Every finding on record at Pelham Parkway Nursing Care And Rehabilitation Fac

Based on interview and record review conducted during an Abbreviated Survey (2741076), the facility failed to ensure that an alleged violation involving abuse, neglect, exploitation or mistreatment, was reported immediately but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This was evident for one (1) of six (6) residents (Resident #1) sampled for abuse. Specifically, on 02/08/2026 at approximately 10:30 PM, Certified Nursing Assistant #1 informed Registered Nurse Supervisor #1 that they observed Certified Nursing Assistant #2 inappropriately touched Resident #1's private organ. The Administrator was notified on 02/10/2026 at approximately 11:00 AM, the New York State Department of Health was notified on 02/10/2026 at 1:20 PM, and local law enforcement notified on 02/10/2026 at 1:24 PM. The facility did not report the alleged allegation of abuse timely.The findings include: The facility Policy and Procedure titled 'Abuse Prevention' dated 01/05/2026 stated allegations of abuse must be immediately reported to the Administrator and no later than two hours to other officials (including to the State Survey Agency) after the allegation is made. Resident #1 was admitted to the facility with diagnoses including Cerebral Palsy, Aphasia, and Seizure DisorderThe Minimum Data Set (an assessment tool) dated 11/27/2025 documented Resident #1 had short and long memory problems. A review of the facility 'Summary of the Investigation' dated 02/12/2026 by the Director of Nursing documented on 02/08/2026 at approximately 10:30 PM Certified Nursing Assistant #1 informed Registered Nursing Supervisor #1 that they walked into Resident #1's room and saw Certified Nursing Assistant #2 on their knees, in the dark, inappropriately touching Resident #1. Facility concluded that evidence of abuse, neglect, or mistreatment could not be verified. The investigation also documented that the Administrator was informed on 02/10/2026 at approximately 11:00 AM and the police were informed on 02/10/2026 at 1:24 PM. A Webform submission from: Nursing Home Facility Incident Report dated 02/10/2026, documented the facility submitted the incident to New York State Department of Health on 02/10/2026 at 1:20 PM. During an interview on 02/25/2026 at 1:33 PM, the Director of Nursing stated on 02/08/2026 at around 11:00 PM, Registered Nurse Supervisor #1 informed them of the alleged sexual abuse allegation against Certified Nursing Assistant #2 and that they removed Certified Nursing Assistant #2 off the unit. The Director of Nursing stated they did not inform the facility's Administrator right away because they initially thought the event was not credible, no other witnesses, and Certified Nursing Assistant #1 had verbal disputes with other staff members and was not a credible accusation. The Director of Nursing stated they discussed the allegation on 02/10/2026 at 11:00 AM with the Administrator who explained to them that event was alleged sexual abuse and should have been reported immediately to Administrator, New York State Department of Health, Attorney General, and police. During an interview on 02/25/26 at 4:30 PM Administrator stated the Director of Nursing informed them of the alleged sexual abuse on 02/10/2026 at around 11:00 AM. The Administrator stated they and the Director of Nursing are responsible for reporting the allegation of abuse to police and the Department of Health within two hours after the allegation was made. The Administrator stated they educated and disciplined the Director of Nursing on reporting any allegation of abuse immediately despite the evidence. 10 NYCRR 415.4(b)(2)

Based on record review, and interviews conducted during the abbreviated survey (#2622204), the facility did not ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involve abuse or result in serious bodily injury, or no 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 New York State Department of Health. This was evident for one (1) of one (1) (Resident #1) sampled. Specifically, Resident #1 had an unwitnessed incident on 09/06/2025 when they were observed on the floor and noted with swelling to the forehead, left peri-orbital (area around the eye) swelling and an abrasion on the nose. Resident #1 was unable to explain the occurrence and the incident was not reported to the New York State Department of Health.The findings are: The facility's policy titled 'Accident and Incident (A/I) Investigation and Reporting' last revised 12/04/2024 documented the facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established proceduresResident #1 had a diagnosis of Epilepsy and Alzheimer's Disease.The Comprehensive Care Plan titled 'Actual Falls/Accident/Incident' initiated on 10/01/2024 documented Resident #1 has a diagnosis of epilepsy. Interventions included to keep the bed in the lowest position and keep call bed within reach.The Registered Nurse Supervisor Progress Note dated 09/06/2025 documented the Registered Nurse responded to staff call on the floor and observed Resident #1 on the floor by the left side of the bed in left side position. Upon Registered Nurse's assessment, Resident #1 was unable to narrate incident due to cognitive impairment. Observed slight swelling of the forehead, left peri-orbital swelling and abrasion on the bridge of the nose. No change in mentation. Range of Motion intact to upper extremities and left lower extremity. Percocet administered routinely for pain management. Patient was assisted back to bed by 4 assist. Doctor notified with recommendation to transfer Resident #1 to the hospital.The Accident Investigation Report dated 09/06/2025 documented time of report at 4:30PM. Resident #1 was observed to be alert and verbally responsive, unable to explain incident, noted with slight swelling on forehead, left periorbital swelling and ecchymosis in addition to slight abrasion on the bridge of the nose. No change in mental status and no loss of consciousness observed. The plan included to transfer the resident to the hospital for CT scan of the face.There was no documented evidence the facility reported Resident #1's unwitnessed incident to the New York State Department of Health.On 10/31/2025 at 3:37 PM, the Director of Nursing [NAME] was interviewed and stated there was an unwitnessed event where Resident #1 was found on the floor on 09/06/2025, and as Resident #1 was found on the floor, it was attributed to a fall because there was no one else present in the room with Resident #1 at that time. The Director of Nursing also stated Resident #1 sustained an abrasion to the nose and was transferred to the hospital. The Director of Nursing Services further stated injuries of unknown origin are called in to the Department of Health, however, in this case, since there was no fracture, it was not a major injury which was reportable to the state.On 10/31/2025 at 3:42 PM, the Medical Doctor was interviewed and stated injuries with fractures and questionable abuse are reported to the Department of Health. The Medical Doctor also stated if a resident is seen on the floor, then it is assumed that they sustained a fall. The Medical Doctor further stated if a resident was seen lying on the bed with bruises, then that is a different scenario and would warrant a call to the Department of Health. On 11/03/2025 at 10:06 AM, the Administrator was interviewed and stated major injuries, suspected abuse, and injuries of unknown origin with major injury are reportable to the Department of Health. The Administrator also stated this incident was not reported to the state because it was attributed to a fall. The Administrator further stated Resident #1 has been at the facility a long time, has a history of falls, and has a room right by the nursing station with a roommate that was bedbound at the time the incident occurred. The Administrator stated the incident also occurred during daylight hours which all points to the fact that the injury was due to a fall, and at that time, Resident #1 also had a history of trying to walk when they were supposed to be non-weight bearing. The Administrator also stated while it was not a witnessed event, there were people around at that time, and since there was no major injury, the incident was attributed to a regular fall which was not reportable to the Department of Health. The Administrator further stated that they have no camera footage available from September 5th through September 11th as all the cameras on the floors were not working at that time. 10 NYCRR 415.4(b)(2)

Based on observations and staff interviews conducted during the Recertification survey, the facility did not ensure that each resident was treated with respect, dignity and care in a manner that promotes maintenance or enhancement of their quality of life and recognizes each resident's individuality. This was observed on five (5) out of five (5) units observed during the kitchen and Dining Observation Task. Specifically, the residents' meals were served on disposable dishware with plastic cutlery.The findings are: The facility policy titled Dining, with effective date January 3, 2024, stated food will be prepared and served in a manner that meets the individual needs of the resident. The facility policy titled Home Life, Safe, Clean and Comfortable Environment, reviewed October 15, 2024, stated it is the policy of the facility to provide a safe, clean, comfortable homelike environment in such a manner to acknowledge and respect resident rights to the extent possible. This includes but is not limited to residents will be provided with regular cutlery and dishes unless otherwise indicated. A list of residents who are to receive disposable plates and cutlery documented a total of 16 residents: 4 residents on Unit 1, 6 residents on Unit 2, 4 residents on Unit 3, 1 resident on Unit 4, and 1 resident on Unit 5.On 08/19/2025 at 12:08 PM and 08/20/2025 at 12:15PM, during lunch observation on Unit 2, with the exception of puree meals, all other residents' meals were observed served on Styrofoam plates. All residents were observed eating with plastic utensils. On 08/22/2025 at 3:50 PM, during a Kitchen Observation, all residents' trays were observed set up on tray trucks for the dinner meal. All trays were observed with plastic utensils. On 08/22/2025 at 4:00PM, an interview was conducted with the Food Service Director who stated the facility does not have any metal silverware, and they have never seen metal silverware in the facility since their hire in December 2024. The Food Service Director also stated they were told the metal silverware was used by residents with behavioral issues to potentially hurt each other, and other residents were hoarding the silverware. The Food Service Director further stated since their hire in December 2024, the facility has not had enough China plates because they were chipped, broken and hoarded by the residents and not replaced, so Styrofoam plates are used. The Food Service Director stated the facility should provide metal silverware and China plates to sustain or improve the resident's quality of life and that they have a list of the residents who should receive Styrofoam plates and plastic utensils for safety. Those resident's names are provided by nursing, and disposable silverware is documented on those meal tickets as they are the only residents who should be served Styrofoam plates and plastic utensils.On 08/25/2025 at 4:01 PM, an interview was conducted with the Administrator who stated there must have been a misunderstanding with the new Food Service Director regarding plates and flatware as not all residents should be eating on Styrofoam plates and using plastic utensils. The Administrator also stated there had been an issue with residents hoarding dishes and residents with behavioral issues were placed on a list not to receive metal utensils but other than that everyone else should have been served with regular plates and metal utensils. 10 NYCRR 415.5

Based on record review and interview conducted during the Recertification survey, the facility did not ensure that the resident's comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the episodic, comprehensive, and quarterly review assessments. This was evident for one resident (Resident #8) reviewed for Hospice and one resident (Resident #192) reviewed for Unnecessary Medications out of an investigative sample of 38 residents. Specifically, 1). The care plan related to Hospice for Resident #8 was last reviewed on 04/09/2025, and 2). Resident #192's care plan related to Cognitive loss was last reviewed on 01/03/2025, the care plan related to Social Isolation was last reviewed on 10/22/2024, and the care plan related to psychosocial well-being was last reviewed on 07/22/2024. The findings are: The facility policy and procedure titled Resident Care Planning, last revised on February 5, 2025, stated each resident will have an individualized, interdisciplinary plan of care in place per federal regulations. The comprehensive care plan will be reviewed and revised every quarter upon a significant change in condition, upon readmission from an inpatient hospital stay, and as required by the resident or resident representative. 1.Resident #8 was admitted with diagnoses that include Alzheimer's Disease and Hypertension The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #8's cognition was severely impaired, they never/rarely made decisions, and was on Hospice Care. The Medical Doctor's Order dated 09/29/2024 documented Hospice care. A comprehensive care plan related to Hospice Care was initiated for Resident #8 on 10/01/2024. There was no documented evidence that the care plan was reviewed and revised after the quarterly assessment on 06/27/2025. On 08/25/2025 at 2:28 PM, Registered Nurse #1, the supervisor, was interviewed and stated the hospice care plan was implemented on 10/01/2024 and was last updated on 04/09/2025. Registered Nurse #1 also stated care plans are updated every three months, and it is the Social Worker's responsibility to update the Hospice care plan and ensure that it is reviewed and revised every quarter. On 08/25/2025 at 3:21 PM, Social Worker #1 was interviewed and stated that they initiated the hospice care plan, and it is usually the Social Worker's responsibility to update the hospice care plan. Social Worker #1 also stated care plans are reviewed and revised every three months, and accordingly if there are changes. Social Worker #1 further stated revision of this care was due sometime in July, and they might have missed it. On 08/26/2025 at 8:24 AM, the Director of Nursing was interviewed and stated that care plans are reviewed and revised quarterly, annually, for significant changes, and at the start of medication. The Director of Nursing also stated the supervisors on the floor are required to renew the nursing aspect of the care plan, and each department is responsible for its care plan. The Director of Nursing further stated Social Services is supposed to renew the hospice care plan, and the director of each department is supposed to ensure the care plans are revised accordingly. 2. Resident #192 was admitted to the facility with diagnoses including Anxiety Disorder, Mood Disorder, Psychotic Disorder, and Vascular Dementia. The Minimum Data Set (a resident assessment tool) dated 03/20/2025 lists Resident #192's active diagnoses as Non-Alzheimer's Dementia, Depression, Psychotic Disorder, and Mood Disorder. Review of Resident #192's comprehensive plan of care revealed the Cognitive Skills for Daily Decision-Making care plan was last updated on 01/03/2025, the Mood State, the Psychosocial Well-being, and the Discharge Planning care plans were last reviewed on 07/22/2024, the Advance Directives care plan was last reviewed on 04/22/2024, and the Social Isolation/Loneliness Care Plan was last reviewed on 10/22/2024. On 08/25/2025 at 10:38 AM, Social Worker #1 was interviewed and stated they are responsible for updating all care plans related to psychosocial functioning every three months within one week of each resident's care plan meeting. Social Worker #1 also stated Resident #192 had care plan meetings on 01/03/2025, 03/27/2025 and 06/16/2025 but they were working alone as the only Social Worker in the building up until July 2025 and there were some things that just did not get done. Social Worker #1 further stated they are supervised by the Director Social Services, but that position had been vacant, and the new Director has only been here for a couple of months, so nobody noticed these care plans had not been revised. On 08/26/2025 at 2:20 PM, the Director Social Services was interviewed and stated that they began working in the facility in July 2025. The Director Social Services also stated that responsible staff know when to update care plans by following the Assessment Reference Dates on the Minimum Data Sets and that with appropriate time management, it should be possible to update the care plans even when working alone. The Director Social Services further stated that they are responsible for reviewing the care plans to make sure that those involving psychosocial issues are updated by the Social Worker and that they had not noticed that Resident #192's had not been recently updated. 10 NYCRR 415.11(c)(2)(i-iii)

