Every finding on record at Long Island State Veterans Home

Based on observation, record review, and interviews during the Recertification Survey initiated on 3/5/2025 and completed on 3/11/2025, the facility did not ensure it implemented a comprehensive person-centered care plan for each resident to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. This was identified for one (Resident #260) of two residents observed for Medication Administration. Specifically, on 3/6/2025, during the medication pass observation for Resident #260, Licensed Practical Nurse #1 did not rinse the resident's mouth after administering a Symbicort inhaler (a medication that helps reduce inflammation and keep airways open; the inhaler contains a steroid medication that increases the risk of oral fungal infection) as per the physician's orders. The finding is: The facility's policy titled Medication Administration, last revised 2/2023 documented that it is the responsibility of each licensed nurse to be aware of drug classifications, actions/interactions, standard dosages, standards of administration, side effects, and the reason the drug is being given to the resident. Licensed nurses are expected to demonstrate competency in medication administration. Steroidal inhalation medications require the resident's mouth to be completely rinsed after administration. Resident #260 was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Hypertension, and Heart Failure. The 1/17/2025 Significant Change Minimum Data Set assessment documented a Brief Interview for Mental Status score of 14, indicating the resident was cognitively intact. A Physician's order initiated on 1/8/2025 and renewed on 3/3/2025 documented Symbicort 160-4.5 microgram inhaler (Budesonide/Formoterol Fumarate) two inhalations every 12 hours (9:00 AM and 9:00 PM); Rinse Mouth After Use! Diagnosis: Chronic Obstructive Pulmonary Disease. During the medication administration observation on 3/6/2025 at 8:18 AM, Licensed Practical Nurse #1 administered two inhalations of the Symbicort inhaler to Resident #260 and did not rinse the resident's mouth after the Symbicort inhalation treatment. During an interview on 3/10/2025 at 8:55 AM, Licensed Practical Nurse #1 stated they were nervous, which is why they missed rinsing the resident's mouth after the Symbicort treatment. Licensed Practical Nurse #1 stated Symbicort is a steroid and can cause oral thrush (fungal infection in the mouth). During an interview on 3/10/2025 at 9:17 AM, Registered Nurse Educator #1 stated Symbicort is a steroid medication and can cause oral thrush. The resident's mouth should be rinsed with water after the inhalation administration. The resident should spit the water out after the rinse. During an interview on 3/10/2025 at 9:25 AM, the Director of Nursing Services stated the nurse should have rinsed the resident's mouth after administering the Symbicort inhaler, It says so in the physician's order. 10 NYCRR 415.11(c)(1)

Based on record review and staff interviews during the Recertification Survey initiated on 3/5/2025 and completed on 3/11/2025, the facility did not ensure that all completed Minimum Data Set (MDS) assessments were electronically transmitted to the Center for Medicare and Medicaid Services (CMS) within 14 days of the resident assessment completion. This was identified for one (Resident #25) of one resident reviewed for the Resident Assessment Task. Specifically, Resident #25's Significant Change Minimum Data Set (MDS) assessment was not electronically submitted to the Center for Medicare and Medicaid Services (CMS) until 35 days after the completion of the assessment. The finding is: The facility's policy and procedure titled MDS 3.0 Completion last revised on 12/2022, documented the Minimum Data Set Coordinator submits the Minimum Data Set to both the Center for Medicare and Medicaid Services (CMS) database. The policy did not include the timeframe for the completion and transmission of the Minimum Data Set assessments. Resident #25 was admitted with diagnoses including Atrial Fibrillation (an irregular, often rapid heart rate), Chronic Obstructive Pulmonary Disease, and Heart Failure. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #25 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated that Resident #25 had moderate cognitive impairment. The Minimum Data Set was completed on 1/16/2025. A review of the Minimum Data Set (MDS) 3.0 Nursing Home Validation Report revealed the following: Resident #25's Significant Change Minimum Data Set (MDS) assessment with the reference date of 1/10/2025 was completed on 1/16/2025 and was submitted to the Center for Medicare and Medicaid Services (CMS) on 3/6/2025, 35 days late. During an interview on 3/6/2025 at 1:32 PM, the Minimum Data Set Director stated the facility used a software system that tracked the Minimum Data Set (MDS) assessment schedules. The Minimum Data Set Assessors entered the Minimum Data Set (MDS) start date and completion date in the system. The software system generated a list of the resident assessments due for transmission; however, Resident #25's name did not appear on the list and they did not know why. The Minimum Data Set Director stated that Resident #25's Minimum Data Set was submitted today, 3/6/2025. During an interview on 3/7/2025 at 12:47 PM, the Minimum Data Set Assistant Director stated they are responsible for generating the Minimum Data Set assessments transmission due date reports daily. The Minimum Data Set Assistant Director stated they had completed the Significant Change assessment for Resident #25 on 1/16/2025 and did not transmit the assessments upon completion because they relied on the system to generate a report and provide the due dates. During an interview on 3/10/2025 at 1:36 PM, the Director of Nursing Services stated all Minimum Data Set assessments should be completed and transmitted timely. During an interview on 3/10/2025 at 2:24 PM, the Administrator (Executive Director) stated all Minimum Data Set (MDS) assessments should be completed and submitted on time. The Administrator stated they relied on the fact that the software system they use for tracking the assessments is accurate. 10NYCRR 415.11(a)(3)(i)

Based on record review and staff interviews during the Recertification Survey initiated on 8/28/2023 and completed on 9/1/2023 facility did not ensure each resident's Comprehensive Care Plan (CCP) was reviewed and revised to reflect the current needs of the resident. This was identified for one (Resident #288) of five residents reviewed for unnecessary medications and one (Resident #163) of two residents reviewed for vision/hearing. Specifically, 1) Resident #288's behavioral and activities care plans were not updated to reflect behaviors the resident exhibited and precautionary measures to be taken when the resident attended activity programs; and 2) Resident #163's communication care plan was not updated to reflect the current status of the resident's use of the hearing aid or a hearing amplifier device. The findings are: The facility's policy, titled Comprehensive Care Planning, last reviewed July 2021, documented all residents at the facility will have a comprehensive care plan that addresses each of their needs. The comprehensive resident-centered care plan will be implemented in accordance with the Centers for Medicare and Medicaid Services (CMS) guidelines. The comprehensive resident-centered care plan will include the onset date of the particular area; a problem statement that will describe the area that needs to be addressed by the interdisciplinary team (IDT); and any applicable interventions or approaches that would assist the resident in reaching the measurable goals. 1) Resident #288 was admitted with diagnoses including Diabetes Mellitus, Psychotic Disorder, and Depression. The 7/22/2023 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. There were no behavioral symptoms documented in the MDS assessment. A progress note, written by Resident #288's primary care physician, dated 6/22/2023 documented the Resident was reported with inappropriate sexual behavior with female staff and a family member of another resident. The resident appeared to be disinhibited. The resident was on Risperidone (an antipsychotic medication) on admission, which was tapered off. The resident's behavior has gotten worse gradually since then. Will start low-dose Risperidone at bedtime and monitor. Spoke with the resident's family member. The family member reported that the resident had inappropriate sexual behavior for a long time including inappropriate sexual behaviors toward children. The Director of Nursing Services (DNS) was interviewed on 8/31/2023 at 1:30 PM. The DNS read the 6/22/2023 primary care physician's note and stated they (DNS) were familiar with the note and that Resident #288 was not allowed to attend intergenerational gatherings. The DNS stated, I hope the care plan was updated. A review of the comprehensive care plan titled Leisure Decline, initiated on 5/30/2023 was revised on 6/27/2023 to include an intervention: During instances of inappropriate behavior, recreation staff will redirect the resident and/or remove from group programming. The CCP was updated on 8/31/2023 at 2:10 PM and the following interventions were added by the Recreation Director: While intergenerational programs are implemented on units or the multipurpose room, recreation staff will provide alternate opportunities to pursue leisure interest of other programs of interest available. In addition, the Behavior CCP, initiated on 5/20/2023, was updated by the DNS on 9/1/2023 to include an intervention to redirect the resident in the event that the resident is inappropriate with others. Resident #288's Certified Nursing Assistant (CNA) #1 was interviewed on 9/1/2023 at 8:50 AM. CNA #1 stated Resident #288 self-propels in their wheelchair and has access to programs on different units. CNA #1 stated the resident attends activity programs and is not restricted from activity programs. CNA #1 stated when the resident wants to go to an activity, the recreation staff allows the resident to attend the activity programs. Registered Nurse (RN) #1, who was the charge nurse, was interviewed on 9/1/2023 at 8:57 AM. RN #1 stated Resident #288 self-propels and goes to different units and programs on their own. RN #1 stated Resident #288 likes to go to activities, can go to any program, and has no restrictions. Recreation Director #1 was interviewed on 9/1/2023 at 9:02 AM. Recreation Director #1 stated the interdisciplinary team discussed Resident #288 yesterday (8/31/2023). Recreation Director #1 stated the facility has not had intergeneration groups since COVID-19, but we are slowly getting back to pre-COVID-19 activities. Recreation Director #1 stated they do not want to restrict the resident and want to make sure the resident has something to do if there is an intergenerational event. Recreation Director #1 stated there are weekly behavior meetings and huddles with the IDT. The IDT will discuss which residents have to be closely monitored, and what behaviors to look out for, then the CNAs are made aware. The DNS was re-interviewed on 9/01/2023 at 9:49 AM. The DNS stated a Recreation Therapist, who is no longer employed, was supposed to update the Leisure Decline care plan regarding the intergenerational meeting restriction, but it was not done. Recreation Director #1 updated the CCP yesterday (8/31/2023). 48829 2) Resident #163 was admitted with diagnoses including Non-Alzheimer's Dementia, Anxiety Disorder, and Depression. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 7 which indicated that the resident had severely impaired cognition. The MDS documented that the resident had minimal hearing difficulty and there was no use of hearing aids or other hearing appliances. A Comprehensive Care Plan (CCP) titled At Risk for Impaired Communication Secondary to Hearing Loss, dated 8/22/2023 documented interventions that included hearing aid will be used daily, assistance as needed, check the functioning of hearing aids daily, report any changes in hearing, assess comprehension and understanding. A review of the Certified Nursing Assistant (CNA) assignment record for August 2023 documented the resident used Bilateral Hearing aids from 8/22/2023 to 8/30/2023 as evidenced by staff signature. Resident #163 was observed sitting in their wheelchair in their room on 8/29/2023 at 10:03 AM. Resident #163 was interviewed and appeared to have difficulty hearing and stated, I am hard of hearing. Resident #163 did not have hearing aids or any other hearing amplification device in their ears. Resident #163's primary CNA # 2 was interviewed on 8/30/2023 at 2:00 PM and stated that Resident #163 did not utilize hearing aids. CNA # 2 reported that they (CNA #2) have never seen Resident #163 wearing hearing aids. Licensed Practical Nurse (LPN) #1 was interviewed on 8/30/2023 at 2:10 PM. LPN # 1 stated that Resident #163 does not have hearing aids. LPN # 1 stated that they (LPN #1) have never seen Resident #163 wearing hearing aids. Registered Nurse (RN) #3, who was the Unit Manager, was interviewed on 8/30/2023 at 2:15 PM. RN #3 stated that Resident #163 had hearing aids; however, had a behavior of removing the hearing aids. RN #3 could not recall when the resident last used the hearing aids. RN #3 searched Resident #163's room, including the night table, and stated that they could not find the resident's hearing aids. The Director of Nursing Services (DNS) was interviewed on 8/30/2023 at 3:42 PM and stated Resident #163's family member took the hearing aids home years ago because the Audiologist could not put a clip on the hearing aids. The DNS stated the resident uses a hearing amplification device instead. The DNS stated the CCP should have indicated the use of the hearing amplification device instead of the hearing aids. The DNS stated that the staff should have known that the resident uses a hearing amplification device. The CCP for At Risk for Impaired Communication was updated on 8/30/2023 to include an intervention for Hearing Aid: Sound Pocket Talker with Headphones. Resident #163 was observed sleeping in bed on 8/31/2023 at 2:10 PM. CNA #1 was present in the resident's room and stated that the resident had the amplifier in their (Resident #163) drawer today, but the resident refused to use it today. CNA #1 opened the drawer, and the amplification device was observed by the surveyor. RN #3 was re-interviewed on 8/31/2023 at 2:15 PM and stated that the Communication CCP should have reflected that Resident #163 utilized a hearing amplifier as the resident was Hard of Hearing. 10 NYCRR 415.11(c)(2)(i-iii)

