Every finding on record at New Riverdale Rehab and Nursing

Based on record review and interview during the Recertification and Complaint (NY00371559) Survey conducted from 03/12/2025 to 03/19/2025, the facility did not ensure that residents were free from abuse, neglect, and exploitation. This was evident in two (2) (Residents #242 and #117) of two (2) residents reviewed for abuse out of 31 total sampled residents. Specifically, Resident #242 who had history of physically abusive behavior and physical altercations with other residents, was not provided adequate supervision and monitoring despite staff being aware of Resident #242's behavior. Subsequently, on 02/08/2025 at approximately 12:30 PM, Resident #242 punched Resident #117 in the head while both residents were in the bathroom. Resident #117 sustained laceration to the left eyebrow area that required emergency medical intervention. Resident #117's injury required seven (7) sutures and necessitated two (2) trips to the emergency room . This resulted in actual harm to Resident #117 that was not Immediate Jeopardy. The findings are: The facility's policy titled Clinical Protocol for Abuse and Neglect with a last reviewed date of 01/2025 stated that abuse may be defined as the willful infliction of injury of punishment with resulting physical harm. Willful, as used in this definition of abuse, means the individual must have acted deliberately. An Accident Investigation Report dated 02/08/2025 documented on 02/08/2025 at approximately 12:30 PM, Resident #117 stated another resident punched them in the forehead while they were using the toilet. Resident #242 stated they punched Resident #117 because they were taking too long, and they wanted to take a shower. The Supervisor Investigative Summary report documented Resident #242 had history of paranoid schizophrenia and had been known to experience periods of severe aggression during which they threatened and physically attacked staff and residents. Resident #242 was erratic and displayed flat affect with no remorse for the occurrence. To prevent reoccurrence, Resident #242 was escorted by the police to the precinct. The Facility Investigation dated 02/08/2025 completed by the Director of Nursing stated on 02/08/2025 at approximately 12:30 PM, staff responded to Resident #117 who was holding their forehead stating that Resident #242 punched them several times in the forehead. Resident #117 was noted with bleeding and skin opening to the forehead. The facility investigation documented on 02/08/2025 at 12:15 PM, Resident #242 was observed exiting their room with washcloth and towels in their hand heading towards the bathroom. At 12:25 PM Resident #117 was observed entering the same bathroom and then exited at 12:30 PM holding their forehead. 911 was activated. Two police officers responded and escorted Resident #242 out of the facility in handcuffs. The Social Worker followed up with the precinct and was informed that Resident #242 had been released to a shelter on 02/09/2025 . Resident #117 was transferred to the emergency room and returned the same day with diagnosis of laceration repair with seven (7) intact sutures. The facility investigation did not indicate which part of Resident #117 had laceration. The facility concluded it was an isolated incident and there was no cause to believe any alleged resident abuse, exploitation, or neglect occurred. The investigation documented the investigation had not identified deviation from residents' care plan. The facility investigation further documented it was an isolated incident and systemic actions were not identified. 1.) Resident #242 was admitted to the facility with diagnoses of paranoid schizophrenia (a mental health condition characterized by persistent, irrational, and unfounded beliefs that others are conspiring or intending to harm or deceive the individual), Diabetes Mellitus (a disorder characterized by high blood sugar level), and peripheral vascular disease (a condition where blood vessels outside the heart and brain become narrowed or blocked, reducing blood flow to the extremities). The Minimum Data Set (a resident assessment tool) dated 11/24/2024 documented Resident #242 had intact cognition, was ambulatory, and was independent in activities of daily living. A care plan for abuse/victim was initiated for Resident #242 on 06/14/2022. The care plan documented Resident #242 was at risk to abuse others related to poor impulse control, as well as verbally and physically abusive behavior. There were no goals or interventions documented in the care plan. A care plan note dated 05/05/2023 documented Resident #242 hit another resident on the head with a chair. A care plan note dated 04/04/2024 documented Resident #242 slapped their roommate's face. There was no documented evidence that the care plan for abuse/victim has been reviewed for each episode of resident altercations or that interventions were in place to prevent resident to resident abuse. A care plan for behavior as evidenced by actual peer-to-peer physical altercation and aggressive/destructive behavior was initiated for Resident #242 on 07/27/2022. The facility interventions included to notify the physician of changes in behavior, social service evaluation and follow-up, and staff to observe and redirect when resident wanders away from their room. The behavior care plan notes documented as per nursing progress note dated 07/31/2022, Resident #242 exhibited threatening and verbally aggressive behavior toward staff. A care plan note dated 05/05/2023 documented Resident #242 hit another resident on the head with a chair. A care plan note dated 01/18/2024 documented on 01/15/2024, Resident #242 used offensive language towards their roommate and was moving towards the roommate in a threatening manner. A care plan note dated 02/16/2024 documented Resident #242 hit another resident in the face. A care plan note dated 04/04/2024 documented Resident #242 slapped their roommate in the face. There was no documented evidence that the facility evaluated the effectiveness of the care plan interventions or updated the interventions after each episode of resident altercations, and there were no interventions to assure the safety of other residents. A nurse's progress note dated 02/08/2025 at 7:33 PM documented at approximately 12:30 PM, Resident #242 punched Resident #117 in the head. Resident #242 had been known to exhibit periods of severe aggression during which they physically attacked and threatened staff and residents. Given the escalating nature of the situation, 911 was called. Resident #242 was transported by the police at approximately 1:20 PM. 2.) Resident #117 was admitted to the facility with diagnoses of opioid dependence (a physical and psychological need for pain relieving medications), Hypothyroidism (a condition that happens when your thyroid gland doesn't make or release enough hormone) and chronic viral Hepatitis C (an infection that affects the liver). The Minimum Data Set, dated dated dated [DATE] documented Resident #117 was moderately cognitively impaired and required partial/moderate assistance with toileting, and shower/bathing. Resident #117 was able to walk 10 feet with partial/moderate assistance and used a manual wheelchair for mobility. A care plan for potential for abuse was initiated for Resident #117 on 09/23/2024. The care plan documented Resident #117 had potential to be abused by peers secondary to congregate living. The care plan goal was for Resident #117 to be free from abuse by others. The facility interventions included to assist resident to develop familiar and trusting relationship and offer positive behavior. A nurse's progress note dated 02/08/2025 at 7:09 PM documented at 12:30 PM, staff responded to Resident #117 who stated they were punched by another resident. Resident #117 was noted with 1.5 x 0.5 x 1.0 centimeter laceration on the forehead. Resident #117 stated Resident #242 told them to get out while they were using the toilet. Resident #117 stated they were taking too long and then Resident #242 punched them several times in the head. Resident #117 was transferred to the emergency room for further evaluation. A nurse's progress note dated 02/08/2025 at 10:31 PM documented Resident #117 returned from the hospital at 7:39 PM. The notes documented as per emergency room after visit summary, Resident #117 had a computed tomography scan (a type of imaging that uses X-ray techniques to create detailed images of the body) of the cervical spine, head, and face with negative findings. Laceration repair done (the note did not indicate which body part) with seven (7) intact sutures. Resident's left eye was swollen with minimal bleeding noted. A nurse's progress note date dated 02/10/2025 at 10:49 PM by Registered Nurse #3 documented Resident #117 had profuse bleeding in his left inner upper eyelid, dressing was saturated with blood oozing from the skin opening. Pressure dressing was not enough to control the bleeding, 911 was called and resident was transferred to the emergency room . Resident returned to the facility with no new orders. A physician's progress note dated 02/11/2025 at 4:01 PM documented Resident #117 was seen and examined following an emergency room visit for traumatic facial injury sustained during a resident-to-resident altercation. Physical examination revealed redness of the right conjunctiva (outer membrane of the eyeball and inner eyelid), facial bruises, bilateral eyelid swelling, with the left eye swollen completely shut. Resident #117 had a cut on the forehead with stitches, right eye redness, and left eye swollen shut due to eyelid edema. The progress note documented bleeding was controlled, to increase staff surveillance for safety precautions, eye bandaging to prevent scratching, eyedrops for irritated eyes to both eyes, to continue eye care and wound monitoring, and reassess for swelling and signs of infection. On 03/18/2025 at 12:44 PM, The Social Service Director was interviewed and stated Resident #242 was known to have a short fuse and has had a history of aggressive behavior. On 03/19/2025 at 9:44 AM, the Director of Nursing was interviewed and stated they investigated the incident that occurred on 02/08/2025 involving Residents #242 and #117. They stated Resident #242 had no insight and their action was psychiatrically motivated. They stated Resident #117 likes to stay in the hallway in front of their room and chose to use the bathroom at the same time that Resident #242 wanted to shower. The Director of Nursing stated they concluded abuse had not occurred because Resident #242 had no actual intent to harm Resident #117. On 03/19/2025 at 4:22 PM, the Administrator was interviewed and stated the incident on 02/08/2025 involving Residents #242 and #117 could have not been predicted or prevented. 10 NYCRR 415(b)(1)(i)

Based on observation, record review, and interviews during the Recertification Survey conducted from 03/12/2025 to 03/19/2025, the facility did not ensure that a resident's right to a safe, clean, comfortable, and homelike environment was maintained. This was evident in 1 (Unit 3) of 3 resident units. Specifically, residents' rooms were not cleaned, had broken appliance and furniture, and chipped paint. The findings include but are not limited to: The facility's policy titled Maintenance Service with a revised date of 01/07/2025 documented maintenance service shall be provided to all areas of the building, grounds, and equipment in a safe and operable manner at all times. During multiple observations from 03/12/2025 at 9:23 AM to 03/14/2025 at 12:35 PM, the following were observed in Unit 3: room [ROOM NUMBER]E 308A had urine-stained mattress, and a closet with holes and missing a lock. room [ROOM NUMBER]E 308B was noted with strong urine odor, missing nightstand, and sticky floor with brown colored stains. room [ROOM NUMBER]E 310B had damaged wall surface by the head of the bed board, blue tape was observed on the television remote control. room [ROOM NUMBER]E 312B was without a television. room [ROOM NUMBER]E 312C had dusty and broken television which was missing a power cord, and stained privacy curtain. Multiple rooms in Unit 3 had walls with scratches/scruff marks, cracked and chipped paints and floors were noted with sticky stained substance. Wooden closets were observed with scuff marks and scratches and were missing locks. The Unit 3 Maintenance Log from 01/01/2025 to 03/14/2025 did not contain repair requests for the above observations. The Environmental Rounding Checklist dated 03/04/2025 documented room [ROOM NUMBER] was noted with a broken dresser and room [ROOM NUMBER] had walls with splatter. On 03/18/2025 at 12:31 PM, the Facilities Director stated they conduct weekly environmental rounds, and repairs are completed when there are issues found. The Facilities Director stated they replaced the broken dresser in room [ROOM NUMBER] and completed the repairs found during environmental rounds conducted on 03/04/2025. The Facilities Director stated the housekeeping staff are responsible for emptying garbage bins and basic cleaning of resident rooms and bathrooms. They stated privacy curtains are checked daily and must be replaced if stained. On 03/19/2025 at 2:21 PM, the Administrator was interviewed and stated the team will work on a plan to correct the environmental problems to ensure residents are provided with clean, homelike environment 10 NYCRR 415.5(h)(2)