Based on observation, record review, and interviews conducted during the Recertification survey, the facility did not ensure that medical records were maintained in accordance with accepted professional standards and practices and that they were complete and accurately documented for each resident. This was evident for one (Resident #57) of five residents reviewed for Unnecessary Medication and one (Resident #174) of five residents reviewed for Pressure Ulcer/Injury) out of 85 total sampled residents. Specifically, 1). A care plan for schizophrenia was documented for Resident #57 who does not have a schizophrenia diagnosis, and 2). The Treatment Administration Records for Resident #174 documented nursing staff performed wound care when Resident #174 refused to allow the facility staff to perform the treatments. The findings include: The facility policy and procedure titled Accurate Medical and Clinical Record Documentation, revised January 2025, stated it is the policy of the facility to provide accurate medical and clinical documentation. All facility staff who document in the medical record and/or clinical records will be responsible to ensure their documentation is accurate and dated correctly. All medical and nursing services provided should be accurately documented in the medical record by the individual providing services. Staff may only document services or tasks that they have personally provided for a Resident. Staff may only document the completion of medical or clinical services or tasks provided for the Resident. All services or tasks provided by staff should be verified by providing an electronic signature that the medical or clinical services were provided. 1). Resident #57 was admitted to the facility with diagnoses including Dementia and Schizophrenia. The admission Minimum Data Set assessment dated [DATE], documented that Resident #57 had moderately impaired cognition for daily decision making, had active diagnoses of non-Alzheimer's dementia and Schizophrenia and was administered antidepressant and antipsychotic medications. An admission Face sheet dated 04/28/2022, documented Resident #57 had diagnoses of Unspecified dementia and Psychotic disorder. A Psychiatric Initial Consultation Note dated 05/11/2022, documented Resident #57 had diagnoses which included Dementia, Depression and Adjustment disorder. A Physician Assessment Form/Progress Note dated 06/01/2022, documented Resident #57 with diagnoses of Dementia and Depression. The Quarterly Minimum Data Set assessment dated [DATE], documented Resident #57 had severely impaired cognition for daily decision making, had active diagnoses of non-Alzheimer's dementia with insomnia and was administered antidepressant medications. The Comprehensive Data Set assessment dated [DATE] documented Resident #57 had severely impaired cognition for daily decision making, had active diagnoses of Non-Alzheimer's dementia with insomnia, Depression and Psychotic Disorder (other than schizophrenia), and was administered antidepressant and antipsychotic medications. A Schizophrenia care plan with a creation and onset date of 08/18/2025, documented Resident #57 had a diagnosis of Schizophrenia as diagnosed by a qualified practitioner. A Psychotropic Medication Care Plan Note dated 07/17/2025 documented Resident #57 was seen by the in-house psychiatrist for follow up on current diagnoses of Dementia, Depression, and Psychotic disorder. On 08/25/2025 at 1:40 PM, an interview was conducted with the Director of Nursing who stated that an audit was performed for residents who had a diagnosis of schizophrenia. The audit was to ensure that schizophrenia care plans are in place and updated. The Director of Nursing also stated that Resident #57 came up on the list during the audit as having a diagnosis of Schizophrenia. The Director of Nursing further stated that Resident #57 was diagnosed with schizophrenia on 05/11/2022 at admission. The schizophrenia diagnosis was removed by the psychiatrist on 08/07/2023, but the Care Plan was added in error on 08/18/2025 following the audit.On 08/25/2025 at 1:53 PM, An interview was conducted with the Minimum Data System Coordinator who that Resident #57 was admitted in May 2022 with the antipsychotic medication Seroquel and once the diagnosis is in an MD progress note at admission the diagnosis of schizophrenia is added to the admission Minimum Data Set assessment. The Minimum Data System Coordinator also stated Resident #57 was found not to meet the criteria for the diagnosis in August 2022, and so the diagnosis was not carried over in the ongoing assessments. The Minimum Data System Coordinator further stated Resident #57 never had a schizophrenia care plan in the medical record until 08/18/2025. 2). Resident #174 was admitted to the facility with diagnoses including Peripheral Vascular Disease and three venous or arterial ulcers.The Quarterly Minimum Data Set assessment dated [DATE], documented Resident #174 had moderately impaired cognition for daily decision making, had active diagnoses of Peripheral Vascular Disease and one surgical wound. On 08/20/2025 at 12:46 PM, Resident #174 was observed with an ace wrap dressing to the left lower leg. A Wound Care plan with onset date of 02/16/2024 documented a skin graft failure/venous stasis ulcer to the left lower leg. A Waiver/Choice of Treatment Form dated 10/31/2024 documented Resident #174 refused weekly wound rounds by the physician and daily wound care. The Medication and Treatment Administration Records dated 07/01/2025 to 08/26/2025 documented check marks that the Left shin treatment: Cleanse left medial shin with normal saline, apply Calcium alginate with Medi honey and cover with a dry protective dressing was completed daily from 07/01/2025 -07/31/2025 and 08/01/2025 to 08/19/2025. On 08/20/2025 at 12:46 PM, Resident #174 was interviewed and stated they perform the dressing change to the left leg because they are not happy with the performance of the facility staff. On 08/22/2025 at 12:36 PM, Resident #174 refused left leg wound observation and dressing change by Registered Nurse #1. On 08/25/2025 at 3:36 PM, an interview was conducted with Registered Nurse #1, the nursing supervisor, who stated they review the residents' care plans and not the Medication and Treatment Administration Records. Registered Nurse #1 also stated the nursing staff is entering a checkmark in the Treatment Administration Records which indicates they have performed/completed the treatments. Registered Nurse #1 further stated Resident #174 performs their own wound treatment and in most cases the nurses have not observed the resident perform the treatment. On 08/25/2025 PM, an interview was conducted with the Director of Nursing who stated that the check mark entries in the Medication and Treatment Administration Record document the treatment has been completed. The Director of Nursing also stated Resident #174 refuses to allow staff to perform the treatment and the nursing staff sometimes observe the treatment being performed. The Director of Nursing further stated Resident #174 performs the treatment but the nurse documents that it is completed in the Treatment Administration Records. 10 NYCRR 415.22(a)(1-4)

Based on interviews, observations and record reviews conducted during a recertification survey, the facility did not ensure that a comprehensive care plan was developed within 7 days after completion of the comprehensive assessment. This was evident for one (Resident #192) of five residents sampled for Unnecessary Medications. Specifically, Resident #192 was taking medication for Gastrointestinal issues and there was no care plan in place. The findings are:The facility's policy and procedure entitled Resident Care Plans, last reviewed 02/05/2025, states that each resident will have an individualized interdisciplinary plan of care developed within 21 days of admission and reviewed and revised on a quarterly basis.Resident #192 was admitted to the facility with diagnoses including Vascular Dementia, Psychotic Disorder and Gastroesophageal Reflux Disease with Esophagitis.The Annual Minimum Data Set (a resident assessment tool) dated 03/20/2025 lists Resident #192's active diagnoses as Gastroesophageal Reflux Disease, Non-Alzheimer's Dementia, Depression and Psychotic Disorder. The Physician orders dated 08/12/2025 documented Resident #192 was prescribed Pantoprazole 40 mg once a day for Gastroesophageal Reflux Disease. There was no documented evidence a care plan was created for Resident #192 to address care of a resident with a diagnosis of Gastroesophageal Reflux Disease.On 08/25/2025 at 1:43 PM, Registered Nurse Supervisor #1 was interviewed and stated they usually enter the care plans into the electronic medical record, and a Gastrointestinal Status care plan had not been initiated for Resident #192. Registered Nurse Supervisor #1 also stated they were new to the facility and had not reviewed Resident #192's medical diagnoses when reviewing their care plans but had just followed what was in place before.On 08/26/2025 at 12:32 PM, the Director of Nursing was interviewed and stated upon admission, each resident's medications are reconciled with the physician, the nurse supervisor, the Minimum Data Set department and themself. The Director of Nursing also stated Resident #192 was taking Pantoprazole and therefore had symptomatic Gastroesophageal Reflux Disease, so a care plan for Gastrointestinal Status would be appropriate. The Director of Nursing further stated it was possible the care plan could have been discontinued for some reason, but it should have been included within Resident #193's comprehensive plan of care.10NYCRR 415.11(c)(2)(i-iii)

Based on observation, record review, and interviews conducted during the Recertification Survey from 08/19/2025 to 08/26/2025, the facility did not ensure that residents' right to a clean, comfortable, and homelike environment was maintained. This was evident on 3 units (Unit1, Unit 2, and Unit 4) out of 5 units observed during the Environmental Task. Specifically, 1). On Unit 1 doors to the foyer and utility room were observed with multiple large areas of chipped and scrapped paint. The wall of the pull station was observed with dried uneven plaster, and the first-floor conference room windowsills were observed with peeling tape and 1 ripped window shade. 2) On Unit 2, multiple resident rooms were observed with broken and or missing slats from vertical blinds. The ceiling in room [ROOM NUMBER] was observed brown stained with peeling paint and a cracked window. The Unit 2 Dining room contained 1 missing window covering and the adjacent wall was unevenly plastered and unpainted. 3) On Unit 4, room [ROOM NUMBER] was observed with missing slats on the vertical blinds, a dirty air conditioner grill was observed attached to the unit with paper tape, and television remote control did not work properly. The findings include but are not limited to: The facility policy titled Home Life: Safe, Clean, and Comfortable Environment reviewed October 15th, 2024, stated it is the policy of the facility to provide a safe, clean, comfortable homelike environment in such a manner to acknowledge and respect resident rights to the extent possible. This includes but is not limited to: ensuring the resident can receive care and services safely and the physical layout of the facility maximizes resident independence and does not pose a safety risk. Providing housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. During multiple observations from 08/19/2025 through 08/26/25, the following were observed: 1). In Unit 1, doors to the foyer and utility room were observed with multiple large areas of chipped and scraped paint. The wall next to the dining room was observed with uneven plaster around the pull station and adjacent door frame. The conference room windowsills were observed with peeling, dirty duct tape that was hanging, and a ripped window shade. On 08/26/2025 12:58 PM, the Environmental Director was interviewed and stated they do environmental rounds and every now and then they assign one of their staff to paint and plaster. The Director of Maintenance stated they are aware of the chipped paint and are thinking to put a vinyl covering on doors to prevent this. The pull station became loose and was plastered a week ago and it will be sanded down. The Director of Maintenance also stated they were unaware of the ripped shade and hanging duct tape in the conference room. 2). On 08/19/2025 at 11:16 AM, room [ROOM NUMBER] was observed with multiple missing slats from the vertical blinds. On 08/19/2025 at 11:16 AM, in room [ROOM NUMBER] the vertical blinds were observed with 11 out of 20 slats missing. On 08/20/2025 at 10:44 AM, the Unit 2 dining room window was observed missing a window covering and the adjacent wall was unevenly plastered and unpainted. On 08/21/2025 at 12:32 PM, room [ROOM NUMBER] was observed with multiple missing slats from the vertical blinds, and the vertical blinds in room [ROOM NUMBER] were observed with 9 out of 20 slats missing. On 08/21/2025 at 12:33 PM, in room [ROOM NUMBER] there was peeling paint, a cracked window and the ceiling above B bed was observed with brown stains. 3). On 08/19/2025 at 1:52 PM and on 08/21/2025 at 12:57 PM, room [ROOM NUMBER] was observed with missing slats on the vertical blinds, and an air conditioner grill that was dirty and attached to the unit with paper tape, and the television remote did not work properly. The Unit 4 Maintenance book documented the following for room [ROOM NUMBER]: 6/17/2025-TV, check table, 6/19/2025-blinds missing, 6/24/2025- Bed table + remote 7/27/2025-check A/C. On 08/21/2025 at 12:57 PM, the resident who resided in room [ROOM NUMBER] was interviewed and stated the issues continue to persist and they have complained to the staff several times and at times when staff comes to the room to make repairs, they state they will return but never return to make the repairs. On 08/25/2025 at 9:18 AM, observations of the rooms on Unit 2 and Unit 4 that were identified with environmental issues were conducted with the Environmental Director. The Environmental Director was then interviewed and stated the black stain on the ceiling in room [ROOM NUMBER] is moisture from the rain coming through the bricks which was previously painted and plastered but they had no documentation of the repair. The Environmental Director also stated they were unaware of the cracked window in room [ROOM NUMBER] and they and the maintenance and housekeeping staff perform rounds in every room daily and they must have missed the needed window repair. The Environmental Director further stated the multiple missing vertical blind slats in residents' rooms is unacceptable, however the residents pull the slats out individually and they have to be replaced. On 08/25/2025 at 9:34 AM, an observation of room [ROOM NUMBER] was performed with the Environmental Director. The Environmental Director was then interviewed and stated that they knew the air conditioner grill in room [ROOM NUMBER] was held up with tape but they are ordering new grills and are working on replacing the cracked and missing vertical blinds slats. On 08/25/2025 at 4:01 PM, an interview was conducted with the Administrator who stated that they make rounds regularly and did not notice the missing vertical blinds were a trend but when they have noticed the missing blinds and other issues maintenance was contacted immediately to make repairs. 10 NYCRR 415.5(h)(2)

Based on observation, record review, and interviews conducted during an Abbreviated Survey (NY00344413 and NY00376155), the facility failed to report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This was evident in two (2) out of seven (7) residents (Resident #3 and #5) sampled. Specifically, on 05/30/2025 at 9:30 AM, Resident #3 was escorted by Certified Nursing Assistant #6 for clinic appointment and Resident #3 had an accident by sliding off from wheelchair in the vehicle. Certified Nursing Assistant #6 did not report the incident to anyone at the facility. On 05/31/2025 at 11:35 AM, Resident #3 told Registered Nurse Supervisor #1 on 05/30/2024 an incident occurred while being transported to an appointment. Registered Nurse Supervisor #1 assessed Resident #3 and there were no signs of injuries. On 06/02/2025 at 11:00 AM, Resident #3 went out on pass with family and returned to the facility at 9:20 PM. On 06/03/2024 at 1:27 PM, Resident #3 complaint of burning and tingling to their left leg and foot. In the Nurse Practitioner notes dated 06/04/2024 at 1:02 PM, documented Resident #3 was observed with bilateral knee bruises and redness. An x-ray of the right and left knee was ordered, and the result was received at approximately 10:10 PM which documented Resident #3 had an acute fracture of both knees and osteopenia. Resident #3 was transferred to the hospital. The facility did not report timely to the New York State Department of Health and did not submit the follow up investigation within five days. On 03/24/2025 at 7:30 PM, Resident # 5's Residential Case Manager visited the facility and informed Registered Nurse Supervisor #2 that Resident #5 alleged they were abused and attacked by multiple staff members. The facility investigated and reported the incident to New York State Department of Health on 03/25/2025 at 6:09 PM, and did not report the allegation to local law enforcement. The findings are: The facility's policy and procedure titled Abuse Prevention dated 10/03/2023, documented that all findings of investigations will be documented. An investigative report will be completed within 5 days and summarize the findings and outcome as well as any corrective action(s). If abuse cannot be ruled out the New York State Department of Health will be notified. Resident #3 was admitted to the facility with diagnoses including morbid obesity, spina bifida (a congenital defect of the spine in which part of the spinal cord is exposed through a gap in the backbone, often causing paralysis of the lower limbs). The Minimum Data Set (an assessment tool) dated 03/02/2024, documented Resident #3 was assessed with intact cognition. The facility Summary of Investigation dated 06/06/2024, documented Resident #3 reported to Registered Nurse Supervisor #1 on 05/31/2024 at 11:35 AM that on 05/30/2024 during their transport to their appointment, the driver suddenly stopped, and Resident #3 moved forward in their wheelchair but did not fall. Resident #3 was assessed by Registered Nurse Supervisor #1 on 05/31/2024 there were no injuries. Resident #3 denied pain. Certified Nursing Assistant #6 was interviewed, and they stated Resident #3 slid slightly forward in their wheelchair and was repositioned. Resident #3 did not fall. On 06/04/2024, Resident #3 was observed with bilateral knee redness, and swelling of lower extremities. An x-ray was ordered on bilateral knee and left leg. The x-ray result of left and right knee revealed acute fracture and osteopenia. The facility's investigation concluded that there was no abuse or neglect occurred. The incident was reported to the New York State Department of Health on 06/05/2024 at 2:19 PM. There was no documented follow up report submitted to New York State Department of Health within five (5) days. Resident #5 was admitted to the facility with diagnosis including thyroid disorder, bipolar and depression. The Minimum Data Set (an assessment tool) dated 01/16/2025, documented Resident #5 had intact cognition. In a Nursing Note dated 03/24/2025 at 8:24 PM, Registered Nurse Supervisor #2 documented at approximately 8:00 PM, they responded to Resident #5 's unit to speak with Resident #5's Residential case manager. Resident #5's Residential case manager informed Registered Nurse Supervisor #2 that they received a call from Resident #5 stating that they were attacked by two (2) Certified Nursing Assistants in their room and as a result, they sustained scratch marks to their right cheek. Registered Nurse Supervisor #2 reassessed Resident #5 and observed some scratch mark on their right cheek. The Facility Summary of Investigation dated 03/26/2025 documented Resident #5 had behavior of fabricating stories being accusatory towards staff and peers. Investigation summary further documented Resident #5's allegation could not be substantiated due to inconsistencies in interviews and the alleged incident was not in areas of surveillance footage. A Webform Submission from the Nursing Home Facility Incident Report showed that the facility submitted their incident report to New York State Department of Health on 03/25/2025 at 6:09 PM. During an interview on 06/04/2025 at 1:20 PM, the Director of Nursing stated they were involved in the investigation, but it was the previous Director of Nursing who does the reporting and submission of five (5) day report to the New York State Department of Health. The Director of Nursing stated they were not aware that the follow up investigation of incident dated 05/31/2024 was not submitted to New York State Department of Health within 5 days. During an interview on 06/04/2025 at 3:40 PM, the Administrator stated they were not aware that the five (5) day report was not submitted to New York Stated Department of Health. The Administrator stated that the completed investigation should have been submitted to the Department of Health within 5 business days. During an interview on 06/05/2025 at 12:25 PM, Registered Nurse Supervisor #2 stated on 03/24/2025 at 8:00 PM they met with Resident #5's Residential Case Manager on the unit and they reported to Registered Nurse Supervisor #2 that Resident #5 told them they were attacked by two (2) Certified Nursing Assistants in their room and sustained a scratch mark on their right cheek. Registered Nurse Supervisor #2 stated the Director of Nursing, and the Medical Doctor were informed that same night on 03/24/2025, they can't recall the time. During an interview on 06/11/25 at 2:03 PM, the Director of Nursing stated on 03/24/2025 at approximately 8:15 PM, they received a call from Registered Nurse Supervisor #2 stating that Resident #5's Residential Case Manager reported that Resident #5 told them that they were attacked by staff. The Director of Nursing stated at approximately 8:20 PM, they called the Administrator and informed them of the information provided by Registered Nurse Supervisor #2 and based on their conversation they agreed to further investigate the concern in the morning because Resident #5 has history of fabricating stories. The Director of Nursing stated after they and the Administrator reviewed the surveillance footage on 03/25/2025 and interviewed Resident #5 and other staff members, they reported the allegation of abuse to the Department of Health. The Director of Nursing stated they are aware that any allegation of abuse should be reported to the Department of Health within 2 hours, however they and the Administrator agreed to review the surveillance video footage before reporting to the New York State Department of Health. The Director of Nursing stated that the local law enforcement was not contacted. During an interview on 06/06/2025 at 12:20 PM, the Administrator stated they received a call from the Director of Nursing on 03/24/2025 at approximately 8:00 PM that Resident #5 had an aggressive behavior with a staff. The Administrator acknowledged that the Department of Health was informed on 03/25/2025. 10 NYCRR 415.4 (b)(1)(ii)

