Every finding on record at Park Nursing Home

Based on observations, record review, and interviews, the facility failed to update the electronic medical record with a resident's Medical Order for Life-Sustaining Treatment (MOLST) after returning to the facility from a hospitalization. This was evident for one (1) out of six (6) residents (Resident #1) reviewed for advanced directives. Specifically, Resident #1 had a Do Not Resuscitate (DNR)/ Do Not Intubate (DNI) order in place dated [DATE]. On [DATE], the resident was hospitalized and returned to the facility on [DATE]. On [DATE] at 9:47 PM, Resident #1 was found to be unresponsive. Licensed Practical Nurse #1 and Registered Nurse Supervisor #1 both could not locate the resident's advanced directive/code status in the Electronic Medical Record and initiated cardiopulmonary resuscitation against Resident #1's wishes and Emergency Medical Service was called and continued cardiopulmonary resuscitation until the resident was pronounced deceased . This resulted in Immediate Jeopardy Past Noncompliance.The findings include:The facility's policy and procedure titled Advanced Directives Specific to Do Not Resuscitate was last reviewed on [DATE] and states when a resident is admitted with a Medical Order for Life Sustaining Treatment, if the resident/family wishes to keep Medical Order for Life-Sustaining Treatment orders as is, the admitting nurse will communicate this with the physician and ensure that a physician's order is obtained.Resident #1 was admitted to the facility with diagnoses including chronic obstructive pulmonary edema (a progressive, treatable, but incurable lung disease), type 2 diabetes mellitus and heart failure (the heart muscle cannot pump enough blood to meet the body's needs).The Minimum Data Set (a resident assessment tool) dated [DATE] identified Resident #1 to have intact cognition. The Medical Order for Life Sustaining Treatment signed and dated [DATE] by the resident and physician, documented Do Not Resuscitate and Do Not Intubate.An Advance Directive Care Plan dated [DATE] identified Resident #1 as Do Not Resuscitate. The interventions included Physician's Order for advanced directive and document in chart. There is no documented evidence that the resident or their representative rescinded the [DATE] Do Not Resuscitate/Do Not Intubate directives, however, a review of the resident's Electronic Medical Record revealed the physician's order for the Do Not Resuscitate/Do Not Intubate had been de-activated while the resident was in the hospital.The facility's investigative summary dated [DATE], documented that on [DATE] at approximately 9:47 PM, the resident was observed by unit staff to be unresponsive. The assigned Licensed Practical Nurse #1 immediately notified Registered Nurse Supervisor #1 that the resident was unresponsive and had no palpable pulse. Registered Nurse Supervisor #1 promptly assessed the resident and confirmed unresponsiveness and absence of palpable pulse. A Code Stat (immediately or without delay) was immediately activated via overhead page and Registered Nurse Supervisor #2 responded at approximately 9:50 PM to assist with the emergency response. At the time of the emergency, Registered Nurse Supervisor #1 reviewed the electronic medical record to verify code status. No active/current physician order indicating Do Not Resuscitate was present in the physician order section of the chart. Based on the resident's clinical condition, cardiopulmonary resuscitation was initiated at approximately 9:53 PM. Emergency Medical Services arrived at approximately 10:02 PM and resuscitative efforts continued until approximately 10:27 PM, when the resident was pronounced deceased by Emergency Medical Services. The investigation concluded that there was no evidence of abuse, neglect or intentional harm.During an interview on [DATE] at 12:30 PM, Certified Nursing Assistant #1 stated that during rounds on [DATE] at 8:45 PM, Resident #1 was alert, watching television and talking. They stated during their 9:45 PM rounding on [DATE], Resident #1 was unresponsive, and they immediately called Licensed Practical Nurse #1.During an interview on [DATE] at 1:00 PM, Licensed Practical Nurse #1 stated that on [DATE], Certified Nursing Assistant #1 notified them that Resident #1 was unresponsive. They went to Resident #1's room and noted they were unresponsive and without a palpable pulse. Licensed Practical Nurse #1 stated they left the room and notified Registered Nurse Supervisor #1. Licensed Practical Nurse #1 stated they and Registered Nurse Supervisor #1 went to Resident #1's room and they found Resident #1 unresponsive and without a palpable pulse. Licensed Practical Nurse #1 stated Registered Nurse Supervisor #1 left the room and called Code Stat. Licensed Practical Nurse #1 stated they remained with Resident #1 and continued to check for pulse and responsiveness. They stated that Registered Nurse Supervisors #1 and #2 came to Resident #1's room and Registered Nurse Supervisor #2 started chest compressions on Resident #1. Licensed Practical Nurse #1 stated they were assigned to Resident #1, they were in-serviced on advanced directives and that they were certified in cardiopulmonary resuscitation.During an interview on [DATE] at 1:45 PM, Registered Nurse Supervisor #1 stated that Licensed Practical Nurse #1 notified them that Resident #1 was unresponsive. They assessed Resident #1, left the room to check code status and called Code Stat. Registered Nurse Supervisor #1 stated Do Not Resuscitate was not noted in the electronic medical record and there was no purple binder with the Medical Order for Life Sustaining Treatment form. They stated that since there was no documentation, they activated a full code by calling Code Stat. Registered Nurse Supervisor #1 stated they left Licensed Practical Nurse #1 with Resident #1 while they went to the first floor to get the Automatic External Defibrillator (AED). They stated that they and Registered Nurse Supervisor #2 went to Resident #1's room and Registered Nurse Supervisor #2 initiated cardiopulmonary resuscitation. Registered Nurse Supervisor #1 stated on hire to the facility, they were inserviced on advanced directives and that they are certified in cardiopulmonary resuscitation. During an interview on [DATE] at 2:15 PM, Registered Nurse Supervisor #2 stated they were on the first floor when they heard the overhead page for Code Stat. They stated that on their way to Resident #1's room on the second floor, they met Registered Nurse Supervisor #1 exiting the second floor and stated they think Resident #1 is dead and that they were going to get the Automatic External Defibrillator. Registered Nurse Supervisor #2 stated they and Registered Nurse Supervisor #1 went to Resident #1's room and they (Registered Nurse Supervisor #2) found Resident #1 unresponsive and without a palpable pulse. They stated that they initiated chest compressions based on information from Registered Nurse Supervisor #1 that Resident #1 was a full code. Registered Nurse Supervisor #2 stated they continued chest compressions until Emergency Medical Services arrived. They stated that Emergency Medical Services continued chest compressions and that Resident #1's status was unchanged. Registered Nurse Supervisor #2 stated that Emergency Medical Services pronounced the resident deceased at 10:27 PM. Registered Nurse Supervisor #2 stated the physician and Resident #1's family were notified.During an interview on [DATE] at 3:30 PM, the Director of Nursing stated that Certified Nursing Assistant #1 found Resident #1 unresponsive on [DATE] at 9:47 PM and notified Licensed Practical Nurse #1 immediately. The Director of Nursing stated that Licensed Practical Nurse #1 went to Resident #1's room and found them unresponsive without a palpable pulse. They stated that that Licensed Practical Nurse #1 immediately notified Registered Nurse Supervisor #1 who assessed Resident #1, checked the Electronic Medical Record for code status and called Code Stat. The Director of Nursing stated Registered Nurse Supervisor #2 responded and initiated chest compressions. The Director of Nursing stated that Registered Nurse Supervisor #1 checked the Electronic Medical Record and did not find an order for Do Not Resuscitate. They stated that that the order was not re-entered when Resident #1 returned from a hospitalization on [DATE]. The Director of Nursing stated they investigated the incident and identified that cardiopulmonary resuscitation was initiated against the resident's wish for Do Not Resuscitate. In addition, they stated the staff acted in good faith based on Resident #1's clinical condition.During a follow-up interview on [DATE] at 1:00 PM, the Director of Nursing stated staff stated they did not see a binder with the Medical Order for Life Sustaining Treatment (MOLST), at the nurses' station during the emergency on [DATE]. The Director of Nursing stated after the incident, the facility has changed the procedure for filing Medical Order for Life-Sustaining Treatment forms. They stated the Medical Order for Life Sustaining Treatment forms for all residents on each unit, are filed in one purple binder and secured with a chain at the nurses' station. The Director of Nursing stated they received Resident #1's Medical Order for Life-Sustaining Treatment paper copy from the Administrator who received it from the medical records staff on [DATE]. During an interview on [DATE] at 11:00 AM, Medical Records Staff #1 stated on [DATE], they found Resident #1's purple binder on a shelf at the nurses' station on the second floor. They stated the pink form Medical Order for Life Sustaining Treatment was in the binder, and they gave it to the Administrator.During an interview with the Medical Director on [DATE] at 11:51 AM, they stated staff should not have performed chest compressions on Resident #1. The Medical Director stated Resident #1 had a Medical Order for Life-Sustaining Treatment that indicated Do Not Resuscitate that was signed by them (Medical Director) on [DATE] and a physician order for Do Not Resuscitate/Do Not Intubate, signed by them [DATE]. The Medical Director stated the Administrator informed them of the incident on [DATE]. 10 New York Code, Rules, and Regulations 415.3(e)(2)(iii) Based on the following corrective actions taken, there was sufficient evidence that the facility corrected the non-compliance and was in substantial compliance for this specific regulatory requirement prior to and during the time of this survey. A Plan of Correction is not required for this citation. The facility took immediate corrective actions and was found to be in substantial compliance on [DATE], prior to Surveyors' onsite visit on [DATE]. Immediate Corrective Actions[DATE] - [DATE] - facility wide audit done to ensure all residents' advanced directives are accurately reflected as active/current physician orders. All residents were audited to ensure that each resident has an active physician order reflecting their current advance directive/code status-Full Code and Do Not Resuscitate/Do Not IntubateXXX[DATE] - [DATE] - a comprehensive audit of all residents' advanced directives, including prior admissions and readmissions reviewedXXX[DATE] - [DATE] - Care plan review completed to ensure care plans are current, accurate, and aligned with each resident's advance directives and active/current physician ordersXXX[DATE] - [DATE] - Policy and procedure Advance Directives Specific to DNR was reviewed and updated to standardize advanced directive verification processes ensuring consistent, accurate alignment with active/current physician orders, clearly defined roles and responsibilities for nursing, social services and providersXXX[DATE] - Policy and procedure, Advance Directives Specific to Do Not Resuscitate, was revised to reinforce that during an emergency or code event, staff must rely on readily accessible, active physician orders in the electronic medical record to determine code status. Consistent with regulatory standards, the Medical Order for Life Sustaining Treatment (MOLST)form constitutes a valid and actionable medical order; therefore, in the absence of a clearly visible or active physician order in the electronic medical record, staff are directed to immediately locate and verify the most current signed Medical Order for Life-Sustaining Treatment or advance directive in the medical record. Lesson Plan and In-service Attendances on Code Status/Advance Directives/ Medical Order for Life-Sustaining Treatment dated [DATE]-[DATE] reviewed with no concerns.TOTAL EMPLOYEES ---195TitleCompleted % CompleteCertified nursing Assistants90100% - 5 staff on leave, 1 on vacation.Registered Nurses18100%Licensed Practical Nurses30100%Dietary Staff16100%Housekeeping Staff16100%Maintenance Staff2100%Recreation Staff5100%Administration Employees13100%Rehabilitation5100%

Based on interview and record review conducted during the survey, the facility failed to maintain medical records on each resident that are complete, accurately documented, and readily accessible and systematically organized. This was evident for one (1) of six (6) residents reviewed for Advanced Directive. Specifically, Resident #1 had Do Not Resuscitate (DNR)/ Do Not Intubate (DNI) order in place dated [DATE]. On [DATE] the resident was hospitalized and returned to the facility on [DATE]. On [DATE] at 9:47 PM, Resident #1 was found to be unresponsive. Licensed Practical Nurse #1 and Registered Nurse Supervisor #1 both could not locate the resident's advanced directive/code status in the Electronic Medical Record and initiated cardiopulmonary resuscitation against Resident #1's wishes and Emergency Medical Service was called and continued cardiopulmonary resuscitation and intubation until the resident was pronounced deceased . Findings are:The facility Policy on Advance Directive title Advance Directive Specific to DNR was last revised on [DATE]. The policy states to ensure that each resident's advanced directives, including code status, are accurately established, verified, clearly documented and consistently aligned with active physician orders in the electronic medical record.The facility recognizes the Medical Orders for Life Sustaining Treatment (MOLST) as a valid and actionable medical order under New York State law and requires that all advanced directives decisions are readily accessible and immediately actionable to guide clinical care particularly during emergencies.Resident #1 was admitted to the facility with diagnoses including chronic obstructive pulmonary edema (a progressive, treatable, but incurable lung disease), type 2 diabetes mellitus and heart failure (the heart muscle cannot pump enough blood to meet the body's needs).The Minimum Data Set (a resident assessment tool) dated [DATE] identified assessed Resident #1 to have had intact cognition and able to make medical decisions. The Medical Order for Life Sustaining Treatment (MOLST) signed and dated [DATE] by the resident and physician, documented Do Not Resuscitate and Do Not Intubate.An Advance Directive Care Plan dated [DATE] identified Resident #1 as Do Not Resuscitate. The interventions include physician's order for advanced directive and to document in chart. There is no documented evidence that the resident or their representative rescinded the [DATE] Do Not Resuscitate/Do Not Intubate directives, however, a review of the resident's Electronic Medical Record revealed the physician's order for the Do Not Resuscitate/Do Not Intubate had been de-activated while the resident was in the hospital.The facility's investigative summary dated [DATE], documented that on [DATE] at approximately 9:47 PM, the resident was observed by unit staff to be unresponsive. The assigned Licensed Practical Nurse #1 immediately notified Registered Nurse Supervisor #1 that the resident was unresponsive and had no palpable pulse. Registered Nurse Supervisor #1 promptly assessed the resident and confirmed unresponsiveness and absence of palpable pulse. A Code Stat (immediately or without delay) was immediately activated via overhead page and Registered Nurse Supervisor #2 responded at approximately 9:50 PM to assist with the emergency response. At the time of the emergency, Registered Nurse Supervisor #1 reviewed the electronic medical record to verify code status. No active/current physician order indicating Do Not Resuscitate was present in the physician order section of the chart. Based on the resident's clinical condition, cardiopulmonary resuscitation was initiated at approximately 9:53 PM. Emergency Medical Services arrived at approximately 10:02 PM and resuscitative efforts continued until approximately 10:27 PM, when the resident was pronounced deceased by Emergency Medical Services. The investigation concluded that there was no evidence of abuse, neglect or intentional harm.During an interview on [DATE] at 1:45 PM, Registered Nurse Supervisor #1 stated that Licensed Practical Nurse #1 notified them that Resident #1 was unresponsive. They assessed Resident #1, left the room to check code status and called Code Stat. Registered Nurse Supervisor #1 stated Do Not Resuscitate was not noted in the electronic medical record and there was no purple binder with the Medical Order for Life Sustaining Treatment form. They stated that since there was no documentation, they activated a full code by calling Code Stat. Registered Nurse Supervisor #1 stated they left Licensed Practical Nurse #1 with Resident #1 while they went to the first floor to get the Automatic External Defibrillator (AED). They stated that they and Registered Nurse Supervisor #2 went to Resident #1's room and Registered Nurse Supervisor #2 initiated cardiopulmonary resuscitation. Registered Nurse Supervisor #1 stated on hire to the facility, they were in-serviced on advanced directives and that they are certified in cardiopulmonary resuscitation. During an interview on [DATE] at 3:30 PM, the Director of Nursing stated that Certified Nursing Assistant #1 found Resident #1 unresponsive on [DATE] at 9:47 PM and notified Licensed Practical Nurse #1 immediately. The Director of Nursing stated that Licensed Practical Nurse #1 went to Resident #1's room and found them unresponsive without a palpable pulse. They stated that that Licensed Practical Nurse #1 immediately notified Registered Nurse Supervisor #1 who assessed Resident #1, checked the Electronic Medical Record for code status and called Code Stat. The Director of Nursing stated Registered Nurse Supervisor #2 responded and initiated chest compressions. The Director of Nursing stated that Registered Nurse Supervisor #1 checked the Electronic Medical Record and did not find an order for Do Not Resuscitate. They stated that that the order was not re-entered when Resident #1 returned from a hospitalization on [DATE]. The Director of Nursing stated they investigated the incident and identified that cardiopulmonary resuscitation was initiated against the resident's wish for Do Not Resuscitate. In addition, they stated the staff acted in good faith based on Resident #1's clinical condition.During a follow-up interview on [DATE] at 1:00 PM, the Director of Nursing stated staff stated they did not see a binder with the Medical Order for Life Sustaining Treatment (MOLST), at the nurses' station during the emergency on [DATE]. The Director of Nursing stated after the incident, the facility has changed the procedure for filing Medical Order for Life-Sustaining Treatment forms. They stated the Medical Order for Life Sustaining Treatment forms for all residents on each unit, are filed in one purple binder and secured with a chain at the nurses' station. The Director of Nursing stated they received Resident #1's Medical Order for Life-Sustaining Treatment paper copy from the Administrator who received it from the medical records staff on [DATE]. During an interview on [DATE] at 11:00 AM, Medical Records Staff #1 stated on [DATE], they found Resident #1's purple binder on a shelf at the nurses' station on the second floor. They stated the pink form Medical Order for Life Sustaining Treatment was in the binder, and they gave it to the Administrator.During an interview with the Medical Director on [DATE] at 11:51 AM, they stated staff should not have performed chest compressions on Resident #1. The Medical Director stated Resident #1 had a Medical Order for Life-Sustaining Treatment that indicated Do Not Resuscitate that was signed by them (Medical Director) on [DATE] and a physician order for Do Not Resuscitate/Do Not Intubate, signed by them [DATE]. The Medical Director stated the Administrator informed them of the incident on [DATE]. 10 New York Code, Rules, and Regulations 415.22(a)(1-24) Based on the following corrective actions taken, there was sufficient evidence that the facility corrected the non-compliance and was in substantial compliance for this specific regulatory requirement prior to and during the time of this survey. A Plan of Correction is not required for this citation. The facility took immediate corrective actions and was found to be in substantial compliance on [DATE], prior to Surveyors' onsite visit on [DATE]. Immediate Corrective Actions[DATE] - [DATE] - facility wide audit done to ensure all residents' advanced directives are accurately reflected as active/current physician orders. All residents were audited to ensure that each resident has an active physician order reflecting their current advance directive/code status-Full Code and Do Not Resuscitate/Do Not IntubateXXX[DATE] - [DATE] - a comprehensive audit of all residents' advanced directives, including prior admissions and readmissions reviewedXXX[DATE] - [DATE] - Care plan review completed to ensure care plans are current, accurate, and aligned with each resident's advance directives and active/current physician ordersXXX[DATE] - [DATE] - Policy and procedure Advance Directives Specific to DNR was reviewed and updated to standardize advanced directive verification processes ensuring consistent, accurate alignment with active/current physician orders, clearly defined roles and responsibilities for nursing, social services and providersXXX[DATE] - Policy and procedure, Advance Directives Specific to Do Not Resuscitate, was revised to reinforce that during an emergency or code event, staff must rely on readily accessible, active physician orders in the electronic medical record to determine code status. Consistent with regulatory standards, the Medical Order for Life Sustaining Treatment (MOLST) form constitutes a valid and actionable medical order; therefore, in the absence of a clearly visible or active physician order in the electronic medical record, staff are directed to immediately locate and verify the most current signed Medical Order for Life-Sustaining Treatment or advance directive in the medical record. Lesson Plan and In-service Attendances on Code Status/Advance Directives/ Medical Order for Life-Sustaining Treatment dated [DATE]-[DATE] reviewed with no concerns.TOTAL EMPLOYEES ---195TitleCompleted % CompleteCertified nursing Assistants90100% - 5 staff on leave, 1 on vacation.Registered Nurses18100%Licensed Practical Nurses30100%Dietary Staff16100%Housekeeping Staff16100%Maintenance Staff2100%Recreation Staff5100%Administration Employees13100%Rehabilitation5100%