Based on record review and interviews during the Recertification and Complaint (NY00371559 and NY00372528) Survey conducted from 03/12/2025 to 03/19/2025, the facility did not ensure all alleged violations involving abuse, neglect, or mistreatment including injuries of unknown origin are reported immediately, but not later than 2 hours after the allegation is made to the administrator of the facility and to the State survey agency. This was evident in 5 (Residents #25, #36, #93, #117 and #242) of 31 total sampled residents. Specifically, 1.) On 02/14/2025 at approximately 4:00 PM, Resident #25 reported that the Certified Nursing Assistant assigned to them the night before was too rough. This alleged abuse incident was not reported to the New York State Department of Health. 2.) On 02/04/2025, Resident #93 was observed with right eyelid swelling and dark discoloration. Resident #93 was unable to explain how they sustained the swelling and discoloration. This injury of unknown source was not reported to the New York State Department of Health. 3.) On 02/25/2025 at approximately 12:30 PM, Resident #36 reported that a Certified Nursing Assistant called them handicapped and crippled. This allegation of verbal abuse was not reported to the facility administrator and to the New York State Department of Health. 4.) On 02/08/2025 at approximately 12:30 PM, Resident #242 punched Resident #117 in the head. This incident was reported to the New York State Department of Health on 02/09/2025 at 1:51 AM. The findings are: The facility's policy titled Abuse and Neglect with a revised date of 01/2025 documented the facility will ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown source and misappropriation of resident property, are reported immediately but not later than two hours after the allegation is made, if the event cause the allegation involve abuse, or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse or result in serious bodily injury to the administrator of the facility and to other officials including to the State Survey Agency. 1. Resident #25 had diagnoses of Diabetes Mellitus, Major Depressive Disorder, and Cerebrovascular Disease. The Minimum Data Set assessment dated [DATE] documented Resident #25 had intact cognition. On 03/12/2025 at 10:55 AM, Resident #25 was interviewed and stated they were assaulted by a staff in the morning of 2/14/2025 and was reported to the charge nurse. The facility Incident Report dated 02/14/2025 documented Resident #25 reported their assigned Certified Nursing Assistant was too rough and tried to woke resident up from their sleep on 02/14/2025 around 5:00 AM. The facility investigation concluded there was no reasonable cause to believe that alleged abuse, neglect, or mistreatment occurred. There was no documented evidence Resident #25's allegation that the staff was rough during care was reported to the New York State Department of Health. On 3/18/2025 at 11:30 AM, the Assistant Director of Nursing was interviewed and stated on 02/14/2025 at around 3:00 PM, Resident #25 reported that the aide assigned to them was too rough during care earlier that morning. The Assistant Director of Nursing stated they immediately initiated the investigation and was able to conclude that the allegation was not an abuse but a staff performance and customer service issue. On 03/19/2025 at 12:33 PM, the Director of Nursing was interviewed and stated that the report made by Resident #25 that a staff was rough during care was not an allegation of abuse therefore, they did not report the alleged incident to the New York State Department of Health. 2. Resident #93 had diagnoses of Dementia, Mood Disorder, and Paranoid Schizophrenia. The Minimum Data Set assessment dated [DATE] documented Resident #93 had short and long term memory problem and moderately impaired cognitively skills for daily decision making. A medical progress note dated 02/24/2025 documented Resident #93 had right eyelid swelling and dark discoloration. Resident #93 had dementia and history was not obtainable. The medical note documented Resident #93 was assessed with traumatic right eyelid injury. There was no documented evidence that the injury was reported to the New York State Department of Health. On 03/19/2025 at 12:33 PM, the Director of Nursing stated Resident #93 has a behavior of rubbing their face on the wall which is their baseline. It was not reported to the New York State Department of Health since it was not considered an unknown injury. 39136 3. Resident #36 had diagnoses of Arthritis and Hypertension. The Minimum Data Set assessment dated [DATE] documented Resident # 36 had intact cognition and required substantial assistance with personal hygiene. On 03/12/2025 at 2:14 PM, Resident #36 was interviewed and stated that two weeks ago, a Certified Nursing Assistant called them handicapped and reported the incident to the Assistant Director of Nursing. The facility incident report dated 02/25/2025 documented that Resident #36 reported that the Certified Nursing Assistant who was assigned to them called them handicapped and crippled . The facility investigation concluded there was no evidence to believe an alleged abuse, neglect, or mistreatment occurred. On 03/19/2025 at 1:23 PM, the Director of Nursing was interviewed and stated Resident #36 told them that a Certified Nursing Assistant called them handicapped. The Director stated they initiated an investigation and Certified Nursing Assistant 7 denied the allegation. The Director of Nursing stated the allegation was not reported to the New York State Department of Health because they concluded that the incident was a customer service issue and not verbal abuse. On 03/19/2025 at 9:18 AM, the Administrator was interviewed and stated that the Director of Nursing is responsible for reporting abuse cases to the Department of Health. The Administrator stated the Director of Nursing did not inform them of Resident #36's allegation of verbal abuse against the aide. The Administrator stated the allegation was verbal abuse and should have been reported to the New York State Department of Health. 43350 4. Resident #242 was admitted to the facility with diagnoses of paranoid schizophrenia (a mental health condition characterized by persistent, irrational, and unfounded beliefs that others are conspiring or intending to harm or deceive the individual), Diabetes Mellitus (a disorder characterized by high blood sugar level), and peripheral vascular disease (a condition where blood vessels outside the heart and brain become narrowed or blocked, reducing blood flow to the extremities). The Minimum Data Set (a resident assessment tool) dated 11/24/2024 documented Resident #242 had intact cognition, was ambulatory, and was independent in activities of daily living. An Accident Investigation Report dated 02/08/2025 documented on 02/08/2025 at approximately 12:30 PM, Resident #117 stated another resident punched them in the forehead while they were using the toilet. Resident #242 stated they punched Resident #117 because they were taking too long, and they wanted to take a shower. The Supervisor Investigative Summary report documented Resident #242 had history of paranoid schizophrenia and had been known to experience periods of severe aggression during which they threatened and physically attacked staff and residents. Resident #242 was erratic and displayed flat affect with no remorse for the occurrence. The incident was reported to the New York State Department of Health on 02/09/2025 at 1:51 AM. On 03/19/2025 at 9:44 AM, the Director of Nursing was interviewed and stated the team felt abuse had not occurred because they felt that Resident #242 had no insight and did not intend to injure Resident #117, therefore, they felt no urgency to report the incident within the 2 hour timeframe to the New York State Department of Health. 10 NYCRR 415.4(b)(2)

Based on record review and interviews during the Recertification Survey conducted from 03/12/2025 to 03/19/2025, the facility did not ensure that a resident's comprehensive care plan was reviewed and revised by the interdisciplinary team based on a resident's changing needs, goals, and in response to current interventions. This was evident in 1 (Resident #40) of 31 sampled residents. Specifically, Resident #40's comprehensive care plan was not reviewed and revised after each incident of non-compliance with the smoking policy. The findings are: The facility policy titled Care Plan-Comprehensive with a last revised date of 01/2025 documented that assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The Interdisciplinary Team reviews and updates the care plan when the desired outcome is not met. Resident #40 had diagnoses that included Anxiety Disorder and Schizophrenia. The quarterly Minimum Data Set assessment dated [DATE] documented Resident # 40 had moderately impaired cognition. A Comprehensive Care Plan for Smoking - danger to self and other was initiated for Resident #40 on 05/09/2023. The care plan documented that Resident #40 was a known smoker. The facility interventions included allowing the resident to smoke in a designated smoking area with supervision as needed and checking clothing regularly for signs of unsafe smoking. A care plan note dated 05/24/2023 documented Resident #40 was observed hiding a cigarette in their pocket, a lighter was also found in their pocket. A care plan notes dated 10/24/2023 and 12/26/2023 documented Resident #40 was observed smoking in their room. There was no documented evidence that the facility updated the care plan interventions after the incidents on 05/24/2023, 10/24/2023, and 12/26/2023. A nuse's progress note dated 09/12/2024 at 1:54 AM documented that at approximately 12:30 AM, Resident #40 was seen going to the first-floor bathroom. The staff checked Resident #40's pockets and found a lit cigarette and a lighter. Resident #40 was redirected back to their room and reminded of the facility's smoking policy. A review of Resident #40's smoking care plan had no documented evidence that the care plan was revised with new interventions after the incident on 09/12/2024. On 03/18/2025 at 12:30 PM, Registered Nurse #1, who was the nursing supervisor, was interviewed and stated that Resident #40 was found with a lit cigarette in their pocket on 09/12/2024. They stated the nursing supervisors are responsible for revising the care plan and that no new intervention was added to Resident #40's smoking care plan after the 09/12/2024 incident. On 03/19/2025 at 2:09 PM, the Director of Nursing was interviewed and stated they became aware of the incident on 09/12/2024. They stated that the nursing supervisor is responsible in updating the care plans and that there was no new intervention added to Resident #40's smoking care plan after the 09/12/2024 incident. 10 NYCRR 415.11(c)(2)(i-iii)

Based on record review and interview during the Recertification Survey conducted from 03/12/2025 to 03/19/2025, the facility did not ensure that it promoted and facilitated a resident's right to self-determination through support of resident's choice. This was evident in 1 (Resident #5) of 1 resident reviewed for Choices out of 31 total sampled residents. Specifically, Resident #5's bathing preference was not honored. The findings are: The facility policy titled Activities of Daily Living, Shower with the last revised date of 01/2025 documented that it is the facility's policy to shower residents, cleanse and refresh them, observe their skin, and increase circulation. Staff are to check the assigned shower schedule for their shift. Resident #5 was admitted to the facility with diagnoses that include Chronic Obstructive Pulmonary Diseases and Heart Failure. The annual Minimum Data Set assessment dated [DATE] documented Resident #5 had intact cognition and that it was very important for Resident #5 to choose between a tub bath, shower, or sponge bath. On 03/13/2025 at 11:29 AM, Resident #5 was observed resting in their room. Resident #5 was interviewed and stated that the last time they got a shower was almost two months ago. The resident stated they were washed in bed although sometimes they would like to get a shower. A care plan for occupational therapy, activities of daily living, self-care perfromance deficit was initiated for Resident #5 on 02/03/2025. The facility interventions included one person physical assist for bathing, bathing types were bed bath, shower, and sponge bath. The Resident Shower Schedule documented that Resident 5 had showers scheduled on Tuesdays and Fridays during the 3:00 PM to 11:00 PM shift. The Resident Certified Nursing Assistant Documentation History Detail Report dated 01/03/2025 to 03/14/2025 documented Resident #5 received bed baths. Review of Resident #5's medical record did not reveal documentation that the resident refused showers. On 03/17/2025 at 3:44 PM, Certified Nursing Assistant #1 was interviewed and stated that Resident # 5 was scheduled for showers in the afternoon. They stated Resident #5 gets a bed bath because they refuse showers. On 03/17/2025 at 3:57 PM, Licensed Practical Nurse #1 was interviewed and stated that Resident #5 gets a bed bath and does not get a shower. They stated they had not receive any report from the Certified Nursing Assistant that Resident #5 refused showers. On 03/17/2025 at 4:05 PM, Registered Nurse #1, who was the nursing supervisor, was interviewed and stated that Resident #5 has shower scheduled on Tuesdays and Fridays during the 3:00 PM to 11:00 PM shift. They stated Resident #5 is given bed baths and was never taken to the bathroom for a shower. Registered Nurse #1 stated there was no documentation that the bed bath is the resident's preference, or that Resident #5 refused showers, or that the resident preferred a bed bath to a shower. On 03/19/2025 at 1:54 PM, the Director of Nursing was interviewed and stated that it is the facility's policy to shower the residents twice a week and as needed. They stated that, it was documented that Resident #5 received bed baths and there was no documentation that Resident #5 refused showers. The Director of Nursing stated the nurse on the unit is responsible for ensuring that care is provided to the residents as ordered. 10 NYCRR 415.5(b) (1-3)

