Every finding on record at Independence Care Center for Nursing and Rehabilit

Based on observation, record review, and interviews conducted during an abbreviated survey (NY00359953), the facility did not ensure that each resident received adequate supervision to prevent an elopement. This was evident for one (1) out of two (2) residents (Resident #1) sampled for elopement. Specifically, the facility Elopement Incident Timeline dated 11/08/2024 documented that the surveillance video footage showed at 2:46 PM on 11/07/2024 Resident #1 exited the facility grounds. Resident #1 was wearing a wander guard on their left ankle at the time they left the facility, and the wander guard alarm system did not activate. Facility staff became aware between 3:20 PM and 3:58 PM that Resident #1 was missing from the facility. Resident #1 was located by a facility staff at 10:45 PM on 11/07/2024 walking towards their home. Resident #1 had no injury but was transferred to the hospital on [DATE] at 12:18 AM for evaluation. The findings include:The facility's Policy and Procedure titled Resident Elopement Prevention revised 09/2024 documented that it is the policy of the facility to provide residents with a safe and secure environment and protected from harm. The facility will make every possible effort to identify residents who have the potential for elopement. If a resident is found missing, the facility will ensure immediate implementation of missing resident search procedures.The facility's Policy and Procedure titled Front Desk effective dated 10/2023 documented the purpose is to ensure the safety and security of all residents, staff, and visitors by enforcing standardized protocols at the facility's front desk. This includes proper sign-in procedures, verification of authorized visitors, and monitoring of residents with [NAME] guard alerts. The Reception/Security watch for residents on the list approaching the exit unescorted. Resident #1 was admitted to the facility with diagnoses including Alcohol abuse, Hypertension, and Dementia.The Minimum Data Set (an assessment tool) dated 10/17/2024 documented Resident #1 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) score of 8 associated with moderately impaired cognition. Resident #1 ambulates independently.An Elopement Risk assessment dated [DATE] documented that Resident #1 was identified at risk for elopement due to Resident #1 verbalizing that they want to leave the facility and wandering behavior.An Elopement Care Plan dated 10/12/2024 documented that Resident #1 was unaware of safety needs and had a history of wandering behavior in the community. A wander guard was placed on Resident #1's left ankle.There was no documented evidence of a monitoring sheet for Resident #1.A nursing progress note dated 11/07/2024 at 8:52 PM by Registered Nursing #1, documented that Resident #1's adult child visited at 3:20 PM and Resident #1 was not in their room. A nursing progress note dated 11/07/2024 at 10:56 PM by Registered Nursing #2, documented that they heard Code Orange alarmed at 3:58 PM due to Resident #1 being missing from the third floor and could not be found. 911 and the Director of Nursing was notified. Resident #1 was later found in the street and was brought back to facility. Resident #1 was transferred to hospital for evaluation. An Elopement Incident Timeline dated 11/08/2024 documented at 3:20 PM Resident #1's adult child arrived at the facility and Resident #1 was not in their room. The staff were notified and immediately searched the building. At approximately 3:20 PM to 3:58 PM the search continued to common areas where Resident #1 frequently goes. At approximately 3:58 PM, the elopement protocol was formally activated. The police were notified, and local transportation were contacted to aid in the search. At approximately 4:00 PM a headcount was completed for all residents. At approximately 4:20 PM the surveillance footage reviewed and confirmed that Resident #1 exited the facility at 2:46 PM. At approximately 4:40 PM, the Department of Health was notified. At approximately 5:50 PM, it was discovered that the entrance door alarm was malfunctioning. At approximately 10:45 PM, Resident #1 was found approximately 10 minutes from their home by facility staff. At approximately 11:13 PM, Resident #1 was returned to facility and was assessed with no injuries or medical concern. The family were notified and requested the resident be transferred to the hospital for further evaluation. The Medical Doctor was notified. The Investigation Summary dated 11/08/2024 documented based on the facility's investigation, Resident #1 had eloped. During an interview on 07/16/2025 at 1:33 PM, Certified Nursing Assistant #1 stated that Resident #1 was assigned to them on 11/07/2024 from 7:00 AM to 3:00 PM. Certified Nursing Assistant #1 stated that Resident #1 had a wander guard on their left ankle and was being monitored on the unit. Certified Nursing Assistant #1 stated that they do not have a monitoring log - they just visually check on Resident #1 because the resident was at risk for elopement and was wearing a wander guard. Certified Nursing Assistant #1 stated that Resident #1 did not verbalize wanting to leave the facility and did not exhibit any unusual behavior on 11/07/2024. Certified Nursing Assistant #1 stated that after lunch (lunch is between 12:00 PM - 1:00 PM) Resident #1 went to the day room to watch television (unsure of time) but was in their room at 2:00 PM when they made rounds. Certified Nursing Assistant #1 stated that they did not hear any activated alarms on the unit including the elevator wander guard alarm. During a telephone interview on 07/22/2025 at 11:59 AM, Registered Nurse #1 stated that they worked on 11/07/2024 on the 7:30 AM-3:30 PM shift. Registered Nurse #1 stated Resident #1 had a wander guard in place on their left ankle. Registered Nurse #1 stated prior to their break time (unsure of time), they checked on Resident #1 and they were in their room at approximately 2:00 PM standing next to their bed moving their overbed table. Registered Nurse #1 stated that Resident #1 was calm and did not exhibit any exit seeking behavior. Registered Nurse #1 stated that when they returned from their break (unsure of time) the Orange Alert protocol (missing resident) was in progress, and they assisted with searching for Resident #1 who was not located. Registered Nurse #1 stated that they are responsible for checking wander guard placements every shift and that the nursing supervisor checks for the wander guard functionality daily at bedtime. Registered Nurse #1 stated that they frequently perform rounds at least hourly and visually check Resident #1. Registered Nurse #1 stated that they were still trying to ascertain how Resident #1 exited the unit without activating an alarm. The previous Director of Nursing who investigated the incident is no longer employed at the facility and whereabouts were unknown.The facility did not have a statement from Security Guard #1 on 11/07/2024.During a telephone interview on 07/22/2025 at 12:11 PM, Registered Nurse Manager #1 stated that they are no longer employed at the facility. Registered Nurse Manager #1 stated Resident #1 was ambulatory and walked around the unit independently. Registered Nurse Manager #1 stated that Resident #1 only goes downstairs when they are escorted by a staff. Registered Nurse Manager #1 stated that Resident #1 had no exit seeking behavior on 11/07/2024. Registered Nurse Manager #1 stated as per their statement they were informed (unsure of staff name) that Resident #1 was missing at 3:20 PM when Resident #1's adult child went to visit with the resident in their room. Registered Nurse Manager #1 stated they searched for the resident, Orange Alert was activated and 911 was called. During an interview on 07/16/2025 at 1:45 PM, the Assistant Director of Nursing stated that they were in the facility on 11/07/2024 at the time of the elopement and Orange Alert was activated at 3:58 PM after a head count was done on the unit and Resident #1 was confirmed missing. The Assistant Director of Nursing stated if Resident #1 had entered the elevator, the elevator wander guard alarm would have been activated, and would need to deactivate by a staff for the elevator to move. The Assistant Director of Nursing stated that they are not sure how Resident #1 left the unit unsupervised. The Assistant Director of Nursing stated there were no reports of the wander guard not functioning. The Assistant Director of Nursing stated only the staff members have access to code to deactivate the alarms. The Assistant Director of Nursing stated that they participated in the search for Resident #1 who was found at 10:45 PM walking in the direction of their home. The Assistant Director of Nursing stated Resident #1 was interviewed and stated that they wanted to go home to meet their landlord. The Assistant Director of Nursing stated that they brought Resident #1 back to the facility and an assessment was conducted. The Assistant Director of Nursing stated that Resident #1 had no visible injuries, did not complain of pain, was stable, and in good spirit. The Assistant Director of Nursing stated that when Resident #1 was located on street, the resident was wearing their wander guard on their left ankle. The wander guard was tested when the resident was brought back to the facility, and it was functioning. The Assistant Director of Nursing stated that Resident #1 was transferred to the hospital for further evaluation as per the family request. During an interview on 07/17/2025 at 2:25 PM, the Administrator stated that they were made aware of the elopement at 3:58 PM on 11/07/2024 and the Orange Alert protocol was initiated. The Administrator stated that they reviewed the video footage at 4:20 PM and saw that Resident #1 exited the facility on 11/07/2024 at 2:46 PM unsupervised wearing a gray [NAME] Kelin T-shirt and blue jeans. The Administrator stated that they contacted the police at 4:00 PM and visited all local hospitals, parks close to the facility and called Resident #1's home. The Administrator stated that all the surrounding blocks were checked, and a vehicle grid search was coordinated and launched to cover a wider Bronx area from facility to Resident #1's home. The Administrator stated that Resident #1 was found walking in the street at 10:45 PM and was brought back to the facility. The Administrator stated that Security Guard #1 was terminated immediately and reported to their agency. The Administrator stated they discovered that the front entrance door alarm system had malfunctioned. The Administrator stated that they had contacted the wander guard company for immediate service on 11/07/2024. The Administrator stated all other facility exit doors were inspected and was found to be in good working condition. The Administrator stated to prevent a recurrence a temporary monitoring desk was placed near the front entrance to enhanced visibility to prevent further unauthorized exits. The Administrator stated that the facility has had no further elopement.Based on the following corrective actions taken, there were sufficient credible evidence that the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement. The facility noncompliance was corrected on 12/09/2024. A Plan of Correction is not required for this citation.The facility implemented the following corrective action prior to surveyor entrance on 07/16/2025. The facility's Director of Nursing and Administrator investigated the elopement incident, and the team concluded that Resident #1 left the facility without an escorted. The facility developed an action plan which includes the following: On 11/07/2024 at 4:00 PM, the New York Police Department was called and responded at 4:20 PM and was given Resident #1's information and a photograph. An Elopement Care Plan was updated 11/07/2024 to reflect the actual elopement incident. On 11/07/2024, Security Guard #1 was terminated from the facility. Wander Guard/Door Alarm Audit was done on 11/07/2024 - the front door wander guard sensor was malfunctioning. Total Kare Company service was called and service ticket initiated. Weekly Wander Guard/Door Alarm Audit was done on 11/07/2024 through 06/30/2025. On 11/07/2024 the facility immediately put a temporary desk closer to the front exit door located in the lobby for closer supervision pending permanent solution. Policy and Procedure for Front Desk dated 10/2023 was revised on 11/07/2024 to include a memo that all staff must always wear a badge when in the facility and show it to security upon entry and exiting of the building, all visitors and vendors needs a sticker with name and date. Anyone who exits the building needs to have a badge or sticker, if not, someone from administration or the nursing supervisor needs to confirm they are not a resident. Policy and Procedure on Resident Elopement Prevention revised 09/2024 reviewed with no revision. On 11/07/2024-11/08/2024, the facility in-serviced all staff members from all departments. Lesson Plan: Elopement Prevention and Response. On 11/08/2024 visitor passes were initiated. On 11/10/2024 the Crowd Control Stanchions (barriers) were installed to limit movement going outside. Wander Guard Function Audit tool dated 11/10/2024 was put in place to monitor compliance with residents at risk for elopement/wandering. On 11/11/2024 and 12/19/2024, a Quality Assurance meeting was held with department heads. Attendance sheets noted. On 11/16/2024 the Security desk was built and installed near the front door. Elopement Drills were done on 11/26/2024, 12/19/2024, 01/14/2025, 04/10/2025 with staff members. On 12/09/2024 the wander guard device alarm system located on the front door was completely fixed. 10NYCRR415.12(h)(2)

