Every finding on record at Park Gardens Rehabilitation & Nursing Center LLC

Number of residents sampled: 2Number of residents cited:1 Based on observation and staff interviews, the facility did not ensure a resident was cared for in a manner that maintained or enhanced their dignity. This was evident for one (1) of two (2) residents (Resident #28) reviewed for Urinary Catheter out of a total sample of 38 residents. Specifically, Resident #28's urinary catheter tubing was noted to be exposed and visible in the hallway during multiple observations. The findings are:The facility policy titled 'Dignity Policy' last reviewed 01/02/2026 stated the facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in recognition of a person-centered approach. The policy also stated employees shall treat all residents with kindness, respect, and dignity.Resident #28 has an active diagnosis of benign prostatic hyperplasia and Non-Alzheimer's Dementia.The Annual Minimum Data Set assessment dated [DATE] documented Resident #28 had intact cognition and was dependent on staff for bed mobility, toilet use and lower body dressing. The Annual Minimum Data Set also documented Resident #28 had a catheter.The Physician's order last renewed 1/27/2026 documented to monitor urine and record urinary output every shift.The Physician's order last renewed on 01/27/2026 documented to change urinary leg bag daily when out of bed.During observations on 02/09/2026 at 11:16 AM and 02/12/2026 at11:56 AM, Resident #28 was seen in the hallway with a catheter drainage bag in a privacy bag. The catheter tubing was exposed, and light-yellow urine was visible in the tubing, draining into the bag. On 02/12/2026 at 11:57 AM, Resident #28 was observed in the hallway with an exposed catheter tubing. The Registered Nurse Manager #3 was also present during the time of the observation.On 02/12/2026 at 11:56 AM, Registered Nurse Manager #3 was interviewed and stated they were not sure if the catheter tubing should be concealed. Registered Nurse Manager #3 also stated that since there is a privacy bag in place for the drainage bag, it would make sense the catheter tubing is also concealed in order to protect the dignity of the resident.On 02/12/2026 at 12:42 PM, Certified Nursing Assistant #2 was interviewed and stated they usually place the leg bag for Resident #28 in the mornings. Certified Nursing Assistant #2 also stated they had not applied the leg bag for Resident #28 for the past couple of days as Resident #28 was rushing the Certified Nursing Assistant to bring them down to therapy. Certified Nursing Assistant #2 further stated they believe the exposed tubing can be a hazard to Resident #28 as the tubing could get stuck.On 02/17/26 at 9:20 AM, the Director of Nursing Services was interviewed and stated an exposed catheter tubing is a dignity and resident's rights issue. The catheter tubing should have been concealed better around the pants, or a leg bag should have been placed to maintain the residents' dignity. The Director of Nursing Services also stated nursing staff are educated to change the catheter bag when out of bed into a leg bag. If that is not possible, then staff are to ensure a privacy bag is in place. The Director of Nursing Services further stated that they, along with the supervisors and nurses, do rounds on the units to ensure no issues are identified. The Director of Nursing Services stated there is also a physician's order in the electronic medical record, that a leg bag should be placed when a resident with a catheter is out of bed.On 02/17/2026 at 12:35 PM, Licensed Practical Nurse #1 was interviewed and stated that when any resident with a catheter comes out of their room, there should be a leg bag in place to protect the resident's privacy. 10 NYCRR 415.5(a)

Number of residents sampled: 5Number of residents cited: 1 Based on observations, interviews, and record review, facility did not ensure that services provided meet professional standards of quality. This was evident for one (1) of five (5) residents (Resident #22) reviewed for Unnecessary Medications out of a total sample of 38 residents. Specifically, Licensed Practical Nurse #2 and Registered Nurse 2 failed to hold and continued to administer Midodrine 8mg to Resident #22 on several occasions, despite having received in-service regarding the protocol to hold Midodrine if systolic blood pressure is greater than 115mm/hg The findings are:The New York State Education Law Article 139, Section 6902 stated the practice of the profession of nursing includes the executing of medical regimens prescribed by a licensed physician. Section 6902 also states the nursing regimen shall be consistent with and shall not vary any existing medical regimen.Resident #22 had diagnoses which included Hypotension, Iron Deficiency Anemia, Anxiety Disorder, and Seizure Disorder.The Quarterly Minimum Data Set assessment dated [DATE], documented Resident #22 was cognitively intact, and required supervisory assistance with Activities of Daily Living.The Physician's Order dated 08/07/2025 documented Midodrine 5 milligram tablet, give 1 tablet every 8 hours for Hypotension (low blood pressure). Monitor blood pressure daily and do not give if systolic blood pressure is greater than 115mm/hg (millimeters of mercury).The monthly Medication Regimen Reviews dated 09/17/2025,10/30/2025, 11/28/2025,12/29/2025 and 01/31/2026 documented the resident had an order for Midodrine 5 milligram 1 tablet by mouth every 8 hours for Hypotension. Protocol was to hold Midodrine if systolic blood pressure is greater than 115mm/hg. Systolic blood pressure was higher than 115mm/hg and yet, Midodrine was not held. Please review the Medication Administration Records and address.Review of Medication Administration Records for September 2025, October 2025, November 20225, December 2025 and January 2026 revealed that Midodrine 5 milligram 1 tablet was not held on several occasions. This included but was not limited to 09/05/2025, 09/19/2025, 09/20/2025, 09/26/2025, 09/28/2025, 10/03/2025, 10/17/2025, 10/26/2025,12/27/2025, 01/10/2026 and 01/24/2026, and Midodrine 5mg was administered when Resident #22's systolic blood pressures ranged from 120mm/hg to 142mm/hg.The in-service lesson plan titled 'Midodrine In-Service' dated and signed by Licensed Practical Nurse #2 and Registered Nurse #2 on 10/08/25, documented nurses are to ensure they read the entire order for the resident and follow blood pressure parameters. The in-service lesson plan also documented nurses are to hold systolic blood pressure is greater than 115mm/hg (millimeters of mercury) before administering Midodrine. On 02/11/2026 at 11:42 AM, an interview was conducted with the unit manager, Registered Nurse #1 who stated that they were aware that the medication nurses are not following the midodrine blood pressure protocol. Registered Nurse #1 also stated that medication nurses were reeducated on proper blood pressure protocol when administering Midodrine for hypotension. Registered Nurse #1 further stated they were unaware that the medication nurses continued to make the same mistakes despite the in-services and close supervision they received from Registered Nurse #1.On 02/13/2026 at 09:59 AM, an interview was conducted with Registered Nurse #2 who explained Midodrine is used for certain residents who have symptoms of low blood pressure. Registered Nurse #2 also stated the unit manager had in-serviced them before regarding the midodrine blood pressure protocol, and they were surprised to find out the same errors were made by them again. Registered Nurse #2 further stated they believe those medications were not administered, and that instead of signing them as held, they signed them as administered. Registered Nurse #2 concluded it was an error on their part, and they were not being careful enough.On 02/13/2026 at 10:15 AM, an interview was conducted with Licensed Practical Nurse #2 who stated they could not understand how the error occurred as they pay close attention when administering medications. Licensed Practical Nurse #2 also stated they believe those medications were not administered, and it could be that they signed them incorrectly. Licensed Practical Nurse #2 further stated they received an in-service regarding the Midodrine blood pressure protocol but could not explain why they still continued to make same errors.On 02/13/2026 at 10:28 AM, an interview was conducted with the Director of Nursing, who stated nurses were in-serviced regarding the Midodrine protocol, and yet, they continued to make mistakes. The Director of Nursing also stated the unit manager was responsible for supervising nurses and making sure nurses are following plan of care and administering medication based on the physician's order. The Director of Nursing could not explain why nurses continued to make the mistake despite reeducation on the Midodrine protocol. 10 NYCRR 415.11(c)(3)(i)