Based on record review and interview during the Recertification Survey conducted from 03/12/2025 to 03/19/2025, the facility did not ensure that a comprehensive person-centered care plan for each resident was developed and implemented, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. This was evident in 1 (Resident #36) of 3 residents reviewed for care planning out of 31 total sampled residents. Specifically, Resident #36 had no comprehensive care plan developed to address at risk for abuse. The findings are: The facility policy titled Care Planning- Interdisciplinary Team with a last revised date of 01/2025 documented that the interdisciplinary team is responsible for the development of resident care plans. Resident #36 was admitted to the facility with diagnoses that included Arthritis and Hypertension. The admission Minimum Data Set assessment dated [DATE] documented Resident #36's cognition was intact. On 03/12/2025 at 2:14 PM, Resident #36 was interviewed and stated that 2 weeks ago, a Certified Nursing Assistant called them handicapped and reported the incident to the Assistant Director of Nursing. The facility incident report dated 01/25/2025 documented that at approximately 12:00 PM, Resident #36 reported that the Certified Nursing Assistant called them handicapped and crippled A review of Resident #36's comprehensive care plans had no documented evidence that a care plan for at risk for abuse or victimization was developed for Resident #36. On 03/19/2025 at 1:39 PM, the Director of Nursing was interviewed and stated Resident #36 was discharged to their home in 2024 and was readmitted to the facility in January of this year. They stated there was no abuse care plan initiated for Resident #36 when they were again admitted to the facility. On 03/19/2025 at 9:18 AM, the Administrator was interviewed and stated they should have opened a new medical chart when Resident #36 was again admitted to the facility in January 2025. The alleged verbal abuse allegation should have been included in the abuse care plan. 10 NYCRR 415.11(c)(1)

Based on record review and interviews during the Recertification Survey conducted from 03/12/2025 to 03/19/2025, the facility did not ensure that the services provided or arranged by the facility as outlined by the comprehensive care plan, met professional standards of quality. This was evident in 1 (Resident #39) of 5 residents reviewed for Unnecessary Medications and Medication Regimen Review. Specifically, serum depakote level was ordered for Resident #39 on 02/12/2025. There was no documented evidence that the serum level was obtained. Cross Reference: F756 Drug Regimen Review, Report Irregular, Act on F711 Physician Visits - Review Care/notes/order The findings are: The facility policy titled Laboratory and Diagnostic Test Results with a revised date of 01/2025 documented that the Physician will identify, and order diagnostic and laboratory testing based on the resident's diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. The laboratory, diagnostic radiology provider or other testing source will report test results to the facility. Physicians or nurses who have concerns about how test results have been handled or reported should communicate such concerns to the Director of Nursing and/or the Medical Director. Such concerns or disagreements should not prevent timely, clinically appropriate management of a current result or clinical situation. Resident #39 had diagnoses of Non-Alzheimer's Dementia and Schizoaffective Disorder. The quarterly Minimum Data Set assessment dated [DATE] documented Resident #39 had moderately impaired cognition and had received anticonvulsive and antipsychotic medications since admission/entry or reentry into the facility. A physician order which was initiated on 01/25/2023 and renewed on 02/25/2025 documented a medication order for Depakote Sprinkles 125 milligram capsules, delayed release, 5 capsules (625 milligrams) to be administered by oral route 3 times a day with food. A Medication Administration Record dated March 2025 documented that Resident #39 was administered 625 milligrams of Depakote Sprinkles by oral route 3 times a day. A care plan for psychotropic use was initiated for Resident #39 which was last reviewed on 03/07/2025. The facility interventions include to monitor laboratory results for drug levels. A Pharmacy Consultant Medication Regimen Review progress note dated 02/11/2025 documented Resident #39 was currently receiving Depakote, unable to locate a recent serum level in the chart, recommended 2 weeks after start then every 6 months thereafter. The note documented to please consider ordering. A Medication Regimen Review Response progress note dated 02/12/2025 documented the Nurse Practitioner's response to the Consultant Pharmacist's recommendation for Resident #39 as follows -Agree Will do. A Physician Laboratory Order dated 02/12/2025, documented Depakene - Serum Valproate one time 02/13/2025. There was no documented evidence that the serum level for Depakote was drawn. There was no documented evidence that the licensed nurses, physician, or the nurse practitioner followed up if the serum level has been completed. On 03/19/2025 at 9:23 AM, the Nurse Practitioner was interviewed and stated that Depakote level was ordered for Resident #39 on 02/12/2025 as recommended by the pharmacy consultant. The Nurse Practitioner stated they wait for the Registered Nurse to inform them of the laboratory test results. They stated they were not notified of the results or the reason why was the serum level not obtained. On 03/19/2025 at 12:23 PM, the Medical Director was interviewed and stated the Nurse Practitioner should have followed up timely when they had not received the laboratory results. On 03/19/2025 at 10:58 AM, the Director of Nursing was interviewed and stated that the expectation was that the attending physician or rhe nurse practitioner will follow up on the laboratory results. 10 NYCRR 415.11(c)(3)(i)

Based on observation, record review, and interview during the Recertification Survey conducted from 03/12/2025 to 03/19/2025, the facility did not ensure that a resident maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. This was evident in 1 (Resident #122) of 5 residents reviewed for nutrition. Specifically, Resident #122 had significant weight loss of greater than 7.5 % in the last 3 months from November 2024 through February 2025 with no proactive interventions. The findings are: The facility policy titled Weight Policy with a revision date of 03/2025 documented the purpose of this procedure are to determine the resident's weight and height, to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident, and to provide a baseline height in order to determine the idea weight of the resident. Resident #122 had diagnoses of Hypertension, Unspecified Protein Calorie Malnutrition, and Right Below Knee Amputation and Right Foot Burn. The Minimum Data Set assessment dated [DATE] documented Resident #122 had intact cognition and required minimal assistance and supervision with activities of daily living. A review of the Comprehensive Care Plan on Nutritional Status dated 09/22/2024 documented Resident #122 was at risk for nutrition related problem secondary to diagnosis of thiamine and vitamin deficiency. The goal set was nutrition - related laboratories results will be at baseline for medical condition, will be free from chewing and swallowing difficulties, will increase 1-2 pounds weight gradually and Per Orem intake will be sufficient to support nutrition and hydration needs. The interventions were listed as follows: consult with physician as needed, consult with dietician as needed , daily calorie needs based on ideal Body weight of 148 pounds or 67 kilograms. The total calorie needs was calculated at 1675-2010 total calorie needs, 67 grams of protein and 1657 to 2101 milliliter of fluids, to monitor food consumption during mealtimes, and monitor weekly weight. A review of the resident's weight from 11/29/2024 to 02/28/2025 showed an undesirable weight loss of 12% in the last 3 months. 11/29/2024 - 133 pounds 12/13/2024 - 125.2 pounds 12/20/2024 - 134 pounds 12/27/2024 - 133.9 pounds 01/03/2025 - 116.6 pounds 01/10/2025 - 116 pounds 01/24/2025 - 116.1 pounds 02/28/2025 - 117 pounds A review of Resident #122's care plan and dietary notes revealed no intervention to address the significant weight loss of 17.3 pounds in January 2025. The 03/11/2025 3:51 PM dietary progress note documented Resident #122 had significant and undesirable weight loss of 16 pounds, 12% in 3 months; 20.4 pound weight loss, 14.8% in 5 months. Weight is pending for March. The dietary note documented, weight loss was discussed with the resident who acknowledged he has good appetite and that they were losing weight prior to admission due to their illness. The plan was to monitor intake and weekly weights. During an interview with the Registered Dietician on 03/14/2025 at 12:06 PM, they stated they have not seen Resident #122's January and February weight record and was informed of the weight loss in March. They stated they only come to the facility twice a week and cannot do everything. During an interview with Nurse Practitioner #1 on 03/14/2025 at 12:51 PM, they stated they were not aware of Resident #122's weight loss until March. They stated they do not remember anybody discussing the resident's weight loss with them. They stated that the recommendations to manage weight loss should come from the dietitian. During an interview with the Assistant Director of Nursing on 03/14/2025 at 1:14 PM, they stated changes in a resident's diet and weight loss are discussed during the morning meeting and is communicated to the dietary department. They stated weight records are on the resident's notes and can be reviewed by the dietitian. 10 NYCRR 415.12 (i)(1)

