Every finding on record at Prestige Nursing Care & Rehab Center

Based on observations and interviews, the facility failed to ensure that food was stored in accordance with professional standards for food service safety. This was evident for three (3) of five (5) kitchen refrigerators that were observed during the initial kitchen tour. Specifically, walk-in refrigerator #1 was observed to contain unlabeled and undated cups of almond milk, walk-in refrigerator #2 was observed to contain outdated cooked food and undated defrosting food, and the kitchen pantry refrigerator contained four (4) ounce fruit and pudding cups that were undated and/or outdated.The findings include: The facility policy and procedure titled, Food Storage, with review date of 10/2025, documented that all use by dates will function as safety dates and all frozen food will be stored in a solid state. All perishable food will be dated by a staff member and stored immediately upon receival. Best by or best if used by dates are a suggestion for when the food item will be at its best quality. The facility standard is to treat this as the expiration date.The facility policy and procedure titled, Pantry Refrigerators, with review date of 01/2026, documented that any food placed in the pantry refrigerator must be labeled and dated. All food is discarded after seventy-two (72) hours or if there is no date. No exceptions.On 04/09/2026 at 9:11 AM, an initial kitchen observation was carried out with the Food Service Director. The findings included:Walk-in refrigerator #1 was observed to contain two (2) unlabeled, undated eight (8) ounce Styrofoam cups of almond milk.Walk-in refrigerator #2 was observed to contain one (1) metal pan covered in aluminum foil containing cooked ground chicken dated 04/02/2026, one (1) metal pan covered in plastic wrap containing mixed vegetables dated 04/02/2026, and a one (1) gallon container of whole eggs in citric acid defrosted without a defrost date.The kitchen pantry refrigerator was observed to contain one (1) four (4) ounce fruit cup dated 03/31/2026, one (1) four (4) ounce fruit cup dated 04/05/2026, one (1) four (4) ounce fruit cup labeled with an illegible date, one (1) four (4) ounce fruit cup undated, and one (1) four (4) ounce chocolate pudding cup dated 04/04/2026. On 04/09/2026 at 9:30 AM, an immediate interview was conducted with the Director of Food Service who stated when prepared or cooked food is placed in the refrigerator the items should be labeled with the preparation date. The cooked food should be served within three (3) days or discarded. The cooked chicken and vegetables dated 04/02/2026 should have been discarded if not served by 04/05/2026. The Director of Food Service also stated the prepared fruit cups should also be served or discarded within three (3) days. The Director of Food Service stated they did not know that defrosting food items had to be labeled with the defrost date. The Director of Food Service further stated that they, along with the dietary supervisor, perform daily rounds of all refrigerated food items, but they must have misread the date on the cooked food items. The Director of Food Service further stated that a dietary supervisor called out and they could not perform rounds that day.On 04/09/2026 at 9:35 AM, an interview was conducted with Dietary Aide #1 who stated that they were very busy and did not notice the outdated fruit cups stored in the pantry refrigerator. Dietary Aide #1 further stated that the fruit cups should have been discarded within 3 days. On 04/13/2026 at 3:23 PM, an interview was conducted with Dietary [NAME] #1 who stated that the chicken stored in the refrigerator was cooked on 04/07/2026. The vegetables are raw and both the vegetables and cooked ground chicken were labeled on 04/07/2026 for use on 04/09/2026 because foods that are prepared can be stored for seventy-two (72) hours. Dietary [NAME] #1 also stated that the chicken and vegetables were labeled 04/07/2026 but admitted the number seven (7) could be mistaken for the number two (2). Dietary [NAME] #1 also stated that they are responsible for food preparation and storage, and all stored food items should be clearly dated. Also, frozen food that is placed in the refrigerator for defrost should be clearly labeled with the date it was placed in the refrigerator. Dietary [NAME] #1 further stated any item opened, stored, defrosting or perishable must be discarded within seventy-two (72) hours and that the Food Service Director or anyone assigned to perform rounds is responsible to discard the food items daily. 10 New York Codes Rules and Regulations 415.14(h)

Based on observation, record review, and interviews, the facility failed to ensure that residents' right to a safe, homelike environment was maintained. This was evident in two (2) shower rooms observed during the Environmental Task. Specifically, two (2) clear overhead lighting fixture coverings in the Six (6) [NAME] unit shower room were observed to be cracked or had broken circular areas, and the faucet on a sink in the Four (4) East unit was loose and became partially detached from the sink's base when used. The findings include:The facility policy and procedure titled, Homelike Environment, reviewed 01/2026, documented it is the policy of the facility to create and sustain a home-like environment that supports each residents' physical, emotional, and psychosocial well-being. The facility will respect resident preferences, encourage individuality, and promote autonomy while maintaining a safe and sanitary environment. The facility will maintain a clean, comfortable, and safe environment. Efforts will be made to reduce institutional appearance and maintain appropriate lighting. All efforts to create a home-like environment must comply with Life Safety Codes and facility policy and procedures. Environmental rounds will be conducted routinely to identify and correct hazards. The facility policy and procedure titled, Routine Maintenance, reviewed 01/2026, documented all essential mechanical, electrical, structural, resident care equipment and resident furnishings will be maintained in a safe operating condition. The Director of Maintenance is responsible for maintaining a schedule to ensure timely monitoring, repair and maintenance. If the maintenance director or any staff member feels the work is out of scope and they are unsure how to safely and effectively perform a duty, it should be brought to the attention of the Administrator, and an outside professional can be contacted. Routine monitoring, repair and maintenance services will be performed on, but not limited to the electrical systems, equipment, appliances, outlets, plumbing, drainage, sinks, toilets, repair of interior walls, floors and ceiling tilesOn 04/13/2026 at 10:31 AM, an observation of the Six (6) [NAME] unit shower room was performed. Two (2) of three (3) clear overhead light coverings were observed to be in disrepair: one (1) was cracked and one (1) was broken revealing two (2) circular holes. On 04/13/2026 at 11:40 AM, a tour of the Four (4) East unit shower room was performed with Maintenance Worker #2. A faucet was observed to be loose and became partially detached from the base of the sink when in use.The unit Maintenance Department Repair Log entry dated 03/06/2026 documented a request for repair for the bathroom ceiling tiles. On 04/13/2026 at 10:49 AM, an interview was conducted with Maintenance Worker #1 who stated that they were supposed to repair the ceiling tiles and lights in the Six (6) [NAME] unit shower room one week ago. Maintenance Worker #1 acknowledged the entry in the repair logbook was dated 03/06/2026 and further stated that the repair was delayed because the work had to be completed after hours when residents would not be using the shower. On 04/13/2026 at 11:40 AM, an interview was conducted with Maintenance Worker #2 who stated that they were not made aware of the loose faucet in the Four (4) East unit shower room. Maintenance Worker #2 also stated that today they were following up on the repairs that are documented in the floor's maintenance logbook. After touring the shower room with the surveyor, Maintenance Worker #2 stated the faucet would be logged and addressed for repair. On 04/13/2026 at 11:21 AM, an interview was conducted with the Director of Housekeeping, who stated that they are aware of the Comptroller's recent assessment in February 2026, and that the report of observations identified needed repairs. The Director of Housekeeping also stated that they repaired all items listed on the Comptroller's Report that was provided to the facility. The Director of Housekeeping also stated the equipment for repair of the ceiling lights in the Six (6) [NAME] unit shower room had come in but that the repair must be scheduled at night. On 04/16/2026 at 10:26 AM, an interview was conducted with the facility Administrator who stated that an unannounced visit to inspect the physical environment of the facility by the Comptroller's Office occurred in February 2026. The Comptroller performed an exit presentation which included a verbal report of the identified issues. The Administrator stated that all needed repairs identified by the Comptroller were completed in February and March 2026. The Administrator stated they conducted environmental rounds to ensure the completion of repairs. The Administrator also stated that on rounds they did not notice the need for repair of the Six (6) [NAME] shower room light fixtures or the Four (4) East shower room faucet that was identified in the Comptroller's Report. The facility Administrator further stated the loose faucet base is normal wear and tear and the supplies needed to repair the lights on Six (6) East were delivered earlier this month, but the repair was not completed prior to the surveyor's observations. 10 New York Code Rules and Regulations 415.5(h)(2)

Based on observation, record review, and interviews, the facility failed to act upon the recommendations documented in the drug regimen review for one (1) (Resident # 347) of five (5) residents reviewed for unnecessary medications out of 38 total sampled residents. Specifically, the irregularity noted in the drug regimen review for Resident #347, dated 02/09/2026, was to consider a gradual dose reduction of Olanzapine five (5) milligrams; the physician did not document a rationale for not changing the medication order in the resident's medical record.The findings are:The facility policy and procedure titled, Drug Regimen Review, last revised January 2026, documented that the consultant pharmacist shall perform medication regimen reviews for each resident at least monthly. They shall provide written documentation of all recommendations and submit it to the facility for the attending prescriber or designee's review and response. The prescriber or designee shall act upon the Drug Regimen Review findings/recommendations in a timely manner of seven to fourteen (7-14) days or less. They shall document on the drug regimen review form whether they agree or disagree with the recommendation and provide a brief clinical rationale. Resident # 347 was admitted to the facility with diagnoses that include non-Alzheimer's dementia, depression, and psychotic disorder. The quarterly Minimum Data Set (MDS) assessment, dated 01/06/2026, documented Resident #347's cognition as severely impaired and noted they receive antipsychotic and antidepressant medications. A physician's order for Resident #347 dated 04/13/2026 included Olanzapine (Zyprexa) five (5) milligram tablet: give one tablet by oral route once daily in the evening for Psychosis.A medication regimen review report dated 02/09/2026 documented that Resident #347 is currently receiving Olanzapine five (5mg) once daily. The report noted that the most recent psychiatry consult recommended a gradual dose reduction from five (5) milligrams daily to two and a half (2.5) milligrams daily for seven (7) days, two and a half (2.5) milligrams every other day for seven (7) days, and then to be discontinued.The attending physician's response dated 02/11/2026 documented agree, will do.A review of the physician orders dated 02/11/2026 to 4/15/2026 evidenced no documentation that the order was changed to reflect the recommendation.A review of Resident #347's medical progress notes had no documentation that action had been taken to address the recommendation.On 04/15/2026 at 9:59 AM, Psychiatric Nurse Practitioner #1 was interviewed and stated that they saw Resident #347. The resident was drowsy, so they recommended a gradual dose reduction for the Olanzapine. The recommendation was not carried out, and it was beyond their control.On 04/15/2026 at 11:30 AM, Attending Physician #1 was interviewed and stated that the pharmacy consultant recommended a gradual dose reduction of the Olanzapine from five (5) milligrams to two and a half (2.5) milligrams; they agreed with the recommendation. Attending Physician #1 stated that the order was not changed after they spoke to the staff who said that resident was aggressive and refused care. The order was not changed, and no follow-up note was added.On 04/16/2026 at 10:24 AM, the Medical Director was interviewed and stated that when the pharmacy reviews the medications and makes a recommendation, it is up to the clinician to accept or decline it. If they choose not to accept, they must write the reason for their disagreement with the recommendation. If they agree with the recommendation, they must do so. If they do not do it, it must be documented.On 04/16/2026 at 1:24 PM, the Director of Nursing was interviewed and stated that when the pharmacy consultant entered their documentation into the chart, the chart was flagged for the doctor's response. The doctor is responsible for accepting or declining the recommendation. They must provide the reason if they do not accept the recommendation. If they accept, they must follow through, just as with a psychiatrist's recommendation. Upon review of the electronic medical record, the Director of Nursing stated there was no documentation in Resident #347's chart as to why the recommendation was not followed. 10 New York Codes, Rules and Regulations 415.18 (c)(2)

Based on observations, record review, and staff interviews, the facility did not ensure that the resident's drug regimen is free from unnecessary drugs. This was evident for one (1) resident (Resident #131) out of a total sample of thirty-eight (38) residents. Specifically, Resident #131 was ordered Morphine fifteen (15) milligram extended-release tablets to be given with frequency of as needed, which is not an adequate indication or duration for its use. The findings include: The facility's policy titled, Pain Assessment and Management, last reviewed 01/2026, documented that residents admitted on pain medication regimens will have their pain medications continued uninterrupted after evaluation by the medical provider. Staff will assess the effectiveness of medication in managing the pain by evaluating the dosage and administration intervals.Resident #131 was admitted to the facility with diagnoses that include chronic obstructive pulmonary disease, renal insufficiency, and obstructive uropathy.The Quarterly Minimum Data Set, dated [DATE], documented the resident's cognition as intact. Additional documentation noted the resident did not receive scheduled pain medication regiment, but received PRN pain medication. The Quarterly Minimum Data Set, dated [DATE], documented the resident's cognition as intact. Additional documentation noted the resident had no behavioral symptoms, no pain, took an anticonvulsant, and that Resident #131 participates in assessment and goal setting. The resident did not receive scheduled pain medication and did not receive PRN pain medication.The physician's order originally ordered 03/07/2026 and last renewed on 04/09/2026, documented Morphine extended-release (ER) 15 milligram tablet, give one (1) tablet (fifteen (15) milligram) by oral route every twelve (12) hours as needed.The Medication Administration Record for April 2026 revealed that Resident #131 received Morphine extended-release (ER) fifteen (15) milligram tablet on 04/07/2026 at 5:30 AM, 04/08/2026 at 5:00 AM, 04/13/2026 at 5:00 AM and 04/14/2026 at 7:52 AM.The Comprehensive Care Plan titled Pain, effective 11/05/2024, documented an etiology of primary generalized osteoarthritis. Goals included the resident will have decreased complaints of pain in 90 days. Interventions include administering medications as ordered by Medical Doctor.A Nurse Practitioner monthly progress note dated 04/13/2026 documented a follow up on chronic conditions, no falls, infections or emergency department visits during the last interim. Documentation included that Resident #131 was refusing meds, labs and medical care. Nurse Practitioner note also documented that received Morphine extended-release (ER) fifteen (15) milligram tablet every twelve (12) hours by an outside pain management specialist, however, the patient is non-compliant with the scheduled regimen and requests that the medication be administered on a as needed basis, stating they don't need medication all the time. Additionally, the patient is expected to follow up monthly with the outside pain management specialist but has been non-compliant with scheduled appointments.On 04/15/2026 at 10:47 AM, Nurse Practitioner #2 was interviewed and stated that they are Resident #131's primary provider and that Resident #131 complains of chronic pain. Nurse Practitioner #2 stated that Resident #131 has been receiving Morphine and that the pain management consultant ordered a standing dose for Resident#131, but Resident #131 wanted the medication as needed. Nurse Practitioner #2 stated that Resident #131refuses to go to the pain management consultation.On 04/16/2026 at 12:49 PM, Nurse Practitioner #2 further stated that they spoke to the pain management doctor previously, and that they are trying to wean Resident #131 from the medication, so the Morphine 15mg is ordered for 30 days only. Then Resident #131 would go back to the pain doctor, and they would reevaluate the medication.On 04/15/2026 at 11:07 AM, Registered Nurse #9 was interviewed and stated that they monitor the residents and give the medications, and if there were any significant changes, they would report it to their Charge Nurse. Registered Nurse #9 stated that Resident #131 chooses what they want to take and if the medication is generic, they refuse. Registered Nurse #9 stated that the resident states when they need pain medication.On 04/16/2026 at 12:22 PM, the attending Medical Doctor was interviewed and stated that although Resident #131 is indirectly under their care, Resident#131 does not want to be examined by a male doctor. For this reason, they are seen by Nurse Practitioner #2, who is under the medical doctor's supervision. The attending Medical Doctor stated that Resident #131's chronic back pain has been a problem, and a major point of contention for Resident #131 is that their pain has not been managed by the pain consultant. Resident #131 wants what they want, and they do not trust the clinicians in the building, so they follow up with an outside pain management physician to reduce the pain. The attending Medical Doctor stated that they should have given the Morphine immediate-release (IR) instead of the Morphine extended-release (ER) if it was to be given on as needed basis. On 04/16/2026 at 1:51 PM, the Director of Nursing was interviewed and stated that Resident#131 has behaviors, dictates their care and that they are non-compliant with their care. The Director of Nursing stated that they were was not aware Resident#131 was receiving Morphine extended-release on an as needed basis. On 04/16/2026 at 2:16 PM, the Medical Director was interviewed and stated that Resident#131 has suffered from pain for a long time and that the Morphine extended-release works for the resident. The Medical Director stated that the resident has reactions to short-term medications. The Medical Director also stated that Resident #131 has not complained of pain and that this regimen has worked for them. The Medical Director stated that residents who experience pain can determine what is best for them and know how to manage it. The Medical Director further stated that Resident #131 has had bad experiences with other medications, and therefore care should be tailored so that their pain is managed and to satisfy their needs. 10 New York Code Rules and Regulations 415.12(l)(1)