Based on interviews and record review during an abbreviated survey (Case # NY00304466), the facility did not ensure that advanced directives were implemented for 1 (Resident #1) of 9 resident reviewed. Specifically, the facility did not ensure that Resident #1's advanced directive status for Do Not Resuscitate (DNR), withhold cardiopulmonary resuscitation, (CPR), when the heart stops beating) was honored. On [DATE], the resident was found without a pulse and respirations and cardiopulmonary resuscitation (CPR) was administered. The findings are: The Facility's policy titled Resident's Rights last revised ,d+[DATE] documented the facility will protect and promote the rights of each resident and will encourage and assist each resident in the fullest, possible way to exercise their rights. The policy further documented that the facility would comply with the New York State provisions regarding orders not to resuscitate. The Facility's policy titled Advance Directives Do Not Resuscitate orders Resident with Capacity Health Care Agent revised ,d+[DATE] documented it is the rights and obligations of residents, resident representative, families and health care providers regarding cardiopulmonary resuscitation and orders not to resuscitate. The Facility's policy titled Emergency Medical Response System revised ,d+[DATE] documented cardiopulmonary arrest of a resident with DNR: The resident will be assessed for absence of pulse and respirations; the nurse will have one staff member obtain the medical record for verification of advanced directives and family contact information. Resident #1 was admitted to the facility on [DATE] with diagnoses including coronary artery disease (CAD), Benign Prostatic Hyperplasia (BPH) and Dementia. The Minimum Data Set (MDS-an assessment tool) dated [DATE] documented the resident with severely impaired cognition. The Comprehensive Care Plan (CCP) titled Advance Directives dated [DATE] documented resident is a Do Not Resuscitate. Interventions included review advanced directive quarterly. The Medical Orders for Life -Sustaining Treatment (MOLST) signed [DATE] documented resident is a DNR The Advanced Directives documented resident was DNR since [DATE]. Resuscitation would impose an extraordinary burden on the resident. The Nursing Readmission assessment dated [DATE] at 4:30 PM documented Resident #1 readmitted with unspecified Dementia, unspecified severity with CAD. Advanced Directives: DNR. The Physician orders initiated [DATE] 17:09 documented Advance Directive- Do Not Resuscitate. The Social Worker (SW) note dated [DATE] documented that the resident was readmitted from the hospital on [DATE]. Advanced Directives reviewed and included DNR. The Nursing Progress Note (NPN) dated [DATE] documented that during rounds at 6:04 AM Resident #1 was noted with [NAME] stokes respirations and unresponsive. Applied supplemental Oxygen via mask. Vital signs Blood Pressure (B/P) ,d+[DATE], Pulse (P)44. Resident status continued to decline. Nursing Supervisor and Medical Doctor (MD) notified. Paramedics were called and responded. On [DATE] at 6:30 AM resident noted with clinical signs of death, no respirations, no pulse, pupils fixed and dilated. Health Care Proxy (HCP) notified. Verbal comfort and emotional support provided. The (MD) note dated [DATE] documented patient pronounced dead at 6:30 AM today by Emergency Medical Services (EMS). Patient found this morning unresponsive with [NAME] stokes breathing pattern. CPR was started. Later on, CPR stopped as patient found to be DNR status. The undated Facility's Nursing Home Investigative Report documented that on [DATE] that there is clear evidence that CPR was performed on Resident #1 in-spite of their advanced directive not to be resuscitate in the event that they are found with no pulse or respiration. The facility documented that there were deviations from the Policy/Procedure regarding the incident: The resident's advance directive code status was not confirmed by the staff. RN#1 statement documented that on [DATE], at 6:04 AM, noted resident, Resident#1, unresponsive with [NAME] stokes respiration. They applied supplemental oxygen via mask B/P ,d+[DATE], Pulse:44. Resident continued to decline. RN#1 informed RNS#1 of Resident #1's status and stated they are a full code. RNS#2 entered the resident's room, and RNS#2 left the room and called code 99 on paging system. RN#1 and RNS#2 initiated CPR. Paramedics arrived at approximately 6:17 AM and responded. Shortly after, RNS#1 entered room and informed paramedics that there has been an error, resident is not a full code, they are a DNR. CPR was stopped immediately, and resident was pronounced dead at 6:30 AM. RNS#1 statement documented that at approximately 6:06 AM on [DATE], RN#1 informed them that Resident #1 is actively dying and they are a full code. They documented that they left the room to go page the code 99 to get more support. EMS arrived at approximately 6:20 AM. RNS #1 further documented that they went to the desk to prepare Resident#1's paperwork for transfer to the hospital. At a point, they documented that they noticed that Resident #1 was a DNR. They immediately went to alert the EMS personnel and CPR was stopped. Resident was pronounced dead by EMS at 6:30 AM. During an interview with the RN#1 on [DATE] at 9:32 AM, they stated that Resident #1 at approximately 6:00 AM, was observed with [NAME] stoke respirations. They elevated the head of the bed and applied oxygen. They notified RNS #1 and told them that Resident#1 was a full code. RN#1 stated that they did not check Resident #1's code status. They stated, that's my error. RNS #1 and 2 came on the unit and assessed Resident #1. RN#1 and RNS#2 initiated CPR on Resident #1. RNS#1 left the room to call a code for assistance. Approximately 6:17 AM, paramedics arrived and took over the CPR. RNS#1 returned to the room and informed staff and paramedics that Resident #1 was a DNR, and CPR was stopped. During an interview with RNS #1 on [DATE] at 10:49 AM they stated that approximately 6:05 AM, RN#1 called and stated that Resident #1 was actively dying and is a full code. They came to the unit and assessed Resident #1. Resident #1 was unconscious and unresponsive with [NAME] stokes respirations and a weak pulse. The resident had oxygen in place and the head of the bed elevated. RNS#1 stated that they called the doctor and RNS#2 for assistance with a resident who was actively dying and is a full code. RNS#1 stated that they assumed the RN#1 checked Resident #1's advance directives prior. The RN#1 and RNS #2 initiated CPR and the Paramedics also performed CPR. RNS#1 further stated that while gathering the hospital transfer paperwork they noted that Resident #1 was a DNR. RNS #1 stated that they immediately went to the room and informed the paramedics that the resident was a DNR. CPR was stopped and Resident #1 was pronounced. During an interview with RNS #2 on [DATE] at 11:51 AM, they stated that RNS#1 called approximately 6:10 AM and informed them that a resident who is a full code is actively dying. Resident #1 was assessed and noted with no pulse and CPR was initiated. They stated that CPR was stopped when they were notified that the resident was a DNR. During an interview with the Medical Doctor (MD) on [DATE] at 1:31 PM, they stated that Resident #1 had an advanced directive that included DNR. They were notified by a nurse that Resident#1 expired, and that they received CPR and 911 was called. The MD stated that CPR should not have been initiated on Resident #1 as they were a DNR. During the interview with the Associate Director (AD) on [DATE] at 2:22 PM they stated that on [DATE] approximately 8:00 AM, the Nurse Manager informed them that Resident #1 was a DNR, and that CPR was performed. The AD stated that CPR was performed against the resident's advance directive. During an interview with the DON on [DATE] at 3:34 PM, they stated that on [DATE] the AD called them and informed them that RN#1 performed CPR on Resident #1 who had a DNR in place. They stated that staff involved did not question the code and continued CPR. They added that CPR was stopped immediately when the code status was verified by RNS#1. Based on the following corrective actions taken, there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance at the time of this survey for this specific regulatory requirement. - Facility-wide audit of resident's identification bands were reviewed to determine compliance with physician orders/resident wishes for advance directives. The facility identified 5 residents with DNR code status that did not have armbands. The armbands were replaced immediately upon identification. Completed on [DATE] with (100%) compliance. - Education provided to all facility nursing staff regarding advanced directives and how to determine a resident's code status. The facility documented that a total of 91% of nursing staff were educated as of [DATE] on new policy. - Code 99 (facility-specific notification system for absence of a pulse or respirations in residents) drills was conducted on [DATE] and [DATE]. Thereafter, code 99 drills will be completed on a monthly basis for three months (December, January and February) and a quarterly (march-May, June-August, September-November) basis for three consecutive quarters. - Policy and Procedure reviewed and revised to indicate that nursing staff responding to residents who are found to be in medical distress will confirm the residents advanced directive status by reviewing the signed advanced directive section of the resident medical record. - The facility provided a signing sheet dated [DATE], [DATE], [DATE], [DATE] and [DATE] of all nursing staff on Resident Identification and Advance Directive- DNR. 10 NYCRR 400.21