Based on observation, interviews, and record review conducted during the recertification survey from 6/13/23 through 6/21/23, the facility did not ensure that food was prepared, distributed, and served in accordance with professional standards for food service safety. This was evident during the Kitchen facility task. Specifically, 2 cold sandwiches were not held at a safe temperature of 41 F or below. The findings are: A undated facility policy titled Food Temperatures documented cold foods are kept refrigerated and are taken out in small batches to maintain a temperature of 40 degrees Fahrenheit or lower during meal service. Daily temperatures are recorded at meals to ensure proper procedure is being followed. On 6/20/23 at 10:53 AM, lunch meal service was being observed in the Kitchen and a dietary aide was observed making cold sandwiches and placing them in the refrigerator. On 6/20/23 at 11:07 AM, dietary staff were observed taking the prepared cold sandwiches out of the refrigerator. The cold sandwiches were lying on a pan of ice. Staff began placing the cold sandwiches onto residnt trays. The temperature of 2 random sample sandwiches (1 turkey and 1 tuna) were taken and both sandwiches were at 65 F. On 06/20/23 at 11:10 am, the Food Service Director (FSD) was interviewed and stated they do not typically check the temperature of the sandwiches. The sandwiches are usually made before 9:30 AM. The FSD did not know why the dietary aide was still making sandwiches so late. 415.14

Based on observations, interviews, and record review conducted during the recertification survey from 6/13/23 to 6/21/23, the facility did not ensure residents received notices orally and in writing with the list of names and addresses of the State regulatory agencies, resident advocacy groups, and Ombudsman information. This was evident for 6 (Resident #s 133, 113, 64, 30, 96, 109) of 8 residents in attendance at Residnt Council out of 30 total sampled residents. Specifically, Resident #s 133, 113, 64, 30, 96, and 109 stated they were not aware of their rights and were not provided with contact information for State agencies and advocates. The findings are: The facility policy titled Resident Rights dated 1/23 did not document the method or procedure of informing and educating residents of their rights. On 6/16/23 at 11:01 AM, Resident Council Meeting was held with 8 residents in attendance. The Council was asked whether their resident rights had been reviewed with them and provided to them in a format an language they can understand. There were 6 (Resident #s 133, 113, 30, 109, and 96) of the 8 residents that stated they did not recall being educated about their resident rights and were not provided with the contact information for State agencies of the Ombudsman. There was no documented evidence Resident #64 was provided with an Admission Agreement with the resident's rights included. The facility Admission Agreement sample documented a section for your Rights and Protection as a Nursing Home Resident. The Admission Agreement did not contain written information related to State agency contact numbers and the Ombudsman contact information. An Admission Agreement dated 7/23/12 documented Resident #30's signature with a [NAME] of Rights included and no contact information for State agencies or the Ombudsman. - signed and bill of rights included. An Admission Agreement dated 12/7/21 did not document Resident #96's or a designated representative's signature confirming receipt of the Admission Agreement. An Admission Agreement dated 2/17/21 documented Resident #109's signature with a [NAME] of Rights included and no contact information for State agencies or the Ombudsman. - signed and bill of rights included. An Admission Agreement dated 3/24/21 documented Resident #113's signature with a [NAME] of Rights included and no contact information for State agencies or the Ombudsman. - signed and bill of rights included. An Admission Agreement dated 11/4/22 documented Resident #133's signature with a [NAME] of Rights included and no contact information for State agencies or the Ombudsman. - signed and bill of rights included. Resident Council Meeting Minutes dated 3/6/23, 4/3/23, 5/3/23, and 6/5/23 were reviewed with no mention of educating or informing residents of their rights as a resident of a facility. On 06/16/23 at 12:10 PM and 06/21/23 at 02:20 PM, the Admission Director (AD) was interviewed and stated the only patient [NAME] of Rights they are of is in the Admission Agreement that is provided to a resident when they are admitted to the facility. The Administrator compiled the Admission Agreement. There have been changes to the Admission Agreement over the years and the patient [NAME] of Rights was revised 7/29/2020. On 06/21/23 at 12:06 PM, the Director of Social Work (DSW) was interviewed and stated Administration determined the appropriateness of documents provided to residents in their Admission package upon admission. The DSW reviewed the Your Rights and Protection as a Nursing Home Resident and they are the correct version of resident rights for nursing home residents. Admissions reviews the admission package with the residents. During the admission assessment, the Social Worker (SW) verbally tells the resident about their rights. Recreation reviews the resident rights at resident council meetings. The residents are informed of their rights upon admission and they are told that the rights are posted on each floor. The DSW would have to check with recreation to find out when they last reviewed resident rights at resident council. The residents do not sign that their rights were reviewed with them except upon admission. Resident rights are only verbally discuss with them. The DSW was not sure if the resident rights were available in multiple languages. The DSW stated the resident rights are only available in English. On 06/21/23 at 03:23 PM, the Administrator was interviewed and stated they were responsible for putting together the Admission Agreements. The version of Your Rights and Protection as a Nursing Home Resident is a version the facility determined was appropriate and the Administrator was unable to recall how the facility came across the current version of resident rights they use in their Admission Agreement but believes they were given to the facility by another facility. The admission package was updated 7/2020 but the Administrator was unable to say when the resident rights section was updated. If the resident does not speak English, a translator will be used to interpret the Admission Agreement and the facility only uses a English version for resident to sign. If there is a change in resident rights, this is discussed during resident council meeting. Residents do not get regular reeducation of their resident rights they do not receive it in writing. The resident bill of Rights should be posted on every unit. 415.3

Based on observation, interviews, and record review conducted during the recertification survey from 6/13/23 to 6/21/23 the facility did not ensure a resident was provided with respiratory care in accordance with professional standards of practice. This was evident for 1 (Resident #149) of 30 total sampled residents. Specifically, Resident #149 was ordered to receive oxygen via nasal canula and was observed with a oxygen face mask and received no oxygen saturation monitored. The findings are: The facility policy titled Respiratory Therapy and Evaluation dated 4/2014 documented the resident's respiratory status will be monitored pre and post therapy and documented in the medical record. The nurse will notify the primary medical doctor regarding any unstable resident conditions and follow up as directed. Resident #149 had diagnoses of hydrocephalus, shortness of breath and intracerebral hemorrhage. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #149 was severely cognitively impaired and did not have shortness of breath. On 06/14/23 at 01:30 PM, Resident #149 was observed lying in bed with oxygen flowing from an oxygen concentrator at 3 Liters Per Minute (LPM) to the resident via tubing and a full facemask. On 06/14/23 at 11:48 AM, Resident #149 was observed in a recliner in the floor dayroom without oxygen in place. On 06/14/23 at 01:33 PM, Resident #149 was observed in recliner in the hallway with no oxygen in place. On 06/15/23 at 12:24 PM, Resident #149 was observed lying in bed with the oxygen full facemask pulled down under their chin and oxygen flowing at 2 LPM. On 06/20/23 at 12:46 PM, Resident #149 was observed in a recliner in their room. Licensed Practical Nurse was administering a supplement to the Resident #149 via their feeding tube. Resident #149 was receiving oxygen via a full facemask at 2 LPM. The Medical Doctor Orders (MDO) dated 5/19/23 documented Resident #149 was to receive oxygen at 2 LPM via nasal canula every shift. There was no MDO for oxygen saturation monitoring. Treatment Administration Record (TAR) for June 2023 documented Resident #149 had oxygen tubing changed weekly and received oxygen via nasal canula per shift. There was no documented evidence a CCP related to respiratory therapy of oxygen use was developed for Resident #149. There was no documented evidence oxygen saturation monitoring was done since Resident #149's admission to the facility on [DATE] until 6/20/23. On 06/20/23 at 02:40 PM, the Licensed Practical Nurse (LPN) #4 was interviewed and stated they take Resident #149's vitals every morning. If the oxygen saturation drops below 90, then Resident #149 will be provided with oxygen therapy. When medications are given to Resident #149, their oxygen saturation is assessed while oxygen therapy is ongoing. Resident #149 frequently removes the oxygen mask. Every nurse is responsible for checking the settings for the flow rate of the oxygen to ensure the LPM are according to MDO. Sometimes patients play with oxygen concentrator and the flow rate gets turned up or down inadvertently. The face mask and the nasal canula are interchangeable. Resident #149 might have a face mask instead of nasal canula because the nasal canula may have gotten dirty. The resident did not have a face mask on this morning when I rounded. Unless the MDO says as needed, the oxygen should be provided continuously. Resident #149 had a standing order for continuous oxygen. Regardless of oxygen saturation, the resident should be getting oxygen. The only thing I can think of is that the nasal canula got dirty or something happened to it so we replaced the face mask. If the Medical Doctor (MD) does not specify parameters, the basic protocol is to call the MD if below 90. On 06/20/23 at 03:08 PM, Registered Nurse (RN) #3 was interviewed and stated Resident #149 was admitted from the hospital on oxygen therapy. There is no reason the Resident #149 should have a face mask instead of nasal canula when the MDO says nasal canula. Resident #149 is ordered to receive oxygen continuously. Oxygen saturation is to be taken every shift depending on what the MDO says. If the oxygen saturation is improving, then the MD is made aware. If the oxygen saturation is below 90 then the MD should be contacted. Oxygen saturation is taken with the vital signs. Resident #149 does not have a MDO in place to monitor their oxygen saturation. If the MD does not write the oxygen sat monitoring MDO, the nurse still checks the vital signs as part of the protocol. Even with that, the MD needs to order the parameters. On 06/21/23 at 02:39 PM, the Director of Nursing (DNS) was interviewed and stated when a resident is admitted on oxygen, the nurse obtains the oxygen, transcribes the order, and the MD signs. The MD reviews the transcribed order to determine if adequate and changes may be needed. Oxygen was given to Resident #149 as a comfort measure. The DNS stated that when they have observed Resident #149, the resident appear short of breath. Acceptable oxygen saturation would be 92 and above. This would be determined upon assessment by the nurse or MD. If their oxygen saturation is high then the nurse may tell the MD and the oxygen maybe changed to as needed. The oxygen saturation is taken with the vitals upon admission for at least for 3 days. The MD order states oxygen via nasal canula In an emergency situation, staff can use the face mask instead of nasal canula. If the oxygen saturation is below 90, the MD should be contacted. It should be in the facility policy. This applies to every resident. oxygen saturation should be read for Resident #149 every shift. The facility policy does not require the nurses to take oxygen saturation readings for residents who are on oxygen. An MD order would communicate to the nurse the frequency and parameters of treatment. On 06/20/23 at 01:03 PM, the MD #2 was interviewed and stated Resident #149 uses oxygen to keep their oxygen saturation at 90-92. There is no need for face mask. Nasal canula would be better. Resident #149 is supposed to be receiving oxygen as needed but MD #2 stated they did not pay attention to how the MDO was written. Any oxygen saturation over 90 is okay. Oxygen saturation monitoring is automatic from admission. MS #2 does not need to write orders for monitoring. Resident #149 is not on oxygen saturation monitoring. MD #2 checks the nursing notes for oxygen saturation readings. Nursing should know if the oxygen saturation falls below 90, they call the MD. The general practice us that if oxygen saturation is high enough, then possibly no oxygen is needed. MD #2 will tell the nurses to check the oxygen saturation. 415.12(k)(6)

