dignity. Resident #1 was admitted to the facility with diagnoses including Alzheimer's disease, Dementia with agitation, and Depression. The Minimum Data Set (MDS, a resident assessment tool) dated 01/31/2023 documented that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 02/15 indicating severely impaired cognition. Resident #1 required limited assistance with bed mobility and extensive assistance by one person with transfer. Resident #1 used a wheelchair for mobility. A Comprehensive Care Plan (CCP) Abuse dated 11/02/2022 documented that Resident #1 had a behavior of resisting care and kicking/hitting. The interventions documented that staff should approach the Resident in a calm manner, staff to monitor and document the Resident's unusual behavior, staff to monitor the Resident's interactions with peers, and remove the Resident from danger. A Resident Nursing Instructions dated as of 02/01/2023 documented instructions for staff to monitor the Resident every shift for behavior of resisting care, hitting, and kicking. The facility SVR was reviewed with the Director of Nursing (DON) on 02/09/2023 at 10:45 AM. As per DON, the surveillance camera was recorded in real-time. The facility's SVR showed on 02/05/2023 at 10:06:23 PM, Resident #1 was sitting alone in the dining room in the wheelchair at the table. Resident #1 was dressed in a sleeping gown and had a blue and read cap on their head. CNA #1 was sitting in the back at the corner of the dining room. No other residents or staff were in the dining room. Resident #1 was leaning toward at the table. CNA #1 approached Resident #1 from the behind and slapped, one-time, the Resident on the head and Resident #1 reacted by turning their head toward CNA #1. CNA #1 tapped Resident #1 multiple times on the shoulder and back. At 10:08:09 PM Registered Nurse #1 (RN #1) came to the dining room, appeared to be having a conversation with CNA #1, then walked out of the dining room. At 10:09:00 PM CNA #1 put both their arms under the Resident's armpits and repositioned Resident #1 in the wheelchair. Resident #1 waived their right hand at CNA #1 as the CNA squeezed Resident #1 at the neck. CNA #1 tapped Resident #1 on the shoulder and squeezed the Resident's neck and walked away. Resident #1 threw their right hand at the CNA after CNA squeezed the Resident's neck. CNA #1 left the dining room and disappear from camera view. As per the DON, Resident #1 sustained a fall after CNA #1 left the dining room but there was no video recording of the fall. A review of the facility's investigation dated 02/07/2023 documented that on 02/07/2023 while investigating a fall incident on 02/05/2023, CNA #1 was observed slapping Resident #1 on the top of their head. No visible injury was observed but Resident #1 was noted restless before and after the incident. The camera revealed that CNA #1 got up and walked toward Resident #1. As CNA #1 came to Resident #1's side, CNA #1 slapped the top of Resident #1 's head. CNA #1 was also observed handling Resident #1 roughly during repositioning in the wheelchair. CNA #1 denied purposely hitting Resident #1 stating that they just want to help Resident #1 reposition in the chair. Staff on the unit was interviewed and no one witnessed the incident. The investigation concluded there is evidence to suspect abuse, neglect, or mistreatment. CNA #1's written statement to the facility, dated 02/07/2023 documented that CNA #1 denied abusing Resident #1 and stated that it was not something bad, it was kind of a tap to play with the Resident, not abuse. A Nurse's Progress Note dated 02/07/2023 at 2:18 PM, documented that Resident #1 on Post Accident /Incident monitoring for 72 hours. The assessment was done with no visible injury noted. No change in mental status. No behavior or mood was observed. During an interview on 02/09/2023 at 1:01 PM, CNA #1 stated that they were watching Resident #1 in the dining room and saw that the Resident was leaning forward in the chair, and they decided to reposition the Resident. CNA #1 stated that they approached Resident #1 and tapped Resident #1 on the head. CNA #1 stated that they were playing with Resident #1 and tapped the Resident on the hat that the Resident was wearing. CNA #1 stated that they grabbed Resident #1 under their armpits and pulled the Resident up in the wheelchair. During an interview on 02/09/2023 at 12:00 PM, the Director of Nursing (DNS) stated they were reviewing the facility's SVR on 02/07/2023, they saw CNA #1 taped Resident #1 on the back of the head. The DON stated that it was not really a slap but rather a tap. The DON stated that they decided to report the incident because CNA #1 should not have done that. The DON stated that they called the police, and the police came and reviewed SVR and said that it was a tap, and it constitute harassment. The police said that there was no assault and CNA #1 was not arrested or charged. The DON stated that after the incident CNA #1 was immediately terminated. During an interview on 02/10/2023 at 12:20 PM, the Administrator stated that they were notified about the abuse on 02/07/2023 at around 1:00 PM. The Administrator stated that the DON and ADON notified them that they were investigating a fall that happen on 02/05/2023 and saw on the camera that CNA #1 strongly tapped Resident #1 on the top of the head. The Administrator stated that they watched the video and saw CNA #1 strongly tap Resident's head and it also looked like CNA #1 squeezed the Resident's neck and roughly repositioned Resident #1 in the chair. The Administrator stated that it constitutes abuse and mistreatment. The Administrator stated that CNA #1 was terminated immediately. 10 NYC RR 415.4(b)(1)(i)

Based on observation, record review and interviews conducted during the extended recertification and abbreviated (NY 309) survey from 6/27/2022 through 7/12/2022, 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 14 of 14 residents reviewed for Physical Restraints (Resident #s 85, 95, 42, 190, 23, 69, 76, 121, 63, 136, 71, 12, 40 and 31) out of a sample of 43 residents. Specifically, Resident #42 had severely impaired cognition and required extensive assist of one person for bed mobility and transfers. Resident #42 had orders for bilateral ½ side rails SR, and the SR were not identified as a restraint. Resident #42 sustained an injury to the right eyelid after hitting their head on a ½ SR. There was no medical justification, SR safety assessment prior to SR use, restraint care plan, or evidence of alternatives attempted before using the bilateral ½ SR. Resident #s 85, 95, 190, 23, 69, 76, 121, 63, 136, 71, 12, 40, and 31 had severely impaired cognition and required extensive to total assistance of two persons for bed mobility and transfers. The affected residents had orders for bilateral ½ SR, and the SR were not identified as a restraint per the SR assessment. There was no medical justification, SR safety assessment prior to SR use, restraint care plan, or evidence of alternatives attempted before using the bilateral ½ SR. This resulted in Immediate Jeopardy (IJ) with the likelihood for serious, injury, serious harm, serious impairment, or death to all residents using SR or other devices that were potential restraints. IJ was identified and declared. IJ began on 07/05/2022 and was called on 07/05/2022 at 8:59AM. The facility submitted an IJ removal plan on 07/08/2022. IJ was removed on 07/08/2022 at 4:00 PM. The findings include but are not limited to: The facility policy titled Use of Restraints last reviewed 9/2021 documented: Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative. The order shall include the following: a. the specific reason for the restraint (as it relates to the resident's medical symptom); b. how the restraint will be used to benefit the resident's medical symptom, and c. the type of restraint, and period of time for the use of the restraint. Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptom(s), but the underlying problems that may be causing the symptom(s). References: related documents: risk-benefit acknowledgement form (MP5540); Physical Restraints - record of informed consent. The policy titled Proper Use of SR last reviewed 12/2021 documented SR are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed). SR are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using SR. When used for mobility or transfer, an assessment will include a review of the resident's: bed mobility, ability to change positions, transfer to and from bed or chair, and to stand and toilet; risk of entrapment from the use of SR, and that the bed's dimensions are appropriate for the resident's size and weight. When SR usage is appropriate, the facility will assess the space between the mattress and SR to reduce the risk for entrapment. 1.) Resident #42 was diagnosed with dementia and [CONDITION(S)]. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #42 was severely cognitively impaired and required extensive assistance of two people for bed mobility and transfers. On 7/06/2022 at 7:40 AM, Resident #42 was observed sleeping in bed with the right ½ SR in the raised position. No staff were observed in the room. On 7/06/2022 at 7:57 AM, Resident #42 was observed awake in bed with the right ½ SR in the raised position. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ½ SRs. There was no indication of medical necessity in the order. A Facility Accident/Incident Investigation dated 9/13/2020 documented Resident #42 turned to their right side while receiving care from the Certified Nursing Assistant (CNA) and hit their eye on the SR sustaining a scratch to the right eye lid. The corrective action was to encourage the resident to turn slowly. The Fall Risk assessment dated [DATE] documented Resident #42 did not have any falls and scored a 7, indicating they were not at high risk for falls. The SR assessment dated [DATE] documented Resident #42 was able to follow instructions, not able to retain information, not physically able to release the SR, used the SRs to enhance mobility, and attempted to get out of bed by themselves. The assessment did not contain a medical justification for the use of SRs. There was no documented evidence other devices were used as enablers or a SR safety assessment was completed prior to the use of the ½ SRs. The bilateral ½ SRs were not identified as a restraint. On 7/5/2022 at 1:26 PM, Licensed Practical Nurse (LPN) #1 was interviewed and stated SRs can be used when the resident can hold onto the SRs to help turn themselves. SRs were considered a restraint if the resident was unable to use the SRs independently. The Registered Nurse Manager (RNM) assesses the residents to determine whether SR use is appropriate. During an interview on 7/5/2022 at 1:13 PM, RNM #1 stated Resident #42 needed bilateral 1/2 SR to prevent falls and assist with bed mobility. The RNM obtains consent from the resident or resident's family for SR use. If the resident is cognitively impaired and there is no family, an Interdisciplinary Team (IDT) meeting is held, and the Physician decides if SRs are necessary. A 3-day assessment is done for new admissions, readmissions, and residents with significant changes to determine if SRs are necessary. The RNMs write the PO, a progress note, and update the resident's care plan. Bilateral ½ SRs are not considered a restraint. 2.) Resident #85 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #85 had severely impaired cognition and required the total assistance of two staff for bed mobility and transfers. Resident #85 had no falls since the last assessment, and SRs and restraints were not in use. On 7/05/2022 at 8:59 AM, Resident #85 was observed in bed after receiving care with bilateral ½ SRs raised. There were no observations of Resident #85 being able to grab the SR. On 7/6/2022 at 9:01 AM, Resident #85 was observed receiving morning care from (Certified Nursing Assistant) CNA #2 and CNA #6. Bilateral ½ SRs were raised at the start of care. CNA #2 and CNA #6 both lowered a ½ SR and washed Resident #85's face and body. Both CNAs positioned Resident #85 in bed and raised the bilateral ½ SRs after care was completed. Resident #85's body was stiff and unable to move without assistance. One of the CNAs prompted Resident #85 to grab onto the ½ siderail, and Resident #85 was unable to follow the command. The Comprehensive Care Plan (CCP) related to fall potential initiated 7/23/2020 and last revised 7/2/2022 documented Resident #85 was at risk for falls due to the behavior of trying to get out of bed unassisted, impaired cognition, impaired judgement, and poor safety awareness. The interventions included bed alarm and floor mats for safety. The CCP related to skin integrity initiated 7/23/2020 and last revised 10/24/2021 documented Resident #85 was provided with bilateral ½ SR to assist with positioning and comfort. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ½ SRs. There was no indication of medical necessity in the order. The SR assessment dated [DATE] documented Resident #85 was able to follow instructions, unable to retain information, unable to physically release the SRs, had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #85's designated representative requested SR use and ½ upper SRs were indicated to assist in bed mobility. The Briggs Fall Risk assessment dated [DATE] documented Resident #85 scored a 10, indicating Resident #85 was at high risk for falls. There was no documented evidence other alternatives were tried prior to the use of bilateral ½ SRs. There was no documented evidence a SR safety assessment was completed prior to the application of bilateral ½ SRs. There was no documented evidence Resident #85 was observed using the ½ SR as an enabler. The bilateral ½ SRs were not identified as a restraint, and there was no restraint CCP in place. During an interview conducted on 7/05/2022 at 8:59 AM, CNA #2 stated Resident #85 was totally dependent on staff for turning and positioning and cannot move side to side in bed without assistance. Bilateral floor mats are in place and the bed is kept in the lowest position because Resident #85 attempts to get up without assistance. CNA #2 stated Resident #85 has attempted to get out of bed by grabbing the SR. During an interview conducted during an observation of care on 7/6/2022 at 9:01 AM, CNA #6 and CNA #2 were interviewed and both stated Resident #85 can move their arms, cannot move in bed by themselves, and cannot assist in their own care. On 7/1/2022 at 10:15 AM, Licensed Practical Nurse (LPN) #3 was interviewed and stated Resident #85 could not release the SRs and the SRs were used for Resident #85 because the resident has a behavior of moving up and down in the bed. Along with floor mats, it is a safety feature. 