Number of residents sampled: 5Number of residents cited: 1 Based on observation, record reviews and interviews, the facility did not ensure each resident receives treatment and care in accordance with professional standards of practice. This was evident for one (1) of five (5) residents (Resident #22) reviewed for Unnecessary Medications out of a total sample of 38 residents. Specifically, 1). Resident #22 continued to receive Midodrine 8mg 1 tablet on several occasions when the blood pressure was higher than the required parameters as per the physician's order. The Midodrine protocol was to hold medication if the systolic blood pressure is greater than 115mm/hg and yet, Midodrine was not held on different occasions despite in-services received by medication nurses (blood pressure ranges from 120mm/hg to 142mm/hg), and 2). There was no comprehensive care plan developed to address management of hypotension (low blood pressure).The findings are:1. Resident #22 had diagnoses which included Hypotension, Anxiety Disorder, and Seizure Disorder.The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #22 was cognitively intact and required supervisory assistance with Activities of Daily Living.The Physician's Order dated 08/07/2025 documented Midodrine 5 milligram tablet, give 1 tablet every 8 hours for Hypotension (low blood pressure). Monitor blood pressure daily and do not give if systolic blood pressure is greater than 115mm/hg (millimeters of mercury)The monthly Medication Regimen Reviews dated 09/17/2025,10/30/2025, 11/28/2025,12/29/2025 and 01/31/2026 documented the resident had an order for Midodrine 5 milligram 1 tablet by mouth every 8 hours for Hypotension. Protocol was to hold Midodrine if systolic blood pressure is greater than 115mm/hg. Systolic blood pressure was higher than 115mm/hg and yet, Midodrine was not held. Please review the Medication Administration Records and address.Review of Medication Administration Records for September 2025, October 2025, November 20225, December 2025 and January 2026 revealed that Midodrine 5 milligram 1 tablet was not held on several occasions. This included but was not limited to 09/05/2025, 09/19/2025, 09/20/2025, 09/26/2025, 09/28/2025, 10/03/2025, 10/17/2025, 10/26/2025,12/27/2025, 01/10/2026 and 01/24/2026, and Midodrine 5mg was administered when Resident #22's systolic blood pressures ranged from 120mm/hg to 142mm/hg.The in-service lesson plan titled 'Midodrine In-Service' dated and signed by Licensed Practical Nurse #2 and Registered Nurse #2 on 10/08/25, documented nurses are to ensure they read the entire order for the resident and follow blood pressure parameters. The in-service lesson plan also documented nurses are to hold systolic blood pressure is greater than 115mm/hg (millimeters of mercury) before administering Midodrine.On 02/11/2026 at 11:42 AM, an interview was conducted with the unit manager, Registered Nurse #1 who stated they were aware the medication nurses had not been following the midodrine blood pressure protocol. Registered Nurse #1 also stated medication nurses were reeducated on proper blood pressure protocol when administering Midodrine for hypotension. Registered Nurse #1 further stated they were unaware that the medication nurses continued to make the same error despite the in-services and close supervision they received from Registered Nurse #1.On 02/13/2026 at 09:59 AM, an interview was conducted with Registered Nurse #2 who explained Midodrine is used for certain residents who have symptoms of low blood pressure. Registered Nurse #2 also stated the unit manager had in-serviced them before regarding the midodrine blood pressure protocol, and they were surprised to find out the same errors were made by them again. The Registered Nurse #2 further stated they believe those medications were not administered, and that instead of signing them as held, they signed them as administered. Registered Nurse #2 concluded it was an error on their part, and they were not being careful enough.On 02/13/2026 at 10:15 AM, an interview was conducted with Licensed Practical Nurse #2 who stated they could not understand how the error occurred as they pay a close attention when administering medications. Licensed Practical Nurse #2 also stated they believe those medications were not administered, and it could be that they signed them incorrectly. Licensed Practical Nurse #2 further stated they received an in-service regarding the Midodrine blood pressure protocol but could not explain why they still continued to make same errors.On 02/13/2026 at 10:28 AM, an interview was conducted with the Director of Nursing, who stated nurses were in-serviced regarding Midodrine protocol, and yet, they continued to make mistakes. The Director of Nursing also stated the unit manager was responsible for supervising nurses and making sure nurses are following plan of care and administering medication based on the of physician's order. The Director of Nursing could not explain why nurses continued to make the mistake despite reeducation on the Midodrine protocol.2. Resident #22 had diagnoses which included Hypotension.The Physician's order dated 08/07/2025, last renewed on 02/01/2026 documented Resident #22 was to receive Midodrine 5 milligram tablet, give 1 tablet every 8 hours for Hypotension. Monitor blood pressure daily and do not give if systolic blood pressure is greater than 115mm/hg (millimeters of mercury). Review of the Medication Administration Records for September 2025, October 2025, November 20225, December 2025 and January 2026 revealed Midodrine 5 milligram 1 tablet was administered.There was no documented evidence that a comprehensive care plan was created for Resident #22 that addressed management of hypotension. On 02/13/2026 at 10:22 AM, an interview was conducted with the unit manager, Registered Nurse #1 who stated the registered nurse on the unit is responsible for developing admission, readmission, quarterly and episodic plans. Registered Nurse #1 also stated Resident #22 was supposed to have care plans developed for cardiac related problems due to their diagnosis of hypotension, however, they missed it. Registered Nurse #1 concluded that the missing cardiac care plan was an oversight. On 02/17/2026 at 2:33 PM, an interview was conducted with the Director of Nursing who stated the Unit Nurse managers are responsible for ensuring care plans are developed and updated accordingly. The Director of Nursing also stated they reviewed Resident #22's record yesterday after they were informed about the missing care plan and found that there was no care plan developed management of hypotension for Resident #22. The Director of Nursing further stated that any cardiac related problems, such as hypotension or hypertension should be reflected on a cardiac care plan. The Director of Nursing concluded that they did not have any care plan issues during their daily interdisciplinary team meeting, and the missing cardiac care plan was an oversight. 10 NYCRR 415.12

Number of residents sampled: 5Number of residents cited: 1 Based on record reviews and staff interviews, the facility did not ensure the attending physician reviewed the resident's total program of care, including medications and treatments, at each visit. This was evident for one (1) of five (5) residents (Resident #22) reviewed for Unnecessary Medications out of a total sample of 38 residents. Specifically, there was no documented evidence that the attending physician evaluated Resident #22's medication regimen and addressed irregularities as identified by the pharmacist. The findings are:Resident #22 had diagnoses which included Hypotension, Iron Deficiency Anemia, Anxiety Disorder, and Seizure Disorder.The Quarterly Minimum Data Set assessment dated [DATE], documented Resident #22 was cognitively intact, and required supervisory assistance with Activities of Daily Living.The Physician's Order dated 08/07/2025 documented Midodrine 5 milligram tablet, give 1 tablet every 8 hours for Hypotension (low blood pressure). Monitor blood pressure daily and do not give if systolic blood pressure is greater than 115mm/hg (millimeters of mercury).The monthly Medication Regimen Reviews dated 09/17/2025,10/30/2025, 11/28/2025,12/29/2025 and 01/31/2026 documented the resident had an order for Midodrine 5 milligram 1 tablet by mouth every 8 hours for Hypotension (low blood pressure). Protocol was to hold Midodrine if systolic blood pressure is greater than 115mm/hg. Systolic blood pressure was higher than 115mm/hg and yet, Midodrine was not held. Please review the Medication Administration Records and address.Review of Medication Administration Records for September 2025, October 2025, November 20225, December 2025 and January 2026 revealed that Midodrine 5 milligram 1 tablet was not held on several occasions. This included but was not limited to 09/05/2025, 09/19/2025, 09/20/2025, 09/26/2025, 09/28/2025, 10/03/2025, 10/17/2025, 10/26/2025,12/27/2025, 01/10/2026 and 01/24/2026, and Midodrine 5mg was administered when Resident #22's systolic blood pressures ranged from 120mm/hg to 142mm/hg.On 02/13/2026 at 10:28 AM, an interview was conducted with the Director of Nursing who stated the pharmacist performs a drug regimen review every month on each resident and recommendations are sent to either the Director of Nursing or the Attending Physician. The Director of Nursing also stated that the pharmacist usually emails them recommendations that are related to nursing, however, the recommendation to the physicians will be documented in the medical records under the assessment tool. The Director of Nursing further stated they reviewed all of the Midodrine recommendations and sent them to the Nurse Manager on the unit to follow up with the medication nurses. The Director of Nursing stated they did not send the Midodrine recommendations to the attending physician for review because they believe the nurses needed to address the errors, not the physician. On 02/13/2026 at 12:23PM, an interview was conducted with the Pharmacist who stated that not all pharmacy recommendations are sent to the physician. The Pharmacist also stated they did not send the Midodrine recommendation to the attending physician because those errors were made by the nursing staff, so they sent them to the Director of Nursing only. The Pharmacist further stated some recommendations are meant for the attending physician, such as labs that need to be addressed by physicians, and they will document them under the assessment tab. The Pharmacist concluded that they continued to send the Midodrine errors to the Director of Nursing for several months and they never contacted anyone verbally regarding this matter because it was not considered urgent. On 02/13/2026 at 12:55 PM, an interview was conducted with the Medical Director who stated the pharmacist sends recommendations to individual doctors, and the doctors will address them accordingly. The Medical Director also stated they do not receive pharmacy recommendations; however, they have meetings with the medical providers regularly to address any medical issues that arise. The Medical Director further stated they were made aware of the Midodrine errors today and they were told they were addressed by the nursing department. The Medical Director concluded that it is the responsibility of nurses to follow orders appropriately and any errors should be addressed by the nursing staff.On 02/13/2026 at 01:35 PM, an interview was conducted with the assigned Attending Physician #1 stated they never received any recommendation from the pharmacist via email; however, they have access to electronic medical records where the pharmacist documents irregularities that need to be addressed by them. Attending Physician #1 also stated they were not aware of the Midodrine recommendations, and they do not review the medication administration records. Attending Physician #1 concluded that, even though Midodrine was not held on several occasions, it would not have had any negative impact on Resident #22. 10 NYCRR 415.15(b)(2)(iii)