Based on observation, interview, and record review conducted during the recertification survey from 6/13/23 to 6/21/23, the facility did not ensure a resident received treatment and care in accordance with professional standards of practice. This was evident for 1 (Resident #123) of 30 total sampled residents. Specifically, Resident #123 was delayed in receiving an appointment to be seen by the neurologist. The findings are: The facility policy titled Communication with Physician Consultants dated 7/22/01 documented timely discussion between a resident's primary care physician and the consultant are important. Consultation sheets are to be given to the nursing office who will schedule appointments. Resident #123 was admitted to the facility 12/20/22 with diagnoses of anxiety disorder and schizophrenia. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #123 was cognitively intact, did not exhibit behavior, had trouble sleeping and disrupted appetite, and received antipsychotic medications 7 out of 7 days prior to the assessment. On 06/14/23 at 01:45 PM, Resident #123 was interviewed and stated they have a right hand tremor that began after being admitted to the facility from a psychiatric hospital on psychotropic medication. Resident #123 requested to see the neurologist over a month ago and stated the tremor is uncomfortable. Resident #123 stated no one followed up with them about scheduling a neurology consult. A Notice of PASARR Level II Outcome dated 11/24/22 documented Resident #123 will need to be provided with a neurology consult to evaluate cognition due to the diagnosis of dementia. Physician Orders renewed 5/23/23 documented Resident #123 received Donepezil 10mg daily for Alzheimer's dementia, Zyprexa 10mg at bedtime and 5 mg daily (12/21/22). Psychiatry consult as needed. No order for Neurology consult was documented. Comprehensive Care Plan (CCP) related to psychotropic drug use initiated 12/21/22 documented Resident #123 has a diagnosis of schizophrenia, receives antipsychotic medication, and should be observed for signs of inventory movement. The CCP was updated 5/11/23 with the Psychiatrist recommendation for Resident #123 to have Melatonin. NP Note dated 2/17/23 documented Resident #123 was exhibiting right hand tremor and psychiatry consult will be placed. Tremor also documented 3/29/23, 3/15/23, 4/25/23, Psychiatry consult dated 3/17/23 and 5/10/23 documented Resident #123 reported feeling better. The Psychiatrist documented Resident #123 did not display akathesia, Parkinson, or tardive dyskinesia. There was no documentation referencing NP recommendation for medication review or resident's right hand tremors. NP note dated 5/1/23, 5/16/23, 5/24/23 and 6/7/23 documented Resident #123 had a right arm resting tremor with no evidence of metabolic changes and no dyskinesia. Resident #123 was on multiple medications that may cause Parkinson/tremors. Psychiatry consult ordered to reduce medication however no recommendation for dose decrease or alternative made. Neurology consult placed. A Neurology Consult form dated 4/25/23 documented Resident #123 was referred to the neurology clinic and had an appointment schedule for 12/4/23 at 10:45 AM. There was no documented evidence a neurology consult was obtained within timely manner for Resident #123's right hand tremors. On 06/20/23 at 02:59 PM, the Registered Nurse (RN) #3 was interviewed and stated there was no Medical Doctor Order for Resident #123 to have a neurology consult. It takes a long time for the Nursing Secretary to schedule clinic appointments. The RN gets alerted to orders for consults when the Medical Doctor (MD) writes an order and it is flagged to be cosigned. Then the RN prints out the consult and send it to the Nursing Secretary to make the appointment and arrangements. Sometimes the MD might write the note and forget to write the order. RN #3 was unable to find a consult request for Resident #123 to have a neurology consult and was unaware Resident #123 was referred for a neurology consult. The resident has been having right hand tremors. On 06/21/23 at 02:27 PM, the Nursing Secretary was interviewed and stated they referred Resident #123 for a neurology consult on 4/25/23. When the Nursing Secretary requested an appointment, they were originally told there were no appointments at all for Resident #123 to see the neurologist. The neurology clinic found another location and, a few weeks ago, was able to get Residnt #123 an appointment 12/4/2023. The Nursing Secretary is uncertain who requested for Resident #123 to use an outside clinic. On 06/20/23 at 11:50 AM, the NP was interviewed and stated they did not see a recommendation for Resident #123 to have a neurology consult in their admission level II referral. Resident #123 was referred to Psychiatry to evaluate their medication regime since Zyprexa can cause tremors. The NP then reviewed the Psychiatrist consult that recommended to continue with medications and then decided to order the neurology consult. Resident #123 has an appointment to see the neurologist in December 2023. NPO stated that wither they or the Nursing Secretary will attempt to get Resident #123 a sooner appointment. Residnt #123 did discuss the discomfort and concern with right hand tremors. This is not acceptable time for a resident to wait for specialist referrals. On 06/21/23 at 12:45 PM, the Medical Doctor (MD) was interviewed and stated they do not recall a recommendation from admission that Resident #123 see the neurologist. Resident #123 began to show right hand tremors in March/[DATE]. Because the tremor was not deemed to be an acute life threatening condition, the psychiatrist was asked to give their advice whether a reduction of antipsychotic medication would be indicated. The outcome was that it was not indicated. The MD does not recall speaking with the psychiatrist about their recommendation. Neurology consult was then recommended. This is to see if any medication could be causing the tremor and if they can be reduced. The expectation is that the consult would be obtained. It is disappointing that Resident #123 is scheduled for a neurology appointment 6-7 months out. On 06/21/23 at 03:00 PM, the Director of Nursing (DNS) was interviewed and stated resident should not have to wait extensive periods of time for outside clinic appointments. The NP recommended for Resident #123 to see a specific Neurology Clinic. The DNS was unable to say what specialty within neurology and was unable to give a reason the resident was referred for neurology consult with an outside clinic. The DNS then stated the facility has a in-house neurologist that would be able to see Resident #123 within 2 weeks of a referral for evaluation. The DNS stated they are going to determine whether Resident #123 can be seen by the facility's neurologist. 415.12

Based on observation, interviews, and record review conducted during the recertification survey from 6/13/23 through 6/21/23, the facility did not ensure the comprehensive care plans (CCP) were reviewed and revised after each assessment. This was evident for 2 of 2 residents (#101 and #21) reviewed for Nutrition out of 30 total sampled residents. Specifically, 1) the CCP related to oral care/dental and cancer for Resident #101 were not reviewed upon significant change assessment, and 2) the CCP related to diabetes mellitus (DM) was not reviewed or reviewed or revised upon change in the resident's medication regime. The findings are: A facility policy titled Comprehensive Assessment and Care Planning dated 5/9/21 documented the resident is assessed in keeping with regulatory requirements, and when the resident/patient's physical, psychosocial, functional, or nutritional status significantly changes. The Interdisciplinary Team (IDT) updates the CCP for readmissions, hospital returns, and episodic events. 1. Resident #101 had a diagnoses of Basal cell carcinoma and thrombocytopenia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] and significant change MDS dated [DATE] documented Resident #101 was severely cognitively impaired with likely cavities of broke natural teeth. The CCP related to Oral Care/Dental initiated 3/20/20 was last reviewed 3/23/23, Resident #101 had a likely cavity or broken natural teeth and was at risk for decline related to cognitive deficit. The CCP related to Cancer (Basal cell carcinoma of Resident #101's left cheek) initiated 5/19/21, was last reviewed 3/23/23, and documented a goal that resident will be able to express fears/concerns surrounding the cancer diagnosis. There was no documented evidence the CCPs related to oral/dental and cancer were reviewed and revised upon each MDS assessment. On 6/20/23 at 9:53 AM, the Registered Nurse (RN) #2 was interviewed and states the RN is responsible for completing, updating, and initiating the CCPs. The RN assesses the resident and devises the CCP. CCPs are updated every quarterly and if there is any change in condition. RN #2 stated they update the CCPs every time an MDS is done. On 6/20/23 at 10:02 AM, the MDSC was interviewed and stated initiating CCPs is done by RNs. The review and revision is based on the changes in the resident condition and on a quarterly basis based on the dashboard on the electronic medical record. The MDSC stated updating care plans does not have anything to do with the MDS schedule. CCPs are updated based on the date of the target goals. The MDSC checks to make sure CCPs are updated and current when they complete the MDS. CCPs are expected to be updated upon a resident's readmission. After reviewing Resident #101's CCPs related to cancer and oral/dental status, the MDSC stated the CCPs should have been reviewed and revised when Resident #101 was readmitted to the hospital and upon significant change. 45988 Resident #21 had diagnoses of non-Alzheimer's dementia and DM. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #21 was cognitively intact and received insulin injections 5 of 7 days prior to the assessment. A physician's order dated 4/21/23 documented Resident #21 was ordered 4 units of Lantus 100 units/ml subcutaneously every night for DM. On 6/8/23, the Lantus insulin was discontinued and Resident #21 was started on Farxiga 5 mg daily for DM. The Medication Administration Record (MAR) for June 2023 documented Resident #21 received DM medications according to physician's order. A physician's note dated 6/8/23 documented Lantus was to be discontinued and Farxiga started at 5mg by mouth daily. The CCP related to Diabetes Mellitus initiated 2/1/22 documented Resident #21 was receiving Lantus insulin. The CCP was last updated on 3/2/23. There was no documented evidence the CCP related to Resident #21's DM diagnosis was reviewed and revised upon MDS assessment and change in DM medication. On 06/21/23 at 11:49 AM, Registered Nurse (RN) #1 was interviewed and stated they are still learning the computer system for medical record documentation. CCPs are initiated by RNs on admission according to diagnosis, behaviors, and medications. CCPs are revised every 90 days and if there is a change in a medication. The CCP related to DM should have been updated for Resident #21 because they are not on insulin anymore. If a resident's insulin is discontinued and switched to oral medications, the CCP should be updated. On 6/20/23 at 3:21 PM and 06/21/23 at 1:26 PM, the Director of Nursing (DNS) was interviewed and stated Resident #21's CCP related to DM should have been updated to reflect the change in their medication. It seems there was a miscommunication between the doctor, the nurse, and the RN Manager. The facility increased their RN Managers and hired new staff and they are behind on CCP updates but are catching up now. The RN Managers do the CCPs which are updated with a change of condition/acute issue, significant change, readmission, and with the MDS schedule. CCPs are audited via a list from MDS of outstanding CCPs or anything that needs to be updated. The DNS stated the MDSC would not update the care plan unless there is a change. An interview was conducted on 6/20/23 at 3:39 pm with the Administrator who stated that they were not aware of a larger issue with CCPs and the facility has been working on making sure that CCPs are up to date. 415.11(c)(2) (i-iii)

Based on observation, interviews, and record review conducted during the recertification survey from 6/13/23 to 6/21/23 the facility did not ensure a Comprehensive Care Plan (CCP) was developed and implemented to address resident needs. This was evident for 1 (Resident #149) of 30 total sampled residents. Specifically, a CCP related to oxygen use was not developed and implemented for Resident #149. The findings are: The facility policy titled Respiratory Therapy and Evaluation dated 4/2014 documented the resident's respiratory status will be monitored pre and post therapy and documented in the medical record. The nurse will notify the primary medical doctor regarding any unstable resident conditions and follow up as directed. Resident #149 had diagnoses of hydrocephalus, shortness of breath and intracerebral hemorrhage. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #149 was severely cognitively impaired and did not have shortness of breath. On 06/14/23 at 01:30 PM, Resident #149 was observed lying in bed with oxygen flowing from an oxygen concentrator at 3 Liters Per Minute (LPM) to the resident via tubing and a full facemask. On 06/14/23 at 11:48 AM, Resident #149 was observed in a recliner in the floor dayroom without oxygen in place. On 06/14/23 at 01:33 PM, Resident #149 was observed in recliner in the hallway with no oxygen in place. On 06/15/23 at 12:24 PM, Resident #149 was observed lying in bed with the oxygen full facemask pulled down under their chin and oxygen flowing at 2 LPM. On 06/20/23 at 12:46 PM, Resident #149 was observed in a recliner in their room. Licensed Practical Nurse was administering a supplement to the Resident #149 via their feeding tube. Resident #149 was receiving oxygen via a full facemask at 2 LPM. The Medical Doctor Orders (MDO) dated 5/19/23 documented Resident #149 was to receive oxygen at 2 LPM via nasal canula every shift. There was no MDO for oxygen saturation monitoring. Treatment Administration Record (TAR) for June 2023 documented Resident #149 had oxygen tubing changed weekly and received oxygen via nasal canula per shift. There was no documented evidence a CCP related to oxygen use was developed and implemented for Resident #149. On 06/20/23 at 03:08 PM, Registered Nurse (RN) #3 was interviewed and stated RN #3 is responsible for completing the CCPs for the residents on the unit. After checking Resident #149's CCPs, RN #3 stated there is no CCP related to respiratory therapy or oxygen care. RN #3 missed the CCP by mistake. RN #3 did not admit Resident #149 from the hospital but subsequent RNs should pick up that a resident is missing a CCP even if the admission nurse misses one. When the resident is admitted , the RN does the initial baseline care plan. Then the RN will initiate the longer term CCPs. 415.11(c)(1)

Based on observation, interviews, and record review conducted the recertification survey from 6/13/23 to 6/21/23, the facility did not ensure incorporate the recommendations from the Pre-Admission Screening and Resident Review) PASARR level II determination into the resident's assessment, care planning, and transitions of care. This was evident for 1 (Resident #123) of 30 total sampled residents. Specifically, The facility did not obtain a neurology consult for Resident #123 after the resident was admitted with a PASARR level II recommendation for a neurology consult. The findings are: The facility policy titled SCREEN dated 2/20 documented the Social Worker (SW) will make sure that the PASARR recommendation are incorporated in the resident's care plan. Resident #123 was admitted [DATE] with diagnoses of anxiety disorder and schizophrenia. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #123 was cognitively intact and received antipsychotic 7 out of 7 days prior to the assessment. On 06/14/23 at 01:45 PM, Resident #123 was interviewed and stated they were having right hand tremors that started upon their admission to the facility. Resident #123 stated they were recently hospitalized in a psychiatric facility, is receiving psychotropic medication, and requested to see the neurologist over a month ago. A Notice of PASRR Level II Outcome dated 11/24/22 documented Resident #123 will need to be provided with a neurology consult to evaluate cognition due to the diagnosis of dementia. Physician Orders renewed 5/23/23 documented Resident #123 received Donepezil 10mg daily for Alzheimer's dementia, Zyprexa 10mg at bedtime and 5 mg daily (12/21/22). Psychiatry consult as needed. No order for Neurology consult. NP note dated 5/1/23, 5/16/23, 5/24/23 and 6/7/23 documented Resident #123 had a right arm resting tremor with no evidence of metabolic changes and no dyskinesia. On multiple medications that may cause Parkinson/tremors. Psychiatry consult ordered to reduce medication however no recommendation for dose decrease or alternative made. Neurology consult placed. NP Note dated 2/17/23 documented Resident #123 was exhibiting right hand tremor and psychiatry consult will be placed. The NP Note also documented Resident #123 exhibited right hand tremor on 3/29/23, 3/15/23, 4/25/23. A Neurology Consult form dated 4/25/23 documented Resident #123 was referred to the neurology clinic and had an appointment schedule for 12/4/23 at 10:45 AM. There was no documented evidence the facility followed the PASARR level II recommendation for Resident #123 to have a neurology consult upon admission not the facility. On 06/21/23 at 11:52 AM, the Director of Social Work (DSW) was interviewed and stated, as soon as the admission department send them a an expected admission's medical records's fro the hospital, the DSW checks the SCREEN's for any resident that trigger a level II evaluation. There is a log that DSW keeps of all residents with level II recommendations. The DSW evaluates the PASARR and lets the interdisciplinary team know so that recommendations can be followed. The DSW does not really seeing Resident #123's PASARR level II recommendation for the resident to have a neurology consult. The nurses really should be reading through this and addressing the medical concerns. The SW Department ensures that psychological and behavioral recommendations are addressed but it is a team effort and the nursing should be looking through for medical recommendations. It is part of the admission record and the team looks at it to address what their discipline is responsible for. On 06/20/23 at 11:50 AM, an interview was conducted with the Nurse Practitioner (NP) who stated the PASARR level II recommendations are generally reviewed by the SW upon admission. The NP was unaware Resident #123's PASARR level II recommended for the resident to have a neurology consult. Resident #123 has a neurology appointment in December 2023 and this is not an acceptable time for a resident to wait for an appointment to see a specialist. On 06/21/23 at 03:00 PM, the Director of Nursing (DNS) was interviewed and stated the SW is responsible for reviewing the SCREEN and PASARR level II recommendations for prospective admissions to the facility. The SW is involved when the resident has a psychiatric diagnosis. Prior to a resident's admission to the facility, the DNS reviews the hospital information. 415.11(e)

Based on observation, interview, and record review conducted during the recertification survey, the facility did not ensure a resident received notice of their rights and services upon admission. This was evident for 1 of 30 total sampled residents. Specifically, Resident #64 was not provided with an Admission Agreement explaining their rights and services upon admission to the facility. The findings are: The facility policy titled Resident Rights and dated 1/23 documented each resident has the right to exercise their personal rights and to not be discriminated against for admission to the facility. Resident #64 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus and osteomyelitis. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #64 was cognitively intact. On 6/16/23 at 11:01 AM, Resident Council Meeting was held with Resident #64 in attendance. Resident #64 stated they were not aware of their rights and responsibilities as a resident and had not signed an admission agreement since heir admission a few weeks prior. There was no documented evidence Resident #64 was provided with an Admission Agreement defining their rights and responsibilities as a resident of the facility. On 06/16/23 at 12:10 PM and 06/21/23 at 02:20 PM, the Admissions Director (AD) was interviewed and stated Resident #64 did not have an Admission Agreement signed and the AD was in the process of going to meet with the resident to them sign. The AD stated they complete Admission Agreements with new admissions to the facility timely, within 3 weeks of admission, but the AD is the only one reviewing there Admission Agreements with residents and their families. On 06/21/23 at 03:23 PM, the Administrator was interviewed and stated Administration was responsible for putting together the Admission and contents. If there is a change in resident rights it will be reviewed at resident council meetings. 415.3(g)(2)(i)