Based on record review and interviews during an abbreviated survey (Complaint #NY 076)) completed on 9/12/2022, the facility did not ensure each resident was free from physical restraints not required to treat the resident's medical symptoms for 1 (Resident #1) of 3 residents reviewed. Specifically, Resident #1 was restrained to their wheelchair by use of a nightgown tucked under Resident #1's thighs and tied to the bar on the right side of the wheelchair which was restraining and restricting Resident#1 from rising from the wheelchair. The finding is: The facility's policy titled Freedom from Abuse, Mistreatment, Neglect and Exploitation revised 5/2022 defined mistreatment as the inappropriate treatment or exploitation of a resident or registrant, such as but not limited to inappropriate use of medications, inappropriate use of isolation, or inappropriate use of physical or chemical restraints. The facility's policy titled Restraint-Free Environment revised 9/2019 documented residents have the right to be free from any physical or chemical restraints that are not required to treat the resident's medical symptoms. The facility will never use restraints for staff convenience, for purpose of discipline, or a substitute for direct care, activities, or other services. The facility will preserve and protect resident's rights, dignity, safety, and well-being and maintain resident's autonomy, quality of life, and rights to be free from restraint. Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS-an assessment tool) dated 2/11/2021documented Resident#1 had a Brief Interview for Mental Status (BIMS) score of 99. A staff assessment documented Resident#1 had moderately impaired cognition. Resident#1 required extensive assistance of 2 staff members for transfer, and personal hygiene. The MDS further documented that Resident #1 had no other physical restraints such as (chair alarm, bed alarm, trunk restraint, limb restraint, or chair prevents rising). The Comprehensive Care Plan (CCP) titled falls dated 8/21/2020 documented that Resident#1 was at risk for falls. Interventions were to supervise Resident #1 when they (Resident #1) were up at night and provide general surveillance. The Nursing Fall Risk Assessment (NFRA) dated 2/11/2021 documented that Resident#1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nursing Progress Note (NPN) dated 3/9/2021 documented that Resident#1 had an episode of attempting to pull self out of the wheelchair and pulling at their (Resident #1's) Foley catheter. Resident #1 was evaluated by the Medical Doctor and was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] Psychiatric consultations dated 3/10/2021 and 3/26/2021 documented that Resident#1 was diagnosed with [CONDITION(S)] with Delusions. Resident#1 had documented behavior of screaming, was combative during care and had been diagnosed with a Urinary Tract Infection. Resident#1 appears restless and had poor judgment. The Psychiatric Consultation also documented that Resident #1's current symptoms are likely secondary to a Urinary Tract Infection. The Nursing Progress Notes (NPN's) dated 4/6/2021, 4/16/2021 and 4/17/2021 during the night shift documented that Resident#1 was attempting to get out of their (Resident#1's) wheelchair,was removing their clothing and thrashing their limbs. The NPN documented that Resident #1 was sitting in their wheelchair near the nurses' station for staff observation. A Nursing Progress Note (NPN) dated 4/21/2021 documented that at 3:01 AM Resident#1 was near the nurses station for safety. Resident#1 was very confused, restless, and moving in the wheelchair. The NPN documented that Resident#1 was transferred to bed for personal care and was observed to have blood near the penile area. The NPN documented that Resident #1 received Tylenol for discomfort and then Resident#1 was assisted back to their wheelchair and brought back to the nurses station. A Nursing Progress Note (NPN) dated 4/21/2021 at 3:08 PM documented that at 9:40 AM Certified Nursing Assistant #1 (CNA#3) reported that Resident#1's night gown was wrapped around the bar of Resident #1's wheelchair. The NPN documented that CNA#3 removed the night gown from the bar of the Resident'#1s wheelchair. The Nurse Manager (NM) was notified at 9:45 AM. The NM documented that a full body assessment was completed on Resident #1 and there was no bruising, redness or injuries. The Physician's Progress Note (PNP) dated 4/22/2021 documented that Resident#1 was examined to follow up on a report that Resident#1's gown was found wrapped around the resident's wheelchair on 4/22/2021. The PNP documented that the staff reported that a full body assessment was done, and no abnormalities were found. The Quality Assurance Post Evaluation (QAPE) report dated 4/21/2021 documented that Resident#1's night gown was potentially used as a physical restraint to prevent Resident#1 from falling or pulling on their Foley catheter. . The Facility's Investigative Summary (FIS) dated 4/22/2021 documented that at approximately 10:00 AM on 4/21/2021, Certified Nursing assistant #3 (CNA#3) reported that upon attempting to transfer Resident#1, CNA#3 and CNA#4 met resistance. The FIS documented that, Resident#1 indicated that they felt discomfort. CNA#3 and CNA#4 stopped the transfer and inspected Resident#1. They (CNA#3 and CNA#4) noticed the resident ' s night gown was tied at the top, behind resident's neck and midway down the resident's back in a normal fashion. The FIS documented that the bottom part of the resident's night gown was tucked under Resident#1's thighs and attached to the bar on the right side of the resident's wheelchair. CNA#3 and CNA#4 attempted to free the night gown from the wheelchair but were not successful. CNA#4 cut the night gown from the wheelchair. The FIS documented that the charge Nurse was informed if the incident and went to Resident #1's room. The FIS also documented that Resident#1 was last known to be unrestricted from movement at 3:01 AM when Resident #1 was transferred into their wheelchair and placed near the nurses station. CNA#3 and CNA#4 s reported the incident to the Registered Nurse Charge Nurse #1 (RNCN#1) at 9:40 AM. The FIS documented that it can be deducted that at some point on the night shift, Resident#1s gown was attached to the wheelchair. Police were notified on 4/22/2021 at 2:26 PM. Police attempted to interview Resident#1 but Resident #1 was not able to answer the questions. The facility concluded that there was cause to believe an alleged mistreatment situation regarding Resident#1 had occurred. There was evidence that Resident#1 was transferred to the wheelchair at approximately 3:01 AM. There was potential that a staff member was acting in the resident's interest to ensure safety. During an interview with the Registered Nurse Charge Nurse (RNCN) on 9/7/2022 at 3:57 PM they stated that on 4/21/2021 at about 9:40 AM (CNA #3 and CNA#4) informed the RNCN that Resident'#1s night gown was tied to the wheelchair. RNCN stated that they (RNCN) did not see the nightgown tied to the chair because CNA #4 had cut off the gown to free the resident. The RNCN stated that CNA #4 was holding a piece of the gown in their hand and reenacted to the RNCN how the gown was cut. The RNCN stated that CNA #4 cut the knot because they could not untie it. RNCN stated they saw that the other end of the night gown was still attached to the wheelchair. RNCN stated the Comprehensive Care Plan (CCP) did not document that Resident#1 should be tied in the wheelchair. The RNCN stated that Resident #1 could not have tied themselves. During an interview with the day shift Certified Nursing Assistant (CNA) #3 stated that they had been assigned to the Resident#1 on 4/21/2022 and that Resident#1 required 2 persons staff assistance for transferring. CNA#3 stated that on 4/21/2021 CNA #3 asked CNA #4 for help with Resident #1's transfer. As CNA#3 and CNA#4 were attempting to get Resident#1 up from their wheelchair , they were unable due to resistance. CNA#3 and CNA#4 observed that Resident#1's night gown was tied around their neck and their waist and that the night gown was tied in to the right side of their wheelchair in a knot. CNA#3 stated that both sides of Resident #1's night gown was tucked under the resident's thigh so that Resident#1 could not move. CNA#3 stated that Resident#1's nightgown was tied so tight that the resident was saying it was hurting them (Resident#1) .CNA#3 stated that CNA #4 retrieved scissors to cut the night gown. CNA #3 stated they did not know who tied the Resident#1. During a phone interview with Certified Nursing Assistant (CNA #4) on 9/8/2022 at 2:21 PM, CNA #4 stated they assisted CNA #3 with Resident 1's transfer. CNA#4 stated they were trying to move Resident#1 from the wheelchair, and they could not. CNA #4 stated they then observed that Resident#1's nightgown was tied on their (Resident #1's) wheelchair and that is why they could not move the resident. CNA#4 stated Resident#1's night gown was tied in a knot to the right side of their wheelchair and was restricting Resident'#1s movement. CNA#4 stated they went to get a pair of scissors and cut the night gown from Resident#1's wheelchair. During a phone interview with Registered Nurse (RN #1) on 9/8/2022 at 2:48 PM, RN #1 stated they did not see a restraint when Resident#1 was in the hallway on 4/21/2022 and they did not tie the resident. During an interview with the Director of Human Resources (DHR) on 9/8/2022 at 3:00 PM, the DHR stated that the nursing department conducted an investigation for Resident #1 and then provided Resident #1's investigation to the DHR. The DHR stated they were informed that there was an incident involving Resident#1's night gown being tied at the back of their wheelchair. The DHR stated they conducted an interrogation of all the involved staff. The DHR stated that based on statements provided from the night shift staff provided concluded that Resident#1 must have been tied between 2:00 AM until approximately 9:40 AM. The DHR interrogated (Registered Nurse) RN #1 and 2 Certified Nursing Assistants (CNA #1 and CNA #2) and they all denied tying Resident #1's night gown and additionally, they did not see Resident#1's night gown tied. The DHR concluded that the facility did not have enough evidence to substantiate a staff member who tied Resident#1's night gown to the wheelchair. During an interview with the Director of Nurses (DON) on 9/8/2022 at 4:43 PM, the DON stated that sometime between 3:00 AM and 9:45 AM somebody possibly tied the gown. The DON stated they found it nearly impossible for the gown to be tied by itself and that Resident#1 could not possibly tie it. The DON stated they were shown how the gown was tied in the wheelchair and from their recollection, the waist tie was tied to the back of the wheelchair behind the Resident#1. The DON stated that they were told by Director of Human Resources (DHR) that three staff members that worked on the night shift on 4/21/2022 denied restraining Resident #1. The DON stated that the facility concluded that there was evidence that mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During a phone interview with the Certified Nursing Assistant ( CNA #2) on 9/12/2022 at 9:25 AM, CNA #2 stated they did not tie Resident #1 to their wheelchair. During a phone interview with Certified Nursing Assistant (CNA #1) on 9/12/2022 at 4:00 PM, CNA#1 stated that they were assigned to the resident#1 on April 21, 2021. CNA #1 stated they provided Resident #1 care in the middle of the night (could not recall exactly the time). CNA #1 stated they and CNA #2 transferred Resident#1 to their wheelchair and then placed them by the nurses station. CNA #1 stated they provided care to Resident#1 again approximately 6:00 AM or 6:30 AM. CNA#1 stated that Registered Nurse ( RN #1) was with CNA #1 during the transfer of Resident #1 into their bed for personal care then back to their wheelchair. CNA #1 stated they then left the Resident#1 by the nurses station. CNA #1 stated that could not recall the time. they were told that the facility found Resident#1 tied with their nightgown to their wheelchair approximately 9:00 AM to 10:00 AM. CNA#1 stated the facility asked them if they noticed Resident#1 was tied. CNA #1 stated they did not see anybody tie Resident #1 to their wheelchair. 415.4(b)(1)(i)