Based on record review and interview during the Recertification Survey conducted from 03/12/2025 to 03/19/2025, the facility did not ensure that the physician reviewed the resident's total program of care, including medications and treatments, at each visit. This was evident in 1 (Resident #39) of 5 residents reviewed for Unnecessary Medications and Medication Regimen Review. Specifically, the Nurse Practitioner failed to follow up on the results of a serum Depakote level ordered on 02/12/2025. Cross Reference: F756 Drug Regimen Review, Report Irregular, Act on F658 Services Meet Professional Standards The findings are: The facility policy titled Laboratory and Diagnostic Test Results with a revised date of 01/2025 documented that the Physician will identify and order diagnostic and laboratory testing based on the resident's diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. The laboratory, diagnostic radiology provider or other testing source will report test results to the facility. Physicians or nurses who have concerns about how test results have been handled or reported should communicate such concerns to the Director of Nursing and/or the Medical Director. Such concerns or disagreements should not prevent timely, clinically appropriate management of a current result or clinical situation. The facility policy titled Physician Services with a reviewed date of 01/2025 documented that the physician will address laboratory and other diagnostic test results in a timely manner based on the resident's condition and the clinical significance of the results. The physician will periodically review all medications prescribed for their patients and will monitor both for continuing indications and for possible adverse drug reactions. The medication review should take into account observations and concerns offered by pharmacy consultants and others regarding beneficial and possible adverse impacts of medications on the resident. The attending physician will perform accurate, timely and relevant assessments as needed. The physician will respond to notification of and will assess and manage acute and significant changes in resident condition. Resident #39 had diagnoses of Non-Alzheimer's Dementia and Schizoaffective Disorder. The quarterly Minimum Data Set assessment dated [DATE] documented Resident #39 had moderately impaired cognition and had received anticonvulsive and antipsychotic medications since admission/entry or reentry into the facility. A physician order which was initiated on 01/25/2023 and renewed on 02/25/2025 documented a medication order for Depakote Sprinkles 125 milligram capsules, delayed release, 5 capsules (625 milligrams) to be administered by oral route 3 times a day with food. A Medication Administration Record dated March 2025 documented that Resident #39 was administered 625 milligrams of Depakote Sprinkles by oral route 3 times a day. A care plan for psychotropic use was initiated for Resident #39 which was last reviewed on 03/07/2025. The facility interventions include to monitor laboratory results for drug levels. A Pharmacy Consultant Medication Regimen Review progress note dated 02/11/2025 documented Resident #39 was currently receiving Depakote, unable to locate a recent serum level in the chart, recommended 2 weeks after start then every 6 months thereafter. The note documented to please consider ordering. A Medication Regimen Review Response progress note dated 02/12/2025 documented the Nurse Practitioner's response to the Consultant Pharmacist's recommendation for Resident #39 as follows -Agree Will do. A Physician Laboratory Order dated 02/12/2025, documented Depakene - Serum Valproate one time 02/13/2025. There was no documented evidence that the serum level for Depakote was drawn. There was no documented evidence that the physician or the nurse practitioner followed up if the serum level has been completed. On 03/19/2025 at 9:23 AM, the Nurse Practitioner was interviewed and stated that Depakote level was ordered for Resident #39 on 02/12/2025 as recommended by the pharmacy consultant. The Nurse Practitioner stated they wait for the Registered Nurse to inform them of the laboratory test results. They stated they were not notified of the results or the reason why was the serum level not obtained. On 03/19/2025 at 12:23 PM, the Medical Director was interviewed and stated the Nurse Practitioner should have followed up timely when they had not received the laboratory results. 10 NYCRR 415.15 (b)(2)(iii)

Based on record review and interviews during the Recertification Survey conducted from 03/12/2025 to 03/19/2025, the facility failed to address an irregularity identified during Drug Regimen Review to minimize or prevent adverse consequences. This was evident in 1 Resident (Resident #39) of 5 residents reviewed for Unnecessary Medications and Medication Regimen Review. Specifically, on 02/11/2025, the pharmacy consultant recommended Depakote serum level for Resident #39. There was no evidence that the serum level has been obtained. The findings are: The facility policy titled Drug Regimen Review with a revised date of 03/2025 documented that in accordance with Code of Federal Regulations 42 CFR 483.45, the Consultant Pharmacist shall review the medical record of each resident and perform a Drug Regimen Review at least once each calendar month. The Consultant Pharmacist shall identify, document, and report possible medication irregularities for review and action by the attending Physician, where appropriate. The attending Physician or licensed designee shall respond to the Drug Regimen Review within 30 days or more promptly whenever possible and act upon the Drug Regimen Review Findings/recommendation in a timely manner of 30 days or less by documenting on the drug regimen review form whether they agree or disagree with the recommendation. The facility policy titled Laboratory and Diagnostic Test Results with a revised date of 01/2025 documented that the physician will identify and order diagnostic and laboratory testing based on the resident's diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. The laboratory, diagnostic radiology provider or other testing source will report test results to the facility. Physicians or nurses who have concerns about how test results have been handled or reported should communicate such concerns to the Director of Nursing and/or the Medical Director. Such concerns or disagreements should not prevent timely, clinically appropriate management of a current result or clinical situation. Resident #39 had diagnoses of Non-Alzheimer's Dementia and Schizoaffective Disorder. The quarterly Minimum Data Set assessment dated [DATE] documented Resident #39 had moderately impaired cognition and had received anticonvulsive and antipsychotic medications since admission/entry or reentry into the facility. A physician order which was initiated on 01/25/2023 and renewed on 02/25/2025 documented a medication order for Depakote Sprinkles 125 milligram capsules, delayed release, 5 capsules (625 milligrams) to be administered by oral route 3 times a day with food. A care plan for psychotropic use was initiated for Resident #39 which was last reviewed on 03/07/2025. The facility interventions include to monitor laboratory results for drug levels. A Pharmacy Consultant Medication Regimen Review progress note dated 02/11/2025 documented Resident #39 was currently receiving Depakote, unable to locate a recent serum level in the chart, recommended 2 weeks after start then every 6 months thereafter. The note documented to please consider ordering. A Medication Regimen Review Response progress note dated 02/12/2025 documented the Nurse Practitioner's response to the Consultant Pharmacist's recommendation for Resident #39 as follows -Agree Will do. A Physician Laboratory Order dated 02/12/2025, documented Depakene - Serum Valproate one time 02/13/2025. There was no documented evidence that the serum level for Depakote was drawn. On 03/19/2025 at 9:23 AM, the Nurse Practitioner was interviewed and stated that Depakote level was ordered for Resident #39 on 02/12/2025 as recommended by the pharmacy consultant. The Nurse Practitioner stated they wait for the Registered Nurse to inform them of the laboratory test results. They stated they were not notified of the results or the reason why was the serum level not obtained. On 03/19/25 at 10:58 AM, the Director of Nursing was interviewed and stated if the sample was not collected, the laboratory should communicate with the nurse. The Director of Nursing stated a follow up should have been done for laboraory requests that were not completed. 10 NYCRR 415.18(c)(2)

Based on observation, record review, and interviews during the Recertification Survey conducted from 03/12/2025 to 03/19/2025, the facility did not ensure that the results of the most recent survey was posted in a place readily accessible to residents, visitors, or legal representatives of residents. Additionally, there was no posted notice of availability of such reports in areas of the facility that are prominent and accessible to the public. Specifically, the facility's survey results were located in a binder inside the security office. The findings are: The facility's policy titled Examination of Survey Results with a reviewed date of 01/2025 documented that survey reports and plans of correction are readily accessible to the residents, family members, resident representatives and to the public. A copy of the most recent survey report and any plans of correction are kept in a binder in the lobby. Survey reports, certifications, complaint investigations and plans of correction for the preceding three years are available for any individual to review upon request. Information containing the right to examine, the location of and how to request preceding years' survey reports and plans of correction are posted on the resident bulletin board and at each nurses' station. Inquiries concerning the examination of survey results should be referred to the administrator and/or to the Director of Nursing. During multiple observations on 03/12/2025 and 03/13/2025, there were no notices of availability of the survey results posted throughout the facility including the facility lobby was observed. On 03/14/2025 at 9:16 AM, a binder labeled Survey Results was observed inside the security office. On 03/14/2025 at 2:59 PM, an observation of the facility lobby, reception area, and security office was performed with the Director of Recreation and the Director of Nursing. A binder labeled Survey Results was observed on the wall inside the security office. The Activities Director stated that the security staff will provide the binder to anyone who asks to view it. There was no notice of availability of the survey results posted in the facility lobby, reception area, or the security office. The minutes of the Resident Council Meetings for the months of December 2024, January and February 2025 had no documentation that the resident council was informed of the availability and location of the most recent New York State Department of Health survey reports and plans of correction. On 03/14/2025 at 2:15 PM, during the Resident Council Meeting, Residents #13, #32, #36, #58, #76, #79, #100, #109, #123 stated they did not know where to find the survey results in the facility and they have not seen any notice telling them where to find such reports. On 03/14/2025 at 3:05 PM, the Director of Nursing was interviewed and stated that the binder containing the survey results and the notice of its availability were previously located on the wall in front of the reception/security office but over the weekend, the painters removed the posting and were not replaced. On 03/14/2025 at 3:16 PM, the Administrator was interviewed and stated that a signage of the availability of the survey results and a binder containing the survey results should have been placed by the security desk which would provide access to all visitors and residents. The Administrator stated that no one should have to ask to view the survey results as they should be easily accessible and readily available. The Administrator further stated that the binder containing the survey results, and the sign of the availability was removed for renovations and was not put back in the same place as staff was instructed to do. 10 NYCRR 415.3(d)(1)(vi)

Based on observation, interviews, and record review conducted during the recertification and abbreviated survey (NY00315600, NY00316068) from 6/13/23 to 6/21/23, the facility did not ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours, to the New York State Department of Health (NYSDOH). This was evident for 4 (Resident #43, Resident #92, Resident #99 and Resident #117) of 4 reviewed for abuse out of 27 sampled residents. Specifically, 1) the facility did not report an allegation of resident to resident abuse involving Resident #43 and Resident #117 to the NYSDOH within 2 hours. 2) the facility did not report an allegation of resident to resident abuse involving Resident #92 and Resident #99 to the NYSDOH within 2 hours. The findings are: The facility policy titled Abuse, Mistreatment, and Neglect dated 1/95 and updated 2/7/23 documented the Office of Health Systems Management (OHSM) will be notified immediately by administration, if in fact there is a reasonable cause to believe that an occasion of abuse, mistreatment, or neglect did occur, followed by a written report within 48 hours, on DOH 513, which is mailed to OHSM. 1) Resident # 43 had diagnoses of bipolar disorder and unspecified intellectual disabilities. The Minimum Data Set 3.0 (MDS) dated [DATE] documented the resident had moderately impaired cognition. Resident #117 had diagnoses of acute osteomyelitis and type 2 diabetes. The MDS dated [DATE] documented Resident #117 was cognitively intact. The facility's incident reported initiated 5/5/23 documented resident #43 and resident #117 were involved in a physical altercation on 5/5/23 at 10:05am. Resident #43 was sitting outside of residents #117 room. Resident #117 asked resident #43 to move and resident #43 did not. Resident #117 then hit the resident #43 with a chair. Staff reported they heard a loud scream and responded to Resident $43 bleeding. The Aspen Complaint Tracking System documented the facility reported this allegation of physical abuse to the NYSDOH on 5/5/23 at 2:38 PM, more than 2 hours after the incident. On 06/20/23 at 10:44 AM the Director of Nursing (DON) was interviewed and stated the incident involving Resident #117 and Resident #43 happened at 10:05am on 5/5/23. It was reported to the NYSDOH at 1:02 PM. The DON reported by the time the staff stabilize, interview, investigate, inform family, and then report the incident to the NYSDOH, it was over two hours. The DON reported the incident should have been reported within 2 hours. 45351 2) Resident #92 had diagnoses of vascular dementia and paranoid schizophrenia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #92 had severely impaired cognition. Resident #99 had diagnoses of opioid abuse and coronary artery disease. The MDS dated [DATE] documented Resident #99 had severely impaired cognition. The facility's incident report initiated 4/27/23 documented Resident #92 and Resident #99 were involved in a physical altercation on 4/27/23 at 5PM. Resident #92 punched Resident #99 and then Resident #99 punched and pushed Resident #92. Resident #92 was noted with scant bleeding from the mouth and was transferred for evaluation and treatment. Resident #99 was noted with a bump on the forehead and bleeding from the mouth. Resident #99 was also transferred to the hospital for evaluation and treatment. Resident #92 was transferred to another unit upon returning from the hospital to prevent reoccurrence. The investigation was completed on 4/28/23 to conclude that there was no reasonable cause to believe that any alleged abuse occurred. The Aspen Complaint Tracking System documented the facility reported this allegation of physical abuse to NYSDOH on 4/28/23 at 12:18 PM, more than 2 hours after the incident occurred On 6/21/23 at 11:24 AM, the Director of Nursing (DON) was interviewed and stated the incident involving Resident #92 and Resident #99 occurred on 4/27/23 at 5PM. The investigation was initiated immediately and was completed on the following day. DON acknowledged that alleged incident was not reported to NYSDOH within 2 hours and was submitted on 4/28/23 at 12:18 PM. 415.4(b)(1)(i)