Based on record review and interviews during an abbreviated survey (NY00302773), the facility failed to ensure that an alleged violation involving neglect was reported to the New_York State Department of Health (NYSDOH), immediately, but no later than 2 hours after the allegation was made, or not later than 24 hours, if the event that cause the allegation resulted in bodily injury. This was evident for 1 of 2 residents sampled for neglect (Resident #1). Specifically, on 09/24/22 at 10:30 AM, Certified Nursing Assistant #1 (CNA #1), provide personal care of Resident #1 alone and did not follow the care plan. The plan of care documented those two persons must provide personal care to Resident #1. Resident #1 fell out of bed and got a laceration to the left forehead. On 09/25/22 at 7:14 PM, the facility reported the allegation to the NYSDOH. The findings are: The facility Policy and Procedure titled, Resident Abuse, Neglect, Mistreatment, Misappropriation of Property, dated 07/09, documented: All incidents of alleged patient abuse, neglect, mistreatment or misappropriation of property shall be investigated and reported. The Facility Investigation Procedure documented that, Administrator begin or continue the investigation and notifies NYSDOH. Resident #1 with diagnoses that included Cerebrovascular Incident, Dementia, and Hemiplegia or Hemiparesis. The quarterly Minimum Data Set (MDS, a resident assessment tool), dated 08/3/22, documented that Resident #1 required the total assistance of two staff members for bed mobility and a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 0. Resident #1's cognition was severely impaired. An Activity of Daily Living (ADL) care plan dated 04/30/20, documented that Resident #1 was totally dependent on staff to provide care due to Cardiovascular Accident (CVA) contractures. The interventions documented that two persons must use the Hoyer lift to transfer Resident #1. On 08/23/22, the updated care plan documented that Resident #1 was discharged from Occupation Therapy and required total assistance for hygiene and grooming. A Total Self-Care deficit plan dated 05/27/20, and revised on 08/23/22, documented that Resident #1 with diagnoses of Dementia, Hemiplegia and Hemiparesis following Cerebral Infarction, and was totally dependent on staff related to Cardiovascular Accident (CVA) Contractures. An Actual Falls/Accident/Incident Care plan dated 09/26/22, documented that Resident #1 fell from the bed on 09/24/22. The interventions included counseling for safety, Medical Doctor (MD), Physical Therapy (PT), and Occupational Therapy (OT) evaluations, and safety while providing care. A facility's Accident/ Incident Report dated 09/24/22 at 10:30 AM, documented that CNA #1 performed care without the assistance of another staff member. The CNAs tasks assignment documented that two persons must provide care. The facility's Investigation revealed that there was no neglect, however, it was indicated that CNA #1 failed to adhere to facility protocol and to the plan of care, which resulted in an injury to a Resident #1. CNA #1 was found to have unsatisfactory work and received a two-day suspension. On 09/25/22 at 7:14 PM, the Director of Nursing (DON), reported to the NYSDOH, Aspen Complaint Tracking System (ACTS), that Resident #1 was being given care by CNA #1 alone. CNA #1 turned to reached for an item and Resident #1 rolled off the bed. Resident #1 sustained a laceration to the forehead. Resident #1 was transferred to the emergency department and received sutures to the laceration. A Nurse's Progress note(s) dated 9/24/22 at 10: 30 PM, written by LPN #1, documented that Resident #1 fell out of bed while being washed by a CNA #1, alone without the assistance of a second staff member. Resident#1 was transferred to the emergency department and returned to the facility with sutures to the laceration on their forehead. A Nurse Practitioner Progress Notes dated 09/26/22, documented that on 09/24/22 at 10:30 AM, Resident #1 was seen for an evaluation after a fall and was alert, oriented, and with not in any distress. Resident #1 was sent to the emergency department (ED) to ensure that there was no internal bleeding in the head. The x-rays of the left shoulder, pelvis and chest were negative for fracture. The CNA accountability (tasks to performed by CNAs) dated 09/1/22, 09/15/22, and 09/24/22, documented that two persons must assist Resident #1 for bed mobility. During an interview on 10/28/22 at 11:02 AM, CNA #1 stated that he/she was assigned to Resident #1 for many years, and bed mobility was done by two people, and personal hygiene was one person. On 09/24/22 at 10:30 AM, they started to provide care by setting up supplies on the nightstand, then step away from the resident's bed to get another item when Resident #1 rolled over. Normally, before they turn the resident, they will call for assistance. They screamed when Resident #1 fell , the License Practical #1 (LPN #1) was in the hallway, and they called the Registered Nursing Supervisor #1(RNS #1). The resident was transferred back to bed. CNA #1 stated that they have received in-services on following the plan of care before and after the incident and was suspended during the investigation time. During an interview on 10/27/22 at 10:14 AM, CNA #2 stated that the resident requires two persons to assist with bed mobility and transfers. They call another staff member to assist. During an interview on 10/27/22 at 12:19 PM, LPN #1 stated that they were at the other end of the hallway when they heard CNA #1 call for assistance. When they got to the room, they saw the Resident #1 on the floor. They then called for help and for the RNS #1. They observed that only CNA #1 was in the room at that time. No other staff members were present. During an interview on 10/28/22 at 12:50 PM, the Director of Nursing (DON) stated that the DON, Assistant Director of Nursing (ADON) and/or the Administrator are responsible for reporting to NYS DOH. Reporting was within 2 hours as per NYS guidelines, if there was a suspected abuse, neglect, and mistreatment. The RNS thought that it was not abuse or neglect and did not report it to administration at the time of the incident. The event occurred on Saturday and the DON learned about it on Saturday night and reported the next day. During an interview on 10/28/22 at 1:30 PM, the Administrator stated that the incident/accident was reported to them by the DON/ADON. They review the case, discuss anything else that needs to be done. Reporting to the State was the responsibility of either the Administrator or the DON/ADON. Suspicion of abuse was reported within 2 hours, 24 hours for regular incidents (such as a fall without suspicion of abuse/neglect/mistreatment). At the time of the incident, the DON did not have access to the reporting system, they have it now. 10 NYCRR: 415.4(b)(1)(i)

Based on observation, interviews and record review conducted during an Abbreviated survey (NY 031) on 01/04/2022, the facility did not ensure that a resident receive adequate supervision to prevent elopement. This was evident for 1 out of 3 residents sampled (Resident #1). Specifically, the facility surveillance camera revealed that on 12/15/2021 at approximately 12:03 AM, Receptionist #1 opened the main entrance door in the lobby and allowed Resident #1 to walk out of the facility. Resident #1 was missing for approximately six hours before facility staff began searching for Resident #1 (at approximately 6:00 AM). Facility staff documented from 1:00 AM to 3:00 AM that Resident #1 was on the unit. There was no documentation for Resident #1's whereabouts from 4:00 AM to 6:00AM. The Police found Resident #1 on 12/23/2021 and notified the facility. The findings are: A facility policy entitled Elopement Prevention, Missing Resident, Code Green Policy and Procedure, revised on 06/2020 documented that it is to safeguard the health and welfare of those residents who are cognitively impaired; wandering, emotionally disturbed; or any resident that leaves the facility without notification of the staff. The policy also documented it is to locate a missing resident in a timely manner. The facility policy entitled Resident safety monitoring revised on 06/21/2021 documented to provide continuous observation for an individual resident for a period of acute physical and mental wellness and to check resident and complete hourly monitoring. A Facility Receptionist's Responsibilities Job Description revised on 06/2016 documented that the front door should be monitored to ensure the safety of the residents and to make sure that residents do not leave the building unaccompanied. Should call the nurse supervisor if there are any questions about the status of a resident. There were no instructions in the job description for the receptionist to stop visitors or residents entering and exiting the facility. There were no instructions for visitors/or residents to sign in or out of the facility. Resident #1 was admitted to the facility on [DATE] with diagnoses which included [CONDITION(S)] with delusion, Mood Disorder, Alcohol Dependence, and [CONDITION(S)] Disorder. The Minimum Data Set (MDS, a resident assessment tool), dated 12/14/2021 documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determined attention, orientation, and ability to recall information) score of 15/15 associated with intact cognition. The resident's Activity of Daily Living (ADL's) documented that Resident #1 required limited assistance of one staff for locomotion on and off the unit. The facility's Accident/Incident Report and Internal Investigation dated 12/15/2021 documented that upon investigation, Resident #1 left the facility without telling staff or notifying anyone. At approximately 6:15 AM after Certified Nursing Aide (CNA) #1 completed ADL care and while making rounds, CNA #1 was unable to locate Resident #1 and immediately notified Licensed Practical Nurse (LPN) #1. An immediate search and facility elopement protocol was initiated. Facility was unable to locate Resident #1. The Resident Monitoring Sheet dated 12/14/2021 at 11:00 PM to 12/15/2021 at 7:00 AM, revealed that CNA #1 and CNA #2 documented that Resident #1 was in the dining room on 12/15/2021 from 1:00 AM to 3:00 AM. There was no documentation regarding Resident #1's whereabouts on 12/15/2021 between 4:00 AM and 6:00 AM. The facility's surveillance video dated 12/15/2021, revealed that at 12:00 AM, Resident #1 was observed sitting next to the nursing station in front of the elevator. At 12:01 AM, Resident #1 pressed the elevator button and entered the elevator. There were no staff members at the elevator or in the corridor when Resident #1 entered the elevator. At 12:03 AM, Resident #1 exited the elevator in the lobby and walked towards the exit door. Receptionist #1 was observed sitting at the desk in the reception area in the lobby. Receptionist #1 opened the main entrance door in the lobby and Resident #1 walked out the door. A Reception Communication form dated 12/15/2021 documented that Code Green (for missing resident) was called at 6:56 AM because Resident #1 was observed missing. Nursing progress note created by the Assistant Director of Nursing (ADON) dated 12/15/2021 documented that the resident left the facility unsupervised or without telling anyone. Upon investigation resident left at 12:03 AM. ADON was notified at 6:30 AM and facility elopement protocol was started. Police were called and search continued. The Administrator, Medical Director, and Department of Health was notified. A Reception Communication form dated 12/23/2021 at 9:15 PM documented that a call came from Emergency Medical services (EMS) stating that Resident #1 was found in [NAME]. At 9:28 PM, two officers from the 81st Precinct brought the resident back to the facility. Nursing Progress Note dated 12/23/2021 documented that the resident returned to the facility ambulating, accompanied by two Detectives from the 81st Precinct. Resident had unsteady gait. The resident was greeted but refused to answer. The resident sat in the lobby and removed their boots and resident's feet were observed to be swollen. Resident #1 was taken to the 2nd floor and was placed on 1:1 observation. Physician order was given to transfer the resident to Psych emergency room and hospital was made aware that the resident was a high risk for elopement. While waiting for the ambulance, the resident started acting out and 911 was called instead. The resident left with the Emergency Medical service (EMS) to the hospital. The General Form Order by Physician dated 12/23/21 documented an order to transfer Resident #1 to the hospital for evaluation. During an interview on 01/04/2022 at 10:30 AM, Resident #1 stated that they did not have any desire to leave the facility but during the holiday season they missed drinking and wanted to get drunk with their buddies and decided to leave the facility. Resident #1 stated that they left the facility to get drunk and the cops found them in [NAME] and brought them back to the facility. During an interview on 01/04/2022 at 4:30 PM, Receptionist #1 stated that around midnight they saw a man passing by the lobby without saying anything or making eye contact. Receptionist #1 added that after they opened the entrance door, they thought it was one of the regular staff who left the facility late. Receptionist #1 stated that Resident #1 was walking around and left the facility calmly. There were no codes called from any of the units. Receptionist #1 added that they did not know that a resident was missing from the 2nd floor until they got home at 7:15 AM and received a call from the facility asking them to complete a report. During an interview on 01/04/2022 at 5:01 PM, CNA #2 stated that at 1:45 AM after their break, they thought that Resident #1 was in the Dining Room, so they started ADL care for the other residents. CNA #2 also stated that they did not check Resident #1's location at 2:00 AM because they thought that the resident was still in the Dining Room. CNA #2 further stated that they did not fill out the hourly monitoring sheet for 2:00 AM. CNA #2 added that they were unable to fill out the hourly monitoring sheet at 4:00 AM and 5:00 AM as they were overwhelmed with providing ADL care to the residents. CNA #2 stated that they did not check for Resident #1's whereabouts. CNA #2 also stated that any CNA who is not busy can fill out the monitoring sheet because they work as a team. During an interview on 01/04/2022 at 5:30 PM, the Assistant Director of Nursing (ADON) stated that right after they arrived at the facility on 12/15/2021 at approximately 6:36 AM, Licensed Practical Nurse (LPN) #1 notified them that Resident #1 was missing, and that Code Green was immediately initiated. The ADON also stated that it is standard of practice that all CNAs should check the residents hourly as ordered to ensure residents are safe. The ADON further stated that the investigation revealed that both CNA #1 and CNA #2 failed to follow the hourly monitoring order and signed that they saw Resident #1 from 1:00 AM to 3:00 AM without physically checking for Resident #1's exact location. The ADON stated that it is unacceptable for the staff to document on the hourly resident monitoring without physically checking the resident's exact location. ADON added that Receptionist #1 failed to monitor the front door. Receptionist #1 did not ensure Resident #1's safety when they opened the entrance door without thoroughly checking if it was a staff or a resident and so caused Resident #1 to elope from the facility. During an interview on 01/04/2022 at 5:45 PM, the Administrator stated that they were not present during the incident but later arrived at the facility to assist with the internal investigation. The Administrator stated that they found out from the facility surveillance video that Reception #1 opened the entrance door and let Resident #1 leave the facility without confirming who was exiting the building. The Administrator added that the facility provided in-services on elopement to all staff, including the receptionist. The Administrator added that the receptionist job required checking any person coming and leaving the facility. The Administrator stated that they did not understand why the receptionist opened the entrance door at 12:03 AM for the resident. The Administrator also stated that the moment the resident was noted missing, all staff followed the elopement protocol. During an interview on 01/05/2022 at 2:12 PM, CNA #1 stated that all the 11:00 PM to 7:00 AM CNAs are instructed to conduct hourly monitoring for all the residents on the 2nd floor. CNA #1 stated that they signed and documented on Resident #1's monitoring sheet for 12/15/2021 from 1:00 AM and 3:00 AM. CNA #1 stated that they documented that Resident #1 was in the Dining Room. CNA #1 stated that CNA #2 documented and signed Resident #1's hourly monitoring sheet on 12/15/2021 at 2:00 AM, indicating that Resident #1 was also in the Dining Room. CNA #1 stated that they heard residents talking in the Dining Room but they did not go and check to see if Resident #1 was actually in the Dining Room. CNA #1 added that on 12/15/2021 at 6:00 AM, after they completed care for other residents, they observed that Resident #1 was not in their room and could not be located. CNA #1 stated that they immediately notified LPN #1 and Code Green for elopement was called. During an interview on 01/31/2022 at 4:15 PM, the Registered Nurse Supervisor (RNS) #1, who worked on 12/14/2021 on the 11-7 shift stated that they had a prior arrangement with the Director of Nursing Service to leave the facility early and they left the facility between 6:30 AM and 6:45 AM on 12/15/2021. RNS #1 further stated that they made rounds about three times during the 11-7 shift and did not see Resident #1. RNS #1 stated that they were not aware that the resident had eloped from the facility and that no one notified them. RNS also stated that the CNAs are to confirm the residents' whereabouts before filling in the monitoring sheet and the charge nurses are responsible for ensuring that the CNAs are checking the residents' whereabouts before filling in the monitoring sheet. 415.12(h)(2)

