Every finding on record at Richmond Center for Rehabilitation and Specialty H

Based on observation, record review and interviews the facility did not ensure a building elevator was maintained in a safe working condition. This was observed in 1 (Elevator #4) of 4 facility elevators. Specifically, residents and staff complained Elevator #4 was not in good working condition, and on 12/12/2025 at 12:28 PM, a staff was stuck inside Elevator #4 and was not able to get out of the elevator until staff came to assist them The findings are:The facility policy and procedure titled 'Maintenance Services' dated 5/28/2025 documented the facility provides maintenance service to the facility, grounds and equipment.Review of multiple 'Completed Service Ticket' from the elevator vendor revealed that service calls were made on 07/02/2025, 07/23/2025, 08/11/2025, 08/17/2025, 08/27/2025, 08/29/2025, and 09/04/2025.On 12/12/2025 at 11:25 AM, Resident #41 was interviewed and stated Elevator #4 skips floors, bounces and does not always work properly.On 12/12/2025 at 12:28 PM, screams for help and banging were heard coming from inside Elevator #4. Certified Nursing Assistant #5 quickly rushed to Elevator #4 and started to press the elevator button several times. Elevator #4 finally opened halfway, and Registered Nurse #5 was able to get off the elevator.On 12/12/2025 at 12:35 PM, an interview was conducted with Registered Nurse #5 who stated this was their first time being stuck in the elevator. Registered Nurse #5 also stated it was very scary as they pressed the button several times, but the elevator refused to open.On 12/12/2025 at 1:04 PM, an interview was conducted with Certified Nursing Assistant #5 who stated this was not the first time people got stuck inside Elevator #4. Certified Nursing Assistant #5 also stated management knows Elevator #4 was not working well as people constantly get stuck in it. Certified Nursing Assistant #4 concluded they do not have a log to report if elevator is broken, instead they call the front desk, however this issue has been going on for several months.On 12/12/2025 at 1:20 PM, an interview was conducted with Resident #10, who was sitting in front the elevators at the time of the incident. Resident #10 stated Elevator #4 is a problem, as people get stuck on it very often and this is an ongoing issue.On 12/12/2025 at 1:28 PM, an interview was conducted with Licensed Practical Nurse #5 who also confirmed Elevator #4 has always been a problem, people get stuck in it easily and they do not have a logbook to record the number of times they have had to call for assistance. Licensed Practical Nurse #5 also stated they only call the front door or press the help button in the elevator.On 12/15/2025 at 1:32 PM, the State Surveyor was seated at the 4th Floor Nurses station and observed dietary and unit staff observed bringing food by foot through the stairway from the 3rd Floor to 4th Floor. Elevator not functioning.On 12/15/2025 at 1:34 PM, Dietary Aide #1 Stated on occasions the elevator that services the 4th Floor does not work and they will have to bring the food trucks to the 3rd Floor and bring meals to the floor via the staircase. Dietary Aide #1 the elevator goes out a lot but usually the facility is able to get it working without calling out for service.On 12/15/2025 at 1:48 PM, Nurse Manager #3 stated the two elevators that service the 4th Floor are working at this time. Nurse Manager #3 also stated the issue has happened before and has been happening a lot lately, but it usually does not happen at lunch timeOn 12/17/2025 at 12:54 PM, an interview was conducted with the Director of Maintenance and Housekeeping who stated there are 4 elevators in the main building. The Director of Maintenance and Housekeeping also stated they were that Elevator # 4 was not working well and became aware of the elevator issues two (2) days ago. The Director of Maintenance and Housekeeping further stated the elevator had a broken board, which they found out themselves when they did general rounds. The Director of Maintenance and Housekeeping stated this is their third week at the facility and the previous maintenance director did not report to them that Elevator #4 was broken. The Director of Maintenance and Housekeeping concluded they have shut Elevator #4 down until they figure out what the issues was.On 12/17/25 at 02:58 PM, an interview was conducted with the Administrator who stated they were aware Elevator #4 sometimes has some issues. The Administrator also stated they have been fixing the elevators anytime staff calls them. The Administrator further stated they were not aware that staff had gotten stuck in the elevators. The Administrator stated they have plenty of work orders and invoices to prove repairs are constantly ongoing. 10 NYCRR 415.29

Based on observations and interview, the facility did not ensure it provided a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This was evident for staff bathrooms and nurses station. Specifically, staff bathrooms and nursing stations were not maintained in a sanitary and comfortable manner. The findings are: The facility policy titled 'Maintenance Services' created 20/12 and revised 5/28/2025 documented the maintenance Department is responsible for maintaining the facility, grounds and equipment in a safe and operable manner. 1. During multiple observations of the environment conducted from 12/11/2025 to 12/18/2025 the following were observed: a). In the 1st Floor staff bathroom, the walls were in disrepair and were stained with a blackish, brown colored substance, the white metal trash bin on the wall had brown discoloration, and gray colored material exposed. b). In the 1st Floor Nurses Station, the blue colored drawers had brownish discoloration and drawers leaning out of the desk, and white paint located underneath the nurse's station thick with brown colored discoloration. c). In the 2nd floor Nurses Station, there was missing tile on the floor, the blue colored desk drawers were observed to be in disrepair and had brown discoloration. 2. During multiple observations of the staff bathroom on Unit 4 B from 12/17/2025 to 12/18/2025 the following was noted: a). The toilet tissue holder cover was hanging down exposing the toilet tissue. b). The soap dispenser was hanging off the wall. c). The toilet seat liner holder was broken and hanging at an angle. d). There were holes in wall above the hand towel dispenser. e). There were brown colored stains on the wall under the had towel dispenser. f). The shelf above the sink was dusty. g). The top of the mirror and the air vent were dusty. h). There were broken tiles on the floor under the sink. i). The base of the light fixture above the sink was dusty and detached on the right side. On 12/18/2025 at 2:33 PM, an interview was conducted with the Director of Maintenance and Housekeeping who stated they have been in the position for the past two weeks. The Director of Maintenance and Housekeeping also stated their responsibilities include making rounds on the units daily, ensuring toilets are functioning, hand sanitizer and soap is available, and all spaces are clean. The Director of Maintenance and Housekeeping further stated they had made rounds in the building and was working on compiling a list of things that need to be taken care of. 10 NYCRR 415.29

Based on observations, record review and staff interviews, the facility failed to ensure that food was served at an appetizing temperature during meal service. This was evident for one (1) of seven (7) neurobehavioral units (Unit 2 AB) out of total 13 units observed during Dining Observation. Specifically, food items served during lunch meal service were not maintained at palatable and appetizing temperatures. The findings are:The facility's policy and procedure titled 'Meal Service' reviewed 01/2023 documented individuals will be encouraged to receive their meals in the dining room. The policy also documented meals will be served promptly to maintain adequate temperature and appearance. The Meal Delivery Schedule Sheet documented lunch for Unit 2 AB was served at 12:00 PM. On 12/11/2025 at 12:08 PM, a dining observation was conducted on neurobehavioral unit 2 AB. Meals were observed served in a disposable lunch box and appeared unappetizing, and lukewarm in temperature.On 12/15/2025 at 11:11 AM, a test tray was requested for neurobehavioral Unit 2 AB.On 12/15/2025 at 11:30 PM, lunch meals were assembled, distributed to assigned tables until 12:00 PM. At 12:12 PM, residents entered the dining room and sat at their assigned table upon staff opening the dining room for meal service at 12:12 PM.On 12/15/2025 at 12:12 PM, test trays were conducted with the Food Service Director. It revealed the following: corn at 113 degrees Fahrenheit, ground chicken at 105 degrees Fahrenheit, mixed vegetables at 117 degrees Fahrenheit, chopped chicken at 103 degrees Fahrenheit, baked potato at 126 degrees Fahrenheit, and chicken tenders at 110 degrees Fahrenheit.On 12/18/2025 at 10:13 AM, Registered Nurse #2 stated the lunch truck arrives to the unit, is set up in the steam table and plated by the dietary worker. The dietary worker starts plating hot foods, while cold foods are assembled by two certified nursing assistants. Registered Nurse #2 also stated the nurse will do a final check of the foods with the individual ticket before meals are ready for service. The dining room is open for meal service once meals are all checked and distributed to assigned table. On 12/17/2025 at 11:55 AM, the Food Service Director stated hot foods should be held and served to residents at least at 140 degrees Fahrenheit. The Food Service Director also stated they are trying to keep hot foods around 165 degrees Fahrenheit on the steam table so that temperatures are maintained once they are plated, served, and ready for the meal. The Food Service Director further stated the process for the neurobehavioral units is that hot foods are delivered in an insulated food cart and set up in the steam table about 30 minutes prior to meal service. Hot foods are then dished out and set with cold food items on assigned table for residents, and then the dining room is open for all residents after all meals are plated and setup on the table. The Food Service Director stated hot foods should be served at least 140 degrees or above and cold food should be at 41 degrees or below in Fahrenheit. The Food Service Director acknowledged hot foods were not maintained at the appropriate temperature range for hot foods served on 12/15/2025. 10 NYCRR 415.14(d)(1)(2)

Number of residents sampled: 4Number of residents cited: 1 Based on record reviews and interviews, the facility did not ensure a person-centered comprehensive care plan was developed and implemented to meet a resident's need. This was evident of one (1) of four (4) residents (Resident #6) reviewed for Care Planning out of 38 sampled residents. Specifically, a comprehensive care plan for bowel management was not developed for Resident #6 who had a history of constipation. The findings are:The policy titled 'Care Plan Comprehensive' created 10/2015 and revised 12/18/2024 documented interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The policy also documented identifying problem areas and their cause and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process.Resident #6 was admitted with diagnoses that included Cerebrovascular Accident, Malnutrition, and Depression. On 12/11/2025 at 3:40 PM, Resident #6 was interviewed and stated they have a long history of constipation and on occasion have to receive an enema or a laxative. The Physician's orders dated 10/11/2025 and revised 11/20/2025 documented Fleet Oil Rectal Enema Insert 1 application rectally as needed for constipationThe Physician's order dated 11/06/2025 and revised 11/20/2025 documented Docusate Sodium 100 MG give three capsules by mouth one time a day for bowel regimen. Hold for diarrhea.The Physician's order dated 11/11/2025 and revised 11/20/2025 documented Sennosides tablet 8.6 mg give three tablets by mouth in the evening for bowel regimen. Hold for loose bowel movement. There was no documented evidence a comprehensive care plan was developed to address Resident #6's bowel management. On 12/18/2025 at 1:22 PM, an interview was conducted with Nurse Manager #3 who stated Resident #6 has issues with constipation and is on a host of medications. Nurse Manager #3 also stated Resident #6 can be noncompliant with medications at times and has to be encouraged to take medications and drink extra fluids. Nurse Manager #3 further stated care plans are created based on the complaints of the resident, type of care they need and if they have medical issues. Nurse Manager #3 stated based on Resident #6's history of constipation they should have a care plan with interventions related to preventing complications. Nurse Manager #3 also stated they thought they had created a care plan for constipation, but they must have overlooked it. On 12/18/2025 at 2:01 PM, the Director of Nursing was interviewed and stated following the admission assessment, the first set of care plans are created. The Director of Nursing also stated the nurse managers on the unit then review the admission documents, medications, and diagnoses and initiate the appropriate care plans. The Director of Nursing further stated that they, along with the Assistant Director of Nursing, also review charts to ensure that any additional care plans that are needed are created based on other incidents or changes with the resident. The Director of Nursing stated they were not aware that a care plan for constipation had not been created for Resident #6. 10 NYCRR 415.11(c)(1)