Based on observations, record review, and staff interviews, the facility failed to ensure that a resident received dental services in a timely manner. This was evident for one (1) resident (Resident #60) reviewed for Dental out of a total sample of thirty-eight (38) residents. Specifically, Resident #60 was not provided with dental services to meet the needs of the resident since resident was admitted to the facility.The findings include:The facility policy titled, Consults: In-house and Off-site, with a last revised date of 01/2026 stated that consultation services are provided by the Medical Department as part of the comprehensive plan of care for all resident at the facility. The Physician will write an order for the consult. The nurse will pick up the order and bring the consult to the nursing office; The nursing office will review the in-house consults on a weekly basis and make the necessary phone calls to the in-house consultants to inform them of the pending consults that are due. The completed consultations will be left for the physician in the Medical Doctor order book for his/her signature.Resident #60 was admitted to the facility on [DATE], with diagnoses that included anemia, renal insufficiency, renal failure, and malnutrition.The Quarterly Minimum Data Set, dated [DATE], documented that Resident #60 has intact cognitive status and is independent of staff for most activities of daily living. The Minimum Data Set assessment also documented that Resident #60 had no concerns with swallowing and oral/dental status.Comprehensive Care Plan for Dental Care, dated 10/30/2025, documented that Resident #60 has actual impairment.Monitoring/Evaluation notes for Dental Care plan, dated 11/06/2025, documented that Resident #60 is partially edentulous with full upper and partial lower dentures, functions well, clean and treat symptomatically.A dental consult progress note dated 11/21/2025 documented that Resident #60 was seen for dental annual examination. Documentation included soft tissue within normal limits, partially edentulous with full upper denture and partial lower denture, functions well, clean and treat symptomatically; Resident is free from oral /dental pain and discomfort.On 04/09/2026 at 10:30 AM, Resident #60 was interviewed and stated that they have a lot of missing teeth and have never seen the dentist since admission. Resident #60 stated that they have been requesting the staff to see the dentist; Resident #60 stated that the facility has not helped with appointments to see the dentist. On 04/09/2026 at 12:17 PM, during a dining room observation, Resident #60 was observed eating lunch, noted with only one upper front tooth and a lot of missing bottom teeth; resident was noted to be having difficulty chewing chopped meat served. Resident #60 expressed eating and chewing has not been easy. Resident #60 further stated that it would have been easier if they had dentures, and they had been waiting for so long to see the dentist.On 04/13/2026 at 2:31 PM, Certified Nursing Assistant #3 was interviewed and stated that they have been taking care of Resident #60 since admission; Certified Nursing Assistant #3 stated that Resident #60 requires set up with meals, is able to feed themself and is able to perform oral care independently after being provided with materials needed. Certified Nursing Assistant #3 further stated that Resident #60 has some missing teeth, and they had never seen the resident wearing dentures.On 04/15/2026 at 11:10 AM, Registered Nurse #1 was interviewed and stated that they just started on the unit about 3 weeks ago. Registered Nurse #1 stated that they are not sure if Resident #60 has dentures and they don't know the last time Resident #60 was seen by the dentist.On 04/15/2026 at 11:16 AM, Registered Nurse #2 was interviewed and stated that when any resident complains of dental discomfort, a consultation would be ordered, and the dentist would be notified to come and see the resident. Registered Nurse #2 stated that based on Resident #60's chart review, there was dental consult ordered on 10/30/2025, 10/31/2025, 11/28/2025, 12/30/2025, and 4/6/2026. Documentation evidenced that Resident #60 was last seen by the dentist on 11/21/2025. Registered Nurse #2 further stated that they were not sure if Resident #60 was seen because they are not regularly scheduled to work on the unit.On 04/15/2026 at 11:45 AM, Assistant Director of Nursing was interviewed and stated that residents are always referred to dental for initial evaluation upon admission. Depending on the recommendation of the dentist after seeing the resident, follow-up could be scheduled for three (3) months or annually. The Assistant Director of Nursing stated that the dentist comes to the facility every Thursday to see the residents that need dental services. The Assistant Director of Nursing further stated that Resident #60 was admitted on [DATE], and the dentist documented that Resident #60 was seen for initial visit on 11/07/2025 but was uncooperative; follow up visit was done on 11/13/2025. The Assistant Director of Nursing stated that they were not aware that Resident #60 has not been seen by the dentist. Whenever they make rounds, they always see Resident #60 and Resident #60 never reported to them that they were not yet seen by the dentist. The Assistant Director of Nursing could not confirm if Resident #60 has dentures.04/15/2026 at 11:58 AM, Attending Medical Doctor #1 was interviewed and stated that residents are routinely seen by consultation, and depending on the resident they are seen every three (3) months or annually. If there is a special request, a new order is placed. Medical Doctor #1 could not say if Resident #60 has dentures or if the resident was seen by the dentist. Medical Doctor #1 stated that most of the time they cannot review the consultation recommendation in the residents' chart before they fall out of the system, and that they keep on reminding the facility to check and fix the problem. Medical Doctor #1 stated that a dentist writing that Resident #60 was seen without seeing the resident is not acceptable. Medical Doctor #1 stated that the order may have fallen off before they reviewed it, and they will talk with the Medical Director to get it resolved.On 04/16/2026 at 8:42 AM, the Dentist was interviewed and stated that they remembered seeing Resident #60 once when admitted and could not remember the exact time. The Dentist stated that when they went to see Resident #60 for initial evaluation, they were unable to assess the resident because Resident #60 stated that they were tired. The Dentist stated they believed they went back on 11/23/2025 to evaluate the resident, but the evaluation written for Resident #60 must have been mixed up with someone else. The Dentist further stated that Resident #60 was eventually seen yesterday 04/15/2026, and there is a plan to make arrangement for Resident #60 to get dentures as soon as possible.On 04/16/2026 at 9:37 AM, Registered Nurse #3 was interviewed and stated that Resident #60 came to the station about 2 weeks ago requesting to see the dentist to get dentures. Registered Nurse #3 noted that when the resident's chart was reviewed it was documented that Resident #60 was seen last by the dentist in November, and another dental consultation was ordered for the resident on 04/06/2026. Registered Nurse #3 stated that they did not confirm with Resident #60 if they were seen in November and were not sure if Resident #60 had dentures. Registered Nurse #3 also stated that they are not sure of what was done for Resident #60 in November 2025 by the dentist. Registered Nurse #3 stated that they supervised 2 units, and they don't normally review consult notes; they are only notified of consult recommendation if there is emergency recommendation. Also, they don't usually review the consultation documentation afterwards.On 04/16/2026 at 10:18 AM, the Medical Director was interviewed and stated that they have a dentist that comes in weekly to see the residents, usually within 2-3 weeks of admission, so newly admitted residents should have been seen. The Medical Director stated that they are surprised that Resident #60 has not been provided with needed dental services since admission. Medical Director stated this is not acceptable and would be investigated immediately. On 04/16/2026 at 10:45 AM, the Administrator was interviewed and stated that they are working with the Medical Director to ensure that whatever consultations they put in are addressed in a timely manner. The Administrator stated that the facility is trying their best to ensure that residents are provided with the necessary services needed in a timely manner. Administrator further stated that they were made aware that Resident #60 was seen immediately yesterday, 04/15/2026, by the dentist and arrangement has been made to provide the dentures to Resident #60. 10 New York Code, Rules and Regulations 415.17 (a-d).

Based on observations, record review and staff interviews, the facility failed to ensure that a person-centered comprehensive care plan was developed and implemented to address the residents' medical, physical, mental, and psychosocial needs. This was evident for one (1) resident (Resident #60) reviewed for Dental out of a total sample of 38 residents; specifically, a person-centered comprehensive care plan was not developed and implemented to address the resident's dental care needs. Additionally, a comprehensive care plan was not developed and implemented for Resident #73's use of plastic utensils in the resident's Activity of Daily Living or Behavior care plans.The findings include: The facility policy and procedure titled, Comprehensive Person-Centered Care Planning, dated 11/28/2017, last revised 01/2026, stated that a comprehensive, person-centered care plan for each resident is developed within (7) days of completion of the resident assessment. The care plan is based on the resident's comprehensive assessment and is developed by Care Planning/Interdisciplinary Team members. The facility policy and procedure titled, Mealtime Assistance, with review date of 07/2025, documented residents will receive assistance with meals in a manner that meets the individual needs of each resident. Residents who are assessed as suicidal ideation, behaviors, hoarders or infection control purposes may be assigned disposable tableware and cutlery. All devises will be placed in the care plan and certified nursing assistant accountability. Resident #60 was admitted to the facility on [DATE] with diagnoses that included anemia, renal insufficiency, renal failure, and malnutrition. The Quarterly Minimum Data Set, dated [DATE] documented that Resident #60 has intact cognitive status and is independent of staff for most activities of daily living. The Minimum Data Set assessment also documented that Resident #60 had no concerns with swallowing and oral/dental status. The Comprehensive Care Plan for Dental Care dated 10/30/2025 documented that Resident #60 has actual impairment. Monitoring/Evaluation notes for Dental Care plan dated 11/06/2025 documented that Resident #60 is partially edentulous with full upper and partial lower dentures, functions well, clean and treat symptomatically. On 04/09/2026 at 10:30 AM, Resident #60 was interviewed and stated that they have a lot of missing teeth and had never seen the dentist since admission. Resident #60 stated that they have been requesting the staff to see the dentist since admission. Resident #60 stated that the facility has not helped with appointments to see the dentist yet. On 04/09/2026 at 12:17 PM, during a dining room observation, Resident #60 was observed eating lunch, noted with only one upper front tooth and a lot of missing bottom teeth; resident was noted to be having difficulty chewing the chopped meat served. When approached during lunch, the resident expressed difficulty to eat. Resident #60 further stated that it would have been easier if they had dentures and they had been waiting for so long to see the dentist. There is no documented evidence that a person-centered comprehensive care plan was developed and implemented to address Resident #60's dental care. On 04/15/2026 at 11:10 AM, Registered Nurse #1 was interviewed and stated that they just started on the unit about three (3) weeks ago. Registered Nurse #1 stated that they are not sure if Resident #60 has dentures and they don't know the last time Resident #60 was seen by the dentist. Registered Nurse #1 further stated that it is the Registered Nursing Supervisor's responsibility to initiate the residents' comprehensive care plans upon admission. On 04/16/2026 at 8:58, AM The Assistant Director of Nursing was interviewed and stated that the Night Nursing Supervisor that was responsible for reviewing the comprehensive care plan stated that they just copied and pasted the dental note on Resident #60's care plan and that it was not appropriate to do so. The Assistant Director of Nursing stated that the care plan documented for Resident #60 did not address the resident's plan of care as Resident #60 did not apparently have dentures as documented in the comprehensive care plan in place. On 04/16/2026 at 9:37 AM, Registered Nurse #3 was interviewed and stated that they just realized that the current Dental Care comprehensive care plan in place did not address Resident #60's dental problem. Registered Nurse #3 stated that the review of resident's care plan is assigned to night shift supervisor and they have not been checking to see if it is appropriate for the resident's problem. On 04/16/2026 at 9:46 AM, The Director of Nursing was interviewed and stated that the nurse on the unit is responsible for ensuring that there is a person-centered comprehensive care plan for all residents. The Director of Nursing also stated that care plan is initiated upon admission by the admission nurse and developed over fourteen (14) days until the care plan meetings. The Interdisciplinary Team is expected to go over the care plans to ensure that the care plan is addressing resident's needs. The Director of Nursing further stated that the night nurse that entered the information for Resident #60's Dental care plan admitted entering wrong information on the resident. Resident #73 was admitted to the facility on [DATE], with diagnoses that included seizure disorder, dementia and traumatic brain injury. The Quarterly Minimum Data Set assessment, dated 03/21/2026, documented that Resident #73 had severely impaired cognitive function for daily decision making with behavioral symptoms of rejection of care and wandering. The Minimum Data Set assessment also documented that Resident #73 required supervision or touching assistance for eating, all personal care needs, all activities of daily living and mobility. On 04/13/2026 at 12:00 PM, during a dining observation, Resident #73 was observed eating in their room using plastic cutlery. The tray ticket documented, plastic utensils no knife. On 04/14/2026 at 12:08 PM, during a dining observation, Resident #73 was observed eating in their room using plastic cutlery. The tray ticket documented, plastic utensils no knife. The Care Plan Activity Report titled, Activities of Daily Living: Self Care Performance Deficit- Eating, effective 08/06/2024 and last reviewed 03/19/2026, did not document plastic utensils as an intervention for use by Resident #73. The Certified Nursing Assistant Documentation History Detail, Category for Eating, dated 03/16/2026-04/16/2026 did not document that plastic utensils were used by Resident #73. There is no documented evidence that a person-centered Comprehensive Care Plan and Certified Nursing Assistant Accountability record were developed and implemented for Resident #73's use of plastic utensils. On 04/16/2026 at 11:36 AM, an interview was conducted with the Director of Nursing who stated plastic utensils are recommended for use for residents who have behavioral issues including suicidal ideation, homicidal ideation, and threatening behaviors. The interdisciplinary team, including nursing, identifies the behaviors and the Registered Nurse on the floor or the Nurse Manager documents the intervention for use of the utensils in the Activities of Daily Living or Behavior Care Plan. The Director of Nursing also stated that the care plan needs to be updated quarterly by the nurse manager. Once entered in the care plan, the task of using plastic utensils is forwarded to the Certified Nursing Assistant Accountability so that they are aware of the need for use and possible assistance. Resident #73's Activities of Daily Living and Behavior Care Plans were reviewed in the electronic medical record with the Director of Nursing who stated that neither the care plans, nor the accountability sheets documented Resident #73's use of plastic utensils. The Director of Nursing further stated that the nurse manager should have reviewed the record quarterly to ensure the care plan documented the use of plastic utensils. On 04/16/2026 at 11:50 PM, an interview was conducted with Registered Nurse #6 who stated that Resident #73 gets agitated, they have a history of verbally threatening staff and there was a determination made that the resident should not have access to metal silverware. Registered Nurse #6 also stated that after those behaviors are noticed, the social worker is notified, along with the nursing supervisor, and the dietician. A decision is made by the team for use of plastic utensils, and the nurse manager enters the intervention of utilizing plastic utensils in the activities of daily living care plan and updates them quarterly. Care Plans were reviewed in the electronic medical record with Registered Nurse #6 who further stated plastic cutlery with no knife should be documented on the care plans but is not. On 04/16/2026 at 12:41 PM, an interview was performed with Registered Nurse #7, the nurse manager, who stated they spoke with the facility dietician approximately two (2) weeks prior. Registered Nurse #7 stated that residents are provided plastic utensils and no knife if they have suicidal ideation, homicidal ideation, and or threatening behaviors. Once the behavior has been determined, an intervention should be placed on the Activities of Daily Living care plan and updated every ninety (90) days. Registered Nurse #7 further stated that the nurse manager does not have to always enter the intervention or update the care plan, but any nurse on the unit could have done that; Registered Nurse #7 recognized the care plan was not completed. 10 New York Code, Rules and Regulations 415.11(c)(1)

Based on observation, record review, and staff interviews, the facility failed to ensure each resident was treated with respect and dignity. This was evident for one (1) (Resident #4) of two (2) residents reviewed for Activities of Daily Living out of a total sample of thirty-eight (38) residents. Specifically, Resident #4 was transferred via Hoyer Lift through the doorway, to a bariatric Geri chair. The findings include:The facility's policy titled, Lift and Transferring, last reviewed 03/2025, documented that preparation of the procedure includes providing enough space to move freely.The facility's policy titled, Resident's [NAME] of Rights, last revised 01/2026, documented that all staff members have a responsibility to enable a resident to have personal dignity, well-being and proper delivery of care.Resident #4 was admitted to the facility with diagnoses that include Coronary Artery Disease, Diabetes Mellitus and Non-Alzheimer's Dementia. On 04/13/2026 at 11:13 AM Resident #4 was observed for a transfer via Hoyer lift. Resident #4's bed was located closest to the door. Resident #4 was hoisted into the Hoyer lift with the assistance of two (2) Certified Nursing Assistants. Resident #4's bariatric Geri chair was located in the hallway in front of Resident #4's room's doorway. As Resident #4 was then turned and moved with the Hoyer Lift, the resident's head had to be steered away and protected from the doorway by the one of the Certified Nursing Assistant's hands. Resident #4 continued to be transferred through the doorway and to the bariatric Geri chair. The quarterly Minimum Data Set, dated [DATE], documented the resident's cognition as severely impaired, with impairment on both sides to upper and lower extremities, and that they are dependent on staff for bed mobility and chair-to-bed transfer. The Physician's order, last renewed 03/28/2026, documented as directed on/off unit: bariatric Geri chair with overlay cushion, positioning wedge.The Comprehensive Care Plan Titled, Activities of Daily Living: self-care performance deficit, created 03/22/2019, documented goals including that the resident will remain clean, neat, dressed appropriately and free of body odor through next review 06/10/2026. Interventions included out of bed to Geri chair with two (2) personal assists via Hoyer Lift. On 04/13/2026 at 10:17 AM, Certified Nursing Assistant #7 was interviewed and stated that they have been assigned to the resident for more than two (2) years. Certified Nursing Assistant #7 stated that Resident #4 needs total assistance with transfers, needs two (2) persons to help them move from one side, and is a Hoyer lift transfer resident. Certified Nursing Assistant #7 stated that Resident #4 comes out of bed on Monday, Wednesday and Friday and does go to activities. Certified Nursing Assistant #7 stated that they usually take Resident #4 out of bed by 11:30 AM.On 04/13/2026 at 11:17 AM, Certified Nursing Assistant #7 explained that they usually transfer Resident #4 out of bed via Hoyer lift to the bariatric Geri chair in the hallway because the chair will not fit in the resident's room.On 04/16/2026 at 10:08 AM, Registered Nurse #7 was interviewed and stated that they are the Charge Nurse, and their responsibilities involve overseeing the Certified Nursing Assistants with the residents on the units. Registered Nurse #7 stated that they oversee the division of work given to the Certified Nursing Assistants and will also supervise and monitor that the Certified Nursing Assistants do transfers correctly and will communicate the patient's needs. Registered Nurse #7 stated they were aware that Resident #4 was often transferred from bed to a Geri chair located outside of their room via Hoyer lift. Registered Nurse #7 was unable to identify an issue in this practice. On 04/16/2026 at 10:13 AM, Registered Nurse #4 was interviewed and stated that they supervise the unit which includes monitoring the Certified Nursing Assistants. Registered Nurse #4 stated that they were aware that Resident #4 uses a bariatric Geri chair and that the Rehab department gave Resident#4 a bigger chair to accommodate the resident's positioning. Registered Nurse #4 also said that the Rehab department is responsible for ensuring that the chair is able to be used in a safe manner. Registered Nurse #4 stated the Rehab department is also aware of Resident #4's bed-to-chair transfer involves moving the resident through the doorway.On 04/16/2026 at 10:20 AM, the Occupational Therapist was interviewed and stated that Resident #4 previously had a high back reclining chair which was changed to a reclining chair to accommodate the contractures on Resident #4's leg. The Occupational Therapist suggested that the issue with transferring the resident from bed-to-chair in the room was due to the size of the bariatric Geri chair. The Occupational Therapist also stated that the Rehab department's responsibility is to ensure a safe transfer status for the residents; for Resident #4 that included the use of a Hoyer lift with the assistance of two (2) Certified Nursing AssistantsOn 04/16/2026 at 10:32 AM, the Director of Nursing was interviewed and stated that the transfer assessment starts with an initial assessment conducted by the Rehab department. The Director of Nursing was unable to provide details on the Rehab department's follow-up assessment procedures, but stated assessments are completed on a quarterly basis. The Director of Nursing stated the Charge Nurse and the Supervisors are involved to ensure the safety and dignity of the residents. The Director of Nursing stated that placing the Geri chair outside of the resident's room and transferring the resident through the doorway was the safest way to transfer Resident #4.On 04/16/2026 at 11:02 AM, the Rehab Director was interviewed and stated that a resident is assessed based on the referral from nursing. The Rehab Director also stated that for a wheelchair transfer, they assess the resident's position in the chair. The Rehab Director further stated that for Resident#4, the assessment was conducted after the resident was already seated in the Geri chair. The Rehab Director stated that they were not aware if there was an issue with the actual transferring of Resident #4 into the Geri chair via the Hoyer lift from the room. 10 New York Code Rules and Regulations 483.10(a)(b) (1) (2)