Based on interviews and record review conducted during the abbreviated survey (NY00264110), the facility did not implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. Specifically, the facility did not review and revise the care plan to develop interventions to protect residents from Resident #349, a Dementia resident with a history of physically abusive behaviors and aggression towards others in the community and with staff in the facility. Resident #349 was the aggressor in 8 resident-to-resident altercations (Resident #s 1, 2, 3, 4, 5, 6, 7, and 348), and no interventions were put in place to protect the victim and other residents from the abuse after each altercation. Three of 8 resident-to-resident abuse incidents were not investigated (Resident #s 1, 6, and 7). The facility did not report all alleged violations of abuse to NYS Department of Health (NYSDOH) within 2 hours. Six of 8 resident-to-resident abuse allegations were never reported (Resident #s 1, 2, 4, 5, 6, and 7), and 2 of 8 resident-to-resident abuse allegations were reported late (Resident #3 and #348). The findings include but are not limited to: Facility policy Resident to Resident Abuse rev 9/20 documented residents with identified behavior problems will be evaluated and monitored via the Comprehensive Care Plan, direct observation, and morning meetings. Residents with identified behavior problems will have specific, individualized CCP developed by the interdisciplinary team to protect residents and staff from inappropriate, problematic behaviors and prevent resident to resident abuse. The following behaviors are included in resident to resident abuse: resident to resident altercation and physical abuse including hitting, slapping . Behaviors that pose a threat to self or others will necessitate an immediate care plan meeting. The RN Supervisor will immediately institute an investigation in addition of notifying the DNS and /or Administrator when indicated. Incident reports are to be completed for all resident to resident incidents. Incident may be reported to NYSDOH. Resident to resident incidents will be reviewed at the weekly Safety Subcommittee meetings. Care plans will be developed based on the documented behaviors and staff input. Residents' behaviors and implementation of the care plan will be evaluated for effectiveness episodically and quarterly. Resident #349, the Aggressor, was admitted on [DATE] with diagnoses which include Alzheimer's Disease, Major Depressive Disorder (MDD), and Psychotic D/O with hallucinations due to known physiological condition and Unspecified Psychosis. The Hospital and Community Patient Review Instrument (PRI) dated 7/8/20 documented the resident had hallucinations, but no known history of disruptive, infantile or socially inappropriate behavior. The primary diagnosis was Alzheimer's, and the resident was on Quetiapine Fumarate 25mg (2 tabs) BID (twice per day) and Namzaric 10mg QD (daily). The Admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had severely impaired cognition. The resident displayed physical behavioral symptoms directed toward others 1 to 3 days that put the resident at significant risk for physical illness or injury, significantly intruded on the privacy or activity of others, and significantly disrupted care or the living environment. The resident rejected care for 1 to 3 days. The MDS documented Resident #349 was able to walk, required supervision for bed mobility/transfer and extensive assist with one person assist for eating/toilet use. Resident #349 was on antipsychotic and antidepressant medication daily. The Comprehensive Care Plan (CCP) for Verbal Abuse, initiated 7/22/20, documented the resident was cursing at staff. The Interventions dated 7/23/20 included engage in activity, family involvement, monitor for changes, Psych. Services, redirect and discourage negative behavior. On 8/7/20 the intervention to provide extensive assist of 2 with care due to unpredictable aggression towards staff was added. The Behavioral Symptom CCP, initiated 7/23/20, documented the resident exhibited wandering, verbalized wanting to jump out the window without a plan, verbally abusive and disruptive behaviors, and resistance to care. Interventions included: discuss routine with resident, maintain calm environment, and use calm gentle approach. A Care Plan Note dated 7/31/20 documented the Psychologist informed staff that the resident may be triggered by perceived disrespectfulness, sudden movements, and being told NO. The note documented staff should approach slowly and calmly and distract with positive affirmation to avoid increased aggression. Staff should continue 30 min observation, offer books, newspapers and games to distract and keep occupied. The intervention of 2 persons to assist with care was added 8/7/20. The Non-compliance CCP, initiated 7/24/20, included the interventions of constant redirection and report issues to social service and IDCP team. The intervention to provide extensive assist of 2 with care due to unpredictable aggression towards staff was added 8/7/20. The Physically Abusive Behavioral CCP, initiated 7/24/20, documented the goal of fewer episodes of aggression and inappropriate/disruptive behavior. The interventions dated 7/24/20 included intervene and evaluate immediately, monitor for changes, psychiatry evaluation or follow up PRN, and 1:1 close monitoring. The 1:1 close monitoring was discontinued (d/c) 7/29/20. The intervention of providing extensive assist of 2 with care due to unpredictable aggression to staff was added on 8/7/20. The Care Plan was not updated/reviewed after 8/7/20. The CCP did not include specific interventions that address the resident's aggressiveness/unpredictable behavior or interventions to protect other residents from abuse. The Daily Monitoring Sheets from September to December 2020 documented all residents on the unit, including Resident #349, were monitored during the day and evening shift at 7:00am, 12pm, 2:30pm, 3pm, 5:00pm, 10:30pm. The daily sheets for Resident Monitoring 11pm -7am documented all residents, including Resident #349, were on hourly monitoring during the night shift. The facility was able to provide sheets for 7/22/20, 7/24/20, 7/25/20, 7/27/20, 9/1/20-9/2/20, and 9/4/20-9/9/20. A Psychological consultation dated 7/22/20 documented the resident had Unspecified Mood (affective) Disorder. The resident made false statements alleging they threw themselves out the window twice that day. The Resident had not harmed self or others and appeared confused. The Nursing staff was notified of the resident's statements, and increased supervision was recommended. A Nursing Note dated 7/22/20 documented Resident #349 was placed on every (q) 30- minute monitoring, and the resident had no attempt or plan to hurt themselves. Psych consult pending. A Nursing Note dated 7/23/20 documented Resident #349 had no issues with wanting to leave or hurting self; q15-minute checks maintained. A Nursing Note dated 7/24/20 documented Resident #349 was alert and oriented, very confused, and verbally abusive to staff. At 11:30am, the resident grabbed the Dentist and pushed them into a wall without provocation and punched the wall. The Psychiatrist ordered Desyrel (Trazodone) 50 mg (milligrams) BID (twice per day). A Nursing Note dated 7/24/20 documented Resident #349 continued to wander the hallway; q15 min checks and safety precautions maintained. A Medical Note written by the Nurse Practitioner (NP) dated 7/27/20, documented Resident #349 was awake, alert and oriented x(times) 1. The resident had Agitation and was physically aggressive to the Dentist without provocation. The resident was started on Trazadone, and the plan was to continue monitoring. A Nursing Note dated 7/28/20 documented that around 11:45 AM, Resident #349 followed a Certified Nursing Assistant (CNA) to another resident's room. After telling the resident to remain outside, the CNA attempted to close the door when Resident #349 slammed the door open and pushed the CNA. The Psychiatrist was called, and stat Haldol and an increase from Desyrel 50mg BID to TID (three times per day) were ordered. The resident was put on 1:1 monitoring. A Nursing note dated 7/29/20 documented 1:1 visual monitoring would be discontinued at 3:30 because the Resident #349 had not had any aggression at the time. The resident would continue on 30-minute visual monitoring. A Medical Note written by the NP, dated 7/29/20, documented the resident was physically aggressive towards staff 2 times on 7/24/20 and 7/28/20. Psychiatry was consulted and Trazadone was increased to 50mg TID (three times per day). Haldol IM (Intramuscular injection) 1mg x one dose was given on 7/28/20, and the resident was placed on 1:1 monitoring for 24 hours. The plan was to continue monitoring. A Psychological consultation dated 7/31/20 documented the resident had Unspecified Mood (affective) Disorder and Unspecified Dementia with Behavioral Disturbance and Psychotic Features. The resident had significant memory challenges, delusions, disorganized thinking, paranoia, frustration, anxiety, labile affect (rapid changes in emotion unrelated to external stimuli), and internal preoccupation. Resident #349 had a recent incident of pushing a staff member and other episodes of aggression. Mood was mostly calm but with intermittent angry/emotional outbursts. The resident responded well to calm approaches, quiet and [NAME] techniques and redirection. Staff were provided with recommendations for calm approaches. A Nursing Note, written by the Director of Nursing (DON), dated 7/31/20, documented per discussion with the Psychologist resident may be triggered by perceived disrespectfulness, sudden movements, being told NO. Staff should approach slowly and calmly and distract with positive affirmation to avoid increased aggression. Behaviors from resident are unpredictable and often triggers are unknown. Continue 30-minute observation, offer books, newspapers and games to distract and keep occupied. A Nursing note dated 7/31/20 documented staff were in-serviced to approach Resident #349 calmly and slowly, no sudden movements and when resident refused care to walk away and give resident time or call LPN/Supervisor for help. There was no documented evidence that the treatment team put interventions in place to prevent Resident #349 from abusing other residents after these incidents of abuse towards staff. A Social Work (SW) note dated 8/4/20 documented a CCP meeting was held with the CCP team, resident and wife in attendance. Staff continue to monitor the resident's whereabouts. The resident can get agitated at times, and calm approach and staff intervention are ongoing. The resident was redirected most of the time. SW 1:1 visits were ongoing, and the resident was seen by the psychiatrist and psychologist. Continue with plan of care. The Physician's (MD) Monthly Progress note dated 8/4/20 documented nursing staff reported periods of unpredictable aggressive behavior toward staff and peers that was redirectable. The plan was to continue current meds and supportive care. The Psychiatry consultation dated 8/4/20 documented the resident had a history of Alzheimer's disease with behavioral problems and Major Depression, recurrent. Resident #349 came from the community because they needed more care. The resident was cared for by their spouse and was physically aggressive, refused showers and care, and was confused. The resident was paranoid, delusional, and suffering acute psychotic episodes. Seroquel was decreased and the resident was still psychotic/delusional. Diagnoses were Senile depression, MDD with psychosis, ruled out drug psychosis, delusional. Resident #349 on Desyrel 50mg TID, Seroquel 50 BID, Remeron 50 mg BID, Aricept 10 mg at bedtime and Namenda 10mg daily. The plan was to increase Seroquel to 50mg BID + 75 mg at HS, decrease Desyrel to 50mg in morning and 50mg in the afternoon and Psychological services. A Nursing note dated 8/7/20 documented the resident was on 30-minute monitoring. The Psychological consultation dated 8/12/20 documented the resident continued to have episodes of aggression and noncompliance with care. The treatment plan included continue to offer life review therapy techniques and calming interventions to improve mood and maintain safe behavior. Continue to provide empathic listening and emotional support as patient adjusts to situation and personal functioning. Resident #349 was the Aggressor in eight resident-to-resident altercations beginning 8/14/20. Resident #349's CCP was not updated with new interventions to protect other residents from abuse after any of the incidents. In addition, there was no documented evidence that team meetings to revise interventions or enhanced monitoring was put into place after the altercations. There were no non-pharmacological interventions documented to address Resident #349's continued aggression. 1) Resident #2, A Victim, had a diagnosis of Major Depressive Disorder and Paranoid Schizophrenia. The Quarterly MDS dated [DATE] documented the resident had intact cognition, no behaviors, and required extensive assist for most Activities of Daily Living (ADLs). On 4/26/21 at 3:47pm, Resident #2 was interviewed and stated they were sitting by the shower room and yelled at Resident #349, and Resident #349 slapped them. Resident #2 stated they sustained a bruise near the eye and received a cold compress on eye. Resident #2 could not recall a second incident with Resident #349. A Nursing Note dated 8/15/20 documented at 10:20AM, Resident #2 was punched on the right side of the face by Resident #349 in the hallway by the nursing station. An Accident/Incident Report dated 8/15/20 documented Resident #2 was punched by Resident #349. The report concluded that there was not sufficient evidence of mistreatment or neglect because Resident #2 was alert and oriented, able to make needs known, with no behavioral problems exhibited. The section for determining abuse/neglect/mistreatment section was blank. The A/I Report dated 8/15/20 for Resident #349, the Aggressor, documented Resident #349 was alert and able to make needs known, with no physical injury noted. The section for determining abuse/neglect/mistreatment section was blank. A Nursing Note dated 8/29/20 documented staff reported Resident #2 was sitting in front of Resident #349's door in a wheelchair and did not move when prompted by Resident #349. Resident #2 suddenly started screaming aloud and reported being slapped by Resident #349. Nursing notes dated 8/29/20 documented Resident #2 had mild pain at 6:36PM and 10:36PM and Tylenol 680 mg was given. No further complaints of pain were documented. An Accident/Incident Report dated 8/29/20 at 5:50PM documented incident. The report documented there was not sufficient evidence of neglect or mistreatment because Resident #2 was alert, calm, verbally responsive, and able to make needs known. The abuse/neglect/mistreatment section is blank for Resident #2. The A/I Report dated 8/29/20 for Resident #349, the Aggressor, did not contain the document for determining abuse/neglect/mistreatment. The resident-to-resident abuse incidents on 8/15/20 and 8/29/20 were not identified as abuse because Resident #2 was alert and oriented. These incidents were not reported to NYSDOH. There was no documented evidence in Resident #349's medical record that new CCP interventions or enhanced monitoring were put in place to protect other residents from aggressive behavior after these incidents. 2) Resident #3, a Victim, had diagnoses of Hypertension (HTN), Bipolar Disorder, and End Stage Renal Disease (ESRD). The MDS dated [DATE] documented Resident #3 had intact cognition and no behaviors. The CCP for Abuse, initiated 9/19/19, included the intervention to seek out staff assistance if having difficulty with peers and relocate resident to more structured unit for behavior management. On 4/26/21 at 3:57pm, Resident #3 was interviewed and stated they were sitting in front of their room in the hallway when Resident #349 asked for some chips. Resident #3 told Resident #349 no, and Resident #349 hit Resident #3 and busted their lip. Resident #3 was separated from Resident #349, given a bandage, and visited by SW. Resident #3 stated I could not believe it. Resident #3 stated they were not afraid, and they are not in the facility to fight. A Nursing note for Resident #3 dated 9/1/20 documented around 3:30pm Resident #3 was sitting in a wheelchair in front of their room when Resident #349 was seen punching Resident #3 in the face. Resident #3 was bleeding from the mouth. First aid was provided, ice was applied, and Resident #3 complained of mild pain but refused Tylenol. Accident/Incident Report dated 9/1/20 documented Resident #3 was punched by Resident #349. The investigation attached included statements from staff. The corrective actions attached documented Resident #349 would be seen by the psychiatrist and transferred to the hospital for a Psychiatric evaluation. There were no interventions regarding actions that would be taken to prevent future abuse and altercations with others. The report did not contain the document for determining if there was abuse/neglect/mistreatment. The A/I Report dated 9/1/20 for Resident #349, the Aggressor, did not contain the document for determining abuse/neglect/mistreatment. The HERDS (Health Electronic Response Data System) Nursing Home Incident Form documented the facility reported this incident to NYSDOH as an addendum to an unrelated complaint involving Resident #3 and another resident (Complaint # NY00245391) on 9/2/20 at 2:12PM. This allegation of resident-to-resident abuse was not reported within 2 hours, and it was not reported as a separate incident. Resident #349 medical record/facility records did contain evidence of a revised CCP, interdisciplinary team meetings, or enhanced monitoring to protect other residents from abuse after returning to the facility on [DATE]. 3) Resident #348, a Victim, had diagnoses of Major Depressive Disorder (D/O) and Hypertension (HTN). The Quarterly Minimum Data Set 3.0 (MDS) dated [DATE] documented the resident had intact cognition and no negative behaviors. The Comprehensive Care Plan (CCP) for At Risk for Potential Abuse, initiated 6/18/20, included interventions to counsel victims/suspected victims of abuse and their families on coping strategies and provide a safe environment for abused/neglected client. A Nursing note for Resident #348 dated 9/10/20 documented Resident #348 was punched by Resident #349, unprovoked. Resident #349 appeared to be talking to Resident #348 and punched Resident #348 twice in the left eye and mouth causing bleeding and pain. Tylenol was given, and Resident #348 was sent to the hospital upon request. The Accident/Incident Report dated 9/10/20 documented the incident above. An investigation was attached with staff statements. The corrective actions attached documented Resident #349 was transferred to the hospital for a psyche admission. The report did contain a conclusion of abuse/neglect/mistreatment for this incident and the related form is blank for Resident #348. The section used for determining abuse/neglect/mistreatment was blank. The A/I Report dated 9/10/20 for Resident #349, the Aggressor, did not contain the document for determining abuse/neglect/mistreatment. The HERDS Nursing Home Incident Form for complaint # NY00264110 documented the incident occurred 9/10/20 at 7:15 PM, and the facility reported the incident to NYSDOH on 9/14/20 at 2:39PM. This allegation of resident-to-resident abuse was not reported within 2 hours to NYSDOH. There was no documented evidence in Resident #349's medical record that the CCP was revised with new interventions or enhanced monitoring to protect other residents from Resident #349's aggressive behaviors after the incident. There was no documented evidence that any interdisciplinary team meetings were held to discuss interventions to protect other residents from abuse. 4) Resident #7, a Victim, was diagnosed with Chronic Obstructive Pulmonary disease and Postprocedural Hypertension. The Quarterly MDS dated [DATE] documented Resident #6 with intact cognition, no behaviors, and mainly supervision for ADLs. The CCP At risk for Potential Abuse dated 9/16/20 documented interventions included to provide a safe environment. Nursing note for Resident #7 dated 11/23/20 documented Resident #7 as alert and responsive in the hallway engaging with Resident #349. The two were observed in a physical altercation with Resident #349 hitting Resident #7 in the face with a fist. Writer asked Resident #7 who stated Resident #349 was going to hit me and felt threatened. Resident #7 was assessed; no injuries were noted and was counseled not to engage in any physical altercations with anyone. This incident occurred after Resident #349 slapped another resident, Resident #6, in the face the same day. There was no Accident/Incident report for this incident. There was no documented evidence that this incident of resident-to-resident abuse was investigated. The incident was not reported to NYSDOH. On 4/27/21 at 4:05PM, the recently appointed Acting Director of Nursing Services (DNS) was interviewed and stated when resident-to-resident altercations occur, the residents are separated immediately. The supervisor then assesses what was going on and ensures the residents are safe. The DNS is called immediately. The DNS calls the Administrator and makes another assessment. The Acting DNS was not the DNS at the time of these incidents. The team met and came up with interventions and tried to see if they worked. There are no team meeting minutes, but the previous DNS took notes. Sometimes, Resident #349 was sent out to the hospital. The Acting DNS stated some incidents were not reported to NYSDOH because there was no physical harm when the DNS assessed what happened. When there is harm, the residents go out to the hospital to be evaluated. Abuse can be verbal or physical, and it depends on the severity like a good punch or slap. After the previous DNS made the decision on reporting the incident to DOH, the DNS informed the team. The previous DNS kept a timeline of all the incidents and informed the State that the facility could not take care of the resident. The Acting DNS stated this was a special case. The Physician, Psychiatrist, Psychologist, Social Work, and the family were all involved. The Acting DNS stated we tried to engage Resident #349 in recreation activities on the floor and downstairs. The Psychologist and Psychiatrist were involved, and the resident's medications were adjusted. Care plans were reviewed. The Acting DNS stated moving forward the care plan will be updated and the date reviewed will be manually entered next to the intervention statement. The Acting DNS stated Q 30-minute checks and one to one (1:1) monitoring was done, but the facility could not provide documentation of this monitoring. Resident #349 was moved to other floors to protect the victims. The issue was brought to morning meetings, MD was notified. The Acting DNS stated two Accident and Incident reports that occurred on 11/23/20 were not located. Accident and Incident report on 8/14/20 was also not found, but the Acting DNS brought documentation of steps taken after the incident. On 4/29/21 at 11:17AM, the Acting DNS stated videos are reviewed based on the incident. They did not personally review any of the videos because they were not present for every incident. On 4/27/21 at 5:39PM an interview was conducted with the Administrator who stated the former DNS had complete control related to A/Is, specifically to Resident #349. The Administrator stated the DNS would report that there was an incident, and if there was an injury, it would be submitted to DOH within the required time of 24 hours as soon as possible or, if over the weekend, the next business day. The Administrator stated two incidents with injury were reported to DOH. The Administrator stated the previous DNS who is no longer at the facility, would be able to answer more questions. After the incidents, Resident #349's room was changed, and the resident was placed on 1:1 monitoring while waiting to be transferred to the hospital. The hospital contacted the state because the facility refused to re-admit Resident #349. The Administrator stated the hospital was informed multiple times that the facility was not the right environment, and it was not safe for the residents and staff. The facility informed the resident's spouse that the facility could not provide care to Resident #349, and the spouse called the hospital regarding alternate placement. The hospital escalated the matter to the DOH, which we also informed that the NH was not the right environment and it was not safe for the residents and staff but was told by the DOH that NH had to take the resident back. The Administrator stated meetings were held discussing the incidents and plan of care, but the meeting minutes were not documented. The Administrator stated the facility knew they had an issue and tried to put interventions in place. This was a very difficult case. They had staff that refused to work with the resident, and they were short of staff due to COVID-19. 415.4 (b)