Based on observations, record review and staff interviews conducted during the Recertification survey, the facility did not ensure a clean, comfortable, and homelike environment was maintained. This was evident on one (1) of seven (7) units (Unit 2 AB) in the neurobehavioral building. Specifically, resident's rooms were noted with broken and worn furniture, bed frames and legs with rust, discolored, streaked floors, television and dining room furniture in disrepair. The findings include but are not limited to: The facility's policy and procedure titled 'Home Like Environment' reviewed 9/1/2024 documented residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings. The facility policy and procedure titled 'Maintenance Services' dated 5/28/2025 documented the facility provides maintenance service to the facility, grounds and equipment.During observations of Unit 2 AB from 12/11/2025 at 10:30 AM to 12/18/2025 at 1:00 PM, the following were observed throughout the common areas, dining room and resident rooms but not limited to: 1. Dining Room:a. Dining room tables were heavily worn, noted with scratches, chipped and broken edges.b. Chairs with tears, ripped cushion, and with food stains on back rest and wooden legs noted with grime. c. Dining tables and chairs were all heavily worn and were mismatched.d. The accordion room divider was stained, soiled with dirt and dust.e. Dining room floors were discolored, had stains and brown scruff marks. f. Floor corners were embedded with grime and dirt.g. Dust and dirt build up noted on the radiators and metal vent grill.h. Three well steam tables noted with two indicator lights not functioning, the exterior was observed with smudges and dried food residue/grease, and inside the wells were observed with a buildup of minerals and rust. 2. Television Room a. Radiator without a cover and was exposed.b. Sofa couch noted with a broken frame and was sagging to the floor.c. Table surface damaged with scratches, markings and chipped edges. d. Chairs with ripped seat and back rest cushion.e. Floors observed with streaks and scruff marks. 3. room [ROOM NUMBER] had discolored floors with streaks, dusty privacy curtain, dusty windowsill, closets without locks. Bed frames, and legs heavily worn and had rust stains. 4. room [ROOM NUMBER] had closet noted with partially peeled sticker residue and was missing a lock, brown stains noted on the floors, bed frames, legs heavily worn with rust stains, rusty handrail, bathroom/shower stall floor tiles and wall tiles discolored and ingrained with grime. 5. room [ROOM NUMBER] had dresser with a missing drawer, closet with missing handles, air conditioning unit was layered with dust and was not firmly affixed to the ceiling, floors with streaks and brown stains. Bed frames, and legs heavily worn with rust stains. 6. room [ROOM NUMBER] had bed frames, and legs heavily worn with rust stains, torn damaged chair, closets with scruff marks, partially peeled sticker residues and there was no lock. Dusty privacy curtains, floors were uncleaned, brown stained. 7. Multiple rooms on the unit a. Floors were noted with discolored brown stains and scruff marks.b. Wooden closets were observed with scruff marks, scratches, sticker residue and were missing locks. c. Bed frames, and legs heavily worn with rust stains.d. Bathroom/shower stall tiles with grime. On 12/15/2025 at 9:40AM, Housekeeper #1 was interviewed and stated they are responsible for cleaning all resident rooms, bathrooms, and common rooms on Unit 2 AB. Housekeeper #1 also stated they have a daily cleaning routine which starts with sweeping, mopping floors of nursing station, staff lounge room, then they clean the toilets, sinks, shower stalls, wipe and dust windows, sweep and mop floors, and take garbage out for every resident room. Housekeeper #1 further stated they also wipe dining room tables, and clean floors in the dining room after every meal, and dust daily, clean windows and radiators. Housekeeper #1 stated they are notified of additional or emergency cleaning work via phone call or directly in person. Housekeeper #1 also stated no resident refuses to have their rooms cleaned, and the Certified Nursing Assistants will assist with removing resident items off the floor so rooms can be cleaned daily. Housekeeper #1 further stated they are aware of the issues observed in the dining room and resident rooms, and while they do clean these areas daily, because of the condition of the building and furniture, they are still looking dull and not clean. Housekeeper #1 stated the previous Housekeeping and Maintenance Director was notified and was aware of these environmental concerns, but they do not know if the new director is aware of them. On 12/15/2025 at 9:55 AM, Maintenance Worker #1 was interviewed and stated all work requests are submitted electronically and once they are notified, the work can be done right away. Maintenance Worker #1 also stated they round on the units daily and address any issues reported to them during the rounding. Maintenance Worker #1 further stated they will fix any broken equipment or furniture that is reparable. Maintenance Worker #1 stated they have not receive any work request for the issues noted and observed by the State Surveyor. Maintenance Worker #1 also stated worn out furniture and structural damage that requires major constructions are addressed by administration. Maintenance Worker #1 further stated there were two sofa couches that were replaced about 6 months ago and resident dressers were replaced last year. Maintenance Worker #1 stated there is no maintenance logbook on Unit 2 AB, so all maintenance work is submitted electronically. and they were able to show the State Surveyor on their phone that there were no pending work requests for the identified concerns on the facility's application.On 12/15/2025 at 10:14 AM, Certified Nursing Assistant #3 was interviewed and stated any emergency issues with broken equipment is submitted electronically and any immediate cleaning is requested of housekeeping staff who is on the unit. Certified Nursing Assistant #3 also stated they will assist in removing items from the floor when floors are being cleaned by the housekeeper. Certified Nursing Assistant #3 further stated some bed frames, closets, dressers, and tables in resident rooms have been worn out for a while, but they have not seen any furniture replaced other than sunken or broken mattresses being replaced. On 12/17/2025 at 3:19 PM, all issues noted above in dining room, television room, and resident rooms on Unit 2 AB were observed with the Director of Maintenance and Housekeeping.On 12/17/2025 at 3:30 PM, the Director of Maintenance and Housekeeping was interviewed and stated housekeeping staff will checks supplies, clean bathroom sinks, toilets, shower stalls, mop and sweep floors, dust high and low areas, wipe all tables, and clean equipment. Privacy curtains are wiped or changed. The Director of Maintenance and Housekeeping also stated they address any work request submitted electronically, and do periodic inspection and maintenance of upholstered furniture, which includes checking for signs of wear and tear, repairing any damages, and replacing worn-out upholstery. The Director of Maintenance and Housekeeping further stated they are responsible to do rounding on the units and inspect ceiling tiles every week, cracks or damages to floors monthly, and checks for furniture with damage in resident rooms occasionally. The Director of Maintenance and Housekeeping stated they are also responsible to do monthly rounds of communal areas including dining/television room however, they are recently hired so they have not gotten to do their routine rounding in the neurobehavioral building. The Director of Maintenance and Housekeeping also stated they do not know if these inspections were being done prior to them starting, acknowledged the environmental/maintenance concerns, and stated they will need to do thorough inspection of every room and repair any identified issues.On 12/18/2025 at 12:20 PM, the Administrator was interviewed and stated the Director of Maintenance and Housekeeping does unit rounding every few days to look for malfunctioning equipment and broken furniture. The Administrator also stated the unit nurses also report environmental issues and requests work to be done, and furniture is replaced as necessary. The Administrator further stated their team has some work to do to fix these areas, and the team has already been discussing these concerns. 10 NYCRR 415.5(h)(2)

Based on record review and interviews the facility failed to ensure resident's and/or resident's representative were afforded the right to participate in the care plan process. This was evident for two (2) of four (4) residents (Resident #348 and Resident #349) reviewed for Care Planning out of 37 residents. Specifically, Resident #349 and Resident #348's representative were not invited to participate in all of their care plan meetings. The findings are: The facility policy titled Care Planning-Interdisciplinary Team dated 10/2025 and last revised date 08/2019 documented, the resident, the resident's family and/or the resident's legal representative/guardian or surrogate are invited and encourage to participate in the development of and revisions to the resident's care plan. Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family. Resident #349 was admitted to the facility with diagnoses that included paraplegia and muscle spasms. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #349 was cognitively intact and participated in assessment and goal setting. On 12/11/2025 at 2:55 PM, Resident #349 was interviewed and stated they used to be invited to attend care planning meetings but has not been invited and has not attended in some time. a). The Team Meeting note dated 02/18/2025 documented meeting attendance included the following: Nursing, Social Services, Dietary, Recreation/Activities, and Resident #349. The Interdisciplinary Care Plan Attendance Sheet contained a signature for Resident #349. b). There was no Team Meeting note for the care plan meeting on 05/20/2025. The Interdisciplinary Care Plan Attendance Sheet dated 05/20/2025 did not contain a signature for Resident #349 or their representative, however there were signatures for Nursing, Certified Nursing Assistant, Minimum Data Set, Social Worker, Dietary and Activities. c). The Team Meeting note dated 08/04/2025 documented meeting attendance included the following: Nursing, Social Services, Dietary, Recreation/Activities, Minimum Data Set, and Resident #349. The Interdisciplinary Care Plan Attendance Sheet dated 08/04/2025 did not contain a signature for Resident #349 or their representative. d). The Team Meeting note dated 10/04/2025 documented meeting attendance included the following: Nursing, Social Services, Dietary, Recreation/Activities, Minimum Data Set, and Resident #349. The Interdisciplinary Care Plan Attendance Sheet dated 10/21/2025 did not contain a signature for Resident #349 or their designated representative. On 12/18/2025 at 9:55 AM, the Director of Social Services was interviewed and stated that for care planning meetings a letter should be sent out to family, and if the resident is cognitively intact, they are spoken to and invited to the meetings and given a letter also. The Director of Social Services also stated residents are invited to meetings every quarter or if there is a significant change. The Director of Social Services further stated there is an attendance sheet at each meeting which is signed by everyone in attendance including the resident. The Director of Social Services stated the care plan meeting notes are completed by nursing done in the electronic medical record. On 12/18/2025 at 1:21 PM, Nurse Manager #3 was interviewed and stated care planning meetings are an integrated meeting, but nursing does the note. Nurse Manager #3 also stated usually the signature sheet is distributed by the Social Worker at the meetings and sometimes the attendance sheet is not brought to the meeting, or they forget to have the resident sign. Nurse Manager #3 further stated there was no note completed for the meeting on 05/20/2025 as they were absent, so the person who was covering should have written the note. On 12/18/2025 at 2:01 PM, the Director of Nursing was interviewed and stated residents should be invited to attend all care planning meetings. the Director of Nursing also stated the nurse manager, or the social worker usually documents attendance at the meetings but sometimes the nurse does it, however this should be an interdisciplinary process. 2.Resident #348 was admitted with diagnoses which included Traumatic Brain Injury and Benign Prostatic Hyperplasia. The Quarterly Minimum Data Set, dated [DATE] documented Resident #348 has severely impaired cognition and participated in assessment and goal setting. On 12/11/2025 at 03:08 PM, an interview was conducted with Resident #348's representative who stated they do not receive any letters or a telephone call regarding care plan meetings. Resident #348's representative also stated the only form of communication they get is a text about the care plan meeting and sometimes it would be the day of the meeting or when the meeting was completed. Resident #348's representative further stated they had not attended meetings either in person or by telephone. a). The 'Interdisciplinary Care Plan Meeting Attendance' sheet dated 11/19/2024 documented Resident #348 lacks capacity, was invited and declined. The 'Interdisciplinary Care Plan Meeting Attendance' sheet also documented Resident Representative was invited and did not attend. b). The Care Plan Meeting letter dated 02/12/2025 documented a Quarterly Care Plan meeting on 02/18/2025. There was no documented evidence the letter was mailed to Resident #348's representative. The 'Interdisciplinary Care Plan Meeting Attendance' sheet dated 02/18/2025 documented Resident #348 lacks capacity, was invited and declined. The attendance sheet documented Resident #348's representative attended via telephone call. c). The Care Plan Meeting letter dated 05/13/2025 documented on 05/13/2025 a Care Plan Meeting letter was mailed out to Resident #348 family representative for a Care Plan Meeting taking place on 05/20/2025. There was no evidence provided by the facility that the care plan meeting letter was mailed to Resident #348's representative. The Social Service Documentation note dated 05/13/2025 documented Social Work invited Resident #348's representative to the upcoming Annual Care Plan Meeting Schedule for 03/20/2025, which was not the meeting date indicated above, via email. There was no documented evidence that a care planning meeting was held for Resident #348 on 03/20/2025. The 'Interdisciplinary Care Plan Meeting Attendance' sheet dated 05/25/2025 documented Resident #348 lacks capacity, was invited and declined. Resident representative attended via telephone call. d). The Social Service Documentation note dated 08/19/2025 documented Social Work invited Resident #348's representative to an upcoming Quarterly Care Plan meeting scheduled for 03/20/2025, which was not the meeting date indicated above, via email. There was no documented evidence a care plan meeting was scheduled for 03/20/2025 or that Resident #348's representative was sent an email inviting them to the care planning meeting scheduled for 08/19/2025. The 'Interdisciplinary Care Plan Meeting Attendance' sheet dated 08/19/2025 documented Resident #348 lacks capacity, was invited and declined. The 'Interdisciplinary Care Plan Meeting Attendance' sheet also documented Resident #348's representative was invited and there was no response. e). The Social Service Documentation note dated 11/12/2025 documented Social Work invited Resident #348's representative to the upcoming Quarterly Care Plan Meeting scheduled for 11/18/2025 via email. An untitled document listing Resident #348's name, meeting date and meeting time as 11/18/25 1:30pm to 3pm, contained contact information to confirm attendance at the meeting. The boxes indicating 'given to resident' and 'mailed to Resident's Representative' were both checked and dated 11/18/25. There were no signatures from either Resident #348, or their representative affixed to this notice. The 'Interdisciplinary Care Plan Meeting Attendance' sheet dated 11/18/2025 documented Resident #348 lacks capacity. The 'Interdisciplinary Care Plan Meeting Attendance' sheet also documented Resident #348's representative was invited and there was no response. There was no documented evidence Resident #348's representative was sent an email with an attachment inviting them to the care planning meeting scheduled for 11/18/2025 or that Resident #348's representative was consistently invited to attend care planning meetings. On 12/16/2025 at 11:15 AM, an interview was conducted with Social Worker #3 who stated the process for inviting the family to the care plan meetings is they send out letters or emails and/or make telephone calls one week prior to the meeting. Social Worker #3 also stated they do not send text messages via telephone. Social Worker #3 further stated sometimes resident representatives attend via telephone. Social Worker #3 stated to confirm the process is followed they save the emails and take a photo of the letter they send out via regular mail and document in the electronic medical record system. On 12/17/2025 at 03:00 PM, an interview was conducted with the Director of Social Work who stated they did not have full staff, and it was a strain to provide invitation letters to the resident's representatives. The Director of Social Work also stated that once the Minimum Data Set staff provide them with dates for the meetings, the corporate office and/or the social workers will generate the care plan invitation letters which is done at least two (2) weeks prior to the care plan meeting and followed up with a telephone call, and/or if there is an email address, an email will be sent out. The Director of Social Work further stated the invitation care plan meeting letters go out in regular mail and there is no way to determine if the letters went out and if the family/resident's representative received the letters. The Director of Social Work stated social workers are responsible for creating the letters, making sure the letters went out to the resident's representative, and following up with a telephone call. The Director of Social Work also stated if in three (3) days, there is no response from the resident's representative, a telephone call should go out to the resident's representative, and another letter should go out. The Director of Social Work further stated there is currently no way to confirm letters have been sent or received by residents or their representatives. On 12/18/2025 at 1:30 PM, an interview was conducted with the Director of Nursing who stated they are aware the care plan invitation process has not been working accurately and the documentation needs work. The Director of Nursing also stated the information for the meetings gets distributed to the families by telephone call, emails, and letters, and mostly through mostly email communication for the residents in neurobehavioral building. The Director of Nursing further stated email confirmation would have to be provided by the corporate office and was not readily available. The Director of Nursing stated social workers are responsible for following up with the family to make sure they have received the care plan meeting invitation and responded. 10 NYCRR 415.12(c)(2)(i-iii)