Based on record review and interviews during the Recertification Survey and the Abbreviated Survey (Complaint # NY 584) completed on 7/1/2021, the facility failed to ensure resident rights to be free from abuse for two of two residents reviewed for abuse (Resident #23 and Resident #157). Specifically, Resident #23 who was identified with aggressive behavior, pushed a wandering resident (Resident #157) when Resident #157 grabbed and shook Resident #23's arm. Resident #157 fell to the floor and sustained two lacerations to the back of the head. Subsequently Resident #157 was sent to the hospital with a change in mental status and the two lacerations to the back of the head required five staples. Furthermore, Resident #157 was not adequately supervised upon return from the hospital the next day and entered Resident #23's room when Resident #23 punched Resident #157 in the face causing the resident to sustain a bloody nose with bruising and cuts to the face. This resulted in actual harm to Resident #157 that is not Immediate Jeopardy. The finding is: The Facility Freedom from Abuse, Mistreatment, Neglect and Exploitation policy dated 4/1/1991 and revised on 11/2018 documented that abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Inflictions of abuse can include but are not limited to the following: Physical Abuse includes hitting, slapping, pinching and kicking. 1) Resident #157 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #157's BIMS score was 4, indicating severely impaired cognition. The nurses progress note dated 8/30/2020 documented that at 1:40 PM, Resident #157 was found lying on their back in the doorway to their room, assisted from the floor by staff to the wheelchair. Resident #157 had two lacerations to the scalp; one measuring 1.5 centimeter (cm) in length, the other measuring 1 cm in length. The lacerations were cleaned with normal saline, [MEDICATION(S)] and steri strips were applied and were covered with a clean dressing as ordered. The supervisor, physician and family were notified. Resident #157 had complaints of pain from the laceration on the head and Tylenol was given. Neuro checks for every shift for 24 hours as ordered by physician. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Cleanse lacerations with normal saline and apply steri-strips. The orders on 8/30/2020 also documented Neuro-check every 2 hours for 1 day and to transfer to the hospital for altered mental status. The nurses progress note dated 8/30/2020 at 9:27 PM documented Resident #157 was showing increased signs of lethargy and confusion. Resident #157 was sent out for emergency room at 8:20 PM for further evaluation. The Nurses Progress notes dated 8/31/2020 documented that Resident #157 returned from the hospital at 8:50 AM. Resident #157 was noted with 5 staples to the back of the head. The injury was obtained during a peer to peer incident on 8/30/20. The Physician's progress notes dated 8/31/2020 documented Resident #157 was found on the floor by Resident #157's room with two lacerations to the back of the scalp. Resident #157 was transferred to the emergency room after there was a change in mental status. Resident #157's lacerations were approximated with staples. The plan was to monitor the laceration site and monitor temperature. The Behavior care plan for Resident #157 dated 5/20/2020 documented Resident #157 was at risk for distress, disruption to environment, and injury to self/others due to behavioral symptoms which included cursing at others, hitting, pushing, refusal of care and wandering. The goals included that Resident #157 will be free from harm and will not harm others. The interventions included to redirect Resident #157 when going into peer's rooms and redirect other residents from entering Resident #157's room. The CCP was not updated or revised after the resident's return from the hospital on 8/31/2020. The Victimization care plan for Resident #157 dated 5/20/2020 documented Resident #157 is at risk for victimization related to reacting negatively towards peers when redirected. The goals included that Resident #157 will remain free from victimization as evidenced by absence of peer altercation. The interventions included to observe peer interactions and offer redirection as needed and remove peers for safety if resident does not accept redirection. The CCP was not updated or revised after the resident's return from the hospital. The nurses progress note dated 8/31/2020 documented that after lunch, Resident #157 was found in another resident's room (Resident #23) sitting in a chair with blood on their face. Staff assisted Resident #157 out of the room. Resident #157 had multiple small lacerations to the left side of their face near the ear, left check, under left nostril and the nose was bruised. The altercation took place with the same resident as the incident on the previous day. Resident #157's face was cleaned; ice was applied to the nose with good effect. The physician, supervisor, and social worker were made aware. 2) Resident #23 was admitted to the facility with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data set (MDS) assessment dated [DATE] documented Resident #23 had a BIMS score of 3, indicating severely impaired cognition. The Behavior care plan for Resident #23 dated 8/18/2020 documented Resident #23 is at risk for distress, disruption to environment, and injury to self/others due to limited insight to safety, territorial behaviors related to Resident #23's room and belongings, pushing, grabbing, pacing, and screaming and cursing at others. The goals included that Resident #23 will be free from harm and will not harm others. Interventions included to redirect peers away from Resident #23, provide a newspaper, offer music and provide familiar caregiver when able. The CCP was not updated/revised after the altercation on 8/30/2020. The Accident and Incident report dated 8/30/2020 documented that at 1:40 PM, CNA #1 saw Resident #23 standing by the entrance of Resident #23's room and observed Resident #157 lying on their back on the floor by Resident #157's room with blood on the floor by Resident #157's head. Resident #23 was standing by the entrance of Resident #23's room, which was adjacent to Resident #157's room. Resident #23 said that Resident #157 grabbed Resident #23's arm and was shaking Resident #23. Resident #23 pushed Resident #157 and Resident #157 fell . Resident #23 repeated and re-enacted the events to make sure that people understood why Resident #23 did what Resident #23 did. A body check revealed 2 lacerations to the top of Resident #157's head measuring 1.5 centimeters (cm) and 1.0 cm. New orders included steri-strips (to the lacerations), [MEDICATION(S)] (topical antibiotic ointment) and a dry clean dressing. Resident # 157 complained of a headache about 1 hour after the incident and was administered Tylenol 650 Milligrams (mg) with good result. Later in the evening, Resident # 157 was noted with increased lethargy and confusion. The resident was sent to the hospital for evaluation of the altered mental status post [MEDICAL RECORD OR PHYSICIAN ORDER] The facility summary of findings dated 9/4/2020 (from the 8/30/2020 Accident Incident report) documented that Resident # 157 received 5 staples to his head. The residents' rooms were adjacent to each other and possibly Resident #23's misjudged the location of their room and perceived that Resident #157 was in Resident #23's room. The plan for improvement included a re-evaluation for Resident #157 upon return from the hospital and the care plan was not reviewed and revised. Staff will continue to observe, monitor, and redirect residents while near each other and to anticipate any untold behavior between the two residents. The facility's investigation identified that the incident occurred because both residents had the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility concluded that there was no reasonable cause to believe any alleged resident abuse, neglect or mistreatment occurred. The Accident and Incident report dated 8/31/2020 documented Resident #157 was sitting in front of the television where a staff member was feeding another resident. The staff member proceeded to place Resident #157 in the hallway across from the dining room to clean up after lunch leaving the hallway unattended. Resident #157 walked past the nurse's station, and no one realized that Resident #157 moved from the seat and probably wandered accidentally in to the peer's room (Resident #23) which was right next to Resident #157's room. Resident (#157) has a history of wandering in other resident rooms. Resident #23 came out of Resident #23's room and asked for someone to get this resident (Resident #157) out of their room. CNA #2 responded, and Resident #157 was found sitting in a chair in Resident #23's room with multiple small lacerations to the left side of the face near the ear, lacerations under the left nostril and a bruised nose. Resident #23 had blood on the right hand. Resident #23 stated that Resident #157 came into Resident #23's room uninvited and when someone wants to fight, you need to hit them first. The facility concluded there was no reasonable cause to believe any alleged resident abuse, neglect or mistreatment occurred. CNA #1 was interviewed on 6/29/2021 at 2:17 PM. CNA #1 stated that on 8/30/2020, CNA #1 was at the nurses station charting and observed Resident #157 wandering in the hallway and they redirected Resident #157 away from Resident #23's room. CNA #1 then continued charting at the nurse's station and then CNA #1 heard a commotion. CNA #1 walked out of the nurse's station to Resident #157's room which was by the station and observed Resident #157 on the floor at Resident #157's doorway, laying on their back with blood on the floor. Resident #23 said Resident #157 was trying to get into Resident #23's room. Resident #23 told CNA #1 that Resident #157 grabbed Resident #23's arm and shook it. Resident #23 then pushed Resident #157 and Resident #157 fell to the floor. CNA #1 stated that Resident #23 can be aggressive and impulsive, so she knows they should be kept separated. CNA #1 stated within moments of the last redirection, Resident #157 still wandered near Resident #23. CNA #1 could not recall the exact time of the events and did not recall if other staff members were around at the time of the incident. CNA #2 was interviewed on 6/29/21 at 2:41 PM. CNA #2 stated that on 8/31/2020, Resident #23 came out to the doorway and asked would you get this person out the room? CNA #2 looked past Resident #23 and saw Resident #157 seated in the room with blood on their face. Resident #23 told CNA #2 that Resident #23 punched Resident #157 on the nose and Resident #23 was observed with blood on their hand. CNA #2 brought Resident #157 out of the room and reported to Charge Nurse #1 what was encountered. CNA #2 stated that CNA #2 generally picks up assignments and monitors everyone on the unit. CNA #2 does not recall if they were assigned to Resident # 157 or Resident #23. CNA #2 stated that Resident #23 has a temper and they know that Resident #157 should be redirected away from Resident #23. Resident #157 had a behavior of habitually returning to Resident #23's room because it used to be Resident #157's room in the past. CNA #2 stated that unless there is a 1:1 assigned to Resident #157, there is no way to do continuous monitoring for Resident #157. CNA #2 was not instructed to increase monitoring for Resident #157 on 8/31/2020. The Director of Nursing Services (DNS) was interviewed on 6/29/2021 at 3:55 PM. The DNS stated that on 8/30/2020, Resident #157 was on the floor and Resident #23 stated Resident #23 pushed Resident #157 and Resident #157 sustained 2 lacerations on the head. Prior to the event, Resident #157 was seen ambulating on the unit. Resident #157 was sent out to the hospital for an evaluation and received 5 staples to the head. The DNS stated that there were no new preventative measures put in the care plan on 8/30/2020 for Resident #157. On 8/31/20, Resident #157 walked into Resident #23's room. The DNS further stated that according to the New York State and Federal definitions of Abuse, both incidents were abuse. The Charge Registered Nurse (RN) was interviewed on 7/1/21 at 1:59 PM. The Charge RN stated that the two residents did not have any altercations prior to 8/30/2020. The Charge Nurse was on the unit on 8/31/20 when Resident #157 returned from the hospital. The Charge RN stated that the plan of care was to observe Resident #157's peer interactions and to offer redirection prior to 8/30/2020. The plan of care also instructed staff to keep other residents away from Resident #157 when Resident #157 does not accept redirection. The interventions in the plan of care did not specify the frequency of monitoring. The Charge RN stated the basic protocol was one-hour visual checks on Resident #157 and Resident #157's monitoring was not increased when the resident returned from the hospital. The Medical Director was interviewed on 7/1/21 at 2:37 PM. The Medical Director reviewed the accident and incident reports for 8/30/20 and 8/31/20. The Medical Director stated that Resident #157 sustained lacerations to the occipital scalp area with staples in place after the 8/30/2020 altercation. The Medical Director stated that Resident #157 incurred injuries and was harmed by Resident #23. The Medical Director expected Resident #157 to be kept in a visual area to keep them away from other residents. Normally when an abuse case occurs, the team determines the frequency of supervision which can be every (Q)15 minutes, Q 30 minutes or 1:1 supervision. In this case, the baseline was 1-hour checks and the frequency of supervision should have been increased. 415.4(b)(1)(i)

Based on observations and staff interviews during the Recertification Survey completed on 7/1/2021, the facility did not dispose of refuse and garbage properly. Specifically, the facility did not ensure that the area surrounding the garbage compactor was kept clean and free of debris. This was identified on two separate observations; during the initial tour of the kitchen on 6/24/2021, and a subsequent visit to the garbage storage area five days later on 6/29/2021. The finding is: During the initial kitchen tour on 6/24/2021 at 11:30 AM, the area surrounding the garbage compactor was observed to be littered with 3 pairs of used blue surgical gloves and 2 opened institutional size #10 food cans. The General Manager of Food Service was present during the tour and acknowledged the presence of blue gloves and empty cans on the ground near the garbage compactor. The garbage area was observed on 6/29/2021 at 1:00 PM with the General Manager of Food Service. A clear plastic bag was observed on the ground to the left of the elevated platform leading to the garbage compactor. The plastic bag contained waste including empty glove boxes, empty surgical mask boxes, napkins, tissues and plastic wraps. In addition, an opened institutional size #10 food can, a single blue surgical glove, one large empty plastic jar, one sealed blue recycling bag, three flattened cardboard boxes and a clear plastic bag which contained used paper cups were identified on the ground at the base of the compactor. The Director of Support Services was interviewed on 6/30/2021 at 11:25 AM. The Director of Support Services stated that the dumpster container was removed and replaced once every 1-2 weeks and as needed. The Director of Support Services stated that an assigned staff member usually cleaned the area when the dumpster was pulled out to be replaced because it was easier to clean when the dumpster was removed. The Director of Support Services and the Housekeeping Manager were interviewed concurrently on 6/30/2021 at 12:00 PM. The Housekeeping Manager stated the dumpster was removed and replaced twice a week and as needed. The Housekeeping Manager stated that the garbage compactor and the area surrounding the compactor should be kept clean. The Director of Support Services stated that the facility did not have a scheduled routine cleaning of the area. The Director of Support Service further stated that there was no policy related to scheduled cleaning. 415.14(h)

Based on observation, record review, staff interviews during the Recertification Survey completed on 7/1/2021, the facility did not ensure that a person-centered Comprehensive Care Plan (CCP) was developed to meet the resident's current needs. This was identified for 1 (Resident #101) of 2 residents reviewed for Pressure Ulcers (PU). Specifically, Resident #101 was identified with a Stage II PU to the Sacrum on 12/30/2020. There was no documented evidence that a CCP was developed until 1/27/2021 when the PU deteriorated to a Deep Tissue Injury (DTI). The finding is: Resident #101 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented the resident had one Stage II PU. A Braden Scale (tool to assess pressure ulcer risk) dated 11/16/2020 documented the resident scored a 13, which indicated the resident was at moderate risk for pressure ulcer development A Pressure Ulcer Record dated 12/30/2020 documented a Stage II PU to the Sacrum measuring 0.3 centimeter (cm) x 0.3 cm x 0.1 cm. The wound base was identified as pink in color and had scant drainage. A CCP dated 12/3/2020 for Potential for Skin Breakdown documented the resident was at risk for skin break down related to incontinence of bowel and bladder and decreased mobility. Interventions included to assist the resident with turning and positioning while in bed every two hours and to encourage the resident to change their position while in the chair. A CCP for PU to the Sacrum dated 1/27/2021 included interventions for use of a pressure ulcer relieving cushion in the wheelchair (w/c) while out of bed, to assess for pain prior to the dressing change, and to administer medication as directed for reports of pain. A wound care observation was conducted on 7/1/2021 at 9:00 AM with the Registered Nurse (RN#10), Charge nurse. The wound to the sacrum was approximately the size of a quarter, with no odor or drainage present, and the wound bed was pink in color. An interview was conducted on 6/30/2021 at 3:12 PM with the Wound Care nurse (RN #9). The RN stated that the PU to the resident's sacrum was first identified on 12/30/2020 as a Stage II PU. The Wound Care RN (#9) stated that there were preventative interventions in place prior to the skin breakdown, however, a CCP for the PU was not developed. The Wound Care RN #9 stated that there should have been a CCP initiated when the PU was identified. RN #5 (Nurse Manager) was interviewed on 7/01/2021 at 1:00 PM. The RN (#5) stated that when a new PU area is identified the wound care RN and MD are notified. RN #5 stated that the Charge nurse is responsible for initiating the CCP for any newly identified PU. The RN further stated that a CCP should have been developed when the wound was first identified. The Director of Nursing Services (DNS) was interviewed on 7/1/2021 at 1:31 PM and stated that a CCP should have been developed with goals and interventions when the PU was identified. 415.11(c)(1)