Based on observation, record review, and interviews conducted during an Abbreviated Survey (NY00335650), the facility failed to provide adequate supervision to a resident to prevent accidents. This was evident for one (1) of three (3) residents (Resident #1) sampled. Specifically, on [DATE] at 11:00 AM, Resident #1 fell off their bed onto the floor while Certified Nursing Assistant #1 was providing bed mobility care by themself. Registered Nurse Supervisor #1 assessed Resident #1 to have swelling of their right elbow, and complaints of pain to their head, right arm, elbow, and back. Resident #1 was transferred to the hospital on [DATE] at 2:55 PM and was admitted to the hospital with diagnoses of right arm and pelvis fracture. The Resident Nursing Instructions dated [DATE] documented Resident #1 was dependent (two (2) or more helpers are required) for bed mobility. Certified Nursing Assistant #1 did not review Resident #1's Resident Nursing Instructions before providing care to Resident #1. This resulted in actual harm to Resident #1 with the potential for serious injury, serious harm, serious impairment, or death to 15 residents on the unit who are dependent for bed mobility, that was not Immediate Jeopardy. The findings include: The facility policy titled Falls and Fall Risk, revised ,d+[DATE], documented staff to identify interventions related to the resident's specific risks and causes of falls, to prevent the resident from falling, and to try to minimize complications from falling. The facility's policy titled Accident/Incident Investigation, revised on ,d+[DATE], defined accident as an uncontrollable event that results in unintentional injury that requires therapeutic intervention. Examples include, but are not limited to, laceration (a deep, long cut), contusion, fractures, ecchymosis, second- and third-degree burns, and any head trauma (with or without visible injury). Incident was defined as an uncontrollable event that results in no injury or superficial injury. Examples include, but are not limited to, scratches, scrapes, and blisters, reddened area with no swelling or pain, falls with no injury, first degree burns, and skin tears. The policy titled Assignment of Care, with a review date of ,d+[DATE], documented that it was the responsibility of all nursing personnel to check the assignment and accountability section at the start of the shift for their daily assignment. Resident #1 was admitted to the facility with diagnoses including Non-Alzheimer's Dementia, Osteoarthritis of Bilateral Shoulders, and Osteoporosis. The Minimum Data Set, dated dated dated [DATE] documented Resident #1 had severe cognitive impairment. Resident #1 was identified as being dependent (helper does all the effort. Resident does none of the effort to complete the activity or the assistance of two (2) or more helpers is required for the resident to complete the activity) with roll left and right (the ability to roll from lying on back to left and right side and return to lying on back on the bed). An Activities of Daily Living Self- Care Performance Deficit Care Plan dated [DATE] documented Resident #1 was assessed to be dependent for bed mobility. The Care Plan Note dated [DATE] documented staff reported Resident #1 now required two-person assist for bed mobility. The Resident Nursing Instructions dated [DATE] identified Resident #1 to be dependent for bed mobility. An Accident/Incident Investigation Report dated [DATE] at 11:00 AM documented Resident #1 had fallen off their bed onto the floor while Certified Nursing Assistant #1 was providing bed mobility care to Resident #1 by themself. Registered Nurse Supervisor #1 assessed Resident #1 to have right elbow swelling and complaints of pain to the head, right arm, elbow, and back. Resident #1 was transferred to the hospital on [DATE] at 2:55 PM. The investigation concluded that abuse and neglect had occurred. A nursing note by Registered Nurse #1 dated [DATE] at 3:10 PM documented Resident #1's right arm appeared to be more swollen, and Resident #1 continued to complain of pain. Resident #1's family member requested for Resident #1 to be transferred to the hospital for evaluation. Tramadol 25 milligram tablet was given at 1:40 PM. Resident #1 left the facility at 2:55 PM via ambulance. A nursing note by Registered Nurse #2 dated [DATE] at 10:50 PM documented facility received report from hospital Emergency Department that Resident #1 was admitted with diagnosis of arm and pelvic fracture. Review of an Emergency Department to Hospital Admission (Discharge) document dated [DATE], revealed Resident #1 sustained an acute fracture of the posterosuperior T12 vertebral body, acute mildly displaced fractures of the pelvis and right sacral area, and an acute displaced transverse fracture of the right upper arm. During an interview on [DATE] at 10:00 AM, Certified Nursing Assistant #1 stated they floated to Resident #1's unit on [DATE] on the day shift and was assigned to Resident #1. Certified Nursing Assistant #1 stated that the other Certified Nursing Assistants (no names mentioned) on the unit told them Resident #1 requires one (1) person to wash them and two (2) persons for transfer. Certified Nursing Assistant #1 stated on [DATE] at 11:00 AM they gathered all their supplies and placed them on Resident #1's wheelchair, which was at the foot of Resident #1's bed. Certified Nursing Assistant #1 stated they washed and turned Resident #1 by themself. When they turned Resident #1 on their left side towards them, they reached for the towel that was on the wheelchair at the foot of the bed. Suddenly, Resident #1 slid off the bed and fell on to the floor. Certified Nursing Assistant #1 stated they reported the accident to Licensed Practical Nurse #1. Certified Nursing Assistant #1 stated they did not have the bed rails up while they were providing care, did not review the Resident Nursing Instructions, and did not receive a report from the charge nurse prior to providing caring to Resident #1. Certified Nursing Assistant #1 stated they were not aware Resident #1 required two-person assistance for bed mobility. Certified Nursing Assistant #1 stated they had received in-service on reviewing the Resident Nursing Instructions prior to providing care. Certified Nursing Assistant #1 stated they buddied up with another Certified Nursing Assistant during orientation and received training on how to review the Resident Nursing Instructions prior to providing care. During an interview on [DATE] at 10:52 AM, Licensed Practical Nurse #1 stated they were the charge nurse on the unit on [DATE]. Licensed Practical Nurse #1 stated they were not aware Certified Nursing Assistant #1 was providing care to Resident #1 by themself. Licensed Practical Nurse #1 stated they went to Resident #1's room to perform wound care and when they opened the room door, they observed Resident #1 lying on the floor next to their bed. Licensed Practical Nurse #1 stated Resident #1 was in pain. Tramadol 25 milligram was administered and Registered Nurse Supervisor #1 was notified. Licensed Practical Nurse #1 stated Resident #1 did not have any visible injuries. Licensed Practical Nurse #1 stated they are responsible for monitoring the staff on the unit to ensure staff are following the residents' plans of care. Licensed Practical Nurse #1 stated the unit was not short staffed and that they gave the staff report at the beginning of the shift. Licensed Practical Nurse #1 went on to say that Certified Nursing Assistant #1 (who was new to the unit) also received a report pertaining to Resident #1's care. Registered Nurse Supervisor #1 is no longer employed in the facility and their whereabouts are unknown. During an interview on [DATE] at 3:00 PM, the Assistant Director of Nursing stated Certified Nursing Assistant #1 provided care to Resident #1 by themself without calling for another staff. Assistant Director of Nursing stated Resident #1 is totally dependent with two-person assistance for bed mobility, as indicated in the Activities of Daily Living care plan. The Assistant Director of Nursing stated that the Resident Nursing Instructions also mentioned Resident #1 was dependent for bed mobility. The Assistant Director of Nursing stated when they reviewed the Resident Nursing Instructions for Resident #1, it did not indicate how many staff were required to provide bed mobility care for Resident #1. However, Certified Nursing Assistant #1 received an in-service on Activities of Daily Living on [DATE], identifying that when a resident is totally dependent for care, they require two (2) or more staff assistance to complete the care. The Assistant Director of Nursing stated Certified Nursing Assistant #1, who has been employed by the facility for six months, was trained and given instructions to get a report from the charge nurse and to call for assistance. The Assistant Director of Nursing stated Certified Nursing Assistant #1 was responsible for reading the Resident Nursing Instructions prior to providing care. The Assistant Director of Nursing stated the nurse on the unit and the Nursing Supervisors are responsible for monitoring the staff to ensure care is being provided as indicated on the plan of care. They stated the facility concluded that neglect had occurred; the fall was avoidable, and Certified Nursing Assistant #1 should have asked for assistance from other staff during care. During an interview on [DATE] at 10:00 AM, the Administrator stated that they were notified of the incident on [DATE] by the Assistant Director of Nursing and Director of Nursing. The Administrator also stated that law enforcement was notified and came to the facility, where they took a report. The Administrator stated that Certified Nursing Assistant #1 was suspended and subsequently terminated for not following the plan of care. The Administrator stated that their view of the incident is that the facility is not culpable because Certified Nursing Assistant #1 received relevant training and in-services prior to the incident. During an interview on [DATE] at 2:56 PM, Nurse Practitioner #1 stated that they were notified of the accident and assessed Resident #1, who was observed with swelling to their right arm and complaints of pain. Nurse Practitioner #1 stated that they had ordered an x-ray and notified Resident #1's family member, who requested Resident #1 to be transferred to the hospital. Nurse Practitioner #1 stated the accident could have been avoided if Certified Nursing Assistant #1 had requested help. 10NYCRR 415.12(h)(1)

Based on record review and interviews conducted during the recertification and complaint (NY00324696 and NY00318663) survey from 3/3/2024 to 3/8/2024, the facility did not ensure that all alleged violations involving abuse were immediately reported to the New York State Department of Health, but not later than 2 hours after the allegation was made. This was evident for 3 (Resident #265, #181, and #66) of 38 total sampled residents. Specifically, 1) Resident #265's abrasion and bruise to their face and head of unknown origin were not reported to the New York State Department of Health, and 2) a resident-to-resident altercation between Resident #181 and #66 was not reported to the New York State Department of Health within 2 hours of occurrence. The findings are: The facility policy titled Abuse Prevention Program dated 1/2024 documented all reports of resident abuse, neglect, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies as defined by current regulations. 1) Resident #265 had diagnoses of non-Alzheimer's dementia and aphasia. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #265 was severely cognitively impaired. The Accident/Incident Report dated 9/18/2023 documented Resident #265 was observed with an abrasion and bruise on the left side of their face and back of their head. The Aspen Complaint Tracking System (ACTS) intake dated 9/22/2023 documented a complainant called to report Resident #265 was found with injuries of unknown origin to their face and head on 9/18/2023. There was no documented evidence Resident #265's injuries of unknown origin were reported to the New York State Department of health within 2 hours of discovery on 9/18/2023. During an interview on 3/8/2024 at 12:48 PM, the Director of Nursing stated they were informed of Resident #265's injuries on 9/19/2023, more than 2 hours after the injuries were discovered on 9/18/2023. The Director of Nursing was unable to explain the reason the facility did not report Resident #265's injuries of unknown origin to the New York State Department of Health. 48876 2) Resident #181 had diagnoses of non-Alzheimer's dementia and heart failure. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #181 had severe cognitive impairment and did not display behavioral symptoms. Resident #66 had diagnoses of Alzheimer's dementia and coronary artery disease. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #66 had severe cognitive impairment and displayed behavioral symptoms. An Accident/Incident Report dated 6/19/2023 documented staff responded to an altercation in the hallway between Resident #66 and Resident #181. Resident #66 alleged they were slapped in the face by Resident #181 and Resident #181 alleged Resident #66 threw coffee at them. The Facility Incident Report documented the facility reported the resident-to-resident altercation between Resident #66 and Resident #181 on 6/21/2023, more than 2 hours after the occurrence on 6/19/2023. On 3/8/2024 at 12:15 PM, the Director of Nursing was interviewed and stated they were aware they reported the resident-to-resident altercation between Resident #66 and Resident #181 to the New York State Department of Health more than 2 hours after the occurrence and this was not in compliance with the regulatory requirement to report abuse suspicion immediately, but not later than 2 hours of occurrence. 10 NYCRR 415.4(b)(2)

Based on observation, record review and interviews conducted during the Recertification survey from 3/3/2024 to 3/8/2024, the facility did not provide an environment that is free from hazards. This was evident for 1 (Resident #274) of 6 residents reviewed for accidents out of 38 total sampled residents. Specifically, Resident #274 was provided with a disproportionately smaller mattress atop a wider bedframe, a hazard increasing the resident's risk for falling from bed. The findings are: Resident #274 had diagnoses of coronary artery disease and dementia. The facility policy titled Bed Inspection and Maintenance revised 2/2024 documented the safety and comfort of the residents will be ensured by regularly inspecting and maintaining bedframes and mattresses upon admission, readmission, and during a periodic comprehensive audit including bed area assessment. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #274 had severe cognitive impairment. On 3/05/2024 at 11:23 AM, Resident #274 was observed in their room lying on a mattress that was approximately 4 inches smaller in width than the bedframe [NAME] out beneath it. Resident #274 appeared confused, sat up in bed, and attempted to stand up by swinging their legs over to one side of the bed and placing their feet on the exposed edge of the bedframe that the mattress did not cover. Resident #274 appeared unsteady and at risk for sliding or falling from the bed. Unit Nursing staff were made aware and Certified Nursing Assistant #11 and Registered Nurse #5 were observed entering Resident #274's room and assisting the resident with repositioning. The Comprehensive Care Plan related to falls last revised 3/2/2024 documented Resident #274 had actual falls on 2/12/2023, 4/14/2023, 11/13/2023, 12/12/2023, and 1/5/2024 due to cognitive impairment, poor coordination, and poor balance. Documented interventions included providing a hazard-free environment to Resident #274. The Accident/Incident Investigation Report dated 12/1/2023 and 1/5/2024 documented Resident #274 was found lying on their bedroom floor next to their bed. Resident #274 was unable to state what occurred due to cognitive impairment. An Annual Bed/Side Rail Audit dated 2/27/2024 documented the mattress in Resident #274's room was appropriate for the bedframe. There was no documented evidence Resident #274's mattress size was appropriate for their bedframe on 3/5/2024 and the size discrepancy was a fall-risk hazard. On 03/07/2024 at 2:38 PM, Certified Nursing Assistant #11 was interviewed and stated they were assigned to Resident #274 every day for approximately one week prior to 3/5/2024 and did not realize Resident #274's mattress was smaller than the resident's bedframe until Resident #274 was observed attempting to get out of bed unassisted. Certified Nursing Assistant #11 stated they provided Resident #274 with activity of daily living assistance and change their sheets frequently due to the resident's incontinence and did not notice the resident's mismatched mattress and bedframe sizes. On 03/08/2024 at 11:11 AM, Registered Nurse #5 was interviewed and stated Resident #274 was confused, at risk for falls, and hospitalized for falls. Registered Nurse #5 was called to Resident #274's room on 3/5/2024 because Resident #274 appeared to be at risk for falling from their bed. Resident #274 was seated at the edge of their mattress on one side of their bed with their right leg hanging down off the bed and their right foot touching the floor mattress. The mattress on the opposite side of the bed was tilted up off the bedframe and Resident #274 leaned on their right elbow for support. Resident #274 was in a slanted position at the edge of the mattress placing them at risk for falling off the bed. Registered Nurse #5 and Certified Nursing Assistant #11 assisted Resident #274 with sitting up in bed and repositioned the mattress to the center of the bedframe. Registered Nurse #5 informed Assistant Director of Nursing #1 about the resident's smaller mattress versus bedframe and the entire bed was changed. Registered Manager #5 did not notice Resident #274's mismatched mattress and bedframe sizes until 3/5/2024 and stated Resident #274 was at risk of falling off the bed or getting entrapped between the mattress and bedframe because the mattress was too small. On 03/08/2024 at 11:52 AM, Maintenance Worker #1 was interviewed and stated they completed bed size and safety audits for the entire facility on 2/27/2024 and Resident #274's mattress and bedframe size matched. Maintenance Worker #1 observed that Resident #274's bedframe was the same on 3/5/2024 but the mattress was different and no longer fit the bedframe. Maintenance Worker #1 was unable to determine how or when Resident #274's mattress was switched after the audit completed on 2/27/2024. On 03/07/2024 at 3:01 PM, an interview was conducted with Assistant Director of Nursing #1 who stated they were responsible for coordinating bed requests from the Maintenance Department during a resident's admission to the facility and as needed based upon the bed safety audits. Resident #274 was readmitted from the hospital on 2/20/2024 and their bed safety audit was completed 2/27/2024. The bed in Resident #274's room on 3/5/2024 was not the same bedframe and mattress observed during the 2/27/2024 audit. Assistant Director of Nursing #1 stated they were unable to explain how Resident #147's bedframe and mattress were switched since the audit on 2/27/2024. On 03/07/2024 at 4:10 PM, the Director of Maintenance was interviewed and stated they observed Resident #274's mismatched mattress and bedframe on 3/5/2024. Resident #274 had a 38-inch-wide mattress on a 42-inch-wide bedframe. The mattress was the facility's standard size. Standard bedframes measured 38-inches wide to match the standard size mattress. The bedframe in Resident #274's room was wider than standard size and did not match the mattress on top of it. On 3/08/2024 at 12:14 PM, the Director of Nursing was interviewed and stated bed sizes were checked upon a resident's admission to the facility and the Certified Nursing Assistants were responsible for checking bed safety when they cleaned resident's rooms. On 3/8/2024 at 12:30 PM, the Administrator was interviewed and stated that there is no formal process for checking bed safety and that they are in the process of putting a process in place to check new admission and readmission beds. The Administrator stated they were made aware of issues identified during the bed safety audits. 10 NYCRR 415.12(h)(1)

Based on record reviews and interviews conducted during the Recertification and Abbreviated survey (NY 038 and NY 716), the facility did not ensure that an alleged violations involving Abuse and serious bodily injury were reported to the New York State Department of Health (NYSDOH) within 2 hours. Specifically, (1) allegations of resident-to-resident abuse were not reported within 2 hours, and (2) incidents of resident-to-resident abuse and a fracture of unknown source were not reported. This was evident for 7 of 8 residents reviewed for Abuse (Resident #130, #131, # 191, #199, # 205, #536, and #386). The findings include but are not limited to: The facility policy titled Abuse Prevention Program with revised date 11/2017 documented that An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. 1) Resident #191 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE] identified Resident # 191 had severely impaired cognition with a Brief Interview of Mental Status score of 3 out of 15. Resident #130, the was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #130 cognition as intact with a Brief Interview for Mental Status (BIMS) score of 13. The facility Summary of Investigation dated 05/05/2020 documented that at 4:30 PM, Resident #191 was lying on Resident #130's bed. Resident #130 asked Resident #191 to leave, but it resulted in a physical altercation, and both residents had an injury. Resident #130 sustained 7.5 centimeters cut on the head with mild bleeding. Resident # 191 sustained a superficial linear skin tear above the left eyebrow and bruised with mild bleeding. The facility Summary of Investigation dated 05/08/2020 documented that at 3:25 AM, Resident #130 was sitting in front of the nurse's station. Resident #130 came out of the elevator and assaulted Resident #191 with a belt. Resident #191 sustained a 1-centimeter cut to the right forehead at the hairline, two superficial scratches to the forehead, and one superficial scratch to the left forearm The NYSDOH Intake Information form dated 05/13/2020 documented the facility reported the incident between Resident #191 and Resident #130 had a resident -to-resident altercation on 5/5/2020. The facility made no reference to the second altercation that occurred on 5/8/2020. The incident on 5/5/2020 was not reported within 2 hours, and the incident on 5/8/2020 was never reported. 2) Resident #205 was admitted to the facility on [DATE] with the diagnoses, including Heart Failure, Diabetes Mellitus, and Major Depressive Disorders. The MDS assessment dated [DATE] identified Resident # 205 had severely impaired cognition. The facility summary of investigation dated 08/05/2020 at 2:47 PM documented that Resident #205's wheelchair hit Resident #191's foot. A verbal altercation started and escalated to a physical altercation. Both residents sustained injury from the incident. The NYSDOH Intake Information form documented that the alleged incident occurred on 08/05/2020. The incident was reported to NYSDOH on 08/12/2020. During an interview on 02/04/2022 at 11:08 AM, the Assistant Director of Nursing #2 (ADNS #2) stated that the incident with Resident #130 and Resident #191 on 05/08/2020 was not reported because it was a related to the previous incident on 5/5/2020 with the same residents. ADNS #2 stated he/she reported the incidents late because they had to complete the investigation and obtain statements prior to reporting. During an interview on 02/04/2022 at 11:40 AM, the Director of Nursing (DON) stated that resident to resident altercations, abuse, and mistreatment should be reported to the Department of Health (DOH). The Administrator, DON, and ADONs are responsible for reporting incidents to DOH. The DON stated cases of confirmed abuse are supposed to be reported within two hours, and suspected abuse is reported within 24 hours. The facility has five days to complete the investigation. The incident between Resident #130 and Resident 191 on 05/08/2020 should have been included in the report on 05/12/2020, but it was not mentioned. The DON said that they recognized that their submissions were late and will take the concern to the Quality Assurance committee. During an interview on 02/04/22 at 12:11 PM, the Administrator stated that the DON, ADONs, and the Administrator are responsible for reporting incidents to the DOH. Resident to resident altercation is a reportable incident to rule out abuse. The incidents were not reported in time because it was the height of COVID. The Administrator said that there was no reason why the 05/08/2020 incident between Resident #130 and Resident #191 was not reported, and it should have been reported. The Administrator acknowledged that the facility submissions were late. 3) Resident #386 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #386 had severely impaired cognition with short-term memory problem. The MDS documented that resident required extensive assistance with one person assist for bed mobility, transfer, eating and toilet use. The resident required total dependence with one person assist for personal hygiene. The resident was frequently incontinent of urinary and always incontinent of bowel. On 1/31/22 at 11:13 AM, Complainant was interviewed via phone. Complainant stated that he/she was not notified of any accidents or incidents that led up to the event of hospitalization . Complainant stated he/she received a call on 4/2/20 when resident was being hospitalized for [CONDITION(S)]. The Comprehensive Care Plan (CCP) titled Fall Actual related to use of BP medication, dx of [CONDITION(S)], wandering episode, impaired balance and mobility, incontinence, fall risk = 5 was created on 5/13/2019 and revised on 3/20/20 with goal of no incidence of falls or serious injuries in the next 90 days. The interventions include family notification, MD evaluation and medical work up prn, keep resident's items within easy reach and level of vision, keep call bell within reach and answer promptly. The Nursing Note dated 4/1/20 at 9:07 PM, documented that Resident #386 was observed with right thigh swelling and resident complained of pain. Attending Physician was notified, and STAT ordered right hip and right femur x-rays and Tylenol for pain. The Physician Note dated 4/2/20 at 9:44 AM, documented Resident #386 was seen and was noted with shortened and externally rotated right hip and tenderness to the right hip. Review of x-ray report dated 4/2/20 revealed the radiographs of the right hip demonstrate an acute comminuted fracture of the right femur. The Nursing Note dated 4/2/20 at 7:29 PM, documented Attending Physician was informed of positive x-ray result for fracture. Resident #386 to be transferred to hospital for further evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician Note dated 4/2/20 at 7:39 PM, documented Resident #386 had a right hip fracture and was transferred to the hospital for evaluation. There was no documented evidence in the medical record that the resident had any accidents or falls from 3/30/20 to 4/1/20. This fracture of unknown origin was not reported to the NYSDOH or the administration. An Accident/Incident (A/I) Investigation written by the Assistant Director of Nursing (ADON #1) was initiated on 4/3/20 after a phone call was received from the designated representative. The A/I documented ADON #1 received a call from Resident #386's designated representative on 4/3/20. The representative was upset regarding Resident s#386's transfer to the hospital. ADON #1 informed the NOK that an investigation is on-going. The investigation documented RN #2 was interviewed, and the facility's surveillance camera was reviewed. The summary documented that RN #2 was interviewed and stated Resident #386 had a fall incident during RN #2's tour on 3/30/20. Resident #386 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/2/22 at 3:09 PM, Assistant Director of Nursing (ADON #1) was interviewed. ADON #1 stated when a resident was noted with a serious bodily injury of unknown origin, the resident's representatives were notified immediately and document in the nurse's note. It is the licensed unit nurse who will complete A/I Report and notify nursing supervisor on duty, attending physician, and resident's representative. Nursing A/I Investigation for all accidents are also completed by RN Supervisor. ADON #1 stated that ADON #1 received a call on 4/3/20 from Resident #386's designated representative who was very upset about Resident #386's hospitalization . ADON #1 stated that it was then the investigation was initiated. ADON #1 also stated after interview with the RN on duty and reviewing the camera footage, Resident #386 was observed getting up from the wheelchair and lost balance and fell to the floor. Therefore, it was ruled out that there was no alleged abuse, mistreatment, or neglect. ADON #1 stated that Resident #386's A/I Report was not found in the binder located in the Nursing Office. On 2/3/22 at 10:23 AM, Registered Nurse (RN #2) was interviewed via phone. RN #2 stated RN #2 was on duty during 7 AM to 3 PM on 3/30/20. RN #2 stated Resident #386 was trying to get up from the wheelchair and fell on the floor. RN #2 stated A/I Report was completed as per protocol but could not recall the names of CNAs assigned to the unit on the day of the incident. RN #2 stated the nursing supervisor was informed but does not recall the name of the nursing supervisor. On 2/04/22 at 9:28 AM, the Registered Nurse Supervisor (RN #1) who worked on 3/30/2020 was interviewed. RN #1 stated they could not recall any fall occurring for Resident #386, and no fall was reported to him/her on 3/30/2020. 415.4(b)(2)