Number of residents sampled:6Number of residents cited:1 Based on observations, record review, and interviews, the facility did not ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding. This was evident for one (1) of (six) 6 residents (Resident #184) reviewed during the Medication Administration task. Specifically, the functioning of the Gastrostomy tube was not verified prior to administration of medications to Resident #184. The findings are: The facility policy titled 'Enteral Tube Placement Verification' last revised 08/27/2025 documented placement verification of an established enteral tube will be confirmed utilizing bedside verification methods (examples external tube length, evaluation of gastric residual volume and/or power of hydrogen of gastric aspirate). The Licensed Nurse will verify placement of the enteral tube prior to each use including but not limited to feedings, flushes and medication administration by first measuring the length of the enteral tube and/or comparisons of the incremental marking on the enteral tube.Resident #184 had diagnosis which included Gastrostomy status, Dysphagia, and Altered Mental Status. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #184 had a feeding tube and received 51% or more of calories through tube feeding.The Physicians order dated 04/21/2025 last renewed 12/02/2025 documented to check the placement of gastrostomy tube before any administration.The nursing care plan with focus the resident requires tube feeding, related to Altered Mental Status, documented interventions that included to check for tube placement prior to administration. During an observation of Medication Administration on 12/16/2025 at 1:12 PM, Licensed Practical Nurse #1 administered medications to Resident #184 via a Gastrostomy Tube. Licensed Practical Nurse #1 did not verify functioning of the Gastrostomy Tube before administering the medication.Clinical Competency assessment dated [DATE] documented that Licensed Practical Nurse #1 had successfully checked the placement of gastrostomy tube prior to medication administration. On 12/16/2025 at 1:30 PM, the Licensed Practical Nurse #1 was interviewed and stated that they already checked the patency of the gastrostomy tube in the morning by flushing the tube with water and listening for bowel sounds with stethoscope at which time the tube was noted to be functioning. Residuals are checked after feeding but not prior to or after medication administration. The Licensed Practical Nurse #1 further stated that checking for placement of the gastrostomy tube involves listening for bowel sounds with the stethoscope prior to administration. The Licensed Practical Nurse #1 further stated that they have not been in-serviced on other methods of verifying the functioning of the tube. On 12/16/2025 at 2:51PM, the Nurse Manager #1 was interviewed and stated to confirm placement of the gastrostomy tube, the nurse should use the stethoscope to listen to bowel sounds. Nurse Manager #1 also stated residuals are supposed to be checked each time prior to giving medications and before starting feeding. Nurse Manager #1 further stated the gastrostomy tube can be misplaced, and so it is important that residuals are checked prior to administration of medications and before feeding. On 12/17/2025 4:06 PM, the Director of Nursing Services was interviewed and stated it is important to check for patency by flushing the tube and listening with the stethoscope for bowel sounds. The Director of Nursing Services also stated the functioning of the gastrostomy tube is verified by confirming placement, which is done by checking the length of the gastrostomy tube before medication administration and feeding. The Director of Nursing Services there are orders in place for nurses to check for placement prior to medication administration for residents with a feeding tube.On 12/17/2025 at 4:37 PM, the Regional Clinical Director was interviewed and stated they are a part of the policy committee who writes the policies for the facility. The Regional Clinical Director also stated in order to verify functioning of the gastrostomy tube, the tube is to be flushed with 15 milliliters of water to ensure patency, and placement is checked by monitoring the length of the tube and/or aspirating contents. The Regional Clinical Director further stated they understood the Licensed Practical Nurse #1 did not measure the length of the tubing prior to medication administration as the Licensed Practical Nurse #1 admitted they did not, and the length of the tube is to be measured prior to administration of medications to ensure there is no migration of the tubing. If there is migration of tube, the nurses are to hold and notify the physician. The Regional Clinical Director stated there are clinical assessments and annual competencies for nurses to ensure that they are up to date with their skills.10 NYCRR 415.12

Based on observation, record review, and interviews conducted during an Abbreviated Survey (NY00333922), the facility failed to ensure that a Resident received adequate supervision to prevent elopement. This was evident in one out of six residents sampled (Resident #1). Specifically, Resident #1, who was escorted by Home Health Aide #1, eloped from a clinic appointment on 02/20/24 at 12:35 am. Home Health Aide #1 stated that Resident #1 was a few steps behind them in the waiting room of the clinic and when they turned around Resident #1 was gone. Resident #1 was located on 02/27/24 and was transported to the hospital by Emergency Medical Service on 02/27/24 with diagnosis of alcohol withdrawal. The findings are: The facility's Policy and Procedure, entitled Elopement Prevention with revision date 09/01/23, documented that the facility strives to promote resident safety while maintaining the least restrictive environment to protect the rights and dignity of the resident. The facility policy did not include preventive measures for Residents at risk for elopement and being escorted to outside appointments. Resident #1 was admitted to the facility with diagnoses including diagnoses including Frostbite, Gangrene of Bilateral hand digits, and uncontrolled Diabetes. A Minimum Data Set (a resident assessment tool) dated 02/14/24 documented that Resident #1 had moderately impaired cognition. A Hospital and Community Patient Review Instrument dated 12/01/23 documented that Resident #1 was an Elopement Risk. An Elopement Risk Evaluation dated 12/06/23, revealed that Resident #1 was assessed for elopement risk and scored 8 indicating low risk for elopement. According to the Elopement Risk Evaluation instructions, if a Resident score is below 10, the Resident is Low Risk for Elopement. A score of 10 and above the Resident is at High Risk for Elopement. A Care Plan dated 12/06/23 documented that Resident #1 was a potential risk for elopement due to a history of elopement risk. The interventions documented that Resident #1 was on every 15 minutes monitoring for safety. A Nursing Progress Note dated 02/20/24 at 10:05 am, written by Licensed Practical Nurse #1, documented that Resident #1 went out to a clinic appointment for suture removal with an escort at 10:00 am. A Nursing Clinical Evaluation Note dated 02/20/24 at 12:40 pm, written by Registered Nurse #1, documented that Home Health Aide #1 escorted Resident #1 to their Plastic Surgery Clinic appointment at 10:00 am for suture removal. At 12:35 pm, Home Health Aide #1 called the facility and reported that Resident #1 was missing. A facility investigation dated 02/20/24 documented that on 02/20/24 at approximately 12:36 pm, Home Health Aide #1 called the facility and reported that Resident #1 was missing. Resident #1 had a follow up appointment with a plastic surgeon at the clinic for removal staples. Bathrooms and clinic grounds were checked immediately and 911 was called at 12:39 pm. The facility concluded that abuse, neglect, or mistreatment may have occurred. During an interview on 02/26/24 at 12:18 pm, Home Health Aide #1 stated that before taking Resident #1 to their appointment on 02/20/24 at around 10:00 am, the unit nurse instructed Home Health Aide #1 to keep an eye on Resident #1 because Resident #1 was high risk for elopement. Home Health Aide #1 stated that Resident #1 was calm and did not say that they wanted to leave the clinic or that they did not want to return to the facility. Home Health Aide #1 stated that they were in the waiting area of the clinic waiting for Resident #1's papers. Home Health Aide #1 stated that when the front desk called Resident #1's name, they both stood up and were approaching the front desk. Home Health Aide #1 stated that Resident #1 was a few steps behind Home Health Aide #1 and when they took the paper and turned around Resident #1 was gone in just a few seconds. Home Health Aide #1 stated that no one saw where Resident #1 went. Home Health Aide #1 stated that they searched for Resident #1, called the facility, 911, and the police came and started searching for Resident #1. During an interview on 02/26/24 at 2:01 pm, Licensed Practical Nurse #1 stated that Resident #1 was escorted by Home Health Aide #1 to a follow-up appointment on 02/20/24. Licensed Practical Nurse #1 stated that they verbally instructed Home Health Aide #1 that Resident #1 was at risk for elopement. Licensed Practical Nurse #1 also stated that they had instructed Home Health Aide #1 to keep an eye on Resident #1 and not to leave Resident #1 by themself. During an interview on 02/28/24 at 2:25 pm, the Director of Nursing stated that the unit nurse informed Home Health Aide #1 that Resident #1 was at risk for elopement. The Director of Nursing stated that Home Health Aide #1 should have always kept their eyes on Resident #1 and keep Resident #1 at arm's length. During an interview on 02/28/24 at 2:25 pm, the Administrator stated that the Director of Nursing notified them on 02/20/24 at 12:40 pm that Resident #1 was missing from the clinic. The Administrator stated that Home Health Aide #1 turned around for one minute, and Resident #1 was gone. The Administrator stated that the Director of Nursing is responsible for overseeing escort staff and making sure they are doing what they are supposed to do when taking the residents on outside appointments. 10NYCRR 415.12(h)(1)(2)

Based on observation, interviews, and record review conducted during the Recertification survey from 8/14/2023 to 8/21/2023, the facility did not ensure garbage and refuse were disposed of properly. This was evident during kitchen observation. Specifically, the garbage compactor was observed without a lid or door to prevent the harboring and feeding of flies. The findings are: The facility policy titled Garbage and Rubbish Disposal dated 1/2023 documented outside dumpsters provided by garbage pick-up services will be kept closed and free of surrounding litter. During a kitchen observation on 8/17/2023 at 9:25 AM, the garbage compactor located outside of the facility did not have a lid or door, was filled with garbage, and had multiple flies surrounding the pile of garbage. On 8/21/2023 at 9:02 AM, the Director of Housekeeping (DH) was interviewed and stated the waste management company provides the compactor and does the waste pick up service. The trash compactor has never been and is not currently equipped with a lid or door and always remains open. The DH stated any pest issues are addressed by the facility's contracted pest control company. On 8/21/2023 at 11:15 AM, the Administrator was interviewed and stated they were not aware the trash compactor did not have a lid or door to contain the garbage. They will address the issue. 415.14(h)