Based on record review and interviews during the Recertification Survey and the Abbreviated Survey (Complaint # NY 584) completed on 7/1/2021, the facility did not ensure that further potential abuse was prevented while the investigation was in progress for 2 of 2 residents reviewed for abuse (Resident #157 and Resident #23). Specifically, Resident #157 and Resident #23 had a physical altercation on 8/30/2020. Resident #157 was sent to the hospital for evaluation and returned on 8/31/2020. The facility investigation was not thorough to ensure interventions to prevent reoccurrence remained appropriate and effective. Subsequently, on 8/31/2020 Resident #157 and Resident #23 had a second physical altercation. The finding is: Facility Freedom from Abuse, Mistreatment, Neglect and Exploitation policy revised on 11/2018 documented that the facility will prevent and protect residents against further potential abuse while an investigation is in process. Prevention was defined as the continuous assessment, care planning and monitoring of residents/registrants with needs and behaviors which might lead to abuse. Resident #157 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #157's Brief Interview for Mental Status (BIMS) score was 4, indicating severely impaired cognition. Resident #23 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #23 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition. The Accident Incident report dated 8/30/2020 documented that at 1:40 PM, Resident #157 was pushed by Resident #23 which resulted in 2 lacerations to the back of Resident # 157's head that required 5 staples. The facility summary of findings dated 9/4/2020 (from the 8/30/2020 Accident Incident report) documented that Resident # 157 received 5 staples to his head. The residents' rooms were adjacent to each other and possibly Resident #23 misjudged the location of their room and perceived that Resident #157 was in Resident #23's room. The care plan was not reviewed and revised. Staff will continue to observe, monitor, and redirect residents while near each other and to anticipate any untold behavior between the two residents. The facility's investigation identified that the incident occurred because both residents had the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility concluded that there was no reasonable cause to believe any alleged resident abuse, neglect, or mistreatment occurred. The nurses progress note dated 8/30/2020 at 9:27 PM documented Resident #157 was showing increased signs of lethargy and confusion. Resident #157 was sent out for emergency room at 8:20 PM for further evaluation. The Nurses Progress notes dated 8/31/2020 documented that Resident #157 returned from the hospital at 8:50 AM. Resident #157 was noted with 5 staples to the back of the head. The injury was obtained during a peer to peer incident on 8/30/20. The Accident Incident report dated 8/31/2020 documented that Resident #157 was observed sitting in front of the television where a staff member was feeding another resident. The staff member proceeded to place Resident #157 in the hallway across from the dining room to clean up after lunch, leaving the hallway unattended. At 12:55 PM, Resident # 157 was found sitting on the stationary chair in Resident #23's room. Resident #157 was found with small lacerations to the left side of their face, near the ear, and under the left nostril. Resident #23 informed the staff that Resident #23 punched Resident #157 in the face. CNA #2 was interviewed on 6/29/2021 at 2:41 PM. CNA #2 stated that on 8/31/2020, Resident #23 came out to the doorway and asked, would you get this person out the room? CNA #2 looked past Resident #23 and saw Resident #157 seated in the room with blood on their face. Resident #23 told CNA #2 that Resident #23 punched Resident #157 on the nose and Resident #23 was observed with blood on their hand. CNA #2 brought Resident #157 out of the room and reported to Charge Nurse #1 what was encountered. CNA #2 stated that Resident #23 has a temper and they know that Resident #157 should be redirected away from Resident #23. Resident #157 had a behavior of habitually returning to Resident #23's room because it used to be Resident #157's room in the past. CNA #2 stated that unless there is a 1:1 assigned to Resident #157, there is no way to do continuous monitoring for Resident #157. CNA #2 was not instructed to increase monitoring for Resident #157 on 8/31/2020. The Director of Nursing Services (DNS) was interviewed on 6/29/2021 at 3:55 PM. The DNS stated there were no new preventative measures put into the care plan on 8/30/2020 for Resident #157. On 8/31/2020, Resident #157 walked into Resident #23's room which resulted in another altercation. The staff member who had left Resident #157 in the hallway was not identified in any of the staff statements. The DNS further stated that the investigation was not complete. 415.4(b)(3)

Based on observations, interviews and record review during the Recertification Survey completed on 7/01/2021, the facility did not ensure that each residents' Comprehensive Care Plan (CCP) was reviewed and revised to address the residents' current care needs. This is identified for one (Resident #137) of 3 residents reviewed for accommodation of needs. Specifically, Resident #137 did not have a CCP reviewed and revised to address the resident's need for a specialized call bell. The finding is: The Policy and Procedure entitled Comprehensive Care Plan effective 11/2/93 documented the facility will develop a person-centered care plan for each resident to ensure that appropriate care is provided to the resident. The resident's overall health status will be taken into account to ensure that their physical, emotional, psychosocial, and spiritual needs and preferences are met to attain the individual resident's highest practical level of well-being. Initial goals will be developed, and resident centered interventions will be put in place to assist the resident achieve those goals. The Policy and Procedure entitled Call Bell (Lights) effective 9/1/91 documented the facility will ensure that residents' call bells are operable at all times and will be accessible to all residents when needed. The standard system will be modified as necessary to meet the residents' needs. Resident #137 was admitted with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #137 sometimes makes self-understood, and usually understands. Required extensive assistance of 2 people for bed mobility, transfers, bathing, and toilet use. Resident #137 required extensive assistance of one person for dressing, eating, and personal hygiene and was always incontinent of bowel and bladder. Resident #137 was observed on 6/24/2021 at 11:10 AM with a tap bell (a specialized call bell) and a remote control on the resident's chest. The resident was observed with their hands under the sheets. The resident stated that they had difficulty using the tap bell and the remote control. Resident # 137 was observed on 6/29/2021 at 2:32 PM sleeping in bed with a remote on their chest and a specialized call bell on their abdomen. Resident # 137 was observed lying in their bed on 6/29/2021 at 3:15 PM. The specialized call bell was observed to be not within the resident's reach. The RNM who was present during the observation moved the specialized call bell closer to the resident's hand for the resident to access the call bell. The CCP for Communication dated 3/12/2021 documented the resident was at risk for impaired communication secondary to decreased and delayed communication. The interventions included to speak clearly and allow the resident to see staffs' face and mouth while speaking. The interventions were updated on 6/29/2021 (after the surveyor's observation) to include a special call bell. The staff to ensure that the special call bell is securely in place to assist resident to call for assistance. The Activity of Daily Level (ADL) Data Report (directions to the Certified Nursing Assistants regarding the resident's care needs) from 3/1/2021 to 6/30/2021 did not include specialized call bell use for Resident #137. Nursing note dated 4/17/2021 documented that resident complained of increased weakness to the right arm. The Physician was notified. The Physician's (MD) Progress note dated 4/17/2021 documented the resident reported weakness to the right arm that has been ongoing for several months and the resident was now having difficulty with using the call bell. The resident had some movement of upper extremities but was quite limited. Would request Occupational Therapy follow up for best call bell option. The Occupational Therapy evaluation dated on 4/27/2021 documented the resident was seen for increased [CONDITION(S)] of bilateral upper extremities. The resident had severely impaired coordination/dexterity. The Occupational Therapy assessment lacked documented evidence of an evaluation for the use of the specialized call bell. The Certified Nursing Assistant (CNA#3) was interviewed on 6/29/2021 at 12:00 PM and stated that the resident is alert and cannot move their arms because both arms are weak. The resident has a special call bell that is placed on their abdomen and the resident can use the call bell. The Licensed Practical Nurse (LPN #1) was interviewed on 6/29/2021 at 12:21 PM and stated that Resident #137 needs total care. The resident can make needs known. The resident has a special call bell because of the difficulty using their hands. The Registered Nurse Manager (#4) was interviewed on 6/29/2021 at 3:02 PM and stated when a resident is admitted to the facility, nursing will assess the resident's ability to use the call bell. Occupational Therapy makes the assessment and recommendation for the use of the tap bell. The use of the tap bell should be documented on the care plan. The Director of Nursing Services (DNS) was interviewed on 6/30/2021 at 12:25 PM and stated they (DNS) expected the staff to document the use of the special call bell for the resident in their care plan. The Occupational Therapist was interviewed via telephone on 7/0120/21 at 2:15 PM and stated that they recall evaluating the resident for a specialized call bell. The Occupational Therapist stated that the resident's care plan should have been updated to reflect the need for the use of the specialized call bell. 415.11(c)(2)(i-iii)

Based on observation, record review, and interviews during the Recertification Survey completed on 7/1/2021, the facility did not ensure that all drugs and biologicals were stored in locked compartments. This was identified for 1 (Resident # 631) of 3 residents reviewed for skin conditions, and 1 (Resident # 264) of 4 residents reviewed for Accidents. Specifically, Resident #264 was observed with [MEDICATION(S)] 20% cream on the over-the-bed table within Resident # 264's room and Resident #631 was observed with [MEDICATION(S)] 20% cream on the window sill in Resident #631's room. There were no staff members present in either Resident #264 or Resident #631's room at the time of the observations. The findings are: The facility policy and procedure for Storage of Medications, last revised 5/2021, documented that all medications, treatments, and other drugs shall be stored in a locked medication room, cabinet, or medications cart, accessible only to authorized facility personnel. 1) Resident #631 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 5 which indicated severely impaired cognition. Section M of the MDS for skin conditions documented the resident had Moist Associated Skin Damage. The MDS documented the resident was always incontinent of bowel. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/24/2021 at 11:30 AM, Resident #631 was observed sitting in a wheelchair in their room. A topical [MEDICATION(S)] 20% container was observed on the window sill in Resident #631's room. 2) Resident #264 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS documented the resident was always incontinent of bowel. The MDS documented the resident was at risk for pressure ulcer development. The resident had one or more venous or arterial ulcers present. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/24/2021 at 11:00 AM Resident #264 was observed in their bed and was subsequently observed at 2:00 PM sitting in the wheelchair in their room. A topical [MEDICATION(S)] 20% container was observed on the over-the-bed table in Resident #264's room on both observations. The Material Safety Data Sheet (MSDS) for [MEDICATION(S)] Ointment dated 9/6/ , provided by the facility, documented that [MEDICATION(S)] ointment is a white ointment with a petroleum jelly odor. Health Hazards include that the product may be harmful if swallowed and eye contact may cause irritation. The Registered Nurse (RN) Charge Nurse (RN#5) was interviewed on 6/29/2021 at 2 PM and stated that they (RN#5) and the other nurses apply the ointments and creams. After the treatments are done the prescribed creams must be stored and secured in the treatment carts. The Director of Nursing Services (DNS) was interviewed on 6/30/2021 at 2:35 PM and stated that the prescribed creams and ointments must be stored securely in the treatment carts after the treatments are completed. 415.18(e)(1-4)

Based on record review and interviews during the Recertification Survey and the Abbreviated Survey (Complaint # NY 584) completed on 7/1/2021, the facility did not ensure that all alleged violations involving abuse are reported immediately but not later than 24 hours after the allegation is made for 2 of 2 residents reviewed for abuse. Specifically, the facility did not report a Resident to Resident physical altercation between Resident #23 and Resident #157 on 8/30/2020 until 9/4/2020 (a 5-day delay) and another altercation between Resident #23 and Resident # 157 on 8/31/2020 until 9/4/2020 (a 4-day delay). The finding is: The Facility's Freedom from Abuse, Mistreatment, Neglect, and Exploitation policy dated 4/1/91 and last revised on 11/2018 documented that the facility will immediately report alleged violations of abuse to the New York State Department of Health (NYSDOH). The Accident and Incident report dated 8/30/2020 documented that at 1:40 PM, Resident #157 was pushed by Resident #23 resulting in 2 lacerations to the back of Resident # 157's head which required 5 staples. The Accident and Incident report documented that the NYSDOH was notified on 9/4/2020. The Accident and Incident report dated 8/31/2020 documented that at 12:55 PM, Resident # 157 was found sitting on a chair in Resident #23's room. Resident # 157 was found with small lacerations to the left side of their face, near the ear, and under the left nostril. Resident #23 informed the staff that Resident #23 punched Resident #157 in the face. The report documented that the NYSDOH was notified on 9/4/2020. The Director of Nursing Services (DNS) was interviewed on 6/29/2021 at 3:55 PM. The DNS stated the two incidents were reported on 9/4/2020 and were not reported within the required timeframe in the regulation. The Administrator was interviewed on 6/30/2021 at 1:18 PM. The Administrator stated that the Administrator was aware of the incidents and reviewed them when they were reported to the Administrator. The Administrator stated that there was a delay in reporting the incidents to the NYSDOH because of the Labor Day weekend. The Administrator further stated that the incident should have been reported within 24 hours of the incident. 415.4(b)(2)