Based on record review and interviews during the Recertification and Complaint surveys (NY 417 and NY 710), the facility did not ensure that residents' representatives were immediately notified about residents' change of condition. Specifically, 1) the facility did not notify the resident's representative immediately when a resident was diagnosed with a urinary tract infection and treated with IV antibiotics; (2) the facility did not notify the resident's representative immediately after a resident had a fall. This was evident for 2 of 2 residents reviewed for notification of change out of a sample of 35 residents (Resident #73 and Resident #386) The findings are: The facility's policy and procedure entitled Notification of hospitalization /Change in Condition revised on 6/16 documented: It is the facility's policy to inform a resident's family of all transfers to the hospital, significant changes in physical, mental, and/or psychosocial status, use of [CONDITION(S)] medication, antibiotic therapy, weight loss, alteration in skin integrity, accidents, incidents, change in plan of care, outside clinic appointment, diagnostic testing, change in room or roommate, change in a resident's right. It further documented that the Nurse Manger/ Designee will attempt to call the family as soon as possible after a change has occurred and notification will be documented in a nurse's notes and to include the name of person notified. 1) Resident #73 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #73 had intact cognition. The Comprehensive Care Plan (CCP) titled Infection: diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions include administer medications as ordered. Collect urine specimen for culture and sensitivity testing carefully and promptly. Encourage frequent voiding to promote bladder emptying. Encourage increased fluid intake as medically applicable. Maintain infection control practices through proper handwashing. Monitor for signs and symptoms of side effects of antibiotics. Monitor for signs and symptoms of urinary tract infection such as painful urination, frequency, and urgency etc. Monitor laboratory report for WBC, urinalysis or culture as ordered. Monitor vital signs as ordered. Provide prompt perineal care and change diaper as needed. The Physician Note dated 12/28/20 at 3:11 PM, revealed resident's diagnostic result. It documented Urine Culture result of Proteus Mirabilis greater than 100,000 COL/ML. Urinalysis report of Glucose, Protein, Leukocyte Esterase were noted for abnormal in value. Microscopy report of [MEDICATION(S)], WBC, RBC, BACT, CASTS were noted for abnormal in value. It further documented resident to start [MEDICATION(S)] 500 mg IV q 6 hours for 5 days for [CONDITION(S)]. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nursing Note dated 12/29/20 at 6:47 AM, documented resident to start [MEDICATION(S)]-[MEDICATION(S)] 500 mg by intravenous route every 6 hours for 7 days for [CONDITION(S)]. The Nursing Note dated 12/29/20 at 3:09 PM, documented peripheral line was successfully inserted on right hand with good outflow, IV ABT therapy started as initial dose due to [CONDITION(S)]. The Nurse Practitioner Note dated 12/29/20 at 7:45 PM, documented resident seen for follow-up and to monitor [CONDITION(S)], IV antibiotics ordered. The Nursing Note dated 12/30/20 at 2:33 AM, documented day 1/7 on [MEDICATION(S)]-[MEDICATION(S)] 500 mg by intravenous route every 6 hours for [CONDITION(S)]. The Nursing Note dated 12/31/20 at 4:16 AM, documented day 2/7 on [MEDICATION(S)]-[MEDICATION(S)] 500 mg by intravenous route every 6 hours for [CONDITION(S)]. Review of Nursing Notes dated from 12/28/20 through 12/30/20 revealed no documented evidence that the resident's representative was informed of the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/04/22 at 8:56 AM, Registered Nurse Supervisor (RN #1) was interviewed. RN #1 stated that if resident is diagnosed with [CONDITION(S)], and being treated with antibiotic therapy, the resident's representatives should be notified immediately. RN #1 also stated that resident's family notification should be documented in the nurse's note. RN #1 was asked to display documented evidence of family notification in the nurse's notes dated from 12/28/20 to 12/30/20. RN #1 was not able to provide the documented evidence in the nurse's notes dated from 12/28/20 to 12/30/20. On 2/4/22 at 12:15 PM, the Director of Nursing (DON) was interviewed. DON stated the nursing supervisor and licensed unit nurse are responsible for notifying resident representatives, usually the same day, when there is a significant change in status such as a fall, accident, or antibiotic therapy. The DON stated if a resident has a significant change in status or is started on antibiotic therapy, the resident's representative is notified immediately, and the notification is documented in the nurse's note. The DON was not aware that Resident #73's representative was not informed when Resident #73 was diagnosed with a [CONDITION(S)] and started on antibiotic therapy. 2) The facility's policy and procedure entitled Accident/Incident Investigations revised 2/17 documented the accident/incident report is completed for all occurrences of bruises or abrasions; all accidents or incidents where there is injury or the potential to result in injury; all accident where there is no apparent injury. It documented Licensed Unit Nurse completes the Accident/Incident Report, notifies Physician or Nurse Practitioner and family, documents in the nurses' notes an accurate, objective description of the occurrence, results of ROM, body exam and vital signs, treatment done, notification of physician and family (name the family member). Nursing Q.A. Investigation form is also completed by RN Supervisor for all accidents. It further documented that Accident/Incident report and Q.A. Investigation are submitted to the DNS within 24 hours for review and signed by the Director of Nursing, the Medical Director, and the Administrator to rule out any evidence of abuse, neglect, mistreatment, or misappropriation of property. Resident #386 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #386 had severely impaired cognition with short-term memory problem. The MDS documented that resident required extensive assistance with one person assist for bed mobility, transfer, eating and toilet use. The resident required total dependence with one person assist for personal hygiene. The resident was frequently incontinent of urinary and always incontinent of bowel. The Comprehensive Care Plan (CCP) titled Fall Actual related to use of BP medication, dx of [CONDITION(S)], wandering episode, impaired balance and mobility, incontinence, fall risk = 5 was created on 5/13/2019 and revised on 3/20/20 with goal of no incidence of falls or serious injuries in the next 90 days. The interventions include family notification, MD evaluation and medical work up prn, keep resident's items within easy reach and level of vision, keep call bell within reach and answer promptly. The Nursing Note dated 4/1/20 at 9:07 PM, documented that Resident #386 was observed with right thigh swelling and resident complained of pain. Attending Physician was notified, and STAT ordered right hip and right femur x-rays and Tylenol for pain. The Physician Note dated 4/2/20 at 9:44 AM, documented Resident #386 was seen and was noted with shortened and externally rotated right hip and tenderness to the right hip. Review of x-ray report dated 4/2/20 revealed the radiographs of the right hip demonstrate an acute comminuted fracture of the right femur. The Nursing Note dated 4/2/20 at 7:29 PM, documented Attending Physician was informed x-ray result and ordered Resident #386 to be transferred to the hospital for further evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician Note dated 4/2/20 at 7:39 PM, documented Resident #386 had a right hip fracture and required transfer to the hospital for evaluation. The Nursing Note dated 4/2/20 at 6:44 PM, documented a transfer/discharge notice was issued to resident's family representative. An Accident/Incident (A/I) Investigation written by the Assistant Director of Nursing (ADON #1) was initiated on 4/3/20 after a phone call was received from the designated representative. The A/I documented ADON #1 received a call from Resident #386's designated representative on 4/3/20. The representative was upset regarding Resident s#386's transfer to the hospital. ADON #1 informed the NOK that an investigation is on-going. The investigation documented RN #2 was interviewed, and the facility's surveillance camera was reviewed. The summary documented that RN #2 was interviewed and stated Resident #386 had a fall incident during RN #2's tour on 3/30/20. Resident #386 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] There was no documentation in the medical record that Resident #386 had a fall on 3/30/20 or was assessed by RN #2. In addition, there was no documented evidence the residents's designated representative was informed that a fall occurred. On 1/31/22 at 11:13 AM, Complainant was interviewed via phone. Complainant stated that he/she was not notified of the occurrence that led up to the event of hospitalization . Complainant stated he/she received a call on 4/2/20 when resident was being hospitalized for fractured hip. On 2/3/22 at 10:23 AM, Registered Nurse (RN #2) was interviewed via phone. RN #2 stated RN #2 was on duty during 7 AM to 3 PM on 3/30/20. RN #2 stated Resident #386 was trying to get up from the wheelchair and fell on the floor. RN #2 stated A/I Report was completed as per protocol but does not recall the names of CNAs assigned to the unit on the day of the Resident #386's fall. RN #2 stated nursing supervisor was informed but does not recall the name of the nursing supervisor. On 2/04/22 at 9:28 AM, Registered Nurse (RN #1) was interviewed. RN #1 stated the accident occurred on 3/30/20 for resident 386 was not reported to RN #1. RN #1 does not recall this incident. On 2/4/22 at 10:00 AM, the Attending Physician (AP) was interviewed. The AP stated when they are informed of a resident's accident or fall with injury or without injury, he/she will initiate the treatment and any orders on the same day. The AP stated x-rays were ordered for Resident #386 on 4/1/20. The AP stated he/she was probably not informed of the resident's injury prior to 4/1/20. On 2/4/22 at 12:15 PM, the Director of Nursing (DON) was interviewed. DON stated if resident had an accident, licensed unit nurse is responsible to notify MD, nursing supervisor, and family representative and complete Accident/Incident report immediately. 415.3(e)(2)(ii)(ab)

Based on record review and staff interview conducted during the Recertification and Abbreviated survey (NY 716), the Facility did not ensure that a resident was free from Physical Abuse. Specifically, Resident #191, a confused resideent, had a physical altercation with Resident #130 on 5/5/2020. On 05/08/2020 at 3:25 AM, Resident #191hit by Resident #130 with a belt buckle in a second altercation and sustained a 1-centimeter (cm) cut to the right forehead and scratches on the forehead and left forearm. This was evident in 1 out of 8 residents reviewed for Abuse out of 38 sampled residents (Resident # 191). The Findings include: The facility policy and procedure titled Abuse Prevention Program with a revised date 11/2017 state that the residents have a right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility administration will protect residents from abuse by anyone including but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individuals. The policy defines abuse as the willful infliction of injury, resulting in physical harm, pain, or mental anguish. Resident #130, the Aggressor, was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) dated [DATE] identified Resident #130 cognition as intact with a BIMS score of 13. Resident #191, the Victim, was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) assessment dated [DATE] identified Resident #191 cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of 3. The Abuse/Altercation Care Plan was initiated on 09/05/2017. The interventions included provide emotional support and monitor resident's interaction with peers and remove from potential danger. A care plan note dated 05/08/2020 documented that Resident #191 was hit with a belt buckle by Resident #130 while sitting at the nursing station. A Nurse's Progress Note dated 05/05/2020 at 5:59 PM documented that around 4:30 PM Resident #191 had physical altercation with Resident #130 in Resident #130's room. Resident #191 and Resident #130 were observed on Resident #130's bed punching each other. Resident #191 was holding a belt during the altercation. The residents were quickly separated. Resident #191 was noted with a superficial linear skin tear above the left eyebrow and bruise with mild bleeding. Resident #130 was noted with a cut on top of the head approximately 7.5 cm (centimeter). with mild bleeding and redness on the right lower back. The Accident/Incident report and Investigation dated 5/5/2020 documented Resident #130 would be placed on hourly monitoring, use of wander guard at all times, and unit staff would alert front desk if Resident #130 leaves the unit. The corrections also included the front desk would notify unit when Resident #130 leaves first floor. Resident #191 had a room change to the west building. A Nurse's Progress Note dated 05/06/2020 at 10:13 PM documented that Resident #191 was post in-house transfer. A Nurse's Progress Note dated 05/08/2020 at 4:24 AM documented that Resident #191 was sitting in a chair at the nursing station in the hallway for safety monitoring secondary to wandering on the new unit in the west building. At 3:25 AM, Resident #130 from the East building got off the elevator and started hitting Resident #191 with a belt buckle. Resident #191 sustained a 1 cm cut to the right forehead at the hairline, two superficial scratches to the forehead, and one superficial scratch to the left forearm. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #191 had a mild bruise under the left eye and cut to the forehead. The treatment plan included neurological checks and vital signs for 72 hours. During an interview on 02/04/2022 at 8:55 AM, Registered Nurse #4 (RN #4) stated that Resident #130 left the unit during the night. The front desk and the supervisor were informed that Resident #130 was off the unit. During an interview on 02/04/2022 at 11:08 AM, the Assistant Director of Nursing #2 (ADNS #2) stated that the incident was related to a previous altercation, and Resident # 191 was moved to the west building. Resident # 130 went to the west building around 3:25 AM. Resident # 191 was sitting in a chair at the nursing station, and when the elevator opened, Resident # 130 proceeded to hit Resident # 191. Resident # 130 ignored the nurse and proceeded to hit Resident # 191. The residents were separated, and assessment revealed that Resident # 191 sustained a 1cm cut to his right forehead and a superficial scratch to the left forearm and forehead. The investigation concluded that because both residents had dementia, there was no abuse in the case. During an interview on 02/04/22 at 11:40 AM, the Director of Nursing (DON) stated that the facility investigation concluded that it was a Resident-to-Resident Altercation, but not abuse. 415.4(b)(1)(i)

Based on record review and interviews during the Recertification and Complaint survey (NY 710), the facility did not ensure that all allegations of abuse and neglect, including injuries of unknown source, were thoroughly investigated. Specifically, a fracture of unknown origin was not thoroughly investigated to rule out abuse or neglect. This was evident for 1 of 13 residents reviewed for Accident out of a sample of 35 residents (Resident #386). The finding is: The facility's policy and procedure entitled Accident/Incident Investigations revised 2/17 documented Accident/Incident(A/I) Report is completed for all occurrences of bruises or abrasions; all accidents or incidents where there is injury or the potential to result in injury; all accident where there is no apparent injury. Licensed Unit Nurse completes the A/I Report, notifies Physician or Nurse Practitioner and family, documents in the nurses' notes an accurate, objective description of the occurrence, results of ROM, body exam and vital signs, treatment done, notification of physician and family (name the family member). Nursing A/I Investigation is also completed by RN Supervisor for all accidents. It further documented that A/I report and A/I Investigation are submitted to the DNS within 24 hours for review and signed by the Director of Nursing, the Medical Director, and the Administrator to rule out any evidence of abuse, neglect, mistreatment, or misappropriation of property. Resident #386 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #386 had severely impaired cognition with short-term memory problem. The MDS documented that resident required extensive assistance with one person assist for bed mobility, transfer, eating and toilet use. The resident required total dependence with one person assist for personal hygiene. The resident was frequently incontinent of urinary and always incontinent of bowel. On 1/31/22 at 11:13 AM, Complainant was interviewed via phone. Complainant stated that he/she was not notified of any accidents or incidents that led up to the event of hospitalization . Complainant stated he/she received a call on 4/2/20 when resident was being hospitalized for [CONDITION(S)]. The Comprehensive Care Plan (CCP) titled Fall Actual related to use of BP medication, dx of [CONDITION(S)], wandering episode, impaired balance and mobility, incontinence, fall risk = 5 was created on 5/13/2019 and revised on 3/20/20. Interventions of family notification, MD evaluation and medical work up prn, keep resident's items within easy reach and level of vision, keep call bell within reach and answer promptly. The Nursing Note dated 4/1/20 at 9:07 PM, documented that Resident #386 was observed with right thigh swelling and resident complained of pain. Attending Physician was notified, and STAT ordered right hip and right femur x-rays and Tylenol for pain. The Physician Note dated 4/2/20 at 9:44 AM, documented Resident #386 was seen and was noted with shortened and externally rotated right hip and tenderness to the right hip. The x-ray report dated 4/2/20 documented the radiographs of the right hip demonstrate an acute comminuted fracture of the right femur. The Nursing Note dated 4/2/20 at 7:29 PM, documented Attending Physician was informed of positive x-ray result for fracture. Resident #386 to be transferred to St. Joseph Medical Center for further evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician Note dated 4/2/20 at 7:39 PM, documented Resident #386 had a right hip fracture and was transferred to the hospital for evaluation. There was no documented evidence in the medical record that the resident had any accidents or falls from 3/30/20 to 4/1/20. This fracture of unknown origin was not reported to the NYSDOH or the administration. An Accident/Incident (A/I) Investigation written by the Assistant Director of Nursing (ADON #1) was initiated on 4/3/20 after a phone call was received from the designated representative. The A/I documented ADON #1 received a call from Resident #386's designated representative on 4/3/20. The representative was upset regarding Resident s#386's transfer to the hospital. ADON #1 informed the NOK that an investigation is on-going. The investigation documented RN #2 was interviewed, and the facility's surveillance camera was reviewed. The summary documented that RN #2 was interviewed and stated Resident #386 had a fall incident during RN #2's tour on 3/30/20. Resident #386 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] There was no documented evidence staff interviews were conducted for staff who worked on the unit during the shifts on 3/30/2020, 3/31/2020, and 4/1/2020 to rule out abuse, neglect, or mistreatment. On 2/2/22 at 3:09 PM, the Assistant Director of Nursing (ADON #1) was interviewed. ADON #1 stated if a resident has a fall with or without injury, the resident's representative should be notified immediately, and the notification should be documented in the nurse's note. The licensed nurse should complete the A/I Report and notify the nursing supervisor on duty, attending physician, and the resident's representative. A Nursing A/I Investigation for all accidents should be completed by RN Supervisor. ADON #1 stated that ADON #1 received a call on 4/3/20 from Resident #386's designated representative who was very upset about Resident #386's hospitalization . ADON #1 stated they were not aware of the injury or hospitalization prior to the call, and an investigation was initiated at that time. ADON #1 stated they learned Resident #386 got up from the wheelchair, lost their balance and fell to the floor on 3/30/20 after reviewing the camera footage and interviewing the Registered Nurse (RN #2) on duty. ADON #1 stated no A/I report was found in the Nursing office related to the fall on 3/30/20. ADON #1 stated they concluded no abuse ocurred because the resident was probably injured in the fall on 3/30/2020. On 2/3/22 at 10:23 AM, Registered Nurse (RN #2) was interviewed via phone. RN #2 stated RN #2 was on duty during 7 AM to 3 PM on 3/30/20. RN #2 stated Resident #386 was trying to get up from the wheelchair and fell on the floor. RN #2 stated A/I Report was completed as per protocol but does not recall the names of CNAs assigned to the unit on the day of the Resident #386's fall. RN #2 stated nursing supervisor was informed but does not recall the name of the nursing supervisor. RN #2 state the resident's family was called, but they were not available. RN #2 admitted they did not make any documentation regarding the incident in the medical record. On 2/04/22 at 9:28 AM, the Registered Nurse Supervisor (RN #1) was interviewed. RN #1 stated they could not recall any fall occurring for Resident #386, and no fall was reported to him/her on 3/30/2020. On 2/4/22 at 10:00 AM, the Attending Physician (AP) was interviewed. The AP stated when they are informed of a resident's injury, he/she will initiate the treatment and any orders on the same day. The AP stated x-rays were ordered for Resident #386 on 4/1/20. The AP stated he/she was probably not informed of the resident's injury prior to 4/1/20. On 2/4/22 at 12:15 PM, the Director of Nursing (DON) was interviewed. DON stated that it is the facility's policy that the Director of Nursing, Medical Director, and Administrator review all A/I Reports and A/I Investigations. The DON stated that the Medical Director who worked during the time of the fall is no longer working at the facility. 415.4 (b)(3)