Based on observation and staff interviews during the Recertification survey it was determined that the facility did not ensure that the maintenance and housekeeping services provided, were maintained a sanitary, orderly, and comfortable interior on two (3S, 3N) of five resident units. This was evidenced by soiled, stained, torn, or broken furniture, dusty and soiled air conditioners, soiled, stained torn wallpaper, stained ceiling tiles, resident sinks and corridor bathrooms in disrepair, soiled torn clean linen cart covers. The findings are: The facility's policy and procedure, titled Environmental Services dated 04/25/25 stated it is the policy of this facility to ensure all resident rooms are comfortable, cleaned and sanitized according to set standards to maintain a safe sanitary and comfortable homelike environment. The resident has a right to a safe clean comfortable and homelike environment including but not limited to receiving treatment and supports for daily living safely. This includes Housekeeping and Maintenance services necessary to maintain a sanitary orderly and comfortable interior. 1.During multiple observations made from 08/19/2025 to 08/26/2025 the following was observed on unit 3N: 1. In the bathroom opposite room [ROOM NUMBER] a) one of three soap dispensers were broken, and the outside covers were dusty. b) all three mirrors were soiled, stained, and streaked. c) both paper towel dispensers were dusty. d) there were stained, dirty, broken wall tiles. 2. Dining Room a) eight (8) wooden framed vinyl chairs had torn seat cushions, cracked and worn wooden frame. b) two (2) fabric covered chairs were heavily soiled, discolored and the back side was pulled out. 3. Corridor: a) clean linen cart cover torn tattered. 4. In room [ROOM NUMBER], the sink was not firmly affixed to the wall, and the surrounding ceramic tiles were broken. 5. In room [ROOM NUMBER], there were torn window screens. 6. In room [ROOM NUMBER], there was a missing closet doorknob near bed B, and a rusty and soiled bed frame at bed D. The Housekeeping and Maintenance logbook for Unit 3 was reviewed and contained blank forms and there were no written requests for repairs for any of the above-mentioned areas. On 08/26/2025 at 8:48 AM, Licensed Practical Nurse #2, was interviewed and stated that a Housekeeping and Maintenance logbook is kept on all units for any staff to submit a concern. Licensed Practical Nurse #2 also stated if there is an immediate concern, they notify the department by phone. Licensed Practical Nurse #2 further stated that an environmental staff person checks the logbooks on a daily basis. On 08/26/2025 at 9:34 AM, the Maintenance Director was interviewed and stated the following they have to ensure the maintenance of the building is done in keeping with infection control prevention and practices. The Maintenance Director also stated environmental cleanliness is important for all residents' staff and visitors, and they want to maintain a clean and sanitary place for residents to live in and staff to work in. The Maintenance Director further stated there is a logbook on each unit where staff can describe an issue with housekeeping or maintenance; this book is checked every day and issues are addressed right away. The Maintenance Director stated they make rounds to ensure that equipment, furniture, and rooms are clean and functional, they look for accumulation of dust when making rounds, and they address any rounding concerns immediately with their staff. On 08/26/2025 at 10:39 AM, the Administrator was interviewed and stated their role includes but is not limited to oversight of daily facility operations. The Administrator also stated they have ongoing communication with staff via e-mails, phone calls, and meetings regarding resident or family concerns. The Administrator further stated there had been no recent requests for new furniture or resident equipment. 2. During multiple observations from 08/19/2025 at 10:03 AM to 08/21/2025 at 11:55 AM, the following were observed on the floor 3 South but not limited to: 1.Elevator Cart A - wall panel noted area with white patch, stained and scratched surfaces on the floor. 2. In room [ROOM NUMBER], there was dried substance on the floor by tube feeding pump and pole, a sticky overbed table, misaligned closet drawers, and a privacy curtain hanging around the bed which was missing hooks and partially unhanged. 3. In room [ROOM NUMBER], the bed frames and legs were rusted and peeled. 4. In room [ROOM NUMBER], the window screens were torn, windows were taped shut with blue tape, and windowsills were covered with dust. Also, the baseboard heating vents and cracks above it were noted with dirt/dust and the baseboard heater was also partially detached from the wall, exposing dirt/dust under it. In addition, the floors were observed with sticky brown stains. 5. In room [ROOM NUMBER], the wooden bedside table had chipped edges/corners, the wheelchair cushion was soiled and stained, and the wooden closet had a white patched area. 6. Several resident rooms and common areas had damaged wall surfaces, sticky bedside tables, wooden furniture with chipped edges, soiled wheelchair cushions, a buildup of dust/dirt noted on the metal heating vents, and floors noted with brown stained areas. The Maintenance Logbook for 3 South dated 8/1/2025 to 8/21/2025 did not contain requests to address any of the above observations. During an interview on 08/21/2025 at 01:18 PM, the Assistant Director of Nursing stated unit nursing staff is responsible to report any housekeeping issues to the housekeeping staff on the unit and equipment issues to the unit nurse. The Assistant Director of Nursing also stated the Nurse will submit a work order form in the binder and/or notify the maintenance department if urgent. During an interview on 08/21/2025 at 01:42PM, the Maintenance Director stated housekeeping staff is on the unit doing routine cleaning daily and maintenance staff does daily round of all the rooms to do work if needed. The Maintenance Director also stated Maintenance staff also does work based on the submitted requests. The Maintenance Director further stated they were aware of the concerning areas found in the residents' rooms and stated maintenance staff should have been already checking for broken furniture, walls, closets, and floors to ensure they are maintained, kept in good condition. 10 NYCRR 415.12(h)(2)

Based on observations, record review, and interviews during the Recertification survey, the facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition. This was evident for 2 (Elevator A and Elevator B) of 2 elevators. Specifically, during the Resident Council meeting, nine of nine residents complained of frequent elevator breakdowns. In addition, during the Recertification survey, the elevators were observed to shake, rattle, and bounce during use.The finding is:The facility policy titled Elevator Policy dated 12/10/2024 stated the purpose of this policy is to ensure the safe and proper operation of the elevators and to conform to regarding inspection and maintenance of elevators to ensure resident, staff and guest safety.On 08/19/2025 at 10:00 AM, and during multiple observations throughout the survey, Elevators A and B bounced when in motion, and shook and rattled before they came to a stop. On 08/21/2025 at 3:30 PM, during the Resident Council meeting, nine (9) of (9) residents reported frequent elevator issues and breakdown. On 08/26/2025 at 9:34 AM, the Maintenance Director was interviewed and stated they are responsible for ensuring resident equipment and electrical equipment is working safely. The Maintenance Director also stated they have an outside company they use for the maintenance of the elevators, and when there are issues, they notify the company. The Maintenance Director further stated they recently changed the elevator company in January 2025, and they have called the elevator company for issues such as the front elevator doors not opening or closing. The Maintenance Director stated there can be issues with either Elevator A or B and if a part is needed, it is ordered by the company, and the elevator may need to be shut down and will be repaired within a few hours, but not more than one day. The Maintenance Director also stated they did have both A and B elevators down a few months ago, but they were up and running within the same day. The Maintenance Director further stated there is also a Freight elevator (Elevator C) that can be used. On 08/26/25 at 10:39 AM, the Administrator was interviewed and stated they changed elevator vendors in January 2025 as they were not satisfied with the services being provided by the previous company. The Administrator also stated the vendor will come in to make repairs within a few hours after notification, or they may come in the early morning hours of the following day if issues occur during the evening or late-night hours. If there is need for servicing the elevators, they are shut down until an assessment is made by the company. The Administrator further stated on one occasion a resident was stuck in the elevator, the Fire Department was called, and the resident was gotten out safely. The Administrator stated they have had less problems with the elevators since they changed vendors. 10 NYCRR 415.29

Based on observations, interviews, and record reviews during the Recertification survey, the facility did not ensure that an effective pest control program was in place. This was evident for one (Unit 3 N) of five units and the 1st Floor Conference Room. Specifically, multiple flies, gnats, and roaches were observed during the initial and subsequent tours of the Pantry Room, corridors, resident bathrooms, and Nurse Station on Unit 3 N and the 1st floor Conference Room. The finding is: The facility policy titled Procedure in the event of Pest Sightings or Complaints dated 04/23/24 stated the facility is to ensure residents environment is clean, safe and pest free. All staff to document of sightings of pest in the pest book. The following observations of Unit 3N were made on 08/19/2025 at 10:40 AM, 08/20/2025 at 9:15 AM, and 08/26/2025 at 09:00 AM and at other times throughout the survey: 1. Pantry Room:a) Multiple live and approximately eight (8) dead roaches were observed throughout the refrigerator, floor, and underneath the pantry sink. 2. Corridor: a) multiple observations of flying gnats/flies. 3. Nurse Station: a) multiple observations of flying gnats. 4. Resident Corridor Bathrooms: a) multiple observations of live roaches.b) multiple observations of flying gnats. 5. 1st Floor Conference Room:a) multiple gnats observed. The Pest Control Logbook for unit 3N dated 02/06/2025 to 08/21/2025 contained no documented evidence of pest sightings. There was no documentation of specific areas of treatments provided by the pest control technician. On 08/26/25 at 8:35 AM, an interview was conducted with Licensed Practical Nurse #2 who stated a Pest Control logbook is located on each unit, and the Pest Control Technician comes on a weekly basis. Licensed Practical Nurse #2 also stated any staff can document sightings in the logbook. Licensed Practical Nurse #2 further stated the exterminator is not accompanied by facility staff when they make their rounds. On 08/26/2025 at 9:34 AM, the Maintenance Director was interviewed and stated there is an outside vendor for Pest Control who makes weekly visits usually on Thursdays or more often as is necessary. A Pest Control Logbook is located on each unit for staff to document sightings which is checked weekly by the exterminator. The Maintenance Director also stated currently construction is actively taking place across the street which may have an effect of more sightings, and in their recollection the control of pests and or rodents has gotten better from some years ago. The Maintenance Director further stated the exterminator goes from throughout the building including the basement and deposits glue traps, roach traps and whatever else is needed. On 08/26/2025 at 10:39 AM, the Administrator was interviewed and stated the exterminator makes weekly visits or more if needed by the facility. The Administrator also stated the Pest Control Logbook on each unit is for staff to note any sightings and locations of pests, which the exterminator will review and treat the affected areas. The Administrator further stated staff have received in-services in the past on how to utilize the Pest Control Logbook. 10 NYCRR 415.29(j)(5)