Based on record review and interviews conducted during an Abbreviated Survey (NY00362877), the facility did not ensure that the alleged violations involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property were reported immediately, but not later that two (2) hours after the allegation is made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involved abuse and do not involve serious bodily injury, to the administrator of the facility and to other officials (including to the State Agency). This was evident in one (1) out of three (3) residents (Residents #3 and #4) sampled. Specifically, on 12/02/2024 at 7:12 AM, Resident #4 stated that Resident #3 threw a chair, and the chair hit them on their back. The facility reported the incident to New York State Department of Health on 12/02/2024 at 8:28 PM. The findings include: The Facility's Policy and Procedure titled Abuse and Neglect Policy with a revised dated 08/20/2024 documented that it is the policy of the facility to assure residents are free from abuse and neglect, including involuntary seclusion. Furthermore, residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, family members, legal guardians or outside members of the community. The Administrator or designee will provide a 2- hour notification to the New York State Department of Health for any alleged or suspected or confirmed case of abuse or neglect.Resident #3 was admitted to the facility with diagnoses including Right Humerus Fracture and Diabetes Mellitus. The Minimum Data Set (a resident assessment tool) dated 11/01/2024 documented that Resident #3's cognition was intact.Resident #4 admitted to facility with diagnoses including Opioid Dependence, Alcohol Substance Abuse and Pain Disorder. The Minimum Data Set (a resident assessment tool) dated 12/03/2024 documented Resident #4 was assessed with intact cognition.The Investigation Summary dated 12/04/2024 documented that Resident #4 reported to staff that on 12/02/2024 at approximately 7:12 AM, they and Resident #3 had an altercation, and that Resident #3 threw a chair on them hitting them on their back. Resident #4 was assessed with no redness, bruising or swelling. The skin was intact. Resident #4 denied pain at the time of incident. The Medical Doctor and family were notified. The investigation revealed that both residents had a disagreement because Resident #4's television remote control was changing Resident #3's television channel every time Resident #4 changed their television channel. Prior to the altercation, neither resident reported their concerns to the staff. As per video footage investigation, Resident #3 became frustrated and tossed a chair down the hallway towards Resident #4's direction. Resident #4 caught the chair at the floor level with their hand and dragged it down the hall. The facility's investigation concluded that there was no reasonable cause to believe abuse has occurred. To prevent reoccurrence, the maintenance checked all television remote to ensure that they were not synching to roommates, Resident #4 was transferred to different unit, staff were in-service on abuse, neglect and mistreatment and the policy on abuse was reviewed with no revision. A Webform Submission from the Nursing Home Facility Incident Report showed that the facility submitted their initial incident report to New York State Department of Health on 12/02/2024 at 8:28 PM.Previous Director of Nursing who investigated the incident was no longer employed in the facility.During an interview on 07/17/2024 at 2:30 PM, the Administrator stated that they were notified of the incident on 12/02/2024 at 8:00 AM and that they reported the incident to the New York State Department of Health on 12/02/2024 at 8:28 PM. The Administrator stated that they are aware that any form of allegation of abuse must be reported within 2-hour to New York State Department of Health. The Administrator stated that they reported the incident a little late because they reviewed the video footage and got busy investigating the incident. 10 NYCRR 415.4 (b)(1)(ii)

Based on observation, interviews, and record reviews conducted during Abbreviated Survey (NY00348529), the facility failed to protect a resident from physical abuse by nursing home staff. This was evident in 1 out of 3 residents (Resident #1) sampled for abuse. Specifically, the facility's surveillance camera recording dated on 07/17/2024 at 4:56pm showed Resident #1 hit Receptionist #1's face and Receptionist #1 retaliated and hit Resident #1 on the top of their head. Resident #1 was assessed by Registered Nurse Supervisors #1 and #2 and there were no visible injuries. The findings are: The facility's Policy and Procedure titled Abuse Prevention and Reporting was last revised on 03/18/2024. The policy states that residents will be free from abuse, neglect, mistreatment, exploitation, or misappropriation of property which include the following components: Screening, Timing, Prevention, Identification, Investigation, Protection and Reporting/response. Resident #1 was admitted to the facility with diagnoses including Depression, Schizophrenia, and Bipolar Disorder. A Minimum Data Set, dated dated dated [DATE] documented that Resident #1's cognition was intact. There were no mood or behavioral symptoms documented present. A Psychosocial Well-Being Care Plan initiated 02/06/2022 documented that Resident #1 had the potential to be abused due to cognitive and medical decline. The interventions include Social Worker to establish a good rapport, monitor for any alteration in Psychosocial well-being, and refer to medical doctor. The care plan also documented that an evaluation was done on 07/15/2024 and that Resident #1 was transferred to the emergency room for suicidal ideation, aggressive behavior, throwing items at staff, and throwing milk on a staff stating, I will kill one of you before you kill me. Resident #1's loud and aggressive behavior was disturbing on the unit. The care plan was not updated to reflect on the abuse incident of 07/17/2024. A Behavioral Comprehensive Care Plan dated 09/20/2023 documented Resident #1 has socially inappropriate/disruptive behavioral symptoms. The interventions include staff to assess and anticipate the resident needs and to intervene if necessary. Avoid over stimulation. This care plan was last updated on 07/15/2024. The care plan was not updated to reflect on the abuse incident of 07/17/2024. The surveillance camera recording dated 07/17/2024 was reviewed on 07/29/2024 at 10:04am with the Administrator and Assistant Administrator. According to the Assistant Administrator, the timestamped on the surveillance record was 2 hours behind real time. The surveillance camera recording showed: At 07/17/2024 at 2:56:20pm (real time 4:56:20pm), Resident #1 was sitting in their wheelchair in the lobby facing the elevator. At 2:56:24pm (4:56:24pm), Receptionist #1 walked over to Resident #1. Receptionist #1's mouth appeared to be moving (talking to Resident #1). Receptionist #1's hand could be seen touching the displays on the wall in between the two elevators. Resident #1 reached out and grabbed the displays on the wall and Receptionist #1 pulled Resident #1's hand off the displays. At 2:56:30pm (4:56:30pm), Receptionist #1 walked away from Resident #1 while making hand gestures (Assistant Administrator stated that Receptionist was calling for help). Receptionist #1 then walked back to the elevator where Resident #1 was still sitting. At 2:56:35pm (4:56:35pm), the Assistant Administrator appeared in the lobby in camera's view and walked over to the elevators where Resident #1 and Receptionist #1 were. At 2:56:40pm (4:56:40), Assistant Administrator held Resident #1's wheelchair from behind, pushing the wheelchair away from elevators and Receptionist #1. Resident #1 reached around the Assistant Administrator and hit Receptionist #1's face. Receptionist #1 walked back (a few steps) to Resident #1 and hit Resident #1 on the top of their head as the Assistant Administrator was pushing the wheelchair away from the elevator. Camera recording ended. The Accident/Incident Report dated 07/17/2024, at 4:45pm documented Resident #1 swung at Receptionist #1 and Receptionist #1 hit Resident #1 on the head. Resident #1 was assessed by Registered Nurse Supervisors #1 and #2 and there was no visible injury. Resident #1 was transferred to the hospital at 5:55pm for psychiatric evaluation. The investigation concluded that abuse did occur. During an interview on 07/29/2024 at 12:25pm, Receptionist #1 stated that Resident #1 came down into the lobby and started ripping the sign off the wall. Receptionist #1 stated that they went over to Resident #1 and told Resident #1 to stop. Receptionist #1 stated that they (Receptionist #1) put their hand on the wall to prevent Resident #1 from removing the sign. Receptionist #1 stated that Resident #1 used their wheelchair to pin Receptionist #1 to the wall. Receptionist #1 stated that they were trying to prevent Resident #1 from hitting them as they tried to unpin themself. Receptionist #1 stated that they did not hit Resident #1. Receptionist #1 stated that they have been working in the facility for over [AGE] years and would never hit a resident. During an interview on 07/29/2024 at 12:17pm, the Assistant Administrator stated that Receptionist #1 called them to assist with Resident #1 who was trying to remove the sign from the wall. The Assistant Administrator stated that Receptionist #1 was trying to go behind Resident #1's wheelchair to reattach the sign and Resident #1 backed their wheelchair into Receptionist #1. The Assistant Administrator stated that they immediately intervene and while they were in the process of protecting Resident #1, Resident #1 threw a punch at Receptionist #1's face. The Assistant Administrator stated that Receptionist #1 pat over Resident #1's head. The Assistant Administrator stated that they don't know if the pat on the head was hard or soft. The Assistant Administrator stated that they are willing to testify if needed. During an interview on 07/30/2024 at 12:10am, the Director of Nursing stated that they were notified of the abuse incident on 07/17/2024 at approximately at 4:46pm by the Registered Nurse Supervisor #1. The Director of Nursing stated that they were informed that Resident #1 was trying to get the Ombudsman's number from the wall and Receptionist #1 held Resident #1's hand. The Director of Nurse also stated that Resident #1 swung their hand and hit Receptionist #1's face and Receptionist #1 hit Resident #1 on the top of their head. The Director of Nursing stated that Resident #1 was immediately separated from Receptionist #1 by the Assistant Administrator. The Director of Nursing stated that 911 was called and the police responded. The Director of Nursing went on to say that Resident #1 was assessed by Registered Nurse Supervisors with no visible injuries observed. The Director of Nursing stated that Resident #1 was agitated and aggressive and was transferred to the hospital for psychiatric evaluation. The Director of Nursing stated that the police review the video footage and confirmed that Receptionist #1 hit Resident #1 on the head. 10 NYCRR 415.4(b)(1)(i)

Based on staff interviews and record review conducted during an abbreviated survey (NY00348529), the facility did not ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after a significant change. This was evident for 1 out of 4 residents (Resident #1) sampled. Specifically, the facility's surveillance camera recording dated 07/17/2024 showed Resident #1 was involved in an altercation with Receptionist #1. Resident #1 hit Receptionist #1 and Receptionist #1 retaliated and hit Resident #1 on the top of their head. Resident #1's Psychosocial Well-Being Care Plan was not updated to reflect on the abuse incident of 07/17/2024. The findings include: The facility Policy and Procedure for Comprehensive Care Plan revised on 10/2023 documented the interdisciplinary team in junction with the resident and their family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The comprehensive, person-centered care plan is developed within seven days of the completion of the required Minimum Data Set assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. Resident #1 was admitted to the facility with diagnoses including Depression, Schizophrenia, and Bipolar Disorder. The Minimum Data Set, dated dated dated [DATE] documented Resident #1's cognition was intact. A Psychosocial Well-Being Care Plan initiated 02/06/2022 documented that Resident #1 had the potential to be abused due to cognitive and medical decline. The interventions include Social Worker to establish a good rapport, monitor for any alteration in Psychosocial well-being, and refer to medical doctor. The care plan also documented that an evaluation was done on 07/15/2024 and that Resident #1 was transferred to the emergency room for suicidal ideation, aggressive behavior, throwing items at staff, and throwing milk on a staff stating, I will kill one of you before you kill me. Resident #1's loud and aggressive behavior was disturbing on the unit. The care plan was not updated to reflect on the abuse incident of 07/17/2024. A Behavioral Comprehensive Care Plan dated 09/20/2023 documented Resident #1 has socially inappropriate/disruptive behavioral symptoms. The interventions include staff to assess and anticipate the resident needs and to intervene if necessary. Avoid over stimulation. This care plan was last updated on 07/15/2024. The care plan was not updated to reflect on the abuse incident of 07/17/2024. During an interview on 07/29/2024 at 1:55pm, the Director of Social Services stated that they are responsible for implementing the Psychosocial Well-being Care Plans. The Director of Social Services went on to say that the Registered Nurses and Supervisors are also responsible for initiating and updating the care plans. During an interview on 07/30/2024 at 12:10am, the Director of Nursing stated that the Registered Nurse Supervisor who was on duty at the time of the incident on 07/17/2024, was responsible for updating the care plan. The Director of Nursing stated that Registered Nurse Unit Manager #1 should have followed up to ensure the care plan was updated. 10 NYCRR 415.11 (c)(2) (i-iii)