Based on observations, interviews, and record review conducted during the Recertification survey from 8/14/2023 to 8/21/2023, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was evident during kitchen observation. Specifically, the facility did not ensure that cold foods were stored at a temperature of 41 degrees Fahrenheit (F) and below, and the refrigerator temperature was not maintained at 41 F and below. The findings are: The facility policy titled Food Safety and Handling dated 9/2021 documented the food will be stored, prepared, handled, and served so that the risk of foodborne illness is minimized. During an observation with the Food Service Manager (FSM) on 8/14/2023 at 9:18 AM, the kitchen beverage refrigerator was 45 F, and the bread refrigerator was 60 F. During an observation on 8/18/2023 at 12:13 PM, the Cook's refrigerator #2 was 45 F. Refrigerator #2 contained liquid eggs that were 44.2 F and a pan of leftover barbecue chicken that was 42.1 F. On 8/18/2023 at 12:27 PM, the [NAME] was interviewed and stated they were not aware that the temperature of the cook's refrigerator #2 was above 41 F. The [NAME] stated stored cold items should not be above 41 F and should be discarded if above 41 F. On 8/18/2023 at 12:39 PM, the FSM was interviewed and stated the refrigerators were malfunctioning and the maintenance department was immediately notified on 8/14/2023 when the FSM observed temperatures above 41 F. Issues were identified, and work is in progress to fix the temperatures of the refrigerators. The FSM did not know there was an issue with the Cook's refrigerator #2. Items need to be taken out of the malfunctioning refrigerator and it will be taken out of service. The FSM stated they will inform the maintenance department right away for this new issue with the Cook's refrigerator #2. 415.14(h)

Based on observation, interview, and record review during the Recertification survey conducted from 08/14/2023 to 08/21/2023, the facility did not ensure infection prevention and control practices were maintained. This was evident for 5 residents (Resident #336, #99, #155, #335, and #325) out of 38 total sampled residents. Specifically, 1) hand hygiene was not performed during tracheostomy care, 2) a Licensed Practical Nurse (LPN) was observed not donning Personal Protective Equipment (PPE) appropriately prior to entering the room of a resident on contact precautions for Candida Auris. In addition, blood sugar monitoring devices and insulin pen placed on surfaces in the resident's room were taken out of the room to be discarded/stored on the medication cart without being sanitized; 3) an LPN used a stethoscope for a resident on contact isolation, did not sanitize it upon leaving the resident's room, and placed in on the top surface of the medication cart, 4) hand hygiene was not performed appropriately during wound care, and 5) an LPN was observed removing an intravenous catheter for a resident placed on contact precaution while not wearing appropriately PPE. This was evident during observations on Unit 1 and 4. The findings are but not limited to: 1. The facility's untitled policy last revised in August 2022 documented that tracheostomy care is to prevent infection, and an aseptic technique must be used. Resident #336 had diagnoses of tracheostomy status and ventilator dependence. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #336 was cognitively intact and require tracheostomy care. The Comprehensive Care Plan (CCP) related to tracheostomy care last revised 5/24/2023 documented Resident #336 required tracheostomy care using an aseptic technique. A Medical Doctor's Order (MDO) dated 5/25/2023 documented Resident #336 required tracheostomy care every shift. A tracheostomy care observation was conducted on 8/18/2023 at 8:55 AM and the Respiratory Therapist (RT) donned a gown and gloves before entering Resident #336's room. The RT placed the tracheostomy care supplies on the resident's bed without a sterile field. The RT removed the soiled dressing around the trach site, cleaned the area with a gauze pad and normal saline, changed the trach color, removed the old inner cannula, and inserted a new inner cannula with the same gloves. The RT did not perform hand hygiene or change gloves throughout the tracheostomy care. During an interview on 8/18/2023 at 9:51 AM, the RT stated that they performed hand hygiene and donned a gown before they went to the resident's room. The RT stated change their gloves during trach care if the resident has excessive secretions. Resident #336 did not have excessive secretions and the RT stated that is the reason they did not change their gloves. The RT was supposed to take extra gloves to the room and change the gloves when they removed the inner cannula. The RT stated that they used a gauze pad to clean their gloves instead. They were trained to place the supplies on the resident bedside table. They did not used the bedside table because the table was dirty. During an interview on 8/21/2023 at 10:03 AM, the Assistant Director of Nursing Services (ADNS) who is the Infection Control Nurse, stated that the RT was supposed to wipe the bedside table and place the sterile field on the table. The RT was supposed to perform hand hygiene and change their gloves during the tracheostomy care. They are required to perform hand hygiene after they remove the old inner cannula and don on new gloves before they insert the new cannula. During an interview on 8/21/2023 at 10:29 AM, the Director of Nursing (DON) stated that infection control must be maintained during tracheostomy care and the RT should keep a sterile field. The RT was supposed to change the gloves and sanitize their hands during the tracheostomy care. The infection control nurse and staff educator ensure that the staff is trained, and that infection control is maintained during tracheostomy care. 48711 The facility policy titled Transmission based precautions reviewed on created 11/2016 and revised on 5/18/2023 documented transmission-based precautions a second tier of infection control which are implemented in addition to standard precautions that are based upon the means of transmission (airborne, contact, and droplet precautions) to prevent or control infections. Signage at the entrance of the resident's room will provide instruction to the type of precaution implemented with guidance to healthcare personnel and visitors (e.g., use of PPE, hand hygiene, etc.) Resident care equipment will be managed in a manner to reduce the risks of transmission of infectious pathogens. Single patient equipment (e.g., dedicated B/P cuff, stethoscope, etc.) will be used to the extent possible. Shared patient equipment will be cleaned and disinfected between each resident with an approved EPA hospital grade disinfectant product following manufacturer's instruction for use, based on the pathogen identified. Upon entering the room of a resident in contact precautions, health care personnel and visitors should don a gown and gloves. Prior to leaving the room of a resident in contact precautions, healthcare personnel and visitors should doff personal protective equipment (e.g., gown, gloves) and perform hand hygiene. The facility policy titled Cleaning Disinfecting Equipment dated 4/2013 and revised on 2/2022 documented that reusable items are cleaned and disinfected between residents if visibly soiled, resident is on contact precautions and or there was direct contact to non-intact skin or mucus membrane (e.g., blood pressure cuff, durable medical equipment). 2. A Physician's Order dated 3/15/2023 documented that Resident #99 is on contact isolation precautions every shift for Candida Auris. A precaution sign in front the resident's room indicated Contact Isolation. Gown and gloves for all entries. On 08/16/23 at 03:39 PM, Licensed Practical Nurse (LPN) #3 was observed entering Resident # 99's room without donning a gown. LPN #3 exited the room and then donned PPE. LPN #3 re-entered the room, performed fingerstick, and removed gown and gloves. Lancet was taken out of the room and discarded on the sharps container located on the medication cart in the hallway. The glucometer was cleaned after use, and LPN #3 did not perform hand hygiene. LPN #3 donned a gown, placed an insulin pen on the tray table in room. Hand hygiene performed, Lantus insulin was administered in the residents abdomen, and insulin pen was then then placed onto of linen on the nightstand. LPN #3 removed their gown, washed hands, then placed the insulin in a plastic bag and placed it in the medication cart. 3. A Physician's Order dated 8/2/2022 documented that Resident #155 is on contact isolation precautions every shift for Candida Auris. A precaution sign in front the resident's room indicated Contact Isolation. Gown and gloves for all entries. On 08/16/23 at 04:59 PM, LPN #3 was observed donning PPE appropriately and checking for G-tube placement with a stethoscope, which they then placed stethoscope around neck. Upon exiting the resident's room LPN doffed PPE, performed hand hygiene and placed the stethoscope on the top surface of the medication cart without sanitizing it first. On 08/16/23 at 05:13 PM, an interview was contacted with LPN #3 who stated that they thought they had put a gown on in the hallway before entering the Resident #99's room. LPN #3 also stated that there is no sharps container in the room, and it is located on the medication cart located in the hallway. LPN #3 further stated they did not clean the insulin pen before placing it back in the cart, and they are supposed to clean it after they use it and before placing it back on the cart. LPN #3 stated that they clean their stethoscope before and after use, and did not clean it after this time as somebody called them and they forgot. On 08/16/23 at 05:21 PM, Registered Nurse/Nurse Manager (RN #4) was interviewed and stated that staff are observed for infection practices through rounds and in-services which are provided as needed and if an issue is identified, education is provided on the spot and routinely yearly. RN #4 also stated that gown and gloves should be put on prior to entering the room. RN #4 further stated that there should be portable sharps that the nurses are using but they were not sure if we have them. Insulin pens should be disinfected before it goes on the cart, and the stethoscope should be cleaned before and after use with any residents on precautions who should have dedicated equipment for the resident. 4. The Admission Minimum Data Set assessment dated [DATE], documented Resident #335 was severely cognitively impaired, required dependent assistance of two staff with activities of daily living, was at risk for pressure ulcer, and had one Stage 4 and two unstageable pressure ulcers present on admission. The Physician Order dated 7/24/2023 documented to apply to sacrum topically every day shift for deep tissue injury (DTI). Cleanse with normal saline (NSS), pat dry, apply Silvadene and cover with DPD. On 08/17/23 at 08:21 AM, during a wound care observation LPN #4 was observed preparing to perform wound care for Resident #335. LPN #4 washed hands, donned gloves and gown and placed drape sheet placed on overbed table. Sterile gauze, bordered gauze, and Silvadene cream placed on field. LPN #4 removed gloves, did not perform hand hygiene, and donned gloves. There was no dressing present and LPN #4 proceeded to cleanse wound with normal saline, removed gloves, did not perform hand hygiene, and donned another pair of gloves before applying treatment and dry, protective dressing to the wound. 5. A physician order dated 5/20/2023 documented Resident #325 is on contact isolation precautions every shift for Candida Auris. A precaution sign in front the resident's room indicated Contact Isolation. Gown and gloves for all entries. At 08/17/23 at 01:05 PM, LPN #4 was observed standing next to the bed of Resident #325 attending to the resident. LPN #4 was observed wearing gloves only. LPN #4 was interviewed immediately upon exiting the room and stated that Resident #325 is on precautions for Candida Auris, and they were supposed to have on a gown and gloves but was only removing an IV access from the resident. As it relates to Resident #335, LPN #4 stated that when doing wound care they remove the old treatment, change gloves, clean the wound, change gloves, and then put the treatment. After the treatment I wash my hands. LPN #4 further stated that they have had training in infection control and is supposed to wash hands when they remove gloves. On 08/18/23 at 09:45 AM, an interview was conducted with Registered Nurse/Nurse Manager (RN #1) who stated that they check to make sure that the staff are aware that residents are on precaution and ensure that door signs and isolation cart are in place. RN #1 stated that when supplies are prepared, hands should be washed before, gloves changed and sanitize and apply gloves in between. RN #1 further stated that hands have to be cleaned each time gloves are removed. RN #1 stated that if a resident is on contact precautions staff must have on PPE no matter what. RN #1 also stated that in-services are done periodically and staff are monitored during rounds and corrected if necessary. On 08/18/23 at 10:24 AM, the Assistant Director of Nursing/Infection Preventionist (IP) was interviewed and stated that PPE for resident's on contact precaution should be donned before entering the room. The IP also stated that ideally there should be individual equipment for each resident, but if we do not have that then the insulin pen, vital sign machine, stethoscope should be wiped clean before leaving the room. There is a sharps container on the medication cart so nurses would have to leave room to discard soiled items. When providing wound care hands should be washed before, set up supply, remove dressing, wash hands. Hand hygiene between glove changes. If entering to remove an IV, PPE including gown and gloves should be worn if the resident is on contact precautions. The IP further stated that they do rounds daily on units, and if they find issues that is corrected immediately. Competencies are also done periodically for staff. 415.19(a)(1-3)