Based on observation, record review, and interview conducted during an Abbreviated survey (NY00335621), the facility failed to provide adequate supervision to a resident to prevent an accident. This was evident in 1 out of 6 residents (Resident #3) sampled for accidents. Specifically, on 03/11/24 at 9:50 am Resident #3 was assisted into a bathroom toilet stall by Certified Nursing Assistant #3, who was assigned to provide 1:1 monitoring of Resident #3. At 10:35 am, Resident #3 exited from the toilet stall and was noted with a linear laceration measuring 1 centimeter above their left eye. Subsequently, Resident #3 was transferred to the hospital on 03/11/24 at 12:12 pm and was diagnosed with a Left Proximal Humerus Fracture (breaking the bone in the upper arm). This resulted in actual harm to Resident #3 that was not Immediate Jeopardy. The findings are: The facility Policy and Procedure titled Resident Monitoring and Visual Checks dated 07/12/22 was last reviewed on 01/19/23. The policy states that all residents will be monitored by caregivers at the start and end of each shift. The residents need will be assessed for increased monitoring and closer supervision based upon individual needs and behaviors. The Interdisciplinary Team will determine when a resident needs additional monitoring. Caregivers will be informed regarding residents monitoring needs during the shift report, and specific Monitoring forms will be utilized to document the increased monitoring. The facility Policy and Procedure titled Fall Prevention dated 02/2022 states that each resident will be assessed for his/her risk for falls on admission, re-admission, quarterly, and for change in condition. Each resident will have an individualized care plan outlining their fall prevention measures. Residents who require dayroom monitoring or close supervision when out of bed will have this clearly documented on the Certified Nursing Assistant Accountability Record. Resident #3 was admitted to the facility with diagnoses including Paranoid Schizophrenia (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly), Generalized Anxiety Disorder, and a history of sacrum fracture (broken bone). A Minimum Data Set (a resident assessment tool) dated 02/07/24 documented Resident #3 had short-term and long-term memory impairments and moderately impaired cognitive skills for daily decision-making. Resident #3 required partial/moderate assistance for toileting hygiene (the ability to maintain perineal hygiene, adjust clothes, before and after voiding or having a bowel movement) which means - helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. The Minimum Data Set documented that Resident #3 uses a wheelchair. A Fall Prevention / Risk assessment dated [DATE] documented Resident #3 was assessed and identified with a score of 9. The form also documented that a score greater than 5 is high risk for fall. According to the form, a fall prevention protocol should be initiated. A Care Plan for Falls initiated on 07/23/20 was last reviewed (quarterly) on 02/10/24. The interventions instructed to always place Resident #3 in an area closely supervised by staff, keep immediate necessities within easy reach, 1:1 monitoring for falls and behavior on the 7:00 am-3:00 pm and the 3:00 pm-11:00 pm shifts, and visual every 30 minutes during the 11:00 pm-7:00 am shift. Resident Nursing Instructions dated 12/04/23 documented 1:1 staff monitoring from 7:00 am-3:00 pm and every 30 minutes monitoring from 3:00 pm-11:00 pm, and 11:00 pm-7:00 am shifts. The Resident Nursing Instructions were not updated when the care plan was updated on 02/10/24 for Resident to be on 1:1 monitoring from 7:00 am - 3:00 pm and 3:00 pm - 11:00 pm shifts. The lesson plan titled Supervision and Safeguarding Resident related to 1:1 Monitoring states that 1:1 monitor must always be arm's length away from the resident that they are monitoring. The lesson plan also documents those certain residents on 1:1 monitoring requires that the monitor be always in proximity. This is for residents with suicidal ideation, fall risks, and unsafe behaviors. This means that the monitor must be present in the room with the resident and at arm's length away. Review of the above lesson plan with attached in-service sheets dated from 09/01/23 - 09/09/23, revealed that Certified Nursing Assistant #3 received in-service on 1:1 monitoring between 09/01/23 and 09/09/23 as indicated by Certified Nursing Assistant #3's signature. The One-to-One Resident Monitoring Documentation Form dated 03/11/24 documented Resident #3 was on 1:1 monitoring due to impulsive behaviors and fall risk. Certified Nurse Assistant #3 was assigned to provide 1:1 monitoring (must always have the resident in line of vision or be directly outside the door and follow when resident leaves) for Resident #3. The monitoring form 9:00 am entry documented Resident #3 was in the restroom, and at 10:00 am documented Resident #3 was sitting on their bed. The Toilet Use section of the Resident Nursing Instructions, last updated 10/05/23, had no instructions on what staff should do when Resident #3 is being toileted. A Nurse's Progress Note written by Registered Nurse Supervisor #1, dated 3/11/24 at 11:39 am, documented Licensed Practical Nurse #1 reported to them Resident #3 was observed with a cut above their eyebrow. Resident #3 was assessed with a linear laceration measuring 1 centimeter in length above their left eyebrow with no active bleeding. During palpation of the left arm/shoulder, Resident #3 complained of severe pain and had a decrease in Range of Motion. As per translator, Resident #3 verbalized having pain but does not recall any traumatic event. Resident #3 was assessed by the Medical Doctor. An order was obtained for an anti-bacterial ointment to apply to the left eyebrow and to transfer Resident #3 to the hospital for a STAT (immediate) x-ray to rule out a fracture. Diagnostic imaging done in the hospital on 03/11/24 documented the radiographs of Resident #3's shoulder showed an acute fracture through the surgical neck of the humerus with displacement of the shaft anterior/superiorly (broken bone in the upper arm). The Facility's Investigative Summary documented on 03/11/24 Resident #3 was on 1:1 monitoring and was assigned to be monitored by Certified Nursing Assistant #3. The investigation documented Certified Nursing Assistant #3 stated they took Resident #3 to the community bathroom (which has two stalls) at 9:50 am. Certified Nurse Assistant #3 stated Resident #3 had no injury prior to going to the bathroom. Certified Nurse Assistant #3 stated they remained in the bathroom, and they were able to see Resident #3's feet through the crack between the two stalls. Certified Nursing Assistant #3 stated at 10:35 am, Resident #3 came out of the toilet stall, and they noticed a cut over Resident #3's left eye. After entering Resident #3's room, Resident #3 was holding their arm /shoulder as if in pain. Certified Nurse Assistant #3 reported to Licensed Practical Nurse #1 that Resident #3 had a bump on the side of their eye. Nursing Supervisor #1 and the Medical Doctor were notified, and Resident #3 was transferred to the hospital and was diagnosed with Left Proximal Humerus Fracture. The facility concluded it was reasonable to believe Resident #3 was left unattended by Certified Nurse Assistant #3 and there is credible evidence to believe abuse, mistreatment, and neglect have occurred as a result of a violation of Resident #3's plan of care. A Nursing Progress Note written by the Assistant Director of Nursing, dated 03/22/24 at 3:57 pm documented the Orthopedic Consultant called and stated based on the imaging completed, if treatment only includes putting Resident #3's arm in a sling the arm will not properly heal, and without surgery the healing process will be prolonged. Surgery was recommended. An Orthopedic Consultation dated 03/26/24 documented Resident #3 had a Left Proximal Humerus Fracture, Resident #3 was not a good candidate for surgery, and should have no weight bearing for 3 more weeks. During an interview with Resident #3 on 04/03/24 at 1:00 pm, Resident #3 did not respond to surveyor's questions. During an interview on 04/10/24 at 1:56 pm, Certified Nursing Assistant #3 stated they were assigned to provide 1:1 monitoring for Resident #3 on 03/11/24 on the 7:00 am-3:00 pm shift. Certified Nursing Assistant #3 stated Resident #3 had wandering behavior and was on fall precautions. Certified Nursing Assistant #3 stated sometime between 9:30 am and 10:00 am (not sure of the time) they took Resident #3 in their wheelchair to the common restroom located in the hallway. Certified Nursing Assistant #3 stated they assisted Resident #3 with walking into one of the toilet stalls and Resident #3 pulled down their incontinence brief and sat down on the toilet independently while holding onto the hand bar. Certified Nursing Assistant #3 stated they left the toilet area and stood behind the door to the toilet where they could see Resident #3 from between the cracks of the door. Certified Nursing Assistant #3 stated Resident #3 got up, closed the door to toilet, and sat back down on the toilet. Certified Nursing Assistant #3 stated they stayed with Resident #3 until at approximately 10:35 am when they observed (through the door crack) Resident #3 bent over cleaning themselves. Certified Nursing Assistant #3 stated when Resident #3 opened the door to the toilet, they observed Resident #3 with a cut above their left eye with a few drops of fresh blood. Certified Nursing Assistant #3 stated they did not hear any crying, screaming, or noise while Resident #3 was in the toilet stall. Certified Nursing Assistant #3 stated Resident #3 did not fall because it would have been difficult for Resident #3 to pick themselves up. Resident #3 is a heavy person, and the toilet space is small. Certified Nursing Assistant #3 stated they escorted Resident #3 to the wheelchair and took Resident #3 back to their room when they observed Resident #3 holding their left arm saying oy, oy sounding as if they were in pain. Certified Nursing Assistant #3 stated they reported to Licensed Practical Nurse #1 immediately. During an interview on 04/15/24 at 10:00 am, Licensed Practical Nurse #1 stated sometime after 10:00 am and 10:30 am (not sure of the time), Certified Nurse Assistant #3 notified them Resident #3 had a bump on their head. Licensed Practical Nurse #1 stated they observed Resident #3 sitting on their bed, holding their left shoulder. They were observed to have a small, slightly bleeding cut above their left eye. Licensed Practical Nurse #1 stated they called Registered Nurse Supervisor #1. Licensed Practical Nurse #1 stated Certified Nurse Assistant #3 reported to them Resident #3 went to the bathroom by themselves, and they think Resident #3 hit their head. Licensed Practical Nurse #1 stated they told Certified Nursing Assistant #3 they were supposed to stay with Resident #3 inside of the bathroom the entire time. Licensed Practical Nurse #1 stated one-to-one monitoring means staff must see the resident 24 hours a day and be very close to the resident at arm's length in case something happens. Licensed Practical Nurse #1 stated they are responsible for overseeing if the staff are monitoring the residents. During an interview on 04/03/24 at 1:14 pm, Registered Nurse Supervisor #1 stated they assessed Resident #3 and observed an abrasion on Resident #3's left eyebrow. The abrasion was not bleeding, but Resident #3 was moaning while holding their left arm and verbalized pain via a translator. Attending Physician #1 was in the building and assessed Resident #3 who screamed out in pain when their arm was touched Resident #3 was transferred immediately to the hospital for an x-ray. Registered Nurse Supervisor #1 stated a synthetic opioid/narcotic that relieves pain was given to Resident #3 prior to the incident, for a different concern, so additional pain medication was not administered. Registered Nurse Supervisor #1 stated Resident #3 was on 1:1 monitoring for safety, wandering, and a history of falls. Registered Nurse Supervisor #1 stated the nurse on the unit is responsible for overseeing if the staff are monitoring residents properly. Registered Nurse Supervisor #1 stated staff who are assigned to do 1:1 is supposed to be at arm's length and always monitoring the resident visually. Registered Nurse Supervisor #1 stated they initiated an investigation and Certified Nurse Assistant #3's version of what happened does not make any sense. During an interview on 04/03/24 at 12:00 pm, Attending Physician #1 stated they assessed Resident #3 on 03/11/24 and observed a fresh superficial laceration above the left eyebrow which did not require any sutures. Attending Physician #1 went on to say Resident #3 was guarding their left arm, and there was no deformity, but tenderness to touch and pain as assessed via verbal cues was around 5-6 out of 10. Attending Physician #1 stated there was no other visible injury or swelling at the time of assessment. The Attending Physician #1 stated Resident #3 returned from the hospital with the diagnosis of a Left Proximal Humerus Fracture with an order to wear a sling because surgery was not an option. Attending Physician #1 stated it was not clear how Resident #3 sustained a fracture because there would be ecchymosis (a discoloration of the skin resulting from bleeding underneath) on the body if Resident #3 had fallen. Attending Physician #1 stated Resident #3 had declined physically after sustaining the fracture and had required more assistance because Resident #3 was unable to use their left arm. Resident #3 was seen by an Orthopedic doctor on 03/26/24 and was not a candidate for surgery at that time. During an interview on 04/03/24 at 12:30 pm, the Administrator stated they were part of the investigation and went to the restroom to check because Certified Nurse Assistant #3 said they did not leave Resident #3 unattended and could not explain how Resident #3 sustained the injuries. The Administrator stated they checked the sidebars in the toilet stall, and they were in working condition. There was no sign of trauma except a dry stain dark in color (looked like dry blood, but not sure) on the metal latch of the toilet door. The Administrator stated they suspect Resident #3 hit their head on that metal latch when they tried to get up. During an interview on 04/03/24 at 1:45 pm, the Director of Nursing stated Resident #3 was on 1:1 monitoring since 2020 for safety, due to wandering behavior and falls. Staff, including Certified Nurse Assistant #3, were in-serviced previously on 1:1 monitoring, which means they should have known to be at arm's length from the resident and to always have the resident in sight. Certified Nurse Assistant #3 should not have closed the toilet door and should have stayed with Resident #3. Certified Nurse Assistant #3 told them they were behind the door all the time and saw Resident #3 through the crack in the door between stalls but were not able to explain how they did not hear or see how Resident #3 sustained a laceration over their eyebrow and injury to the left upper arm. According to Certified Nurse Assistant #3, Resident #3 was in the restroom for 40 minutes (according to Certified Nursing Assistant #3, this is Resident #3's usual behavior). The Director of Nursing went on to say they suspected Certified Nurse Assistant #3 left Resident #3 on the toilet for an extended time. The Director of Nursing stated due to the extent of the injury, they did not believe Certified Nurse Assistant #3 monitored Resident #3 properly and they suspended Certified Nursing Assistant #3. The Director of Nursing stated the investigation concluded abuse, neglect, and mistreatment had occurred. 10 NYCRR 415.12(h)(1)

Based on observations, interviews, and record review during the Abbreviated Survey (NY00337011), the facility failed to protect residents' rights to be free from physical and verbal abuse by nursing home staff. This was evident in 2 out of 6 residents (Resident #1 and Resident #2) reviewed for abuse. Specifically, 1) On 03/25/24 between 5:00 am and 6:00 am, Certified Nurse Assistant #1 reported that they witnessed Certified Nursing Assistant #2 hit Resident #1 on their left cheek with a closed fit and used profanity at Resident #1 on 03/24/24 during care between 4:00 am and 5:00 am. 2) Certified Nursing Assistant #1 also reported on 03/25/24 at 8:00 am that they witnessed Certified Nursing Assistant #2 roughly washed Resident #2's testicle and hit Resident #2 on their hand with a lotion bottle during peri-care on 03/24/24 between 4:00 am and 5:00 am. The findings are: The Facility's Policy and Procedure entitled Abuse Prevention, last review date of 12/29/23, documented that the resident had a right to be free from abuse, neglect, misappropriation of resident property, and exploitation by anyone in this facility. Resident #1 was admitted to the facility with diagnoses including Alcoholic Cirrhosis of the Liver, Alzheimer's disease, and Paraplegia. A Minimum Data Set (a resident assessment tool) dated 01/29/24 documented that Resident #1 had short-term and long-term memory impairments and moderately impaired cognitive skills for daily decision-making. Resident #1 depends on staff (the helper makes all efforts) for turning, positioning, and transfer. Resident #1 had an Abuse Care Plan initiated on 06/17/19. The interventions documented monitoring for changes in mood and manner and addressed Resident #1's concerns as they arose. The abuse care plan was last updated on 02/08/24 and document that Resident #1 remained at risk for abuse. The care plan was not updated to reflect the allegation of abuse made on 03/25/24. A Resident Nursing Instruction dated 06/05/20 documented Resident #1 yells, screams, and resists care. There were no instructions on what staff should do if Resident #1 resists care. An Investigation Summary dated 03/24/24 documented Certified Nursing Assistant #1, who worked with Certified Nursing Assistant #2 on the night shift of 03/23/24, reported that they witnessed Certified Nursing Assistant #2 being aggressive with Resident #1. Certified Nursing Assistant #2 held Resident #1's right arm and punched Resident #1 on the left side of their face while using profanity at Resident #1. Certified Nursing Assistant #1 also reported witnessing Certified Nursing Assistant #2 roughly washed Resident #2's testicle on 03/24/24 while they were providing care. Resident #2 was also hit on their hand with a lotion bottle by Certified Nursing Assistant #2. The investigation concluded that abuse, neglect, and mistreatment had occurred. A Late Entry Nursing Progress Note dated 04/02/24 at 12:54 pm (for 03/25/24 at 9:30 am), written by the Assistant Director of Nursing, documented Licensed Practical Nurse #1 reported an alleged abuse on 03/25/24. The Assistant Director of Nursing responded to the unit at approximately 9:30 am and assessed Resident #1. There were no visible signs of injury and Resident #1 denied pain and discomfort. The Director of Nursing and the Medical Doctor were notified. There was no documented physician's assessment for the allegation of abuse made on 03/25/24. Resident #2 was admitted to the facility with diagnoses including Dementia, Bipolar Disorder, and Depressive Disorder. A Minimum Data Set, dated dated dated [DATE] documented that Resident #2 had short-term and long-term memory impairment with moderately impaired cognitive skills for daily decision-making. Resident #2 required substantial/maximal assistance (the helper makes more than half the effort) with bed mobility and transfer. A Risk for Abuse Care Plan for Resident #2 was initiated on 02/08/19 and was last updated on 01/09/24. The interventions documented that staff should address Resident #2's concerns and observe Resident #2 during rounds and care. Late Entry Nursing Note dated 04/02/24 at 4:37 pm (for 03/25/24 at 10:30 am), written by the Director of Nursing, documented that on 03/25/2024, Licensed Practical Nurse #1 reported an alleged physical abuse. At approximately 10:30 am, this writer performed a physical body assessment on Resident #2. Resident #2 does not appear to be in pain or discomfort. There was no redness, bruising, swelling, or discoloration, and the skin was intact, with no injuries observed, specifically to the hands. The Medical Doctor was made aware. There was no documented physician's assessment for the allegation of abuse made on 03/25/24. During an interview on 04/02/24 at 12:21 pm, Certified Nursing Assistant #1 stated that they worked with Certified Nursing Assistant #2 for the first time on 03/23/24 on the night shift (11:00 pm to 7:00 am). Certified Nursing Assistant #1 stated that they assisted Certified Nursing Assistant #2 in caring for Resident #1 between 4:00 am and 5:00 am on 03/24/24. Certified Nursing Assistant #1 stated that Resident #1 refused care, and Certified Nursing Assistant #2 voiced that they needed the work to be done. Certified Nursing Assistant #1 stated that they and Certified Nursing Assistant #2 went to Resident #1's room, and Resident #1 began swinging their arm trying to punch them. Certified Nursing Assistant #1 stated that Certified Nursing Assistant #2 grabbed Resident #1's right hand and pressed it against the left side of Resident #1's neck and directed Certified Nursing Assistant #1 to perform the incontinent care. Certified Nursing Assistant #1 stated that Resident #1's left hand is paralyzed. Certified Nursing Assistant #1 went on to say after Resident #1's care was completed Certified Nursing Assistant #2 let go of Resident #1 right hand, but Resident #1 started to swing their right hand at them. Certified Nursing Assistant #1 stated that Certified Nursing Assistant #2 then grabbed Resident #1's right arm and pressed it again at Resident #1's neck, and punched Resident #1 on the left side of Resident #1's face while saying, don't f--k with me. Certified Nursing Assistant #1 also reported that on 03/24/24 between 4:00 am and 5:00 am, they assisted Certified Nursing Assistant #2 in caring for Resident #2. Certified Nursing Assistant #1 went on to say that they also observed Certified Nursing Assistant #2 washed Resident #2's testicles roughly. Certified Nursing Assistant #1 stated that Resident #2 covered their groin area with their hands and had a facial expression like pain. Certified Nursing Assistant #1 said that Certified Nursing Assistant #2 yelled at Resident #2 three times telling Resident #2 to move their hands. When Resident #2 did not comply, Certified Nursing Assistant #2 hit Resident #2's hand with a lotion bottle. Certified Nursing Assistant #1 stated they reported the incident to Licensed Practical Nurse #1 on 03/25/24 between 5:00 am and 6:00 am. During an interview on 04/02/24 at 11:50 am, Certified Nurse Assistant #2 stated they were assigned to Resident #1 on 03/23/24 on the 11:00 pm to 7:00 am shift and Certified Nursing Assistant #1 assisted them in providing care to Resident #1. Certified Nursing Assistant #2 stated that Resident #1 was agitated, and they held Resident #1's hand while Certified Nursing Assistant #1 changed Resident #1's incontinent brief. Certified Nursing Assistant #2 stated that Resident #1 cursed and yelled at them to let go of their hand. Certified Nursing Assistant #2 stated that they explained to Resident #1 that they needed to complete their care, but they did not hit Resident #1. Certified Nursing Assistant #2 stated that Resident #2 was assigned to Certified Nursing Assistant #1, and they assisted Certified Nursing Assistant #1 with caring for Resident #2. Certified Nursing Assistant #2 stated that Resident #2 was resistive to care and that they did not roughly wash Resident #2's testicles. Certified Nurse Assistant #2 stated that the lotion bottle could have contacted Resident #2's skin while they were applying lotion to Resident #2. During an interview on 04/02/24 at 4:53 pm, Licensed Practical Nurse #1, who worked on 03/23/24 on the night shift (11:00 pm -7:00 am) on Resident #1 and Resident #2's unit, stated that on 03/24/24 (at the end of the shift) Certified Nursing Assistant #1 reported that they did not want to work with Certified Nursing Assistant #2 but did not specify the reason. Licensed Practical Nurse #1 went on to say Certified Nursing Assistant #1 approached them on 03/25/24 between 4:00 am and 5:00 am stating that they witnessed Certified Nursing Assistant #2 being physically and verbally abusive towards Resident #1 on 03/24/24. Licensed Practical Nurse #1 stated that they reported the allegation of abuse to the Assistant Director of Nursing on 03/25/24 at around 8:30 am. Licensed Practical Nurse #1 also stated they do not recall Certified Nurse Assistant #1 mentioning Resident #2's abuse. During an interview on 04/02/24 at 10:47 am, the Assistant Director of Nursing stated that Licensed Practical Nurse #1 informed them and the Director of Nursing on 03/25/24 at around 8:30 am that Certified Nursing Assistant #1 reported that Resident #1 was aggressive with them and Certified Nursing Assistant #2 during care on 03/24/24. The Assistant Director of Nursing stated that Licensed Practical Nurse #1 did not say anything about Resident #2, but Certified Nursing Assistant #1 reported to them that Resident #2 was also abused by Certified Nursing Assistant #2. The Assistant Director of Nursing stated that they performed a body assessment on Resident #1, and there was no redness, swelling, or bruising observed, and Resident #1 denied pain and discomfort. The Assistant Director of Nursing went on to say that Resident #2 was also assessed with no visible injury, and no signs of pain observed. During an interview on 04/02/24 at 10:15 am, the Director of Nursing stated they investigated the allegation of abuse and based on the witness's reports, they concluded that abuse did occur. The Director of Nursing stated that the police was not notified. 10 NYC RR 415.4(b)(1)(i)