Based on observation, record review, and interviews conducted during an abbreviated survey (NY00320218), the facility did not ensure that a resident was free from physical abuse by nursing home staff. This was evident for 1 out of 3 residents sampled for abuse (Resident #1). Specifically, on 07/17/23 at 11:37:25 am, Resident #1, who was cognitively intact, reported to the Assistant Director of Nursing they were punched in the nose by Licensed Practical Nurse #1. Review of the facility's surveillance camera dated 07/17/23 at 11:37 am (real time) showed Licensed Practical Nurse #1 exiting Resident #1's room, retrieved their belongings, and exited the nursing unit. Resident #1 was seen crawling on hands and knees on the floor bleeding. Licensed Practical Nurse #1 left the nursing unit without reporting to Registered Nurse Supervisor #1 that Resident #1 was injured, or how Resident #1's injuries occurred. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy. The findings are: The Facility's Policy and Procedure on Abuse and Neglect, revised date of 01/23, documented the facility assures that residents are free from abuse and neglect by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, family members, legal guardians, or outside members of the community. All Employees will be trained and be knowledgeable about the Abuse Prevention Policy. The Abuse Prevention policy will be incorporated into the employee orientation procedure. A mandatory annual in-service for all facility staff will be provided. Resident #1 was admitted on [DATE] to the facility with diagnoses including Depression and Alcohol abuse with intoxication. The Minimum Data Set, dated dated [DATE], documented that Resident #1 had a Brief Interview of Mental Status and scored 14 out of 15, indicating intact cognition. A Comprehensive Care Plan for Psychosocial well-being, dated 09/27/22, documented Resident #1 potential for abuse due to cognitive and medical decline, documented interventions to allow Resident #1 to verbalize any questions or concerns. A Comprehensive Care Plan for Behavioral symptoms, dated 01/27/24, documented interventions to provide physical and verbal cues to alleviate anxiety, assist verbalization of source of agitation, and encourage seeking out for staff member when agitated. A nursing progress note written by Assistant Director of Nursing, dated 07/17/23 at 5:47 pm, documented they were called by Social Worker #1 to the unit at 10:00 am, because Resident #1 had headbutted Licensed Practical Nurse #1. Assistant Director of Nursing and Social Worker #1 calmed Resident #1, and Resident #1 apologized to Licensed Practical Nurse #1. At around 11:30 am, Assistant Director of Nursing #1 was called onto the unit because Resident #1 was bleeding on the floor. Assistant Director of Nursing #1 responded and observed Resident #1 lying in a prone position in the hallway, bleeding from their nose. Resident #1 stated to Assistant Director of Nursing #1 that Licensed Practical Nurse #1 punched Resident #1 twice in their face. Resident #1 was assessed, and stated they were fine. The Medical Doctor was notified and ordered to transfer Resident #1 to the hospital for a computerized tomography scan. Resident #1's family member was notified about the incident and the transfer of Resident #1 to the hospital. The facility's Occurrence report, dated 07/17/23 at 11:36 am, documented Resident #1 stated Licensed Practical Nurse #1 punched them. Resident #1 was observed bleeding from their nose on the floor in the hallway close to their room. Resident #1 was assessed, Medical Doctor informed, and 911 was called at 11:55 am. Resident #1 was transferred to the hospital for further evaluation. The facility concluded that abuse occurred because License Practical Nurse #1 was inconsistent with their statement during a telephone interview, and the surveillance footage showed Licensed Practical Nurse #1 exiting the room shortly before Resident #1 was seen crawling and bleeding. Administrator #1, Director of Nursing #1, Assistant Director of Nursing and Social Worker #1 responded to the call that Resident #1 was seen bleeding on the floor and Licensed Practical Nurse #1 could not be located. When Administrator #1 asked Licensed Practical Nurse #1 if they punched Resident #1, Licensed Practical Nurse #1 informed the Administrator they would not let a resident abuse them. Hospital Discharge Summary (imaging report), dated 07/17/23 at 3:34 pm, documented that an x-ray of Resident #1's right elbow, revealed the elbow was fractured, and a computerized tomography scan (CAT Scan) of Resident #1's face revealed a nasal bone fracture (nose fracture). During an interview on 03/18/24 at 1:08 pm, Resident #1 stated Licensed Practical Nurse #1 told them to go to their room. Resident #1 stated Licensed Practical Nurse #1 came into the room, and they had something metal in their hand and Licensed Practical Nurse #1 punched them several times. Resident #1 stated they were unaware of any witnesses. Resident #1 cannot remember the date or time. During a telephone interview on 03/18/24 at 2:36 pm, Licensed Practical Nurse #1 stated Resident #2 was causing a disturbance on the unit and was disturbing Resident #1. Licensed Practical Nurse #1 stated they were trying to de-escalate the issue between the residents when Resident #1 became aggressive, and headbutted Licensed Practical Nurse #1 in front of Social Worker #1, Registered Nurse Supervisor #1, and Director of Nursing. Licensed Practical Nurse #1 stated they called Director of Nursing later that day to ask if police would be called because Resident #1 headbutted them. Director of Nursing said they would follow up with Licensed Practical Nurse #1 later. Licensed Practical Nurse #1 stated they went into the room to provide care at the end of the shift to Resident #3 when Resident #1 approached Licensed Practical Nurse #1 to apologize. Licensed Practical Nurse #1 stated Resident #1 became angry because Licensed Practical Nurse #1 did not want to accept Resident #1's apology, so Resident #1 grabbed a pouch/grooming kit, pulled out scissors, and charged at Licensed Practical Nurse #1. Licensed Practical Nurse #1 stated Resident #1 was blocking the door when Licensed Practical Nurse #1 was attempting to exit, so Licensed Practical Nurse #1 pushed Resident #1 out their way and Resident #1 dropped themselves on the floor to create a scene. Licensed Practical Nurse #1 stated they left the facility at approximately 1:20 pm and called the facility 10 minutes later to notify the Administrator and the Director of Nursing that Resident #1 had a weapon (scissors), and that Licensed Practical Nurse #1 was going to urgent care. During that conversation, Licensed Practical Nurse #1 stated Administrator #1 informed Licensed Practical Nurse #1 that Resident #1 was injured. Licensed Practical Nurse #1 stated they believe Resident #1 could have injured themselves when Resident #1 put themselves on the floor. Licensed Practical Nurse #1 stated they did not punch or hit Resident #1. During an interview on 03/18/24 at 1:05 pm, Assistant Director of Nursing #1 stated they were called to the unit to assess Resident #1, and when they arrived on the unit, they observed Resident #1 in a prone position bleeding from their nose. Assistant Director of Nursing #1 stated Resident #1 reported to them that Licensed Practical Nurse #1 hit them. During a telephone interview on 03/19/24 at 10:04 am, Social Worker #1 stated they arrived on the unit at approximately 10:40 am and saw Resident #1 and Licensed Practical Nurse #1 exchanging words back and forth. Social Worker #1 intervened and calmed Resident #1 down. Social Worker #1 stated after Resident #1 was calm, Resident #1 headbutted Licensed Practical Nurse #1. Social Worker #1 stated at approximately 11:36 am, they and Assistant Director of Nursing #1 responded to a call on the unit about Resident #1 bleeding and Resident #1 reported that they were punched in their nose by Licensed Practical Nurse #1. During a telephone interview on 03/19/24 at 1:39 pm, Director of Nursing #1 stated on 07/17/23, they received a call from the nursing unit because Resident #1 was agitated. Director of Nursing #1 stated when they arrived on the unit, Social Worker #1, Licensed Practical Nurse #1, and Resident #1 were present. Licensed Practical Nurse #1 and Resident #1 informed Director of Nursing #1 that Resident #1 headbutted Licensed Practical Nurse #1. (Director of Nursing #1 stated that they could not recall the time.) Director of Nursing #1 stated they asked Licensed Practical Nurse #1 if they were okay, and if they wanted to go to the hospital. Licensed Practical Nurse #1 stated they were fine. Director of Nursing #1 stated Social Worker #1 and Assistant Director of Nursing #1 were in the process of checking for an empty room on a different unit to transfer Resident #1, when they received a second call at approximately 11:36 am from the unit, informing them that Resident #1 was bleeding on the floor. Director of Nursing #1 stated they, Administrator #1, and the Director of Human Resources responded to the call. Licensed Practical Nurse #1 could not be located. Director of Nursing #1 stated that after several attempts to reach Licensed Practical Nurse #1 to inquire about what happened, Licensed Practical Nurse #1 answered their phone and stated that they could not talk. During a telephone interview on 03/19/24 at 2:15 pm, Certified Nursing Assistant #1 stated at approximately 11:20 am, they heard someone crying out for help down the hallway, walked towards the cry, and saw Licensed Practical Nurse #1 exiting Resident #1's room. Certified Nursing Assistant #1 stated that a few seconds later they saw Resident #1 crawling on the floor from their room bleeding and Resident #1 told them that Licensed Practical Nurse #1 hit them. During a telephone interview on 03/19/24 at 9:41 am, Housekeeper #1 stated around 11:00 am, they heard screaming for help and saw Licensed Practical Nurse #1 coming out of Resident #1's room and Resident #1 was seen crawling on the floor from their room bleeding. Housekeeper #1 stated that Resident #1 stated to them that Licensed Practical Nurse #1 beat them. During an interview on 03/18/24 at 1:50 pm, Administrator stated Social Worker #1 observed when Resident #1 headbutted Licensed Practical Nurse #1. Administrator #1 stated they watched the surveillance camera and saw Licensed Practical Nurse #1 went into Resident #1's room at 11:35 am. Administrator #1 stated Licensed Practical Nurse #1 was not carrying any medication in their hand or the medication cart, or any other items that would indicate they entered the room to provide care to Resident #2. Licensed Practical Nurse #1 exited Resident #1's room at 11:37 am and immediately retrieved their belongings and left the facility. Administrator #1 stated that 911 was called at 11:55 am and Resident #1 was transferred to the emergency room . 10 NYCRR 415.4(b)(1)(i)