Based on interviews and record review conducted during the Recertification survey from 8/14/23 to 8/21/23, the facility did not ensure residents' right to communicate with individuals and entities external to the facility. This was evident for 11 of 11 attendees of the Resident Council meeting. Specifically, the facility did not have a system in place for residents to receive and send mail on Saturdays. The findings are: The facility's policy titled Resident Mail revised 09/2021 documented all resident mail/packages need to be delivered daily, including Saturdays. On 08/16/23 at 11:00 AM, a Resident Council meeting was held with 11 residents of the facility. All eleven residents present at the meeting stated that they were not able to receive mail on Saturdays and the Recreation Director delivers the mail Monday through Friday. On 08/21/23 at 10:57 AM, the Director of Recreation (DOR) was interviewed and stated that when mail is delivered, it is sorted and dispersed to the Recreation department from the Admission department. If packages are delivered they are provided to Security who will have Recreation staff deliver it. The DOR also stated that Recreation staff will deliver the resident mail on all the units Monday to Friday. If mail comes in on a Saturday, the mail will stay until it is sorted on Monday by the Admissions department, and then it is delivered on Monday. On 08/21/23 at 11:09 AM, the Admissions/Finance Coordinator (AFC) was interviewed and stated that mail is received from front desk security daily, and is sorted according to departments and residents. The AFC then gives the mail to the Director of Recreation. The AFC also stated that they work Monday to Friday from 9AM to 5 PM so any mail received on Saturday is not sorted or distributed until Monday. The AFC further stated that mail is received every Monday morning from security. On 08/21/23 at 12:54 PM, the Administrator was interviewed and stated that mail comes in and goes to the Admission/Finance office where resident's mail is sorted and given to Recreation department to be distributed. The Administrator also stated that resident's do not receive mail on Saturday because the staff that handles the mail works Monday through Friday so residents have to wait until Monday to receive any mail that was delivered on Saturday. 415.3(e)(2)(ii)

Based on record review and staff interviews conducted during the recertification survey conducted from 8/14/2023 to 8/21/23, the facility did not ensure a person-centered Comprehensive Care Plan (CCP) was developed and implemented to meet the resident's goal, and address the resident's medical, physical, mental, and psychosocial needs. This was evident for 1 (Resident #351) of 1 resident reviewed for Dental out of 38 total sample residents. Specifically, there was no documented evidence that a CCP was developed and implemented for oral/dental concerns for a resident who was observed with missing teeth and poor dentition. The findings are: The facility's policy and procedure titled Care Plans - Comprehensive reviewed 8/21/2023 documented it is facility's policy that the Interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered, care plan for each resident. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). The policy also documented that the care plan should describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, and incorporate identified problem areas. Resident #351 was admitted to the facility with diagnosis that included Depression and Schizophrenia. The Comprehensive Admission Minimum Data Set assessment dated [DATE] documented Resident #351 was cognitively intact and documented there were no dental issues present. During an interview on 08/15/23 at 11:46 AM, Resident #351 was observed with teeth missing, and reported that they had not seen a dentist. The Comprehensive Physician History and Physical assessment dated [DATE] documented the resident had their own teeth with poor dentition. The Comprehensive Nutrition assessment dated [DATE] documented the resident has missing teeth. The Dental consult dated 8/20/2023 documented resident was seen for a new patient examination and was missing their natural teeth. Review of the medical record revealed that there was no care plan addressing the resident's dental status. On 08/21/23 at 11:28 AM, Nurse Manager (NM) #4 was interviewed and stated that different team members are responsible for different care plans and the dental care plan is one of the initial care plans that should be done on admission within 24 hours or so. NM #4 also stated that the admitting nurse or the supervisor opens the care plan and the Nurse Manager is responsible for following up. NM #4 further stated that in following up with outstanding consults, they noticed that the dental care plan had not yet been created so is working on it now. On 08/21/23 at 12:32 PM, an interview was conducted with the Director of Nursing, who stated that supervisors do the admission, and the nurse managers are responsible for doing the follow up. The DON also stated that on admission one of the basic care plans created is for dental. The DON further stated that the Assistant Director of Nursing and themselves are responsible for ensuring all care plans are created. 415.11(c)(1)

Based on interviews, observations and record reviews conducted during a Recertification survey from 8/14/23 to 8/21/23, the facility did not ensure timely identification and removal of expired medications. Specifically, expired medications were observed in the Emergency Medication Box on Unit 4. The findings are: The facility's policy and procedure entitled Medication Storage effective 2/2014 and revised 1/2022 documented that expired, discontinued and/or contaminated medications will be removed from the medication storage area and disposed of in accordance with facility policy. On 08/17/2023 at 04:15 PM, during the Medication Storage task conducted on Unit 4, the sealed emergency box medication checklist documented that Narcan 0.4mg/ml, quantity of 2, had an expiration date of 7/23/2023. Licensed Practical Nurse (LPN) #2 was interviewed immediately and stated that all nurses are supposed to check the emergency box. On 08/17/23 at 04:51 PM, LPN #8 was interviewed and stated that the emergency box monthly is checked monthly if it is not opened. LPN #8 also stated that they had looked at the box in August month and did not notice that there was expired medication in the box. LPN #8 further stated that the box is supposed to be given to the manager if there are expired medications in it. On 8/17/2023 at 5:00 PM, Registered Nurse (RN) #4 who was the Nurse Manager for the unit was interviewed and stated that the LPNs are responsible to check the Emergency box daily, and RN manager is responsible for overseeing that they check the box. RN #4 also stated that the LPNs are supposed to check the emergency box each shift. RN #4 further stated that there is no log kept confirming that the emergency box is being checked on each shift. 415.18 (a)

Based on interview and record review conducted during a recertification and complaint (NY00318827) survey from 8/14/2023 to 8/21/2023, the facility did not ensure all alleged violations involving major injury were reported to the New York State Department of Health (NYSDOH). This was evident for 1 (Resident #505) of residents reviewed for Abuse of 35 total sampled residents. Specifically, the facility did not report Resident #505's unwitnessed fall resulting in a head laceration was not reported to the NYSDOH. The findings include: The facility policy titled Abuse, Neglect, Mistreatment, Exploitation Prohibition dated 12/2022 documented the facility prohibits the mistreatment, neglect, and abuse of residents and misappropriation of resident property by anyone. Resident #505 had diagnoses of anemia and coronary artery disease (CAD). The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #505 was severely cognitively impaired and required the assistance of 2 people to complete activities of daily living. The Comprehensive Care Plan (CCP) related to falls was initiated 6/3/2023 and documented Resident #505 was at risk for falls due to confusion and deconditioning. Nursing Note dated 6/22/2023 documented Resident #505 was found lying on the floor bedside with a right elbow laceration and right eyebrow laceration. Medical Doctor (MD) note dated 6/22/2023 documented Resident #505 was transferred to the hospital for suturing of the laceration to their right eyebrow. On 08/17/2023 at 12:59 PM, an interview was conducted with the Registered Nurse (RN) #1 who stated they were called to observe Resident #505 on the floor with a right eyebrow laceration. Resident #505 was placed back to bed and the family was informed. Resident #505 was transferred to the hospital as per MD order. RN #1 stated 2 staff were assisting Resident #505 and the resident rolled onto the floor after one of the staff stepped away to go to the bathroom, sustaining the head laceration. RN #1 stated the Director of Nursing (DNS) was immediately informed and RN #1 was not responsible for notifying the NYSDOH of the incident. On 08/17/2023 at 01:08 PM, an interview was conducted DNS who stated the incident involving Resident #505 was not reported to the NYSDOH because the fall was observed by staff and the facility's investigation ruled out abuse and neglect. 415.4 (b)(2)

Based on observation, record review, and interviews conducted during the recertification survey from 8/14/2023 to 8/21/2023, the facility did not ensure a resident maintained acceptable parameters of nutritional status. This was evident for 1 (Resident #166) of 4 residents reviewed for nutrition out of 35 total sampled residents. Specifically, interventions to address Resident #166's significant weight loss were not implemented to prevent further weight loss. The findings are: Resident # 166 had diagnoses of diabetes mellitus and dementia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #166 was severely cognitively impaired, required extensive assistance with feeding, and had an unplanned weight loss. The Comprehensive Care Plan (CCP) related to nutritional status last reviewed 05/23/2023 documented Resident #166 had a significant undesired 3-month weight loss. Interventions included a gastroenterologist (GI) consult for possible feeding tube. the goal was to maintain Resident #166's current body weight of 126 pounds (lbs). The Weight Record documented Resident #166 weighed 157.4 lbs on 3/01/2023, 127 lbs on 7/26/2023, 124 lbs on 8/1/2023, and 123.1 lbs on 8/17/2023. Dietary Note dated 5/31/2023 documented Resident #166 had a diet and consistency downgrade to pureed and nectar thick liquids. The plan of care is to encourage Resident #166 to intake meals and fluids. Nurse Practitioner (NP) Note dated 5/31/2023 documented Resident #166 was referred for GI consult for potential feeding tube placement. Nursing Note dated 6/23/2023 documented Resident #166 had a GI consult due to weight loss. A computerized tomography (CT) scan of the abdomen and pelvis with oral and intravenous (IV) contrast to rule out gastric outlet obstruction. There was no documented evidence the a CT scan was ordered and performed to establish Resident #166's candidacy for a feeding tube to address their significant weight loss. On 08/17/2023 at 11:29 AM, Certified Nursing Assistant (CNA) #6 was interviewed and stated Resident #166 eats 25-50% of their meals. On 08/17/2023 at 11:13 AM, the Registered Dietician (RD) was interviewed and stated Resident #166's meal texture was downgraded and supplements were increased. Resident #166 was referred to GI to address the weight loss; however, Resident #166's weight continues to decrease. On 08/17/2023 at 12:10 PM, the NP was interviewed and stated Resident #166 had a significant weight loss and was referred to GI in May or June 2023. A CT scan of the abdomen was recommended but was not done for Resident #166 thus far. 415.12(i)(1)

Based on interview and record review conducted during a recertification and complaint (NY00318827) survey from 8/14/2023 to 8/21/2023, the facility did not ensure a resident received adequate supervision and assistance to prevent accidents. This was evident for 1 (Resident #505) of 35 total sampled residents. Specifically, Resident #505 fell and sustained a head laceration when a Certified Nursing Assistant (CNA) stepped away from the resident while providing care. The findings include: The facility policy titled Abuse, Neglect, Mistreatment, Exploitation Prohibition dated 12/2022 documented the facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident abuse, neglect, and mistreatment. Resident #505 had diagnoses of anemia and coronary artery disease (CAD). The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #505 was severely cognitively impaired and required the assistance of 2 people to complete activities of daily living. The Comprehensive Care Plan (CCP) related to fall risk initiated 6/3/2023 documented Resident #505 was at risk for falls due to confusion and deconditioning. Provide toileting assistance per resident's needs. Nursing Note dated 6/22/2023 documented Resident #505 was found lying on the floor bedside with a right elbow laceration and right eyebrow laceration. Medical Doctor (MD) notes dated 6/22/2023 documented Resident #505 was transferred to the hospital for suturing of the laceration to their right eyebrow. 08/16/2023 at 03:06 PM, an interview was conducted with the CNA #1 who stated Resident #505 required the total assistance of 2 people to complete activities of daily living. CNA #1 assisted Resident #505's assigned CNA on 6/22/2023 when Resident #505 fell out of bed. CNA #1 stated they went to the bathroom while providing care to Resident #505 to get the resident some warm water. Resident #505 began coughing while being held by the 2nd CNA at bedside. CNA #1 then observed Resident #505's assigned CNA lower the resident to the floor face first. Resident #505's right side of their face hit the floor before CNA #1 could return to the bedside to assist the other CNA with lowering the resident to the ground. The Licensed Practical Nurse (LPN) and Registered Nurse (RN) supervisor was made aware. On 08/16/2023 at 03:17 PM, LPN #1 was interviewed and stated they were called to Resident #505's room on 6/22/2023 after the resident had fallen on the floor at bedside. There were 2 CNA s attending to Resident #505 at the time of their fall. Resident #505 was assisted back to bed and was observed with an injury to their right forehead. A pressure dressing was applied to stop the bleeding from Resident #505's forehead and the MD ordered for Resident #505 to be transferred to the hospital for suturing of head laceration. On 08/17/2023 at 12:59 PM, an interview was conducted with the Registered Nurse (RN) #1 who stated they were called to observe Resident #505 on the floor with a right eyebrow laceration. Resident #505 was placed back to bed, the family was informed, and the MD ordered for Resident #505 to be transferred to the hospital for further evaluation. RN #1 stated 2 staff were assisting Resident #505 and the resident rolled onto the floor after one of the staff stepped away to go to the bathroom, sustaining the head laceration. RN #1 stated the Director of Nursing (DNS) was immediately informed. 415.12(h)(1)