Based on observation, record review, and interview conducted during the Recertification survey, the facility did not ensure that the assessment accurately reflected the resident's status. Specifically, a resident's wander guard was not captured on the Minimum Data Sets (MDS). This was evident for 1 of 13 residents reviewed for Accidents out of total sample of 35 residents (Resident # 184). The findings are: The facility policy and procedure titled Resident Assessment MDS 3.0 revised 11/2021, documented: All persons who have completed any portion of the MDS resident assessment forms must sign and document attesting to the accuracy of such information. and The results of the assessments are used to develop, review and revise the resident's comprehensive care plan. Resident #184 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/02/22 at 3:16 PM, Resident #184 was observed wandering in the hallway and then standing in another resident's doorway. MD orders dated 12/14/2021 and renewed 1/11/22 documented: Wanderguard to right ankle for elopement risk. The Comprehensive Care Plan (CCP) for Wandering/Elopement Risk, created on 12/14/21, documented: Wanderguard placed to right ankle and check on the beginning and at the end of each shift. The Certified Nurse Aide (CNA) documentation history dated 12/14/2021-12/31/2021, documented Wanderguard in place. The Resident Nursing Instructions dated 12/14/21 -12/31/21 documented: Wanderguard placed to right ankle and check on the beginning and at the end of each shift. The Admission MDS dated [DATE] documented in Section P0200 Alarms that the resident did not use a Wander/elopement alarm. The MDS did not accurately capture that the resident used a Wanderguard daily. On 02/04/22 at 9:26 AM, MDS Coordinator (MDSC) was interviewed. MDSC stated that Section P of MDS which captures Restraints and Alarms is completed by the MDS Assessor (MDSA). MDSC also stated the MDSA did not capture Wander/elopement alarm during the 7 day look back period for the Admission MDS dated [DATE]. MDSC further stated that the MDSA was instructed to review CNA Documentation, Physician orders, Care plans, and progress notes when completing the MDS. On 02/04/22 09:53 AM, (CNA) #2 Interviewed. CNA #2 stated resident has a Wanderguard and has had it for a couple of months. CNA #2 further stated the resident's Wanderguard is checked for placement at 7:00 AM and at 3:00 PM. The resident's Wanderguard is checked around the clock. This is documented in the computer. On 02/04/22 at 9:59 AM, MDSA was interviewed. Wanderguard is documented in the doctor's order dated 12/14/21. I missed coding Wanderguard in section P on Admission MDS dated [DATE]. MDSA also stated we were instructed to check doctor's orders, assess resident, CNA documentation, and progress notes when completing MDS. MDSA further stated there is a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . I am responsible for accuracy of this section since I signed for it. On 02/04/22 at 1:31 PM, Assistant Director of Nursing (ADNS) was interviewed. ADNS stated resident #184 is a wanderer with a wander guard in place. ADNS also stated the Assessors are responsible for coding the MDS Assessments. The Wanderguard should have been coded in the MDS. ADNS further stated there is documentation on resident's wander guard to check placement at beginning and end of every shift. The CNA documentation history dated 12/14/2021-12/31/2021, documented a G in Safety section for alarms which indicates Wanderguard is present. 415.11(b)

F689- S/S = L Free of Accident Hazards/Supervision/Devices The Citadel Rehab and Nursing Center at Kingsbridge NY 906 Based on observation, interviews and record review conducted during an abbreviated survey (Complaint # NY 906) from [DATE] to [DATE], the facility staff failed to provide adequate supervision and an environment free from accident hazards. Specifically, new windows were installed in the resident's fourth floor room during a project completed from [DATE] to [DATE]. The facility failed to ensure the window's safety latch was in place to prevent the window from tilting into the room and fully opening. The resident was identified as being at risk for elopement due to increased wandering, frequent expressions of a desire to leave the facility, and attempts to leave the facility through the stairwell. The Wandering/Elopement Comprehensive Care Plan, initiated [DATE], included the interventions of a wander guard and half hour visual checks. On [DATE], the resident was observed wandering on the unit, searching for exits, and holding a call bell cord and heavy-duty extension cord. The Physician was not notified of the increase in exit seeking behaviors, and the CCP was not updated. The surveillance video dated [DATE] at 12:20 a.m., showed the resident opened the window, threw tied sheets out, and climbed out the window. The Half-Hourly Visual Check sheet indicated the resident was last seen by staff on [DATE] at 4:00 a.m. The resident fell to the ground and was not found by staff until 4:30 a.m. The resident was transferred to the hospital and expired on [DATE]. This resulted in IMMEDIATE JEOPARDY and SUBSTANDARD QUALITY OF CARE with actual harm to Resident #1 and the potential for serious harm to resident health and safety. The findings are: Review of the facility's policy entitled Elopement Prevention Plan Policy last revised on [DATE] included but was not limited to the following specifications: Residents of the facility will be maintained in a safe and secure manner and protected from actual harm. The facility will make every effort to identify residents who have the potential for elopement. Residents will be assessed on admission and no less than quarterly for the potential for elopement via direct observation, history. The resident's cognitive ability and mood state will be taken into consideration. If a resident continually tries to leave the unit or building, he/she may require visual checks at an established time interval such as every half hour. Review of the facility's policy entitled Interim Life Safety Plan Policy last revised in ,[DATE] documented that the contractors and facility managers will meet prior to the beginning of construction and decide upon the interim life safety measures to implement to ensure that the project runs smoothly and safely. Also, to ensure that no resident services are disrupted or negatively affected during construction. It is the responsibility of employees to report any conditions to their superiors that they deem possibly dangerous or hazardous to residents or staff. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated [DATE] documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of ,[DATE], associated with moderately impaired cognition. The MDS documented that Resident #1 had no behavioral symptoms. Review of a Behavior Care Plan initiated on [DATE] documented Resident #1's mood fluctuated, resisted activities of daily living assistance, wandering, verbalized intent to harm self, attempts to open exit doors. Interventions included: redirect negative behaviors, provided emotional support, provided 1:1 observation/visit, administered medications as ordered by Physician, Psychiatry and Social Service follow up. Review of the Weekly Behavior note dated [DATE] at 11:20 p.m. documented that Resident #1 wandered and had little interest in doing things. Review of the Nursing Progress Note dated [DATE] at 6:12 p.m. documented that Resident #1 was monitored for wandering in the hallway and attempted at exiting the unit. Review of the Activities assessment dated [DATE] documented that Resident #1 reported wanting to leave the facility. Resident#1 packed up their personal belongings. Review of the Nursing Progress Note dated [DATE] at 12:32 p.m. documented that Resident #1 was observed crying, restless and holding packed personal belongings. Begged staff to be released home. In collaboration with Social Worker and resident's daughter, resident cannot be discharged to home due to safety issues and history of violent behavior towards their spouse resident #1 verbalized that someone outside of the facility told resident to take their own life. Resident #1 was constantly crying and in a depressed mood. Primary Medical Doctor ordered to transfer the resident to hospital with suicidal ideation. Resident #1 was holding a paper in their hand with the National Suicide Prevention Hotline. Resident #1 was informed and requested transfer to hospital where the resident was admitted from (NYP Lower Manhattan). Review of the Nursing Progress Note dated [DATE] at 2:24 p.m. documented that Resident #1 was transferred to hospital by ambulance. Review of the Nursing Progress Note dated [DATE] at 8:48 p.m. documented that Resident #1 returned to facility by ambulance with no documents from hospital. Resident #1 was calm, and a wander guard was in place. Review of the physician's orders [REDACTED]. Review of the Nursing Progress Note dated [DATE] at 9:32 a.m. documented that Resident #1 was found on 3rd floor stairway with their personal belongings, half hourly was monitoring in progress. Review of the Elopement Risk assessment dated [DATE] documented: Resident #1 asked about how to leave the facility, wandered, had exit seeking behavior, verbalized desire to leave, had history of elopement or elopement attempts, exhibited restlessness or agitation and was unhappy with placement. Resident #1 was placed on elopement risk, wander guard applied to right wrist. Review of Resident Nursing Instructions entered on [DATE] documented half hourly visual checks, wandering, elopement risk with wander guard, attempted to open exit doors. Redirect to room, monitor resident's whereabouts. History of suicidal ideation. Review of a Wandering/ Elopement Risk Care Plan initiated on [DATE] documented goals that Resident #1 would wander safely on unit and would not wander out of the facility for next 90 days. The interventions included apply wander guard to right wrist, check for placement at the beginning and end of each shift, half hourly visual check and provide picture at security desk. Review of the Nursing Progress Note dated [DATE] at 10:34 p.m. documented that at approximately 9:02 p.m., Resident #1 was observed heading to the exit door and was redirected. Review of Psychology Consult dated [DATE] at 4:51 p.m. documented Primary Psychological [DIAGNOSES REDACTED]. Reason for referral-resident reported resident wanting to commit suicide when frustrated with family. Clinical interventions included: cognitive behavior therapy and coping skills training, provide empathetic listening and statements to facilitate adjustment, provide low stimulation environment, provide simple concrete explanations, provide positive reinforcement and redirection, consider Psychiatry follow up. Review of the Resident Medication Administration Record [REDACTED] A Nursing Progress Note dated [DATE] at 3:37 p.m. documented that Resident #1 tried to go on the elevator and was redirected. A broken glass vase was noted in Resident #1's room and resident hid a piece in their drawer. Staff took the broken vase pieces and checked Resident #1's closet. Registered Nurse Supervisor (RNS) made aware. Review of the Half Hourly Visual Check sheets dated [DATE] 11:00 p.m. to [DATE] at 4:00 a.m. revealed that CNA #2 documented that Resident #1 was checked every half hour and was in their room. A Corrected Nursing Progress Note dated [DATE] at 7:02 p.m. (original [DATE] at 10:27 p.m.) documented that Resident #1 was alert and verbally responsive, ambulated in hallway. Observed Resident #1 peeping in construction area and visited an empty room twice. Earlier in shift, Resident #1's call bell rang. Observed Resident #1 fidgeting with cord and the cord bell was out of the wall. Once again during rounds, writer peeped in resident's room and observed a long construction cord on the floor with the resident's feet guarding it. Writer alerted staff and they took it from Resident #1 and placed it in the nurse's station. The resident was getting annoyed when checked on by staff. The Supervisor was informed and endorsed to incoming shift. A Nursing Progress Note dated [DATE] at 8:39 a.m. documented writer received a call from charge nurse on [DATE] at 4:20 a.m. that during the night shift, Resident #1 jumped out the window. Resident #1 was observed lying on their left side on the 2nd floor patio outside of a window below their room. Code blue and emergency medical system was activated, and Resident #1 was brought in the 2nd floor hallway. Emergency Medical Service (EMS) arrived on the unit as Resident #1 was still breathing and moving their legs. Resident #1 stopped breathing and Cardiopulmonary resuscitation was initiated. Review of the facility's Investigation Report dated [DATE] documented that at about 4:20 a.m., roommate went to Certified Nursing Assistant (CNA) to report that the window in the room was open and it was cold. Upon entering the room, CNA noted that Resident #1 was not in bed and the window was opened. The window was pulled down and tilted into the room. CNA called the nurse; Supervisor was informed, and search initiated. Resident #1 was found on the patio, alive, breathing. Emergency medical services were initiated. On [DATE] at 12:10 p.m., the surveillance video was viewed with the Administrator and revealed that: On [DATE] at 12:13 a.m., Resident #1 dropped 2 bags from the window, then sheets were seen hanging from the window. At 12:20 a.m., Resident #1 was seen falling from the window and landed on the ground. At 12:24 a.m. Resident #1 was kneeling, at 12:24:26 a.m., Resident #1 stood up and sat on a pallet with some construction materials. At 12:26 a.m., Resident #1 was seen mingling with a bag. At 12:28 a.m., Resident #1 was observed putting on a shoe on the left foot. At 12:32 a.m., Resident #1 observed trying to put on right-side shoe. At 12:38 a.m., Resident #1 observed talking off right shoe and putting on a slipper. At 12:39 a.m., Resident #1 picked up a bag. At 12:46 a.m., Resident #1 stood up and made approximately 4 steps then fell to the ground, noted lying on their left side. At 12:48 a.m., resident noted moving right arm and hitting body on the right side. At 12:49 a.m., no further motions noted from Resident #1. During interview on [DATE] at 3:30 p.m. and [DATE] at 4:10 p.m., the Maintenance Director stated that Resident #1 was able to fully tilt the window in a flat plane parallel to the floor and then tie the sheets to fully escape. Investigation of the window indicated a red streaking mark in the middle of the glass. On further interview with the Maintenance Director, he stated that these windows were installed on [DATE] and walk through were conducted by the contractor and by himself. The Maintenance Director stated that we were not aware of the Tilt mechanism of the windows and the only checked was for the 4-inch opening from the bottom of the window. The Maintenance Director also stated that a total of 176 new window was installed. During an interview on [DATE] at 3:40 p.m., Certified Nursing Assistant #3 (CNA #3) stated that they were regularly assigned to the unit during the evening shift. She was not assigned to Resident #1 but did monitor the resident. She further stated that during the evening shift on [DATE], Resident #1 wandered up and down the hallway several times. CNA #3 stated that she redirected Resident #1 to the resident's room several times during the shift. They last saw Resident#1 lying in bed just before she left at 11:00 p.m. During an interview on [DATE] at 3:45 p.m., Licensed Practical Nurse #2 (LPN#2) stated that she is regularly assigned to the unit on the evening shift. She stated that on the evening shift of [DATE], she instructed the staff to focus on monitoring Resident #1 since she was made aware that staff found broken glass in the resident's room. LPN #2 further stated that Resident #1 wandered on the unit several times during the shift and the staff saw the resident enter an empty room twice. Resident #1 was redirected by staff. LPN #2 stated that she responded to Resident #1's call bell during the shift and observed the resident fidgeting with the call light, which was out of the wall. LPN #2 further stated that she placed the call bell back in the wall. Resident #1 was also seen guarding a construction (electrical) cord with their foot in room during the shift which staff removed and informed the Supervisor. During interviews on [DATE] at 7:50 a.m. and [DATE] at 3:18 p.m., CNA #2 stated that she was not assigned to Resident #1. CNA#2 further stated that she monitored Resident #1 because the CNA #1 who was assigned to Resident #1 was new and didn't know the resident was supposed to be on half hour monitoring. CNA #2 also stated that she documented on Resident #1's Half Hourly Visual Check sheet from [DATE] at 11:00 p.m. to [DATE] at 4:00 a.m. She observed Resident #1 sleeping in bed at around 3:45 a.m. She also sat beside the resident's room during the shift. Resident #1's roommate called her around 4:20 a.m. and complained of feeling cold. CNA#2 checked the room and observed that the window was wide open, and Resident #1 was not in the room. CNA#2 stated that they alerted LPN #1. During an interview on [DATE] at 8:02AM, LPN #1 stated that she worked the night shift on [DATE] starting at 11:00 p.m. to 7:00 a.m. on [DATE]. She further stated that she observed Resident #1 asleep in their bed during rounds at the beginning of the shift. LPN #1 stated that she saw Resident #1 again in bed around 12:00 a.m. during medication administration. She stated, she saw resident sleeping during rounds at 12:30 a.m. LPN #1 stated that they last saw Resident #1 before she left for her break at 3:00 a.m., and resident was sleeping. She was called from her break at 4:20 a.m. by CNA#2 and went to Resident #1's room then alerted RNS #1 that Resident #1's was missing, and the bedroom window was open. At 5:00 p.m. a follow up interview was conducted with LPN #1. On inquiry, LPN#1 stated that they signed Resident #1's Visual Check from [DATE] at 11:00 p.m. until [DATE] at 3:30 a.m. She further stated that she documented in the 4:00 a.m. slot in error. During an interview on [DATE] at 9:20 a.m., RNS #2 stated that he is regularly assigned to the evening shift. RNS #2 further stated that he was aware that Resident #1 was on half hourly monitoring and had a wander guard in place. RNS #2 also stated that during the evening shift on [DATE], he was notified by LPN #2 that Resident #1 was observed playing with the call bell. He stated that he was not informed that Resident #1 had an electrical cord in their room. During an interview on [DATE] at 10:00 a.m., RNS #1 stated that she went to Resident #1's unit at around 3:00 a.m. on [DATE]. Resident #1's door was open, and CNA #2 was sitting across from the resident's room. RNS #1 was informed of the incident at around 4:20 a.m. RNS #1 asked another staff to call emergency medical system while she went towards the 2nd floor below the resident's room. They observed the resident lying on the ground on their left side, code blue was initiated. Staff brought the resident to the hallway on 2 West, the resident was breathing and moving their legs. Resident #1 was still breathing when emergency responders arrived and initiated Cardiopulmonary resuscitation on Resident #1 who was then taken to the emergency room . During an interview on [DATE] at 4:37 p.m., CNA#1 stated that she was assigned to Resident #1 during the night shift of [DATE]-[DATE]. CNA #1 verbalized that they received no verbal instructions from LPN #1 regarding Resident #1's risk for elopement. She stated that she observed Resident #1 in bed when they made rounds around 11:00 p.m. CNA#1 also stated that they observed Resident #1 lying in bed approximately 2 hours later. CNA#1 added that she did not document on the monitoring sheet. During observations conducted from [DATE] through [DATE], a sample of 44 rooms were observed by the surveyor. (20 of these rooms were observed while surveyor was accompanied by facility staff on various units). In addition, survey staff was accompanied by the Maintenance Director and another sample of 7 rooms were observed on [DATE]. All the windows were bolted to disable the tilt functionality of the windows with two ½ inch Philips head self-tapping screw with the thread size of #8 and all were secured. During an interview on [DATE] at 10:05 a.m., the Assistant Director of Nursing (ADON) stated that she was made aware of the incident on [DATE] at 4:30 a.m. She called the Administrator and the Director of Nursing. Resident #1 was already transferred to the hospital when she arrived. Resident #1 was on half hourly monitoring and the investigation revealed that the monitoring was not completed as scheduled. The charge nurse is responsible for ensuring and enforcing that the CNAs performed the rounds and documented on the half-hourly visual check sheets. The assigned CNA performs the half hourly visual checks. The surveillance camera review showed that Resident #1 attempted to elope through the window at 12:30 a.m. and the resident was not discovered missing until around 4:30 a.m. During an interview on [DATE] at 12:35 p.m. the Director of Nursing (DON) stated that the Assistant Director of Nursing informed her of the incident on [DATE] at 4:30 a.m. The DON stated that the facility had elopement risk care plan in place, but the CNAs and LPN #1 did not follow Resident #1's plan of care for monitoring. During the investigation, after surveillance video review, the facility found out that the staff on the unit were not truthful regarding Resident #1's visual monitoring; about the last time Resident #1 was visually seen and that the documentation was inaccurate. The video showed that Resident #1 successfully eloped through the window 4 hours before the resident was discovered missing. During an interview on [DATE] at 12:50 p.m. the Administrator stated that he was made aware of the incident around 4:30 a.m. on the morning of [DATE]. He arrived at the facility at around 5:15 a.m. On inquiry, the Administrator stated that the incident was a result of staff failure to perform the resident's monitoring and the windows did not have the anti-tilt feature. The Administrator stated that he was aware of Resident #1's desire to go home, the facility discussed the resident's desire with the resident's family, but the family refused to accept the resident back home. The Administrator also stated that the facility found out that the electrical cord that Resident #1 was found with on [DATE] was determined to be from the suction machine. The Administrator added that the cords are now placed in zip tied bags and secured to the suction machines. Immediate Jeopardy (IJ) was identified, declared, and the facility Administrator and DON were notified on [DATE] at 8:30 PM. The survey team declared the immediacy of the IJ had been abated after receiving an acceptable corrective action plan from the facility on [DATE] at 5:10 PM. On [DATE] at 5:30 PM, the survey team declared the IJ was removed as of [DATE] based on the following corrective actions taken by the facility: 1. During [DATE] to [DATE]: The facility Maintenance Director installed two (2) Scorpion Model Number DPZ716 #6 x ,[DATE]-inch Philips head self-tapping screws, thereby leaving the tilt feature of the all windows permanently disabled. 100% of staff the house were educated to never remove the screws that were placed to disable the tilting features. 100% of staff in house were educated to not attempt to clean windows from the inside using the tilting feature. 100% of staff in house are aware that window cleaning will only be performed from the building exterior. In house staff were in-serviced and education will be provided prior to the start of shift until 100% compliance is achieved. 2. The elopement risk assessment in the EMR was reviewed. All residents identified with a score of 3 or greater will be identified as requiring an IDT meeting. An IDT meeting will be held for all residents who demonstrate or verbalize exit-seeking behavior. During this IDT meeting, residents will be dentified in need for visual checks and individualized Plan of Care. 100% of team members have been in-serviced regarding this process and that it is effective imediately. All residents who require visual monitoring will have an order placed in EMR. The CNA instructions will indicate visual monitoring and frequency. The LPN will be required to sign every two hours to ensure that CNA completed visual monitoring and documentation. An audit tool was created and implemented for RN Supervisors to document every three hours that residents are on visual checks have the following processes in place. CNA assigned to resident will reviewed that visual check was performed. The Nurse signed visual monitoring in the Sigma documentation system. The RN Manager/Supervisor will visually checked resident to validate location in unit every three hours and apply a check mark to acknowledge time of visit. 3. The facility implemented education on the revised process. The Surveyors on site conducted interviews with 5 Housekeeping staff, 6 RN Supervisors, 2 RNs,7 LPNs and 13 CNAs. All persons were knowledgable of the updated process, accurate documentation with appropriate and timely visual and safety assessment of residents. 415.12(h)(1)(2)