F609 S/S E Based on observation, record review, and interviews conducted during an Abbreviated Survey (NY00337011), the facility failed to ensure that an alleged violation involving abuse was reported immediately but not later than two hours after the allegation was made if the events that caused the allegation involve abuse or result in serious bodily injury to New York State Department of Health and to local law enforcement. This was evident in 2 out of 6 residents reviewed for abuse (Resident #1 and Resident #2). Specifically, 1) On 03/25/24 between 5:00 am and 6:00 am, Certified Nurse Assistant #1 reported that they witnessed Certified Nursing Assistant #2 hit Resident #1 on their left cheek with a closed fit and used profanity at Resident #1 on 03/24/24 during care between 4:00 am and 5:00 am. The facility did not report the abuse allegation to the New York State Department of Health within two hours and did not notify local law enforcement timely. 2) Certified Nursing Assistant #1 also reported on 03/25/24 at 8:00 am that they witnessed Certified Nursing Assistant #2 roughly washed Resident #2's testicle and hit Resident #1 on their hand during peri-care on 03/24/24 between 4:00 am and 5:00 am. The facility did not report the abuse allegation to the New York State Department of Health within two hours. The facility reported the abuse allegations to New York State Department of Health on 03/25/24 at 1:32 pm. Additionally, the facility did not report the allegations of abuse to local law enforcement timely. The facility reported the allegations of abuse to local law enforcement while New York State Department of Health Surveyor was onsite 04/02/24. The findings are: The Facility's Policy and Procedure titled Accident and Incident Investigation and Reporting, with the last review date of 12/29/23, documented the responsibility of all Registered Nurse Supervisors and department heads to report alleged violations of mistreatment, neglect, and abuse, including injuries of unknown origin and misappropriation of resident property, immediately to the Administrator and/or Director of Nursing. The responsibility of the Administrator/ Director of Nursing or designee is to report to the New York State Department of Health the above-listed violations immediately but no more than two hours after the allegation is made if the event that causes the allegation involves abuse or results in serious bodily harm. The responsibility of the Administrator/Director of Nursing and or designee is to report suspicions of crimes to the New York Department of Health and local police within 24 hours or two hours if the crime results in serious bodily harm. Resident #1 was admitted to the facility with diagnoses including Alcoholic Cirrhosis of the Liver, Alzheimer's disease, and Paraplegia. A Minimum Data Set (a resident assessment tool) dated 01/29/24 documented that Resident #1 had short-term and long-term memory impairments and moderately impaired cognitive skills for daily decision-making. Resident #2 was admitted to the facility with diagnoses including Dementia, Bipolar Disorder, and Depressive Disorder. A Minimum Data Set, dated dated dated [DATE] documented that Resident #2 had short-term and long-term memory impairments and moderately impaired cognitive skills for daily decision-making. An Investigation Summary dated 03/24/24 documented Certified Nursing Assistant #1, who worked with Certified Nursing Assistant #2 on the night shift of 03/23/24, reported that they witnessed Certified Nursing Assistant #2 being aggressive with Resident #1. Certified Nursing Assistant #2 held Resident #1's right arm, punched Resident #1 on the left side of their face and used profanity at Resident #1 while Certified Nursing Assistant #1 changed Resident #1's brief. Certified Nursing Assistant #1 also reported on 03/24/24 that they also witnessed Certified Nursing Assistant #2 roughly washed Resident #2's testicle and hit Resident #2 on their hand with a lotion bottle. The investigation concluded that abuse, neglect, and mistreatment had occurred. An addendum to the facility Investigation Summary dated 04/02/24 documented that the facility called the police on 04/02/24 at 10:40 am. Review of a Webform Submission from the Nursing Home Facility Incident Report showed that the facility submitted to allegation of abuse to New York State Department of Health on 03/25/24 at 1:32 pm. During an interview on 04/02/24 between 10:15 am and 5:30 pm, the Director of Nursing stated they became aware of the allegation at 8:30 am on 03/25/24. The Director of Nursing went on to say that they did not report the allegation of abuse to New York State Department of Health within two hours because they spoke with Certified Nursing Assistant #1 at 12:30 pm on 03/25/24. The Director of Nursing stated that they did not call the police when the allegation of abuse was initially reported on 03/25/24 and that they have five days to do an investigation. The Director of Nursing stated the allegation of abuse was substantiated based on Certified Nurse Assistant #1 witnessing the abuse and the police was notified on 04/02/24. During an interview on 04/02/24 at 3:25 pm, the Administrator stated that they were out of the country at the time the incident and that the allegation of abuse should have been reported within two hours to New York State Department of Health. 10 NYCRR 415.4(b)(2)

Based on observations, record review, and interviews conducted during an Abbreviated Survey (NY00337011), the facility failed to ensure that a care plan was reviewed and revised by the interdisciplinary team after each assessment. This was evident in 2 out of 6 residents sampled (Resident #1 and Resident #2). Specifically, 1) On 03/25/24 between 5:00 am and 6:00 am, Certified Nurse Assistant #1 reported that they witnessed Certified Nursing Assistant #2 hit Resident #1 on their left cheek with a closed fit and used profanity at Resident #1 on 03/24/24 during care between 4:00 am and 5:00 am. Resident #1's care plan was not reviewed and revised to reflect the allegation of abuse. 2) Certified Nursing Assistant #1 also reported on 03/25/24 at 8:00 am that they witnessed Certified Nursing Assistant #2 roughly washed Resident #2's testicle and hit Resident #1 with a lotion bottle on their hand during peri-care on 03/24/24 between 4:00 am and 5:00 am. Resident #2's care plan was not reviewed and revised to reflect the allegation of abuse. The findings are: The Facility's Policy and Procedure titled Comprehensive Care Planning was last reviewed on 10/16/23. The policy documented that each resident would have a comprehensive person-centered care plan in compliance with Federal and State regulations. The facility will establish an interdisciplinary team care plan process to ensure that resident care and treatment are planned appropriately for the resident's needs and condition, impairment, disability, or disease process in a timely, systematic, and comprehensive manner. The policy also documented that the care plan should be revised when appropriate to reflect the resident's current needs based on evaluation and episodic changes to include but not limited to: Accidents and /or Incidents, Behaviors/Mood State Changes. Resident #1 was admitted to the facility with diagnoses including Alcoholic Cirrhosis of the Liver, Alzheimer's disease, and Paraplegia. A Minimum Data Set (a resident assessment tool) dated 01/29/24 documented that Resident #1 had short-term and long-term memory impairments and moderately impaired cognitive skills for daily decision-making. Resident #1's Risk for Abuse Care Plan was initiated on 02/08/19 and was last updated 01/09/24. The interventions documented for staff to address Resident #1's concerns as they arise, staff to observe Resident #1 during rounds and care. The Care Plan was last reviewed and revised on 02/08/24 and documented Resident #1 remained at risk for abuse. Resident #2 was initially admitted to the facility on [DATE] with diagnoses including Dementia, Bipolar Disorder, and Depressive Disorder. A Minimum Data Set, dated dated dated [DATE] documented that Resident #2 had short-term and long-term memory impairment and moderately impaired cognitive skills for daily decision-making. Resident #2's Abuse Care Plan was initiated on 02/08/19 and was last reviewed on 01/09/24. The Care Plans for Resident #1 and Resident #2 were not updated to reflect on the allegations of abuse made on 03/25/24. An Investigation Summary dated 03/24/24 documented Certified Nursing Assistant #1, who worked with Certified Nursing Assistant #2 on the night shift of 03/23/24, reported that they witnessed Certified Nursing Assistant #2 being aggressive with Resident #1. Certified Nursing Assistant #2 held Resident #1's right arm, punched Resident #1 on the left side of their face and used profanity at Resident #1 while Certified Nursing Assistant #1 changed Resident #1's brief. Certified Nursing Assistant #1 also reported on 03/24/24 that they witnessed Certified Nursing Assistant #2 roughly washed Resident #2's testicle and hit Resident #2 on their hand with a lotion bottle. The investigation concluded that abuse, neglect, and mistreatment had occurred. During an interview on 04/02/24 at 10:47 am, the Assistant Director of Nursing stated that they did not update the care plans for Resident #1 and Resident #2 after the allegations of abuse were made. The Assistant Director of Nursing went on to say that the care plans should have been updated with new interventions to prevent a reoccurrence of abuse. The Assistant Director of Nursing stated that the Nursing Supervisors and Assistant Director of Nursing are responsible for updating care plans. 10 NYCRR 415.11(c)(1)

Based on observation, interviews, and record review conducted during an Abbreviated Survey (NY00337011), the facility failed to maintain clinical records that are complete and accurately documented in accordance with accepted professional standards and practices. This was evident in 2 out of 6 residents (Resident #1 and Resident #2) reviewed for Abuse. Specifically, on 03/25/24, Certified Nurse Assistant #1 reported that they witnessed Certified Nurse Assistant #2 being verbally and physically abusive to Resident #1 and Resident #2. There were no assessments documented in Resident #1 and Resident #2's medical records prior to New York State Department of Health Surveyor's onsite visit on 04/02/24. Additionally, there were no physician's assessments documented in Resident #1 and Resident #2's medical record. The findings are: The facility's Policy and Procedure titled Documentation in the Medical Record with the last review date of 04/13/22, documented that the objective to ensure that the facility was incompliance with F842 and that the progress notes document all events pertaining to the resident's stay in the facility. The policy also documented that it is the policy of the facility to ensure that licensed professionals document changes in resident condition, accidents, incidents, transfers, expirations, and leave against medical advice to ensure that all events of the resident stay are included. Resident #1 was admitted to the facility with diagnoses including Alcoholic Cirrhosis of the Liver, Alzheimer's disease, and Paraplegia. A Minimum Data Set (a resident assessment tool) dated 01/29/24 documented that Resident #1 had short-term and long-term memory impairments and moderately impaired cognitive skills for daily decision-making. Resident #2 was initially admitted to the facility on [DATE] with diagnoses including Dementia, Bipolar Disorder, and Depressive Disorder. A Minimum Data Set, dated dated dated [DATE] documented that Resident #2 had short-term and long-term memory impairment and moderately impaired cognitive skills for daily decision-making. An Investigation Summary dated 03/24/24 documented Certified Nursing Assistant #1, who worked with Certified Nursing Assistant #2 on the night shift of 03/23/24, reported that they witnessed Certified Nursing Assistant #2 being aggressive with Resident #1. Certified Nursing Assistant #2 held Resident #1's right arm, punched Resident #1 on the left side of their face and used profanity at Resident #1 while Certified Nursing Assistant #1 changed Resident #1's brief. Certified Nursing Assistant #1 also reported on 03/24/24 that they also witnessed Certified Nursing Assistant #2 roughly washed Resident #2's testicle and hit Resident #2 on their hand with a lotion bottle. The investigation concluded that abuse, neglect, and mistreatment had occurred. An addendum to the facility Investigation Summary dated 04/02/24 documented that the facility called the police on 04/02/24 at 10:40 am. During an interview on 04/02/24 at 10:47 am, the Assistant Director of Nursing stated that they assessed Resident #1 and Resident #2 on 03/25/24 and there were no visible signs of injuries. Neither Resident #1 nor Resident #2 complained of pain. The Assistant Director of Nursing went on to say that they reported their findings to the Director of Nursing and the assessment was documented into the investigation summary report. The Assistant Director of Nursing stated that they should have documented the assessment findings into the Residents' medical records. The Assistant Director of Nursing stated that it is the supervisor's responsibility to assessed and document in the Resident's medical record, but the facility did not have a supervisor on duty, and that they were overwhelmed. During an interview on 04/02/24 at 2:50 pm, the Attending Physician stated they were notified of the abuse allegation by the Assistant Director of Nursing on 03/25/24. The Attending stated it was reported that Resident #1 and Resident #2 did not sustain any injury or have complaints of pain. The Attending Physician stated they examined Resident #2's private area during the monthly review on 03/27/24 and there were visible injuries or complaints of pain. The Attending Physician also stated they evaluated Resident #1 during their monthly review on 03/29/24, and there no visible injury or pain. 10 NYCRR 415.22(a) (1-4)

Based on observation, record review, and interviews conducted during the Recertification and Complaint (NY00321629) survey from 10/26/2023 to 11/02/2023, the facility did not ensure that a resident was free from misappropriate of property. This was evident for 1 (Resident #77) of 9 residents reviewed for abuse out of 36 total sampled residents. Specifically, a Home Health Aide (HHA) employed by the facility used Resident #77's bank card to purchase items totaling $1100.00. The findings are: The facility policy titled Abuse Prevention dated 9/10/2022 documented the resident has the right to be free from misappropriation of property - the deliberate use of a resident's money without the resident's consent, including theft, unauthorized use, or removal of money. Resident #77 had diagnoses of diabetes mellitus and coronary heart disease. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #77 was cognitively intact. On 11/01/2023 at 12:37 PM, Resident #77 was interviewed and stated they gave their bank card to the HHA to purchase items and became suspicious, checked their bank statements, and found unauthorized purchases totaling $1100.00. Resident #77 reported the HHA to the Registered Nurse (RN) on 08/06/2023. Social Work (SW) note dated 08/07/2023 documented Resident #77 alleged misappropriation of property on 8/6/2023. Emotional support was provided, and the police were notified. Facility investigation was ongoing. Nursing Notes dated 08/08/2023 documented Resident #77 reported they gave their bank card to the HHA to make purchases and withdrawals. Resident #77 first noticed unauthorized charges to their account in 5/2023 but the HHA denied making the charges and Resident #77 did not want to report it and get the HHA in trouble. Resident #77 saw that their account balance is only $500 and decided to report the HHA on 8/6/2023. The Accident/Incident (AI) Investigation Report dated 8/8/2023 documented Resident #77 reported to nurse on 8/6/2023 that they were upset someone they trusted was taking money from their bank account. The HHA involved was interviewed and admitted doing to the store and bank for Resident #77 for 3 months. The HHA received inservice from the facility that no employee was to purchase and/or deliver items to residents and the HHA knew they were wrong for doing so. The facility attempted to contact the HHA to write their statement and the HHA would not cooperate. On 8/8/2023, the staffing agency was informed not to send the HHA to the facility any longer. The AI Investigation Report concluded that financial abuse of Resident #77 did occur as a result of the HHA using the resident's bank card. The Comprehensive Care Plan (CCP) related to Abuse/Misappropriation of Resident Property dated 08/15/2023 documented Resident #77 was encouraged to voice their concerns and would be monitored for changes in mood. On 11/02/2023 at 1:28 PM, Human Resources (HR) was interviewed and stated the HHA was responsible for escorting residents to clinic appointments, providing ice and water to residents, and acting as a liaison between residents and facility staff. The HHA no longer works for the facility. On 11/02/2023 at 2:45 PM, the Administrator was interviewed and stated the facility provided inservice to staff re: misappropriation of resident property. The Administrator questioned how the facility could control a resident's trusting behavior. The Administrator stated that when the police came to the facility to obtain a report from Resident #77, the police wanted the resident to go to the precinct to complete the report but the resident was unable to be transported to the police station due to being bedbound. The Administrator went to the police precinct on behalf of Resident #77 and filed the report of theft against the HHA on behalf of Resident #77. 10 NYCRR 415.4(b)

Based on interview and record review conducted during the recertification and complaint (NY00321227) survey from 10/26/2023 to 11/2/2023, the facility did not ensure that an alleged violation involving abuse was reported immediately, but not later than 2 hours after the allegations were made to the New York State Department of Health (NYSDOH). This was evident for 2 (Resident #46 and Resident #6) of 9 residents reviewed for abuse out of 36 total sampled residents. Specifically, an altercation involving Resident #46 and Resident #6 was not reported to the NYSDOH within 2 hours of the occurrence. The findings are: A facility policy titled Abuse Prevention dated 9/19/2022 documented all allegations of abuse and accidents resulting in serious bodily injuries must be reported to the NYSDOH within 2 hours. Resident #46 had diagnoses of schizophrenia and non-Alzheimer's dementia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #46 was moderately cognitively impaired. Resident #6 had diagnoses of schizophrenia and anxiety. The MDS dated [DATE] documented Resident #6 had mild cognitive impairment. The facility Incident Report dated 8/2/2023 documented Resident #6 was pushed by Resident #46 on 7/30/2023. The Aspen Complaint Tracking System documented the facility reported the incident between Resident #6 and Resident #46 on 8/2/2023, more than 2 hours after the occurrence. The Administrator was interviewed on 11/2/2023 at 10:31 AM and stated the incident was not reported timely to the facility Administration and, therefore, was not reported timely to the NYSDOH. 10 NYCRR 415.4(b)