Based on observations, record reviews, and staff interviews during a Focused Infection Control Survey conducted on 11/24/2020, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of COVID-19. Specifically, Licensed Practical Nurse (LPN) #1 was observed inside a resident's room without wearing a gown on 1 (Unit A) of 3 units that were on Transmission-Based Precautions (TBP). The Finding is: The Health Advisory: COVID-19 Cases in Nursing Homes (NH) and Adult Care Facilities revised 7/10/2020 documented there are confirmed cases of COVID-19 in a NH, all residents on affected units should be placed on droplet and contact precautions, regardless of the presence of symptoms and regardless of COVID-19 status. Health Care Providers (HCPs) and other direct care providers should wear gown, gloves, eye protection (goggles or a face shield), and N95 respirators (or equivalent) if the facility has a respiratory program with fit tested staff and N95. Otherwise, HCP and other direct care providers should wear gown, gloves, eye protection, and face masks. Facilities may implement extended use of eye protection and facemasks/N95s when moving from resident to resident (i.e. do not change between residents) unless other medical conditions which necessitate droplet precautions are present. However, gloves and gowns must be changed and hand hygiene must be performed. The Centers for Disease Control and Prevention (CDC) guidance titled Transmission-Based Precautions (undated), provides: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning Personal Protective Equipment (PPE) upon room entry and properly discarding before exiting the patient room is done to contain pathogens. CDC guidance titled Using Personal Protective Equipment (PPE), updated 08/19/2020, documents the following first steps to doff PPE before exiting a patient's room: 1. Remove gloves. Ensure glove removal does not cause additional contamination of hands. Gloves can be removed using more than one technique (e.g., glove-in-glove or bird beak); 2. Remove gown.; 3. Healthcare personnel may now exit patient room. Upon exiting a patient's room, HCP should perform the following steps, per such guidance: 4. Perform hand hygiene; 5. Remove face shield or goggles; 6. Remove and discard respirator (or facemask if used instead of respirator); and 7. Perform hand hygiene after removing the respirator/facemask and before putting it on again if your workplace is [MEDICATION NAME] reuse. The Facility Policy titled COVID 19 Pandemic reviewed and revised on 10/13/2020 documented that all units are placed on contact/droplet precautions and signage was placed outside each unit and resident's rooms; staff adherence to Standard, Contact, and Droplet precautions and that standard precautions are followed on all residents regardless of infection status, PPE will be used in a manner to prevent self-contamination, staff will be educated on the proper use of PPE, how to properly dispose PPE, and limitations of PPE as needed. Resident #1 Comprehensive Care Plan for COVID-19 dated 11/19/2020 documented interventions included to implement Droplet and Contact Precautions. The laboratory results dated [DATE] documented that a specimen was collected from Resident #1 on 11/12/2020 for a COVID-19 polymerase chain reaction (PCR) nasopharynx test, and the result was received on 11/19/20 indicating a positive COVID-19 result for Resident #1. Observation on Unit A on 11/24/2020 at 11:02 AM revealed the doors to enter the unit were closed and the unit had signs to wear N95 mask and face shield/goggles before entering the unit. If you are within 6 feet of the resident, gown, gloves, surgical mask should be added. Gown, gloves, and surgical mask should be removed when exiting the room or resident's area. Further observation revealed there were stop signs on all resident doors. An LPN (#1) was observed at 11:04 AM inside Resident #1's room without wearing a gown. LPN #1 was interviewed on 11/24/2020 at 11:07 AM and stated she thinks it is okay to not wear a gown inside a resident's room as long as she is not performing personal care for the resident. She stated she was in-serviced regarding COVID-19 policy and procedures. The Infection Control Preventionist (ICP) was interviewed on 11/24/2020 at 1:00 PM and stated staff members should wear a gown every time they enter a COVID-19 room and remove the gown prior to exiting the room, especially on Unit A, a designated COVID-19 Unit. LPN #1 was re-interviewed on 11/24/2020 at 1:38 PM and stated she was helping the resident with their computer by moving the computer screen keyboard and the bedside table for the resident to visualize the computer. The RN Unit Manager was interviewed on 11/24/2020 at 1:46 PM and revealed she was in-serviced regarding COVID-19 policy and procedures. The Unit Manager stated that when entering a room on Unit A, staff members should wear a gown and gloves in addition to the masks and eye shield even if staff were not performing personal care. The gown and gloves should be removed when exiting the room. The Director of Nursing Services (DNS) was interviewed on 11/24/2020 at 1:54 PM and stated on Unit A, the designated COVID-19 Unit, staff should wear a gown regardless of the task they are performing when they enter a resident's room. It is important to wear gowns to prevent the spread of infection and to protect staff. 415.19(a)(1-3) 400.2

Based on observations, interview and policy review on 11/16/2020 it was determined that the facility failed to properly follow infection control protocols to protect residents against the spread of infection by tamping down dirty PPE that was disposed of in a garbage can and by not properly conducting hand hygiene and using gloves properly during a dressing change. The Findings Include: It was observed on 11/16/2020 at 1:08 pm that a housekeeper on 1B took used PPE and put it in the garbage can which seemed to be full and tamped the PPE down into the can with his gloved hands in front of the surveyor and the Director of Nursing. The CDC has stated that used PPE should not be tamped or pushed down because this action can aerosolize any COVID-19 Virus that may be on the used PPE and potentially spread [MEDICAL CONDITION]. The Director of Nursing was made aware of this directly after the observation and she stated that she would have the staff inserviced to assure that they do not do this going forward. It was observed on 11/16/2020 from 1:14 pm to 1:26 pm that a Nurse #1 was observed to conduct a dressing change on a residents toes. The nurse put on her PPE before entering the room, when she entered she found a dirty towel on the residents bed and disposed of it in a plastic bag which she sealed. The nurse proceeded to go and wash her hands, the problem with the nurse washing her hands was that she was wearing a PPE gown which had loops to place your thumbs in while wearing the gown. The loops were to keep the sleeves in place and not slide up the arm. The nurse proceeded to wash her hands with the loop of plastic from the gown still in place making it impossible to wash her hands correctly. The nurse proceeded to conduct the dressing change by layering 3 pairs of gloves on her hands and then after removing the dressings she removed a pair of gloves and disposed of them and put alcohol based hand rub on the 2nd pair of gloves, but did not reach all areas of the 2nd pair of gloves because she did not cover all areas and did not go between the fingers. The nurse then cleaned the wounds and disposed of the 2nd pair of gloves. She repeated the same improper procedure of using the alcohol based hand rub on the 3rd pair of gloves and then placed the dressings on the wounds. An interview was conducted on 1116/2020 at 130 pm with the Director of Nursing and the infection Control Nurse who were told of the procedures used by the nurse during the dressing change and they both stated that the nurses hand washing with the loops of the gown on were improper and against facility hand washing policy and that it was a break in infection control technique. They further stated that the nurse should not have layered her gloves and utilized alcohol based hand rub in that fashion on the gloves. They stated that the nurse should have used a pair of gloves to take off the dressing and then used alcohol based hand rub or properly washed her hands with soap and water and then put on a new pair of gloves to clean the wounds. After cleaning wounds the nurse should have cleaned her hands with soap and water or utilized alcohol based hand rub. The Director of Nursing and Infection Control Nurse stated that they would address these breaks in infection control after they finished accompanying the surveyor throughout the facility, with both the nurse and all staff members. It was observed on 11/16/2020 at 1:43 pm that a housekeeper was observed on unit 2B to tamp and push down use PPE into the garbage can that the staff member was using. This was done in front of the surveyor and the Director of Nursing and Infection Control Nurse. An interview was conducted with the Director of Nursing and Infection Control Nurse at the time of the observation and they stated that they would inservice all staff not to tamp or push down used PPE into the garbage.