3.) Resident #95 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/5/2022 at 5:56 PM, Resident #95 was observed in bed with the bilateral ½ SRs raised. The Certified Nursing Assistant (CNA #7) called Resident #95 by name and prompted them to hold onto the ½ SR. Resident #95 did not respond or follow the command. The Minimum Data Set (MDS) dated [DATE] documented Resident #95 required extensive assistance of 1 person for bed mobility and extensive assistance of 2 people to transfer. An active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ½ SRs. There was no indication of medical necessity in the order. A SR assessment dated [DATE] documented Resident #95 used the SR to enhance bed mobility, did not attempt to get out of bed unassisted, did not use the SR to adjust his or her position in bed, and was not able to physically release the SR. The Interdisciplinary Team (IDT) documented a recommendation for Resident #95 to have ½ upper SR to assist in bed mobility and transfers. The Comprehensive Care Plan (CCP) related to Activities of Daily Living (ADL) initiated 10/25/2021 and last revised 6/28/2022 documented Resident #95 was severely cognitively impaired, non-ambulatory, had decreased mobility and required extensive assistance of 1 person and SR for bed mobility. The CCP related to fall potential, initiated 10/25/2021 and last revised 6/28/2022, documented Resident #95 had impaired cognition and impaired vision. Bilateral ½ SRs were used as enablers with bed positioning. A Physical Therapy (PT) Evaluation dated 10/25/2021 documented Resident #95 required maximum assistance for bed mobility. Restorative therapy was recommended, and a goal was set for the resident to be able to perform bed mobility with moderate assistance with use of SRs for initiation / termination of tasks, for proper sequencing and for task segmentation in order to get in/out of bed, prepare for transfers and participate in edge of bed activities. The PT Discharge Summary dated 11/24/2021 documented Resident #95 required maximum assistance for bed mobility and did not meet the therapy goals. The Briggs Fall Risk assessment dated [DATE] documented Resident #95 scored a 12, indicating high risk for falls. There were no observations of Resident #95 using the ½ SR as an enabler. There was no documented evidence other devices were used as enablers or a SR safety assessment was completed prior to the implementation of bilateral ½ SR. The bilateral ½ SR were not identified as a restraint. On 7/5/2022 at 1:04 PM and 6:12 PM, CNA #7 was interviewed and stated Resident #95 could not participate in care or follow instructions. Resident #95's left hand was weak, but Resident #95 can hold onto the SR with the right hand if it is placed there. CNA #7 stated Resident #95 has not attempted to get out of bed. The SRs stop the resident from falling on the floor during care. Resident #95 cannot roll by themselves, but when CNA #7 turns the resident, the resident's body moves and can tip over. CNA #7 stated the resident requires two people to assist them with bed mobility and turning/positioning. SRs can be considered a restraint but not for this resident. During an interview on 7/5/2022 at 3:03 PM, Licensed Practical Nurse (LPN) #4 stated the SRs are used because Resident #95 moves while they are in bed, at times, and staff reported Resident #95 had their leg hanging off the side of the bed. LPN #4 also stated the resident's family wanted side rails in place. On 7/5/2022 at 01:13 PM, the Nurse Educator was interviewed and stated SR were used to assist residents with positioning while in bed. SR were considered a restraint if used for residents who were unable to use the SR unassisted. On 7/8/2022 at 11:38 AM, Physician #1 was interviewed and stated SRs were used for mobility to transition in bed and were not used for resident safety. SRs were considered a restraint if SRs were used without proper indications. During an interview on 7/6/2022 at 3:23 PM, the Director of Rehab stated rehab only assesses residents for bed mobility and transfers, not SR use. The SR assessment is completed by nursing. On 7/6/2022 at 10:53 AM, the Director of Nursing (DON) was interviewed and stated residents were assessed for their ability to move in bed and if they required SRs. The SRs are raised during care, if necessary, otherwise, the SRs are removed. Resident information is reviewed prior to admission to determine the type of bed a resident requires. The Maintenance Department was responsible for measuring the beds and SRs. The nurse assesses and determines whether Maintenance needs to address issues with a resident's bed. On 7/8/2022 at 11:43 am, the Medical Director was interviewed and stated the IDT asked them to make a list of residents who are alert & oriented and who may have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medical Director was asked to review cases on units 1, 2, and 4. Unit 3 has residents with psychiatric diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Immediate Jeopardy (IJ) was identified and declared. The facility Administrator and Director of Nursing were notified on 7/6/2022 at 6:00 PM. The facility submitted a removal plan that was reviewed and accepted by the NYSDOH on 7/8/2022 at 4:00 PM. On 7/8/2022 at 4:00 PM, the survey team declared the IJ was removed based on the following corrective actions taken by the facility: - For Resident #95 and Resident #42, SR assessments were completed, and the Physician discontinued SRs for both residents. Both residents were observed with no SR in place on 7/07/2022 and 7/08/2022. - For Resident #85, a SR assessment was done, and the IDT determined there was a medical justification for bilateral 1/2 SR use. The MDS was reviewed for accuracy. This was completed by 7/08/2022. - All residents with POs for SR were assessed for clinical justification and appropriateness of SR use by 7/8/2022. - The maintenance personnel will remove the SRs for all residents who did not require them based on the assessment by the IDT by 7/11/2022. As of 7/8/2022, 96% of SRs were removed with 4% (3) still pending. - Policy for 'SR Utilization' was reviewed and revised on 7/6/2022. The revised policy ensured consistency between the SR assessment and MDS. PT was included in SR assessments, and the assessment will include the residents' ability to release the SR to determine if it is a restraint. - The Policy for 'Use of Restraints' was reviewed 7/6/2022 to ensure that a mechanism for release of the SR and/or restraint was in place. The opportunity for motion and exercise is provided for a period of no less than ten (10) minutes during each two (2) hours in which restraints are employed. - In-service lesson plan and sign-in sheets were reviewed 7/08/2022 and education was provided to 89% of staff (department heads, Administration, Nursing, MDS Department, Dietary, Housekeeping/Maintenance, Recreation, Social Work, Rehabilitation Department) re: restraints and SR identification, indication, and implementation of policy. - Interviews were conducted with the following staff who were in-serviced on restraints and SRs: 4 RNs, 2 LPNs, 13 CNAs, 1 MD, 2 Social Workers, 1 Recreation staff member, and the Administrator. All staff were in-serviced and knowledgeable on Restraints and SR. Based on observation, interview and record review conducted on 7/8/2022, the facility fully implemented the IJ Removal Plan, and the IJ was removed as of 7/8/2022 at 4:00 PM. 415.4(a)(2-7)

Based upon observation, interview, and record review during the extended recertification and abbreviated (NY 309) survey from 6/27/2022 to 7/12/2022, the facility did not ensure appropriate alternatives to bed/SR (SR) were implemented and that residents were adequately assessed prior to bed/side rails (SR) use. This was evident in 14 (Resident #s 85, 95, 42, 190, 23, 69, 76, 121, 63, 136, 71, 12, 40 and 31) of 14 reviewed for SR out of a sample of 43 residents. Specifically, Resident #s 85, 95, 42, 190, 23, 69, 76, 121, 63, 136, 71, 12, 40 and 31 were observed with SR in use without assessments that included risk of entrapment and ensure the bed's dimensions are appropriate for resident's size and weight prior to SR installation. The findings include, but are not limited to: The policy titled Proper Use of SR dated 6/2016 and last reviewed 12/2021 documented: the purposes of these guidelines are to ensure the safe use of SR as resident mobility aids and to prohibit the use of SR as restraints unless necessary to treat a resident's medical symptoms. SR are considered a restraint when they are used to limit the resident's freedom of movement and are only permissible if they are used to treat a resident's medical symptoms or assist with mobility and transfer. An assessment will be made to determine the resident's symptoms, risk of entrapment from the use of SR, and that the bed's dimensions are appropriate for the resident's size and weight and for the space between the mattress and bed frame. 1.) Resident #42 was diagnosed with dementia and [CONDITION(S)]. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #42 was severely cognitively impaired and required extensive assistance of two people for bed mobility and transfers. On 7/06/2022 at 7:40 AM, Resident #42 was observed sleeping in bed with the right ½ SR in the raised position. No staff were observed in the room. On 7/06/2022 at 7:57 AM, Resident #42 was observed awake in bed with the right ½ SR in the raised position. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ½ SRs. There was no indication of medical necessity in the order. A Facility Accident/Incident Investigation dated 9/13/2020 documented Resident #42 turned to their right side while receiving care from the Certified Nursing Assistant (CNA) and hit their eye on the SR sustaining a scratch to the right eye lid. The corrective action was to encourage the resident to turn slowly. The Fall Risk assessment dated [DATE] documented Resident #42 did not have any falls and scored a 7, indicating they were not at high risk for falls. The SR assessment dated [DATE] documented Resident #42 was able to follow instructions, not able to retain information, not physically able to release the SR, used the SRs to enhance mobility, and attempted to get out of bed by themselves. The assessment did not contain a medical justification for the use of SRs. There was no documented evidence Resident #42 was adequately assessed to ensure alternative interventions were attempted prior to use of SR; and there was no evidence the resident's bed was assessed to ensure there was no risk of entrapment. On 7/5/2022 at 1:20 PM, CNA #1 was interviewed and stated SR are for safety and helps the Resident #42 from falling out of bed. Residents who can become aggressive have SR to prevent them from falling out of bed. All the residents have SR. 2.) Resident #85 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #85 had severely impaired cognition and required the total assistance of two staff for bed mobility and transfers. Resident #85 had no falls since the last assessment, and SRs and restraints were not in use. On 7/05/2022 at 8:59 AM, Resident #85 was observed in bed after receiving care with bilateral ½ SRs raised. There were no observations of Resident #85 being able to grab the SR. On 7/6/2022 at 9:01 AM, Resident #85 was observed receiving morning care from (Certified Nursing Assistant) CNA #2 and CNA #6. Bilateral ½ SRs were raised at the start of care. CNA #2 and CNA #6 both lowered a ½ SR and washed Resident #85's face and body. Both CNAs positioned Resident #85 in bed and raised the bilateral ½ SRs after care was completed. Resident #85's body was stiff and unable to move without assistance. One of the CNAs prompted Resident #85 to grab onto the ½ siderail, and Resident #85 was unable to follow the command. The Comprehensive Care Plan (CCP) related to fall potential initiated 7/23/2020 and last revised 7/2/2022 documented Resident #85 was at risk for falls due to the behavior of trying to get out of bed unassisted, impaired cognition, impaired judgement, and poor safety awareness. The interventions included bed alarm and floor mats for safety. The CCP related to skin integrity initiated 7/23/2020 and last revised 10/24/2021 documented Resident #85 was provided with bilateral ½ SR to assist with positioning and comfort. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ½ SRs. There was no indication of medical necessity in the order. The SR assessment dated [DATE] documented Resident #85 was able to follow instructions, unable to retain information, unable to physically release the SRs, had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #85's designated representative requested SR use and ½ upper SRs were indicated to assist in bed mobility. The Briggs Fall Risk assessment dated [DATE] documented Resident #85 scored a 10, indicating Resident #85 was at high risk for falls. There was no documented evidence Resident #85 was adequately assessed to ensure alternative interventions were attempted prior to use of SR; and there was no evidence the resident's bed was assessed to ensure there was no risk of entrapment. On 7/1/2022 at 10:15 AM, Licensed Practical Nurse (LPN) #3 was interviewed and stated Resident #85 could not release the SR and the SR was used with Resident #85 because the resident moves up and down. 3.) Resident #95 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/5/2022 at 5:56 PM, Resident #95 was observed in bed with the bilateral ½ SRs raised. The Certified Nursing Assistant (CNA #7) called Resident #95 by name and prompted them to hold onto the ½ SR. Resident #95 did not respond or follow the command. The Minimum Data Set (MDS) dated [DATE] documented Resident #95 required extensive assistance of 1 person for bed mobility and extensive assistance of 2 people to transfer. An active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ½ SRs. There was no indication of medical necessity in the order. A SR assessment dated [DATE] documented Resident #95 used the SR to enhance bed mobility, did not attempt to get out of bed unassisted, did not use the SR to adjust his or her position in bed, and was not able to physically release the SR. The Interdisciplinary Team (IDT) documented a recommendation for Resident #95 to have ½ upper SR to assist in bed mobility and transfers. The Comprehensive Care Plan (CCP) related to Activities of Daily Living (ADL) initiated 10/25/2021 and last revised 6/28/2022 documented Resident #95 was severely cognitively impaired, non-ambulatory, had decreased mobility and required extensive assistance of 1 person and SR for bed mobility. The CCP related to fall potential, initiated 10/25/2021 and last revised 6/28/2022, documented Resident #95 had impaired cognition and impaired vision. Bilateral ½ SRs were used as enablers with bed positioning. A Physical Therapy (PT) Evaluation dated 10/25/2021 documented Resident #95 required maximum assistance for bed mobility. Restorative therapy was recommended, and a goal was set for the resident to be able to perform bed mobility with moderate assistance with use of SRs for initiation / termination of tasks, for proper sequencing and for task segmentation in order to get in/out of bed, prepare for transfers and participate in edge of bed activities. The PT Discharge Summary dated 11/24/2021 documented Resident #95 required maximum assistance for bed mobility and did not meet the therapy goals. The Briggs Fall Risk assessment dated [DATE] documented Resident #95 scored a 12, indicating high risk for falls. There was no documented evidence Resident #95 was adequately assessed to ensure alternative interventions were attempted prior to use of SR; and there was no evidence the residents' bed was assessed to ensure there was no risk of entrapment. On 7/5/2022 at 1:04 PM and 6:12 PM, CNA #7 was interviewed and stated SR stop Resident #95 from falling on the floor. Resident #95 cannot roll by themselves, but when CNA #7 turns the resident, the resident's body moves and can tip over. Resident #95 required 2 people to assist them with bed mobility and turning/positioning. CNA#7 stated SR can be considered a restraint. On 7/5/2022 at 3:03 PM, LPN #4 was interviewed and stated Resident #95 sometimes moves while they are in bed. Staff reported Resident #95 had their leg hanging off the side of the bed and the resident's family wanted SR in place. On 7/5/2022 at 1:26 PM, LPN #1 was interviewed and stated SR can be used when the resident can hold onto the SR to help turn themselves in bed. The Registered Nurse (RN) assesses the residents for appropriateness of SR. On 7/5/2022 at 1:13 PM, Registered Nurse Manager (RNM) #1 was interviewed and stated bilateral 1/2 SR are necessary to prevent residents from having falls and promoting bed mobility. The RNM gets consent from the resident's family and completes a 3-day assessment prior to giving a resident SR. Residents are given SR when they also have a low bed. The RNM then obtains an MDO and documents in the progress notes and CCP. On 7/6/2022 at 9:40 AM, Director of Maintenance (DOM) was interviewed and stated the SR automatically come with all the beds. The Maintenance staff check the SR to make sure they go up and down and work properly. All the beds are not supposed to have space from the mattress to the SR. The DOM follows the manufacturer's instructions and does not take resident's height and weight into account when reviewing how the SR are functioning. On 7/6/2022 at 10:53 AM, the Director of Nursing (DON) was interviewed and stated prior to use of SR, residents'' ability to move around in bed is assessed. The facility has bariatric beds and regular beds. The SR can be removed or tied up if not in use. Prior to admission to the facility, the DON reviews the resident's weight to ensure there is an appropriate bed for them upon admission. Maintenance is responsible for measuring the beds. 415.12(h)(1)