Based on record review and interview conducted during the recertification survey from 10/26/2023 to 11/2/2023, the facility did not ensure accuracy of resident assessments. This was evident for 2 (Resident #100 and #170) of 36 total sampled residents. Specifically, 1) Resident #100's Minimum Data Set 3.0 (MDS) assessment did not document the resident's diagnosis of schizophrenia and depression, and 2) the Minimum Data Set 3.0 (MDS) assessment for Resident #170 documented the resident's planned discharge as an unplanned discharge. The findings are: The facility policy titled Resident Assessment Using the MDS dated [DATE] documented the facility will conduct initially and periodically a comprehensive and accurate assessment of each resident's functional capacity. 1) Resident #100 had diagnoses of schizophrenia and major depressive disorder. The MDS dated [DATE] documented Resident #100 was cognitively intact and diagnosed with depression and schizophrenia. The MDS dated [DATE] documented Resident #100 was cognitively intact and did not document Resident #100 was diagnosed with schizophrenia and depression. A comprehensive care plan (CCP) related to behavior initiated 6/13/2019 documented Resident #100 had a diagnosis of schizophrenia. A Psychiatry Note dated 8/22/2023 documented Resident #100 had diagnoses of schizophrenia and depression. An interview was conducted with the MDS Coordinator on 10/30/2023 at 11:47 AM who stated they look at the psychiatry notes to complete the diagnosis section of the MDS. Psychiatry did not document Resident #100's diagnosis of schizophrenia and only documented a history of schizophrenia so the MDS Coordinator did not document schizophrenia on the 9/25/2023 MDS for Resident #100. An interview was conducted with the Director of Nursing (DNS) on 10/30/2023 at 12:14 PM who stated the MDS Coordinator was responsible for filling out the diagnosis section on the MDS. The diagnoses were obtained from the resident's hospital discharge paperwork, physician orders, and progress notes. The DNS was unable to explain the reason Resident #100's 9/25/2023 MDS did not include the diagnosis of schizophrenia or depression. An interview was conducted with the Psychiatrist on 10/31/2023 at 3:10 PM who stated Resident #100 had a diagnosis of schizophrenia according to their documentation in the medical record. 44864 2) Resident #170 had diagnoses of 2nd and 3rd degree burns and anxiety disorder. The MDS dated [DATE] documented Resident #170 had an unplanned discharge and return was not anticipated. The Comprehensive Care Plan (CCP) related to discharge planning initiated 2/23/2023 documented Resident #170 would be safely discharged to the community. A Physician Note dated 8/25/2023 documented Resident #170 was in optimal medical condition and was being discharged home with home care and walker. A Social Work Note dated 08/27/2023 documented Resident #170 was scheduled for discharge home on 8/31/2023. A Nursing Note dated 08/31/2023 documented Resident #170 was discharged home with medications, prescriptions, and belongings. On 10/31/2023 at 02:48 PM, the MDS Coordinator was interviewed and stated they were responsible for completing the discharge MDS assessment for Resident #170 on 8/31/2023. Unplanned discharge was triggered in error and planned discharge should have been triggered on the MDS assessment instead. 10 NYCRR 415.11(b)

Based on observation, interview, and record review conducted during the recertification survey from 10/26/2023 to 11/2/2023, the facility did not ensure a resident received treatment and care in accordance with professional standards of practice. This was evident for 1 (Resident #121) of 9 residents reviewed for accidents out of 36 total sampled residents. Specifically, Resident #121 was observed without a soft helmet in place when out of bed in accordance with Physician's Order (PO). The findings are: A facility policy titled Adaptive Equipment dated 1/2/2021 documented the nursing department and the rehabilitation department will monitor care and proper use of the adaptive device. Nursing will document the use of these devices on the Certified Nursing Assistant (CNA) accountability record. Resident #121 was diagnosed with vascular dementia and schizophrenia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #121 was severely cognitively impaired and required extensive to total assistance to perform activities of daily living. On 10/26/2023 at 12:16 PM, 10/31/2023 at 11:25 AM, and 10/31/2023 at 11:55 AM, Resident #121 was observed out of bed to a recliner without a soft helmet in place. The soft helmet was observed on the resident's bedside table. The PO dated 12/18/2020 documented Resident #121 wear a soft helmet when out of bed for safety. The CNA Instructions for 10/2023 documented Resident #121 wore a helmet when out of bed for safety. On 10/31/2023 at 11:56 AM, CNA #1 was interviewed and stated they look at the CNA instructions to determine resident care needs. CNA #1 was not aware of any safety instructions for Resident #121. When CNA #1 was referred to the helmet on Resident #121's bedside table, CNA #1 stated the helmet is too big for the resident's head, they are not the regular CNA for Resident #121, and they did not report to anyone that the helmet was too big for the resident. On 10/31/2023 at 12:01 PM, Licensed Practical Nurse (LPN) #1, was interviewed and stated they were unaware the helmet for Resident #121 was too big. LPN #1 performs rounds and talks with the residents to ensure CNAs are performing their daily tasks. LPN #1 stated they saw Resident #121 without the helmet in place and did not address it with the resident's assigned CNA. 10 NYCRR 415.12

Based on record review and interviews conducted during an abbreviated survey (Case # NY 00300750), the facility did not ensure that all alleged violations involving abuse, neglect, or mistreatment, resulting in serious bodily injury are reported immediately, but no 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 State Survey Agency, New York State Department of Health (State Agency). This was evident in 1 of 2 residents reviewed for Abuse/Neglect (Resident #1). Specifically, on 10/08/2022, the facility did not report an incident where a Nursing Assistant in Training (TNA) provided care alone to Resident #1 who required two persons for care and Resident #1 fell from the bed. The Findings are: The Policy and Procedure titled Abuse Prevention effective 11/2018, and last reviewed 09/19/2022, documented that it is the policy of this facility to report to the proper authorities within the prescribed timeframe all alleged violations related to abuse, neglect, mistreatment exploitation, including injuries of unknown source and misappropriation of resident property. Resident #1 with diagnoses include Cerebrovascular Accident (CVA), Osteopenia, and Seizures with a history of several falls since admission. The Minimum Data Set (MDS-an assessment tool) dated 07/22/2022, documented that Resident #1 had severe cognitive impairment and required extensive assistance of two persons for bed mobility, transfers via Hoyer lift, toileting, and for personal hygiene. A Care Plans dated 8/2020, documented: Activity of Daily Living (ADL) included bed mobility extensive assistance of two persons, personal hygiene and dressing of one person. A Nursing Progress Note dated 10/08/2022 written by License Practical nurse (LPN) #1 documented informed by assigned Certified Nursing Assistant in Training (TCNA) #1 that Resident #1's left knee was bleeding. LPN#1 responded to re-apply the protective dressing to the knee, noted Resident #1's forehead had an abrasion. Resident #1 was transferred to hospital as ordered by Medical Doctor, for further evaluation and returned on 10/09/2022 with a repaired forehead wound. An Accident/Incident Report dated 10/8/2022, documented Resident #1 was unable to give account of the event on 10/08/2022 due to confusion. CNA#1's statement documented that Resident #1 was lying on their left side, on the floor when the CNA #1 entered the room. Resident #1's had a history of rolling from the ultra-low bed. CNA #1 undated statement documented that Resident #1 fell off the elevated bed during care on 10/08/2022. A scan of head dated 10/09/2022 documented no acute intracranial abnormality. Chronic ischemic changes noted. A Facility's Summary of Investigation dated 12/7/2022, documented the incident of 10/8/2022 was re-opened during an audit of accidents and incidences. The statements documented that CNA #1 changed their statement after further questioning by the former Director of Nursing Services (DNS) and documented that Resident #1 fell off the bed while CNA #1 was providing care. An Email from former DNS dated Monday 10/10/2022, documented DNS interviewed CNA #1 via telephone on 10/10/2022, and CNA #1 stated that Resident #1 fell off the bed while TCNA #1 was providing care which required two persons. The incident was never reported to NYSDOH. The incidence of 10/8/2022 was submitted to NYSDOH on 12/7/2022 after a re-investigation was conducted. During an telephone interview on 03/21/2023 at 1:24 PM, TCNA #1 stated, the nurse was informed Resident #1 fell and was picked up and placed on the bed. Also understood that two persons are required for care, did not ask any of the other CNAs as they were proving care to others. They provided Resident #1 care without a second person before because Resident #1 could not left in the mess, and get pressure ulcers. During an interview on 03/23/2023 at 12:45 PM, License Practical Nurse (LPN) #1 stated that TCNA #1 was a substitute on the unit on 10/08/2023, for the 3-11 PM shift and was called to the room by the CNA #1 who reported that Resident #1's left knee was bleeding. LPN #1 also stated Resident #1 had a protective dressing to an old scratch which should not be bleeding. They went to reapply the protective dressing. Resident #1 was in bed and a discolored area on the center of Resident #1's forehead was observed. The Nurse Supervisor and the MD was called and Resident #1 was sent to the emergency room (ER). TCNA #1 should have known that Resident #1 required two persons for bed mobility because all the care instructions are on the computer that is supposed to be read before care and signed off on at the end of the shift. During a telephone interview on 3/31/2023 at 12:45 PM, the Night Shift Nurse Supervisor (RNS) #2 stated that CNA #1 initially completed their portion of the Accident/Incident report incorrectly. The former DNS spoke with CNA #1 via the telephone and instructed to rewrite the statement which the CNA#1 did, revealing that Resident #1 fell while care was being performed by one person. During an interview on 03/22/2023 at 2:50 PM, the Corporate Nurse #3 , stated that an audit of accident and incidences was done. There was concerns about Resident #1's incident which revealed that the incident of 10/8/2022 was not reported. Statements were reviewed and the investigation re-opened on 12/7/2022 and reported to NYSDOH. Corrective actions were implemented. A Plan of Correction was not required for this citation. The facility took corrective actions and was found to be in substantial compliance on 1/18/2022 prior to the onsite visit on 3/21/2023. Resident #1 was immediately assessed on 10/8/2022 and on re-investigation on 12/7/2022. The assigned TCNA was terminated. Policy and Procedure on Abuse Prevention was reviewed on 9/19/2022 and no changes were made. Systemic changes in effect included an audit tool developed by the RN Quality Assurance Consultant to monitor the facility's compliance with ensuring that all accidents, incidents are investigated and when indicated reported to NYSDOH within the reporting time frames. All Accident and Incidents to be audited by DNS for 12 months. Any identified issues related to timely reporting and reporting of investigation results was immediately addressed and discussed at Morning Meeting. Findings was reviewed at Facility's Quarterly meetings. All staff was re-in-serviced on Abuse/Neglect/Mistreatment. On 03/21/2023 and 03/22/2023, interviews were conducted with two LPN, two RNS, three CNAs, and two TCNAs. The staff that were interviewed, confirmed that training occurred with good understanding. 10 NYCRR 415.4 (b)(1)(i)