Based on record review and interviews conducted during the Recertification Survey from 03/26/2024 through 04/02/2024, the facility failed to ensure that the resident and their representative were provided with a written summary of the baseline care plan. This was evident for 3 (Residents # 5, #39, and #119) of 3 residents reviewed for baseline care plan out of a total sample of 38 residents. Specifically, 1) Resident #5 did not get a copy of their baseline care plan summary. 2) Resident #39's representative did not receive a copy of the resident's baseline care plan summary, and 3) Resident #119's representative did not receive a copy of the resident's baseline care plan summary. The findings are: The facility policy and procedure titled Care Plan - Baseline with a revised date of October 2023 documented that a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission. The resident and their representative will be provided with a summary of the baseline care plan. 1. Resident #5 was admitted to the facility with diagnoses of Depression and Respiratory Failure. The admission Minimum Data Set assessment dated [DATE] documented Resident #5's cognition was intact. A Care Plan History for Resident #5 documented that a Baseline Care Plan was created on 01/26/2024. There was no documentation that the resident or their representative acknowledged receipt of the baseline care plan. A review of Resident #5's medical record did not reveal documented evidence that a copy of baseline care plan was provided to the resident and / or their representative. 2. Resident #39 was admitted with diagnoses of Depression and Toxoplasma Meningoencephalitis. The admission Minimum Data Set assessment dated [DATE] documented Resident #39's cognition as moderately impaired. A Care Plan History for Resident #39 documented that a Baseline Care Plan was created on 01/27/2024. There was no documentation that the resident or their representative acknowledged receipt of the baseline care plan. A review of Resident #39's medical record did not reveal documented evidence that a copy of baseline care plan was provided to the resident and / or their representative. 3. Resident #119 was admitted to the facility with diagnoses of Respiratory Failure and Tracheostomy Status. The admission Minimum Data Set assessment dated [DATE] documented Resident #119's cognition as severely impaired. A Care Plan History for Resident #119 documented that a Baseline Care Plan was created on 02/01/2024. There was no documentation that the resident or their representative acknowledged receipt of the baseline care plan. A review of Resident #119's medical record did not reveal documented evidence that a copy of baseline care plan was provided to the resident and / or their representative. On 04/02/2024 at 12:15 PM Registered Nurse #4, who was the unit manager, was interviewed and stated that the admission nurse initiates the baseline care plan and that they complete it within 48 hours. Registered Nurse #4 stated they do not give out a summary of the baseline care plan and that residents or their representatives do not get a copy of the baseline care plan. On 04/01/2024 at 4:12 PM, the Social Worker was interviewed and stated that a baseline care plan is created within 48 hours from admission. They stated that the social workers are responsible for providing the baseline care plan to the residents and their family representatives to inform them of the plan of care. The Social Worker stated resident does not have a copy of the summary of the baseline care plan because they were not provided. On 04/02/2024 at 2:37 PM, the Director of Nursing was interviewed and stated that the baseline care plan must be completed within 48 hours. They stated that the plan is discussed with the resident and resident representative, and a copy of the summary must be provided to them. 10 NYCRR 415.11 (c)

Based on record review and interviews conducted during the Recertification and Complaint Survey (NY00327454) from 03/26/2024 through 04/02/2024, the facility did not ensure that each resident's comprehensive care plan was reviewed and revised by the interdisciplinary team following an occurrence of resident-to-resident physical abuse. This was evident for 1 (Resident #35) of 35 total sampled residents. Specifically, the comprehensive care plan was not reviewed and revised for Resident #35 following their involvement in a resident-to-resident altercation. The findings are: The facility policy titled Comprehensive Care Plan dated 10/2023 documented a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Resident #35 was admitted to the facility with diagnoses of Diabetes Mellitus, Acute Respiratory Failure, and Bipolar Disorder. The Minimum Data Set assessment dated documented that Resident #35 had severely impaired cognition. The facility investigation summary documented that on 11/04/2023 at 6:35AM, Resident #35 was involved in an unwitnessed altercation with another resident in their room. Both residents were transferred to the hospital for evaluation. Resident #35 returned to the facility with staples to the head. A comprehensive care plan for psychosocial well-being that was initiated on 12/13/2022 documented resident evidences the potential for abuse due to cognitive and medical decline. There was no documented evidence that Resident #35's comprehensive care plan was revised with new interventions following an occurrence of resident-to-resident altercation on 11/04/2023. On 04/01/2024 at 9:06AM, Registered Nurse #7, who was the Registered Nurse Supervisor, stated Resident #35 was involved in an altercation with another resident on 11/04/2023. Registered Nurse #7 stated they reviewed Resident #35's medical record and was not able to find an updated care plan with new interventions for Resident #35 following the altercation. Registered Nurse #7 stated that care plans must be updated after each incident of altercation. 10 NYCRR 415.11(c)(2)(i-iii)

Based on record review and interview conducted during the Recertification Survey from 03/26/2024 to 04/02/2024, the facility failed to address an irregularity identified by the pharmacist during Medication Regimen Review. This was evident in 1 (Resident #31) of 5 residents reviewed for unnecessary medications. Specifically, the pharmacist identified a potential medication irregularity during the Medication Regimen Review dated 02/28/2024 and recommended to change the administration time for Montelukast for maximum benefit. The facility did not address the irregularity. The findings are: The facility's Policy and Procedure for Drug Regimen Review which was last revised on 02/2024 documented that the Consultant Pharmacist shall identify, document, and report possible medication irregularities for review and action by the attending Physician, where appropriate. The attending Physician or licensed designee shall respond to the Drug Regimen Review within 7-14 days or more promptly, whenever possible. Resident #31 was admitted to the facility with diagnosis of Schizophrenia, Chronic Obstructive Pulmonary Disease, and Obstructive Sleep Apnea. The annual Minimum Data Set assessment dated [DATE] documented that Resident #31 had intact cognition. A Medication Regimen Review dated 02/28/2024 documented that Resident #31 was currently receiving Montelukast at 9:00 AM. Recommended to be given at bedtime for maximum benefit. Consider switching to bedtime dosing, if appropriate. The Physician/Prescriber Response documented agreed, will do. The physician order report dated 03/01/2024 through 04/01/2024 documented an order for Montelukast tablet, 10 milligram, 1 tablet, orally, once daily at 9:00 AM for Chronic Obstructive Pulmonary Disease. The start date was on 08/08/2023. The Medication Administration Record dated 02/28/2023 through 03/31/2024 documented Montelukast Scheduled time was at 9:00 AM. During an interview on 04/02/2024 at 09:33 AM, Licensed Pharmacist Consultant #1 stated they made the recommendation for Montelukast, and it was the facility's responsibility to address it. During an interview on 04/02/2024 at 10:42 AM, the Medical Director stated it was an oversight. The Medical Director stated they should have checked the section that says disagree but made a mistake. During an interview on 04/02/2024 at 11:10 AM, the Director of Nursing stated that the physician should have acted upon the recommendation made by the licensed pharmacist. The Director of Nursing stated in this case, the recommendation was not acted upon appropriately and they take full responsibility. 10 NYCRR 415.18 (c)(2)

Based on observation, record review, and interviews conducted during the Recertification Survey from 03/26/2024 through 04/02/2024, the facility did not ensure that an ongoing activities program was provided based on the comprehensive assessment, care plan, and preferences of each resident, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. This was evident for 1 (Residents #39) of 3 residents reviewed for Activities out of 38 total sampled residents. Specifically, there was no evidence Resident #39 was engaged in a meaningful activity program on the unit. The findings are: The facility's policy and procedure titled Quality of Life - Resident Self-Determination and Participation with the last reviewed date of November 2023 documented that the facility respects and promotes the right of each resident to exercise their autonomy regarding what the resident considers to be important facets of their life. Each resident is allowed to choose activities, schedules, and health care that are consistent with their interests, values, assessment, and plan of care. Resident #39 was admitted with diagnoses of Depression and Toxoplasma Meningoencephalitis. The admission Minimum Data Set assessment dated [DATE] documented Resident #39's cognition was moderately impaired. The assessment documented that Resident #39 found it very important to have books, newspapers, and magazines to read, listen to music they like, keep up with the news, do things with groups of people, do favorite activities, and participate in religious services or practices. During observations, on 03/26/2024 at 12:37 PM, Resident # 39 was observed in bed with the television off. There was no ongoing recreation activity noted in the unit. On 03/27/2024 at 10:05 AM, Resident # 39 was observed resting in bed with the television off. No activity was noted on the unit. The resident had their phone on playing Christian music. On 04/01/2024 at 9:27 AM, Resident #39 was observed resting in bed and listening to preaching on their phone. There was no activity noted in the unit. On 03/26/2024 at 12:38 PM, Resident #39 was interviewed and stated they like to listen to music. They stated they listen to Christian music on their phone. Resident #39 stated there were no activities that they want to do but was wondering if the facility had bingo. Resident #39 stated they are of Catholic faith and used to go to church when they were back home. They stated they do not know if there was church service in the facility. The activities care plan that was initiated on 01/29/2024 documented that Resident #39 prefers activities that identify with their prior lifestyle. The interventions include informing them of upcoming activities by providing an activity calendar, verbal reminders, escort, and encouragement and providing materials of interest, such as magazines and newspapers, upon request. The recreation aide will provide room visits, daily orientation, and program invitations. A review of the facility activity calendar for March 2024 showed no listed activity for the 2nd floor. A review of Resident #39's medical records revealed no documented evidence of activity assessment, activity notes, and activity attendance records. On 04/01/2024 at 12:30 PM, Certified Nursing Assistant #2 was interviewed and stated they did not see activity staff coming to the unit. They stated Resident #39 stays in bed and would have their phone and television on. On 04/01/2024 at 12:37 PM, Certified Nursing Assistant #3 was interviewed and stated there was no staff from activity department who came to the unit. They stated there had been no activity on the unit. Certified Nursing Assistant #3 stated there was an activity calendar every month but there was no activity scheduled on the unit. On 04/01/2024 at 12:56 PM, Registered Nurse #3 was interviewed and stated that they have an activity calendar on the 2nd floor, but there was no activity on the unit. On 04/02/2024 at 12:50 PM, Registered Nurse #4, who was the unit manager, was interviewed and stated the residents who can ambulate go to the recreation department downstairs for activities. They stated that prior to COVID-19, they would take residents on ventilator out of bed and take them in the dayroom to watch television. They stated recreation staff used to come and play music for the residents. Registered Nurse #4 stated they have had not returned to this usual routine after COVID-19. They stated there was no activity in the unit and that recreation staff would just turn the television on in residents' room. Registered Nurse #4 stated Resident #39 stays in bed and would play music on their phone. On 04/01/2024 at 4:01 PM, the Director of Recreation was interviewed and stated they do room visits and give daily orientation on the 2nd floor in the morning and sometimes in the afternoon. They stated residents who get out of bed attend activities downstairs, and they invite the alert residents to attend the activities on the first floor. The Director of Recreation stated there was no room visit listed on the calendar. On 04/02/2024 at 2:37 PM, the Director of Nursing was interviewed and stated that the activities on the 2nd floor should be at the bedside, but they cannot confirm that there was activity on the unit. 10 NYCRR 415.5 (f) (1)

Based on observation, record review and interviews conducted during the Recertification and Complaint Survey (NY00318593) from 03/26/2024 through 04/02/2024, the facility did not ensure that each resident receives treatment and care in accordance with professional standards of practice. This was evident for 1 (Resident #99) of 35 total sampled residents. Specifically, on 03/29/2024, Resident #99's right and left lower extremities were observed with severe edema, dry, and thick scaly skin. There was no documented evidence that the skin condition was evaluated and being treated. The findings are: The facility's policy and procedure titled Quality of Care dated 11/2023 documented each resident shall be cared for in a manner that promotes and enhances their quality of life, dignity, respect, and individuality. Resident #99 was admitted to the facility with diagnoses of Acute Embolism and Thrombosis of Unspecified Deep Veins of Right Lower Extremity, Cellulitis of Right/Left Lower Limbs, and Localized Edema. The Minimum Data Set assessment dated [DATE] documented Resident #99 was cognitively intact. During observation on 03/29/2024 at 1:00 PM, Resident #99's right and left lower extremities were noted with redness, severe edema, dry, and thick scaly skin. A care plan for at risk for skin impairment related to fragile skin was initiated on 11/05/2021 and was last reviewed on 02/18/2024. The facility interventions include to conduct a systematic skin inspection daily and weekly, to pay particular attention to unaffected extremity. An evaluation note dated 01/24/2024 documented there was no skin impairment noted. The podiatry note dated 01/27/2024 and 02/25/2024 documented Resident #99 presented for routine foot care. Resident had severe pitting edema of bilateral lower extremities with open lesions. A review of Resident #99's progress notes from 01/03/2024 through 03/29/2024 did not reveal documented evidence that Resident #99's bilateral lower extremities were assessed by the Registered Nurse, Nurse Practitioner, or the Attending Physician. A review of the physician's order report from 01/01/2024 through 03/29/2024 did not show treatment orders to address Resident #99's dry and thick scaly skin on both lower extremities. On 03/29/2024 at 1:00 PM, Resident #99 was interviewed and stated nurses were aware of their skin condition but does not provide them with treatment. On 04/01/2024 at 9:17 AM, Licensed Practical Nurse #4 was interviewed and stated there was no current order for Resident #99's skin on bilateral lower extremities. On 04/02/2024 at 11:15 AM, the Assistant Director of Nursing was interviewed and stated Resident #99 had history of cellulitis and ongoing localized edema of bilateral lower extremities. They stated Resident #99's treatment orders were discontinued last year. On 04/02/2024 at 12:30 PM, the Attending Physician was interviewed and stated Resident #99's had lower extremity edema and chronic skin condition. The attending physician stated there was no report of change or concern for Resident #99, and if there was any reported concern, they would evaluate the resident and order appropriate treatment. 10 NYCRR 415.12