Based on record review and staff interview during an Abbreviated Survey (NY 906), the facility in accordance with accepted professional standard and practices, failed to maintain medical records that are complete and accurately documented a resident Half-Hourly Visual Check Sheet for one out of five residents' medical records sampled. Specifically, the Half-Hour Visual Check sheet was signed from 12:30 AM to 4:00 AM with codes that the resident #1 was in his room while resident #1 was not in the room. Resident #1 climbed out of the window in his room. The surveillance video showed that Resident #1 successfully to eloped through his window four hours before the staff discovered that Resident #1 was missing. The findings include. The Facility's Policy and Procedure titled Charting and Documentation dated 2017 stated that all services provided to the resident, medical, physical functional, or psychological condition shall be documented in the resident medical record. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 02/02/2021 documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 12/15, associated with moderately impaired cognitition. The MDS documented that Resident # 1 had no behavioral symptoms. Wandering/ Elopement Risk Care Plan was initiated on 02/17/2021. The interventions include staff to apply a wander guard to the right wrist, check for placement at the beginning and end of each shift, and half-hourly visual check. A review of the physician's orders [REDACTED]. A review of the Resident Nursing Instructions dated 02/17/2021 documented half-hourly visual checks, wandering, elopement risk with wander guard, attempts to open exit doors. Redirect to room, monitor resident's whereabouts. A review of the Half Hourly Visual Check dated 02/21/2021 from 11:30 PM to 02/22/2021 at 4:00 AM documented that Resident #1 was in his room. A review of the Resident Medication Administration Record [REDACTED]. A review of the facility's Surveillance Camera Video revealed that on 02/22/2021 at 12:13 AM, Resident #1 dropped 2 bags from his window, then tied sheets were seen hanging from the window. At 12:20 AM, Resident #1 was seen falling from the window and landed on the ground' During an interview on 02/23/2021 at 4:37 PM, Certified Nursing Assistant #1 (CNA#1) stated that she was assigned to Resident #1 during the night shift 02/21/2021 to 02/22/2021. CNA #1 verbalized that they received no verbal instructions from LPN #1 regarding Resident #1's risk for elopement. She stated that they observed Resident #1 in bed when she made rounds around 11:00 PM. They observed Resident #1 lying in bed approximately 2 hours later. CNA #1 stated that she did not document on the monitoring sheet. During an interview on 02/23/2021 at 7:50 AM, CNA #2 stated that she was not assigned to Resident #1 but monitored the resident #1 because Resident #1 was on half-hourly monitoring. They observed Resident #1 sleeping in bed at around 3:45 AM. During a follow-up interview on 03/01/2021 at 3:18 PM, CNA #2 stated that they documented Resident #1's Half Hourly Visual Check sheet from 11:00 PM on 02/21/2021 to 02/22/2021 at 4:00 AM. CNA #2 further stated that she documented it for CNA #1 since CNA # 1 was new to the unit and did not know that Resident #1 was on half-hourly monitoring. During an interview on 02/23/2021 at 8:02 AM, Licensed Practical Nurse #1 (LPN #1) stated that she observed Resident #1 asleep in their bed during rounds at the beginning of the shift. She saw Resident #1 again in bed around 12:00 AM during medication administering. At 12:30 AM, during rounds, Resident #1 sleeping in bed. She stated that she last saw Resident #1 before they left for break at 3:00 AM, and Resident #1 was in bed sleeping. During a follow-up interview at 5:00 PM. LPN #1 stated that she signed Resident #1's half-hourly visual check in the MAR from 02/21/2021 at 11:00 PM until 02/22/2021 at 3:30 AM. She further stated that the documented in the 4:00 AM slot was an error. During an interview on 02/23/2021 at 10:00 AM, Registered Nurse Supervisor #1 (RNS #1) stated that she went to Resident #1's unit at around 3:00 AM on 02/22/2021. Resident #1's door was open, and CNA #2 was sitting across from the room. RNS #1 was informed of the incident at around 4:20 AM, During an interview on 02/23/2021 at 4:50 PM, Resident #1's roommate stated that aften being woken up on 02/22/2021 at around 4:00 AM, the room was cold and called the nurse. During an interview on 02/24/2021 at 10:05 AM, the Assistant Director of Nursing (ADON) stated that Resident #1 was on half-hourly monitoring. The investigation revealed that the monitoring was not done as scheduled. The charge nurse was responsible for ensuring that the CNAs perform the rounds and document the half-hourly visual check sheets. The surveillance camera review showed that Resident #1 eloped through the window since 12:30 AM, and was not discovered missing until around 4:30 AM. During an interview on 02/25/2021 at 12:35 PM, the Director of Nursing (DON) stated that the facility had an elopement risk care plan, but the CNAs and LPN #1 did not follow Resident #1's care plan for monitoring. During the investigation, after surveillance camera video review, the facility found out that the unit's staff were not truthful regarding Resident #1's visual monitoring; about the last time, Resident #1 was visually seen, and the documentation was inaccurate. The surveillance video showed that Resident #1 unsuccessfully to eloped through his window four hours before discovered missing. 415.22(a) (1-4)

Based on observations, staff interviews and record review conducted during an abbreviated survey (Complaint NY 818), the Facility did not ensure that a resident was free from physical abuse. This was evident in 1 of 4 residents sampled (Resident #1). Specifically, on 10/09/2020, Resident #1 slapped Certified Nursing Assistant #1 (CNA #1) and CNA #1 retaliated and slapped Resident #1 on the left cheek. Resident #1's eyeglasses fell on to the floor. The findings are: The Facility's Policy and Procedure entitled Abuse Prevention and Reporting, last revised 11/2016, states that the facility respects residents' right to be free from verbal, physical and mental abuse, neglect, corporal punishment, involuntary seclusion and misappropriation of resident property, maintaining a zero tolerance for violation of this right. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Date Set (MDS, a resident assessment tool) dated 10/16/2020 documented that Resident #1 had a Brief Interview for Mental Status (BIMS,) and scored 8/15, associated with severe impairment in cognition. Review of the Behavioral Care Plan, dated 10/05/2020, revealed that Resident #1 was verbally abusive (cursing/yelling); physically abusive (hits); had mood state issues (periods of crying then calmness, emotional lability); and was resistive to care. The interventions included redirecting negative behaviors, orienting to daily routine, honoring preferences in care routines and explaining procedures prior to initiating tasks. The Behavioral Care Plan also documented Special Needs, staff to redirect Resident #1 to her room when observed wandering and to approach the resident calmly. The Resident Nursing Instructions for Resident #1, initiated on 10/05/2020, reflected Resident #1's wandering and repetitive verbalizations. Instructions noted that staff should redirect Resident #1 to the room when observed wandering and to approach calmly. There were no instructions on the Resident Nursing Instructions for staff members to be aware that Resident #1 had violent behavior and could become aggressive. There were no instructions to staff members that Resident #1 was verbally and physically abusive. There were no instructions on what staff should do if the resident became physically abusive. A Nursing Progress Note dated 10/09/2020 at 12:11 PM states that at 10:45 AM, the Nursing Supervisor was informed that Resident #1 had had an episode of aggression towards staff and now resident alleged being hit back by staff. A Nursing Progress Note dated 10/09/2020 at 2:30 PM states that Resident #1's agitation continued to escalate and that the resident was increasingly aggressive upon redirection. The unit doctor was called and ordered a dose of [MEDICATION NAME] 2.5 mg, but the resident spit it out. The resident was provided with 1:1 supervision but began to throw items and toppled a chair. A Medical Progress Note dated 10/09/2020 at 3:36 PM states that upon examination Resident #1 was wandering, disorganized and grossly confused. The doctor ordered the resident to be transferred to the emergency room (ER) for further management. Review of the facility's Accident/Incident Report dated 10/09/2020 revealed that at 10:40 AM, Resident #1 was observed suddenly becoming aggressive and slapped CNA #1 in the face when the CNA had tried to redirect the resident from wandering onto a patch of wet floor. CNA #1 tried to deflect Resident #1's hands and, in so doing, knocked Resident #1's eyeglasses onto the floor. The incident was witnessed by the housekeeper who had been mopping the floor and by CNA #2, who escorted Resident #1 back to the room. The investigation concluded that CNA #1 had acted inadvertently rather than willfully. CNA #1 was suspended and subsequently transferred off Resident #1's unit. CNA #1 was interviewed on 12/28/2020 at 12:20 PM and stated that she had been working at the facility for the past [AGE] years. On 10/09/2020 CNA #1 stated she was documenting at the hallway terminal when Resident #1 was trying to walk onto a portion of the floor that had just been mopped. She said that Resident #1 was not on her assignment and that she was unaware the resident had behaviors. CNA #1 said she tried to block the resident by standing close, and that Resident #1 just hauled off and smacked me; I saw stars. She said she acted on impulse without intention to retaliate but I was off guard and I hit her back. CNA #2 was interviewed on 12/28/3030 at 1:30 PM and stated that she witnessed the incident but that it happened so fast. CNA #2 stated that Resident #1 slapped CNA #1, and CNA #1's hand was trying to slap Resident #1 ' s hand away. The Assistant Director of Nursing (ADON) was interviewed on 12/28/2020 at 1:45 PM. She stated that following the incident, she immediately called the union representative and in-serviced CNA #1 on body language and dementia. CNA #1 was suspended. She then transferred CNA #1 to another unit so that upon the CNA's return to the facility there could be no further contact between CNA #1 and Resident #1. Registered Nurse #1 (RN #1), charge nurse, was interviewed on 01/12/2021 at 3:50 PM. She said that she had not directly witnessed the incident but noticed Resident #1 ' s eyeglasses lying on the floor. She subsequently heard the resident shouting and crying. RN #1 said she typically provides the CNAs with instructions for resident care and that her directions regarding residents with behaviors are to monitor them closely and redirect them. The Nurse Manager (NM) for the unit was interviewed on 01/13/2021 at 1:30 PM. She said that when a resident with a history of violent behavior is admitted to the facility, she immediately orders nursing monitoring every 30 minutes and a Psychiatry consult to limit the chance that the resident might be abused or might abuse others. She instructs the CNAs to monitor the behaviors and reminds them every day to do their monitoring. Subsequent interviews were conducted with the NM on 01/20/2021 and 01/21/2021. Upon inquiry, the NM stated that she was not responsible for putting information into the Resident Nursing Instructions for Resident #1. On 01/21/2021 at 2:24 PM, upon inquiry, the NM stated that she updated the Resident Nursing Instructions on 10/21/2020, with instructions noting that Resident #1 was physically and verbally abusive. Housekeeper #1 was interviewed on 01/14/2021 at 9:50 AM and stated that he also witnessed the incident. He said he had been mopping the floor when Resident #1 had tried to walk on it and CNA #1 had intercepted the resident. Resident #1 then slapped CNA #1 and CNA #1 tried to block the resident's hand and it caught on the resident's cheek. The Director of Nursing (DON) was interviewed on 01/14/2021 at 10:35 AM. She said that regular in-services are provided for CNAs on how to deal with residents with behaviors, interventions to de-escalate agitation, activities to use, redirection and monitoring. Subsequent interview was conducted with the DON on 01/20/2021 at 11:05 AM. Upon inquiry, the DON stated that the Admitting Nurse and the Nurse Manager are responsible for putting instructions in the Resident Nursing Instructions, and that in the case of Resident #1, CNAs were instructed to redirect the resident, approach calmly and provide diversional activities. She said that the CNAs are trained to back away from a resident exhibiting aggression and to give them space. 415.4(b)(1)(i)