Based on record review and interview conducted during an abbreviated survey (NY00264110), the facility did not ensure that residents were free from abuse. Specifically, a resident with Dementia and a history of physically aggressive behavior, Resident #349, had multiple resident-to-resident altercations in which they pushed, hit with a newspaper, punched, slapped, or hit other residents. The facility did not implement interventions to protect other residents from abuse. This was evident for 8 of 8 residents reviewed for abuse (Resident #s 1, 2, 3, 4, 5, 6, 7, and 348). The findings include but are not limited to: The policy and procedure for Resident-to-Resident Abuse, revised 9/20, documented residents with identified behavior problems will be evaluated and monitored via the Comprehensive Care Plan (CCP), direct observation, and morning meetings. Residents with identified behavior problems will have a specific, individualized CCP developed by the interdisciplinary team to protect residents and staff from inappropriate, problematic behaviors and prevent resident to resident abuse. Behaviors considered resident-to-resident abuse include resident-to-resident altercations and physical abuse, including hitting and slapping. Behaviors that pose a threat to self or others will necessitate an immediate care plan meeting. The RN Supervisor will immediately institute an investigation in addition of notifying the DNS and/or Administrator when indicated. Incident reports are to be completed for all resident to resident incidents. Incident may be reported to NYSDOH. Resident-to-resident incidents will be reviewed at the weekly Safety Subcommittee meetings. Residents that do not respond to CCP interventions will be referred to the physician for psychology and psychiatry consultation. Resident #349, the Aggressor, was admitted on [DATE] with diagnoses which include Alzheimer's Disease, Major Depressive Disorder (MDD), and Psychotic D/O with hallucinations due to known physiological condition and Unspecified Psychosis. The Hospital and Community Patient Review Instrument (PRI) dated 7/8/20 documented the resident had hallucinations, but no known history of disruptive, infantile or socially inappropriate behavior. The primary diagnosis was Alzheimer's, and the resident was on Quetiapine Fumarate 25mg (2 tabs) BID (twice per day) and Namzaric 10mg QD (daily). The Admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had severely impaired cognition. The resident displayed physical behavioral symptoms directed toward others 1 to 3 days that put the resident at significant risk for physical illness or injury, significantly intruded on the privacy or activity of others, and significantly disrupted care or the living environment. The resident rejected care for 1 to 3 days. The MDS documented Resident #349 was able to walk, required supervision for bed mobility/transfer and extensive assist with one person assist for eating/toilet use. Resident #349 was on antipsychotic and antidepressant medication daily. The Comprehensive Care Plan (CCP) for Verbal Abuse, initiated 7/22/20, documented the resident was cursing at staff. The Interventions dated 7/23/20 included engage in activity, family involvement, monitor for changes, Psych. Services, redirect and discourage negative behavior. On 8/7/20 the intervention to provide extensive assist of 2 with care due to unpredictable aggression towards staff was added. The Behavioral Symptom CCP, initiated 7/23/20, documented the resident exhibited wandering, verbalized wanting to jump out the window without a plan, verbally abusive and disruptive behaviors, and resistance to care. Interventions included: discuss routine with resident, maintain calm environment, and use calm gentle approach. A Care Plan Note dated 7/31/20 documented the Psychologist informed staff that the resident may be triggered by perceived disrespectfulness, sudden movements, and being told NO. The note documented staff should approach slowly and calmly and distract with positive affirmation to avoid increased aggression. Staff should continue 30 min observation, offer books, newspapers and games to distract and keep occupied. The intervention of 2 persons to assist with care was added 8/7/20. The Non-compliance CCP, initiated 7/24/20, included the interventions of constant redirection and report issues to social service and IDCP team. The intervention to provide extensive assist of 2 with care due to unpredictable aggression towards staff was added 8/7/20. The Physically Abusive Behavioral CCP, initiated 7/24/20, documented the goal of fewer episodes of aggression and inappropriate/disruptive behavior. The interventions dated 7/24/20 included intervene and evaluate immediately, monitor for changes, psychiatry evaluation or follow up PRN, and 1:1 close monitoring. The 1:1 close monitoring was discontinued (d/c) 7/29/20. The intervention of providing extensive assist of 2 with care due to unpredictable aggression to staff was added on 8/7/20. The Care Plan was not updated/reviewed after 8/7/20. The CCP did not include specific interventions that address the resident's aggressiveness/unpredictable behavior or interventions to protect other residents from abuse. The Daily Monitoring Sheets from September to December 2020 documented all residents on the unit, including Resident #349, were monitored during the day and evening shift at 7:00am, 12pm, 2:30pm, 3pm, 5:00pm, 10:30pm. The daily sheets for Resident Monitoring 11PM -7AM documented all residents, including Resident #349, were on hourly monitoring during the night shift. The facility was able to provide sheets for 7/22/20, 7/24/20, 7/25/20, 7/27/20, 9/1/20-9/2/20, and 9/4/20-9/9/20. A Psychological consultation dated 7/22/20 documented the resident had Unspecified Mood (affective) Disorder. The resident made false statements alleging they threw themselves out the window twice that day. The Resident had not harmed self or others and appeared confused. The Nursing staff was notified of the resident's statements, and increased supervision was recommended. A Nursing Note dated 7/22/20 documented Resident #349 was placed on every (q) 30- minute monitoring, and the resident had no attempt or plan to hurt themselves. Psych consult pending. A Nursing Note dated 7/23/20 documented Resident #349 had no issues with wanting to leave or hurting self; q15-minute checks maintained. A Nursing Note dated 7/24/20 documented Resident #349 was alert and oriented, very confused, and verbally abusive to staff. At 11:30am, the resident grabbed the Dentist and pushed them into a wall without provocation and punched the wall. The Psychiatrist ordered Desyrel (Trazodone) 50 mg (milligrams) BID (twice per day). A Nursing Note dated 7/24/20 documented Resident #349 continued to wander the hallway; q15 min checks and safety precautions maintained. A Medical Note written by the Nurse Practitioner (NP) dated 7/27/20, documented Resident #349 was awake, alert and oriented x(times) 1. The resident had Agitation and was physically aggressive to the Dentist without provocation. The resident was started on Trazadone, and the plan was to continue monitoring. A Nursing Note dated 7/28/20 documented that around 11:45 AM, Resident #349 followed a Certified Nursing Assistant (CNA) to another resident's room. After telling the resident to remain outside, the CNA attempted to close the door when Resident #349 slammed the door open and pushed the CNA. The Psychiatrist was called, and stat Haldol and an increase from Desyrel 50mg BID to TID (three times per day) were ordered. The resident was put on 1:1 monitoring. A Nursing note dated 7/29/20 documented 1:1 visual monitoring would be discontinued at 3:30 because the Resident #349 had not had any aggression at the time. The resident would continue on 30-minute visual monitoring. A Medical Note written by the NP, dated 7/29/20, documented the resident was physically aggressive towards staff 2 times on 7/24/20 and 7/28/20. Psychiatry was consulted and Trazadone was increased to 50mg TID (three times per day). Haldol IM (Intramuscular injection) 1mg x one dose was given on 7/28/20, and the resident was placed on 1:1 monitoring for 24 hours. The plan was to continue monitoring. A Psychological consultation dated 7/31/20 documented the resident had Unspecified Mood (affective) Disorder and Unspecified Dementia with Behavioral Disturbance and Psychotic Features. The resident had significant memory challenges, delusions, disorganized thinking, paranoia, frustration, anxiety, labile affect (rapid changes in emotion unrelated to external stimuli), and internal preoccupation. Resident #349 had a recent incident of pushing a staff member and other episodes of aggression. Mood was mostly calm but with intermittent angry/emotional outbursts. The resident responded well to calm approaches, quiet and [NAME] techniques and redirection. Staff were provided with recommendations for calm approaches. A Nursing Note, written by the Director of Nursing (DON), dated 7/31/20, documented per discussion with the Psychologist resident may be triggered by perceived disrespectfulness, sudden movements, being told NO. Staff should approach slowly and calmly and distract with positive affirmation to avoid increased aggression. Behaviors from resident are unpredictable and often triggers are unknown. Continue 30-minute observation, offer books, newspapers and games to distract and keep occupied. A Nursing note dated 7/31/20 documented staff were in-serviced to approach Resident #349 calmly and slowly, no sudden movements and when resident refused care to walk away and give resident time or call LPN/Supervisor for help. There was no documented evidence that the treatment team put interventions in place to prevent Resident #349 from abusing other residents after these incidents of abuse towards staff. A Social Work (SW) note dated 8/4/20 documented a CCP meeting was held with the CCP team, resident and wife in attendance. Staff continue to monitor the resident's whereabouts. The resident can get agitated at times, and calm approach and staff intervention are ongoing. The resident was redirected most of the time. SW 1:1 visits were ongoing, and the resident was seen by the psychiatrist and psychologist. Continue with plan of care. The Physician's (MD) Monthly Progress note dated 8/4/20 documented nursing staff reported periods of unpredictable aggressive behavior toward staff and peers that was redirectable. The plan was to continue current meds and supportive care. The Psychiatry consultation dated 8/4/20 documented the resident had a history of Alzheimer's disease with behavioral problems and Major Depression, recurrent. Resident #349 came from the community because they needed more care. The resident was cared for by their spouse and was physically aggressive, refused showers and care, and was confused. The resident was paranoid, delusional, and suffering acute psychotic episodes. Seroquel was decreased and the resident was still psychotic/delusional. Diagnoses were Senile depression, MDD with psychosis, ruled out drug psychosis, delusional. Resident #349 on Desyrel 50mg TID, Seroquel 50 BID, Remeron 50 mg BID, Aricept 10 mg at bedtime and Namenda 10mg daily. The plan was to increase Seroquel to 50mg BID + 75 mg at HS, decrease Desyrel to 50mg in morning and 50mg in the afternoon and Psychological services. A Nursing note dated 8/7/20 documented the resident was on 30-minute monitoring. The Psychological consultation dated 8/12/20 documented the resident continued to have episodes of aggression and noncompliance with care. The treatment plan included continue to offer life review therapy techniques and calming interventions to improve mood and maintain safe behavior. Continue to provide empathic listening and emotional support as patient adjusts to situation and personal functioning. Resident #349 was the Aggressor in eight resident-to-resident altercations beginning 8/14/20. Resident #349's CCP was not updated with new interventions to protect other residents from abuse after any of the incidents. In addition, there was no documented evidence that team meetings to revise interventions or enhanced monitoring was put into place after the altercations. There were no non-pharmacological interventions documented to address Resident #349's continued aggression. 1) Resident #2 had a diagnosis of Major Depressive Disorder and Paranoid Schizophrenia. The Quarterly MDS dated [DATE] documented the resident had intact cognition, no behaviors, and required extensive assist for most Activities of Daily Living (ADLs). On 4/26/21 at 3:47PM, Resident #2 was interviewed and stated they were sitting by the shower room and yelled at Resident #349, and Resident #349 slapped them. Resident #2 stated they sustained a bruise near the eye and received a cold compress on eye. Resident #2 could not recall a second incident with Resident #349. The CCP for at risk for Potential Abuse, initiated on 10/3/17, included the intervention to provide a safe environment. A Nursing Note dated 8/15/20 documented at 10:20AM, Resident #2 was punched on the right side of the face by Resident #349 in the hallway by the nursing station. An Accident/Incident Report dated 8/15/20 documented Resident #2 was punched by Resident #349. The report concluded that there was not sufficient evidence of mistreatment or neglect because Resident #2 was alert and oriented, able to make needs known, with no behavioral problems exhibited. The section for determining abuse/neglect/mistreatment section was blank. The A/I Report dated 8/15/20 for Resident #349, the Aggressor, documented Resident #349 was alert and able to make needs known, with no physical injury noted. The section for determining abuse/neglect/mistreatment section was blank. A Nursing Note dated 8/29/20 documented staff reported Resident #2 was sitting in front of Resident #349's door in a wheelchair and did not move when prompted by Resident #349. Resident #2 suddenly started screaming aloud and reported being slapped by Resident #349. A Nursing note dated 8/29/20 documented an assessment of Resident #2 who had mild pain at 6:36PM pain 3/10 on a pain scale to the left cheek, Tylenol 680 mg and cold compression was given. A Nursing noted dated 8/29/20 at 10:36PM documented Resident # 2 complained of mild pain, Tylenol administered with good effect, and had no further complaints of pain. An Accident/Incident Report dated 8/29/20 at 5:50PM documented Resident #2 reported being hit by Resident #349. Tylenol 680 mg was given for the mild pain, and cold compress applied to area with good effect as per the Nursing assessment. The report documented there was not sufficient evidence of neglect or mistreatment because Resident #2 was alert, calm, verbally responsive, and able to make needs known. The abuse/neglect/mistreatment section is blank for Resident #2. The A/I Report dated 8/29/20 for Resident #349, the Aggressor, did not contain the document for determining abuse/neglect/mistreatment. On 4/27/21 at 12:55PM LPN #1 was interviewed who stated had left the facility a week ago after two years. LPN #1 stated Resident #349 was aggressive. LPN #1 stated during med pass, near room [ROOM NUMBER]-502 near treatment area, heard a commotion then saw Resident #349 strike Resident #2 in the face. LPN #1 stated the residents were separated and supervisor was called. Resident #349 was redirected, and a CNA stayed with Resident #2 who had redness in face. As per LPN #1, the resident stated while sitting Resident #349 approached, was told to get away and the she was not going to move from her spot. LPN #1 stated Resident #349 was bounced from unit to unit, on and off 1:1 but was not on 1:1 that day. LPN #1 stated Resident #349 was placed on monitoring on 2nd floor, and after hitting multiple staff members. LPN #1 stated being trained on Dementia care at that some point, that included how to redirect residents. LPN #1 stated Resident #2 is alert and oriented, had a stroke speech is slurred, had no behaviors, is very rigid and wants basic things immediately and will go to another unit to get it. On 4/26/21 at 4:08PM an interview was conducted with LPN #2 who stated the incident not witnessed. As per LPN #2, Resident #2 being slapped on the cheek by Resident #349. Resident #349 was asked and replied no when asked he slapped Resident #2. The resident was sitting by the bathroom, away from Resident #349 room. LPN #2 there was on visible injury, swelling or pain. Supervisor was called. LPN #2 stated Resident #349 at times got agitated, most of time stayed in the room and came out to talk. LPN #2 state Resident #349 was always monitored, and on 30 min monitoring. There was no documented evidence in Resident #349's medical record that new CCP interventions or enhanced monitoring were put in place to protect other residents from aggressive behavior after these incidents. A Nursing Note dated 8/15/20 documented the resident continued on 30-minute monitoring. Resident #349 was seen by Psychiatry on 8/17/20 and Remeron was increased to 30 mg from 22mg and Desyrel 50mg at AM was discontinued. Resident #349 was seen by the Psychologist on 8/19/20 who recommended staff use calm approach. 