Based on record review and interviews conducted during the Recertification and Abbreviated Survey (Complaint #NY00331841) from 03/26/2024 through 04/02/2020, the facility failed to ensure that the resident and/or the resident's representative was immediately informed of an accident which results in injury and had the potential for requiring physician intervention. This was evident for 1 (Resident #253) of 2 residents reviewed for Notification of Change out of 38 total sampled residents. Specifically, on 01/15/2024 at 6:30 AM, Resident #253 was observed with discoloration on the forehead. There was no documented evidence that the resident's representative was notified of the change in resident's condition. The findings are: The facility policy and procedure titled Change in Resident Condition or Status which was last revised in November 2023, documented that the facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and status (e.g., changes in level of care, billing/payments, resident rights, etc.). Unless otherwise, instructed by the resident, a nurse will notify the resident's representative when the resident is involved in any accident or incident that results in an injury including injuries of an unknown source. Resident #253 was admitted with diagnoses of Hypertension and Non-Alzheimer's Dementia. The annual Minimum Data Set assessment dated [DATE] documented that Resident #253 had short- and long-term memory problem and was severely impaired in cognitive skills for daily decision making. A Nurse's Progress note dated 01/15/2024 at 6:40 AM documented that at 6:30 AM, Resident #253 was noted with skin discoloration on the forehead. A Nurse's Progress note dated 01/16/2024 at 5:28 AM documented that skin discoloration on Resident #253's forehead was diffusing. The progress notes dated 01/15/2024 through 01/16/2024 had no documented evidence that the family was informed of the discoloration on Resident #253's forehead. A Fall Investigation form dated 01/15/2024 and Peer Review and the Quality Assessment and Assurance Work Product-Confidential form dated 01/15/2024 had no documented evidence that Resident #253's family was informed of the discoloration. The facility's investigation summary dated 01/17/2024 documented that Resident #253 was observed with a discoloration to the center of their forehead on 01/15/2024 during care. The facility concluded that Resident #253 sustained an unwitnessed fall in their room which appeared to have occurred from rolling out of bed in their sleep. On 03/27/2024 at 3:13 PM, Resident #253's representative was interviewed and stated that their sibling visited the resident on 01/16/2024 and observed that the resident had black and blue on their forehead. The facility claimed that they informed them, but they were not informed. On 04/01/2024 at 11:51 AM, Registered Nurse #1, who was the unit manager, was interviewed and stated that the night shift supervisor wrote a note that at 6:30 AM, discoloration was noted on Resident #253's forehead. Registered Nurse #1 stated they did not see a documentation on the resident's chart that the family were notified. On 04/02/2024 at 8:40 AM, Registered Nurse #2, who was the night shift supervisor, was interviewed and stated that on 01/15/2024 at around 6:30 AM, they were called to check on Resident #253 who was noted to have discoloration on the forehead. Registered Nurse #2 stated they called the physician and left a message for the family. Resident #2 stated they might have misdialed the phone number, or they might have had an emergency at that time and might have not called or notified the resident's family. On 04/02/2024 at 2:03 PM, the Director of Nursing was interviewed and stated that the unit manager and supervisors were responsible for notifying the family. They stated that the night shift supervisor stated they reached out to the family and left a voice message but there was no documentation that the family was notified. The Director of Nursing stated they were supposed to document when they called the family. 10 NYCRR 415.3(f)(2)(ii)(c)

Based on observation, interviews, and record review conducted during the Recertification Survey from 03/26/2024 through 04/02/2024, the facility did not ensure that a resident's privacy was maintained. This was evident for 1 (Resident #119) of 1 resident reviewed for Privacy out of 38 sampled residents. Specifically, a Respiratory Therapist was observed performing tracheostomy care with the resident's room door opened. The findings are: The facility policy and procedure titled Residents Rights, with a last revised date of November 2023, documented that the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Resident # 119 was admitted with diagnoses of Respiratory Failure and Tracheostomy Status. The Admission Minimum Data Set assessment dated [DATE] documented that Resident #119 had severe impairment in cognition. The assessment documented that the resident required suctioning and tracheostomy care. A physician's order dated 02/02/2024 documented an order to cleanse tracheostomy area every shift and as needed; and suction tracheal and nasopharyngeal every 4 hours and as needed. On 04/01/2024 at 10:10 AM, Respiratory Therapist #1 was observed suctioning and performing tracheostomy care for Resident #119 with the room door opened. On 04/01/2024 at 10:30 AM, Respiratory Therapist #1 was interviewed and stated everybody was not supposed to see what they were doing in the room. They stated they were supposed to keep the door closed and the curtains pulled to maintain privacy. Respiratory Therapist #1 stated they made a mistake. On 04/01/2024 at 12:20 PM, the Director of Respiratory Therapy was interviewed and stated they are to maintain residents' privacy during tracheostomy care. The door must be closed and the curtains pulled. 04/02/2024 at 2:43 PM, the Director of Nursing was interviewed and stated the staff must provide privacy during tracheostomy care. 10 NYCRR 415.3(e)(1)

Based on record review and interviews conducted during the Recertification and Abbreviated Survey (NY00331841) from 03/26/2024 through 04/02/2024, the facility failed to ensure that all alleged violations involving injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, to the New York State Department of Health. This was evident for 1 (Resident #253) of 38 total sampled residents. Specifically, on 01/15/2024 at 6:30 AM, Resident #253 was observed with discoloration to the forehead that was not reported to the New York State Department of Health. There was no witness on how Resident #253 sustained the discoloration and the source of injury could not be explained by the resident. The findings are: The facility policy and procedure titled Abuse & Neglect, with a last revised date of 03/18/2024 documented that all alleged or suspected incidents of abuse and or neglect will be investigated, and injuries of unknown origin will be investigated to rule out abuse, neglect, or mistreatment. The Administrator or designee will provide a 2-hour notification to the New York State Department of Health for any alleged or suspected or confirmed case of abuse or neglect. Resident #253 was admitted with diagnoses of Hypertension and Non-Alzheimer's Dementia. The annual Minimum Data Set assessment dated [DATE] documented that Resident #253 had short- and long-term memory problem and was severely impaired in cognitive skills for daily decision making. A Nurse's Progress note dated 01/15/2024 at 6:40 AM documented that at 6:30 AM Resident #253 was noted with skin discoloration on the forehead. A Fall Investigation form dated 01/15/2024 documented that the occurrence was unwitnessed. An undated Skin Investigation form documented Resident #253 was observed in bed with discoloration to the forehead. Resident was unable to relate due to dementia. The facility's investigation summary dated 01/17/2024 documented that Resident #253 was observed with a discoloration to the center of their forehead on 01/15/2024 during care. The facility concluded that based on their findings, there was no evidence of abuse, neglect, or mistreatment. The summary documented that Resident #253 sustained an unwitnessed fall in their room which appeared to have occurred from rolling out of bed in their sleep. On 04/02/2024 at 2:03 PM, the Director of Nursing stated that Resident #253 was interviewed but could not tell what happened. The Director of Nursing stated they did not report the discoloration to the Department of Health because they thought it was from a fall based on the roommate's statement. They stated that the resident's roommate said they did not see the resident fall, but they saw the resident getting up from the floor. The Director of Nursing stated they completed the incident report and concluded that it appeared that Resident #253 rolled out of bed. 10 NYCRR 415.4(b)(2)

Based on observations, interviews, and record review conducted during the Recertification and Complaint Survey (NY00331841) from 03/26/2024 through 04/02/2024, the facility did not ensure that a comprehensive person-centered care plan was developed and implemented for each resident. This was evident for 5 (Resident #s 39, 82, 108, 109, and 253) of 38 sampled residents. Specifically, 1.) Resident #39 had no care plan in place for antibiotic therapy. 2.) A care plan was not developed to address Resident #108's preference to wear a night gown in the dayroom. 3.) Resident #82 had no care plan for hospice care. 4.) Resident #109 had no care plan developed to address wandering behavior. 5.) Resident #253 had no care in place for ecchymosis on the forehead. The findings include but are not limited to: The facility policy titled Comprehensive Care Plan with a revised date of 10/2023 stated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The interdisciplinary team, in conjunction with the resident and their family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 1. Resident #39 was admitted with diagnoses of Depression and Toxoplasma Meningoencephalitis. The Admission Minimum Data Set assessment dated [DATE] documented Resident #39's cognition was moderately impaired. A physician's order dated 02/25/2024 documented Bactrim DS (sulfamethoxazole-trimethoprim) tablet; 800-160 milligram; 1 tablet oral once a day for prophylactic measures. A review of the Medication Administration Record dated 03/01/2024 to 03/31/2024 revealed that Bactrim DS was administered to Resident #39. A review of Resident #39's medical records revealed no documented evidence that a comprehensive care plan with interventions for Resident #39's antibiotic therapy was initiated and implemented. On 03/26/2024 at 2:17 PM, Registered Nurse #4, who was the unit manager, was interviewed and stated that Resident #39 was started on Bactrim DS (sulfamethoxazole-trimethoprim) on 02/26/2024 for the prevention of toxoplasmosis. Registered Nurse #4 stated a care plan should have been in place for the antibiotic use, but they forgot to include it. On 04/02/2024 at 2:31 PM, the Director of Nursing was interviewed and stated there should be a care plan for Bactrim use. They stated the unit manager, the supervisor, or the Registered Nurse who picked up the order were responsible for initiating the care plan. They also stated the Infection Control Nurse was supposed to ensure that the care plan was in place for antibiotic therapy. 44842 2. Resident #108 was admitted with diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, Seizures, and Schizoaffective Disorder. The Minimum Data Set assessment dated [DATE] documented that Resident #108 had severely impaired cognition. The Minimum Data Set assessment further documented that Resident #108 required supervision with bed mobility, transfer, upper body dressing, toilet use, personal hygiene, and eating. During observation on 03/26/2024 at 10:10 AM and on 03/27/2024 at 9:40 AM, Resident #108 was noted in the day room sitting in their wheelchair wearing a night gown. A review of Resident #108's medical record revealed no documented evidence that a Comprehensive Care Plan to address Resident #108's preference to wear their night gown in the day room was developed. On 3/28/2024 at 11:15 AM, Certified Nursing Assistant #5 was interviewed and stated Resident #108 sometimes wheels self to the day room in their gown in the early morning. They try to redirect Resident back to their room to get dressed but Resident refused to get dressed until later in the morning. On 3/28/2024 at 2:36 PM, Licensed Practical Nurse #2 was interviewed and stated Resident #108 was resistive to care and has a habit of going to the day room in their night gown. They stated they try to redirect Resident back to their room for care, but Resident would refuse. On 03/28/2024 at 2:51 PM, Registered Nurse #1, who was the unit manager, was interviewed and stated the Certified Nursing Assistants try to encourage Resident #108 to get washed and dressed before going to the day room but Resident would refuse. Registered Nurse #1 stated there should be a care plan for Resident #108's preference to go to the day room wearing a night gown. Registered Nurse #1 stated it was their responsibility to create and update Resident #108's Comprehensive Care Plan. On 03/29/2024 at 2:23 PM, the Director of Nursing Services was interviewed and stated a care plan should have been developed to reflect Resident #108's preference to attend the day room in their gown. They stated that the Registered Nurse Manager is responsible for developing, implementing, and updating the care plans. 45351 3. Resident #82 was admitted with diagnoses of Diabetes Mellitus and Hypothyroidism. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #82 was severely cognitively impaired and was receiving hospice care. The social service progress note dated 09/18/2023 documented Resident #82 was assigned to hospice care. A physician's order dated 09/18/2023 documented Resident #82 was in hospice care. A review of the comprehensive care plans for Resident #82 revealed there was no documented evidence that a care plan for hospice care was initiated. On 03/28/2024 at 12:18 PM, the Assistant Director of Nursing was interviewed and stated Resident #82 was currently receiving hospice service. They stated they reviewed Resident #82's medical record and was not able to locate the care plan for hospice care. They stated the care plan for hospice care was supposed to be created by the social worker. On 3/28/2024 at 12:26 PM, the Director of Social Service was interviewed and stated the care plan for hospice care was not created for Resident #82. They stated that it was an oversight and should have been created when resident started hospice. 10 NYCRR 415.11(c)(1)