Based on observation, interviews and record review conducted during an abbreviated survey (NY 174), the facility did not provide a resident with the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. This was evident in 1 out 3 residents sampled (Resident #1). Specifically, Resident #1 was admitted to the facility on [DATE] with recent attempt to hurt himself, for attention, while in the emergency room (ER). The facility did not implement a person-centered plan of care tailored to meet the resident's physical, mental and psychosocial needs. The findings Include: The facility's Policy and Procedure on Admission/Readmission revised in ,[DATE] documented that each resident's physical, functional, psychosocial and nutritional status is assessed to determine the need for care, the type of care to be provided, and the need for further assessment. A Registered Nurse (RN) reviews the transfer papers from the sending institution and obtains relevant past medical history. Review of the Facility's Undated Policy on Suicide Threats documented that resident suicide threats shall be taken seriously and addressed appropriately. Staff shall report any resident threats of suicide immediately to the Nurse Supervisor/ Charge Nurse. If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until Physician has determined that a risk of suicide does not appear to be present. The Facility's Policy did not address what staff should do when a new resident is admitted with recent suicide attempts or history self- injurious behavior. The Policy did not address interventions for the new admission. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated [DATE] documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation and ability to recall information) score of ,[DATE], (,[DATE] severe impairment, ,[DATE] moderate impairment and ,[DATE] cognitively intact). A Hospital Discharge Summary dated [DATE] documented that Resident #1 was cleared from a toxicology perspective. [DIAGNOSES REDACTED]. for placement. Resident #1 was admitted to hospital on [DATE]. The Emergency Medical Service (EMS) brought the resident to the emergency room (ER) at 2:45pm on [DATE]. Resident #1's Home Health Aide (HHA) found the resident on the floor. The resident claimed that he took 24 Ambien. The Psychiatrist cleared the resident as this was found to be for secondary gain only. The resident was since been observed for a total of 50 hours. Resident #1 was found to be calm and demanded to go to Short Term Rehab (STR) or Nursing Home. A Hospital Psychiatry Consult dated [DATE] documented that Resident #1 with multiple threats of suicide while in Emergency Department, taking screw out of his crutches and attempting to jab his throat and shove it in his ear. Resident #1 stated that he just wanted the attention of the medical team. The resident verbalized that he felt as he was being ignored. The resident feels safe being off 1:1. Agrees to taking all Psychiatric medications. Denies suicidal/ homicidal ideations, Psychotic Features and auditory/visual hallucinations. It was unclear if the resident [MEDICATION NAME] the was alert and oriented x3. A hospital Physician's statement dated [DATE] documented that a discharge meeting was held with the interdisciplinary team; all agreed that the symptom that motivated the resident visit was resolved. Resident #1 improved where he can be followed up by outpatient provider. Resident in no danger to hurt himself or others. A Hospital Discharge Summary dated [DATE] documented that Resident #1 was discharged on medications that included [MEDICATION NAME] 150mg orally twice daily for Depression, [MEDICATION NAME] 15mg orally once daily for Anxiety and [MEDICATION NAME] 25mg orally every 8 hours. Review of the facility Physician's Admission assessment dated [DATE] at 3:05PM documented that while Resident #1 was in the ER, the resident made suicidal gesture to stab self with a screw while experiencing Hiccups. A facility Nursing Admission Note dated [DATE] at 3:28PM documented that Resident #1 had a history of [REDACTED]. The resident was oriented to room, unit, safety precautions and call bell usage. A physician's orders [REDACTED]. A Physician order [REDACTED]. A Comprehensive Care Plan (CCP) titled Behavior with history of Suicidal Ideation and [MEDICAL CONDITION] drugs use, initiated on [DATE], documented: identify behavior pattern, notify Medical Doctor for any changes in behavior, redirect negative behaviors and refer for Psychiatry Consult. There were no documented interventions to address Resident #1's self-injurious and attention-seeking behavior. Review of the Resident Nursing Instructions for Certified Nursing Assistants (CNA) from [DATE]-[DATE], revealed no specific behavioral and monitoring instructions for the Certified Nursing Assistants. A Nursing Progress Note dated [DATE] at 8:41 PM documented that at 3:30PM, Resident #1 informed the nurse that the dressing on the right foot had become dislodged. Treatment was re-done, and the resident reported satisfaction. At approximately 4:10PM, Resident #1 approached the Physician about a new wound on his foot. The wound was evaluated, and a small wound was noted on the right ankle with 100% granulating tissue. A Nursing Progress Note dated [DATE] at 8:45PM documented that around 4:45PM, the nurse responded to a call for help. Resident #1 was observed on the bathroom floor unresponsive and without vital signs. The Physician was on the unit, Cardio-Pulmonary Resuscitation (CPR) was started and 911 was called. Nursing team also responded, and incident report initiated. EMS responded around 5:10PM and took over. The Police Officer came, and EMS pronounced Resident #1. Review of the Facility's investigation revealed that on [DATE] at 4:45PM, a Certified Nursing Assistant (CNA) observed Resident #1 unconscious on the bathroom floor of the room. The resident had a mobile charging device cord wrapped around the neck and the other end was tied to the doorknob. Code Blue called, Cardio-Pulmonary Resuscitation started, staff and Physician responded. 911 was called and responded at 5:10PM and pronounced the resident at 5:54PM. The resident was last seen 35 minutes prior to the incident. The investigation revealed that there was no reason to believe any alleged resident abuse, neglect or mistreatment occurred. A late entry Psychology Consult Note dated [DATE] documented that Resident #1 was evaluated on [DATE]. The resident was alert and oriented x 3. The resident was referred due to suicidal ideation. Resident #1's mood was okay. The resident adamantly denied suicidal ideation, intent or plan, no evidence of Overt [MEDICAL CONDITION], reported hopefulness and future oriented positive thinking. Denied any Depressive symptomology. Thought processes were goal directed. Clinically stable, ongoing Psychological services not indicated. The Surveillance Video view on [DATE] revealed that Resident #1 was last seen walking away from the nurses' station on [DATE] at 3:31PM. Registered Nurse Manager #1 (RNM #1) was interviewed on [DATE] at 12:30PM. She stated that Resident #1 was on visual monitoring, meaning that the staff knew that they had to eyeball him. She stated that Resident #1 was not on any specific scheduled or documented monitoring. Upon inquiry, the RNM stated that Behavior Monitoring, on the CNA Resident Nursing Instructions, was not activated. She stated that on [DATE], the Psychiatrist had virtual visit with the residents, but that the Psychiatrist did not see Resident #1. CNA #1 was interviewed on [DATE] at 2:30PM. She stated that she was assigned to Resident #1 on [DATE]. The dinner trays came at approximately 4:40PM (not sure of the time). CNA #1 stated that she took Resident #1's dinner tray to his room (couldn't remember time). She did not see the resident, so she called out his name and he did not respond. The bathroom door was closed, and she opened the door and observed Resident #1 in a prone position with his head up. A phone cord was tied to the resident's neck and one end attached to the bathroom doorknob. Resident #1 was unresponsive and barely breathing; his breathing was very shallow. CNA #1 took the cord from around the resident's neck and shouted for assistance. She stated that she saw Resident #1 in his room approximately 4:30PM adjusting his shorts. Resident #1's Primary Physician was interviewed on [DATE] at 11:20AM and stated that he reviewed Resident #1's hospital discharge summary and assessed the resident on admission. He did not feel Resident #1 was a threat to himself. As a result, he did not place the resident on a 1:1 monitoring or a scheduled monitoring. Upon inquiry, the Physician stated that he did not believe that Resident #1 needed a STAT Psychiatry Consult intervention since the resident was psychiatrically stable. The Physician verbalized that on [DATE], between 3:30 PM and 4:00PM, Resident #1 approached him at the nursing station with concerns and wanted someone to do his dressing. Subsequent interview was conducted with Resident #1's Primary Physician on [DATE] at 10:20AM. Upon inquiry, the Physician stated that he was aware of the notation in the hospital document, noting that Resident #1 stated that he just wanted the attention of the medical team and that he felt as though he was being ignored. Registered Nurse Manager #2 (RNM #2) was interviewed on [DATE] at 11:05AM and stated that she admitted Resident #1 on [DATE] and reviewed the hospital discharge summary. She was aware of Resident #1's history of suicide attempts. She did not review the Hospital Patient Review Instrument (HPRI) and Screen. Upon inquiry, the RNM stated, for a resident admitted with a history of suicide attempts and [MEDICAL CONDITION], she would have put the resident on monitoring under safety on the CNA Accountability Instructions and put the resident on the 24-hour report. Upon inquiry, RNM #2 stated that she documented on Resident #1's CNA Accountability Record that the resident had a history of [REDACTED]. She also stated that she was aware of Resident #1 stating that he just wanted the attention of the medical team and that he felt as though he was being ignored. Assistant Director of Nursing #2 (ADON #2) was interviewed on [DATE] at 11:20AM and stated that she reviewed the Resident #1's HPRI, Screen and Discharge Summary on [DATE] or [DATE]. The ADON added that she requested Resident #1's Psychiatric clearance from the hospital and saw that the resident [MEDICAL CONDITION] were for secondary gain. The hospital Psychiatry cleared Resident #1 and she found the resident was appropriate for skilled services in the facility. On inquiry, ADON #2 stated that she alerted and coordinated with the interdisciplinary team regarding implementing enhanced monitoring for the resident for 7 days. The ADON added that the enhanced monitoring did not have a schedule and that monitoring instructions should have been written on the CNA Accountability in the behavioral section. Subsequent interview was conducted with ADON #2 on [DATE] at 1:58PM. Upon inquiry, she stated that Resident #1's CNA Nursing Instructions did not document instructions for CNAs to monitor Resident #1 for changes in his mood. ADON #1 was interviewed on [DATE] at 3:00PM and stated that he was covering for the Director of Nursing. He stated that the facility admitted Resident #1 because the hospital Psychiatrist cleared the resident. On inquiry, he stated that the facility initiates 7 days monitoring for residents with behaviors. The resident was on monitoring every shift and he was placed on the 24-hour report. ADON #1 verbalized that the minimum standard practice for resident monitoring is every ,[DATE] hours and Resident #1 was being monitored as such. Care Plans were developed by Nurse Managers and a note was put on the CNA Accountability that the resident had a history of [REDACTED]. The Recreation Leader was interviewed on [DATE] at 9:27AM and stated that she performed Resident #1's initial assessment on [DATE]. The resident stated that he was interested in one to one activity and that he would let her know when he wanted to do same. The Recreation Leader stated that she had no further contact with Resident #1. The Psychologist was Interviewed on [DATE] at 11:50AM and stated that she read the hospital discharge documents. Upon inquiry, she stated that she was not aware that Resident #1 had stated that he just wanted the attention of the medical team and that he felt as though he was being ignored. She stated that she assessed and interviewed Resident #1 on [DATE], he presented without any distress. Resident #1 stated that his suicidal attempt reaction was because he thought that his other leg would be amputated. Resident #1 was calm and assured her that he had no further [MEDICAL CONDITION]. She further stated that Resident #1 stated that he did not want to have Psychotherapy, he would like to continue to see his Psychologist in the community. She did not document any recommendations to meet the resident's mental and psychosocial needs. 415.12(f)(1)

Based on observation and staff interview, the facility did not ensure that the Optometry provided the resident privacy during care. Specifically; the Optometry did not take the resident to her room and provide privacy prior to her examining the resident eye. This was evident for 1 of 40 sampled residents. The findings is: The facility policy and procedure titled Consults dated (MONTH) 2011; rev (YEAR) rev8/27/19pc documented the following. All Consultants will ensure that resident's privacy and dignity during visits. All Consultants will utalize the 1 East Beauty Parlor room to ensure privacy during visit. In-house residents will be escorted to the 1 East Beauty Parlor room by facility staff. Resident # 121 was admitted [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0(MDS) assessment dated [DATE] documented the resident is cognitively intact,requires limited assistance of one person with activities of daily living and impaired vision with no corrective lenses. On 08/26/19 at 11:07AM the SA (State Surveyor) observed the Optometrist performing an eye exmaination of Resident #121 in the 6th floor dining room. There were ten other resident and three staff members in the dining room at the time of the examination. The Optometrist used was a flash light and retinoscopy equipment during the examination. There was no screen or curtain to maintain privacy. On 08/26/19 11:17 AM the Registered Nurse Manager was interviewed. The RN stated the Optometrist should examine the resident in the day/dining room The resident should have been brought to the resident's room where privacy could be mainatained. On 8/26/2019 11:28 AM the Optometrist was interviewed. The Optometrist stated that she usually [MEDICATION NAME] the resident(s) in the day room, or their room. She did not think this was an issue. She further stated that there the facility does not provide any designated areas for examinations. The resident was interviewed on 08/29/19 at 09:21AM. The resident stated the eye doctor usually [MEDICATION NAME] her in the day/dining. She further stated that since she is not taking off her clothes it did not bother her. On 8/29/2019 at 10:30 AM the DNS (Director of Nursing) was interviewed. The DNS stated that all consultants were told during orientation not to examine residents in day/dining room and corridors. They were told that they must use the resident's room and provide privacy. 415.3(d)(i)