Based on observations, record review, and staff interviews conducted during the recertification survey, the facility did not ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 4 (Residents #55, 120, 37 & 77) of 12 residents on 1 (3rd floor) of 4 units observed during the Medication Administration Facility Task. Specifically, a Licensed Practical Nurse (LPN #5) was observed using a glucometer machine for multiple residents without sanitizing the equipment in between the residents. The findings are: The facility's policy titled Administration of Medication, reviewed 03/02/22, documented in the section Obtaining a Fingerstick Glucose level, that staff should always ensure that blood glucose meters intended for reuse are cleaned with germicidal wipes and disinfected between resident uses. On 06/28/22 09:48 AM, Licensed Practical Nurse (LPN) #5 was observed checking residents' blood glucose on the 3rd floor. LPN #5 removed the glucometer from the medication cart and proceeded to perform fingerstick check for Resident #55. LPN #5 was not observed sanitizing the glucometer before use. After completing the fingerstick, the nurse removed and discarded the test strip and then placed the glucometer in the medication cart without sanitizing or cleaning the glucometer. At 11:28 AM, LPN #5 was observed removing the same glucometer, that had not been sanitized after prior use, from the medication cart. LPN#5 then approached Resident #37 and proceeded to perform a fingerstick. LPN #5 then returned the glucometer to the medication cart. LPN #5 was not observed sanitizing the glucometer before or after use. At 11:46 AM, LPN #5 removed the glucometer from the medication cart and then proceeded to perform fingerstick for Resident #77. LPN #5 was not observed sanitizing the glucometer before or after use. At 11:59 AM, LPN #5 removed the glucometer from the medication cart and then proceeded to perform fingerstick for Resident #55. LPN #5 was not observed sanitizing the glucometer before or after use. During an interview on 06/28/22 at 12:04 PM, LPN#5 stated that the glucometer is supposed to be wiped with alcohol before and after each use. LPN #5 stated he/she wipes off the glucometer with alcohol after each finger stick and puts it back in the medication cart. LPN #5 stated that they did not do it today because they were nervous, and they were recently in-serviced on glucometer cleaning and testing. On 06/28/22 at 12:12 PM, LPN #3 was interviewed and stated that they were taught to use the Sani cloth wipes with the purple top to clean the glucometer before and after each patient use and before placing it back in the medication cart. LPN #3 stated they were in-serviced on this task about 2 weeks ago. During an interview on 06/29/22 at 10:46 AM, the Registered Nurse (RN) Educator stated LPN #5 was in-serviced and taught to clean the glucometer between use, and competencies were observed on the units during medication administration. The RN Educator also stated that in-services are done yearly, on orientation, and if there is an incident whereby it is not practiced. The RN Educator also said that staff were taught to clean the glucometer with the purple topped germicidal wipes, which should always be on the medication carts. 415.19(a) (1-3)

Based on observation, record review, and staff interviews conducted during the recertification survey, the Facility did not ensure the Minimum Data Set (MDS) assessment accurately reflects the resident's status for 2 (Resident # 90 and Resident # 108) of 2 residents reviewed for Resident Assessment out of an investigative sample of 42 residents. Specifically, 1) Resident #108's most recent MDS assessment inaccurately documented Resident #108 received [CONDITION(S)]; 2) Resident #90's most recent MDS assessment inaccurately documented Resident #90 had adequate hearing. The findings are: The findings are: The facility's policy titled Resident Assessment last revised 02/2022 documented the MDS Coordinator (MDSC) is responsible for ensuring appropriate resident assessment and reviews. 1) Resident # 108 was had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] did not document Resident #108 documented the Resident #108 was receiving [CONDITION(S)] treatment. There was no documented evidence in the medical record that Resident #108 was receiving [CONDITION(S)] treatment. On 06/30/2022 at 3:30 PM, the MDS Coordinator (MDSC) was interviewed and stated Resident # 108 was coded as receiving [CONDITION(S)], but the resident does not receive [CONDITION(S)] treatment. The error on Resident #108's MDS was a mistake and needs to be modified. The MDSC reviews the completion of the MDS but does not review the accuracy of the MDS section by section. The different disciplines who fill out the MDS are responsible for ensuring that it is accurate. 2) Resident #90 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE] documented Resident #90 was cognitively intact and had adequate hearing. On 06/27/2022 at 03:51 PM and 6/29/2022 at 10:53 AM, Resident #90 was interviewed and wrote they lost their hearing at the age of 2, communicated via written or typed messages, and the facility staff made accommodations for their hearing impairment. A comprehensive care plan (CCP) related to communication and potential for barriers, initiated 11/24/2020 and last reviewed 6/2/22, documented staff presents ideas to Resident #108 one at a time and uses short simple sentences written on paper and uses a telecommunication application on Resident #108's cellphone. On 06/30/22 at 03:02 PM, the MDS Coordinator was interviewed and stated Resident #90 had congenital [CONDITION(S)] and they write as a form of communication. The person who completed the MDS assessment for Resident #90 made a mistake in documenting that Resident #90 had adequate hearing. It was an oversight. 415.11(b)

Based on record review and interviews conducted during the recertification survey from 6/27/2022 to 7/12/2022, the facility did not ensure Minimum Data Set 3.0 (MDS) assessments were transmitted timely. This was evident for 1 (Resident #1) of 2 residents reviewed for Resident Assessment. Specifically, the facility did not transmit a Discharge MDS for Resident #1 within 14 days. The findings are: The facility's policy titled Resident Assessment last reviewed 2/2022 documented the MDS Coordinator (MDSC) is responsible for ensuring the interdisciplinary team conducts timely and appropriate resident assessments and reviews. Discharge assessments are conducted when a resident is discharged from the facility. Resident #1 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Discharge MDS initiated and completed on 1/26/2022 documented Resident #1's return to the facility was not anticipated. As of 6/29/2022, the Discharge MDS did not have a submission date and the status was suspended. On 06/30/22 at 03:02 PM, the MDS Coordinator (MDSC) was interviewed and stated Discharge MDS assessments are completed the same day a resident is discharged from the facility and must be submitted within 14 days. The Discharge MDS for Resident #1 was probably accidentally suspended. The MDSC should have received a notification re: the suspension of Resident #1's Discharge MDS but did not receive one leading to the submission oversight. On 07/12/22 at 12:07 PM, the Director of Nursing (DON) was interviewed and stated the MDSC was responsible for overseeing the MDS completion and submission and randomly checks for accuracy. 415.11