Based on observation, record review, and staff interviews during the recertification survey, the facility did not ensure that each resident's drug regimen was free from unnecessary medications. This was evident for two of eight residents reviewed for unnecessary medications. Specifically, 1) Resident #204 was administered an antipsychotic medication [MEDICATION NAME] ([MEDICATION NAME]) 2.5 milligrams (mg) every eight hours when necessary (PRN) for 14 days. There was no documented evidence that an evaluation was completed or supportive documentation for the use of the 14 day PRN antipsychotic medication prior to the initiation of the medication on 2/11/19 and 2/25/19; and 2) Resident #25 had a [DIAGNOSES REDACTED]. The findings are: A Facility Policy and Procedure (P/P) dated 7/1/03 and reviewed on 10/2018, documented that if a [MEDICAL CONDITION] medication is prescribed to a resident as PRN, the order will not exceed 14 days. The P/P documented after 14 days the Physician will evaluate the resident and provide supportive documentation in the medical record to prescribe or to continue the use of the PRN antipsychotic medication. The P/P documented the Pharmacy Consultant will review the appropriateness of all [MEDICAL CONDITION] medications. The P/P also documented the Pharmacy Consultant will consult with the Physician to ensure each resident is on the correct [MEDICAL CONDITION] or PRN [MEDICAL CONDITION] medication. 1) Resident #204 is [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 4 indicating the resident had severe cognitive impairment. The MDS documented the resident received 7 days of an antipsychotic medication during the look back period. A physician's orders [REDACTED]. A Medication Regimen Review (MRR) dated 2/18/19 documented upon review of the resident's Medication Regimen there were no irregularities. A physician's orders [REDACTED]. Medication Administration Records (MAR) dated 2/11/19 to 2/25/19, and 2/25/19 - 3/11/19 documented [MEDICATION NAME] 2.5 mg one tablet every eight hours PRN for 14 days, administer for a [DIAGNOSES REDACTED]. Resident # 204 was observed on 2/28/19 at 8:30 AM. The resident was in bed, awake, calm and watching television. Resident # 204 was observed on 2/28/19 at 10:15 AM. The resident was yelling out for help. When the staff approached the resident he stopped yelling out. A subsequent observation of Resident # 204 was conducted on 3/6/19 at 9:05 AM. The resident was sitting in his chair and was yelling for help. The staff approached the resident and the resident stopped yelling. A review of the medical record revealed there was no documented evidence that an evaluation or supportive documentation was completed prior to the initiation of the PRN antipsychotic medication [MEDICATION NAME] on 2/11/19 and 2/25/19. An interview was held on 3/6/19 at 9:30 AM with the Unit Manager Registered Nurse (RN). The RN stated that the unit Physician works on the unit daily and the Physician was the one that prescribed [MEDICATION NAME] 2.5 milligrams (mg) every eight hours when necessary (PRN) for 14 days on 2/11/19 and 2/25/19. An interview was held with the Registered Nurse (RN) on 3/6/19 at 10:00 AM. The RN reviewed the medical record and stated that there is no documented evidence in the medical record that an evaluation or supported documentation was completed prior to the initiation of the PRN antipsychotic medication [MEDICATION NAME] on 2/11/19 and 2/25/19. An interview was held with the Physician on 3/6/19 at 12:30 PM. The Physician reviewed the medical record and stated that there was no documented evidence that an evaluation was completed prior to the initiation of the 14 day PRN [MEDICATION NAME] on 2/11/19 and 2/25/19. The Physician stated the [MEDICATION NAME] 2.5 mg every eight hours for 14 days was administered for Terminal Anxiety and [MEDICAL CONDITION] and not [MEDICAL CONDITION]; but could not explain why the signed physician's orders [REDACTED]. An interview was held with the RN on 3/7/19 at 8:00 AM. The RN stated there was no documented evidence since 11/14/18 of a Psychiatric Consultation or a Physician order [REDACTED].>An interview was held on 3/7/19 at 9:00 AM with the Pharmacy Consultant. The Pharmacy Consultant stated that she did not have recommendations for Resident # 204 in the last 4 months. The Pharmacy consultant stated she did not realize an evaluation and supportive documentation was needed prior a 14 day PRN antipsychotic medication being administered. 2) Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short and long term memory problems and was severely impaired for daily decision making. The resident had no mood or behavior symptoms and had no signs or symptoms of [MEDICAL CONDITION]. The resident received antipsychotic, antidepressant and antianxiety medications for seven days during the assessment period. The Annual MDS assessment dated [DATE] documented the resident had short and long term memory problems, and was severely impaired for daily decision making. The resident had no mood or behavior symptoms and had no signs or symptoms of [MEDICAL CONDITION]. A hospital discharge document dated 10/31/17 documented the resident received [MEDICATION NAME] (an antipsychotic medication) 100 milligrams (mg) by mouth (po) 2 times daily for Anxiety. In the Hospital Course section of the discharge summary it documented the resident was admitted with Advanced Alzheimer's Dementia which started 2 years ago and progressed rapidly, and that the resident was on Hospice for one year due to Advanced Dementia. It also documented that the resident gets agitated intermittently, however, there was no documented Psychiatric diagnosis. A physician's orders [REDACTED]. Hold for sedation or lethargy. This order was renewed on 1/18/18, however, the [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Hold for sedation or lethargy. The [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Hold for sedation or lethargy. The [DIAGNOSES REDACTED]. The resident continued to receive [MEDICATION NAME] 100 mg 1 tablet at 9:00 AM. A physician's orders [REDACTED]. A Comprehensive Care Plan (CCP) dated 10/12/18 for Mood documented the resident was at risk for mood and behavior changes related to [DIAGNOSES REDACTED]. The resident was combative and rigid during care. The goal was for the resident's mood to remain stable through the next review date and that the resident will accept care rendered with minimal combativeness, will be re-approached to complete care when necessary through the next review date, and will be maintained on the lowest therapeutic dose of [MEDICAL CONDITION] medication through the next review date. The interventions included Psychiatry consult and follow up per the physician's orders [REDACTED]. A Psychiatry consult dated 1/31/18 documented that per the staff, the resident had severe negative behavior during personal care, particularly peri-care. [MEDICATION NAME] (an antianxiety medication) was started due to anxiety and combativeness during personal care and was usually effective. The consult also documented the combative behaviors reported was confined to personal care, and that it was fine to use a Benzodiazepine (a class of drug that acts as tranquilizers used to treat anxiety) if it was useful in decreasing anxiety during care. The consult further documented that the resident's behaviors do not seem to be Psychotic and if the resident's behavior is more manageable on [MEDICATION NAME] to consider decreasing the [MEDICATION NAME]. A Nursing Progress note dated 10/25/18 titled [MEDICAL CONDITION] Drug Use documented the resident was receiving [MEDICATION NAME] 50 mg po QD at 5:00 PM and [MEDICATION NAME] 100 mg po at 9:00 AM for [MEDICAL CONDITION]. [MEDICATION NAME] 0.25 mg po TID for Anxiety, [MEDICATION NAME] 60 mg po QD at 9:00 AM for Depression. The resident's social interactions are limited due to Dementia. A Pharmacy recommendation dated 11/15/18 documented that the resident had successful reduction of his [MEDICATION NAME] in September. Please evaluate for further reduction. The Pharmacist suggested lowering the morning dose from 100 mg to 75 mg. In the Physician's agreement section it was documented that the Physician disagreed with the recommendation. The rationale documented for disagreeing with the Pharmacy recommendation was as follows: Given the short week, plan to trial next week after discussion with the nursing staff. A Physician's 60 Day Note dated 11/27/18 documented the resident had a past medical history that included Alzheimer's Dementia, [MEDICAL CONDITION] with progressive decline in cognition, and that the resident receives [MEDICATION NAME] for Dementia with Associated [MEDICAL CONDITION]/Mania Depression with [MEDICAL CONDITION]. A Nursing Progress note dated 1/21/19 titled [MEDICAL CONDITION] Drug Use documented the resident was taking [MEDICATION NAME] 60 mg po QD at 9:00 AM for Depression, [MEDICATION NAME] 0.25 mg po TID for Anxiety, [MEDICATION NAME] 50 mg po QD at 5:00 PM and [MEDICATION NAME] 100 mg po at 9:00 AM for [MEDICAL CONDITION]. A 60 Day Medical note dated 1/28/19 documented the resident was [AGE] years old with a past medical history that included [MEDICAL CONDITIONS] and Dementia with progressive decline in cognition. The resident was receiving [MEDICATION NAME] for [DIAGNOSES REDACTED]. A gradual dose reduction (GDR) was conducted on 9/10/18 and the outcome was successful. There was no documented clinical rationale in the Medical note that addressed the recommendation to evaluate for further reduction. A Pharmacy recommendation dated 2/7/19 documented to please evaluate this quarter for a possible dose reduction of [MEDICATION NAME]. It was documented in the Physician section that the Physician disagreed with the recommendation. The Physician's rationale for disagreeing with the Pharmacy recommendations was as follows: Plan to maintain [MEDICATION NAME] at current dose as the resident has occasional distressed behavior. A Social Service assessment dated [DATE] documented the resident had short and long term memory problems and cannot be interviewed. A staff interview was conducted. The resident has no behaviors, however, can be rigid/resistive during care secondary to his [DIAGNOSES REDACTED]. A review of the nursing progress notes dated 1/23/18, 1/29/18, 3/29/18, and 7/27/18 documented the resident was physically aggressive or combative during morning care. A review of the progress notes dated from (MONTH) (YEAR) to (MONTH) 2019 was conducted and there were no documented evidence of any behavioral symptoms for which the resident was receiving [MEDICATION NAME] in the progress notes. There was no documented evidence in the medical record that an evaluation of the resident's behavior with the intent to decrease or discontinue the [MEDICATION NAME] was conducted. Further review of the medical record revealed the resident was last evaluated by a Psychiatrist on 1/31/18. Resident #25 was observed on 3/1/19 at 11:00 AM sitting in a wheel chair in the hallway with a companion present. The resident appeared calm, no behaviors were observed. The resident was observed on 3/5/19 at 10:30 AM sitting in a wheel chair in the hallway with eyes closed. No behaviors were observed. During an interview conducted on 3/5/19 at 11:01 AM with the day shift Certified Nursing Assistant (CNA), she stated that she has been caring for the resident since (MONTH) (YEAR). The CNA stated that the resident requires total care that he was able to hold onto the side rails during turning. The CNA stated when caring for the resident at times his eyes are closed and that the resident swings out, but not aiming at any one, and that this behavior occurs daily during care. The CNA stated that sometimes she waits until the nurse gives the resident his medication as the resident is calmer afterwards. The CNA stated that when she touches the resident's legs to put his pants on the resident swings his legs. The CNA stated the resident will respond appropriately to greetings and simple questions; however, does not initiate conversation and when he resident does speak his words do not make sense. The CNA stated once care is completed and the resident is in the chair the resident is calm. The CNA stated the resident attends program on and off the unit and likes music. The CNA further stated the resident does not have any behaviors towards other residents and that the resident is only resistive during care. During an interview conducted on 3/5/19 at 3:10 PM with the evening shift CNA, she stated that she has worked on the unit for the last two years and has floated to the resident's assignment frequently. The CNA stated the resident requires total assist in all areas of activities of daily living (ADLs). The CNA stated that the resident is put back to bed before dinner, requires the assist of two staff members, and that at times the resident will hold onto the side rail when he is being turned. The CNA stated the resident is combative only when his diaper and clothes are being changed. The CNA stated the resident will hit or kick at the staff, however, when the resident is in his wheel chair he had no behaviors, and enjoys being with his peers in the dining room. The CNA further stated that during care, when staff explains the procedure to the resident prior to care, it helps to calm the resident. An observation of ADL care was conducted on 3/6/19 at 10:15 AM with the resident's assigned CNA and assisted by a second CNA. The CNA was observed to explain care to the resident prior to washing the resident's face and prior to cleansing the resident's perineal area, and there were no behaviors noted. The CNAs were observed to quickly turn the resident onto his right side and the resident was observed reaching out with his left hand, then holding onto the left hand of his assigned CNA. The CNA guided the resident's hand to the side rail and the resident was observed holding on to the rail while the CNA completed care. After care, both CNAs assisted with dressing the resident and there were no behaviors exhibited. The resident's eyes were closed during the care. An interview was conducted on 3/7/19 at 9:06 AM with the Pharmacist for the 2nd floor nursing unit. The Pharmacist stated that she felt that the dose the [MEDICATION NAME] was too high and that she felt an additional GDR was needed. The Pharmacist stated that she made recommendations on 11/15/18 and again on 2/7/19 for further reduction and for the Physician to document a rationale if he disagreed with the recommendation. During an interview conducted on 3/7/19 at 9:27 AM with the Registered Nurse (RN) in charge, she stated that she has been involved in the care of the resident for the past five years. The RN stated that she administers treatment to the resident's buttocks and occasionally will assist the CNAs with care. The RN stated during treatment the resident does not have any behaviors, however, the resident is difficult to turn. The RN stated the only time the resident was observed with behaviors was during brief changes. The RN stated that episodic behavior notes are documented in the progress notes. A review of the progress notes was conducted with the RN during the interview, and there was no documented evidence of behaviors from (MONTH) (YEAR) to 3/8/19. During a subsequent interview on 3/7/19 at 9:40 AM with the RN in charge, she stated that she did not recall any discussions with the Physician regarding a GDR in (MONTH) of (YEAR). The RN stated that the last GDR was successfully attempted in (MONTH) of (YEAR) and since then the resident has been on [MEDICATION NAME] 100 mg in the morning and 25 mg 2 tablets in the evening. The RN further stated that there was no discussion with the Physician regarding the resident's behavior or GDR attempt during the month of (MONTH) 2019. During an interview conducted on 3/7/19 at 10:20 AM with the Physician, he stated he has been caring for the resident from admission. The Physician stated that he did request an evaluation from Psychiatry due to the high doses of [MEDICATION NAME] the resident was receiving. The Physician stated that his intention was to decrease [MEDICATION NAME] and eventually discontinue the medication. The Physician stated, regarding the Pharmacy recommendations on 11/15/18 and 2/7/19 to evaluate for further reduction of the [MEDICATION NAME], that he had a discussion with the nurse in (MONTH) of (YEAR) regarding the resident's behavior and that he did not address the GDR at that time because his intention was to revisit the reduction in his next 60 day visit in (MONTH) of 2019. The Physician stated, regarding the (MONTH) 2019 recommendation from the Pharmacy, his intention was to address the GDR on the next cycle which was towards the end of (MONTH) 2019. The Physician further stated that he had not witnessed the resident with any behavioral symptoms and that his intentions were to initiate a GDR until the [MEDICATION NAME] was discontinued. The Physician stated he did not attempt a further GDR because when he when he confers with the nursing staff they report to him the resident had aggressive behaviors during care. During an interview conducted on 3/8/19 at 2:15 PM with the Psychiatrist, she stated that she followed the resident from admission. The Psychiatrist stated that the resident was admitted on high doses of [MEDICATION NAME] and the intent was to gradually wean the resident off the medication. The Psychiatrist stated that last time she saw the resident was on 1/31/18 and that her recommendation was for the Physician to decrease the [MEDICATION NAME]. The Psychiatrist stated that she believes the resident's behavior was not as a result of [MEDICAL CONDITION] but due to the resident's worsening Dementia. The Psychiatrist further stated that it was an oversight that the resident was not seen since 1/31/18, and that she should have followed through to ensure that further attempts were made to reduce the [MEDICATION NAME]. During an interview conducted on 3/7/19 at 3:23 PM with the Director of Nursing Services (DNS) she stated, after review of the resident medical record, that the resident was not seen by a Psychiatrist since 1/31/18. The DNS stated that residents should be followed by the Psychiatrist as ordered by the resident's Physician. The DNS further stated the expectation is for residents who are receiving [MEDICAL CONDITION] medication, to be on the lowest dose possible and attempts made to discontinue the medication if medically indicated. 415.12(l)(2)(ii)

Based on record review and staff interviews during the Recertification Survey the facility did not ensure that the Pharmacy Consultant reported medication irregularities to the attending physician. Specifically, Resident# 204 received a [MEDICAL CONDITION] medication [MEDICATION NAME] ([MEDICATION NAME]) 2.5 milligrams (mg) every eight hours when necessary (PRN) for 14 days, without supportive documentation for the use. There is no documented evidence the Pharmacy Consultant reported the [MEDICAL CONDITION] medication documentation irregularity to the Physician. The finding is: A facility policy and procedure (P/P) dated 7/1/03 and reviewed on 10/2018, documented the Pharmacy Consultant will review the appropriateness of all [MEDICAL CONDITION] medications. The P/P also documented that the Pharmacy Consultant will consult with the Physician to ensure each resident is on the correct [MEDICAL CONDITION] or PRN [MEDICAL CONDITION] medication. Resident #204 is [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 4 indicating the resident had severe cognitive impairment. The MDS documented the resident received 7 days of an antipsychotic medication during the look back period. A Physician order [REDACTED]. A Medication Regimen Review (MRR) dated 2/18/19 documented upon review of the resident's medication regimen there were no irregularities. A Medication Administration Record [REDACTED]. A review of the medical record revealed there was no documented evidence the Pharmacy Consultant reported to the Physician the lack of an evaluation or supportive documentation prior to the initiation of the PRN antipsychotic medication. An interview was held on 3/7/19 at 9:00 AM with the Pharmacy Consultant. The Pharmacy Consultant stated that she had not found any irregularities in the past 4 months. The Pharmacy Consultant stated she did not realize that an evaluation and supportive documentation was needed prior to administration of a 14 day PRN antipsychotic medication. The Pharmacy Consultant stated she was not aware of the P/P. 415.18(c)(2)