Based on record review and interviews conducted during the Recertification survey from 06/13/2023 to 0 6/21/2023, the facility did not ensure Minimum Data Set 3.0 (MDS) assessments were electronically transmitted to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system within 14 days of completion. This was evident for 24 (Resident #s 57, 90, 70, 88, 115, 75, 10, 128, 45, 7, 53, 2, 67, 15, 102, 18, 30, 111, 94, 58, 3, 36, 81, 116) of 25 residents reviewed for Resident Assessment. Specifically, MDS assessments for Resident #s 57, 90, 70, 88, 115, 75, 10, 128, 45, 7, 53, 2, 67, 15, 102, 18, 30, 111, 94, 58, 3, 36, 81, and 116 were not transmitted and submitted to QIES within 14 days of their completion date. The findings include but are not limited to: The facility's policy titled MDS Comprehensive Assessment, Documentation Completion Policy dated 2/3/2023 documented the MDS Assessor/Coordinator submits MDS assessments that were completed timely to QIES to fulfill Federal regulations. The QIES CMS Submission Report dated 06/12/2023 documented the following MDS information: (1) The MDS assessment for Resident #75 documented Assessment Reference Date (ARD) of 05/05/2023, Completion Date of 05/18/2023 and Transmission Date of 06/12/2023. The Transmission Date was more than 14 days after Completion Date. (2) The MDS assessment for Resident #10 documented Assessment Reference Date (ARD): 05/12/2023, Completion Date: 05/24/2023 and Transmission Date: 06/12/2023. The Transmission Date was more than 14 days after Completion Date. (3) The Annual MDS assessment for Resident #128 documented Assessment Reference Date (ARD): 05/12/2023, Completion Date: 05/22/2023 and Transmission Date: 06/12/2023. The Transmission Date was more than 14 days after Completion Date. On 06/21/2023 at 11:21 AM, the MDS Coordinator was interviewed and stated of the 25 resident MDS data requested by the NYSDOH, 24 had MDS assessments that were submitted late. The MDS Department has had staffing issues and is doing the best they can. The MDS Coordinator takes full responsibility for late MDS submissions and is responsible for monitoring and ensuring that all MDS assessments are submitted timely by running a report for missing assessments. MDS Coordinator further stated they work with another facility to submit the MDS assessments in batches to QIES. The MDS department has a plan to address assessment submissions. The MDS Coordinator stated they are aware there are concerns with timely MDS submissions. 415.11

Based on observation, record review, and interviews conducted during the Recertification Survey from 6/13/23 to 6/21/23, the facility did not ensure residents were cared for in a manner that maintained or enhanced their dignity. This was evident for 1 (Resident #46) of 25 total sampled residents. Specifically, Resident #46 was observed with their Foley Catheter (FC) bag uncovered and exposed to public view. The findings are: The facility's policy titled Urinary Catheter Care dated 02/23/23 did not document privacy bag use for FC. Resident #46 had diagnosis of urinary retention and benign prostatic hyperplasia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #46 had mild cognitive impairment, required extensive assistance to transfer,and had an indwelling catheter. On 06/13/23 at 11:09 AM and 12:14 PM, Resident #46 was observed in a wheelchair in the hallway on their unit. Tubing was observed connecting Resident #46 to a FC drainage bag hanging from the back of the chair. The FC bag was not in a privacy bag. The Physician's order dated 06/11/23 documented Resident #46 had a suprapubic catheter for obstructive uropathy. The Comprehensive Care Plan (CCP) related to alteration in bowel and bladder initiated 10/18/17 documented Resident #46 had an indwelling FC. On 06/20/23 at 08:54 AM, Certified Nursing Assistant (CNA) #1 was interviewed and stated they assist Resident #46 with FC care. CNA #1 places the FC bag into a privacy bag and puts the tubing through the resident's clothing when the resident is placed in the wheelchair. Resident #46 does not refuse to wear the privacy bag. There was a day last week that Resident #46's FC was not in the privacy bag and CNA #1 reported it to the nurse because the resident's FC should have been in once. CNA #1 could not explain the reason Resident #46's FC was not in a privacy bag. On 06/20/23 at 12:21 PM, Licensed Practical Nurse (LPN) #2 was interviewed and stated they monitor catheter care and the CNA is responsible or emptying the FC drainage bag. The FC bag should be in a privacy bag while the resident is in bed and a leg bag when out of bed. Resident #46 uses a leg bag when they are out of bed. The nursing supervisor monitors the use of privacy bags for FC. On 06/21/23 at 10:43 AM, Registered Nurse (RN) #1 was interviewed and stated they expect the staff to put a resident's FC in a privacy bag when the resident is in the bed and when the resident is out of bed the FC drainage bag should be replaced with a leg bag. RN#1 reported they did not notice that Resident #46 did not have a privacy bag on 6/13/23. 415.5(a)

Based on observation, interviews, and record review conducted during the Recertification Survey from 6/13/23 to 6/21/23, the facility did not ensure the resident's right to a safe, clean, comfortable, and homelike environment. This was evident for 2 Units (Unit 1 and Unit 3) of 3 Units. Specifically, 1) Unit 1 was observed with missing window blind blades, window sills dusty and with tape 2) Unit 3 was observed with walls with mismatching paint, plaster, mismatching floor tiles, and radiator cover that was dirty and in disrepair. The findings are: The facility policy titled Environment Care Services dated 02/2023 documented regular environmental care rounds will be conducted to identify and address any broken equipment, furniture and other potential hazards that may affect the well- being and safety of the individuals within the facility. On 06/21/23 11:24 AM, Resident # 83 was interviewed and stated they were unhappy with the state of their room. The blinds didn't work well and they did not like having mismatched floor tiles and patches of different colored wallpaper. Resident # 83 stated they complained to staff about the issues and was told the facility would take care of them, but nothing was done. On 06/13/2023 at 10 AM and 06/20/23 at 10:10 AM, the following were observed: a) Unit 1 - room [ROOM NUMBER] was observed with missing multiple blind blades, gray tape surrounded the windows, and the windows sills were dusty; b) Unit 3 - Shower Room was observed with rusty radiator covers, radiator metal grills were coiled inside, grills had white spackled paints in multiple areas, and the metal grills were dusty with black debris around it; c) Unit 3 - Shower Room was observed with mismatching floor tiles, dirty floor, and mismatching paints on the walls. There was no documented evidence environmental concerns on Unit 1 and Unit 3 were reported in the Maintenance Book. On 06/21/23 10:38 AM, Unit 3 Housekeeper was interviewed and stated they clean the shower room daily, sweep and mop all the rooms, wipe down the room furniture, and if something is broken, they use the Maintenance Logbook to write down the issue. Someone in Maintenance checks the book daily. On 06/21/23 11:09 AM, the Certified Nurse Aide (CNA) #2 was interviewed and stated that there is a Maintenance Logbook on the unit for the staff to write what needs repairing on the unit. CNA stated that if a curtain is missing, they tell the nurse on the floor or sometimes they write the problem in the maintenance book. On 06/21/23 11:50 AM Licensed Practical Nurse (LPN) #1 was interviewed and stated that the facility has an ongoing painting project and if a specific room needed attention or if they saw something not working they call the maintenance to get it fixed. How long it takes to fix depends on maintenance's workload. Requests go in the maintenance book and calls them for urgent matters. On 06/21/23 11:47 AM Director of Housekeeping and Maintenance stated they work on projects all over the building, such as buffing floors and changing blinds and curtains. The nurse calls them if there is a broken blind or dirty curtain, and they go to the floor and fix them. Director of Housekeeping and Maintenance also stated that they oversee replacing wallpaper and painting. There is a maintenance book where requests are put in for maintenance staff. 415.11