2) Resident #3, a Victim, had diagnoses of Hypertension (HTN), Bipolar Disorder, and End Stage Renal Disease (ESRD). The MDS dated [DATE] documented Resident #3 had intact cognition and no behaviors. The CCP for Abuse, initiated 9/19/19, included the intervention to seek out staff assistance if having difficulty with peers and relocate resident to more structured unit for behavior management. On 4/26/21 at 3:57PM, Resident #3 was interviewed and stated they were sitting in front of their room in the hallway when Resident #349 asked for some chips. Resident #3 told Resident #349 no, and Resident #349 hit Resident #3 and busted their lip. Resident #3 was separated from Resident #349, given a bandage, and visited by SW. Resident #3 stated I could not believe it. Resident #3 stated they were not afraid, and they are not in the facility to fight. A Nursing note for Resident #3 dated 9/1/20 documented around 3:30PM Resident #3 was sitting in a wheelchair in front of their room when Resident #349 was seen punching Resident #3 in the face. Resident #3 was bleeding from the mouth. First aid was provided, ice was applied, and Resident #3 complained of mild pain but refused Tylenol. SW Progress note for Resident #3 dated 9/1/20 documented calming down Resident #3 and provided emotional support. Accident/Incident Report dated 9/1/20 documented Resident #3 was punched by Resident #349. The investigation attached included statements from staff. The corrective actions attached documented Resident #349 would be seen by the psychiatrist and transferred to the hospital for a Psychiatric evaluation. There were no interventions regarding actions that would be taken to prevent future abuse and altercations with others. The report did not contain the document for determining abuse/neglect/mistreatment. The A/I Report dated 9/1/20 for Resident #349, the Aggressor, did not contain the document for determining abuse/neglect/mistreatment. A Nursing note for Resident #3 dated 9/1/20 documented s/p post altercation with swollen right upper/lower lip and small laceration of middle of lower lip. Bleeding stopped after ice was placed, and no c/o (complaints of) pain; resident #3 was calm and in bed. Tylenol was administered on 9/2/20, swelling subsided with no complaints voiced. A Nursing note for Resident #349 dated 9/1/20 documented s/p (status post) altercation, Resident #349 was pick up for transfer to hospital at 6PM. A Medical note dated 9/2/20 Resident #349 was admitted without recommendations, will increase Seroquel to 125 mg BID (twice a day), Psych consult requested and continue current meds and supportive care. On 4/27/21 at 10:42 am an interview was conducted with LPN #3 who recalled that Resident #349 had incidences with staff and residents. LPN #3 stated sometimes the resident was calm, talkative, and sometimes strike without you knowing, and the resident's mood just switches. Resident #3 can be calm and sometimes aggressive (curse you out/pick on certain residents). The residents were separated, supervisor, psych, social worker to calm him down, and it is something that requires him to be sent to the hospital that is also done. LPN #3 stated while sitting at the desk, don't know what incited the incident they were talking like the usually did then heard Resident #3 say that you hit me and saw both residents swinging arms towards each other. LPN #3 said while running towards them the supervisor was called from her office and we both separated them. LPN #3 believed Resident #3 had a little bleeding believed on the lip, both residents were assessed. LPN #3 could not recall if #349 was on any form monitoring. LPN #3 stated wife was called to get the resident to comply. LPN #3 stated when resident displayed aggression, monitor the resident more often and when check on the resident when walking in the hallway would. LPN #3 stated Resident #349 sometimes stood at the desk and talked with us. On 4/27/21 at 1:13PM, an interview was conducted with LPN #4 recalled a confrontation, heard loud words, Resident #349 wanted potato chips and reported it the supervisor. LPN #4 stated Resident #3 gets very agitated fast, would be loud, physically/verbally aggressive and needed a lot of attention. LPN #4 stated at one point the resident was 1:1 but does not recall when and was also sent to the hospital. LPN #4 stated has had Dementia related training and include calmy get the resident's attention, get eye contact and the patient usually responds but it depends on the situation. Resident #349 medical record/facility records did contain evidence of a revised CCP, interdisciplinary team meetings, or enhanced monitoring to protect other residents from abuse after returning to the facility on [DATE]. Resident was monitored on the unit, redirected from wandering into other residents' rooms, cursed at staff and refused care. 3) Resident #348, a Victim, had diagnoses of Major Depressive Disorder (D/O) and Hypertension (HTN). The Quarterly Minimum Data Set 3.0 (MDS) dated [DATE] documented the resident had intact cognition and no negative behaviors. The Comprehensive Care Plan (CCP) for At Risk for Potential Abuse, initiated 6/18/20, included interventions to counsel victims/suspected victims of abuse and their families on coping strategies and provide a safe environment for abused/neglected client. A Nursing note for Resident #348 dated 9/10/20 documented Resident #348 was punched by Resident #349, unprovoked. Resident #349 appeared to be talking to Resident #348 and punched Resident #348 twice in the left eye and mouth causing bleeding and pain. Tylenol was given, and Resident #348 was sent to the hospital upon request. The Accident/Incident (A/I) Report dated 9/10/20 documented the incident above. An investigation was attached with staff statements. The corrective actions attached documented Resident #349 was transferred to the hospital for a psyche admission. The section used for determining abuse/neglect/mistreatment was blank. The A/I Report dated 9/10/20 for Resident #349, the Aggressor, did not contain the document for determining abuse/neglect/mistreatment. A Nursing note for Resident #349 dated 9/10/20 documented Resident #349 was sent to the hospital after the incident. The facility could not provide the portion of the A/I used to determine abuse/neglect/mistreatment occurred for Resident #349 related to this incident. On 4/9/21 at 10:58AM an interview was conducted with CNA #1. CNA #1 stated Resident #349 was the aggressor, who liked to hit people even employees, and may hit you if your too close while passing near the resident. Resident #349 was very disoriented, strong, required 2 persons for care and was abusive especially to employees. Resident #349 was calmed with food/drink and CNA #1 stated time must be taken to explain the care going to be performed. CNA #1 also stated leaving and coming back later when the resident had calmed down. CNA #1 stated Resident #349 was in a private room and believed was on 15/30 monitoring. CNA #1 stated when the resident acted out, staff would try to get the resident to the room or was left with a staff. CNA #1 stated the first approach was most important. CNA#1 stated to keep your distance then talk to the resident and offer cookies. Resident #349 was in and out to the hospital and not on this unit long. CNA #1 stated when the resident walked into the dining, staff moved the residents away from Resident #349. CNA #1 stated observing the resident one to one (which included staying with the resident for the whole shift, occupying the resident with activities, ensuring that the resident does not approach others in a way that can be an altercation, and walk with the resident) from 7PM - 7AM. CNA #1 stated the resident did not step out of the room, offered juice/cookies and convince the resident to go to bed. CNA #1 stated being on break when the incident occurred. On 4/9/21 at 12:22PM, an interview was conducted with CNA #2 who stated Resident #349 was unpredictable. CNA #2 stated the resident used profanity, resident would state going to punch/knock you out, would say why are you looking at me when not, would walk back/forth, talked to self, and was emotional. When the resident would approach, CNA #2 would ask what happened, do you want cookies. CNA #2 stated running when Resident #349 exited the room to the nursing station. Resident #348 was standing at nursing station, Resident #349 said something, Resident #349 turned around and said I am not talking to you, don't talk to me and Resident # 349 punched Resident #348. CNA #2 approached Resident #349 who had picked up Resident #348 walker, wanted to swing but was taken away. As Resident #349 got agitated while walking to the room, CNA #2 moved back, and swung at the LPN who was possibly hit. CNA #2 stated Resident #349 was on a general assignment that included 30 monitoring, and not on 1:1 monitoring. CNA #2 stated monitoring included that staff should always keep an eye on the resident and does not come to contact with another resident. CNA #2 stated observing the resident 1:1, documented the residents every movement on 5th floor. CNA #2 stated the resident made closed fists, wanted to feel my arms, stated they would knock me out. CNA #2 stated being uncomfortable and declined 1:1 when asked again. On 4/9/21 at 4:50PM an interview was conducted Registered Nurse (RN#1) a supervisor who has worked for the facility for more than 4 years. RN #1 stated being called about Resident #348 being hit in the face by Resident #349. Resident #348 was bleeding from the lip, left eye was red (no injury), complained of pain to the left eye and was sent to the hospital for evaluation. RN #1 stated an ice pack was applied to the lower lip and bleeding stopped shortly. RN #1 stated Resident #349 was very confused, and behavior was unpredictable. RN #1 stated the resident hit staff/residents, cursed, got into staff/resident faces and was in and out of hospitals many times. RN #1 stated Resident #349 was on 30 minute monitoring (where staff observe and document what the resident is doing) through the entire stay at the facility, and also on 1:1 at times. RN #1 stated the resident was placed on 1:1 when the behavior becomes uncontrollable. RN #1 stated to protect other residents staff made sure that Resident #349 did not get in their space. When going into a resident's space, room, and talking harshly staff would intervene and redirect Resident #349. In the day room a staff member is monitors, if Resident #349 was upset and approaching someone staff would intervene. RN #1 stated the care plan is updated when incident occurred. RN #1 stated the care plan is updated by the Nurse Manager and the MDS Coordinator monitors the care plan for review/updates. There was no documented evidence in Resident #349's medical record that the CCP was revised with new interventions or enhanced monitoring to protect other residents from Resident #349's aggressive behaviors upon return to the facility on [DATE]. There was no documented evidence that any interdisciplinary team meetings were held to discuss interventions to protect other residents from abuse. On 4/12/21 at 10:14AM an interview was conducted with MDS Coordinator/Clinical Coordinator (appointed 3 weeks ago). RN #2 stated being unable to locate or provide a rationale to why the previous DON wrote the note to discontinue 1:1 and provide 30 minute monitoring. RN#2 stated 1:1 was done because the daily staffing schedule showed an extra staff was assigned to the Resident #349 room from 9/2-9/8. RN #2 stated the plans for updating the care plan is the responsibility of nursing, and at that time the 2nd floor was short on supervisors. RN #2 stated the supervisor is supposed to update the goal, intervention, problems, and evaluation when interim plan of care is changed and when an incident occurred. If there are no new changes/problems from the last review of the care plan, staff should document what happened in the last 3 months, that there is no change and to continue the current plan of care. On 4/13/21 at after 9AM, RN #2 stated the former DNS instructed nurses to link the progress notes to the Evaluation section of the resident's care plan instead of revising goals/intervention. RN#7 stated the actual goals and interventions were not updated based on the resident's current behavioral problems and not revisited after each problem/incident. RN #2 stated at this time, all care plans will be revisited and update the goals and interventions based on the evaluation. RN # 2 stated the 1:1 and 30 min monitoring sheets were not found. On 4/13/21 at 10:37AM an interview was conducted with the Acting Director of Nursing (DNS). The DNS stated as per an RN supervisor q 30 min check monitoring was done: and also reminded staff to observe the resident and initial the monitoring sheet. The DNS stated when there is a resident was aggressive behavior, were separated and moved off the unit. The team meets to discuss the incident and update the care plan goals, interventions and evaluation. The evaluation of the care included the outcome, such as, if the intervention was/was not effective after an incident, as needed (PRN), quarterly, and annually. The DNS stated quarterly, annually, and as needed, the MDS Coordinator and associated staff review the care plan for completeness and that the goals and interventions are met. The DNS stated the previous DNS would review the incident, including the care plan and ensured that it is in place. The DNS stated the nurse manager is responsible for updating the care plan. An RN can initiate and update the care plans; MD Coordinator reviews the care plans and if not up to date will inform DNS or nurse manager. As the Assistant DNS, ensured that care plan interventions were in place by observation on the floor. Later in the day, the DNS stated being unable to locate the 1:1 and 30 minute monitoring sheets. On 4/27/21 at 4:05PM, the DNS was interviewed and stated when resident-to-resident altercations occur, the residents are separated immediately. The supervisor then assesses what was going on and ensures the residents are safe. The DNS is called immediately. The DNS calls the Administrator and makes another assessment. The active DNS was not the DNS at the time of these incidents. The team met and came up with interventions and tried to see if they worked. There are no team meeting minutes, but the previous DNS took notes. Sometimes, Resident #349 was sent out to the hospital. The DNS stated some incidents were not reported to NYSDOH because there wa [TRUNCATED]