Number of residents sampled: 5Number of residents cited: 1 Based on observations, record review, and staff the facility did not ensure that Medication Regimen Reviews performed by the Pharmacist were reviewed and acted upon by the attending physician in a timely manner. This was evident for one (1) of five (5) residents (Resident #22) reviewed for Unnecessary Medications out of a total sample of 38 residents. Specifically, the attending physician did not act upon the pharmacist's recommendations dated 09/17/2025,10/30/2025, 11/28/2025,12/29/2025 and 01/31/2026 to address Midodrine that was not held for Resident #22 when systolic blood pressure was greater than 115mm/hg (millimeters of mercury) as per physician's order.The findings are:The facility policy titled Medication Regimen Review' dated 10/24/24 documented the Consultant Pharmacist (the pharmacist) shall review the medication regimen of each resident at least monthly and report any irregularities to the Medical Director, the Director of Nursing and the Attending Physician. The policy further stated the Drug Regimen Review forms will be completed by the physician and nursing department within 30 days from the date of review by the pharmacist.Resident #22 had diagnoses which include Hypotension, Anxiety Disorder, and Seizure Disorder.The Physician's Order dated 08/07/2025 documented Midodrine 5 milligram tablet, give 1 tablet every 8 hours for Hypotension (low blood pressure). Monitor blood pressure daily and do not give if systolic blood pressure is greater than 115mm/hg (millimeters of mercury)The monthly Medication Regimen Reviews dated 09/17/2025,10/30/2025,11/28/2025,12/29/2025, and 01/31/2026 documented Resident #22 had an order for Midodrine 5 milligram 1 tablet by mouth every 8 hours for Hypotension. Protocol was to hold Midodrine if systolic blood pressure is greater than 115mm/hg. Systolic blood pressure was higher than 115mm/hg and yet, Midodrine was not held. Please review the Medication Administration Records and address.There was no documented evidence that the attending physician reviewed and acted upon the irregularities dated 09/17/2025,10/30/2025, 11/28/2025,12/29/2025, and 01/31/2026.On 02/13/2026 at 10:28 AM, an interview was conducted with the Director of Nursing who stated the pharmacist performs a drug regimen review every month on each resident and recommendations are sent to either the Director of Nursing or the Attending Physician. The Director of Nursing also stated that the pharmacist usually emails them recommendations that are related to nursing, however, the recommendation to the physicians will be documented in the medical records under the assessment tool. The Director of Nursing further stated they reviewed all the Midodrine recommendations and sent them to the Nurse Manager on the unit to follow up with the medication nurses. The Director of Nursing stated they did not send the Midodrine recommendations to the attending physician for review because they believe the nurses needed to address the errors, not the physician. On 02/13/2026 at 12:23PM, an interview was conducted with the Pharmacist who stated that not all pharmacy recommendations are sent to the physician. The Pharmacist also stated they did not send the Midodrine recommendation to the attending physician because those errors were made by the nursing staff, so they sent them to the Director of Nursing only. The Pharmacist further stated some recommendations are meant for the attending physician, such as labs that need to be addressed by physicians, and they will document them under the assessment tab. The Pharmacist concluded that they continued to send the Midodrine errors to the Director of Nursing for several months and they never contacted anyone verbally regarding this matter because it was not considered urgent. On 02/13/2026 at 12:55 PM, an interview was conducted with the Medical Director who stated the pharmacist sends recommendations to individual doctors, and the doctors will address them accordingly. The Medical Director also stated they do not receive pharmacy recommendations, however, they have meetings with the medical providers regularly to address any medical issues that arise. The Medical Director further stated they were made aware of the Midodrine errors today and they were told they were addressed by the nursing department. The Medical Director concluded that it is the responsibility of nurses to follow orders appropriately and any errors should be addressed by the nursing staff.On 02/13/2026 at 01:35 PM, an interview was conducted with the assigned Attending Physician #1 who stated they did not receive any recommendations from the pharmacist via email, however, they have access to the electronic medical records where the pharmacist documents irregularities that need to be addressed by them. The Attending Physician #1 also stated they were not aware of the Midodrine recommendations, and they do not review the medication administration records. The Attending Physician #1 concluded that, even though Midodrine was not held on several occasions, it would not have any negative impact on Resident #22. 10 NYCRR 415.18(c)(2)

Based on observations, interviews and record reviews conducted during the recertification survey and complaint (NY00308289) survey, the facility did not ensure that a resident was free from financial abuse. This was evidnet for 1 (Resident #19) of 11 residents sampled for abuse. Specifically, a Certified Nursing Assistant (CNA #1) with a history of a misappropriation allegation at the facility took money from Resident #19. The findings are: The facility's policy and procedure entitled Abuse Prohibition Program, last reviewed 10/24/2022, documented that all residents have the right to be free from abuse, neglect, exploitation or misappropriation of resident property. The policy defines exploitation as 'when a vulnerable adult or their resources/income are used for another's profit or gain.' Resident #19 was initially admitted to the facility with diagnoses including schizophrenia, alcohol abuse and cerebral infarction. The Minimum Data Set 3.0 (MDS), a resident assessment tool, dated 11/22/2022 documented the resident had intact cognition. A Nursing progress note dated 01/06/2023 at 12:50 PM documented that at about 1:15 AM, one of Resident #19's roommates reported that they were getting awakened at night by CNA #1 continually coming into thier room to ask Resident #19 for money. The Assistant Director of Nursing (ADON) and social worker interviewed Resident #19 and both their roommates. Both roommates corroborated that CNA #1 comes into the room at night and asks the resident for money, and Resident #19 gives money to CNA #1. No staff members witnessed the incident. Resident #19 stated, I told the CNA to come to my room for money whenever they need it. The last time they came was 01/04/2023, and I gave them $20. The resident stated that it was their money and they could give it to anyone they wanted. The staff reminded Resident #19 that it was against facility policy for a resident to give money to staff or for staff to ask residents for money. A Potential for Abuse Care Plan was initiated for Resident #19 on 01/06/2023, and the resident was refunded their money. An undated Summary of Investigation documented the allegation was made on 1/6/23 by Resident #19's roommate. CNA #1 was not assigned to Resident #19's unit, but they reported they went to the unit to say hi to the nurse. CNA #1 denied asking Resident #19 for money or going into any resident's rooms. CNA #1 stated they used to order food for Resident #19 in the past, but that was all they did. The facility concluded there was cause to believe misappropriateion occurred. Statements from Resident #19, their two roommates, and CNA #1 were attached to the investigation. A Psychiatry consult dated 01/18/2023 states that the resident was seen due to staff reporting that the resident was giving money to a CNA. The psychiatrist stated that the resident's insight and judgment were limited and that they were unable to make financial decisions. Review of CNA #1's employee file, revealed CNA #1 had previous complaints against them for regarding dignity/privacy (exposing a resident's private area to a roommate), poor customer service (telling a family member they are always complaining and need a wife), failure to follow the abuse policy (failure to report a right eye bruise), and misappropriation. A Record of Corrective Warning dated 11/29/22 documented that on 11/27/2022 two residents reported that on 11/26/2022, during the evening shift whle they were in bed, CNA #1 asked them each for $5.00 and they each gave CNA #1 $5.00. CNA #1 was suspended for one day and re-educated to reinforce that staff members are never allowed to ask residents for money, goods, or property. CNA #1 was also informed future action would be termination if it occurred again. This previous incident occurred on Resident #19's unit. CNA #1 was terminated 1/10/2023. There was no documented evidence CNA #1 would be under any supervision to prevent a reocurrence. On 07/20/2023 at 9:43 AM, Resident #19 was interviewed and stated, There used to be this CNA I used to give money to. They used to buy me things and sometimes they would give me back the change, but they were a little bit crooked and sometimes they kept the change. And because they were a lady, I let them. On 07/28/2023 at 9:10 AM, CNA #1 was contacted and stated that when they worked on Resident #19's unit, there was one staff member who had a problem with them and reported them for taking money from residents. It was common for staff to order outside food for residents when asked and to pay for it using the residents' money, bringing them back the change. The CNA stated that on 01/04/2023, they returned to the unit to see a nurse who had returned from a trip to [NAME], and they went back to their assigned unit immediately afterwards. The CNA stated, I think the same CNA who talked about me the first time set me up. On 07/26/2023 at 9:16 AM, the Director of Nursing (DON) was interviewed and stated that the facility does constant in-services for staff on abuse and misappropriation. They had been hesitant to keep CNA #1 on staff after the first incident but decided to give CNA #1 a second chance after re-educating them and relocating them away from the unit where they had been assigned. However, The CNA #1 returned to the unit without permission on 01/04/2023, stating that they wished to say hello to the nurses there. The DON stated that the facility does not have surveillance footage proving that the CNA spoke only to staff and did not enter any resident rooms on the unit. Attempts were made to reach Resident #19's two roommates, both of whom had been discharged and not left forwarding telephone numbers, but in each case their family members would not provide a phone number for them. 483.12