Based on observations, interviews and record reviews conducted during an abbreviated survey, (NY 660), the facility failed to protect multiple residents from resident-to-resident abuse. This was evident in 3 out of 8 Residents sampled (Resident #1, #2 & #3). 1) Specifically, Resident #4 attacked Resident #1 (roommate) on 03/04/2020 with a fork. Resident #1 sustained lacerations to sternum and abdomen. 2) On 11/28/2020, Resident #4 attacked (roommates) Resident #2 and Resident #3. Resident #2 sustained a Triquetral Fracture to the left hand and Resident #3 sustained contusion and hematoma to the right side of face and jawline. The facility did not protect Resident #1, #2 & #3 from Resident #4 who had known history of aggressive and unpredictable behavior. The findings are: The facility's Policy and Procedure titled Abuse Prevention, last reviewed on 10/22/2018 documented that it is the policy of this facility to provide a safe resident environment that protects residents from abuse including verbal, mental, sexual, physical abuse, corporal punishment, or involuntary seclusion. This includes staff to resident abuse of any type, resident to resident abuse of any type and visitor to resident abuse of any type. The facility's Policy and Procedure titled Resident to Resident Altercation (RTR) with effective date 03/02/2014 documented that it is the policy of the facility to protect the health and safety of all persons residing in the nursing home. Any incident of resident-to-resident abuse will be investigated and reported as per Abuse and Neglect Protocol. 1) Incident of 03/04/2020 A Resident-to-Resident Altercation Report dated 03/04/2020, documented that at approximately 2:30 pm, a recreation staff reported to nursing staff that Resident #4 attacked Resident #1 (roommate) with a fork. Resident #1 was assessed and noted with superficial abrasion to the sternum and the abdominal area with no bleeding. The Medical Doctor (MD) was notified. Resident #1 was placed on 30 minutes monitoring and Psych consult was ordered and the care plan was updated. Resident #4 was transferred to the Psych Hospital and was admitted . The facility concluded that abuse did occur. Record review revealed that Resident #4 had an extensive history of aggressive and unpredictable behavior. After Resident #4 attacked Resident #1 with a fork and inflected injuries on 03/04/2020 Resident #4 was placed in a 4 bedded room with Resident #2 and Resident #3. Resident #1 (victim) was admitted to facility on 12/21/2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, an assessment tool) dated 12/5/2019 documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) and scored 07/15 (00-07 severe impairment, 08-12 moderate impairment and 12-15 cognitively intact). Resident #4 (Aggressor) was admitted to facility on 03/31/2015 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented that Resident #4 had a BIMS score 12/15. Resident #4 was not assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] Record review revealed that Resident #4 displayed physically and verbally aggressive behavior toward resident and staff. On 01/31/2020 Resident #4 threw a tray on a CNA; on 2/13/2020 Resident #4 attacked another resident in the dining room requiring resident to be sent to the hospital; dated 3/4/2020 Resident #4 attacked roommate (Resident #1) with a fork, requiring Resident #1 to be sent to the hospital. Resident #4's Comprehensive Care Plan (CCP) for at risk for abuse, initiated on 03/12/2019, documented interventions for staff to monitor the resident for changes in mood and manner. Staff to address Resident #4's concerns as they arise. Staff to observe the resident during rounds and during care and monitor for changes in customary routines. The CCP was updated with new interventions to reflect on the altercation. Resident #4's Certified Nurse's Assistant (CNA) Accountability Record dated 02/2020 and 03/2020 documented that Resident #4 was being monitored for safety. Review of Resident #4's Resident Nursing Instructions dated as of 02/01/2020, documented that staff should report behavioral changes to the charge nurse. Monitor Resident #4 every 30 minutes for safety and behavior. Also documented, Resident #4 may be very physically aggressive towards staff and other residents. Two staff always approach the resident. Resident #4's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #4's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] 50 mg tablet 2 times per day for [CONDITION(S)] and Psych consultant about 3 weeks. An order also noted to send Resident #4 out to Psych emergency room (ER) secondary to aggressive behaviors and for physically attacking peer and staff. Resident #4, Half Hourly Observation Sheet dated 03/04/2020 documented that Resident #4 was being monitored every 30 minutes and was in his/her room. Resident #4 was awake at 2:00 PM and at 2:30 pm. A Nurse's Note dated 03/04/2020 at 2:54 pm, documented that a recreation personnel called the nurse to Resident #4's room. Upon arrival to the room Resident #4 was observed standing over Resident #1 with a folk in his/her hand. Resident #4 was moved away for safety and the supervisor was notified. The MD was made aware and ordered Resident #4 be transferred to the hospital. A Nurse's Note dated 03/04/2020 at 3:37 pm, documented that Resident #4 was status post [MEDICAL RECORD OR PHYSICIAN ORDER] . The charge nurse called writer to Resident #4's room and upon entering the room, Resident #4 was observed with a metal fork in his/her hand. The writer asked Resident #4 for the fork and Resident #4 threw the fork on the bed. The fork was then taken out the room. As per charge nurse, Resident #4 attacked roommate (Resident #1) with a fork. Resident #1 was observed with 3 abrasions from Resident #1's sternum to the abdominal area. The MD was notified and ordered to send Resident #4 out to Psych emergency room (ER). Resident #4 was in route to the Hospital. A Nurse's Note dated 03/04/2020 at 3:47 pm, documented that Resident #1 was status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was left with 3 abrasions from to the sternum and the abdominal area. The Social Worker and Resident #4's Legal Guardian were notified. A Medical Note dated 03/05/2020 at 3:08 pm, documented that the Medical Doctor assessed Resident #1 for abrasions to chest. On inspection Resident #1 was noted with 3 superficial abrasions to mid chest area. Resident #1 was observed breathing spontaneously without distress. No bleeding was observed at the time of the assessment. Resident #1 did not express pain. Continued with the application of [MEDICATION(S)]. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Psychology and Psychiatry consults also ordered and [MEDICATION(S)] Ointment to apply to the superficial abrasion at the abdominal area two times for 7 days. During an interview on 08/31/2021, at 1:23 pm, assigned CNA #1, who was working on 03/04/2020 the 7-3 shift, stated that he/she was not a regular CNA on the unit and that he/she does not recall the incident between Resident #1 and Resident #4. CNA #1 stated that he/she remembered Resident #4 and that Resident #4 could become very aggressive if anyone (staff or residents) crossed Resident #4's way. CNA #1 stated that Resident #4 spend most of his/her time in the room. CNA #1 also stated that it would have been better if Resident #4 was in a private room where there was less distraction. During an interview on 08/31/2021 at 1:45 pm, CNA #2, who worked on 03/04/2020 on the 7-3 shift, stated that he/she was never assigned to Resident #4 and does not remember the incident between Resident #1 and Resident #4. CNA #2 stated that he/she remembered that Resident #4 had unpredictable behavior. CNA #2 also stated that Resident #4 was on monitoring. During an interview on 08/31/2021 at 2:25 PM, Licensed Practical Nurse (LPN) #1, who worked on 03/04/2020 on the 7-3 shift, stated that they do not recall the incident between Resident #1 and Resident #4. LPN #1 stated that Resident #4 was aggressive and unpredictable. LPN #1 also stated that staff was monitoring Resident #4 every 30 minutes. LPN #4 stated that Resident #4 refused all the medications and that the Doctor was notified. During an interview on 09/01/2021 at 1:08 pm, the Recreation Staff (RS) stated that he/she was no longer working in the facility but that he/she remembered Resident #4 and the incident of 03/04/2020. RS stated, at the time of incident, he/she was passing by Resident #4 and Resident #1's room and observed Resident #4 standing over Resident #1, who was in bed, with a fork in his/her hand. The RS stated that when he/she called out to Resident #4, the Resident walked away from Resident #1. The RS stated that he/she immediately called for help and the staff arrived and took Resident #4 out of the room. The RS reported that Resident #4 did not like to participate in the activity and mostly stayed in the bed and came out of the room only when he/she needed something. 2) Incident of 11/28/2020 A Resident-to-Resident Altercation Report dated 11/28/2020 documented that Resident #4 attacked two other residents (Resident #2 and Resident #3), who were roommates of Resident #4. A Certified Nursing Assistant (CNA) responded to a loud noise in the residents' room. The CNA observed Resident #2 in the hallway and Resident #2 reported to the CNA that Resident #4 had beaten him/her up. The CNA called for help and a 2nd CNA arrived and called Manpower Alert. Staff members entered the residents' room and observed Resident #3 sitting on the floor. Resident #3 reported that he/she was attacked by Resident #4. The Registered Nurse Supervisor (RNS) assessed Resident #2 and Resident #3. Resident #2 was observed with a 2cm cut on right ear, discoloration to right cheek and jawline. Resident #3 had swelling and mild redness to right jawline. Resident #4 was monitored by staff in the room while waiting for the arrival of the New York Police Dept and 911. Resident #4 was taken to the ER and subsequently admitted to the Psychiatric unit. The facility concluded that abuse did occur. Resident #2 and Resident #3 were also transferred to the hospital. Resident #2 returned from the ER with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 (victim) was initially admitted to facility on 05/21/2013 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented that Resident #2 had a BIMS score of 14/15. Resident #3 (victim) was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented that Resident #3 had a BIMS score of 03/15. Resident #4 (Aggressor) was admitted to facility on 03/31/2015 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented that Resident #4 had a BIMS score 12/15. Resident #4 was not assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] Record review revealed that Resident #4 displayed physically and verbally aggressive behavior toward residents and staff. Record review also revealed that Resident #4 had an extensive history of aggressive and unpredictable behavior. On 06/16/2020 Resident #4 pulled kiosk monitor of the wall, threw 2 linen carts down to the floor, and was sent to the hospital; on 08/05/2020 after return from the hospital Resident #4 became very agitated and uncontrollable and destroyed facility property; on 10/28/2020 Resident #4 attacked male resident in hallway; on 11/01/2020 Resident #4 threatened nurse who attempted to give medications; and on 11/28/2020, without provocation(as described above), Resident #4 attacked roommates (Resident #2 and Resident #3) inflicting injuries to both residents. After Resident #4 attacked Resident #2 and #3 Resident #4 was transferred to emergency room and later admitted . A Nurse's Note dated 11/28/2020 12:39 pm, documented that at approximately 7: 50 am, Registered Nurse Supervisor (RNS) was notified by nursing staff that Resident #4 had assaulted two residents that resided in Resident #4's room. Upon arrival to unit, Resident #2 was sitting at the nursing station. Resident #2 stated that Resident #4 hit and scratched him/her multiple times in the face. Resident #2 stated that he/she ran out the room and notified the nursing staff immediately. Resident #2 was observed with the right cheek swollen with discoloration. Multiple scratches observed to Resident #2's left/right ear, the left side of Resident #2's face, mid forehead, and nose. Cold compress applied to right cheek with slight effect. Resident #2 tolerated treatment well. Tylenol was administered. The Medical Doctor was contacted and ordered Resident #2 to be transferred to the hospital for further evaluation. The Administrator and Assistant of Director of Nursing (ADNS) were notified. A Nurse's Note dated 11/28/2020 05:54 pm, documented that Resident #2 returned from the hospital at 4:30 pm, status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 noted with left periorbital ecchymosis. The hospital recommended to return to ER if symptoms worsen. Resident #2 was to Follow up with hand clinic in 1 week. Tylenol 500 mg oral every 6 hours x 7 days for pain. Resident #2 refused all vital signs monitoring. Neurological assessment was initiated every 4 hours for 2 days. Resident #2 was placed on every 30 minutes observations for 7 days. Psychiatry and Psychological consults ordered. Emotional support provided to the resident. Close observation in progress. A Nurse's Note dated 11/28/2020 at 1:11 pm, documented that the Registered Nurse Supervisor was notified that Resident #4 assaulted two residents (Resident #2 and Resident #3) that resided in Resident #4's room; Upon entering room Resident #3 was observed sitting on the buttocks near Resident #3's bed. Resident #3 stated Please help me, Resident #4 hit me in my face. Resident #3 pointed to Resident #4. The right side of Resident' #3's presented with discoloration. Resident #3 complained of slight pain to the right side of the head. Tylenol administered as per Medical Doctor's order with slight effect. Resident #3 was removed from his/her room and was placed in front of the nursing station for observation and safety. Awaiting Emergency Medical Service to arrive. The Medical Doctor contacted, and family was notified. A Nurse's Note dated 11/28/2020 at 6:18 pm, documented that Resident #3 returned from the hospital at 5:27 pm and was status post [MEDICAL RECORD OR PHYSICIAN ORDER] . As per hospital record the resident was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Icepack to apply to the right side of face jawline area for 15 minutes 4 times a day. Resident #3 to return to the ER if symptoms worsen. The Medical Doctor was notified. Resident #3 was placed on 30-minutes observation every shift for 7 days. Neurological assessment as per facility's protocol. Emotional support provided by staff. Psychiatry and Psychological consults ordered. Close observation in progress. Resident #4's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] 10 mg tablet give 1 tablet (10 mg) by oral route once daily in the evening for [CONDITION(S)] disorder. [MEDICATION(S)] 0.5 mg tablet give 1 tablet (0.5 mg) by oral route 2 times per day for [CONDITION(S)]. [MEDICATION(S)] 100 mg tablet, 1 tablet (100 mg) by oral route 2 times per day for [CONDITION(S)]. Resident #4's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #4's Half Hour Observation Sheets for 11/2020 revealed the last date of observation was on 11/25/2020. Some of the Half Hour Observation Sheets had no dates. It was not clear if Resident #4 was being monitored every 30 minutes as ordered by MD. The Nurse's Note dated 11/28/2020 at 11:42 am, documented that at approximately 7:50 am, RNS notified by nursing staff that Resident #4 had assaulted two residents that reside in Resident #4's room: Resident #2 and Resident #3. Upon entering residents' room, Resident #4 was sitting on Resident #4's bed and Resident #3 was on the floor near Resident #3's own bed. This writer questioned Resident #4 how Resident #3 got on the floor and Resident #4 stated I don't know. Resident #4 also denied hitting Resident #2 and Resident #3. During an interview on 08/31/2021 at 2:42 pm, CNA #3, who worked on 11/28/2020 7-3 shift, stated at the time of the incident on 11/28/2020, the staff were serving breakfast. CNA #3 stated that Resident #2 came out of Resident #2's room crying and stated that Resident #4 beat him/her. CNA #3 stated that another CNA came and they both entered the residents' room and observed Resident #3 in a sitting position on the floor. Resident #3 said that Resident #4 pushed him/her. Resident #4 was observed sitting on him/her bed behind curtain. CNA #3 stated that he/she immediately called for Manpower. The staff came and the residents were separated, and the supervisor assessed the residents. CNA #3 stated that Resident #2, #3 and #4 resided in a four bedded room. CNA #3 stated that he/she was assigned to Resident #4 and that Resident #4 was very aggressive. CNA #3 stated that Resident #2 and Resident #3 did not display any behavioral problems that would have annoyed Resident #4. During an interview on 08/31/2021 at 3:17 pm, assigned CNA #4, who was assigned to Resident #2 and Resident #3 on 11/28/2021 on the 7-3 shift, stated that Resident #2 and Resident #3 were quiet residents with no behavior. CNA #4 stated that when he/she made rounds the residents were in their beds. CNA #4 stated that he/she was in another resident's room serving breakfast when he/she heard a noise and went to check. CNA #4 stated that he/she observed Resident #2 in hallway saying that he/she was attacked by Resident #4. CNA #4 stated that he/she entered the room with another CNA and observed Resident #4 in him/her bed and Resident #3 was on the floor in a sitting position next to his/her bed. CNA #4 stated that the residents were separated immediately. During an interview on 09/28/2021 at 12:08 pm, the Psychiatrist stated that he/she was not Resident # 4's doctor. Resident #4 was under the care of the Psychiatric Nurse Practitioner (PNP) who was an independent provider. The Psychiatrist stated that he/she was familiar with Resident #4 and had evaluated Resident #4 a couple of times when the PNP was not available. The Psychiatrist stated that he/she knew that Resident #4 was aggressive and was not taking his/her medications. The Psychiatrist stated that for Resident #4 to be compliant with medications the facility needed to develop, with the input of Psychological Service, a positive behavioral plan to reinforce compliance. The Psychiatrist stated that Resident #4 was being followed by the Psychologist. The Psychiatrist also stated that he/she last saw Resident #4 March 2020 and suggested injectable medication. The Psychiatrist stated that he/she does not know why the recommendation was not implemented. During an interview on 09/29/2021 at 10:45 am, Attending Physician (AP) #1 stated that he/she was familiar with Resident #4 who had under their care for several years. AP #1 stated that he/she followed Resident #4 while the resident was in the psychiatric hospital. AP #1 stated that Resident #4 had multiple hospital transfers for behavior. AP #1 stated that Resident #4 was transferred to different psych hospitals and that every hospital had their own protocol and tools that nursing home does not have. AP #1 also stated that AP #2 was following Resident #4. During an interview on 09/29/2021 at 11:55 am, Psychiatry Nurse Practitioner (PNP) stated that he/she followed Resident #4 in the psych hospital and as a consultant in the nursing home for many years. The PNP stated that Resident #4 had unpredictable behavior. The PNP stated that Resident #4 would be nice one minute with smiles and the next moment, Resident #4 trying to suffocate the doctor. The PCP stated that Resident #4 was aged out from the State Psych Hospital and the only option for Resident #4 was the nursing home. The PNP stated that he/she was aware that Resident #4 was not taking the medications. Sometime Resident #4 refused all the medications and at times Resident #4 would pick and choose the medications to take. The PNP stated that the nursing staff needed to approach Resident #4 in different ways. The PNP stated that he/she recommended on 10/16/2020 that the medications be crashed and put into food. The PNP stated that he/she personally observed Resident #4 in the hospital been given the medications with apple sauce and the Resident took the medications with no problem. The PNP also stated that he/she recommended [MEDICATION(S)] Intramuscular (IM) every 4 weeks but does not know why the IM medication was not implemented. The PNP reported only going to the facility on ce a week and was given a list of residents to be evaluated. The PNP stated that he/she does not recall receiving request to evaluate Resident #4 after 10/16/2020. During an interview on 09/29/2021 at 1:00 pm, AP #2 stated that he/she was aware that Resident #4 was not taking his/her medications. If the nurses notify the doctor that the resident was not taking the medications, the resident would be transferred out to the hospital. AP #2 stated that he/she examined Resident #4 on 11/03/2020 for monthly and that he/she was following the psych recommendations. AP #2 stated that they were not aware of the psych consult dated 10/16/2020. AP #2 stated that if psych evaluated Resident #4, then the Psychiatrist should have placed the orders in the computer themselves. 415.4(b)(1)(i)