Based on observation and interview conducted during the Recertification survey from 2/23/2022 to 3/2/2022, the facility did not ensure that infection prevention and control program practices were maintained. Specifically, 1) the Licensed Practical Nurse (LPN) failed to practice hand hygiene between glove changes during wound care, and 2)oxygen tubing was observed touching the floor on multiple occasions. This was evident for 1 of 7 residents investigated for Pressure Ulcer/Injury and 1 of 3 residents reviewed for Respiratory care out of a sample of 38 residents. (Resident #4 and Resident #107) The finding is: 1.The facility's policy titled Pressure Ulcer Prevention Management and Treatment Program, reviewed on 10/27/21, documented Standard precautions utilizing barrier protection: #2- use clean disposable gloves for removing soiled dressing and place in plastic bag, #3-Remove soiled gloves and wash hands. Resident #4 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physicians Order dated 02/23/22 documented Santyl to the left Heel Pressure Ulcer: Wash with Dakins, apply Santyl to wound bed, Skin Prep to peri wound then cover with dry protective dressing (DPD). Don Heel Protectors. On 03/01/22 at 08:54 AM, a wound care observation was conducted with Licensed Practical Nurse (LPN) #5. LPN #5 entered Resident's #4 room, introduced self, cleaned the overbed table, then washed their hands appropriately. LPN #5 then gathered the supplies from the treatment cart, placed them in a clean plastic bag, and reentered the resident's room. LPN #5 then washed their hands appropriately, draped the table, set up the supplies and performed hand hygiene. LPN #5 then donned gloves and proceeded to remove the soiled dressing, discarded it, then removed the soiled gloves and donned another pair without washing their hands. LPN #5 then cleansed the wound, removed gloves, and donned another pair of gloves without washing their hands. LPN #5 repeated this procedure on two more occasions without washing their hands between glove changes. LPN #5 then placed the appropriate treatment on the resident's heel, placed on a multipodus boot with the assistance of a CNA, tied up the plastic bag with the soiled dressing, then took off their gloves and washed their hands appropriately. An interview was immediately conducted with LPN #5 who stated that they were taught to wash hand between glove changes, or one can use the sanitizer between the glove changes to maintain good infection control. LPN #5 stated that they forgot to bring the sanitizing wipes to wash their hands and that they did not want to leave the resident unattended to get the sanitizer. On 03/01/22 at 12:45 PM, an interview was conducted with Registered Nurse (RN) #2. RN #2 stated that one must wash their hands when gloves are changed to prevent Infection Control. RN #2 also stated that they were in-serviced on dressing change which includes handwashing between gloves changes, and that all the nurses are aware of that practice. On 03/02/22 at 10:01 AM, an interview was conducted with Registered Nurse Supervisor (RNS) #1 who stated that the nurses are aware that they must wash their hands between glove changes, and that they can use hand sanitizers also. RNS #1 also stated that nurses were in-serviced on washing their hands and that periodic in-services are given and that this is also reinforced in Infection Control in-services. RNS #1 further stated that thorough in-services were recently done for all shifts on wound care treatments. On 03/02/22 at 12:19 PM, an interview was conducted with the Director of Nursing (DON) who is also the Infection Control Preventionist (ICP) and is responsible for inservicing the nursing staff. The DON stated that competencies had been recently completed on Saturday, 02/25 for wound care and treatment and that LPN #5 was included in that session. The DON also stated that staff were in-serviced on hand washing between glove changes and that competencies are done upon hire, quarterly and as needed. The DON further stated that the supervisors do periodic in-services and that this is reinforced in infection control training. 2. The facility policy titled Oxygen Administration dated effective and last reviewed 10/21 documented the purpose of this procedure is to provide guidelines for safe oxygen administration. The policy did not address the care of oxygen tubing. The facility policy titled Infection Prevention and Control Program last reviewed 1/21 documented important facets of infection prevention include: instituting measures to avoid complications or dissemination and educating staff and ensuring that they adhere to proper techniques and procedures. Resident #107 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident sometimes understood/understands and required extensive assistance of one person for most Activities of Daily Living (ADL). The MDS further documented the resident was receiving Oxygen therapy. On 2/23/22 at 11:46 AM, 2/23/22 at 2:47 PM, 2/24/22 at 11:35 AM, 2/25/22 at 10:46 AM, and 2/25/22 at 12:49 PM, Resident #107 was observed sitting in Geri chair receiving oxygen via nasal cannula supplied by the concentrator in the room. The oxygen tubing was observed touching the floor. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration History dated 2/23/22, 2/24/22, and 2/25/22 documented resident received oxygen as ordered by the physician. On 2/28/22 at 3:13 PM, Certified Nursing Assistant (CNA) #5 was interviewed. CNA #5 stated resident receives oxygen all the time. CNA #5 also stated that they check to make sure the oxygen tubing is not on the floor and if they find the oxygen is on the floor, they wipe it with a wet washcloth, dry it, and position it so it is not on the floor. On 3/1/22 at 4:00 PM, Registered Nurse (RN) #1. RN #1 stated the CNAs are instructed through Infection Control in-services that oxygen tubing cannot touch the floor. The CNAs are also instructed to notify the charge nurse if tubing is observed on the floor. RN #1 also stated the charge nurse is responsible for making sure the tubing is not on the floor by making rounds on the unit to ensure CNAs are doing as instructed. In addition, if the oxygen tubing is observed on the floor, the charge nurse is instructed to discard and replace tubing. On 3/2/22 at 9:44 AM, the Director of Nursing (DON) was interviewed. The DON stated that the CNAs are instructed to notify the charge nurse on the floor so oxygen tubing can be changed immediately. The DON also stated that the Nurse Manager is responsible for ensuring that the charge nurse is making rounds on the unit to ensure CNAs are doing as instructed. 415.19(a)(1-3)

F578 Fieldston Lodge Care Center [NAME], LMSW Based on interviews, observations and record review completed during a recertification survey 02/23 - 03/02/2022, the facility did not ensure that advance directives were provided. Specifically, there was no evidence that staff assessed a resident's desire regarding advance directives. This was evident for one resident (Resident #420). The findings are: The facility's policy and procedure entitled Advance Directives, last reviewed 10/2021, stated that Social Work shall provide information concerning resident's rights to make decisions regarding medical care or treatment as soon as possible upon admission. The information will be reviewed with each resident, or with their health care proxy in lieu of capacity, and a copy provided to them. Resident #420 was admitted to facility 02/07/2022. The resident was noted to be alert and fully oriented. However, the resident's admission MDS had not yet been locked and posted so that a BIMS score was not available. A Resident is a New Admission Care Plan was initiated for the resident on 02/07/2022 with intervention for Social Services to evaluate, provide options on advance directives, respect/observe resident's rights and preferences, specify advance directives in place. The resident's medical orders were reviewed from 02/07/2022 through 03/02/2022, and it was noted that there was no order for an advance directive. Progress notes were reviewed starting 02/07/2022. No social services notes were observed. Observation section of medical chart was reviewed starting 02/07/2022; no entries were made by the social worker regarding the resident's living situation, discharge status, needs or advance directives. On 02/28/22 at 10:55 AM, the social worker was interviewed and stated that advance directives are usually discussed with residents upon admission and the conversation is documented in an admission note in the Progress Notes section of the medical chart. The resident's mental status assessment (BIMS), trauma assessment and mood assessment are recorded and placed in the observation section of the medical chart. Resident #420 was admitted when the social worker was on leave and the admission was supposed to have been completed by a covering part-time social worker. However, this social worker neglected to document the admission in any way, including wishes regarding advance directives. The social worker stated to have been with the facility for about 9 months and to be the only current full-time social worker, working without a supervisor on site. On 03/02/22 at 9:12 AM, the Director of Nursing (DON) was interviewed and stated that most times, admissions come in the afternoons. It is the social worker's responsibility to discuss advance directives but the nurse does usually have a discussion as well and will then alert and social worker as to the results of that conversation and document it in the progress notes section of the medical chart. Either the nurse or the social worker can initiate a care plan for advance directives, depending upon which of them has the discussion with the resident. In the case of Resident #420, the nurse completed all nursing admission documentation but did not document any discussion of advance directives. The DON stated that the facility is working at the corporate level to hire additional social workers as well as a Director of Social Services. 415.3(e)(1)(ii)

Based on record review and interviews conducted during the Recertification survey 2/23/2022 to 3/2/2022, the facility did not ensure, to the extent practicable, that residents/resident representatives participated in the development of a Comprehensive Care Plan (CCP). Specifically, residents were not afforded the opportunity to participate in the care plan meetings. This was evident for 2 of 2 residents reviewed for Care Plan out of a sample of 38 residents. (Resident #12 and #121) The findings are: The facility policy and procedure titled CCP (Comprehensive Care Plan) Participation - Assessment/Care Plans with effective date 10/27/2021 documented under Policy Interpretation and Implementation 1) The resident and his/her family, and/or the legal representative (sponsor), are invited to attend and participate in the resident's assessment and care planning conference; 3) A seven (7) day advance notice of the care planning conference is provided to the resident and interested family members. Such notice is made by mail and/or telephone; 4) The Social Services Director or designee is responsible for contacting the resident's family and for maintaining records of such notice. Notices include the date, time, and location of conference, name of family member contacted. 5) Documentation of CCP invitations and related interactions must be related in the resident's medical record. 1. Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS dated [DATE] documented Resident # 12 was adequate in hearing, clear in speech, able to make self understood, and to understand others. The MDS also documented that resident had intact cognition, did not reject care and the resident only participated in the assessment. On 02/23/22 at 12:12 PM, Resident #12 was interviewed and stated they were admitted to the facility in May 2021 and were not invited to any care plan meeting since their admission. Resident # 12 also stated they make decisions for themselves and wanted to participate in the care plan meeting. The Social Service note dated 5/25/2021 documented the Interdisciplinary Team conferenced for care planning for Resident #12. Social Services progress notes dated 5/11/2021 to 2/9/2022 contained no documented evidence that Resident #12 or their representative had been invited to participate in any care plan meetings since their admission to the facility. There was no documented evidence in the medical record that Resident #12 and/or family representative was invited to any care plan meeting since their admission to the facility on [DATE]. 2. Resident #121 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS dated [DATE] documented Resident #121 was adequate in hearing, clear in speech, able to understand others, and made self understood, had intact cognition and did not reject care. The MDS also documented that Resident #121 only participated in the assessment. On 02/23/22 at 11:46 AM, Resident #121 was interviewed and stated they were not invited to any care plan meeting since their admission to the facility on [DATE]. Resident #121 stated they make decision for themselves and would like to be invited to care plan meeting. There was no documented evidence in the medical record that CCP meetings were conducted for Resident # 121 since their admission on 11/11/2021. Social Services progress notes dated 11/12/021 to 1/18/2022 contained no documented evidence that Resident #12 or their representative had been invited to participate in care plan meetings since their admission to the facility. There was no documented evidence in the medical record that Resident #121 and/or family representative was invited to any care plan meeting since their admission to the facility on [DATE]. On 02/28/22 at 11:30 AM, Social Worker (SW) was interviewed. The SW stated that care plan meetings were held for Admission, Quarterly, Significant change, Annual and as needed. SW also stated the IDT (interdisciplinary team) including rehab staff, recreation staff, dietitian, attending physician, nurse supervisor, SW, respiratory therapist if applicable attended the care plan meeting and resident or family representative was invited to it. SW further stated they invited cognitive intact residents to the care plan meeting face to face and the family representative by calling a week in advance and documented the invitation in the SW progress note. SW stated Resident # 12 and Resident # 121 were cognitively intact residents who made decisions themselves and were invited to all care plan meetings. SW also stated Resident # 12 had the Admission care plan meeting on 5/25/2021 and Quarterly meetings on 8/24/2021, 11/23/2021, and 2/9/2022 while Resident # 121 had an Admission care plan meeting on 12/14/2021. The SW stated there was no SW note documenting that Resident #12 and Resident #121 had been invited to participate in the care plan meetings and they were not able to explain the reason. SW also stated they did not have the care plan meeting sign-in sheet indicating attendance for either resident #12 or #121 at any meetings. On 02/28/22 at 04:19 PM, the Director of Nursing (DON) was interviewed. The DON stated the care plan meetings were for held Admission, Quarterly, Significant Change, Annual, and as needed. The DON also stated the IDT attends the care plan meetings and resident or family representative are invited to attend these meetings. The DON further stated that the Social Worker was responsible for inviting the resident or family representative to attend a few days before the care plan meeting and should document the invitation in the Social Services progress notes. 415.11(c)(2) (i-iii)