Based on record review and staff interviews conducted during a Recertification Survey from 7/19/23 through 7/26/23, the facility did not ensure that the residents and their representatives received a written summary of the Baseline Care Plan (BCP). This was evident for 3 of 3 residents reviewed for the Baseline Care Plan out of 38 sampled residents. (Residents #177, #235, and #382). The Findings are: The facility policy and procedure titled 48-Hour Baseline Care Plan dated 4/15/19 documented that the facility will develop and implement a baseline care plan summary for each new resident within 48 hours of admission. The Social Service Director/designee will print the 48-hour baseline care plan summary and review it with the resident/representative. The resident/representative signature will be obtained to verify the meeting and agreement with the plan. A signed copy will be maintained in the medical record. 1) Resident #235 was admitted with diagnoses that include a Left Lower leg Fracture and Lower Back pain. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident # 235 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 15. Resident #235's BCP, initiated on 6/22/23 and completed on 6/29/23, had no documented evidence of resident or representative signature. The progress notes from 6/23/23 to 7/11/23 in the Electronic Medical Record (EMR) contained no documented evidence Resident #235 was provided with a copy of or signed the baseline care plan. During an interview on 7/24/23 at 12:02 PM, Resident #235 stated that they did not sign or receive a copy of the BCP. 2) Resident #382 was admitted with diagnoses that include Hypertension and Heart Failure. The Admission MDS dated [DATE] documented Resident #382's cognition as intact, with a BIMS score of 15. Resident #382's BCP, initiated on 6/27/23 and completed on 7/6/23, had no documented evidence of resident or representative signature. The progress notes from 6/28/23 to 7/12/23 in the EMR contained no documented evidence Resident #382 was provided with a copy of or signed the baseline care plan. During an interview on 7/26/23 at 10:30 AM, Resident #382 stated that they did not receive a copy of the BCP. 3) Resident #177 was admitted to the facility 06/08/2023 with diagnoses that included Hypertension, Benign Prostatic Hyperplasia (BPH), and Renal Insufficiency, Renal Failure, or End-Stage Renal Disease (ESRD). The Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident had intact cognitive status. The MDS documented that Resident #177 participated in the assessment and had no guardian or legally authorized representative. On 07/24/23 at 02:21 PM, Resident #177 was interviewed and stated they came to the facility about a month ago, and can not recollect being given any written summary of the BCP. There was no documented evidence in the resident's chart that a signed copy of the Baseline Care Plan was given to the resident/resident's representatives. During an interview on 7/24/23 at 2:45 PM, the Social Worker (SW) stated that BCP is completed within 48 hours of admission, except when the resident comes in on the weekend. They offer a copy of the BCP to the residents and their representatives. They do not have it documented that the BCP provided to the residents. Moving forward, they will enter it in the computer because if it is not written, then it is not done. During an interview on 7/24/23 at 3:27 PM, Registered Nurse Supervisor #2 (RNS #2) stated that a copy of the BCP is offered to the residents/representatives. Resident # 235 did not receive a physical copy of the BCP, but they were informed of the plan of care. There is no indication that the BCP was offered to the resident. It is not documented that it was verbally offered. On 07/26/23 at 10:05 AM, the MDS Coordinator was interviewed and stated that baseline care plan has to be completed within 48 hours of the resident's admission by the team, discussed with the resident and the family, a copy needed to be given to the resident. The MDS Coordinator stated that they are not aware that the copy is not being given to the resident/resident's family. During an interview on 7/25/23 at 8:14 AM, the Director of Social Service (DSS) stated that the BCP is completed within 48 hours after admission. They do not print it out and give a copy to the residents or document it in the EMR. From now on, they will provide a copy to the resident/representative. The SW will ensure that a copy of the BCP is provided and documented. During an interview on 7/25/23 at 3:49 PM, the Director of Nursing (DNS) stated that once BCP is completed, the resident or family should get an overview of the care plan. It should be printed, and a copy should be given to the resident or the family member. They have not been doing it all the time. Moving forward, they will follow the policy 100%. 415.11 (c) 40565

Based on record review and staff interviews conducted during a Recertification Survey from 7/19/23 through 7/26/23, the facility did not ensure that Comprehensive Care Plans (CCP) were developed and implemented to meet resident needs. This was evident for 1 (Resident #235 and #382) of 38 sampled residents. Specifically,1) Resident #235 did not have a CCP related to leg fracture and pain management developed, and 2) Resident #382 did not have a CCP related to bacteriuria, Urinary Tract Infection (UTI) developed. The findings are: The facility policy titled Comprehensive Care Plan dated 3/5/19 documented that the facility will develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timetable to meet a resident medical, nursing, mental and psychological needs, which are identified in the comprehensive assessments and leads to the resident's highest obtainable independence. 1. Resident #235 was admitted with diagnoses that include a Left Lower Leg Fracture and Lower Back Pain. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident # 235 cognition as intact with a Brief Interview of Mental Status (BIMS) score of 15. On 7/21/23 at 9:24 AM Resident # 235 was observed resting in bed-left leg external fixation noted in place. On 7/24/23 at 10:00 AM, Resident # 235 was observed resting in bed and left leg external fixation in place. On 7/25/23 at 9:40 AM, Resident # 235 was observed resting in bed. Left leg external fixation was noted in place. Medical Doctor's Order dated 6/22/23 documented Acetaminophen 325mg, three tablets every 6 hours for low back pain, Oxycodone 5 mg every 6 hours as needed for low back pain, and gabapentin 400mg every 8 hours for low back pains. Physician Note dated 7/4/23 at 12:41 PM documented that Resident # 235 has Chronic back pains post Open Reduction Internal Fixation (ORIF) with external fixation. Pain is being controlled with Oxycodone. The Medication Administration record dated 6/22/23 to 7/24/23 documented that Resident #235 received pain medication as ordered. CCP related to Left Ankle Fracture was created on 6/22/23. There was no documented evidence that interventions were implemented. There was no documented evidence a CCP related to pain management was developed. During an interview on 7/25/23 at 9:40 AM, Resident # 235 stated that they get oxycodone for the pain. During an interview on 7/24/23 at 3:49 PM, Registered Nurse Supervisor # 2 (RNS #2) stated that Resident # 235 was admitted with an ankle fracture and had an external fixation. CCP for the left ankle fracture was initiated on 6/26/23, but no interventions were documented. There should have been interventions documented in the care plan. CCP for pain management was not initiated. Pain management care plans should have been created with interventions implemented for the resident. During an interview on 7/24/23 at 4:02 PM, the Assistant Director of Nursing (ADNS) stated that the left ankle fracture care plan was initiated on 6/26/23, and there were no interventions. The ADNS created the care plan but forgot to add the interventions. The CCP for pain management was initiated today (7/24/23). It should have been initiated on admission with interventions. The ADNS is responsible for creating the care plan. The ADNS does not know why the pain management care plan was not initiated. During an interview on 7/25/23 at 3:49 PM, the Director of Nursing (DNS) stated that the ADNS is responsible for initiating the care plans on admissions. The DNS does not know what happened or why the pain management and fracture care plan was not developed and implemented. 415.11(c)(1) 44842 2) Resident #382 had a diagnosis of Bacteriuria. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #382 was cognitively intact with a Brief Interview for Mental Status score of 15. Physician Orders dated 7/11/23 documented to provide Resident #382 with 250 cc of extra fluid per shift and levofloxacin for 7 days for bacteriuria. There was no documented evidence a CCP related to Resident #382's bacteriuria (UTI) was developed. During an interview on 7/21/23 at 3:49 PM, the Assistant Director of Nursing (ADNS) stated that Resident #382 does not have a CCP related to bacteriuria ( UTI) in place. The Registered Nurse Supervisor is responsible for initiating episodic CCPs. The UTI CCP should have been developed for Resident #382 415.11(c)(1)