Based on observations, interviews and record reviews conducted during an abbreviated survey, (NY 660), the facility did not ensure that a resident who displayed and was diagnosed with mental disorder received appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. This was evident in 1 out of 4 residents sampled (Resident #4). Specifically, 1) Resident #4 who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] .; 2) The Psychiatrist evaluated Resident #4 on 10/16/2020 with recommendations for medications and medication administration that were not implemented by Medical Doctor (MD) and nursing staff; 3) Several Psychiatry Consults were ordered by the MD, but they were not implemented by Psychiatrist; 4) Resident #4's [CONDITION(S)] Care Plan was not updated to reflect recommendations made by the Psychiatrist on 10/16/2020; and 5) There were no Interdisciplinary Team Meetings to address Resident #4's aggressive behavior and refusal of medications. The findings are: The facility Policy and Procedure titled Psychopharmacologic Drugs with effective date 08/10/2015 documented it was the policy of the facility to utilize psychopharmacologic drugs appropriately for the purpose of assisting the resident in attaining and maintaining optimum physical and emotional functioning. The facility Policy and Procedure titled Behavioral Health Service with effective date 12/13/2017 documented that each resident must receive, and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychological well-being in accordance with comprehensive assessment and plan of care. Resident #4 was admitted to facility on 03/31/2015 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented that Resident #4 had a BIMS score of 12/15. The behavioral section of the MDS documented that verbal and physical behavior not exhibited. A Preadmission Screening and Resident Review (PASRR) dated 03/10/2015 revealed that Resident #4 had a Level II Mental Health Evaluation Report in place due to Severe Mental Illness. The Level II recommendation documented that Resident #4 should have the following: Psychiatric and medication evaluation and therapeutic group interventions at least weekly, within 1 week of admission. Recommendation also included a person-centered psychiatric plan. Ongoing psychiatric consultation, and medication management every 4 weeks. A PASRR dated 1/21/2020 documented recommendations for Psychiatrist, medication to be evaluated by Psychiatrist and follow in 1-2 months and as needed. A [CONDITION(S)] Drug Comprehensive Care Plan, last updated on 05/22/2020, documented interventions to continue with current medications, encouraged compliance and provide supportive treatment. Psychiatry to follow-up. A CCP Behavioral Symptoms dated 4/28/2017 last updated 10/27/2020 documented interventions to maintain calm environment, approach in a calm, gentle manner, redirect resident as needed etc. A Resident Nursing Instructions document dated as of 2/1/2020 documented instructions for staff to report behavioral changes to the charge nurse and monitor Resident #4 every 30 minutes for safety and behavior. The instruction also documented that Resident #4 may be very physically aggressive towards staff and other residents. Two staff members should always approach Resident #4. Surveyor reviewed facility monitoring sheets. There were gaps / missing dates in the monitoring sheets for 11/2020. Resident #4's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident-to-Resident Altercation Reports revealed that Resident #4 physically assaulted 3 residents. On 03/04/2020, Resident #4 attacked (roommate) Resident #1 with a fork. Resident #1 sustained laceration to sternum and abdomen. On 11/28/2020 Resident #4 attacked (2 roommates) Resident #2 and Resident #3. Resident #2 sustained a Triquetral Fracture to the left hand and left periorbital ecchymosis. Resident #3 sustained contusion and hematoma to right side of face jawline. A Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . (Psych medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Non-psych medications: [MEDICAL RECORD OR PHYSICIAN ORDER] .) A MAR from 11/1/2020 to 11/28/2020 reviewed and revealed that Resident #4 was refusing all ordered psych and non-psych medications all medications every day that included [MEDICATION(S)] 100 mg 2 time a day for [CONDITION(S)], [MEDICATION(S)] 0.5 mg two time a day for [CONDITION(S)], and [MEDICATION(S)] 10 mg daily for [CONDITION(S)] disorder. A Nursing Note dated 02/18/2020 documented that Resident #4 was not exhibiting any aggressive behavior but refusing [CONDITION(S)] medications. The Psychiatry Nurse Practitioner (PNP) was notified. The Registered Nurse requested [MEDICATION(S)] Intramuscular injection but PNP denied the request and ordered Psych consult to review medication. Resident #4's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order also noted to send Resident #4 out to Psych emergency room (ER) secondary to aggressive behaviors and for physically attacking peer and staff. A Nursing Note dated 03/03/2020 at 9:37 am, documented that Resident #4 still non-compliant with his/her medication regimen. Resident #4 continue to refuse medications despite being encouraged. The Medical Doctor made aware. Psychiatry consult initiated. No family listed on file at this time, Social Worker made aware. Review of Psychiatric Consultation Reports dated 03/03/2020 documented that Resident #4 was evaluated due to staff reports that Resident #4 frequently refused medications. Resident #4 was offered to start on [MEDICATION(S)] [MEDICATION(S)] 25 mg IM every 2 weeks. This order was not implemented. Resident #4 was transferred to the hospital on 03/04/2020. A Psychiatry Consultation Report dated 04/01/2020 documented that Resident #4 was evaluated due to re-admission. Staff reported that the resident had been aggressive and agitated. Resident #4 had paranoid delusion. Recommended to Increase [MEDICATION(S)] to 100 mg two times a day and add [MEDICATION(S)] 0.5 mg two times a day. Continue with [MEDICATION(S)] 10 mg at bedtime. Supportive therapy and encouragement provided. To follow up in 1 month and as needed. Review of Psychology Consults from 05/13/2020 to 11/17/2020 revealed that Resident was receiving Psychotherapy due to Adjustment Difficulty, aggressive behavior toward residents, staff, and for refusal of medications. A [CONDITION(S)] Drug Comprehensive Care Plan (CCP) last updated on 05/22/2020, documented interventions to continue with current medications, encourage compliance and provide supportive treatment. Psychiatry to follow-up. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #4 to be transferred to the hospital secondary to agitation. A Psychiatry Report dated 10/16/2020 01:31 pm, documented that Resident #4 was visited to follow up on current Psychotropics: [MEDICATION(S)] 10 mg PO (by mouth) at HS (hour of sleep), [MEDICATION(S)] 100 mg PO BID, [MEDICATION(S)] 0.5 mg two time a day. Resident #4 was recently readmitted from hospital #1. Prior to that Resident #4 was at a Psychiatric Hospital. Resident #4 was aggressive to nurses in the recent past, was destroying property, and threatening, etc. Resident #4 was confused and internally preoccupied chronically. Resident #4 still believed that he/she was not sick, and, therefore, refused the meds. Resident #4 was given [MEDICATION(S)] [MEDICATION(S)] 200 mg Intramuscular (IM) on 10/6/20 at hospital. Case discussed with nurses Plan/Recommendation: [MEDICATION(S)] [MEDICATION(S)] 200 mg IM every 4 weeks, next dose is due on 11/03/20. Resident #4's medications can be crushed and given with food or liquids. There should be allowed a wider window of time when meds can be given, such as from 8 to 11:30 in am and From 6 pm to 2:30 pm in the evening or HS. This will improve compliance and, hopefully, prevent frequent psych. hospitalization s. Continue with [MEDICATION(S)] to 100 mg PO BID, [MEDICATION(S)] 0.5 mg PO BID and [MEDICATION(S)] 10 mg PO QHS; no S/E; Supportive therapy and reassurance provided. Resident #1's meds were changed at Psych Hospital and Hospital #1 few weeks ago. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 did not receive the recommended [MEDICATION(S)] [MEDICATION(S)] 200 mg IM every 4 weeks. There was no documented evidence that [MEDICATION(S)] [MEDICATION(S)] 200 mg IM was given on 11/03/2020. Review of the [CONDITION(S)] Drug CCP revealed that the Psychiatrist recommendations of 10/16/2020 was not implemented. There were no interventions for Resident #4's medications to be crushed and administered with food or liquids. There were no interventions on the widening of window time for Resident #4 to be more complainant with accepting the medications. There were no interventions to monitor for specific side effects of the [CONDITION(S)] medications. Record review revealed there were no intradisciplinary team meetings to address Resident #4's aggressive behavior and refusal of medications. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented evidence that the Psychiatry Consults were implemented. Record review revealed that the Psychiatrist last evaluated Resident #4 on 10/16/2020. Resident #4's Half Hour Observation Sheets for 11/2020 reviewed with Administrator and revealed last entry date was 11/25/2020. Some of the Half Hour Observation Sheets were without dates. It was not clear that Resident #1 was being monitored as per the doctor's order. A Monthly Review Medical Note dated 11/02/2020 documented that Resident #4 refused all medications. Resident #4 was on [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] due to [CONDITION(S)]. Will request Psychiatry consult as soon as possible. A Nurse Practitioner Note (NP) dated 11/05/2020 documented that he/she was called to see Resident #4 with extreme agitation. Resident #4 was observed angry and agitated. Resident #4 was shouting and screaming in the hallway. Resident #4 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Give [MEDICATION(S)] injection solution x1 dose for [CONDITION(S)] disorder. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 30 minutes monitoring for behavioral management and unpredictable behavior. [MEDICATION(S)] 10 mg tablet give 1 tablet (10 mg) by oral route once daily in the evening for [CONDITION(S)] disorder. [MEDICATION(S)] 0.5 mg tablet give 1 tablet (0.5 mg) by oral route 2 times per day for [CONDITION(S)], [MEDICATION(S)] 100 mg tablet, 1 tablet (100 mg) by oral route 2 times per day. A Psychology Consult dated 11/17/2020 documented that Resident #4 was receiving Psychotherapy session seen due to aggressive behavior, adjustment to placement in facility. Resident was rigid about refusal of medication. Supportive therapy and reassurance were offered. A Physician's Monthly Progress Note dated 11/20/2020 at 8:11 pm, documented to continue current management. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented evidence that the Psychiatry Consult was implemented. Record review revealed that the Psychiatrist last evaluated Resident #4 on 10/16/2020. A Physician's Progress Note dated 11/25/2020 at 7:25 pm documented that Resident #4 was followed up Psychiatrist consultation/recommendation and evaluate the resident for side effect of [CONDITION(S)] meds and adjust meds if needed. Resident is on [MEDICATION(S)] 10 mg, at bedtime, [MEDICATION(S)] 100 mg two time a day, [MEDICATION(S)] 0.5 mg two time a day for [CONDITION(S)] disorder, Dementia, Anxiety disorder. No cognitive behavior impairment or deterioration resulting from the medications. No side effect/adverse reaction or change of behavior noted. Continue current medications. Clinical observation. Follow up Psychiatrist evaluation. A Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the behavioral nursing notes from 11/02/2020 to 11/28/2020 revealed that Resident #4 refused all the medications despite education. Resident #4 was monitored for being aggressive towards staff and other residents. The interventions included encouragement, counseling, supervisor being notified, every 30 minutes monitoring, MD notified, and Psychiatry consult. A Nurse's Note dated 11/28/2020 at 1:11 pm, documented that the Registered Nurse Supervisor was notified that Resident #4 assaulted two residents (Resident #2 and Resident #3) that resided in Resident #4's room; Upon entering the room Resident #3 was observed sitting on the buttocks near Resident #3's bed. Resident #3 stated Please help me, Resident #4 hit me in my face. Resident #3 pointed to Resident #4. The right side of Resident' #3's presented with discoloration. Resident #3 complained of slight pain to the right side of the head. Tylenol administered as per Medical Doctor's order with slight effect. Resident #3 was removed from his/her room and was placed in front of the nursing station for observation and safety. Awaiting Emergency Medical Service to arrive. The Medical Doctor contacted, and family was notified. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Hospital Transfer Note dated 11/30/2020 at 04:55 pm, documented Resident #4 was transferred to the Hospital on 11/28/20 due to physically aggression by hitting two residents without provocation. No Next of Kin on file. The Social Worker will remain available as needed. A Psychiatric Discharge Summary dated 01/13/2021 documented an admitted [DATE]. It was documented that Level II was approved and that Resident #4 psychiatry stable for discharge at this time and does not currently pose a risk to self or other. Resident #4 received [MEDICATION(S)] [MEDICATION(S)] 100 on 01/12/2021. The next dose would be on 01/26/2021. Follow up with Psych in 5-7 days. Record review revealed that Resident #4 was transferred on 11/28/20 and returned to the facility on [DATE]. During an interview on 8/31/2021 at 2:25 PM, Licensed Practical Nurse #1 (LPN #1) who worked on 3/4/2020 at 7-3 shift, stated that they do not recall the incident involved Resident #4 and Resident #1. LPN stated that Resident #4 can be aggressive, unpredictable and staff was monitoring every 30 minutes. Resident was refusing medication at times and MD was notified. Psych and Psychologist were following up Resident #4. If the resident is agitated staff would leave the resident alone for some time. LPN #1 does not remember altercation with other residents. LPN also stated that Resident #4 had their moments, stay in their room. No residents were complaining of Resident #4's behavior. During an interview on 9/28/2021 at 12:08 pm, Psychiatrist stated that they were not Resident # 4's doctor. Resident #4 was under care of Psychiatric Nurse Practitioner who is independent provider. Psychiatrist stated that they were familiar with Resident #4 and evaluated couple time when resident's doctor was not available. Psychiatrist stated that they knew that Resident #4 was aggressive and not taking medications. To promote compliance with medications the facility need develop positive behavior plan to reinforce compliance with input of Psychological Service. The Resident #4 was seen by Psychologist. Psychiatrist also stated that they last seen Resident #4 in March and suggested injectable medication. Psychiatrist don does not know why it was not implemented. During an interview on 9/29/2021 at 10:45 am, Attending Physician #1 stated that they were familiar with Resident #4 who was under their care for several years and followed Resident #4 in Kingsbrook Jewish Psychiatric hospital. The resident was sent to the hospital on multiple occasions due to behavior and sometimes readmitted to another unit under the care of Physician #2. Physician #1 was covering for Physician #2 a couple of times. The resident was sent to different psych hospitals and every hospital has their own protocol and tools that the nursing home does not have. The hospitals were breaking continuity of Resident # 4's care. The nursing home cannot administer the injectable psych medications unless it is an emergency. When facility was sending Resident #4 to the hospital, the hospital was demanding that the facility take the resident back, otherwise they would call the State. They (Psychiatrists in the hospital and in the nursing home) were cutting off Resident #4's psych medications because of the Gradual Drug Reduction (GDR) policy. When Resident #4 was readmitted from the hospital 10/2020 and 11/2020 Resident #4 was under care of Physician #2. The resident came with PO [MEDICATION(S)] and Physician #2 discontinued the order. A onetime injection of [MEDICATION(S)] was given as an emergency measure on 10/9/2020 and on 11/4/2020 Resident #4 received an [MEDICATION(S)] injection. Resident had uncontrolled [CONDITION(S)] and was followed by Psychiatrist. Physician followed Psychiatrist's recommendation. Resident was not taking medications and was aggressive. Nursing staff was calling all the time that the resident was not taking medications, was violent, and out of control, then Physician discussed with nursing staff intervention options and if they did not work, they sent the resident to the hospital. The nursing staff was monitoring the resident and Psychologist was involved due to resident not taking medications. Resident has right not to take a medication and nurses only can educate, convince, or counsel the resident. They cannot put medications in resident's food. Resident #4 due to issue with mental health was paranoid, very suspicious, and mistrustful. Resident #4 had periods of calm behavior and then Resident became loud, aggressive and facility was sending the resident to the hospital. During an interview on 9/29/2021 at 11:55 am, Psychiatry Nurse Practitioner (PNP) stated that they followed Resident #4 in the psych hospital and as a consultant in the nursing home for many years. The resident had unpredictable behavior, one time Resident #4 was nice and smiling, then next moment tried to suffocate the doctor. PNP stated that Resident #4 was aged out from State Psych Hospital and the only option the resident had was a nursing home. PNP was aware that Resident #4 was not taking medications., though It was sporadic. Sometimes Resident refused all medications, sometimes resident would pick and choose. The staff should approach the resident in different ways. PNP recommended on 10/16/2020 that medications may be crushed and put in the food because PNP personally observed Resident #4 in the hospital taking medications with apple sauce with no problem. PNP also recommended [MEDICATION(S)] IM every 4 weeks and a wider window to take the medications. PNP did not know why it was not implemented. PNP stated that they come to the facility on ce a week and facility provides a list of residents who need evaluations. PNP does not recall receiving a request for Resident #4 after 10/16/2020. During an interview on 9/29/2021 at 1:00 pm, Attending Physician #2 stated that they were aware that Resident #4 was not taking medications. MD orders Psych consult and Physician should follow the recommendations. Nurses notifying the doctor if resident is aggressive and not taking medications, and resident is sent out. The staff trying to educate the resident and monitor 1:1, but facility cannot keep the resident who is aggressive and not take medications. Attending Physician #2 stated that they examined Resident #4's monthly evaluation on 11/03/2020 and was following Psychiatry recommendations. Before that, Nurse Practitioner saw Resident #4 and there was another Physician. Attending Physician #2 stated that they were not aware of Psych consult dated 10/16/2020. Attending Physician #2 stated that if Psych evaluated Resident #4, Psychiatrist should have placed orders in the computer themselves. Attending Physician #2 does not know why it was not done. 415.12 (f)(1)

Based on observation, record review and interview conducted during an abbreviated complaint survey (NY 939) initiated on Recertification survey (EC8111) and completed 11/19/21, the facility did not ensure the resident environment remained free from accident hazards and that a resident received adequate supervision to prevent accidents for 1 (Resident #159) out of 11 residents reviewed for Accidents. Specifically, Resident #159's bed was positioned against the radiator and while in bed Resident positioned their leg between the radiator and the bed, sustaining a second-degree burn, requiring hospitalization . This resulted in actual harm to Resident #159 that is not an immediate jeopardy. The findings are: The facility policy and procedure for Occurrence Investigation and Reporting effective 8/2018 documented the following: It is the policy of this facility to ensure all residents are free from abuse, neglect, mistreatment and misappropriation as required under Federal Regulation F 610 (483.12) and the NYCRR Title 10 Part 415.4. It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control as well as providing the supervision and assistive devices that an individual resident requires to prevent avoidable accidents as required under Federal Regulation F689 (483.25) and the NYCRR Title 10 Part 415.12. The DNS/Designee will be responsible for the completion of section II and III of the occurrence investigation summary and for ensuring that all required notifications to the NYDOH and Local Law Enforcement Agency. Occurrence investigation findings will be reviewed to identify additional preventative measure that an individual resident may require to prevent avoidable accidents and to identify any potential hazards in eh resident's environment that need to be addressed. The facility policy and procedure for Residents Room Temperature (Heat) undated documented the facility will ensure the safety and comfort of all residents during the winter season and maintenance department will check heating units as scheduled. Maintenance department will monitor boiler for proper operation. In the event of a boiler failure, the Administrator, Director of Nursing and Director of maintenance will immediately be notified. Resident #159 was admitted with diagnoses which include [CONDITION(S)] disorder depressive type, bilateral primary [CONDITION(S)] of knee and diabetes due to underlying condition with other diabetic ophthalmology complications. The Discharge Minimum Data Set 3.0 (MDS), Assessment Reference Date (ARD) 04/29/2020, documented that Resident #159 had moderately impaired cognition. The MDS documented the resident required supervision with bed mobility and eating, limited assistance with transfer, dressing and toilet use and extensive assistance with personal hygiene. No pressure ulcers and no skin conditions documented. The Accident and Incident report, written by the Registered Nurse Supervisor (RNS #1), documented on 4/29/2020 at 8:45 PM, Resident #159 sustained a reddened area on the outer aspect of their right lower leg with the top layer of skin removed on the outer aspect of the right lower leg. The physician was notified on 4/29/2020 at 9:05 PM, and the family was informed on 4/29/2020 at 9:00 PM. The Occurrence Investigation Summary documented the occurrence was on 4/29/21 at 8:45 PM. The environmental hazard contributing to the occurrence was the radiator in the resident's room. Resident #159 rested their leg against the radiator and was transferred to acute care immediately. The former DNS signed the summary of the investigation on 5/17/20. The report also documented there was reasonable cause to believe abuse, neglect, mistreatment, exploitation, or misappropriation occurred and NYSDOH was notified by the former DNS on 4/30/20. The summary also indicated no crime was committed against Resident #159. It was reviewed on 5/17/2020 by the DNS and by the administrator on 6/23/2020. The Investigation Summary Report dated 5/17/20, written by the former DNS, included interviews with all staff. The Physician reported they were informed the resident was burned on the radiator. The Physician was told the heat was on, and the radiator was hot. The Physician did not ask for a description of the burn and ordered transfer to the hospital. There was no date or time for the Physician interview. The investigation was re-opened based on re-interviews conducted on 5/7/20 with CNAs. CNA#2 stated Resident #159's leg was stuck between the bed and the radiator. CNA#2 stated that the radiator was hot in the resident's room, and CNA#2 burned through the two gloves they were wearing. CNA#2 stated they did not report the hot radiator because they did not want anyone to get in trouble. The assigned day shift CNA on 4/29/20 stated Resident #159's bed was close to the wall and heater. CNA #2 was terminated for leaving the bed against the radiator and not conducting safety rounds every 2 hours even though they documented the rounds were completed. RNs interviewed did not report a warm room temperature. The RN Supervisor (RNS#1) was terminated for documenting assessments completed when they were completed by the RN #3 on orientation. In addition, RN#1 did not obtain any treatment orders or medication orders. The corrective actions included education for Nursing staff about abuse, following the plan of care, doing rounds on all residents, maintaining resident safety, and the significance of giving CNAs report. Per the investigation conducted, staff left Resident #159's bed against the radiator creating unsafe conditions. The CNA assigned reported that the radiator was hot, and they did not report it to anyone. In addition, the RN who assessed the resident also reported a hot radiator. The facility addressed the hazard created by leaving the bed against the radiator by in-servicing nursing staff. CNA #2 and RN #1 were terminated. The Employee Statement, written by the assigned Certified Nursing Assistant (CNA#2), dated 4/30/20 documented CNA#2 went to check on Resident #159 and noticed Resident #159's leg was stuck between the bed and the radiator. CNA#2 placed the resident's legs back on the bed and called the charge nurse, and the supervisor was called. The Nursing note on 4/29/2020 at 10:43PM documented after the unit charge nurse (LPN#1) returned from break they were informed by Certified Nursing Assistant (CNA#2) assigned to the resident that the resident had [CONDITION(S)] to their right lower leg and CNA stated that the resident's leg was hanging over edge of bed against the radiator. The Employee Statement, written by RNS#1, dated 4/30/2020 documented RNS#1 was informed that Resident #159 sustained a burn to the right lower leg on the phone. The top layer of skin was removed. Resident #159's right lower leg was against a warm radiator. The family was informed, and Resident #159 was transferred to the hospital per MD order. The affected area was below the knee extending to the area above the ankle, and the affected layer was the dermis. The Nursing Progress Note on 4/30/2020 at 5:55PM (written by the Registered Nurse Supervisor, RNS#1) documented that during rounds staff observed the top layer of the resident's skin from their right knee area to down to the ankle was removed by heat from the radiator and they were notified by the charge nurse the resident sustained a burn to their right leg. During rounds the CNA observed the reddened area on the outer aspect of right lower leg, top layer of skin was removed as resident was resting their leg against, the radiator near their bed. Resident representative and attending physician were notified of the occurrence and the resident was transferred to hospital via ambulance, resident medicated with Tylenol 650 mg to ease discomfort of the skin removed, affected area of occurrence below right knee extending to the area above the outer aspect of the ankle. The Employee statement, written by RN #3, dated 5/8/2020 documented that on the 3-11 shift, RN #3 was orienting. RN #3 was asked to check on Resident #159 after the RN Supervisor (RNS #1) received a phone call. Resident #159 was lying in bed with facial expressions of pain and grimacing and the right leg was burned from the area below the knee to above the ankle. RN #3 asked the licensed practical nurse if Resident #159 had pain mediation ordered and was informed there were orders for Tylenol. RN #3 returned to the 1st floor and informed RNS #1, in their opinion, Resident #159 had a second degree burn and needed to go to the hospital. There was no documented evidence that a radiator surface temperature, radiator temperature, or room temperature was taken on or before the day of the incident. During an interview on 11/19/2021 at 12:01PM, the former Licensed Practical Nurse (LPN#1) stated the CNA informed them Resident #159 sustained a burn. LPN #1 stated they wrote a statement and could not recall details of the incident. On 09/21/2021 at 03:57 PM, RN Supervisor (RNS#1) was interviewed and stated that the incident was reported to them, and RNS#1 instructed a nurse on orientation to go and assess Resident #159. The nurse informed RNS #1 that Resident #159 sustained a burn with skin loss, and Resident #159 was positioned close to the radiator. On 09/22/2021 at 3:57PM, an interview was conducted with the on call medical doctor (MD#1) who stated the Resident #159 had a burn to the right lower extremity and was sent to the hospital. They were notified by the RN, and they could not recall what caused the burn. It was a high degree burn, second and third degree, and the burn required hospitalization . On 11/15/2021 at 11:48AM and 2:55PM, the Maintenance Worker (MW#1) was interviewed and stated they were not informed of any incident where a resident sustained a burn. MW#1 stated there is no way a resident could get injured from the radiator units. Radiator spot checks are done once a week to check the floor for integrity and ensure clothes or furniture are not blocking the radiators. The radiators are 100% sealed units and there is no way the resident can get in contact with the inside of the unit. The temperature of the radiator and the ambient temperature can be taken using a thermal gun. On 11/16/2021 at 1:10PM, the Maintenance Worker (MW#2) was interviewed and stated they heard a resident sustained a burn from the radiator cover when they returned from leave. MW#2 could not recall if they had a training related to the incident. On 09/22/2021 at 03:23PM, the Director of Maintenance (DOM) was interviewed and stated that they were not aware of an incident where a resident sustained a burn injury. The DOM stated they did not have any documentation that existed prior to them taking over in January 2021. There was no maintenance book located from the second floor for the year 2020. If there was an issue with the radiator, someone would be dispatched to take care of the issue. On 11/15/2021 at10:35 AM and 01:24PM, the Former Nursing Home Administrator (NHA#2) was interviewed and stated that they remembered that a resident was burned on the radiator. NHA #2 had no additional records for the radiators on the day of the incident. On 11/15/2021 at 04:49PM, the Former Director of Housekeeping (DHK) was interviewed and stated that the set-up of the beds belongs to nursing. Housekeeping rounds to make sure nurse leave beds like they are supposed to since residents are positioned by nursing. Daily audits, once a week and monthly. They stated that they did corrective action that included audits for 1 month and taught in-service to staff. The staff educator did training on safety after the incident. On 11/16/2021 at 10:50AM and 3:15PM, the Boiler Service Manager (BSM) was interviewed and stated that the boiler for the facility is serviced once a year, and the company provides oil for the boiler. BSM stated that they were not informed about the accident that occurred, and the BSM was surprised that the facility did not request the company to come and check the hot water in relation to the incident. They serviced the burner in January 2020. Maintenance scheduled hot water check once a year for the building. Hot water is pumped and mixed in tank and then runs to resident's rooms when the heat is running. Several attempts were made to contact the former Certified Nursing Assistant (CNA #2) assigned to Resident #159 at the time of the incident. A voicemail was left, and no return call was received. On 11/15/2021 at 10:07AM, 11/16/2021 at 10:55AM, the former DOM was contacted on for a phone interview and a voice mail left and no phone call returned. The Nursing Notes from 5/18/2020 to 6/17/20 documented Resident #159 was readmitted to the facility on [DATE] with a right lateral leg third degree burn measuring 17.0 cm x 7.0 cm x 0.2 cm and a left big toe second degree burn. The resident required ongoing wound care twice per day and then daily to promote healing. Resident #159 also required OT/PT after the hospitalization due to ADL decline. The Comprehensive Care Plan (CCP) for Skin Impairment potential was updated with a note on 2/23/2021 indicating the resurface of the burn area periodically reopens due to fragile skin. 415.12 (h)(1)