Based on observations, review of records, and interviews, the facility failed to ensure that the resident environment remained free from accident hazards. Specifically, siderails with a space measuring 7.5 inches in width between the bars and a vertical space measuring 17 inches and 9 inches were observed on 50 resident beds. This space exceeded the FDA recommendation that spaces between the bed siderail bars should be no larger than 4 3/4 inches. This was evident for 6 of 6 residents reviewed for Accidents (Resident #s 27, 354, 363, 336, 283 and 347). The facility has 385 certified beds located in two buildings designated as East and West buildings. The observations of deficient practice were noted in the East building. This resulted in no actual harm with the potential for more than minimal harm that was immediate jeopardy and substandard quality of care. The findings are: 1) Resident #27 is a [AGE] year-old, readmitted on [DATE], with [DIAGNOSES REDACTED]. On 7/26/16 at 4:05 PM, the resident was observed in bed with 1/2 siderails up on both left and right side of bed. The siderail to the left of the resident was observed with large spaces between the horizontal and vertical bars. On 7/28/16 at 12:40 PM, the resident's bed was observed, the resident was not in bed at the time of the observation. The siderail were down, the surveyor accompanied by facility staff pulled the side rail up. There were bilateral (B/L) upper half siderail, mismatched in design. The siderails on the right side had close bars with a 3 1/2 inch gap of between the bars. The facility staff member measured the gaps between bars on both left and right siderail. The siderail on the left side had bars with a 7 1/2 inch gap between the bars on both ends located in Zone 1 (head and foot). The Registered nurse (RN) stated that the resident uses B/L upper half siderails when in bed for bed mobility. The FDA recommends that the space between siderail bars should not exceed 4 3/4 inches. On 7/28/16 at 12:45 PM, the resident was observed in the dining room during lunch. The resident was sitting in a high back wheelchair (wheelchair) with a wheelchair alarm, left hand with hand splint, left cushioned arm rest, and a cushioned foot rest. The resident seemed confused and had unclear speech, making noise without any clear words. On 7/29/16 at 10:45 AM, a second observation was made of the resident's bed. The facility changed the left siderail to a different siderail that did not have large gaps between bars, and the new siderails matched the right siderails. The RN stated that they changed the siderails on 7/28/16 in the afternoon. The Minimum Data Set 3.0 (MDS) annual assessment dated [DATE] documented the resident had moderately impaired cognition. The MDS further documented the resident required extensive assist of two people for bed mobility and transfers, and the resident was non-ambulatory. The MDS documented the resident had no restraints. The Comprehensive Care Plan (CCP), revised 12/13/15, for bed mobility documented the resident required extensive assist, and it included the intervention of optimum use of devices such as B/L (bilateral) half siderails for bed mobility. The CCP dated 5/20/16. Identified falls as a risk, it documented that the resident has had no falls since 6/15/15. On that date the CCP noted an intercepted fall with no injury. The CCP for Behavior had a review date of 7/26/16. It documented that the resident is anxious, easily redirected; verbally disruptive, makes noise, attempts to get out of bed and wheelchair unassisted. The EMR (Electronic Medical Record) included a physician's (MD) Order dated 7/13/16 which documented: bilatateral 1/2 siderail for bed mobility. According to the EMR this order was originally initiated on 7/14/15; Resident on Palliative care (4/1/16), with directives (DNR, DNI, DNH), Bed and wheelchair alarm for safety, Left wrist brace for proper positioning to be worn at all times, except care times; out of bed to wheelchair with 2 person assist; on Keflex 500 mg (milligrams) BID (twice a day) x 7 days starting 7/26/16 for Cellulitis of left toe; on Leviteracetam 250 mg BID for Convulsions, Mirtazapine 15 mg QD (daily) HS (at hour of sleep) for major depression; and on PRN (as needed) oxygen. There was no documented evidence that an assessment was done for the use of siderail for this resident. On 7/28/16 at 1:42 PM and 8/1/16 at 12:05 PM the Registered Nurse (RN) (MDS coordinator), who helped measure the siderails, was interviewed and stated that these are old siderails, and many have been changed. She stated the resident is non-ambulatory, requiring 2 assist for transfer; the resident is on Palliative care and too weak to transfer without assist. The RN further stated that nursing does risk assessments for skin break down, pain, fall, elopement and smoking but not on siderail use. She stated that she did not receive in-service on siderail use in the past year, but she was in-serviced on ADLs, including bed mobility. The RN further stated that prior to the in-service the weekend of 7/29/16, she was not aware of the specifications for siderails. When she worked in another facility, she heard about the dangers of siderails, but not the specifications for the space between bars. On 7/28/16 at 12:50 PM, the regular day shift Certified Nursing Assistant (CNA) was interviewed and stated that she knew the resident well, and the resident can occasionally say a few words (ie, bread, drink) and understand simple directions (ie lift your hands). She stated the resident requires total care and assistance of 2 people for transfer. She further stated that the resident is too weak to get up and do anything for herself, and she is fed by staff. The CNA stated that when the resident is in bed, she does not move much and is unable to position herself due to weakness. On 7/29/16 at 11:02 AM, rounds were conducted of the East building. Fifty beds were observed having one or both half siderail with large openings measuring 7.5 inches. The beds were located on 3E, 4E, 5E, 6E, and 7E. On 7/29/16 at 2:10 PM and 8/1/16 at 1:50 PM, the Director of Maintenance was interviewed and stated that the siderails with large gaps were the old ones, which were ordered by the rehabilitation department in the past. He further stated he ordered siderails from the same company one time in the past 6 months, but the new siderails are black in color with closer bars. He stated that the new siderails ordered in the past 6 months meet the FDA guidelines, and the siderails in question have been in the facility prior to the 3 years he has been working here. The Director stated that last year he became aware of the entrapment zones with regard to gaps between the bed and siderails, but not about gaps between the bars. He saw the zone requirement for siderails from the Health Care Association or the Administrator, he does not recall. He also stated that he received a copy to read, but maybe he missed it. He stated he was not aware of the measurements for siderails gaps between vertical /horizontal bars prior to this week when it was discussed during survey. On 7/29/16 at 2:20 PM, the Regional Director of rehabilitation (RD) department was interviewed and stated that the current rehabilitation director has been here for 2 months. The RDR further stated the rehabilitation services have been outsourced to an outside vendor since 2009. The RDR stated that a year ago there were guidelines for measurements between the bars and bed not to exceed 4 and 3/4 inches in diameter to avoid potential entrapment. The (RD) further stated that the rehabilitation staff do not check the siderails on the beds to see if they meet the guidelines. She further stated that rehabilitation staff assess bed mobility but not the siderail requirement and the potential for entrapment. She stated when she joined the facility in May, 2016, the practice was to assess bed mobility of the resident, not the siderail itself. The RD was not aware of the siderail guidelines and space specifications. On 7/29/16 at 2:24 PM, the rehabilitation technician was interviewed and stated that the rehabilitation staff member who used to order siderails in the past is no longer working at the facility. He stated there was only one type of siderails used for beds, and it was ordered. The technician stated he was not aware of any specific guidelines. On 7/29/16 from 3:13 PM to 5:00 PM staff interviews in the East building were conducted. Interviews of staff consisted of 4CNAs (Certified Nursing Assistant, 3LPNs (Licensed Practical Nurse), and 3 RNs (Registered Nurse), and 1 RN Supervisor. Only 2 of 4 CNAs were aware of the safety concerns regarding spacing between the mattress and the siderails and large spaces between the bars. Only one of the two CNAs ever reported a concern with siderail spacing (one time) and the siderail was switched. The 3 LPNs were not aware of what the spacing should be between the siderail bars. Ther 3 RNs were not aware of the guidelines for gaps between the the bars of the siderails and other entrapment zones. They had never received training on the FDA guidelines from the facility. The RN Supervisor was not aware of the FDA guidelines for siderail and bed safety and entrapment zones. She was not aware of the required measurments for spacing between the siderail bars, and she never received an inservice on the FDA guidelines. On 8/1/16 at 11:20 AM, the Licensed Practical Nurse (LPN-Charge nurse) was interviewed and stated the RN does the assessment and identifies the need for siderails, and the Physician writes the order for siderails. She stated that LPNs do determine if siderails are used for a resident. The LPN further stated that the residents who are able to follow commands for bed mobility and hold on to the siderails for movements or who have one sided weakness, like CVA, benefit from the use of siderails. She stated siderails used for safety are considered a restraint. Triangular wedges, bed bolsters or pillows should be used for safety and to prevent accidents. The LPN stated the resident is confused and unable to verbalize needs, and she is unsteady when standing and requires 2 persons for transfer. She stated the resident has bilateral upper half siderails for bed mobility, and this resident needs siderails while giving care. She stated the resident is able to hold on to siderails and take directives sometimes, not always. If you place her hand on the siderails, she will hold on to it. The LPN further stated the resident is able to move side to side in bed but not up and down. She stated she has not observed any of the resident's body parts inside the siderails bars when she sees her in bed, and she is not aware of any incidents of entrapment in the siderails for this resident or any other resident. She stated she became aware of guidelines for siderails bar spacing not to exceed 4 3/4 inches just this weekend, during survey, and prior to that she was under the impression it should be 3 inch gap. The LPN stated she did not receive any in-service on siderail use in the past year, but all staff were in-serviced this past weekend on the siderails bar space, gaps, and zones of body that can be trapped within siderails. The siderails are a restraint if it is for safety, but not if used for bed mobility. On 8/1/16 at 11:50 am, CNA#2, a floater who covers 7-3 pm or 3-11 pm shifts, was interviewed and reported that she cares for the resident sometimes. She stated the resident is confused and follows simple command like lift hand. She is not able to turn and position or move in bed by herself, and requires extensive assist of two people to transfer out of bed. Resident stands up unsteadily; she uses the siderails for bed mobility. If you tell her to hold the siderails, by guiding her hand, she will do it. The siderails for this resident is not a restraint, because, she cannot get up by herself. CNA#2 stated she was not in-serviced in the past year, but just this weekend she was in-serviced on siderails for bed mobility and proper fit, including siderails bar spacing not to exceed 4 and 3/4 inch between bars. She was not aware of any incident of entrapment to this resident or to any other resident in this facility, during her employment in the last 6 years. On 8/1/16 at 12:30 PM, the RN Supervisor (RNS) was interviewed and stated that the RN Supervisor or RN charge nurse, makes the decision for siderails. Staff follow behavior monitoring in bed, and if the resident is identified as fall risk, the RN decides and tells the Physician (MD) to order siderails. She stated for this resident, the siderails are for bed mobility. The resident used to try to get up before, but since the resident was placed on Palliative care (4/1/16), the siderails are for bed mobility only. The RNS further stated the need for siderails is evaluated based on the Bed behavior /mobility Monitoring Form. She stated if the siderails are for bed mobility or safety awareness, they are not considered a restraint and a Restraint evaluation is not done. She recommended the siderails for the resident to the MD, and the MD wrote the order. The RNS stated she did not know any specifications for siderails prior to last weekend, when they were in-serviced. She stated she was not aware of the siderails guidelines memo from DOH or FDA prior to last weekend. She stated all siderails identified as not meeting the guidelines were removed, and changed to the current standard over the weekend, throughout the facility. The Director of Nursing (DNS) in-serviced all the supervisors; In turn, the RNs in-serviced the floor staff, including nurses and CNAs. 2) Resident #354 is an [AGE] year-old with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had moderately impaired cognition, and was sometimes understood and sometimes understands. The MDS further documented the resident had fluctuating inattention and disorganized thinking. The MDS documented the resident required extensive assistance of two people for bed mobility, and the resident had no physical restraints. On 7/29/16 at 11:02 AM, rounds were conducted of the East building. The resident's bed was one of 50 beds observed having one or both half siderail with large openings measuring 7.5 inches. The FDA recommends that the space between siderail bars should not exceed 4 3/4 inches. On 8/01/16 at 12:33 PM, the resident was observed in lunch. The resident was verbal but confused, and she was able to pick up and move items on her tray independently. The Bed Behavior/Mobility Monitoring Form dated 1/13/15 documented a 3-day observation for the resident's behavior in bed. The form documented the resident displayed the ability to turn in bed (staying centered) and maintained supine position. The Comprehensive Care Plan (CCP) for ADL's (Activities of Daily Living): All tasks dated 4/26/16 included the intervention: (Bilateral) 1/2 siderails for bed mobility. The CCP for Falls dated 4/26/16 documented the intervention: bilateral 1/2 siderails for bed mobility for safety. The Physical Therapy (PT) Discharge Summary dated 3/10/16 documented the resident required maximum assist with use of siderails and 75% verbal and tactile cues for bed mobility tasks. The Physician's (MD) Orders dated 7/25/16 (initiated 1/13/15) documented an order for [REDACTED]. The Certified Nursing Assistant Accountability Record (CNAAR) dated July 2016 documented the resident required supervision and half siderails for bed mobility. On 8/1/16 at 12:40 PM, the Certified Nursing Assistant (CNA) assigned to the resident was interviewed and stated the resident is able to participate in her care to varying degrees depending on her level of confusion at the time. She further stated the resident does not require turning and positioning because she is able to move in bed. The CNA stated the resident is able to use the siderails to assist with her movement. She stated that the resident would be able to physically press the call bell, but she may not be able to remember what it is for. She stated that the facility provided inservices in the past regarding how to use the siderails and prevent falls, but the inservices did not cover risks of entrapment and getting caught in the siderails. The CNA stated that she would report loose siderails to the nurse. On 7/29/16 at 3:46 PM and 8/1/16 at 12:08 PM, the Registered Nurse Unit Manager (RNUM) of 3E was interviewed and stated the residents are assessed for bed mobility upon admission, readmission, and as needed to see if a bed alarm is needed. She further stated there is no written documentation for the assessment for half siderails, but the rehabilitation nurse assesses the siderail need and fit of the siderail. She stated the nurse on duty assesses whether the resident is able to hold onto the siderail and use it for moving in bed. She stated the order is entered by nursing and the rehabilitation nurse does the siderail assessment to ensure they are appropriate. The RNM stated that she cannot recall receiving an inservice regarding siderail safety or entrapment prior to now. She was not aware of the spacing requirements between the siderail bars, but she was aware of the risk for entrapment between the mattress and the siderails. She stated that she was also aware that if a resident's whole limb can fit between the bars, it would be considered a hazard. She stated that if a resident has fragile skin or presses themselves against the siderails, padding can be added. 3) Resident #363 is a [AGE] year-old, admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition and displayed the mood symptom of trouble sleeping. The MDS further documented the resident required limited assist of 1 person for bed mobility and transfers and extensive assist of one person for ambulation in the room. The resident was not on psychotropic medication. On 7/27/16 at 10:32 AM, the resident's room was observed. The bed had half siderails with large openings between the horizontal and vertical bars. Meausurements had not been taken at this time. On 7/29/16 at 10:40 am, the resident was observed in his wheelchair in the day room reading a newspaper with his eyeglasses on. The resident was wearing a left hand splint. He was interviewed and stated that he is on a Floor Ambulation Program (FAP), and he is able to transfer himself from bed to wheelchair. The resident further stated he prefers to have the bilateral (B/L) 1/2 siderails as a safety device since he gets seizures. They do not interfere in any way with transfers or sleeping. On 8/1/16 at 12:55 pm, the resident was observed in bed, awake and lying down. The resident stated that both half siderails have been changed to newer ones this past Saturday. He stated that he uses the siderails to get up from bed, transfer himself to the wheelchair, and go to the bathroom. He stated he is not able to walk in the room independently. The Comprehensive Care Plan (CCP) for falls was revised on 7/19/16, documented the resident was high risk for falls due to seizures, and noncompliant behavior. The resident was on fall precautions. The interventions included low bed and B/L upper 1/2 siderails for bed mobility. The CCP notes documented the resident had one incident, on 2/20/16, when he was observed sitting on the bathroom floor after independently transferring without calling for help. There were no further incidents or accidents documented. The CCP for Seizure, revised 7/19/16, documented the resident had no seizuers in the past year, and the resident was on Keppra 500 milligrams (mg) BID (twice per day). The CCP for ADLs dated 9/29/15 documented the intervention of both 1/2 upper siderails for bed mobility. The Certified Nursing Assistant Accountability Record (CNAAR) dated July 2016 documented the resident required 2 half siderails for bed mobility. The rehabilitation Physical Therapy (PT) assessment dated [DATE] documented siderails use for the resident. The Nursing admission assessment dated [DATE] had no documentation of assessment done for siderails; Bed behavior /mobility evaluation done but no recommendations made. No current annual nursing assessment done, that includes siderails evaluation or need for use. The MD order dated 7/19/16 documents orders for B/L 1/2 siderails for bed mobility, Fall precautions, FAP for 200 ft with Rolling Walker (RW) with 1 assist, and seizure precautions. On 8/1/16 at 1:00 PM, the Registered Nurse Supervisor (RNS) was interviewed and stated that if resident has the ability to use siderails for bed mobility, transfers, or turning and positioning, then siderails can be used. For residents lacking safety awareness, i.e. restlessness, bed alarms, and bed bolsters for bed boundaries can be used. Upon admission, the rehabilitation nurse assesses ADLs and the need for siderails, the RN makes a recommendation for siderails, then MD orders the siderails. She further stated this resident has left sided weakness, and he uses right side siderail to turn. She stated now, the resident is mobile in bed and able to transfer himself to the wheelchair with the siderails. She received no in-service in the past year on siderails and the guidelines, but over the weekend she was in-serviced on siderail use. She stated there were no incidents of entrapment for the resident. On 7/29/16 at 10:30 AM, the Administrator was interviewed and stated that he was informed that the gap in siderails could be an accident hazard from a different facility a year back. He further stated he had done rounds and had not noticed any issues with siderails. On 7/29/16 at 10:33 AM , the Director of Nursing (DNS) was interviewed and stated that she did an entire audit of siderails in all the units for any gaps between the bed and siderails as part of Quality Assurance (QA). She further stated that any findings were reported to maintenance and fixed it by either changing the siderails or the mattress. She stated she was not aware the space between bars was a potential problem, so that concern was never looked into, but it will be looked into right away and any siderails are a potential accident hazard will be replaced. 4) Resident #336 is a [AGE] year-old with [DIAGNOSES REDACTED]. On 7/29/16 at 11:02 AM, rounds were conducted of the East building. The resident's bed was one of 50 beds observed having one or both half side rails with large openings measuring 7.5 inches. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had moderately impaired cognition. The MDS further documented the resident required extensive assist of one person for bed mobility and transfer, and the resident only ambulated once or twice with assist of one person. The MDS documented the resident had no physical restraints. On 8/1/16 at 12:48 PM, the resident was interviewed and stated that he is able to use the half siderails, and they help him with positioning. The resident further stated that staff also assist him as needed. The resident was observed with a splint on his right arm and hand, and he used his left hand to move his right arm. The Bed Behavior/Mobility Monitoring Form dated 2/6/14 documented the resident displayed the following at least once: turns but slide to edge of bed, agitated/restless, tries to get up to sit, tries to get out of bed, climb over side rails. The Comprehensive Care Plan (CCP) for ADL's (Activities for Daily Living): All tasks dated 5/11/16 documented the intervention bilateral 1/2 siderails for bed mobility. The CCP for Falls dated 5/11/16 documented the interventions: bilateral 1/2 sideails for Bed mobility, B Floor Mats, Bed at lowest level possible. The Physical Therapy Discharge Summary dated 6/9/16 documented the resident performs bed mobility tasks with Contact Guard Assist (CGA) and use of siderails. The Physician's (MD) Orders dated 7/13/16 documented an order for [REDACTED]. The Certified Nursing Assistant Accountability Record (CNAAR) dated July 2016 documented the resident required bilateral 1/2 side rails for bed mobility. On 8/1/16 at 3:06 PM, the 7-3 Certified Nursing Assistant (CNA) assigned to the resident was interviewed and stated the resident is able to move in bed on his own and transfer using the siderails to assist him. The CNA stated that she had just received education about siderail safety and entrapment, but she did receive an inservice previously. She stated that the staff are instructed to look at the space between the head and sides of the bed and between the siderail bars. She further stated that she is supposed to inform the nurse of any concerns so that maintenance will be contacted. The CNA stated that she never noticed any problems with the siderails for any of the beds. On 7/29/16 at 11:22 AM and 8/1/16 at 1:20 PM, the Registered Nurse Manager (RNM) covering 4E and 5E was interviewed and stated the Bed Behavior/Mobility Monitoring Form is used to determine whether a resident needs siderails. If a resident requires siderails, rehab is called for an evaluation. She stated that there had never been an inservice regarding siderail fit, gaps, or dimensions to reduce the risk for entrapment. She stated that she was not aware of guidelines for spacing between the bars. The RNUM further stated that they would make sure the siderails were ordered, and maintenance or rehab is responsible for checking the siderails. She stated the RN is responsible for determining the need for padding and ensuring it is ordered by the physician and put into place. On 8/1/16 at 11:26 AM, the Medical Director was interviewed and stated that half side rails are usually a nursing issue, and it is mostly used as an enabler. The Director stated that the nurses assess the residents for use of 1/2 siderails and enter the orders into the Electronic Medical Record (EMR). He stated that if a siderail is used as a restraint, it has to be assessed and ordered by the physician. He stated that a siderail is only used for a limited time and as a last resort to prevent a resident from harming themselves. The Director stated that a 1/2 siderail could be seen as a restraint if the resident is totally dependent on staff and unable to move on his or her own. He stated that he was aware of the FDA guidelines recommending the spaces in between the siderail bars and mattress and bed not be more than 4 3/4 inches. He stated that he was not involved in the bed audit conducted by Administration and Nursing, and he was no aware that any of the siderails in the facility did not meet the guidelines. On 8/1/16 at 11:48 AM, the Assistant Medical Director (AMD) was interviewed and stated that nursing determines if 1/2 siderail is needed and enters the order into the EMR. He further stated that the siderails are used as enablers, and they are never used as a restraint. The AMD stated that a 1/2 siderails are not a restraint, and if the resident is totally dependent on staff and unable to move, there is no need for a 1/2 siderail. He stated that the FDA guidelines for bed siderails should be followed, and another administrator informed him of the guidlelines. He stated that it was his understanding that the measurments were required for full siderails and not half siderails. The AMD also stated he was not involved in the bed audits conducted by the Director of Nursing (DON). 5) Resident # 283 is [AGE] yeara old with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition. The MDS further documented the resident required limited assistance with bed mobility. On 7/28/18 at 1:10 PM, the resident was observed sitting on the front of the bed. The resident was awake, alert and oriented, and able to make his needs known, The resident was tall with a right below knee amputation. The bed had bilateral upper 1/2 siderails on it. The left 1/2 siderail was up and the right siderail was down. The resident was sitting on the right side of the bed. The bilateral upper 1/2 siderails had spaces between the bars measuring 7.5 inches. The resident stated that he is able to ambulate using a walker, and he is on floor ambulation with staff assistance. The resident also demonstrated that he was able to pull the siderails up and down himself. The FDA recommends that spaces between siderail bars should not exceed 4 3/4 inches. The Comprehensive Care Plan (CCP) for ADL Functional/Rehabilitation Potential dated 6/24/16 documented the resident required supervision for bed mobility and one person assist for transfers. The CCP included the intervention rignt siderail for bed mobility. The Physician's (MD) Orders dated 7/24/14, revised 7/29/16, documented Bilateral (B) 1/2 SR(Siderails) for bed mobility. The Bed Behavior Mobility Monitoring Form dated 7/24/16 through 7/26/16 documented the resident's behavior in bed on the 3-11PM and 11-7PM shifts. The form documented the resident maintains supine position and turns in bed but stays centered. The Physical Therapy (PT) Discharge Summary dated 7/6/16 documented the resident performed bed mobility tasks with SBA (stand by assist) with use of siderails and 20% verbal cues and 20% tactile cues for safety awareness, and recommended use of hand rails, for proper sequencing and for proper positioning in order to participate in EOB (edge of bed) activities, transfer in/out of bed, and self care activities. The CNA (Certified Nursing Assistant) Assignment/Accountability Record dated June 2016 documented the resident required limited assist with bed mobility and turning & positioning and 1/2 side rails for bed mobility. On 7/29/16 at 10:45 AM, the Registered Nurse Supervisor (RNS) was interviewed and stated the resident ambulates with a left leg prosthesis and rolling walker, and the wheelchair is used when needed and for long distance. She further stated the resident uses the right 1/2 siderail for bed mobility, and the resident is able to pull up and down the siderails independently. On 8/1/16 at 12:32 pm, the Assistant Director of Nursing (ADN) was interviewed and stated that the resident assessment for usage of siderails is a combination between nursing and rehabilitation department. Upon admission, the nurse assesses the resident's need for siderails for bed mobility and forwards the recommendation to the rehabilitation department. The ADN further stated the rehabilitation department measures and provides the siderails for the resident to be used for bed mobility. On 7/29/16 at 11:02 AM, rounds were conducted of the East building. Fifty beds were observed having one or both half side rails with large openings measuring 7.5 inches. The beds were located on 3E, 4E, 5E, 6E, and 7E. One of the beds observed was the bed belonging to Resident # 347. 6) Resident # 347 a [AGE] year old residing in a room on the 5th floor in the East building. The resident was admitted to the facility with Diagnoses: [REDACTED].

Based on observation, record review and staff interviews , the Administrator failed to use the facility's resources in a manner designed to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident . Specifically, the administrator failed to ensure that there were systems in place to provide a safe environment and effectively supervise and monitor residents on the use of the siderails. This was evident for 5 of 5 residents reviewed for Accidents (Resident #s 27, 354, 363, 336, 283 and 347). The facility has 385 certified beds located in two buildings designated as East and West buildings. The observations of deficient practice were noted in the East building. However 50 resident beds in one of two facility buildings were observed to have siderails with bar gaps measuring of 7 and 1/2 inch. This was found in the East building. The findings are: Refer to F 323 This deficient practice resulted in immediate jeopardy with the potential for more than minimal harm and substandard quality of care. The Administrator was interviewed on 7/29/16 at 4:12PM and stated that siderails are used for transfer and as an enabler. The Administrator further stated that an audit was done in June 2015. This audit only looked at the gap between the mattress and the siderails as potential accident and entrapment hazards. The Administrator stated that he was was aware of the DAL NH 15-05 letter. He stated that he reviewed the recommendations made about sidreail measurements overall. He did not look at the recommended measurements regarding the space in between bars, specifically in the area identified as Zone 1. On 8/1/16 at 1:00PM, the facility Administrator was interviewed and stated he came on board as Administrator in September 2015. The DAL (Dear Administrator Letter) came in June 2015 . He stated that to his knowledge the previous Administrator conducted an audit on the siderails. As a result of the audit all siderails were changed in the West building. Howeve, in the East side only 10-15 siderails were changed. The residents on the East side are more ambulatory, high functioning, and alert. The Administrator said most of them use the siderails as enablers for positioning and transfering, and were applied as per physician orders. Everyone of them are with MD ( medical doctor ) orders. The facility has no accidents or incidents involving siderails . On the use of the siderails , to my knowledge , the nurses do the assessment for three (3) days for positioning upon admission and then the rehabilitation department staff will evaluate the residents . I believe there is a good coordination between nursing and rehabilitation in the use of the Siderail as transfers and enablers to assist and help the residents to maintain mobility. On 08/01/2016 the Immediate Jeopardy was removed after monitoring confirmed the facility had implemented a plan to remove the immediacy. The determination to remove the Immediate Jeopardy was based on the facility's Policy and Procedure revision to include an interdisipinary team approach for side rail assessment, education of staff regarding the revised Policy and Procedure, and removal of the siderails which exceeded the FDA recommended 4 3/4 inch space within the rail space. On 08/01/2016 the survey team conducted a visual assessment of all resident beds to validate that all siderails that did not meet the FDA recommendation had been removed. 415.26

Based on resident and staff interviews, and record review, the facility did not ensure that each resident was free from physical and mental abuse. Specifically, a resident reported that a CNA (Certified Nurse Assistant) was mean to her and the alleged abuser continued to work on the resident's unit for 66 days. This was evident for 1 of 2 residents reviewed for Abuse (Resident # 159). This resulted in actual harm that is not immediate jeopardy. The finding is: Resident # 159 is a [AGE] year-old with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had a Brief Interview of Mental Status score of 9, indicating the resident had moderately impaired cognition. On 3/20/12 at 1:51pm, the resident was interviewed using a tablet computer communication device that allowed the resident to type her responses. The resident typed that " (Certified Nursing Assistant #1 (CNA #1)) is very bad with me when you no here. " The resident also typed "She is mean with me. " When asked if she was hit, the resident held up the number two and gestured to her chin and to her leg and became tearful. Resident informed the surveyor that she was scared. The resident informed the surveyor that CNA #1 worked on the 3pm-11pm shift. The resident also typed that CNA #1 was mean to her on 12/26/11 and 12/19/11 and she told the Registered Nurse (RN) and CNA #2. On 3/22/12 at 10:32am, the resident was interviewed and informed the surveyor that CNA #1 was an aide, and the incidents happened on 12/26/11 and 12/12/11. There was no documented evidence in the medical record that the resident made any allegations of abuse or sustained any injuries from December 2011 to March 2012. The unit staffing schedules for 12/12/11, 1219/11 and 12/26/11 were reviewed and documented that CNA #1 worked the 3pm - 11pm shift on all three dates. The "Time & Attendance Employee Punch History" for CNA #1 dated 3/22/12 documented that CNA #1 worked on the unit on 66 days from 12/1/2011 to 3/18/2012. On 3/22/12 at 11:07am, CNA #2 was interviewed and stated that the resident did write that CNA #1 screamed at her or something last week, and she mentioned it to the RN. She further stated that she did not know who the resident was referring to. On 3/22/12 at 11:29am, the RN was interviewed and stated that he was initially told about the resident's allegations about two months ago by the resident's family. He further stated that he asked the resident about her statement that CNA #1 was mean to her in an attempt to get additional information about what she meant. The RN said that the resident answered no when he asked if CNA #1 hit her or yelled at her, and he was unable to get her to elaborate. The RN also stated that he asked the family if they wanted to make a complaint, but they did not want to do so, claiming that the resident always complains about people and they do not take it very seriously. The RN stated that he did not make any documentation regarding the complaint. On 3/22/12 at 11:54am, the RN Unit Manager was interviewed and stated that the resident had never accused the staff of anything to her knowledge, and she did not know of any complaints. On 3/22/12 at 11:44am, the Assistant Director of Nursing (ADON) was interviewed and stated that the RN should have reported the allegation and written an occurrence or grievance report, and an investigation should have been conducted. She further stated that CNA #1 should have been removed from the unit assignment immediately, but CNA #1 had not been working due to illness. The ADON stated that an investigation will be conducted immediately and the family will be contacted. She also stated that she was surprised because the resident had never indicated that she was afraid or had a problem. 415.4(b)(1)(i)