Based on observation, record review, and interviews conducted during the Recertification survey from 7/19/2023 to 7/26/2023, the facility did not ensure comprehensive care plans (CCP) were reviewed and/or revised after each assessment and as needed. This was evident for 2 (Resident #84 and #6) of 38 total sampled residents. Specifically, 1) Resident #84's CCP related to dementia was not reviewed upon each assessment and 2) Resident #6's CCPs related to Advance Directives and cognitive loss/dementia were not reviewed and revised. The findings are: A facility policy titled Comprehensive Care Planning dated 3/5/2019 documented the facility will develop a comprehensive, person-centered care plan for each resident. Goals and objectives are reviewed and/or revised when there has been a significant change in the resident's condition and at least quarterly. 1) Resident #84 had diagnoses of peripheral vascular disease and anemia. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #84 was cognitively intact. The CCP related to cognitive loss/dementia was initiated 3/3/2020 and documented the last review date of 3/27/2023. There was no documented evidence the CCP related to cognitive loss/dementia was reviewed and revised upon the assessment dated [DATE]. 2) Resident #6 had a diagnosis of dementia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #6 had moderately impaired cognition. The CCP related to Resident #6's Advance Directives was initiated 7/24/2018 and last reviewed 8/30/2022. The CCP related to Resident #6's cognitive loss/dementia was initiated 7/24/2018 and last reviewed 2/2/2022. There was no documented evidence the CCP related Resident #6's Advance Directive status and cognitive loss/dementia was reviewed and revised upon the assessment dated [DATE]. An interview was conducted on 7/24/2023 at 11:05 AM with the Social Worker (SW) who stated they probably missed updating one of Resident #84's CCPs because it gets overwhelming to keep up with updating CCPs. An interview was conducted on 7/25/2023 at 11:11 AM with the Director of Nursing (DNS) who stated the facility recently hired a 2nd CCP nurse to complete CCP updated quarterly. The CCPs are updated according to the MDS assessment schedule. 415.11(c)(2) (i

Based on observations, record review, and interviews conducted during the recertification survey from 7/19/2023 to 7/26/2023, the facility did not ensure all drugs and biologicals were stored in accordance with State and Federal laws. This was evident for 2 (Unit 4 and 6) of 5 units observed for medication storage. Specifically, 1) narcotics medications were not stored in a double-locked compartment in the medication cart on the 6th Floor, and 2) the Patient Narcotic's Log (PNL) did not match the narcotics medication count for Resident #5 on the 4th Floor. The findings are: The facility's policy titled Medication Labeling and Storage dated 02/2023 documented controlled substances and other drugs subject to abuse are separately locked in permanently affixed compartments. The facility policy titled Controlled Substances dated 7/20/2019 documented the facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. The Director of Nursing (DNS) shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsibility parties and shall give the Administrator a written report of such findings. On 07/24/2023 at 11:47 AM, the medication cart on the 6th Floor was observed with Registered Nurse (RN) #1 present. The second locked compartment designated for narcotics was in the 3rd drawer of the cart and was observed empty. The 2nd drawer of the cart contained 9 medication blister packs containing the following narcotics: 1 pack Tramadol, 2 packs Lyrica, and 6 packs Clonazepam. RN #1 was interviewed on 07/24/2023 at 3:07 PM and stated they have not done medication pass in some time. RN #1 stated when they came to the unit, residents were already asking for their medications and there was no time to search the medication cart for the narcotics lockbox. The narcotics medications were stored in the single-locked medication cart and RN #1 locked the medication cart when they stepped away. The narcotics were returned to the medication room once medication pass was complete. RN #1 stated they were not familiar with the keys on the 6th Floor. There are many residents taking narcotics on the 6th Floor and RN #1 would not be able to finish their medication pass if they had to retrieve narcotics from a 2nd locked compartment. The Director of Nursing (DON) was interviewed on 07/26/2023 at 9:37 AM and stated that narcotics must be kept in the lockbox in the medication room and are moved during each shift to the lockbox in the medication cart. Some medication carts have the lockbox in the bottom drawer and some in the middle drawer, but these lockbox must be used. In-services are held regularly for nurses and supervisors on using the medication carts, and since the supervisors spend most of their time on the units, they are available to remind medication nurses to use the lockbox for all controls. 44842 2) Resident #5 had diagnoses of schizophrenia and anxiety disorder. On 7/19/2023 at 3:18 PM, the Unit 4 medication room narcotics locker was observed with Registered Nurse Supervisor (RNS) #1. The locker contained 2 blister packs for Resident #5 containing 34 half (1/2) tablets Clonazepam 0.5mg. A Physician Order dated 11/18/2022 and renewed 6/24/2023 documented Resident #5 was prescribed Clonazepam 0.5 mg, give 1/2 tablet (0.25 mg) at 10:00 AM, 2:00 PM and 6:00 PM. The PNL form dated 7/19/2023 documented Resident #5 had 35 of the 1/2 tablets of Clonazepam .5mg remaining in their blister packs. On 7/19/2023 at 3:18 PM, RNS #1 was interviewed and stated the blister packs contained 37 of the 1/2 tablets of Clonazepam this morning and RNS #1 administered a 1/2 tablet to Resident #5 at 10 AM and 2 PM. The narcotics count was done with the outgoing nurse this morning and RNS #1 cannot explain why there is 1 missing 1/2 tablet of Clonazepam missing from the resident's blister pack. On 7/19/2023 at 4:19 PM, the Assistant Director of Nursing (ADNS) was interviewed and stated we are going to interview RNS #1, do an investigation, and try and figure out the cause of the missing dose of Clonazepam. Nurses are instructed to document on the PNL after the resident takes their medication. The ADNS further stated maybe there was a slit in the bag of the blister pack and the 1/2 tablet fell out. On 7/21/2023 at 4:15PM, the DNS was interviewed and stated they don't know what happened to the 1/2 tablet of Clonazepam for Resident #5. The facility searched and was unable to find the missing tablet. RNS #1 reported they counted in the morning and gave 2 doses, and during the afternoon they noticed the count was short 1 dose. The previous shift nurse stated they counted in the morning with the incoming RNS #1, and the count was correct. In addition, the facility had the pharmacy consultant come and check narcotics on all units to make sure counts were accurate. The 1/2 tablet may have accidentally popped out. The DNS further added they completed one on one education with RNS #1 and in-serviced all other nurses on the policy of Controlled Substances. The pharmacy consultant is going to continue doing monthly narcotic counts with the nurse on each unit. 415.18(e)(1-4)

Based on interviews and records review conducted during an Abbreviated Survey (NY00304629), the facility failed to report an alleged violation of abuse immediately but not later than 2 hours to the Administrator, as well as to the State Survey Agency. This was evident in 1 out of the 5 residents sampled (Resident #1). Specifically, Resident #1 reported to Registered Nurse Supervisor (RNS) #1 that Certified Nursing Assistant (CNA) #1 was rough with them during care, causing their private organ (PO) to bleed on 10/28/2022 at approximately 4:00 PM. The facility's Administrator and New York State Department of Health (NYSDOH) were not notified of the allegation of abuse. The facility became aware of the allegation during an onsite visit from NYS DOH on 11/02/2022. The findings are: The facility's Policy and Procedure entitled Abuse and Neglect with revision date 02/07/2022 documented that it is the responsibility of facility employees, facility consults, Attending Physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management. Once an allegation of abuse has been made, the supervisor who initially received the report must inform the Administrator/Director of Nursing as soon as possible and initiate gathering requested information. Federal Regulation (42 CFR 483.13) requires the reporting of all alleged violations involving abuse, neglect, and exploitation of resident property, are reported to the department of health 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 24hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Resident #1 was admitted to the facility with diagnoses including bipolar disorder and Diabetes. The Minimum Data Set (MDS, a resident assessment tool) dated 08/20/2022 documented that Resident #1 had a Brief Interview of Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) and a score of 15 indicating intact cognition. A review of the Nursing Progress Note, by RNS #1, dated 10/28/2022 at 5:05 PM documented that RNS #1 was present on the 5th floor and witnessed Resident #1 getting verbally aggressive toward CNA #1. Resident #1 picked up an adult undergarment and attempted to throw it at CNA #1. RNS #1 stood up at the desk and Resident #1 saw RNS #1 and threw the pack of undergarment backward. CNA #1 firmly told Resident #1 not to attempt to hit CNA #1 again. RNS #1 documented that no other incident was witnessed. RNS #1 also documented that at approximately 4:00 PM Resident #1 came to the nursing station and attempted to show RNS #1 a picture of what Resident #1 said was their bleeding penis. Resident #1 stated that it happened to them while CNA #1 washed them roughly during care. RNS #1 documented that he/she told Resident #1 to wait until he/she was off the phone and Resident #1 started to yell at RNS #1. Resident #1 wheeled themselves off the unit to go to the Administrator. During an interview on 11/02/2022 at 10:15 AM, Resident #1 stated that on 10/28/2022 at around 1:30 PM, they grabbed a pack of incontinent briefs from the closet located in the hallway across from their room and CNA #1 approached and screamed at them what are you doing, no, no, no. Resident #1 stated that he/she was startled and raised their hand with the pack of incontinent briefs. Resident #1 stated that CNA #1 thought that Resident #1 tried to hit CNA #1 with the pack of incontinent briefs. Resident #1 stated that they just wanted to prevent CNA #1 from taking the briefs away from them. Resident #1 stated that after the incontinent brief incident, CNA #1 came to their room and washed them roughly. Resident #1 stated that after CNA #1 completed care Resident #1 took a nap and when they woke up, Resident #1 had bleeding to the PO. Resident #1 stated that they reported to RNS #1 that CNA #1 washed their PO roughly causing them to bleed. Resident #1 stated that they called 911 but that they did not report the rough handling to the 911 team. During an interview on 11/02/2022 at 11:40 PM, RNS #1 stated that at around 4:00 PM Resident #1 attempted to show RNS #1 a picture of their PO that Resident #1 said was bleeding because CNA #1 washed them roughly. RNS #1 stated that he/she was on the phone and told Resident #1 as soon as he/she was off the phone he/she would see Resident #1. RNS #1 stated that he/she reported the allegation to the Assistant Director of Nursing (ADON) and the incoming supervisor. During an interview on 11/02/2022 at 1:04 PM, the ADON stated that at approximately 3:50 PM Resident #1 came downstate in the lobby and said that they have bleeding in the genital area. The ADON stated that he/she instructed Resident #1 to go back to their room and he/she will assess them. Resident #1 called 911 and the Emergency Medical Service (EMS) team went to Resident #1's room with the ADON. The ADON said that he/she assessed Resident #1, but he/she did not report the incident to the DON or to the Administrator. The ADON stated that the Administrator and the DON should have been notified. During an interview on 11/02/2022 at 1:57 PM, the DON stated that he/she was not aware that Resident #1 complained that CNA #1 was rough during care. The DON stated that RNS #1 or the ADON should have notified the DON. The DON also stated that the incident should have been reported immediately but no later than 2 hours to the Administrator and to the NYSDOH. The DON stated that he/she became aware of the incident on 11/02/2022 during the onsite investigation. During an interview on 11/03/2022 at 12:00 PM, the Administrator stated that he/she was not notified of the incident on 10/28/2022. The Administrator stated that he/she became aware of the incident on 11/02/2022 during the onsite investigation. The Administrator stated that the incident should have been reported to them immediately and to NYSDOH. 10 NYC RR 415.4(b)(1)(i)