Based on observations, records review, and interviews during the Recertification survey from 8/14/23 to 8/21/23, the facility did not ensure that a resident with a sacral pressure ulcer receive the necessary care and treatment to prevent infection of ulcer. Specifically, there was no dressing observed to the sacral area for a resident with a Stage Suspected Deep Tissue Injury pressure ulcer. This was evident for one (1) of three (3) resident reviewed for Pressure Ulcers out of 38 sampled residents. (Resident # 335). The finding is: Resident #335 was initially admitted with diagnoses that included Diabetes Mellitus, Necrotizing Fasciitis, and Gastrostomy status. The Admission Minimum Data Set assessment dated [DATE], documented Resident #335 was severely cognitively impaired, required dependent assistance of two staff with activities of daily living, was at risk for pressure ulcer, and had one Stage 4 and two unstageable pressure ulcers present on admission. The Physician Order dated 7/24/2023 documented to apply to sacrum topically every day shift for deep tissue injury (DTI). Cleanse with normal saline (NSS), pat dry, apply Silvadene and cover with DPD. The Comprehensive Care Plan (CCP) created 5/24/2023 and revised 8/3/2023 titled Alteration in Skin Integrity included an intervention to monitor dressing daily to ensure it is clean/dry/intact. The Wound Evaluation & Management Summary dated 8/11/2023 documented that resident had an Unstageable DTI Sacrum Full Thickness which measured 7 cm x 8.9 cm x 0.3cm, had moderate serous exudate with 25% slough. On 08/18/2023 at 08:45 AM, a wound care observation was conducted for Resident #335. Resident #335 was observed lying on their back. With the assistance of a Certified Nursing Assistant, Resident #335 was repositioned by Licensed Practical Nurse (LPN) #4 on the right side and the sacral area was exposed. There was no dressing observed covering the pressure ulcer, and moderate serous drainage was observed on the chuck lying under the buttock. On 8/18/2023 at 9:30 AM, an interview was conducted with the Licensed Practical Nurse (LPN) #4 who stated that Resident #335 had a bowel movement and the dressing was removed while cleaning the resident. LPN #4 also stated that the chuck was clean and they did not place a dressing after as they were going to get ready to do the treatment. LPN #4 further stated that not covering the wound with a gauze pad was an oversight. On 08/18/2023 at 9:45 AM, Registered Nurse (RN) #1 who was the Nurse Manager on the unit was interviewed and stated that wounds should not be exposed before care, and should be covered immediately prior to doing the new dressing. RN #1 also stated that rounds are made of staff to ensure that wound care is being provided appropriately. On 08/18/23 at 10:24 AM, an interview was conducted with the Assistant Director of Nursing (ADON)/Infection Preventionist who stated that wounds should be covered at all times including immediately prior to wound care. If the dressing becomes soiled or wet, the wound can be covered with gauze until wound care can be provided. 415.12(c)(1)

Based on observations, record review, and interview conducted during the Recertification survey from 8/14/2023 to 8/21/2023, the facility did not ensure the resident and their representative were provided with a written summary of the baseline care plan (BCP). This was evident for 4 (Residents #170, #327, #351, and #334) of 35 total sampled residnts. Specifically, 1) Resident #170's designated representative was not provided with a copy of the resident's BCP, 2) Resident #327 was not provided with a copy of their BCP, 3) Resident #351 was not provided with a copy of their BCP, and 4) Resident #334 was not provided with a copy of their BCP. The findings are but not limited to: The facility policy titled BCP dated 4/2023 documented the facility will provide the resident and the representative (if applicable) with a written summary of the BCP by completion of the comprehensive care plan (CCP). Facility will document and record receipt of information by family in the resident's clinical record. 1) Resident #170 had diagnoses of hypertension and anxiety disorder. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #170 was moderately cognitively impaired and participated in the assessment. On 08/14/2023 at 11:10 AM, Resident #170 was interviewed and stated they were not given a written copy of their BCP since admission to the facility approximately 19 months ago. The BCP dated 02/10/2022 did not document a signature of Resident #170 or their representative acknowledging receipt of the BCP. There was no documented evidence Resident #170 was provided with a copy of their BCP. On 08/18/2023 at 10:30 AM, Registered Nurse (RN) #3 was interviewed and stated the BCP is initiated by the admission nurse and reviewed, printed, and given to the resident by the next day after their admission to the facility. RN #3 was unsure whether Resident #170 was provided with a copy of their BCP. On 08/18/2023 at 11:21 AM, an interview was conducted with Social Worker (SW) #1 who stated nursing completes the BCP and provides a copy to the residents. 2) Resident #327 had diagnoses of hypertension and asthma. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #327 was cognitively intact, participated in the assessment, and had no family or significant other. On 08/14/2023 at 12:08 PM, Resident #327 was interviewed and stated they were not provided with a copy of their BCP since admission to the facility 4/2023. The BCP dated 04/10/2023 did not document a signature of Resident #327 or their representative acknowledging receipt of the BCP. There was no documented evidence Resident #327 was provided with a copy of their BCP. On 08/21/2023 at 10:20 AM, an interview was conducted with Registered Nurse (RN) #2 who stated the BCP is created by the admission nurse, is supposed to be signed by the nurse, and a copy of the BCP is given to the resident. RN #2 stated the BCP for Resident #327 was completed on 4/10/2023 and they are unsure whether a copy of the BCP was provided to the residents. On 08/21/2023 at 10:35 AM, Social Worker (SW) #2 was interviewed and stated the BCP is discussed with the residents during the initial care plan meeting. 48711 3. Resident #351 was admitted with diagnoses of Depression and Schizophrenia. The MDS assessment dated [DATE] documented Resident #351 was cognitively intact, and participated in the assessment. On 08/14/23 at 03:46 PM, Resident #351 was interviewed and stated that they had not signed or received any paperwork relating to any initial care plan after admission. The Team: IDT Baseline Care Plan dated 7/18/2023 documented baseline care plan reviewed with the Resident/Resident Representative and a copy was offered. The Baseline Care Plan (BCP) created on 7/18/2023 did not document a signature of Resident #351 or their representative acknowledging receipt of the BCP. There was no documented evidence Resident #351, or their representative was provided with a copy of the BCP. 4. Resident #334 was admitted with diagnoses of Anxiety Disorder, Depression, and Renal insufficiency. On 08/14/23 at 04:35 PM, Resident #334 was interviewed and stated that no one had spoken to them regarding their plan of care or given them any documents regarding this when they were first admitted . The MDS Admission assessment dated [DATE] documented Resident #334 was cognitively intact, and participated in the assessment. The Team: IDT Baseline Care Plan dated 5/12/2023 documented baseline care plan was reviewed with Resident #334/Resident Representative and a copy was offered. There was no signature or date affixed to the document from either Resident #334 or their representative. On 08/21/23 at 11:21 AM, the Director of Social Services (DSS) was interviewed and stated that they were not too involved in the base line care planning process, as the nursing supervisor is more involved. On 08/21/23 at 11:28 AM, Registered Nurse (RN) #4, who was the unit Nurse Manager stated that baseline care plans are done on admission within 24 hours or so. RN #4 also stated that once baseline care plans are completed, the resident is provided a copy which they sign, and that copy then gets scanned into the EMR. RN #4 was not able to locate signed copies of the baseline care plan for either Resident #351 or Resident #334. On 08/21/23 at 12:32 PM, the Director of Nursing (DON) was interviewed and stated that Baseline Care Plans are done on the day of admission or the next day by the Admission nurse. The DON further stated that there is currently no process in place where residents are able to sign for receipt of a BCP as the nurses sign the form electronically. The DON also stated that they have requested that staff print the form, have the resident sign it, and place a signed copy in the chart, however this is not a formal facility policy. 415.11 (c)

Based on observation, record review, and interviews conducted during the recertification survey from 8/14/2023 to 8/21/2023, the facility did not ensure the resident's right to a dignified existence. This was evident for 2 (Resident #225 and #166) of 35 total sampled residents. Specifically, 1) Resident #225 was fed by staff standing over them, and 2) Resident #166 was not provided with clothing to ensure they were dressed appropriately. The findings are: The facility policy titled Quality of Life/Dignity dated 10/2022 documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Resident #225 had diagnoses of autism and hypertension. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #225 had severely impaired cognition and required limited assistance of one person for eating. On 8/14/2023 at 12:20 PM, Licensed Practical Nurse (LPN) #6 was observed standing over Resident #225 while feeding the resident. During an interview on 8/14/2023 at 3:30 PM, LPN #6 stated they were more comfortable standing and assisting residents with their meals because it allows LPN #6 to see all the residents in the dining room. LPN #6 stated they know they are supposed to sit while feeding residents, but they feel more comfortable standing. During an interview on 8/21/2023 at 10:39 AM, the Director of Nursing (DNS) stated that the staff must sit down while assisting residents with their meals. It is ideal for the staff to sit down for the residents' comfort. LPN #6 was supposed to sit and position themselves to see other residents. The managers are responsible for ensuring the staff sit down while assisting the residents with their meals. 18881 2) Resident #166 had diagnoses of hypertension and dementia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #166 was severely cognitively impaired and required extensive assistance for dressing. On 08/16/2023 at 11:24 AM, Resident #166 was observed in their recliner dressed in a faded shirt and oversized sweatpants that appeared too large for the resident. On 08/17/2023 at 10: 27 AM, Resident #166 was observed in their recliner wearing faded shirt and pants. Registered Nurse Supervisor (RNS) #2 was present during the observation Resident #166's closet was observed with the following clothing labeled with various different resident names that were not Resident #166: 4 short sleeved shirts 1 pants 2 pairs of non-skid socks 1 pair of shorts sized 3x (oversized and too large for Resident #166) 1 sweatshirt There was no documented evidence the facility ensured Resident #166 had adequate clothing to ensure a dignified existence. On 08/17/2023 at 11:20 AM, Certified Nursing Assistant (CNA) #5 was interviewed and stated they have been assigned to Resident #166 for the last 3 months and the resident has no clothing. All of Resident #166's clothing is in their closet and CNA #5 stated there was practically nothing there. All staff knows Resident #166 does not have clothing. CNA #5 tells the supervisor when a resident does not have clothing and the facility has donation clothing. On 08/18/2023 at 10:23 AM, CNA #7 was interviewed and stated they dress Resident #166 in whatever fits because the resident does not have any clothing that is theirs. The facility has a closet of extra clothing and staff brought the resident some pants and a sweater yesterday. On 08/16/2023 at 12:07 PM, Social Worker (SW) #3 was interviewed and stated Resident #166 has a legal guardian. No clothing has been purchased for Resident #166 since 2022. On 08/21/2023 at 12: 20 PM, SW #4 was interviewed and stated if residents have no clothing, the SW calls the family or legal guardian. The facility also provided clothing donations to residents with no clothing. The SWs check the resident's personal needs account and buys clothing for residents with the approval of the family or legal guardian. 415.3(a)