F656 Fieldston Lodge Care Center [NAME], LMSW Based on interviews, observations and record reviews completed during a recertification survey 02/23-03/02/2022, the facility did not develop a person-centered care plan for a resident consistent with that resident's medical needs. Specifically, a care plan was not developed to address the use of psychotropics, insulin, antihypertensives or anticoagulants. This was evident in 1 of 4 residents (Resident #140) reviewed for unnecessary medications in a sample of 35. The findings are: Resident #140 was admitted to the facility on [DATE]. The resident's MDS dated [DATE] stated that the resident had received insulin on 7/7 days, antipsychotics on 7/7 days, antianxiety medications on 7/7 days, antidepressants on 7/7 days and an anticoagulant on 7/7 days. Resident #120's medical orders for 01/07/2022 were reviewed and were noted to include: [MEDICATION(S)] 10 mg once a day for Hypertension [MEDICATION(S)] 25 mg once a day for Hypertension [MEDICATION(S)] 15 mg once a day for Depression [MEDICATION(S)] 50 mg once a day for Depression [MEDICATION(S)] 500 mg once a day for [CONDITION(S)] [MEDICATION(S)] 4 mg once a day for [CONDITION(S)] [MEDICATION(S)] 1mg and 2 mg once a day for Diabetes [MEDICATION(S)] 1000 mg twice a day for Diabetes [MEDICATION(S)] insulin U-100, 40 units at bedtime for Diabetes [MEDICATION(S)] 75 mg once a day Resident #140's Care Plans were reviewed. No care plans for [CONDITION(S)] Drug Use, Hypertension, or Diabetes/Insulin Use were observed. On 02/28/22 at 10:42 AM, Licensed Practical Nurse (LPN) #1 was interviewed and stated to provide medication to Resident #140 on a daily basis. The LPN stated that the resident is usually compliant with medications except for some of the psychotropics as they want to discuss cutting down on them with the physician or the psychiatrist. The resident was continuing to take medications as ordered for hypertension, depression, mood regulation, and diabetes. On 03/01/22 at 3:04 PM, the Nurse Manager was interviewed and stated, I just looked at this resident's care plans and I found out that he has no care plans for the medications that he takes. This was an oversight. I will put them in right now, right away. The Nurse Manager stated to be responsible for ensuring that care plans were put in place but said that because of the volume of work, such tasks were generally delegated to Nurse Managers on other shifts. On 03/02/22 at 9:04 AM, the Director of Nursing was interviewed and stated that upon admission, every resident's medications are reviewed and reconciled. The pharmacist consultant looks at the meds within 48 hours of admission to see if there are multiples for the same condition, and checks on dosages and indications. The pharmacist then alerts the physician, who makes changes as indicated. Based on the resident's medical conditions, care plans should then be initiated by the nurse for each disease process the resident is being medicated for. The care plans include the resident's goals of care and staff interventions toward meeting those goals. 415.119(c)(1)

Based on record review and interviews conducted during the Recertification survey from 2/23/2022 to 3/2/2022, the facility did not ensure that residents' assessments were accurate. Specifically, the Minimum Data Set (MDS) 3.0 assessment (1). inaccurately documented that a resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . that a resident had an Indwelling catheter. This was evident for 1 of 3 residents reviewed for Respiratory Care and 1 of 1 resident reviewed for Urinary Catheter out of a sample 38 residents. (Resident #270 and Resident #4) The findings are: The facility policy and procedure titled, MDS Assessment Coordinator, reviewed 10/27/21, documented that each individual who completes a portion of the assessment (MDS), must certify the accuracy of that portion of the assessment by a) dating and signing the assessment (MDS): and b) identifying each section completed 1). Resident # 270 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS assessment dated [DATE] documented that the resident was cognitively intact and required dependent assistance of two persons with toilet use. The MDS also documented that resident was always incontinent of bowel and bladder, Section I of the MDS listed active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Chart review did not reveal any documented evidence of a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #270. The MDS inaccurately documented a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2) Resident #4 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS dated [DATE] documented that resident's cognition was severely impaired and that resident had an indwelling catheter. On 02/23/22 at 12:00 PM, Resident #4 was observed in bed and no foley catheter observed. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing note dated 10/27/21 documented resident was seen and examined by Medical Doctor (MD), with order to discontinue(d/c) Foley Catheter and the order was carried out. The medical record contained no documented evidence that a Foley catheter was reinserted after being discontinued on 10/27/21. The MDS inaccurately documented that resident had an indwelling catheter. On 03/01/22 at 12:37 PM, an interview was conducted with Registered Nurse (RN) #2. RN #2 stated that Resident # 4 was initially admitted on [DATE] with a Foley catheter, however, it was later discontinued the next day, 10/27/21. RN #2 also stated that the resident had not had a Foley catheter reinserted since the order had been discontinued. On 03/01/22 at 03:33 PM, an interview was conducted RN MDS Assessor (MDSA). The MDSA stated that data is collected through chart review including Certified Nursing Assistant (CNA) records, and resident observations. The MDSA also stated that the look back period of 14 days determines the information that is recorded and documented by all disciplines on the MDS. The MDSA stated there was a Foley Catheter in place at the time of the previous MDS, but they made a mistake and documented it also on MDS dated [DATE] for Resident #4. In the case of Resident #270, the MDSA stated that diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDSA further stated that the Doctor's notes are reviewed to ensure that diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDSA stated that they do review the MDS for accuracy but would not check areas that may have been prepopulated. On 3/02/22 at 10:05 AM, an interview was conducted with the MDS Coordinator (MDSC). The MDSC stated that the staff who signs section Z 0400, which indicates accuracy of the MDS, and the staff who completes a specific section, is responsible for accuracy of that section. The MDSC also stated that the MDS Coordinator's signature indicates completion of the booklet. 415.11

Based on record review and interviews during the Recertification and Complaint survey (NY 565) conducted from 2/23/22 to 3/2/22, the facility did not ensure that all alleged violations were thoroughly investigated. Specifically, the facility investigation following a resident's falls did not include staff statements and did not rule out abuse, neglect, or mistreatment. This was evident for 1 of 4 residents reviewed for Accidents out of a sample of 38 residents (Resident #218). The finding is: The facility policy and procedure titled Accident/Incident revised 6/21/21 documented Accident/Incident (A/I) Report is completed for each fall including unwitnessed falls, injury, unexplained bruise or abrasion, or any other sign indicating that an event has occurred. It further documented purpose to obtain information relevant to each occurrence for analysis of the cause of an event to prevent recurrence. Resident #218 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented cognition was severely impaired and resident required extensive assistance of staff with Activities of Daily Living. The MDS also documented that resident had a fall in the last month prior to admission and had 2 falls since admission, 1 with no injury and 1 with injury. The Nursing Note dated 5/1/21 at 4:19 PM documented resident was observed on the floor in the room in a sitting position in front of the bathroom floor. Resident was assisted by two staff from the floor. Resident was noted with no visible injury and MD/resident's family were notified. Resident was placed on every 4-hour neuro-check x 48 hours and closely monitored. The Incident Report with event date on 5/1/21 at 4:29 PM, documented that Resident #218 had a fall in resident room and the fall was unwitnessed. The report also documented assessments of body, neurological, pain, mental status, possible contributing factors, immediate measures taken and that it was notified to attending physician, resident representative. The evaluation section documented the following: N/A: event still open. There was no documented evidence that the facility obtained staff statements and/or investigation was reviewed/completed to rule out abuse, neglect, or mistreatment. The Nursing Note dated 5/8/21 at 1:34 PM documented resident was lying on the floor in the hallway on back bleeding from the back of the head. Resident was picked from the floor and transferred into wheelchair. Resident was noted with 2.5 cm superficial laceration at the back of the head. Area cleanse and pressure applied to the area to stop the bleeding. No change in level of consciousness. However, resident c/o slight pain at the back of head. MD was notified of occurrence. Resident was given Tylenol, closely monitored, and ordered neuro-check every hour x 6 hours and neuro-check every 2 hours x 48 hours. Resident's family was also notified. The Incident Report with event date 5/8/21 at 1:51 PM, documented that Resident #218 had a fall in hallway and fall was witnessed. It further documented assessments of body, neurological, pain, mental status, possible contributing factors, immediate measures taken and that it was notified to attending physician, resident representative. The evaluation section documented the following: N/A: event still open. There was no documented evidence that the facility obtained staff statements and/or investigation was reviewed/completed to rule out abuse, neglect, or mistreatment. The Nursing Note dated 6/3/21 at 7:21 PM documented resident was on the floor in lying position in the hallway in front of resident room, wheelchair near the resident, with left hand on back of the head, both lower extremities extended. Resident was transferred back to wheelchair to bed by 2 staff. It further documented skin assessment was done, no visible injury noted, no complain of pain. Both upper and lower extremities within normal range. Vitals checked and recorded. NOK and MD were notified. Neuro check q4 monitoring was initiated. The Observation Report with event date of 6/3/21 at 6:27 PM, documented resident s/p fall, and included observation details of mental status, ambulation/elimination status, balance and gait, and medication use. The report did not document whether fall was witnessed, and there was no documented evidence that the facility obtained staff statements and/or investigation was reviewed/completed to rule out abuse, neglect, or mistreatment. On 2/28/22 at 11:15 AM, Registered Nurse Supervisor (RNS) #1 was interviewed. RN #1 stated that Resident #218 had a fall a few days after admission and another fall a few days later. RNS #1 also stated that an A/I report was filled out and Certified Nursing Assistant statements were attached as per protocol. RNS #1 further stated it was the former Assistant Director of Nursing Services (ADNS) responsibility to ensure the completed report was reviewed with DON, Administrator and Medical Doctor. RNS #1 stated they reached out to the former ADNS for incident reports for Resident #218 however, additional information for the incident reports was not located. On 3/02/22 at 10:27 AM, the Director of Nursing (DON) was interviewed. The DON stated that it is the RN Supervisor's responsibility to collect staff statements and complete an initial assessment after a fall with or without injury. Based on the assessment, the DON will review and conclude the investigation to rule out abuse, neglect, or mistreatment. The DON also stated they were not here at the time of the fall incidents involving Resident #218 and the summary of findings for these incidents could not be located. 415.4(b)(3)