Based on interviews and records review conducted during an Abbreviated Survey (NY00304629), the facility failed to investigate an alleged violation of abuse and to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation of an alleged violation is in progress. This was evident in 1 out of the 5 residents sampled (Resident #1). Specifically, Resident #1 reported to Registered Nurse Supervisor (RNS) #1 that Certified Nursing Assistant (CNA) #1 was rough with them during care, causing their private organ (PO) to bleed on 10/28/2022 at approximately 4:00 PM. The facility did not have evidence that an investigation was initiated on 10/28/2022. The findings are: The facility's revised Policy and Procedure entitled Abuse and Neglect dated 02/07/2022, documented that the facility shall conduct a thorough investigation of alleged violation/sexual abuse involving mistreatment, neglect, or abuse, including injuries of an unknown source, and prevent further potential abuse while the investigation is in progress. Resident #1 was admitted to the facility with diagnoses including bipolar disorder and Diabetes. The Minimum Data Set (MDS, a resident assessment tool) dated 08/20/2022 documented that Resident #1 had a Brief Interview of Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) and a score of 15 indicating intact cognition. A review of the Nursing Progress Note, by RNS #1, dated 10/28/2022 at 5:05 PM documented that RNS #1 was present on the 5th floor and witnessed Resident #1 getting verbally aggressive toward CNA #1. Resident #1 picked up an adult undergarment and attempted to throw it at CNA #1. RNS #1 stood up at the desk and Resident #1 saw RNS #1 and threw the pack of undergarment backward. CNA #1 firmly told Resident #1 not to attempt to hit CNA #1 again. RNS #1 documented that no other incident was witnessed. RNS #1 also documented that at approximately 4:00 PM Resident #1 came to the nursing station and attempted to show RNS #1 a picture of what Resident #1 said was their bleeding penis. Resident #1 stated that it happened to them while CNA #1 washed them roughly during care. RNS #1 documented that he/she told Resident #1 to wait until he/she was off the phone and Resident #1 started to yell at RNS #1. Resident #1 wheeled themselves off the unit to go to the Administrator. Review of the facility's Accident/Incident Reports from 10/28/2022 through 11/03/2022 revealed there was no investigation for the alleged allegation of rough handling. During an interview on 11/02/2022 at 10:15 AM, Resident #1 stated that they reported to RNS #1 and the ADON that CNA #1 was rough with them during care on 10/28/2022. Resident #1 also stated that they reported that they did not want CNA #1 taking care of them and that CNA #1 was still on their assignment. During an interview on 11/02/2022 at 11:40 PM, RNS #1 stated that at around 4:00 PM Resident #1 attempted to show RNS #1 a picture of their private organ that Resident #1 stated was bleeding because CNA #1 washed them roughly. RNS #1 stated that he/she was on the phone and told Resident #1 as soon as he/she was off the phone he/she would see Resident #1. RNS #1 stated that an investigation should have been initiated and that CNA #1 should have been taken off the schedule pending the investigation outcome. RNS #1 stated that CNA #1 was still assigned to Resident #1 after the allegation was made. During an interview on 11/02/2022 at 1:04 PM, the ADON stated that at approximately 3:50 PM Resident #1 came downstate in the lobby and reported that they were bleeding in the genital area. The ADON stated that Resident #1 did not report any allegations of abuse. The ADON stated that RNS #1 should have initiated an investigation and that CNA #1 should have been removed from the schedule. During an interview on 11/02/2022 at 1:57 PM, the DON stated he/she was not aware that Resident #1 complained that CNA #1 was rough during care. The DON stated that RNS #1 is responsible for initiating the investigation and reporting to the ADON. The DON also stated that the ADON is responsible for the continuation the investigation and notifying the DON of the outcome. The DON stated that RNS #1 should have initiated the investigation on 10/28/2022. 10 NYC RR 415.4 (b)(3)

Based on observations, staff interviews, and record reviews conducted during an abbreviated survey (NY00304629), the facility failed to ensure that a resident's medical record accurately reflected the resident's medical condition. This was evident in 1 out of 5 residents sampled (Resident #1). Specifically, Resident #1 reported to Registered Nurse Supervisor (RNS) #1 that Certified Nursing Assistant (CNA) #1 was rough with them during care, causing their private organ (PO) to bleed on 10/28/2022 at approximately 4:00 PM. Record review of Resident #1's medical record from 10/28/2022 through 11/03/2022, revealed that an assessment of Resident #1 was not documented in the resident's medical record. The findings are: The facility Policy and Procedure entitled Charting and Documentation with dated 12/01/2017 documented that all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychological condition, shall be documented in the resident's medical record. Resident #1 was admitted to the facility with diagnoses including bipolar disorder and Diabetes. The Minimum Data Set (MDS, a resident assessment tool) dated 08/20/2022 documented that Resident #1 had a Brief Interview of Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) and a score of 15 indicating intact cognition. A review of the Nursing Progress Note, by RNS #1, dated 10/28/2022 at 5:05 PM documented that at approximately 4:00 PM, Resident #1 came to the nursing station and attempted to show RNS #1 a picture of what Resident #1 said was their bleeding penis. Resident #1 stated that it happened to them when CNA #1 washed them roughly during care. RNS #1 documented that he/she told Resident #1 to wait until he/she was off the phone and Resident #1 started to yell at RNS #1 and wheeled themselves off the unit. A review of the progress notes dated from 10/28/2022 to 11/03/2022 revealed there was no documented evidence to support that Resident #1 was assessed. During an interview on 11/02/2022 at 10:15 AM, Resident #1 stated that on 10/28/2022 (does not remember the time) CNA #1 provided care to them and washed their private organ roughly. Resident #1 stated that when they woke up from a nap their private organ (PO) was bleeding. Resident #1 stated that they reported to RNS #1 that CNA #1 washed their PO roughly causing them to bleed. Resident #1 stated that they called 911 but did not report the rough handling to the Emergency Medical Service (EMS) team. Resident #1 also stated that the ADON looked at their PO in the presence of the EMS team. During an interview on 11/02/2022 at 1:04 PM, the ADON stated that he/she assessed Resident #1's PO but did not document the assessment in Resident #1's medical record. The ADON verbalized that he/she observed bilateral redness to Resident #1's groin and scrotal area. The ADON stated that there was no active bleeding from Resident #1's PO and there was no blood on the incontinent brief. The ADON stated that Resident #1 had no swelling and denied pain. The ADON stated that the assessment should have been documented in Resident #1's chart. During an interview on 11/02/2022 at 1:57 PM, the DON stated that RNS #1 or the ADON should have assessed Resident #1 and documented the assessment in the resident's medical record. 10 NYC RR 415.12