Based on interview and record review conducted during a complaint survey (NY 939), the facility did not ensure all alleged violations involving abuse, neglect, or mistreatment, resulting in serious bodily injury were reported immediately, but not later than 2 hours after the allegation is made, to the State Survey Agency. Specifically, the facility did not report an incident where a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . This was evident for 1 of 8 residents reviewed for Abuse out of 39 sampled residents (Resident #159). The findings are: The policy and procedure titled Abuse Prevention effective 11/2018 and reviewed 8/26/2021 documented: It is the policy of this facility to report to the proper authorities within the prescribed time frame violations related to treatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property. All allegation of mistreatment, neglect and abuse including injuries of unknown origin and misappropriation of personal property will immediately reported to the Administrator and DNS an as soon as possible but no more than 24 hours to the NYS DOH. If the suspicious event caused serious bodily injury, the administrator has up to 2 hours to call police after forming the suspicious. Serious bodily injury means injury involving extreme physical pain involving protracted loss or impairment of the function of a bodily member, organ or mental faculty, requiring medical interventions such as surgery, hospitalization , or physical rehabilitation. The policy and procedure titled Occurrence Investigation and Reporting effective 08/2018 and reviewed 08/27/2018 documented the facility to ensure all residents are free from abuse, neglect, mistreatment, and misappropriation s required under Federal Regulation F610 (483.12() and NYCRR Title 10 Part 415.2. It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control as well as providing the supervision and assistive device that an individual resident requires to prevent avoidable accidents as required under Federal Regulation F689 (483.15) and the NYCCR Title 10 Part 415.12. Occurrence investigation findings will be reviewed to identify additional preventative measures that an individual resident may require to prevent avoidable accidents and to identify any potential hazards in the resident's environment that need to be addressed. Resident #159 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Discharge Minimum Data Set 3.0 (MDS), Assessment Reference Date (ARD) 04/29/2020, documented that Resident #159 had moderately impaired cognition. The MDS documented the resident required supervision with bed mobility and eating, limited assistance with transfer, dressing and toilet use and extensive assistance with personal hygiene. No pressure ulcers and no skin conditions documented. The Nursing note on 4/29/2020 at 10:43PM documented after the unit charge nurse (LPN#1) returned from break they were informed by Certified Nursing Assistant (CNA #2) assigned to the resident had burn to their right lower leg and CNA stated resident leg was hanging over edge of bed against the radiator. The Nursing Progress Note on 4/29/220 at 11:13PM documented that RN#1 informed the resident's designated representative about the incident, and the resident was transferred to the hospital per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The Accident and Incident report (Report #221) documented the occurrence was on 4/29/2020 at 8:45 PM. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician was notified on 4/29/2020 at 9:05 PM, and the family was informed on 4/29/2020 at 9:00 PM. The Occurrence Investigation Summary documented the occurrence was on 4/29/21 at 8:45 PM. The environmental hazards contributing to the occurrence was the radiator in the resident's room. Resident #159 rested their leg against the radiator and was transferred to acute care immediately. The statement written by the assigned Certified Nursing Assistant (CNA #2) documented CNA #2 when to check on Resident #159 and noticed Resident #159's leg was stuck between the bed and the radiator. CNA #2 placed the resident's legs back on the ed and called the nurse in charge and the supervisor was called. The Unit Nurse Occurrence Statement documented that the occurrence was on 4/29/2020 at 9:00PM, and it was reported to the nurse that the resident had their leg hanging over the side of the bed against the radiator and was burned. The Nursing Progress Note on 4/30/2020 at 5:55PM documented that during rounds staff observed the top layer of the resident's skin from the knee area above the right leg removed by heat from the radiator and they were notified by the charge nurse the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident representative and attending physician were notified of the occurrence and resident transferred to hospital via ambulance, resident medicated with Tylenol 650 mg to ease discomfort of the skin removed, affected area of occurrence below right knee extending to the area above the outer aspect of the ankle. Review of the NYS DOH Automated Complaint Tracking System (ACTS) Complaint/ Incident Investigation Report for compliant NY 939 documented the facility reported the incident involving Resident #159 to NYSDOH on 4/30/2020 at 8:45 PM. The time of the occurrence was 4/29/2020 at 8:45PM. This allegation of serious injury was reported 24 hours after incident. During an interview on 11/19/2021 at 12:01PM, the former Licensed Practical Nurse (LPN#1) stated Resident #159 sustained a burn. LPN #1 was returning from their lunch break when a CNA caught LPN #1 by the elevator. LPN #1 stated they ran to Resident #159's room and saw Resident #159 lying in bed. LPN #1 stated they wrote a statement. LPN #1 called the RN supervisor, and RN supervisor contacted the medical doctor. Resident #159 used to walk and had a decrease in mobility. LPN #1 could not recall if Resident #159 was on monitoring. LPN #1 recalled Resident #159 had an alarm device, but they could not remember if it was for the bed or chair. LPN #1 stated they noted some type of injury on the resident's leg but could not recall what the resident's skin condition looked like since resident was assessed by the RN and the event occurred over 1 year ago. During an interview on 09/21/2021 at 3:57 PM, the former Registered Nurse Supervisor (RN #1) stated it was reported to them that the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The orienting nurse reported there was skin loss to RN #1. RN #1 stated they notified the resident representative and called the medial provider. Resident #159 was sent out due to possible infection. RN#1 notified the DON of the incident, and that Resident #159 was close to the radiator. On 09/22/2021 at 5:09PM, the Assistant Director of Nursing (ADNS) was interviewed and stated that abuse should be reported withing 72 hours. The ADNS stated that, based on the investigation, the RN Manager speaks with the Director of Nursing Services (DNS) regarding the status of the resident, and the DNS determines if it should be reported right away. On 09/22/2021 at 5:11PM, The [NAME] President of Nursing was interviewed and stated this incident should have been reported to NYSDOH within 2 hours as per reporting guidance. Some incidents should be reported within 24 hours, but if there is a definite crime or harm, the incident should be reported immediately. Several attempts were made to contact the former Certified Nursing Assistant (CNA #2) assigned to Resident #159 at the time of the incident. A voicemail was left, and no return call was received. Several attempts were made to contact the former Director of Nursing (DON). A voicemail was left, and no return phone call received. 415.4(b)(1)(i)

Based on record reviews, observations, and staff interviews during the recertification survey EC8111 the facility did not ensure that an incident was thoroughly investigated. Specifically, the facility did not obtain staff statements from the maintenance person on duty at the time of the incident for an investigation conducted regarding a resident who was transferred to the hospital for evaluation after and sustaining a burn in the facility to their right lower extremity from the radiator. This was evident for 1 out of 8 residents reviewed for Abuse (Resident #159) out of 39 sampled residents. The finding is: The policy and procedure titled Abuse Prevention effective 11/2018 and reviewed 8/26/2021 documented the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation by anyone in this facility. This facility has developed policies and procedures to prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property which includes the following components: screening, training, prevention, identification, investigation, protection and reporting/response. Any staff made aware of any violation of abuse, neglect, exploitation and mistreatment from occurring while the investigation is in progress, and take appropriate corrective action, as a result of the investigation findings. It is the policy of this facility to report to the proper authorities within the prescribed time frame violations related to treatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property. All allegation of mistreatment, neglect and abuse including injuries of unknown origin and misappropriation of personal property will immediately reported to the Administrator and DNS an as soon as possible but no more that 24 hours to the NYS DOH. If the suspicious event caused serious bodily injury, the administrator has up to 2 hours to call police after forming the suspicious. Serious bodily injury means injury involving extreme physical pain involving protracted loss or impairment of the function of a bodily member, organ or mental faculty, requiring medical interventions such as surgery, hospitalization , or physical rehabilitation. Under training documented upon hire and annually throughout employment, all staff will undergo training in the following areas: prohibition and preventing all forms of abuse, neglect, misappropriation of resident property and exploitation, reporting abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources, and to whom and when staff and others mush report their knowledge related to any alleged violation without fear or reprisal. The policy and procedure titled Occurrence Investigation and Reporting effective 08/2018 and reviewed 08/27/2018 documented the facility to ensure all residents are free from abuse, neglect, mistreatment, and misappropriation s required under Federal Regulation F610 (483.12() and NYCRR Title 10 Part 415.2. It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control as well as providing the supervision an The Quarterly Minimum Data Set (MDS), Assessment Reference Date (ARD) 09/17/2021 documented that Resident #159 had moderately impaired cognition. The MDS documented the resident required extensive assistance with activity of daily living (ADL) bed mobility, transfer, dressing, beating and personal hygiene. The resident was always continent of bowel and bladder. There were no [CONDITION(S)] documented and the applications of ointments and medication documented. The Quarterly Minimum Data Set (MDS), Assessment Reference Date (ARD) 09/15/2020 documented that Resident #159 had moderately impaired cognition. The MDS documented the resident required extensive assistance with activity of daily living (ADL) bed mobility, transfer, dressing, beating and personal hygiene. The resident was always continent of bowel and bladder. There were [CONDITION(S)] documented and the application of non-surgical dressing, application of ointment/medications, turning and positioning in bed and chair documented. The Significant Change MDS, Assessment Reference Date (ARD) 05/25/2020 documented that Resident #159 had severely impaired cognition. The MDS documented the resident required extensive assistance with activity of daily living (ADL) bed mobility, transfer, dressing, beating and personal hygiene. Burn was documented, pressure reducing device for chair/bed, turning and positioning, nutrition or hydration intervention to manage skin problems, application of non-surgical dressings, application of ointment and medications. The Discharge MDS, Assessment Reference Date (ARD) 04/29/2020 documented that Resident #159 had moderately impaired cognition. The MDS documented the resident required supervision with bed mobility and eating, limited assistance with transfer, dressing and toilet use and extensive assistance with personal hygiene. No pressure ulcers were documented. assistive device that an individual resident requires to prevent avoidable accidents as required under Federal Regulation F689 (483.15) and the NYCCR Title 10 Part 415.12. Occurrence investigation findings will be reviewed to identify additional preventative measures that an individual resident may require to prevent avoidable accidents and to identify any potential hazards in the resident's environment that need to be addressed. The Quarterly MDS dated [DATE] documented Resident #159 had moderately impaired cognition. Resident #159 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an onsite interview on 09/16/2021 at 10:39 AM, resident #159 stated that that their skin got burned and better now and cannot remember how they got burned and the bandage are changed every other day for their burn. On 09/16/2021 at 10:59 AM, there was a dressing on right lateral legs to right of knee and midleg on the right side and healed area noted also between bandages. The Nursing note on 4/29/2020 at 10:43 PM documented after the unit charge nurse (LPN #1) returned from break they were informed by Certified Nursing Assistant-CNA #2 assigned to the resident had burn to their right lower leg and CNA #2 stated resident leg was hanging over edge of bed against the radiator. The Nursing Progress Note on 4/29/220 at 11:13 PM documented that RNS (RN#1) that the resident responsible party was informed about the incident with the resident and resident transfer to the hospital that was ordered by the medical provider. The Nursing Progress Note on 4/30/2020 at 5:55 PM documented that during rounds staff observed the top layer of the resident's skin from the knee area above the right leg removed by heat from the radiator and they were notified by the charge nurse the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident representative and attending physician were notified of the occurrence and resident transferred to hospital via ambulance, resident medicated with Tylenol 650 mg to ease discomfort of the skin removed, affected area of occurrence below right knee extending to the area above the outer aspect of the ankle. The Nursing Progress Note on 5/18/2020 at 10:40 PM documented the resident returned to the facility at 7:31 PM resident was in hospital for evaluation and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . PRI orders reviewed with the medical provider (MD #2) The Medical Progress note dated 5/20/2020 at 9:54 PM documented resident readmitted from hospital with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions documented include apply [MEDICATION(S)] 1% topical cream a 1.5 mm thick layer to entire burn area by topical route after wash with normal saline and cover with dry sterile dressing two times daily and apply [MEDICATION(S)] 1% topical cream a 1.5 mm layer to entire burn area on the left toe/bunion by topical route after was with normal saline and cover with dry sterile dressing two times daily. The investigative summary was not signed until 5/17/2021 by the former DNS. It documented that they were notified on 4/30/2020 and it had the following item checked there is reasonable cause to believe that abuse neglect, mistreatment, exploitation has occurred as a result the NYSDOH was notified. The administrative review section was signed on 6/23/2020 by the former Administrator signed on 6/23/2020 and signed by the Director of Nursing on 5/17/2020. There was no documented evidence that any statements were obtained from the maintenance person assigned on the day of the incident report. The investigation summary did not contain what corrective action was taken by maintenance to address the safety concern related to the resident sustaining a burn requiring hospitalization that was documented as a result of the room radiator documented on staff statements and nursing/medical progress notes. On 09/20/2021 at 10:19 AM, an interview was conducted with CNA #1 stated that the resident was transferred to the present unit from another floor and no other skin changes noted for burn and always use peri guard for resident skin for protection and sometimes they are there when wound care done for resident skin site and resident scratches skin and this why wound care is done. The resident has a bed and chair alarm. stated any incident should be reported to the charge nurse and the Director of Nursing (DON). On 09/21/2021 at 3:57 PM, the former Registered Nurse Supervisor (RN #1) stated it was reported to them that the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . They notified the resident representative and called the medial provider and resident sent put due to possible infection. They notified the Don of the incident and they were informed the resident was close to the radiator. On 9/22/2021 at 03:23 PM, an interview was conducted with the Director of Maintenance (DOM) who stated that they were not aware of any incident where a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . They stated the radiator boiler operates on temperature and monitored by setting the boiler and may operate for 20 minutes then cut off and comes back on. The temperature of the boiler is monitored by once the temperature is set it operates. They check room to see if too cold or hot and comfortable for the resident. The boiler generates steam, and it has a protective cover and would no see actual piping on the unit and [NAME] runs and emits steam. It would have to be a large amount of steam and rupture in valve to emit a large amount of steam and note aware of that. Every room has a heating system that is controlled by the boiler and someone would be dispatched to take care of the issue. No maintenance book from the second floor for 2020. Radiator would be utilized by stated standard when temperature dropped a certain temperature and complaints of cold utilize radiator. Logs would be in the maintenance office. On 09/22/2021 at 5:09 PM, RN/ADNS (RN #2) stated that abuse should be reported within 72 hours. The VP of Nursing stated within 2 hours it should be reported to Department of Health as per reporting guidance and can mean up to 24 hours and if there is a definite crime or harm has to be reported immediately. ADNS stated that based on the investigation the RN Manager speaks with the Director of Nursing Services (DON) and status of the resident and determine if it is to be reported right away. Several attempts were made to contact the former Certified Nursing Assistant (CNA #2) assigned to Resident #159 at the time of the incident. A voicemail was left, and no return call was received. Several attempts were made to contact the former Director of Nursing (DON). A voicemail was left, and no return phone call received. On 11/15/2021 at 10:07AM, 11/16/2021 at 10:55AM, the former DOM was contacted on for a phone interview and a voice mail left and no phone call returned. 415.4(b)(2)