Based on interviews and record review conducted during a Recertification and Abbreviated Survey (NY 652), the facility did not ensure all alleged violations involving abuse, neglect, or mistreatment resulting in serious bodily injury, were reported to State Survey Agency. This was evident for 1 (Resident #240) of 8 residents reviewed for Accidents out of a total sample of 42 residents. Specifically, the facility did not report Resident #240's wrist fracture of unknown origin to New York State Department of Health (NYSDOH). The findings are: The facility's policy titled Accident/Incident (A/I) Prevention last reviewed 03/2022 documented an accident is defined as an unexpected, unintended event that can cause a resident bodily injury. Examples of accidents may include but are not limited to fractures. Resident #240 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #240 was severely cognitively impaired, required the extensive assistance of one person for bed mobility, and extensive assistance of two people for transfers and toilet use. A Nursing Note (NN) dated 07/07/2021 documented Resident #240 was observed sitting on the floor mat on the right side of their bed at 4:00 AM. The resident's bed was in the lowest position. Resident #240 complained of slight left wrist pain. Upon assessment, the left wrist was slightly swollen with no discoloration or redness. The Medical Doctor (MD) was notified, Tylenol was administered, and a left wrist x-ray was ordered. A NN dated 07/07/21 documented x-ray Resident #240 had a fracture of the left distal radius, MD was notified, and Resident #240 was transferred to the hospital for evaluation. The A/I Investigation Report dated 7/07/2021 documented on 7/07/2021 at 4:00 AM, Resident #240 was observed sitting on the right side of the bed on the floor mat. Resident #240 complained of left wrist pain and slight swelling was noted to the affected area. A left wrist x-ray was ordered. The result dated 07/07/2021 showed a left distal radius fracture and Resident #240 was transferred to the hospital for evaluation. The hospital discharge summary dated 07/08/2021 documented Resident #240 had left wrist pain and a fracture to the end of the left distal radius to be treated with immobilization. A NN dated 07/08/2021 documented Resident #240 returned from the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/11/2022 at 12:28 PM, the Assistant Director of Nursing (ADON) was interviewed and stated the ADON was responsible for completing the A/I investigations for incidents involving injuries of unknown origin on the 3rd and 4th floor. Resident #240 had an unwitnessed incident and was found on the floor mat on the right side of their bed. An assessment was done, and it can only be deduced that Resident #240 rolled over from the left side and sustained the left wrist fracture as a result of a fall. The ADON stated the incident was not considered reportable to the NYSDOH. On 07/01/2022 at 1:28PM, the Director of Nursing (DON) was interviewed and stated Resident #240 sustained a fracture from a fall and the injury was not determined to be of unknown origin; therefore, it is not reportable to the NYSDOH. Incidents related to abuse, neglect, and injuries of unknown origin are reportable to the NYSDOH. 415.4(b)

Based on interviews and record review during the recertification survey from 06/27/2022 and 7/12/2022, the facility did not ensure a resident received notification prior to changes in coverage for services covered by Medicare. This was evident for 1 (Resident #90) of 4 resident reviewed for Beneficiary Protection Notice. Specifically, the facility did not provide Resident #90 with a Notice to Medicare Provider Non-coverage (NOMNOC) explaining their right to an expedited review prior to the termination of their Medicare coverage. The findings are: The facility policy titled Skilled Nursing Facility (SNF) Beneficiary Notices Process last reviewed 1/22 documented residents are provided appropriate Medicare SNF notices informing them of their responsibilities for payments and rights to request appeal, Medicare billing or redetermination of coverage from the appropriate agency. Resident #90 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #90 was cognitively intact and had adequate hearing. On 06/27/22 at 03:51 PM, Resident #90 was interviewed, indicated they were deaf, and used written communication documenting the facility stopped therapy and Resident #90 did not know why. On 07/07/22 at 04:45 PM, Resident #90 wrote they had not been informed of their Medicare coverage ending. A NOMNOC letter dated 5/11/2022 documented Resident #90's Medicare coverage will end 5/13/2022 and Resident #90's brother was provided with verbal notice via telephone. On 06/30/22 at 03:55 PM, Social Worker (SW) #1 was interviewed and stated the NOMNOC is provided to alert and oriented residents two days before Medicare coverage ends. Resident who are hearing impaired can read the notice if they prefer. Resident #90 requested we inform their brother of the NOMNOC. There is no documented evidence Resident #90 requested that their brother be informed of the NOMNOC. On 07/12/22 at 12:07 PM, The Director of Nursing (DON) was interviewed and stated the SW provides the NOMNOC to residents. If a resident is hearing impaired, the NOMNOC will be discussed with the family unless the resident can read and write. 415.3(g)(2)(i)

Based on interviews and record review conducted during the Recertification Survey and Abbreviated Survey (NY 217), the facility did not ensure a Resident's Representative (RR) received written notice before the resident's room was changed. This was evident for 1 (Resident #57) of 1 residents reviewed for Notification of Change out of 42 sampled residents. Specifically, the facility changed Resident #57's room without providing the RR with advanced written notification. The findings are: The facility's policy titled Room Change/Roommate Assignment last revised 03/2022 documented a change in room or roommate assignment shall be made when the facility deems it necessary. Prior to changing a room, all parties involved in the room change (e.g., residents and/or their RRs) will be given advance notice, including the reason the move is recommended, and documentation of the room change is recorded in the resident medical record. Resident # 57 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident # 57 was severely cognitively impaired. On 6/09/2022 at 11:56 AM, the New York State Department of Health Complaint Tracking System received a complaint from Resident #57's daughter that Resident #57 was moved 7 times in less than a year of being at the facility. Resident #57 was confused and was crying hysterically the last time they were moved (4/11/2022). The resident's daughter reported the facility made it sound there was no other choice. On 06/27/2022 at 2:29 PM, Resident #57's daughter was interviewed and stated Resident # 57 was in the facility for 1 year and was moved 8 times. Resident #57 becomes more confused with each room change. The last time Resident #57 was moved, the daughter asked the facility not to make the room change. At first, the facility told the resident's daughter that the needed the room. The facility later changed their reason for the room change and said it was related to medical purposes. The Admission, Discharge, and Transfer Report (ADTR) dated 06/03/2021 documented Resident # 57 was admitted to room [ROOM NUMBER]-B. The ADTR dated 06/25/2021 