Based on observation, interviews and record review conducted during the recertification and complaint survey (NY00303941) from 6/13/23 to 6/21/23, the facility did not ensure that resident's environment was free from accident hazards. This was evident for 1 (Resident #340) of 4 reviewed for Accidents out of 27 total sampled residents. Specifically, Resident #340 who was severely cognitively impaired and had a history of removing Wander Alert Device (WAD) was able to bypass locked system to the basement level via elevator and exited the facility undetected through a broken emergency exit door. The findings are: The facility policy titled Wandering and Elopement dated 2/23 documented the safety and wellbeing of all residents with a potential for wandering is always ensured. The Aspen Complaint Tracking System (ACTS) intake documented that on 10/17/22 at 2:30PM, Resident #340 went down to the basement level via elevator and exited through an emergency exit door. Resident #340 was found by a staff member in the parking lot at 3PM and was returned to the facility without injury. No WAD was found on the resident. Review of the camera video footage revealed that staff pushed the button for the elevator from the basement level then had walked off when the elevator came to the basement. The identified staff was suspended, and the broken emergency exit door was serviced by the outside vendor. A facility tour was conducted with the Director of Facility Maintenance (DFM) on 6/21/23 at 9:45 AM. The emergency exit door in the basement was observed closed and tested to be functioning. The two elevators were observed to be locked to basement level, requiring a special key to be able to go to basement level. There were signage posted on the wall between two elevators in the basement level documenting to wait for the elevator to prevent possible elopement. Resident #340 had diagnoses of Alzheimer's disease and bipolar disorder. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #340 had severely impaired cognition and did not exhibit wandering behavior. The Wandering/Elopement assessment dated [DATE] documented Resident #340 was at risk for wandering and elopement. The Medical Doctor Orders (MDO) initiated 8/19/22 and renewed 10/5/22 documented that Certified Nursing Assistant (CNA) checks for the WAD at the beginning and end of each shift, the nurse checks for WAD placement every shift, and the supervisor checks functioning of the WAD once daily. The Comprehensive Care Plan (CCP) related to wandering initiated 8/20/22 and last revised 10/17/22 documented interventions to encourage Resident #340 to engage in group activities/attempt to keep occupied, alert staff regarding the resident exhibiting behavior, provide a picture of the resident to the front desk, assist in re-orienting to their room, periodical check for functioning of WAD, WAD check every shift (removed by resident), visually monitor resident's location every hour, check ID bracelet, and WAD placement to the resident's left ankle. The MDO initiated 8/23/22, renewed 10/5/22 documented to place WAD #2863 on Resident #340's right arm. It was revised 10/17/22 and documented to place the WAD to left ankle. The Ancillary Administration Record from 8/19/22 to 10/17/22 documented Resident #340 had their WAD function checked daily. The hourly monitoring form dated 10/17/22 documented Resident #340 was visually checked by the CNA at every hour. On 6/21/23 at 9:26 AM, the Director of Facility Management (DFM) was interviewed and stated Resident #340 exited the building through an emergency exit door in the basement that led to the parking lot, The door is equipped with an audible alarm when someone presses on the crash bar. This notifies the security staff at the main entrance if there is an unauthorized exit. After 15 seconds of pressing on the crash bar, the emergency door unlocks allowing it to open in an emergency. The facility WAD system also alarms if a resident wearing a WAD is near the door. Resident #340 rode the elevator to the basement level and exited through the emergency door in the basement undetected. The alarm alert system did not activate when Resident #340 eloped through that door. The DFM further stated the basement is inaccessible to residents and the elevator locks if the basement button is pushed. Staff pushed the button for the basement, activating the elevator, and then walked off when the elevator came to the basement. Resident #340 got off the elevator, wandered off and eventually exited the facility to outside. DFM stated that the exit door was serviced immediately on the same day by the outside vendor. The staff member responsible for the elevator was suspended immediately after the incident. Staff in-services and posting of signage (by the basement elevator) for staff to wait for elevator to prevent resident eloping were reinforced. DFM stated that all exit doors are inspected and checked for functioning daily. On 6/21/23 at 11:24 AM, the Director of Nursing (DON) was interviewed and stated Resident #340 was discharged and does not reside in the facility. Resident #340 had no prior attempt of elopement but was assessed and identified as at risk for wandering and elopement. Because resident had history of removing the WAD, resident was monitored and visually checked every hour. Resident eloped undetected because the emergency door alarm system was down, and the resident's WAD was probably removed prior to leaving the facility. Resident #340 returned to the facility safely, without any injury and was noted without the WAD in place. A new WAD was placed on the resident and hourly monitoring was continued. The DON stated that one staff member was suspended, staff were [NAME]-serviced on elopement and all exit doors are checked daily by maintenance staff. 415.12(h)(1)(2) The facility was cited with a past non-compliance and the following Plan of Correction was implemented: For Resident #340: -Resident #340 was returned to the facility and assess with no visible injury -Resident #340 was educated against elopement and a new WAD was placed on the resident's left ankle. WAD functioning checks and hourly visual monitoring of resident were continued. -Entrance and all exit doors were inspected and fixed on 10/17/22. -CCP related to wandering and elopement was reviewed and revised on 10/17/22. -The Policy and Procedure on Elopement was reviewed by the DON and Administrator. No changes were made. -All staff were reeducated on Elopement Policy and Procedure. -Staff responsible to allow elevator to go to basement was suspended and later terminated. For all residents: -Reassessed all residents on elopement risk with wandering and history of exit seeking behaviors for WAD placement and were placed on hourly monitoring for safety. -Al residents are reassessed for elopement risk on quarterly basis. System Changes to prevent re-occurrence: -All elopement incidents will be reviewed to ensure all meet the criteria to ensure timeliness of reporting to DOH. -Episodic elopement drills conducted quarterly. -Exit doors are checked daily by the Maintenance department. -MD orders to reflect elopement risk, WAD placement/number/location and hourly monitoring. Monitoring efforts to prevent re-occurrence: -Quarterly audits were performed by DNS/Designee and as needed. -Audit findings were presented to Quality Assurance Performance Improvement (QAPI) Committee for evaluation and follow up as indicated. -Facility continued to reeducate staff on elopement policy and facility's drills. -DON/Designee monitoring of staff compliance with WAD/elopement prevention protocols and interventions quarterly.

Based on staff interviews and record review during an abbreviated survey (NY00310758), the facility did not ensure that an allegation of an actual elopement was reported timely to the New York State Department of Health (DOH). This was evident in 1 of 7 sampled residents (Resident #1). Specifically, on 02/08/2023, Resident #1 successfully eloped. The facility reported the allegation to DOH on 02/14/2023. The findings are: The Facility's policy on Accidents and Incidents - Investigation and Reporting with a review date of 07/2022, documented that all alleged violations involving suspected abuse, neglect, mistreatment, or exploitation, and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator and all other officials including to the State Survey Agency, and adult protective services in accordance with State law. The final report will be submitted to the State Survey Agency no later than 5 calendar days after first identification of the event. The Facility's Summary of Investigation dated 02/13/2023, documented that Resident #1 went for an ophthalmology clinic appointment on 02/08/2023 at 12:40 PM with an escort. At approximately 02:35 PM, CNA #1 called the facility and informed the nursing secretary that Resident #1 walked away after the appointment. CNA #1 reported that they stop at the food stand to get Resident #1 something to eat and Resident #1 walked away. CNA #1 searched for Resident #1 and activated Emergency Medical Number (911). The Administrator was informed and the facility staff went to the scene and reported the incident to the police. Resident #1's family was notified. The facility concluded that there was no evidence to support that any alleged resident Abuse, Neglect, Exploitation or Mistreatment may have occurred. Resident #1 was admitted to the facility with diagnoses of Cerebellar Stroke Syndrome, Alcohol Abuse with Alcohol Induced Anxiety Disorder, Alzheimer's Disease. Review of the Minimum Data Set (MDS, resident assessment tool) dated 11/25/2022, documented that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 9/15 (00-07 severe impairment, 08-12 moderate impairment, 13-15 cognitively intact). Resident #1 required supervision with ADLs (activities of daily living), ambulates with a cane, and did not have wandering behavior. A nurse's noted dated 02/08/2023 at 11:02 PM documented that Resident #1 left the facility with CNA #1 (Certified Nursing Assistant) to go to an ophthalmology appointment at 12:30 PM. Resident #1 was alert and oriented to time, place, and person. Resident #1 left in a stable condition. CNA #1 returned to the facility without Resident #1. On 02/28/2023, the DON (Director of Nursing) submitted an amended facility's summary of investigation. The facility made an addendum documented that Resident #1's family contacted the facility on 02/17/2023, that Resident #1 was found in the Bronx. During an interview on 02/15/2023 at 12:15 PM, the ADON (Assistant Director of Nursing) stated that they are responsible for investigating and reporting alleged violations and incidents to the DOH. The DON took over the investigation of the 02/08/2023 elopement involving Resident #1. The ADON stated that the incident should have been reported to the DOH within 24 hours, but the DON wanted to gather information first. During an interview on 02/15/2023 at 1:40 PM, the DON stated that the elopement incident on 02/08/2023 was not immediately reported to DOH because they were still gathering and putting information together. They do not want to report the incident without all the facts together. The DON stated that the decision to report depends on the situation and the conclusion of the investigation and that they decided to report the elopement because Resident #1 was still missing until 02/13/2023. The DON stated that the ADON are responsible for investigating and reporting alleged violations to DOH. On a subsequent interview on 02/16/2023 at 1:13 PM, the DON stated that the facility policy on reporting allegations to DOH stated that the facility has at least 24-48 hours to report incidents of abuse, elopement, resident to resident altercations with injury, and covid related deaths. During an interview on 02/16/2023 at 1:48 PM, the Administrator stated that they were made aware of Resident #1's elopement on the same day of the incident, 02/08/2023. The Administrator stated that it was not reported to the DOH immediately because they were still conducting the investigation and that they decided to report it out of abundance of precaution. 10 NNYCRR: 415.4(b)

Based on interviews and record review during an abbreviated survey (NY 00310758), the facility did not ensure that a resident's care plan was reviewed and revised by the interdisciplinary team following an elopement attempt. This was evident in 1 of 7 sampled residents (Resident #1). Specifically, on 12/13/2022, Resident #1 went out for an outpatient clinic appointment accompanied by a Certified Nursing Assistant #1 (CNA #1). On the way back to the facility, Resident #1 ask the driver to stop at a liquor store, when the diver refused to stop, Resident #1 started to hit the driver and attempted to get out of the moving vehicle. The facility did not ensure that Resident #1's care plan was reviewed and revised following the incident on 12/13/2022. The findings are: The facility's policy on Comprehensive Person-Centered Care Plans with a reviewed date of 07/2022, documented that the Interdisciplinary team (IDT) in conjunction with the resident and their family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The policy also documented that assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition changed. The facility's policy on Wandering and Elopement with a reviewed date of 07/2022, documented that if a resident was identified as at risk for wandering and elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Resident #1 was admitted to the facility with diagnoses of Cerebellar Stroke Syndrome, Alcohol Abuse with Alcohol Induced Anxiety Disorder, Alzheimer's Disease. Review of the Minimum Data Set (MDS, resident assessment tool) assessment dated [DATE], documented that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 9/15 (00-07 severe impairment, 08-12 moderate impairment, 13-15 cognitively intact). Resident #1 was moderately cognitively impaired, required supervision with ADLs (activities of daily living), and ambulated with a cane. The Elopement Risk assessment dated [DATE], identified Resident #1 as at risk for elopement, and refused to wear a Wanderguard. The interventions were that staff will continue to monitor Resident #1's whereabouts every hour. Resident #1 had a history of elopement or elopement attempts. A care plan on elopement/wandering was effective on 09/27/2020. Resident #1 had a potential for elopement as evidenced by walking off the unit and not advising staff, verbalization of desire to leave, refuses placement of wander guard. The interventions were to do elopement check every shift due to resident's refusal to wear the Wanderguard, to evaluate resident's desire to leave the facility, to redirect during wandering episode, to monitor resident's location at regular intervals (on hourly monitoring), and to notify security of flight situation. The care plan on elopement/wandering was last reviewed on 12/07/2022, the care plan documented that Resident #1 continued visual monitoring for elopement, continue to refuse Wanderguard, and will continue with the plan of care. The Resident Nursing Instructions (CNA Accountability) documented that Resident #1 is on elopement precautions, but did not contain information and specific instructions regarding Resident #1's risk of elopement when the resident goes out to appointment. The nurse's progress notes dated 12/13/2022, written by Registered Nurses #1 (RN #1) documented that Resident #1 went out for an outpatient clinic appointment accompanied by a CNA #1. On the way back to the facility, Resident #1 ask the driver to stop at a liquor store, when the driver refused to stop, Resident #1 started to hit the driver and attempted to get out of the moving vehicle. The CNA #1 and Driver bought Resident #1 back to the facility. During an interview on 02/16/2023 at 10:45 AM, RN #1 stated that on 12/13/2022, the escort who went with Resident #1 reported that Resident #1 wants to drink liquor before going back to the facility following an appointment. The CNA reported that Resident #1 attempted to get out of the vehicle while it was moving and then started hitting the driver. RN #1 stated that they addressed the information in the progress note as a behavior and spoke with Resident #1 but did not update the care plan. RN #1 stated that they did not notify the Director of Nursing (DON) and the Social Worker (SW). The RN #1 stated that it is the SW's responsibility to review the care plan and update the interventions on behavior. During an interview on 02/16/2023 at 9:57 AM, the SW stated that they were not aware of Resident #1 trying to get out of a moving vehicle to go to a liquor shop in December last year. The SW stated that if they had known about the incident, they could have written a note about the behavior, notified the family, and referred Resident #1 to the psychologist. The SW stated that any member of the interdisciplinary team can update the care plan. During an interview on 02/16/2023 at 1:13 PM, the DON stated that they were not aware of the incident on 12/13/2022 when Resident #1 wanted to stop by a liquor shop and tried to get out of a moving vehicle. The DON stated that if they were made aware, they could have ensured that Resident #1 does not go out for appointments anymore, they will contact the Medical Director and ask if a specialist can come to the facility instead. The care plan could have been updated with interventions, family and the MD could have been notified of the incident. The SW could have been involved too. The DON stated that if they were notified of the incident, they could have addressed it and Resident #1's elopement on 02/08/2023 could have been prevented. The DON stated that the members of the interdisciplinary teams may update the episodic care plans. 10 NYCRR: 415.11(c)(2)(i-iii)