Based on observation, interviews, and record review conducted during an abbreviated and partial extended survey (Complaint # NY 393 and NY 059) from 01/12/2022 to 01/18/2022, the facility failed to protect residents from abuse, neglect, misappropriation of resident property, and exploitation. This was evident in 3 out of 12 residents sampled (Resident #1, #2, & #3). Specifically, on 11/07/2021 Resident #3 punched Resident #2. During the facility investigation, Resident #3 stated that he/she punched Resident #2 because Resident #2 was talking about the sexual activity that Resident #2 had with Resident #3. Resident #2 and Resident #3 were deemed by the psychiatrist to lack the capacity to make decisions regarding sexual activity. Resident #2 and Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15/15 (cognitively intact). There was no investigation as the facility determined that the sexual activity was consensual. On 12/13/2021 the Behavior Specialist (BS) reported that at approximately 7 PM, during rounds he/she entered Resident #1's room. BS looked behind the curtain and observed Resident #2 bent over Resident #1 who was bent over in the bed. Both residents had their pants down and Resident #2's penis was erect. BS immediately separated the residents and reported to the Registered Nurse. Resident #1 and Resident #2 were deemed to lack the capacity by psychiatrist to make decisions regarding sexual activity. Resident #1 had a BIMS of 11/15 (moderate Impairment) This resulted in Immediate Jeopardy and Substandard Quality of Care with the likelihood for serious harm, pain, and mental anguish to all of the residents. The findings are: A Review of the facility Policy titled Abuse with revised date 2/2019 documented the facility prohibits the mistreatment, neglect, and abuse of residents by anyone, including staff, family, friends, etc. The Policy documented that upon receiving reports of physical or sexual abuse, the Director of Nursing (DON)/designee shall immediately examine the resident. Findings of the examination must be recorded in the resident's record. (Note: if sexual abuse is suspected, do not bathe the resident, or wash the resident's clothing or linen. Call the police immediately.) The resident should be sent to the local emergency room for examination. This document also stated to notify the local law enforcement and appropriate State Agency immediately (no longer than 2 hours after allegation/identification of allegation) by Agency's designated process after identification of alleged/suspected incident. (1) Incident of 11/7/2021 A). Resident #2 was initially admitted to the facility for medical management and rehabilitation on 03/30/2005, last admission 02/20/2013 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - a resident assessment tool) dated 12/11/2021 identified that the resident had a BIMS and scored 15/15. Resident #2's Kardex dated 11/2021 documented that resident was monitored with Stop and Watch Early Warning Tool, for behavior, including sexually inappropriate behavior. The instructions included maintaining visual line of sight; if staff observed inappropriate sexual expression (i.e., public display, sexual comments, or gestures to staff or other residents) they will immediately re-educate the resident on appropriate behavior and redirect the resident to a private space as needed; monitor the resident when children were on the unit. A Comprehensive Care Plan (CCP) Behavior documented Resident #2 has behavior, verbal aggression, and sexually inappropriate behavior. The interventions included increasing supervision as needed, monitoring mood and behavior, documenting maladaptive behaviors, etc. A CCP Resident #2 at risk for potential abuse dated 11/7/2021, documented that Resident #2 was a victim of the resident-to-resident altercation and continues to be at risk due to a history of verbal aggression, yelling and inappropriate sexual behavior. At risk for injury to self and others. Interventions included education and teaching to refrain from inappropriate behavior, keep the resident apart from the peer whenever possible, maintain visual line of sight, monitor and document behavior, notify Medical Doctor (MD) of inappropriate behavior. A Psychiatry Consult dated 11/8/2021 documented that Resident #2 has no capacity to make a sexual decision at this time. Continue current management. CCP was updated on 12/13/2021 with interventions Psychiatrist and Psychologist consult, dated 12/14/2021 education and teaching to refrain from inappropriate behavior, every 15 mins monitoring for 3 days. A Unit Rounds dated 11/7/2021 documented that Resident #2 was on every 30 minutes monitoring and was seen at 4:30 PM calm at the Group (recreation). Resident #2 continued on every 30 minutes monitoring (before) and after the incident. There was no documented evidence for changes in monitoring for Resident #2. There was no documented evidence of increased supervision after the facilities knowledge of inappropriate sexual behavior. B). Resident #3 initially admitted to the facility for medical management and rehabilitation on 4/29/2013. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented that Resident #3 has a BIMS and score 15/15. A CCP Behavior initiated 4/22/2021 documented interventions to advise Resident #3 always to try to control themselves and report any issue to staff, document all behavior, determine the cause of the behavior, and remove the resident. CCP was updated on 11/7/2021 with the intervention resident's education on safe sex. A Physician Order dated 11/7/2021 documented order for Psych Consultation. A Psychiatry Consult dated 11/8/2021 documented that Resident #3 was evaluated due to resident-to-resident altercation. Resident #3 was upset because Resident #2 talked about oral sex with Resident #3 to other people; perhaps this has led to the assault. Resident #3 has no capacity to decide on his/her sexual decisions. A review of the facility's investigation dated 11/7/2021 revealed that Resident #3 hit Resident #2 because Resident #3 believed that Resident #2 was telling other residents that they had oral sex. Resident #2 and Resident #3 stated that the oral sex happened, but that it was consensual. Both residents could not give the date and time of when they had oral sex. Both Resident #2 and Resident #3 have Brief Interview of Mental Status (BIMS - a resident assessment tool) scores of 15/15. However, psychiatrist (psych) evaluated both residents and deemed them both with no capacity to make sexual decisions. Resident #3 was transferred out to the ER for psych evaluation and was moved to another unit upon return to the facility. Psych consult and close monitoring were ordered. Resident #2 called the Police. No arrest was made. The facility concluded that abuse did not occur. The incident was reported to New York State Department of Health (NYS DOH) and local law enforcement. An Intradisciplinary team (IDT) meeting dated 11/8/2021 at 1:47 PM documented that the following were in attendance: Social Services, Administration, and Resident #2. Upon interview, a peer (Resident #3) admitted to performing oral sex with Resident #2 and that he/she later struck Resident #2 because Resident #3 believed that Resident #2 was talking to others about their sexual relations. Resident #2 admitted that Resident #3 had performed consensual oral sex on Resident #2 once last week. He/she was unable to provide an exact date. During an interview on 01/13/2022 at 3:59 PM, DON stated that he/she was made aware of the incident on 11/7/2021 between Resident #2 and Resident #3. Resident #2 was a victim because Resident #3 punched Resident #2 in the face. That was why the incident was reported to the New York State Department of Health (NYSDOH), and Resident #2 called the police. There was no arrest made. Resident #3 was transferred to the Psych hospital. The DON stated, upon Resident #3's return to the facility, the resident was transferred to the 4th Unit. During the investigation, Resident #2 said that they had sex with Resident #3, but it was consensual. The DON stated that the staff reported no knowledge of sexual behavior between Resident #2 and Resident #3, and there were no witnesses. The interdisciplinary team met with Resident #2 and #3 and educated them on proper behavior. A Psych consult was ordered, and both residents were evaluated, and it was determined they did not have the capacity to make sexual decisions. The DON stated that both residents were on every 30 minutes monitoring before and after the incident. During an interview on 01/13/2022 at 4:15 pm, the Psychiatrist stated that he/she does not think that Resident # 2 has medical or financial capacity. Resident #2 is alert and oriented, but his/her judgment and insight are poor. Resident #2 has a Psych history and needs medication management. Resident #2 cannot survive in the community. The Psychiatrist stated that Resident #3 is alert and oriented, a very violent resident, and requires medications and behavior management with adjustments when he/she gets episodes of agitation. Resident #3 was sent to the Psych ER every time he/she became physically aggressive. Resident #3 also has poor judgment and poor insight. Psych stated, Resident #3 has no medical, financial, or sexual capacity. The residents' placement in the neurobehavior unit is appropriate at this time. (2) Incident of 12/13/2021 A). Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 9/28/2021 documented that Resident #1 had a Brief Interview of Mental Status (BIMS used to determine attention, orientation, and ability to recall information) and score 11/15. A Physician's Order dated 06/24/2019 (status active) documented Resident #1 had no capacity to make medical and financial decisions. A Comprehensive Care Plan (CCP) initiated 06/26/2019 Resident #1 has a history of verbal, physical aggression, auditory and visual hallucination. The interventions included if the resident is demonstrating inappropriate or maladaptive behavior, ask the resident to stop, explain why the behavior is not appropriate, redirect to proper responses; provide praise and positive regard when the resident is able to respond appropriately. CCP was updated on 12/13/21 due to inappropriate behavior with the peer. Education and teaching to refrain from inappropriate behavior, Psychiatry and psychology consult, every 15 minutes rounds for 3 days. A CCP Resident at risk for being a victim due to inability to understand their surroundings, date 6/26/2019 with target date 2/13/2022 documented interventions to assess resident for signs and symptoms (s/s) of abuse and/or neglect (ex. bruises, behavior, psychosocial status) and report to appropriate resources. Every 15 minutes Round Sheet dated 12/13/2021 -12/15/2021 documented that Resident #1 was monitored every 15 minutes for 3 days. After 3 days, Resident #1 was put back on every 30-minutes monitoring. A Care Plan Note dated 12/17/2021 at 11:44 Late Entry: Resident #1 Status/Post (S/P) altercation on 12/13/21. Resident #1 was seen and evaluated by a psychiatrist. The Psychiatrist ordered to continue on current management. The resident does not have the capacity to make sexual decisions at this time. An Intradisciplinary Team (IDT) Meeting dated 12/14/2021 at 1:45 PM met with Resident #1 to follow up regarding a recent behavioral occurrence where Resident #2 was noted in the resident's room bending over them in an inappropriate manner. Resident #1 denied having sexual relations with the peer or anyone on the unit. Referral for psychology was made, and a psychiatry consult was placed to determine whether the resident has capacity for sexual relations. An Initial Event Documentation dated 12/13/2021 7:00 PM, Type of Event: sexual behavior documented that at approximately at 7:00 PM, BS informed that when he/she went to call Resident #1 for medication, he/she found Resident #2 in Resident #1's room bending over Resident #1. BS immediately went and redirected them to their rooms and reported incident. The writer interviewed Resident #1, and he/she denied having a sexual act with Resident #2. The Nurse Manager was made aware. The Nurse Practitioner was informed. Attempted to call family with no response. Review of the Initial Event Documentation dated 12/13/2021 at 7:00 PM documented that Resident #1 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 denied sexual behavior. A review of the Investigation Form dated 12/13/2021 revealed that the Behavior Specialist (BS) reported that at approximately 7:00 PM, during the round, he/she entered Resident #1's room. BS looked behind the curtain and observed Resident #2 bend over Resident #1, who was bent over in the bed. Both residents had their pants down. BS immediately separated the residents and reported to the Registered Nurse. The facility conducted an investigation and concluded that there is no evidence to support that any alleged resident Abuse may have occurred. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . During the interview, the resident denied any sexual act with the other resident, and he/she stated they were just talking and nothing else. Resident #1 was alert and oriented, with periods of confusion but able to make needs known. Resident #1 was diagnosed with cognitive deficit and [CONDITION(S)]. Resident was not in acute distress and denied having a sexual encounter with another resident. Evaluation and assessment revealed, Resident #1 had no cuts, bruising or reddened areas to any part of the body. Plan: Possible having a sexual encounter with another resident, but resident denies. Psych consultation. SW intervention. Move resident to a different unit. Close monitoring. A Psychiatry Consult dated 12/16/2021 documented Resident #1 was evaluated for capacity for sexual decision. The resident reported a fair mood and denied suicidal ideation. Resident #1 denied any sexual encounter with Resident #2. With Resident #1's Chronic Psychotic state, hearing voices, seeing devils having sex, Resident #1 appeared to not to have the capacity to decide whether or not to have sex. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 remains on the same unit. B). Resident #2 was initially admitted to the facility for medical management and rehabilitation on 03/30/2005, last admission 02/20/2013 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . CCP Resident #2 is at risk for potential abuse, neglect, victimization initiated on 12/03/2013, target date 2/13/2022, documented interventions to provide a safe person to report abuse/ neglect to, provide support and ensure the resident is free from abuse. A Unit Rounds dated 12/13/2021 was reviewed and revealed that Resident #2 was monitored every 30 minutes and last seen at 6:30 PM, calm in the bedroom (in his/her room). A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . During the interview, Resident #2 denied any sexual act with the other resident. Recommended: possible having a sexual encounter with another resident but resident denies; Psych consultation; SW intervention; Move resident to a different unit; Close monitoring. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 remains on the same unit. During an interview on 1/12/2022 at 11:04 AM, the Social Worker (SW) stated that he/she knows Resident #2 for seven years. The SW stated that the resident has a history of inappropriate sexual behavior before admission to the facility. SW stated that he/she was a part of the team that met with both residents after the incident on 12/13/2021. They met with Resident #2 first; he/she denied any sexual activity. Resident #2 went to Resident #1's room and was just talking as a friend. Resident #2 denied any sexual relationship, saying that they are platonic friends. Then the team met with Resident #1, and he/she denied any sexual activity. They were just talking, and nothing happened. All residents on the unit are on every 30 minutes monitoring. Both residents stated they felt safe and comfortable. The SW stated, there was no necessity to change the unit; they were not roommates. Referral to Psych was done for capacity. Psych saw both residents and both residents have no capacity for a sexual relationship. Both residents denied pursuing sexual relationships. During an interview on 1/12/2022 at 2:22 PM, Behavior Specialist #2 (BS #2) stated that he/she is a floater and worked on 12/13/2021 3-11 shift. She/he was doing round to make sure everybody was taking medications. Resident #2 was not in his/her room (sometimes he played cards in the dining room). BS #2 continued to check everybody's rooms until he/she got to Resident #1's room; his/her curtain was pulled over. BS #2 asked Resident #1 if he/she took the medications. Resident #1 answered, yes, we did. BS #2 wanted to know who was we and stepped into the room and opened the curtain. BS #2 saw Resident #1 bent over the bed with their pants down to the floor. Resident #2 was behind Resident #1 with their pants down, penis with an erection was out and positioned toward Resident #1's rectum. BS #2 Immediately asked Resident #2 to leave the room. He/she got dressed and left the room. BS #2 asked Resident #1 if he/she was ok; he/she said yes, and BS #2 went to report to the supervisor. During an interview on 1/12/2022 at 2:40 PM, Nurse Manager #2 (NM #2) stated that BS #2 reported that he/she was making 30 minutes round and observed Resident #2 in Resident #1's room. BS #2 found them in an unacceptable position. Resident #2 was bent down over Resident #1, who was also bent down. Both residents' pants were down. Residents were separated immediately. NM interviewed both residents, and they denied the accusation. During an assessment, Resident #1 was in bed covered with the blanket. Resident #1 said that he/she was sleeping, and Resident #2 was sitting on the chair. According to Resident #1, he/she was not listening, and Resident #2 left the room. NM #2 stated that they interviewed Resident #2, and his/her story confirmed what Resident #1 was saying. That he/she was in Resident #1 room sitting in the chair, but Resident #1 was sleeping and did not pay attention to him/her, and Resident #2 left the room. Both residents denied any sexually inappropriate behavior. The assessment was done for Resident #1; no bruising, body fluids, or swelling on the rectum area or other parts of the body were observed. The assessment was done on Resident #2 with no bruising no marks on the body. NM #2 stated that DON and NP were notified. NM stated that police were not notified because both residents denied any sexual behavior. NM was not aware of any sexual behavior of Resident #2 before that day. NM stated that they call the police when they suspect the abuse or have evidence that abuse occurred. During an interview on 1/12/2022 at 4:39 pm, the Director of Nursing (DON) stated that the incident was not reported to police and NYSDOH because both residents denied the sexual encounter. There was no evidence that abuse happened. The staff member reported that she/he witnessed sexually inappropriate behavior, but both residents denied having a sexual encounter. IDT decided that this unit was most appropriate for both residents. The DON stated, both residents remained on the same unit. They were placed on 15 min monitoring for three days and then returned to a routine every 30 minutes of monitoring. Staff monitored them, and no behavior was reported before or after the incident. The DON stated, Resident #1 was assessed by a Registered Nurse with no visible injury, and a decision was made not to send Resident #1 to the hospital. The next day Physician assessed both residents with no acute findings. The Psychiatrist evaluated Resident #1, and no psychosocial harm was noted. Resident #1 has no capacity for sexual decisions. Resident #2 had no capacity for sexual decisions. They both denied any desire for a sexual relationship. During an additional interview on 01/13/2022 at 3:59 PM, DON stated that he/she was made aware of the incident on 11/7/2021 between resident #2 and Resident #3. Resident #2 was a victim because Resident #3 punched Resident #2 in the face. That was the reason that the incident was reported to the NYSDOH, and Resident #2 called the police. There was no arrest made. Resident #3 was transferred to the Psych hospital. Upon return, Resident #3 was transferred to the 4th Unit. During the investigation, Resident #2 said that he/she (Resident #2) had sex with Resident #3, but it was consensual; the staff reported no knowledge of sexual behavior between Resident #2 and Resident #3, and there were no witnesses. Psych consult was ordered, and both residents were evaluated, and they had no capacity to make a sexual decision. During an interview on 01/13/2022 at 4:15 pm, the Psychiatrist stated that he/she does not think that Resident # 2 has medical or financial capacity. Resident #2 is alert and oriented, but his/her judgment and insight are poor. Resident #2 cannot survive in the community. The psychiatrist stated that Resident #1 is alert and oriented, has a Psych history, is on psych medication, and still hears voices. Resident #1 has poor judgment and poor insight. Resident #1 has no medical, financial, or sexual capacity. During an interview on 1/13/2022 at 4:46 PM, the Administrator stated that he/she was made aware of the incident dated 12/13/2021. The Administrator stated that they were a part of the decision not to report to the police and NYDOH. The Administrator stated that he/she felt that there was no abuse and no harm to Resident #1. The Administrator stated that he/she remembered that it was reported that both residents were having consensual sex. They interviewed both residents, and they denied having sex. During an interview on 1/18/2022 at 3:00 PM, NP stated that he/she assessed Resident #1 and Resident #2 on next day. Resident #1 was examined with no visible injury noted on the skin. The rectum was examined with no redness, swelling, excoriation, or bleeding noted. Resident #2 was examined as well. No visible injury, redness, or swelling on any parts of the body were identified. No pain was verbalized. NP felt that since both residents denied sexual encounters, there was no necessity to send Resident #1 to the hospital. Immediate Jeopardy (IJ) was identified/declared, and the facility Administrator and DNS were notified on 01/13/2022 at 7:50 PM. The facility submitted a removal plan which was reviewed and accepted by NYS DOH on 01/13/2022 at 10:50 PM. On 01/18/2022 at 4:30 pm, the survey team declared the IJ was removed as of 01/18/2022 at 12:15 PM based on the following corrective actions taken by the facility: Police were called on 1/13/2022 and arrived at the facility. No arrest was made. Daily Supervision Checklist 1:1 monitoring for Resident #2 dated 1/13/22-1/18/22 was reviewed with no concerns indicated. The facility reviewed the policy on Abuse/Residents Rights/Sexual Expression; no revision is needed. The facility has 420 employees. Total staff on leave 32 (7.6%). They will be in-serviced after return and before starting their shift. The facility provided in-service to staff 387/420 (92.1%) including Administration - 6/6, RN 21/23; LPN 53/59; CNA 123/139; Behavior Specialist 41/44, others 116. Surveyors observed staff receiving in-service in person before starting a shift. In-service was also given over the phone. Surveyors verified in-service by reviewing lesson plans and counting signatures. The surveyors interviewed Registered Nurse Unit Managers-12, LPN-20, CNA-29; Behavior Specialist- 6; Respiratory Therapist-1; Director of Social Service -1, Fitness Therapist-1; Housekeeper -7; Recreation -3, Physical Therapist-1, Speech Therapist-1, Clerk-2, Security Staff-1, Maintenance Staff -1. Staff interviewed were knowledgeable about Abuse Identification, Prevention, Monitoring Behavior, Reporting, Residents Rights and Sexual Expressions and their role. The facility interviewed 24/24 residents on the 2CD unit and 19/19 on 2FE. Residents report no issue regarding sexual behavior. The Psychiatry Consult done for Resident #1, Resident #2, and Resident #3. o Resident #1. The resident has no capacity to consent to sexual relations or to make medical and financial decisions. Resident #1 continues on 30 min monitoring. o Resident #2. The resident does not have the capacity to consent to sexual relations or make medical and financial decisions. Resident #2 continues 1:1 monitoring. The Psychiatrist will reevaluate Resident #2 in one week to assess the monitoring needed. o Resident #3. The resident does not have the capacity to consent to sexual relations or make medical and financial decisions. All new and re-admit residents from 1/12/2022 Social Worker reviewed sexual expressions and will continue doing so as needed. Resident Council was held on 1/14/2022. Discussion about resident's rights and abuse prevention, including resident's rights to engage and pursue and fulfill intimate sexual desires and engage in sexual relationships. Residents complimented the staff for the way the subject was approached, and the discussion that followed Surveyors conducted onsite monitoring of facility on 1/15/22 (Saturday), 1/16/22 (Sunday), and 1/17/22 (Monday/Holiday). No resident sexual inappropriate behaviors were observed. Staff interviewed were familiar with Policy and Procedures and stated that they had been in-serviced. 415.4(b)(1)(i)