documented Resident # 57 was moved from room [ROOM NUMBER]-B to room [ROOM NUMBER]-A. The ADTR dated 07/14/2021 documented Resident # 57 was moved from room [ROOM NUMBER]-A to room [ROOM NUMBER]-A. A Social Service Progress Note (SSPN) dated 07/15/2021 documented Resident # 57 was informed their room would change from 104-A to 224-A due medical justification and the resident' daughter was informed. The ADTR dated 08/02/2021 documented Resident # 57 was moved from room [ROOM NUMBER]-A to room [ROOM NUMBER]-B. The ADTR dated 08/10/2021 documented Resident # 57 was moved from room [ROOM NUMBER]-B to room [ROOM NUMBER]-B. A Nursing Note (NN) dated 08/11/2021 documented Resident # 57 was confused after being moved to the 4th floor and wanted to go back to the 1st floor. Resident #57 attempted to board the elevator and was redirected several times. The ADTR dated 01/11/2022 documented Resident # 57 was moved from room [ROOM NUMBER]-B to room [ROOM NUMBER]-B. The ADTR dated 01/24/2022 documented Resident # 57 was moved from room [ROOM NUMBER]-B to room [ROOM NUMBER]-S. A SSPN dated 2/03/2022 documented Resident #57 had a room change on 1/11/2022 from 421-B to 406-B due to medical justification and the resident's daughter was informed. A SSPN dated 02/24/2022 documented Resident # 57 had a room change on 01/24/2022 from 406-B to 211-S due to medical justification and the resident's daughter was informed. The ADTR dated 04/11/2022 documented that Resident # 57 was moved from room [ROOM NUMBER]-S to room [ROOM NUMBER] -S. A NN dated 04/12/2022 documented that Resident # 57 was observed going into their previous room and was shouting that someone was in their bed. A SSPN dated 06/08/2022 at 1:35 PM documented that Resident # 57 would be transferred from room [ROOM NUMBER]-S to room [ROOM NUMBER]-A due to medical justification and the resident's daughter was notified. The ADTR dated 06/08/2022 documented Resident # 57 was moved from room [ROOM NUMBER]-S to room [ROOM NUMBER] -A. There was no documented evidence Resident #57's daughter was notified and provided with written notice prior to each of Resident #57's room changes. On 06/30/2022 at 12:38 PM, Unit Manager (UM) #3 was interviewed and stated room changes are done based on medical necessity and decision by the Interdisciplinary Team (IDT). The family is notified the day before the transfer unless it is an emergency. The social worker (SW) is responsible for informing the family and documenting the family was notified. On 06/30/2022 at 2:54 PM, 07/01/2022 at 10:07 AM, and 07/11/2022 at 11:39 AM the Director of Social Services (DSS) was interviewed and stated Resident # 57 was moved from one room to another because they wanted to make room for another resident. There was a resident who needed a room on the 4th floor, so Resident # 57 was moved to the 2nd floor. Resident #57's family was called, and informed Resident #57 would have a room change due to medical justification before the resident moved. Resident #57's family was contacted via telephone and was not provided any written notification of the impending room changes because the policy of the facility does not require a resident or resident's family member receive written notification of room changes. On 07/01/22 at 11:05 AM, the Director of Nursing (DON) was interviewed and stated the SW called Resident #57's family to notify them of the room changes and the reason for the room change is not documented because there are times the room change is done to accommodate another resident's needs. On 07/12/2022 at 2:30 PM, the Administrator was interviewed and stated families are notified of room changes verbally and the facility does not provide the family with an explanation because it can be for the benefit of another resident. 415.5(e)(2)

Based on observations, interviews, and record reviews during the recertification survey, the facility did not ensure that infection control practices were maintained. Specifically, (1) infection control policies were not reviewed and revised annually; and, (2) a resident with a urinary catheter was observed with catheter tubing laying on the floor. (Resident #125) The findings are: 1. The facility Infection Control Policies and Procedures revised on 9/2016 documented that the Nursing department is responsible for reviewing all policies and procedures at least annually and revising them as necessary. The facility policy and procedure titled Influenza revised on 3/10/2017 did not document that employees will be required to wear a face mask during flu season if they declined to receive the flu vaccine. The facility policy and procedure titled Flu (Influenza) Vaccination: Residents documented a revision date of 10/8/2017. On 08/20/19 at 10:05 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON became the head of facility's infection control program in (YEAR). The ADON stated that infection control policies are reviewed and revised when there is an outbreak or a concern. If the facility experiences a situation that the current infection control policies do not cover, then the policy will be revised. There is a corporate compliance person within the facility that ensures that any changes in regulation are reflected in the infection control policies. The Director of Nursing and the Administrator are the ones that will usually update the policies and this is reflected by the date on the bottom of the page. The ADON further stated that these policies had not been revised or updated since the documented dates. 415.19(a)(1-3) 2. The facility Foley Catheter Care/Hygiene Policy and Procedure dated 2/2009 documented that the catheter is a significant portal of entry for bacteria into the urinary tract, potentially causing urinary tract infections. The Certified Nursing Assistant (CNA) is responsible for positioning the drainage bag below level of the bladder at all times, not touching the floor. On 08/15/19 at 10:21 AM, Resident #125 was observed to be lying in bed with a drainage bag attached to the frame of his hospital bed. The catheter tubing was observed to be laying on the floor. On 08/15/19 at 12:12 PM, a CNA was observed coming out of the resident's room. The State Agent observed that the resident had just been served his lunch tray. The resident's catheter tubing was observed to be laying on the floor in the same position. A Quarterly Minimum (MDS) data set [DATE] documented the resident as cognitively intact, with [DIAGNOSES REDACTED]. On 08/16/19 at 11:43 AM, an interview was conducted with CNA #1. CNA #1 stated she has been assigned to provide care to the resident for the past 1-2 months. CNA#1 recalled going in and out of the resident's room around lunch time and did not observe that the catheter tubing was on the floor. CNA #1 also stated that she usually checks for this when attending to the resident, but there were other issues going on with the resident yesterday and she not did not see it. CNA #1 further stated that catheter tubing should not be on the floor because it is an infection control issue. The CNA would address this issue by taking the tubing off the floor and making sure it is properly attached to the drainage bag. CNA #1 stated that she is not responsible for changing the tubing and would tell the nurse. She stated that infection control inservices are given regularly and this includes how to properly care for catheter tubing. On 08/20/19 at 10:05 AM, an interview was conducted with the ADON. The ADON stated that part of the infection control program is to provide inservices to all staff annually and as needed. The ADON stated that she does regular rounds and will educate staff if she sees that infection control practices are not being maintained. Infection control practices also include keeping catheter tubing off the floor at all times. 415.19(b)(4)