Based on observation, interviews, and record review conducted during an abbreviated survey (NY00307575), the facility failed to protect a resident from staff abuse. This was evident for 1 out of 4 residents sampled for abuse (Resident #1). Specifically, the facility's Accident/Incident Investigation Report Summary dated 12/23/2022 documented that Resident #1 and Housekeeping Staff (HKS) #1 were engaged in an altercation. The facility's undated surveillance video recording showed that HKS #1 placed both hands on Resident #1's chest while the resident was sitting in their wheelchair and with force pushed Resident #1 backwards. The wheelchair and Resident #1 fell backwards onto the floor. Resident #1 did not sustain any injuries. The findings are: The facility's undated policy and procedure titled Abuse Prevention Program stated that residents have the right to be free from abuse, neglect, misappropriation of property and exploitation. As part of the resident abuse prevention, the administration will protect residents from abuse by anyone, including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. Resident #1 was admitted to the facility on [DATE] with diagnoses including Diabetes, Bilateral Below Knee Amputations, and schizoaffective disorder. The Minimum Data Set (MDS, an assessment tool) dated 11/11/2022 documented that Resident #1 had intact cognition. Resident #1 required extensive assist of 2 for transfers and extensive assist of 1 for locomotion. A Care Plan (CP) on resident at risk to be abused and at risk to abuse others dated 09/27/2022, documented interventions for staff to observe and document unusual behavior, to assist resident to develop familiar and trusting relationships, and to redirect unacceptable behavior. A review of HKS #1 personnel file revealed that they received in-service on abuse prevention on 02/23/2022 and in-service on Behavioral Management on 08/03/2022 prior to the incident. A Nurse's Progress Note, by the Registered Nurse Supervisor (RNS) #1, dated 12/23/2022 at 11:22 AM documented that Resident #1 reported that they were attacked by a member of staff around 10:15 AM. Due to the nature of the situation, 911 was called and the police was involved. The Police Officers and the Emergency Medical Technicians (EMTs) left the unit around 11:15 AM, leaving Resident #1 behind. The facility's surveillance video recording of the third-floor hallway, undated with no timestamp, was reviewed on 01/06/2023 with the facility's Administrator. The Administrator stated that the date of the incident was on 12/23/2022. The camera footage showed HKS #1 standing outside Resident #1's doorway with their back to the wall; another person (identified as a resident, who was none verbal and not interviewable) was standing between HKS #1 and Resident #1 who was sitting in a wheelchair. The other person walked away from between HKS #1 and Resident #1. HKS #1 did not walk away. HKS #1 was now standing and facing Resident #1. Resident #1 wheeled their wheelchair towards HKS #1 and HKS #1 placed both hands on Resident #1's chest, and with force, pushed Resident #1 backwards. Resident #1 fell backwards in their wheelchair onto the floor. The surveillance video recording ended. The facility Accident/Incident Investigation Report Summary dated 12/23/2022 documented that on 12/23/2022, Resident #1 was observed in an altercation with HKS #1. Resident #1 stated that following a verbal altercation with HKS #1 they got upset and wheeled themself towards HKS #1. HKS #1 pushed Resident #1 and Resident #1 fell off the wheelchair. Resident #1 was assessed with no visible injury noted. 911 was called and left the facility uneventfully. Resident #1 stated that they wanted to retaliate with a broomstick, but the staff intervened. HKS #1 confessed that they pushed Resident #1 for fear of their life as they alleged that Resident #1 had a knife in their hand. The Accident/Incident Investigation Report Summary concluded that the investigation revealed that there is cause to believe an alleged resident abuse, mistreatment, or neglect regarding this resident has occurred. During an interview on 01/09/2023 at 12:15 PM, Resident #1 stated that HKS #1 and they were having an adult conversation when the two began to trade insults. Resident #1 stated that HKS #1 punched them in the chest when they were outside the room and that they tried to hit HKS #1 with a broom handle. Resident #1 stated, they punched me so hard, I went over backwards and hit the floor with the back of my head. I went for the broom handle while I was on the floor. During an interview on 01/09/2023 at 12:29 PM, Resident #2 (Resident #1's roommate) stated that they were in bed on 12/23/2022 and heard Resident #1 and HKS #1 arguing before they both went outside of the room. Resident #2 stated that they do not recall what the argument was about. Resident #2 stated that HKS #1 told Resident #2 to be quiet and then pushed Resident #1. Resident #2 stated that they were in bed with a full view of the area outside the room. Resident #2 stated that they witnessed HKS #1 push Resident #1 out of their wheelchair outside room. Resident #2 stated to have never seen any knives in the room other than those used to butter bread. During an interview on 01/09/2023 at 12:58 PM, RNS #1 stated that they were called to the unit at around 10:00 AM on 12/23/2022 and were told that Resident #1 attacked a staff member. RNS #1 stated that Resident #1 told RNS #1 that they had been hit by HKS #1. RNS #1 stated that the unit staff also told them that HKS #1 had been hit by Resident #1 while HKS #1 was trying to clean the room. RNS #1 stated that Resident #1 denied having a knife and that there was no knife found. During an interview on 01/10/2023 at 10:20 AM, CNA #1 stated that they heard a commotion from Resident #1's room on 12/23/2022 and saw HKS #1 came out of Resident #1's room. CNA #1 stated that Resident #1 followed HKS #1 in an aggressive way. CNA #1 stated from their view, it looked like HKS #1 was bracing the wheelchair so that Resident #1 wouldn't roll into HKS #1. CNA #1 stated that Resident #1 then fell to the floor and picked up HKS #1's broom while threatening HKS #1 with the broom. CNA #1 stated that Resident #1 was throwing racial slurs at HKS #1. During a telephone interview on 01/10/2023 at 11:08 AM, HKS #1 stated that on the morning of 12/23/2022 at around 10:00 AM, they knocked on Resident #1's door and entered the resident's room to clean the floor when Resident #1 began cursing at them. HKS #1 stated that they rested a broom (that they were holding) on the side of the sink and asked Resident #1 what was going on. HKS #1 stated that Resident #1 picked up the broom and swung it at them, hitting them twice in the head. HKS #1 stated that they backed out of the room and Resident #1 followed them out of the room into the hallway. HKS #1 stated that Resident #1 had a sharp object between their legs. HKS #1 stated that they were robbed and stabbed a month ago, so this was the first thing they thought of when Resident #1 kept coming at them and I just did what I had to do. HKS #1 stated that they pushed Resident #1 but did not intend to hurt the resident. HKS #1 stated that they don't know what happened to the alleged knife when Resident #1 fell . HKS #1 stated that Resident #1 continued to move toward them in a threatening manner from the floor and was still wielding the broom. HKS #1 stated that they were able to duck into one of the other rooms and close the door. During an interview on 01/12/2023 at 9:34 AM, the Assistant Director of Nursing (ADON) stated that they investigated the incident between Resident #1 and HKS #1. The ADON stated that HKS #1 admitted to pushing Resident #1 when Resident #1 allegedly charged after them with a knife. The ADON stated that a knife was not found during the search. In a follow up telephone interview with the ADON on 02/03/2023 at 12:15 PM, the ADON stated that the staff are told that when a resident becomes combative, they are to give them space to prevent injury and time to calm down without approaching the resident. The ADON stated that if the staff are pursued, they must escape, but they are to avoid confrontation to protect themselves and to protect the resident. 10NYCRR 483.12(a)(1)