Based on observations, record review, and staff interviews conducted during a recertification survey 04/14/2021-04/21/2021, the facility did not ensure that notice of the availability of the survey results in areas of the facility that are prominent and accessible to the public was posted. Specifically, the survey results were located in unlabeled wall-mounted racks in or near the day rooms and in the building lobby but there was no notice about the availability of results in these locations. This was observed on 4 of 5 resident units and in the facility lobby. The findings are: During multiple building observations conducted between 4/15/21 at 11:00 AM and 4/21/21 at 1:00 PM survey results were observed in a binder in the lobby area. There were no notices observed posted on any of the resident units about where the survey results could be located. On 04/16/21 at 02:41 PM, during the Resident Council meeting, residents were asked about the availability of survey results. 5 of the 6 residents in attendance stated they did not know where the results were located and 1 member stated the results were posted somewhere in the facility lobby but that residents were not allowed in the lobby because of space constraints. On 04/21/21 at 09:50 AM, Social Worker (SW) #1, who provides services for residents on Units 2, 4 and some of 5, was interviewed. SW #1 stated she does not discuss survey results with residents or review with residents where survey results can be located. On 04/21/21 at 01:05 PM, the Director Social Services (DSS) was interviewed. The DSS stated survey results come up from time to time during Resident Council meetings. If a resident who does not attend Resident Council meetings asks about survey results, she would direct them where to find them. On 04/21/21 at 01:20 PM, the Administrator was interviewed. The Administrator stated that binders with the latest survey results are posted in front of each unit day room as well as in the facility lobby. Residents are reminded at Resident Council that the results can be found there, but residents who do not attend the Council would not get this information. The Administrator also stated that there is no signage posted about the availability of survey results. On 04/21/21 at 01:31 PM, observations were made on all units. On Units 2, 4 and 6, a binder was observed in the day room in a wall-mounted rack. On Unit 3, a binder was observed in the unit hallway outside the day room. There was no binder on Unit 5. All binders were placed obscurely on walls and not labelled in print large enough to be read from a distance. 415.3 (c)(1)(v)

Based on observations, record review and interviews conducted during a Recertification survey from 04/14/2021 to 04/21/2021, the facility did not ensure that a clean, comfortable, and homelike environment was provided to residents. Specifically, resident rooms were not maintained in good repair and in a homelike manner. This was observed during Environmental Observations on 1 of 5 resident units. (Unit 4) The findings are: During multiple observations on Unit 4 between 4/15/21 at 11:30 AM and 4/21/21 at 11:00 AM, the following were observed but not limited to: 4th Floor Day Room- rusted heater, rust colored discoloration on top of air conditioner and chipped paint on window ledges. Room 401-peeling wallpaper observed on the walls. Room 405- chipped wall plate, grey duct tape observed on air conditioner. Room 408-peeling, discolored wallpaper on wall. Room 409-discolored wallpaper around the air conditioner. Room 411- broken face panel on air conditioner unit. Room 415- peeling wallpaper. Room 416-dislodged switch plate, grey duct tape attaching wallpaper to the wall. In addition, rusted wheelchair guardrails were observed in multiple rooms on all floors. On 04/21/21 at 11:08 AM, Maintenance Worker (MW) #1 was interviewed. MW #1 stated his job included fixing sinks, televisions, light fixtures, changing light bulbs but did not include painting in the facility because it is not included in the union contract. MW #1 also stated the facility does not have a [NAME] but occasionally contracts with someone on the weekends. A lot of painting needs to be done in the facility and the supervisor has been informed. Some of the room air conditioners have duct tape around them as this is used as insulation in the winter since there is nothing else available that can be used. MW#1 further stated wheelchair guards in front of the heaters in the resident's rooms are rusty and need attention. The wallpaper is old and there is no additional paper to make repairs so he uses whatever he has to match the paper when necessary and re-glues it when it starts to come loose. On 04/21/21 at 11:24 AM, the Director of Maintenance (DOM) was interviewed. The DOM stated he has a schedule for making rounds on each unit twice a month and a thorough check is done by him of the call bell, the bathroom, the lights, the heating systems in each room. Rooms, doors, heaters need to be [NAME] but this job cannot be done during the winter. The DOM also stated the Administrator has been informed that there are many things that need to be done on the building and some of the things identified would be a priority. The heater guards are rusted; they were last painted a long time ago. On 04/21/21 01:13 PM, the Administrator was interviewed. The Administrator stated he makes daily rounds on all units and if anything is found on rounds, Maintenance is informed of the need for repairs. The Administrator also stated that the facility is in the process of seeking to hire a [NAME]. The Administrator further stated that a full building renovation is planned however the facility was waiting for a survey to be conducted before proceeding with needed work. 415.5(h)(2)

Based on observation, record review and staff interview, conducted during the Recertification survey, the facility did not ensure that infection control practices were maintained to control and help prevent the development and transmission of communicable diseases and infections. Specifically, (1). The Licensed Practical Nurse (LPN) did not clean and sanitize a glucometer after uses and (2). An LPN did not clean and sanitize a pulse oximeter before and after each use, and prior to using it on another resident. This was observed during the Medication Administration Task. The facility policy and procedure titled Cleaning and Disinfection of Equipment dated 03/24/2020 documented resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. The policy also documented that intermediate and low level disinfectants for non-critical items include amongst other Sani-Cloth Plus Germicidal Disposable wipes. The facility policy and procedure titled Evencare G3 Glucose Testing dated 10/1/17 documented the meter should be cleaned and disinfected between each resident use with [MEDICATION(S)] Micro-Kill Wipes or Sani-Cloth Plus Germicidal Disposable Cloths. The findings are: 1. On 04/19/2021 at 4:35 PM, Medication Administration was observed with Licensed Practical Nurse (LPN) # 3. LPN #3 washed hands and removed the Glucometer from the drawer of the medication cart, a couple of alcohol prep pads and a lancet. After cleansing Resident #68's finger with an alcohol prep pad, the LPN pierced the resident's finger and the resident smeared the blood by placing fingers together and the test could not be performed. LPN #3 changed gloves and pierced the resident's finger a second time and applied blood to the test strip located in the glucometer. After completing testing for Resident #68 and performing hand hygiene, LPN #3 approached Resident #157 to conduct blood glucose testing. LPN # 3 did not clean the glucometer and LPN #3 inserted a test strip into the glucometer. LPN #3 cleansed the resident's finger and prepared the lancet and before LPN #3 could pierce Resident #157's finger the State Surveyor intervened. An interview was conducted immediately with LPN # 3. LPN #3 stated she was aware that she had not cleaned the glucometer before preparing to test the next resident. LPN #3 then proceeded to the medication cart and cleaned the glucometer with alcohol prep pads. LPN #3 stated that she always uses alcohol prep pads for cleaning. When asked about the facility policy on cleaning of the glucometer, LPN #3 retrieved PDI Sanicloth wipes from the bottom drawer of the Medication Cart. 2. On 04/20/2021 at 10:34 AM, Licensed Practical Nurse # 2 was observed recording Oxygen saturation with the use of the pulse oximeter. LPN # 2 approached Resident # 164. LPN #2 did not clean or sanitize device before or after use. LPN #2 then proceeded to Resident #69 and applied the pulse oximeter to the resident's finger. LPN #2 did not clean the device before or after use and placed the device on top of the medication cart use after she removed it from the resident's finger. An interview was conducted with LPN #2 immediately after the observation. LPN # 2 stated that she is supposed to disinfect the device after each use and in between residents. LPN#2 also stated she usually uses alcohol prep pads to clean the device although disinfectant wipes are also available. LPN#2 could not state what the facility policy was on disinfecting devices after use and before use with another resident. 415.19(a)(1-3)