Based on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure that a Comprehensive Care Plan (CCP) was developed and implemented. Specifically, a resident with a [DIAGNOSES REDACTED]. This was evident for 1 of 6 residents reviewed for Unnecessary Medications out of a sample size of 34 residents. (Resident #125) The findings are: The Quarterly Minimum Data Set ((MDS) dated [DATE] documented that Resident #125 as cognitively intact, with a [DIAGNOSES REDACTED]. The physician's orders [REDACTED].#125 received 7 units of Humalog KwikPen (U-100) Insulin subcutaneously 3 times daily before meals (hold if fingerstick blood sugar (FSBS) is less than 110) and 34 units of [MEDICATION NAME] (U-100) Insulin subcutaneously once daily at 8 PM. The Medication Administration Record [REDACTED]. There was no documented evidence that a comprehensive care plan related to Diabetes care was developed. On 08/19/19 at 10:17 AM, an interview was conducted with Registered Nurse (RN) #1. RN#1 stated that she is responsible for the creation of care plans. RN #1 also stated that the resident does have a [DIAGNOSES REDACTED]. RN #1 further stated that the resident went to the hospital at one point and the CCP may not have been reactivated upon his return to the facility. RN #1 stated that she missed developing a CCP related to IDDM and will now add one. On 08/20/19 at 11:02 AM, a follow up interview was conducted with RN #1. RN #1 stated that a resident's CCPs are initiated upon admission and readmission from the hospital, and if there is any change in the resident's condition. A resident's [DIAGNOSES REDACTED]. CCPs are then reviewed every 3 months/quarterly or if there is a change in the resident's condition. The CCP is used to reflect the plan of care of the resident. 415.11(c)(1)

Based on observation and interviews, the facility did not ensure that essential kitchen equipment was in safe operating condition, specifically the dish washer did not reach acceptable temperatures of 150 Degrees Fahrenheit for wash and 180 Degrees for rinse. This was evident during the Kitchen task. The findings are: On 8/1/16 at 9:36 AM, the dish washer machine was observed with a wash temperature of 105 Degrees Fahrenheit and rinse temperature of 165 Degrees Fahrenheit. An interview was conducted on 8/1/16 at 12:22 PM and 2:47 PM, the Food Service Director (FSD) stated maintenance increased the rinse temperature via booster to 170 Degrees Fahrenheit and that there was no back up sanitization solution because he ran out. He stated this is the first time the machine is not working. On 8/2/16 at 9:12 AM, follow up observation made of the dish washer machine. Wash temperature read 155 Degrees Fahrenheit and rinse temperature read 190 Degrees Fahrenheit. Back up sanitization solution in place. On 8/2/16 at 9:13 AM, the food service worker stated that he reads the gauges every morning before loading the dishwasher. He further stated the tempertures prior to loading the machines read 150 degrees Fahrenheit for wash and 180 degrees Fahrenheit for rinse on the morning of 8/1/16. He further stated he reports discrepencies in the function of the machine to the food service supervisor who then contacts maintenance. The facility Dish Machine Temperature Daily Log Sheet dated 4/13 states .Wash Min. 150 Degrees .Rinse Min 180 Degrees . The FT800 Series Dishwasher Operation Manual reviewed. .Thermometers are provided for monitoring wash, rinse, and final rinse water temperatures and should be checked occasionally to assure that proper temperatures are being maintained. Recommended temperatures .Wash 150 Degrees Fahrenheit Minimum Rinse 160 Degrees Fahrenheit Minimum Final Rinse 180 Degrees Fahrenheit Minimum Chemical Sanitizing 140 Degrees Fahrenheit . The repair order receipt dated 8/1/16 reviewed. .Adjusted thermostat steam replaced solenoid 180 final rinse . 415.5(e)(1)(2)

Based on observation and interview it was determined that the facility did not post notice or make readily accessible a copy of the most recent New York State Department of Health Survey results. The finding is: On 8/1/1616 at 9:05AM upon entry to the facility it was observed that the most recent copy of the New York State Department of Health Survey Report was not displayed. In addition there were no signs observed on the nursing units advising residents, visitors or staff the location of the most recent survey results. During the morning at various times, observations were made on nursing units including 1st floor, 2nd floor, 3rd floor and 4th floor. A copy of the survey report was not observed, nor was a sign posted indicating the location of the survey report. On 8/01/2016 at 12:57 PM the facility Administrator was asked for a copy of the most recent New York State Department of Health survey results and he opened a brown wooden cabinet located behind his desk, opened a drawer, sorted through several file folders and pulled out a copy of last year's survey report. The Administrator was immediately interviewed and stated, To my knowledge of the regulations, there should be a copy of the survey report at the front desk. The surveyor accompanied the Administrator to the reception desk on the first floor. The Administrator stated, There is no copy of last year ' s survey report here at the front desk. It should be located on the top of the counter on the front desk so anybody could have access to it. There should be a sign readily visible at the front desk notifying people of the availability of the survey report. On 8/01/2016 at 1:02 PM the front desk receptionist was interviewed and stated, Usually we keep a copy of the last survey report in a blue loose leaf binder here on the counter. It is not here now. It is usually kept right under the black loose leaf visitor registry binder. The visitor ' s registry binder covers the blue loose leaf survey report. This is how we usually keep it. On 8/2/2016 at 3:10PM the President of the Resident Council was interviewed and stated, that he attended the exit conference for last years survey, however he is not aware where the results are kept and have not seen them. 415.3(1)(c)(1)(v)

Based on observation, record review, and interviews, the facility did not ensure that residents have reasonable access to their funds during non-banking hours on the weekend. Specifically, two residents reported inability to access personal funds during the weekend hours (Resident #5 and #53). This was evident during review of Personal Funds. The findings are: On 8/1/16 at 2:41 PM, a resident interview was conducted during stage one for resident #5. Resident stated she can only get money on weekdays. On 8/2/16 at 10:59 AM, a resident interview was conducted during stage one for resident #53. Resident stated that there is no one available on the weekends to give her money and if she wants it, she has to get it on Friday. On 8/4/16 at 11:46 AM, the business manager stated banking hours are Monday to Friday from 11:00 to 12:00 PM and 2:00 to 3:00 PM and residents are able to obtain funds outside of banking hours in the nursing office. She stated that residents and family are made aware of banking hours via the admission packet agreement and the sign is posted on her door. On 8/4/16 at 11:46 AM, the business office door was observed with a banking hours sign that documented hours as Monday to Friday from 11:00 to 12:00 PM and 2:00 to 3:00 PM. There was no indication of accessibility to access funds during non-banking hours or weekends. On 8/4/16 at 1:08 PM, the night shift Registered Nurse Supervisor (RNS) stated that residents and family are notified verbally, through care plan meetings, and from the sign on the business office door that they can access funds outside of non-banking hours in the nursing office. The facility Admission agreement packet dated 9/14/15 was reviewed. There is no documentation related to banking hours. The facilities Resident Trust Fund policy and procedure dated 3/02 was reviewed. .Banking hours .During off hours, resident funds will always be available in the nursing supervisors office . 415.26(h)(5)