Based on record review and staff interviews during the Recertification Survey the facility did not ensure that a comprehensive person-centered care plan was developed and implemented for each resident that includes measurable objectives and time frames to meet a resident's medical and nursing needs for one (Resident #255) of one resident reviewed for Respiratory Care. Specifically, Resident #255 has a [DIAGNOSES REDACTED]. The finding is: The facility's policy titled Comprehensive Care Planning last revised 8/2018 documents that the facility will develop a person centered care plan for each of the facility's residents to ensure that appropriate care is provided to the residents. The resident's overall health status will be taken into account to ensure that their physical, emotional, psychological, and spiritual needs and preferences are met to attain the individual resident's highest practical level of well-being. Resident #255 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 1/28/2019 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. The MDS documented that the resident received oxygen therapy. The resident had the following physician's orders [REDACTED]. -Oxygen via nasal cannula continuously at 3 liters per minute for [DIAGNOSES REDACTED]. -Montelukast sodium 10 milligram (mg) tablet daily for [DIAGNOSES REDACTED]. -Proair HFA 90 microgram inhaler, two inhalations orally every 6 hours as needed for [DIAGNOSES REDACTED].>-Pulmonology consult; -[MEDICATION NAME] 20 mg tablet daily for [DIAGNOSES REDACTED]. Resident #255 was observed ambulating in the hallway with a physical therapist on 2/28/2019 at 10:45 AM. The resident appeared short of breath and was placed back in his wheelchair. The resident was taken back to his room to rest. The Registered Nurse (RN) unit clinical nurse manager was interviewed on 2/28/2019 at 10:50 AM. She stated that the resident has a history of [MEDICAL CONDITION], recently received a pacemaker due to [MEDICAL CONDITION], and has had issues with recurrent Pneumonia. Review of the medical record revealed that there was no Comprehensive Care Plan (CCP) with nursing interventions and goals addressing respiratory distress, [MEDICAL CONDITION], or oxygen therapy. The RN unit charge nurse was interviewed on 3/5/2019 at 12:11 PM. He stated that care plans are not created necessarily for every diagnosis. He stated the fluid restriction for [MEDICAL CONDITION] should be in the nutrition care plan. Review of the nutrition care plan revealed that fluid restriction was not addressed. The RN unit clinical nurse manager was re-interviewed on 3/6/2019 at 12:11 PM. The RN stated that care plans are made by the charge nurse and reviewed by the clinical nurse manager. She stated there should be a care plan addressing [MEDICAL CONDITION] nursing interventions. In addition, she stated that the resident is on oxygen and that oxygen should be addressed in a care plan. 415.11(c)(1)

Based on record review and staff interviews during a Recertification survey, the Facility did not ensure that a thorough investigation was completed to rule out abuse, mistreatment or neglect. This was noted for one resident (Resident #85) out of 32 reviewed in Stage 2 sample. Specifically,the facility did not thoroughly investigate a skin tear sustained from a fall on 8/11/16. The finding is: Resident # 85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Quality Assurance document dated 7/7/16 revealed an investigation of resident sustaining a right elbow skin tear. The investigation documented that the resident hit the bathroom handle bar and sustained the skin tear. A Comprehensive Care Plan (CCP) dated 7/7/16 was documented for impaired skin integrity related to fragile skin. The CCP documented that the resident had a history of [REDACTED]. Preventative approaches included Geri sleeves to bilateral arms. A Quality Assurance document dated 8/11/16 revealed an investigation of a 4 centimeter (cm) x 4 cm skin tear to right elbow. The investigation documented that the resident sustained [REDACTED]. The investigation documented causes including poor safety awareness, anticoagulant therapy, unsteady gait and sleep -wake disturbance. The investigation documented no interviews or information regarding the Geri sleeves, which were implemented during a prior similar incident. The unit RN Supervisor was interviewed on 8/29/16 at 11:00 AM and stated that as per CCP the Geri sleeves should be on at all times. She stated that the evening shift RN completed the post event evaluation on 8/11/16 and initiated the investigation which was reviewed by the interdisciplinary team on 8/12/16. The RN stated that,we should have asked if they were wearing the Geri sleeves at the time of the incident. 415.4(b)(i)(ii)

Based on observation record review and staff interviews during the standard survey, the facility did not ensure that the Comprehensive Care Plan (CCP) was periodically reviewed and revised by a team of qualified persons. This was evident for one of three residents reviewed for Activities of Daily Living (ADL) (Resident # 181) in a total of thirty two Stage 2 Sampled residents. Specifically,1) Resident #181 had a change in her ADL status for Locomotion on the unit. There is no documented evidence that the ADL CCP was revised to reflect the change. 2) Resident #298's CCP did not reflect a [DIAGNOSES REDACTED]. Additionally, there was no documented evidence that the resident's family member was given in-service education about feeding her family member that had a [DIAGNOSES REDACTED]. The findings are: 1) Resident #181 has [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) Score of 9 which indicated severe cognition loss. The resident required limited assistance with one staff member for locomotion on the unit. The MDS dated [DATE] documented that the resident had a BIMS score of 7 which indicated severe cognition loss. The MDS also documented that the resident now required extensive assistance with one staff member for locomotion on the unit. A CCP dated 4/15/16 and titled ADL documented mobility, supervision to limited assistance is no documented update to the CCP. There was no documented evidence that the ADL CCP was reviewed and revised to reflect the change in locomotion. An interview was held with the MDS Coordinator on 8/30/16 at 12:40 PM. The MDS Coordinator reviewed the medical record and stated that there was no documented evidence that the ADL CCP was reviewed and revised for the ADL change in locomotion. The MDS Coordinator stated that the Unit Charge Nurse who was responsible for the revision of the CCP no longer worked in the facility. 2) Resident # 298 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that the Resident's Brief Interview for Mental Status (BIMS) was 3/15 (severe cognitive impairment). Additionally, the resident required extensive assistance of one person for eating. On 8/29/16 at 1:00 PM Resident # 298 was observed with his head slightly hyperextend (looking up) while being fed by a family member. The resident was seated in the unit dining room. The family member was observed standing over the resident feeding the resident with a spoon. The Charge Nurse Registered Nurse (RN) was interviewed on 8/29/16 at 1:45 PM immediately and stated that the family member (wife) does feed the resident for lunch and dinner. The Certified Nursing Assistant (CNA) was interviewed on 8/29/16 at 1:50 PM. The CNA stated that the resident's wife feeds the resident while standing over him. The facility policy and procedure dated 7/15 titled Resident Feeding by Family documented the following: Family members who feed their relatives will be given a Safe Feeding In-service and will be monitored by the staff for adherence to the guidelines. Any relatives who wish to feed their family member will be identified by the Nutrition Staff. The family member will be given the Safe Feeding booklet by the Nutrition Staff. The Comprehensive Care Plan will be revised to include family feeding. The nurse will observe and document that the relatives provide feeding assistant and follow the Safe Feeding Guidelines. Record review revealed that there was no documented evidence that an assessment was completed for the resident with a [DIAGNOSES REDACTED]. The Charge Nurse Registered Nurse (RN) was interviewed on 8/29/16 at 1:00 PM. The RN stated that there was no care plan developed for the [DIAGNOSES REDACTED]. The RN Manager was interviewed on 8/29/16 at 2:30 PM. The Manager stated that the care plan and in service for the family member will begin today. 415.11(c)(1)

Based on observation, record review, and staff interviews during the standard survey, the facility did not ensure that a facility Comprehensive Care Plan (CCP) was developed for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing and mental and psychosocial needs. This was evident for one (Resident #284) of one resident reviewed for Death in a total of thirty two Stage 2 sampled residents. Specifically, Hospice Care was initiated on 4/16/16 and there was no documented evidence that a facility CCP was developed for Hospice Care. The finding is: Resident #284 is an [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had long and short term memory loss and was severely impaired with making decisions. The resident was evaluated by Hospice on 4/14/16. A Physician order [REDACTED]. Review of the medical record on 8/30/16 revealed that there was no documented evidence that a CCP was developed by the facility for Hospice Care. An interview was held with the MDS Coordinator on 8/31/16 at 12:30 PM. The MDS Coordinator reviewed the medical record and stated that there is no facility CCP developed for Hospice. The MDS stated that the Unit Charge Nurse is responsible for the development of the CCP and that the Unit Charge Nurse was not in the facility today. An interview was held with the Registered Nurse (RN) In service Educator on 8/30/16 at 1:15 PM. The RN stated that there should have been a facility CCP developed for Hospice Care. 415.11(c)(1)

Based on observation, staff interviews and record review during an abbreviated survey, the facility did not ensure that each resident is provided adequate monitoring for effectiveness and modifying intervention when necessary. Specifically for one (Resident #1) of three residents, reviewed for accidents, was previously observed by facility staff in his motorized wheel chair in the facility's parking lot (restricted area for motorized wheel chairs) contrary to his signed contract. However, the plan of care was not reviewed and or revised to assess effectiveness or need for modification of interventions. On [DATE], at approximately 12 noon, Resident #1 fell in the parking lot when his motorized wheel chair tipped off of a curb resulting in fracture of C1 (cervical 1) ring. Resident #1 expired at the hospital four days later. This resulted in actual harm that is not Immediate Jeopardy. Complaint ID Number: NY 898 Findings include: The facility policy dated ,[DATE] titled Motorized Wheelchair/Scooter Safety documented outdoor operation: motorized wheelchairs/scooter are not allowed in the roadways, parking lots or loading dock, keep to the center of the sidewalk. The care plan will be reviewed at least quarterly. Any incident of unsafe driving will be immediately reported to the charge nurse. The charge nurse/rehabilitation staff will assess the resident and initiate appropriate interventions. Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident/registrant motorized/Scooter Agreement dated [DATE] documented that Resident #1 agreed to abide by the facility safety requirement/regulations regarding driving a motorized wheel chair or scooter. Resident #1 may be assessed as an unsafe/hazardous driver if he demonstrated one or more of the following behaviors: drive on the roadway, in the parking lot, and or in other restricted areas. The Minimum Data Set 3.0 dated [DATE] documented Resident #1's cognition status as intact. Locomotion off unit supervision with set up help only. The Comprehensive Care Plan (CCP) dated [DATE] for Activities of Daily Living documented interventions including adaptive equipment wheel chair quantum power (electric) with right calf pad, left foot box, seat belt, head support and tilt function. He uses his electric wheel chair for mobility on and off the unit. The CCP dated [DATE] documented at risk for falls due to history of falls balance deficits side effects of medication and weakness. Interventions including falls care as per facility standard of care. On [DATE] evaluation documented resident with actual fall outside in wheel chair sent to emergency room for evaluation. The Quality Assurance Document (Incident Report) dated [DATE] documented resident observed lying on right side with wheel chair on its side, his head was next to curb, resident alert and responsive. The summary of the event dated [DATE] documented that resident and electric wheelchair observed lying on right side next to curb in the parking. Ambulance called by security. Resident alert and responsive. No change in level of consciousness. Resident transferred to hospital emergency room for further evaluation. Investigation concluded that the investigation has revealed that there was no reasonable cause to believe any alleged resident abuse, neglect or mistreatment occurred. The Nursing Progress Note dated [DATE] documented resident outside, self propelling in electric wheel chair, had a fall off curb. Resident and wheel chair observed lying on right side-his head next to the curb. Resident alert and responsive, moving arm freely, no change in level of consciousness. Skin tear noted to right ear and right elbow. The Nursing Progress Note dated [DATE] documented Emergency Department contacted regarding resident status. Informed resident still in emergency room but had been admitted to hospital with [DIAGNOSES REDACTED]. The medical record lacked documented evidence of Resident #1 being found in the north parking lot prior to the incident on [DATE]. During an interview with the Physical Therapist (PT) on [DATE] at 2:30 PM, the PT stated that he was not aware of Resident #1 being found in the parking lot. The PT stated that resident was assessed for safety using the motorized wheel chair and was allowed to go out on the facility grounds in the designated areas. Resident #1 was alert and oriented and was aware of his safety bounds as he had signed a contract regarding safe use of the motorized wheel chair. The residents using the motorized wheel chair are observed using visual demonstration with verbal instruction, the therapist takes the resident out to the approved area, residents are clearly told to not go to the parking lot. The PT stated that when the residents breach their contract, verbal counseling with an update of the care plan is warranted. During an interview with the 7:00 AM-3:00 PM shift Charge Nurse (CN) on [DATE] at 2:51 PM, the CN stated that a couple of weeks (don't recall date) prior to the incident on [DATE] she was notified (could not recall by whom) that Resident #1 was observed outside in the north parking lot (restricted area for motorized wheel chairs). The CN stated that she verbally counseled the resident and advised him to not go to the restricted areas. The CN stated that she would not normally update the care plan for a one time event of the resident not following the contract agreement. Knowing (Resident #1) his freedom was everything to him and he told me that he would not go out to the parking lot again and I believed him. The CN stated that she should have documented the incident in the nursing progress note. During an interview with the 7:00 AM-3:00 PM shift Registered Nurse Supervisor (RNS) on [DATE] at 3:00 PM, the RNS stated that Resident #1 was found in the north parking lot (unable to recall the date) taking pictures of plants and butterflies. The RNS stated that Resident #1 was verbally counseled and she should have documented the same in the care plan and progress note. The RNS stated that she had verbal conversation with the social worker and charge nurse to notify them of resident being found in the parking lot. 415.12(h)(1)(2)