Based on observations and interviews conducted during a Recertification survey from 04/14/2021 to 04/21/2021, the facility did not ensure that a safe, functional, sanitary, and comfortable environment was provided for residents, staff, and the public. Specifically, the staff bathrooms were observed to be dusty and in disrepair. This was evident on 4 of 5 units observed during Environmental Rounds. (Units 2, 3, 4, and 5) During multiple observations conducted in the facility between 4/15/21 at 1:30 PM and 4/21/21 at 1:00 PM the following was observed: Staff bathroom on 1st Floor had mismatched paint on walls, rusted inner lower door area, black scuff marks on wall near toilet, and air vent was dusty. Staff bathroom located between Room 202 and 203 had a discolored peeling toilet seat, mismatched paint on walls above paper dispenser and next to soap dispenser. Staff bathroom located between Room 206 and 207 had unsealed holes above paper dispenser, and discolored floor tiles. Staff bathroom located between 306 and 307 had discolored floor tiles, the air vent was partially dislodged with chipped paint around the edges. Staff bathroom located between Room 402 and 403 had rusted corner of door, and dusty air vents. Staff bathroom located between Room 406 and 407 had mismatched paint next to the mirror, walls above sink and adjacent to sink were visibly dusty and rusted areas were observed at the base of the door and the door edge. Staff bathroom located between Room 502 and 503 had mismatched paint on wall adjacent to sink and ceiling above door. Staff bathroom located between Room 506 and 507 had mismatched paint on wall adjacent to sink. On 04/21/21 at 11:24 AM, the Director of Maintenance (DOM) was interviewed. The DOM stated the Administrator has been informed that there are many things that need to be done on the building and some of the things identified would be a priority. The DOM also stated that since coming onboard in January 2020 he observed that the staff bathrooms were in need of attention and spoke to the Administrator recently in this regard. Dispensers had been changed in some of the staff bathrooms and walls need to be repainted. The DOM also stated that the facility would be in the process of getting a [NAME] onsite to address multiple areas that are in need of attention. On 04/21/21 at 01:13 PM, the Administrator was interviewed. The Administrator stated he makes rounds of staff bathrooms and if anything is found on rounds, Maintenance is informed of the need for repairs. The Administrator also stated that the facility is in the process of seeking to hire a [NAME]. The Administrator further stated that a full building renovation is planned however the facility was waiting for a survey to be conducted before proceeding with needed work. 415.29

Based on observation, record review, and interview conducted during the recertification survey, the facility did not ensure that the assessment accurately reflected the resident's status. Specifically, the Minimum Data Set (MDS) did not accurately code a resident who was receiving [CONDITION(S)] services. This was evident for 1 of 1 resident reviewed for [CONDITION(S)] out of a sample of 35 residents. (Resident 172) The findings are: The facility policy and procedure titled MDS 3.0 dated 10/26/17 documented the purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. Resident 172 was readmitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change of Status MDS with ARD date 3/12/21 documented the resident reentry on 2/27/21 from the hospital with intact cognition. The MDS documented [CONDITION(S)], Stage 3b as an active diagnosis. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Orders also documented Hemodialysis on Tuesday, Thursday and Saturday, and no blood pressure/blood drawn on left arm. Nursing note dated 2/17/21 documented Resident 172 was transferred to the hospital and admitted for End Stage Renal Disease ([CONDITION(S)]). Nursing note dated 2/27/21 documented readmission of Resident 172 from the hospital with primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 172 was started on [CONDITION(S)] and was dialyzed today; [CONDITION(S)] schedule is Tuesday, Thursday, and Saturday. Central Venous Catheter (CVC) for [CONDITION(S)] noted intact on Right upper chest wall, site clean and dry. Medical note dated 3/1/21 documented patient was readmitted after hospitalization at hospital for [CONDITION(S)] and was newly on Hemodialysis three times per week. Medical note dated 3/2/21 documented resident alert and verbally responsive and returned to the facility from [CONDITION(S)] around 11:25 AM. MDS note dated 3/3/21 documented resident has new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Discussed with ITD (Inter Disciplinary Team), will proceed with Significant Change assessment. The Significant Change of Status dated 3/12/21 MDS did not document [CONDITION(S)] care in the Special Treatment Section O for the resident. On 04/20/21 at 11:25 AM, an interview was conducted with the MDS Coordinator (RN #1) who completed the MDS. RN #1 stated a Significant Change MDS dated [DATE] was due to the change in status to End Stage Renal Disease worsening leading to Hemodialysis. RN #1 stated [CONDITION(S)] was not coded on the MDS and the MDS will need to be modified. 415.11(b)

Based on observation, record review and staff interview, the facility did not ensure that a resident who is unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene. Specifically, a resident was observed on more than one occasion over 2 days to have fingernails approximately half an inch from the tip of the fingers. The fingernails were observed with a black substance imbedded underneath them. This was evident for 1 of 2 residents reviewed for Activities of Daily Living out of a sample of 35 residents. (Resident # 87) The facility policy on Resident Grooming dated 09/08/2020 documented the facility will ensure a resident is given the appropriate treatment and services to maintain or improve ability to carry out activities of daily living. The policy also documented that the facility will provide the necessary care and services for the following activities of daily living hygiene- bathing, dressing, grooming and oral care. The finding is: Resident # 87 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) 3.0 dated 01/29/2021 documented the resident as cognitively intact and required extensive assistance of 1 person for grooming, dressing and personal hygiene. On 04/16/2021 at 12:35 PM, an interview was conducted with Resident #87. Resident was observed with fingernails on both hands a half inch in length from the tip of the finger with a blackish colored substance underneath the fingernails. During the interview, Resident #87 stated I will appreciate it if someone will trim them (fingernails). On 4/19/2021 at 12:00 PM, Resident #87 was observed sitting in chair in room. Resident fingernails were observed to be un-trimmed, half an inch in length with a blackish colored substance imbedded under the fingernails. The Comprehensive Care Plan for ADL's dated 03/19/2021 documented resident needed assistance with grooming, dressing and transfer. Goal was resident's performance in ADL's will not deteriorate for 90 days. Interventions included Active Range of Motion on bilateral upper and lower extremities during care, allow resident freedom to choose clothes, praise effort, monitor any decline and maintain consistency. Review of the Certified Nursing Assistant Accountability Record (CNAAR) revealed there was no documentation recorded on the specific grooming that had been provided to the resident. An interview was conducted with CNA #1 on 04/19/2021 at 2:45 PM. CNA#1 stated she had been assigned to the resident for the past month. CNA could not provide an explanation as to why the resident's fingernails had not been trimmed recently. CNA #1 also stated that maintaining the resident's fingernails in a clean, trimmed manner is part of her responsibilities. On 04/21/2021 at 3:00 PM, the Unit Charge Licensed Practical Nurse (LPN) #2 was interviewed. LPN#2 stated it is the responsibility of the nurse to monitor the CNA's and ensure that the residents are appropriately dressed and nails are clean, trimmed and cut, if resident so wishes. On 04/21/2021 at 3:45 PM, the Director of Nursing (DNS) was interviewed. The DNS stated there is no particular column in the Sigma EMR where the CNA's can document on grooming provided to the residents. The DNS also stated that the cutting and trimming of nails, and appropriately dressing the resident is discussed as part of CNA orientation and reminders and re-in-service is done as needed. The DNS further stated that monitoring and spot checking of the resident is the responsibility of the charge nurses on the unit. 415.12(a)(3)

Based on observations, record review and interviews conducted during a Recertification survey, the facility did not ensure that all medications and biologicals used in the facility were stored and labeled properly and included the expiration date when applicable. Specifically, one opened and undated vial of insulin was observed. This was evident on 1 of 5 units during the Medication Storage Task. (Unit 4) The findings are: The facility policy and procedure titled Opened Multidose Vials and Specific Inhalers, revised ,d+[DATE] documented that the nurse who opens the vial must write the date on the label and that [MEDICATION(S)] insulin must be replaced after 28 days. On [DATE] at 11:30 AM, during an observation of the 4th floor medication room and medication cart an undated vial of [MEDICATION(S)] was observed in the medication cart. On [DATE] at 11:35 AM, Registered Nurse (RN) #1 was interviewed. RN#1 stated she usually checks the labels on each vial at the start of every shift and but that she forgot to check at the start of the shift. RN #1 stated nurses are supposed to check medications at the start of the shift and if there is an unlabeled vial, the supervisor is notified. On [DATE] at 11:40 AM, the RN Supervisor was interviewed. The RNS stated that insulin has to be dated with an expiration date when opened. The medication nurse is supposed to check the medication cart at the start of the shift to make sure that the insulin vials have stickers noting their expiration dates. The RNS also stated that pharmacy provides yellow labels to be used, but if there are no labels from the pharmacy the facility has labels than can be used and should be applied directly to the vial and not just on the plastic bag that the vial is placed in. Each nurse on each shift is responsible for checking insulin. The RNS further stated he periodically checks the carts for errors on an informal basis and does not document the findings of these checks. On [DATE] at 04:57 PM, Licensed Practical Nurse (LPN) #1 who worked on the unit on [DATE] and [DATE] was interviewed. LPN #1 stated that insulin should be labeled every time a vial is opened but that she did not put the date on the vial when she opened this insulin vial. LPN #1 also stated that sometimes the bag comes up with the date already on it and she sometimes gets distracted by the residents. LPN #1 further stated that this was an error on her part and if she observed a vial that had been opened and not dated, she would put a date on it when she saw it. On [DATE] at 11:41 AM, the Director of Nursing was interviewed. The DON stated that nurses must label and date vials of insulin when the vial is opened. Labels are provided for this purpose and should contain 2 dates, the date opened and the date expired. The DON also stated that nurses should be checking the dates on all insulin on every shift. Supervisors do checks but not on a daily basis and the pharmacist checks once a month to ensure this is being done. 415.18(d)