Based on record review, and resident and staff interviews during the recertification survey and abbreviated survey (Complaint#NY 516) conducted from 4/26/21 to 4/30/21, the facility did not ensure a resident received adequate supervision and assistance to prevent accidents. Specifically, a staff member did not check the water temperature prior to spraying the resident with water during a shower. The resident sustained a second-degree burn. This was evident for 1 of 5 residents reviewed for Accidents (Resident #15). This resulted in actual harm that is not immediate jeopardy. The finding is: The facility policy and procedure titled, Bathing and Personal Care (Dated 01/25/2021) documented all residents in the facility will have supervision or direct administration of their personal care by the nursing staff. The procedure for showers documented staff should check the water pressure and temperature conduciveness by dipping their fingertips and then hand into the water stream coming from the shower until the conduciveness has been checked and rechecked. The pressure and temperature should be adjusted according to the resident's tolerance and preference. The procedure also documented that the resident safety should always be maintained. Resident #15 was admitted with diagnoses which include [CONDITION(S)] (PVD), Muscle Weakness, and [CONDITION(S)]. The Annual Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition, and no behaviors were displayed. The resident required the extensive assist of one person for bathing. Resident did not exhibit falls. Resident received both occupational and physical therapy. The Comprehensive Care Plan (CCP) for Activities of Daily Living (ADL)/Bathing, effective 2/12/19, updated 10/12/20, documented the resident needed the physical help of 1 person for bathing. Interventions included body/sponge bath PRN; encourage maximum participation with bathing, showers, or whirlpool biweekly (BW) and PRN; explain care; provide assistance/verbal cues/set up; and provide privacy. The CCP for Pain Management, effective 11/18/16, updated 10/7/2020, documented the following interventions: alleviate anxiety/fear; assess intensity/location/duration/frequency; assist in ADL; observe non-verbal cues; and report change. The Monthly Physician Orders dated 1/20/21 documented orders for Acetaminophen 325 mg (milligram) Tab, 2 Tabs PO (by mouth) every (Q) 6 Hours as needed (PRN) for Pain. Monitor for pain Q shift. The Accident and Incident (A/I) report dated 01/21/2021 documented the resident sustained a burn during a shower. The resident stated that the Certified Nursing Assistant (CNA) turned on the water and pulled the shower spray nozzle over to where the water contacted their left thigh. The CNA stated that the resident grabbed the hose before the CNA could stop them. The family refused to have the resident sent to the hospital. The physician was informed, and the resident was given Tylenol for pain. The nurse continued to monitor the resident's signs and symptoms so that any changes could be reported to the physician promptly. The resident was assessed the next day by the physician, who prescribed treatment. A Nursing Note (NN) dated 01/21/2021 at 09:04 PM documented the resident grabbed the hose before the staff could stop them when the resident was about to be showered. The staff quickly turned off the water and removed the hose from the resident. Redness was noticed on the resident's left thigh measuring 34 centimeters (cm) x 24 cm. The physician was informed, the physician instructed the staff to transfer the resident to the hospital. The family member refused hospital transfer due to possible COVID-19 exposure. The resident was treated for pain via Tylenol and continued to be monitored for signs and symptoms. The CCP for Skin Impairment, effective 8/14/16, was revised post incident on 1/21/21, 1/27/21, and 02/08/2021. Interventions prior to the incident included assess skin condition daily and use caution when giving care. The CCP was revised with an evaluation note dated 1/21/21 documented the resident had redness on the thigh after the incident in the shower. New interventions dated 1/21/21 included notify the doctor and family member; receive and follow orders as given; monitor resident for pain and initiate pain management as per order; assigned aide has been removed from the care of resident; social worker to offer resident emotional support; in-service all CNA's and licensed practical nurse (LPN) facility-wide with respect to the need to test water twice always for the conduciveness of temperature prior to positioning residents for shower care; and shower care giver to ensure that initially, resident is positioned away from the ability to reach shower flexible cable prior to initiating the shower session. The CCP for Trauma/Post Traumatic Stress Disorder (PTSD) (Effective 01/22/2021) was reviewed. Goals and interventions were in place. Resident had unpleasant experience during regular shower and sustained thigh burn. Interventions included but not limited to, encourage resident to express feelings/concerns/thoughts; explain procedures/treatments; identify residents wishes; observe signs and symptoms of depression/anxiety/sleep disturbances; and psychiatrist consult. MD note (Dated 01/22/2021 at 12:25 PM) documented resident sustained a thigh burn while in the shower where the resident grabbed the hose before the staff can stop her. The family refused a hospital transfer due to COVID-19 concerns. The MD assessed resident with denial of pain and no fever. The resident had a large area of [CONDITION(S)] on left thigh with multiple large fluid filled blisters. The MD diagnosed resident with a second degree burn with no overt infection. Recommended Treatment with [MEDICATION(S)] Cream, [MEDICATION(S)], and standing pain medication. The Physician's Orders dated 1/22/21 documented orders for the following: [MEDICATION(S)] 1% Topical Cream to treat affected area 2 times daily for 7 days to left thigh for second degree burn. [MEDICATION(S)] Double Strength (DS) 800 milligram (mg)-160 mg tablet (Tab) orally (PO) twice daily (BID) for 5 days for second degree burn. Gently cleanse thigh area with normal saline (NS), apply [MEDICATION(S)] and cover with loose dry protective dressing (DPD) (Gauze). A NN dated 01/22/2021 at 03:06 PM documented the resident had redness and blisters on the left thigh. The physician was made aware and ordered treatment with [MEDICATION(S)] with DPD, and [MEDICATION(S)] for 5 days. The Physician Notes dated 1/25/21, 1/28/21, and 1/29/21 documented follow-up visits to monitor the resident's progress. The MD noted that the resident was provided with daily treatment, pain management, and had improvement in skin. The Physician's Orders dated 1/27/21 documented orders to monitor the resident for pain related to hot water irritation to left thigh area and monitor for infection. The Nursing Notes dated 1/23/21 to 1/30/21 documented the resident was monitored every shift for vitals, pain, skin condition, and symptoms. The Medication Treatment Records (MARs) dated January 2021 and February 2021 documented all medications were given as ordered. The Treatment Administration Records (TARs) dated January 2021 and February 2021 documented all treatments were done as ordered. The Hot Water Temperature Logs were reviewed from 12/01/2020 to 04/26/2021. Temperatures were monitored daily in resident rooms only for the month of December 2020 where the ranges were from 98 to 104 degrees Fahrenheit (F). Temperatures were monitored three times weekly in resident rooms and shower rooms from 01/02/2021 to 04/26/2021. The shower room ranges were from 92 to112 degrees Fahrenheit. Work Order from East Coast Energy Group/East Coast Petroleum were reviewed. A proposal dated 12/10/2020 documented, Condense tank and return line repairs. Set the heat timer to summer and allow the boiler to run for hot water. Drain the tank and return line in the boiler room . Administrator signed 12/24/2020. A work order dated 01/13/2021 documented, .Checked the unit and found the low water cut off plugged solid. Flushed out the control. Ran the boiler one cycle. Left the boiler working properly . A work order dated 01/22/2021 documented, Went to site to check on no hot water complaint. Attempted to adjust mixing valve but was unable to regulate temperature to a designated temperature as temperature continues to fluctuate. Elements in valve need to be replaced. A proposal has been submitted. A work order dated 01/23/2021 documented .three mixing valve kits completed . During an interview on 04/26/2021 at 02:46 PM with the resident and the assistance of a Spanish interpreter (Occupational Therapist), the resident could not recall the shower incident which resulted in the resident getting injured. During an interview on 04/26/2021 at 03:00 PM, the complainant stated the resident had a second degree burn from a shower. The Registered Nurse (RN) Supervisor informed the complainant that the resident took away the shower head from the CNA which caused the resident to be burned. The complainant stated when the facility completed the investigation, they discovered that the CNA did not check the water temperature prior to showering the resident. During an interview on 04/27/2021 at 12:10 PM, CNA#1 stated they had a good rapport with the resident. The CNA stated after positioning the resident in the shower area, the staff should turn on the water and test the temperature using the back of the hand. After testing the temperature, they wet the resident's hand to see if the temperature is good for the resident. CNA #1 further stated the water temperature should be checked throughout the shower to make sure the temperature is good. CNA #1 stated the resident requested a shower even though it was not her scheduled shower day. The resident needs one assist for showers. The resident was taken to the shower room via wheelchair, then placed on the shower chair. CNA #1 placed the resident along the wall partition between the toilet and shower area. Then, CNA #1 turned on the water with the handheld shower head facing the wall away from the resident. CNA #1 wheeled the resident into the shower area, and the resident grabbed the handheld shower head and sprayed the water on themself. Once the resident stated, caliente, CNA #1 immediately pulled the handheld shower head away from the resident. CNA #1 then stated that the resident grabbed the handheld shower head before she was able to test the water temperature. On 04/29/2021 at 01:55 PM, an attempt was made to contact the involved Licensed Practical Nurse (LPN) via telephone for an interview but the LPN could not be reached. On 04/29/2021 at 01:58 PM, the Registered Nurse Supervisor (RN #1) from the evening shift (4-12 PM) was interviewed. RN #1 stated that they were called to the floor when the resident got hurt during a shower. CNA #1 stated she had the water running and did not check the temperature. The resident grabbed the hose before CNA #1 could check the temperature. CNA #1 notified the floor nurse who notified RN #1. The resident was found with a blister, and the physician ordered a transfer to the hospital. The family was contacted and refused to have the resident sent to the hospital due to COVID-19 fears. Instead, the family wanted the resident to be treated in the facility. The physician was notified of the refusal, and they ordered pain medication and a protective covering. RN #1 stated they were in-serviced after the incident on how to regulate the water temperature before bringing a resident into the shower area. The water must be turned on and tested with a thermometer or hand to check the temperature before the resident can be brought into the shower area to test the water themselves. RN #1 stated that this has always been the protocol of how to bathe/shower residents. RN #1 stated she makes rounds 2 to 3 times throughout the shift on all 3 units. Part of the rounds is to monitor for resident safety, call bells are answered, and to cover staff when they go on break. RN #1 further stated that there were times they assisted staff with showering/bathing and transfers. During the times they assisted, RN #1 did not observe staff bathing/showering residents inappropriately. On 04/30/2021 at 09:32 AM, the Assistant Director of Nursing (ADON) was interviewed. The ADON stated the incident happened during the nighttime, and the ADON was made aware of it the next morning. The ADON started the investigation and interviewed both the resident and CNA #1. The ADON interviewed the resident using the Recreation Director as an interpreter. The Social Services Director witnessed the interview. The resident stated that CNA #1 sprayed the water on the resident, the resident then felt the water was hot and expressed pain. CNA #1 immediately stopped the water. CNA #1 stated she took the resident to the shower room in the wheelchair and transferred the resident to the shower chair. Prior to bringing the resident around towards the shower area, CNA #1 had already turned on the water. CNA #1 reported pointing the handheld shower nozzle towards the wall facing away from the resident. As CNA #1 positioned resident into the shower area, the resident grabbed the shower nozzle before CNA #1 could test the water temperature. The ADON stated that there were no known hot water incidents prior and post incident. Prior to the incident, all nursing staff were aware to check the water temperature prior to starting the shower. After the incident, all nursing staff were in-serviced. Nursing are required to check the water temperature twice, once when they turn the water on, and second before the resident is positioned into the shower area. On 04/28/2021 05:15 PM, the Facilities Director was interviewed. The maintenance workers are responsible for checking water temperatures at random locations 3 times per week from 7 AM to 3 PM. Locations include resident shower rooms and sinks. The water temperature range should be from 80 to 100 degrees Fahrenheit. If the water gets too cold or hot, the maintenance workers will contact the director. The Director will recheck the temperature and check the meter on the boiler. The temperature on the boiler gauge should not be more than 110 degrees Fahrenheit (F). If the temperature is above 110 F, the Director will contact the boiler company. The director further stated that on the day of the incident, the gauge temperature was more than 110 degrees Fahrenheit. The Director stated that he checks the gauges 1 to 2 times daily to make sure the temperatures are within range. The hot water temperature in the showers should be less than 110 degrees, and the hot water in the sinks should be 80 to100 degrees. The director stated the resident shower rooms have a lever that goes from hot to cold, and the staff self-regulate the temperature by using the lever. The boiler company serviced the facility on 01/13/2021 due to low water. The boiler was fixed and left in proper working condition. On 04/28/2021 05:41 PM, the Administrator was interviewed and stated that prior to incident with the resident, there were boiler concerns with water regulation where fluctuating water temperatures was either too high or low. He stated that the boiler company was contacted prior to the incident in efforts to assess the issue. The Administrator stated that all staff are trained to always test the water temperature on themselves prior to testing on the resident. A full investigation was conducted when the resident got burned. It was determined that due to conflicting stories from both the resident and CNA, the CNA was negligent in showering resident by not checking the water temperature to ensure the temperature was appropriate. The boiler company was contacted immediately after the incident and they had come in to fix the boiler. Currently, a new oil tank is replacing the old one. In addition, staff were in-serviced to always check the water temperatures prior to showering residents. 415.12(h)(1)