Based on record review and staff and resident interviews, the facility did not ensure that a resident who alleged that a certified nursing assistant (CNA) twisted her arm was assessed, monitored and evaluated. In addition, the physician was not notified of the incident in a timely manner. Subsequently, the resident experienced pain and sustained a fracture. This was evident for 1 of 29 sampled residents. (Resident #21) This resulted in actual harm that is not immediate jeopardy. The finding is: Resident #21 is a [AGE] year old female with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 assessment dated [DATE] documented that the Brief Interview for Mental Status (BIMS) documented that the resident has intact cognition. On 1/5/2011 at 12:30 PM, the resident was observed seated in a wheelchair in the dining room with a cast and a sling on her left arm. When the resident was asked how the injury occurred, the resident stated that a CNA (Certified Nurse Assistant) twisted her hand and she sustained a fracture. On 1/5/2011 at 2:45 PM, the resident was interviewed and stated the following: On Sunday evening (1/2/2010) a CNA came to her room and insisted on changing her. The resident informed the CNA that she was "dry" and that she didn't "need it." (in reference to providing incontinent care). The CNA then stated "I will change you anyway" approached the resident and twisted her left arm which caused a lot of pain. The resident further stated that she began cursing and screaming at the CNA, who then opened the door and left the resident's room. The resident then got up, and while supporting herself with one arm on the overbed table, came to the door of her room and continued screaming until a nurse came. The resident stated that this CNA was not her regularly assigned evening shift CNA; she worked only sporadically on the weekends and had previously been physically abusive towards her (several weeks prior), but she had not reported that occurrence to anyone. The "Statement of Occurrence" of the evening shift Registered Nursing Supervisor (RNS) dated 1/3/2011 documented " Date of occurrence: 1/2/2011 ... Time: 10:45PM ... " Writer responded to a person screaming coming from ...(residents room number). Investigated by undersigned observed resident from (room number) standing by the door in front of the sink with both arms on top of the overbed table. Resident was asked what happened and said " (name of the CNA) twisted my hand. Both arms of the resident were assessed. No discoloration, swelling observed. No c/o (complaint of) pain at this time. Resident is able to open and close both hands ...I then asked (name of the CNA) what happened she said " I was doing care but resident was fighting and hitting me, so I pushed her hand. " There is no documented evidence that the 3:30pm to 11:30pm Registered Nurse assessed the resident, notified the physician of the incident or implemented the facility's abuse protocol. There is no documented evidence that the physician or the 11:30pm to 7:30am shift Registered Nurse and/or the Licensed Practical Nurse were notified regarding this incident. Also, there is no documented evidence of this incident in the resident's medical record until the morning of 1/3/2011 at 8:15am. The "Daily Patient Care Report" dated 1/2/11 did not contain any documentation of this incident. The Registered Nurse Manager's statement of occurrence dated 1/3/2011 documented "...At 8:15AM resident came to nursing station called to writer that her hand was hurting because CNA ...twisted it last night. She stated everyone knew ... " The nursing progress notes dated 1/3/2011 at 8:15 AM documented "Resident c/o (complaint) left hand pain, decreased ROM (range of motion), able to open hands, fingers did not rouse hand, no discoloration, no swelling. Will f/u (follow up) with MD (Medical Doctor). " The Interim physician's orders [REDACTED].O (telephone order) x-ray L (left) hand/arm/shoulder (pain), [MEDICATION NAME] 200mg PO (orally) Q (every) 6 hours x (times) 5 Days (pain) first dose now - " The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This MAR further documented that the resident was experiencing pain at a level "8". The pain measuring scale on the MAR indicated [REDACTED]." The left hand and wrist x-ray result dated 1/3/2011 documented " [MEDICAL CONDITION] ulna joint which appears acute. " The nursing note dated 1/3/11 at 11;30pm, documented that the resident was sent to the hospital. The nursing note date 1/4/11 at 11:30am, documented that resident was returned to the nursing home at 11;15am, with her left arm in a hard cast, with a [DIAGNOSES REDACTED]. On 1/10/11 at 4PM the Registered Nursing (RN) Supervisor for the evening shift was interviewed and stated that routinely per the abuse protocol if an allegation of abuse is made by the resident, the resident is immediately separated from the alleged abuser, the supervisor is notified by the charge nurse, the resident is assessed for injuries, the Medical Doctor and the Director of Nursing are notified, as well as the designated representative, a Resident Occurrence Report is initiated, documentation is entered in the resident's medical record, and occurrence is communicated either verbally or via 24 report to the oncoming shifts. The RN Supervisor had no explanation why she did not fully implement the Abuse Protocol on 1/2/2011. The RN Supervisor stated that the CNA who allegedly abused the resident was immediately taken off the resident's assignment and shortly after the occurrence left as it was the end of the evening shift. The RN Supervisor continued stating that the she did assess the resident and obtain verbal statements from the resident and the CNA, however she did not interview the roommates, did not notify the attending physician and the Director of Nursing, did not communicate abuse occurrence to the oncoming shifts, and did not document it in the medical record. On 1/11/2011 at 12:20 PM the License Practical Nurse (LPN) for the night shift was interviewed by phone and stated upon her arrival on the unit, she observed the resident seated near the nurses station and accompanied by the night shift CNA. The LPN stated that no one ever told me that the resident was in any way physically abused by the CNA on the evening shift. On 1/10/2011 at 3:30 PM, the Registered Nurse Manager (day shift) was interviewed and stated that the allegation of physical abuse toward the resident was never reported to her by staff. The Registered Nurse Manager stated that she immediately implemented the abuse protocol when the resident informed her that a CNA had physically abused her, and that she was experiencing pain in her left arm. However, this reflects a delay of 9 hours. 415.12

Based on record review and staff and resident interviews, the facility did not ensure that a resident was free from physical abuse, a resident alleged that a certified nursing assistant twisted her arm. Subsequently, the resident sustained [REDACTED]. protocol. This was evident for 1 of 29 sampled residents. (Resident #21) This resulted in actual harm that is not immediate jeopardy. The finding is: Resident #21 is a [AGE] year old female with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 assessment dated [DATE] documented that the Brief Interview for Mental Status (BIMS) documented that the resident has intact cognition. On 1/5/2011 at 12:30 PM, the resident was observed seated in a wheelchair in the dining room with a cast and a sling on her left arm. When the resident was asked how the injury occurred, the resident stated that a CNA (Certified Nurse Assistant) twisted her hand and she sustained a fracture. On 1/5/2011 at 2:45 PM, the resident was interviewed and stated the following: On Sunday evening (1/2/2010) a CNA came to her room and insisted on changing her. The resident informed the CNA that she was "dry" and that she didn't "need it." (in reference to providing incontinent care). The CNA then stated "I will change you anyway" approached the resident and twisted her left arm which caused a lot of pain. The resident further stated that she began cursing and screaming at the CNA, who then opened the door and left the resident's room. The resident then got up, and while supporting herself with one arm on the overbed table, came to the door of her room and continued screaming until a nurse came. The resident stated that this CNA was not her regularly assigned evening shift CNA; she worked only sporadically on the weekends and had previously been physically abusive towards her (several weeks prior), but she had not reported that occurrence to anyone. The "Statement of Occurrence" of the evening shift Registered Nursing Supervisor (RNS) dated 1/3/2011 documented " Date of occurrence: 1/2/2011 ... Time: 10:45PM ... " Writer responded to a person screaming coming from ...(residents room number). Investigated by undersigned observed resident from (room number) standing by the door in front of the sink with both arms on top of the overbed table. Resident was asked what happened and said " (name of the CNA) twisted my hand. Both arms of the resident were assessed. No discoloration, swelling observed. No c/o (complaint of) pain at this time. Resident is able to open and close both hands ...I then asked (name of the CNA) what happened she said " I was doing care but resident was fighting and hitting me, so I pushed her hand. " There is no documented evidence that the physician or the 11:30pm to 7:30am shift Registered Nurse and/or the Licensed Practical Nurse were notified regarding this incident. Also, there is no documented evidence of this incident in the resident's medical record until the morning of 1/3/2011 at 8:15am. The Registered Nurse Manager's statement of occurrence dated 1/3/2011 documented "...At 8:15AM resident came to nursing station called to writer that her hand was hurting because CNA ...twisted it last night. She stated everyone knew ... " The nursing progress notes dated 1/3/2011 at 8:15 AM documented "Resident c/o (complaint) left hand pain, decreased ROM (range of motion), able to open hands, fingers did not rouse hand, no discoloration, no swelling. Will f/u (follow up) with MD (Medical Doctor). " The Interim physician's orders [REDACTED].O (telephone order) x-ray L (left) hand/arm/shoulder (pain), [MEDICATION NAME] 200mg PO (orally) Q (every) 6 hours x (times) 5 Days (pain) first dose now - " The left hand and wrist x-ray result dated 1/3/2011 documented " [MEDICAL CONDITION] ulna joint which appears acute. " The nursing note dated 1/3/11 at 11;30pm, documented that the resident was sent to the hospital. The nursing note date 1/4/11 at 11:30am, documented that resident was returned to the nursing home at 11;15am, with her left arm in a hard cast, with a [DIAGNOSES REDACTED]. On 1/10/11 at 4PM the Registered Nursing (RN) Supervisor for the evening shift was interviewed and stated that routinely per the abuse protocol if an allegation of abuse is made by the resident, the resident is immediately separated from the alleged abuser, the supervisor is notified by the charge nurse, the resident is assessed for injuries, the Medical Doctor and the Director of Nursing are notified, as well as the designated representative, a Resident Occurrence Report is initiated, documentation is entered in the resident's medical record, and occurrence is communicated either verbally or via 24 report to the oncoming shifts. The RN Supervisor had no explanation why she did not fully implement the Abuse Protocol on 1/2/2011. The RN Supervisor stated that the CNA who allegedly abused the resident was immediately taken off the resident's assignment and shortly after the occurrence left as it was the end of the evening shift. The RN Supervisor continued stating that the she did assess the resident and obtain verbal statements from the resident and the CNA, however she did not interview the roommates, did not notify the attending physician and the Director of Nursing, did not communicate abuse occurrence to the oncoming shifts, and did not document it in the medical record. On 1/11/2011 at 12:20 PM the License Practical Nurse (LPN) for the night shift was interviewed by phone and stated upon her arrival on the unit, she observed the resident seated near the nurses station and accompanied by the night shift CNA. The LPN stated that no one ever told me that the resident was in any way physically abused by the CNA on the evening shift. On 1/10/2011 at 3:30 PM, the Registered Nurse Manager (day shift) was interviewed and stated that the allegation of physical abuse toward the resident was never reported to her by staff. The Registered Nurse Manager stated that she immediately implemented the abuse protocol when the resident informed her that a CNA had physically abused her, and that she was experiencing pain in her left arm. However, this reflects a delay of 9 hours, before the abuse protocol was implemented.. On 1/10/2011 at 5:15 PM, the Director of Nursing was interviewed and stated that the investigation of occurrence should have been initiated on 1/2/2011 and the abuse protocol should have been fully implemented at that time. 415.4(b)(1)(i)