Based on staff interviews and record review conducted on a Complaint investigation during a Recertification survey, the facility did not ensure that the unit physician reviewed and followed up on the residents entire plan of care and identified the development of a Stage [MEDICAL CONDITION] tumor. This was evident for 1 of 27 samples residents. (Resident #191). Complaint # NY 342 The findings are: On 2/2/17 at 1:56 PM, a complaint was called into the Department of Health hotline alleging that the resident had a baseball sized tumor rapidly growing on the left side of the neck. The complainant stated that nothing was being done and the resident had not been seen by the physician. Resident # 191 is a [AGE] year old was re-admitted to the facility on [DATE] and 4/18/17 with [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] documented intact cognition and extensive assistance of one person for activities of daily living. On 6/5/17 at 1:05 PM, resident was observed lying in bed with head of the bed elevated, greeted surveyor appropriately. Large, red, pink mass noted in the left-side neck area. Resident stated that the mass had been there for some time and denied pain at the site. Resident stated that it [MEDICAL CONDITION], that treatment is done every week and the mass is getting smaller. 06/07/2017 at 3:33PM, the resident was observed in the day room participating in a Music activity being conducted by facility staff. Resident smiled when greeted. Mass visible in neck area, skin intact, reddish, pink in color. Resident denied pain. The physician progress notes [REDACTED]. The progress note further documented that an x-ray and an ultrasound of the neck was requested. The LPN (Licensed Practical Nurse) progress note dated 9/27/15 at 12:00 AM, documented swelling to the left side of the neck, seen by MD (Medical Doctor), X-ray of the neck, Ultrasound of the neck, Duplex Ultrasound and Carotid Left Side of Neck. The LPN (Licensed Practical Nurse) progress note day 3/3 dated 9/28/15 at 10:44 PM, documented: swelling to left side of neck. Awaiting result of ultrasound. The Carotid Doppler Ultrasonography Report dated 9/28/15 for evaluation of the carotid arteries, documented an incidental finding of a solid mass adjacent to the left mandible (jaw) measuring 3.6 x 3.0 cm (centimeters) of unknown etiology (cause). The physician progress notes [REDACTED]. The progress note further documented that a surgical consultation was requested for further evaluation of the mass. The Physicians Progress Note dated 11/17/15 documented the resident was seen by general surgery for [REDACTED]. An appointment scheduled on 11/20/15 for follow up with general surgery after the CAT Scan result. The Radiology Report dated 12/1/15 documented for CT (Computed Tomography) scan of the soft tissue of the neck was completed w/o (without) contrast (due to poor IV access) to rule out the presence of a mass. The report further documented there was a large 5.8 cm x 3.5 cm left-sided neck mass. The lesion was well-defined with smooth margins, with posterior displacement of the sternomastoid, with anterior, medial and inferior displacement of the submandibular gland. No necrotic adenopathy was identified. The documented impression: Probable large anterior cervical nodal mass. A primary neoplasm is considered less likely. The Physician order dated 12/31/15 documented: Surgical Consult-left side neck mass. There was no documented evidence in the medical record that the surgical consult was completed. There was no documentation that the referral for consultation was followed up on by the physician. The Physician H&P's (History and Physicals) dated 3/9/16 to 10/19/16 documented the residents was neck supple and the skin intact. The Physician H&P dated 6/29/16 documented: neck supple and left neck mass stable. The Physician H&P dated 11/16/16 documented: large mass to left side of neck, hard and non tender, does not disturb swallowing or eating. Plan: Neck mass-not new-patient to follow up with general surgery. The Order Listing Report documented ENT consult to evaluate mass to left neck that is slowly growing one time only for mass to left neck for 14 days dated 12/14/16-12/28/16. There was no documented evidence that the facility referred the resident for further evaluation after the diagnostic work up completed in December 2015. The Soft Tissue-Neck CT Scan report for dated 1/19/17 documented a large necrotic left-sided level two neck mass measuring 6.0 x 6.8 x 6.3 cm. The mass is situated just below the left parotid gland. Impression: 1. Large left-sided level two necrotic mass/lymph node measuring up to 6.8 cm. Suggestive of [MEDICATION NAME] spread. 2. Prominence of left palatine tonsil which may represent primary site of neoplasm. Direct visualization/ENT evaluation is recommended. The [MEDICAL CONDITION] Oncology Consultation dated 3/13/17 documented: [AGE] year old with Stage [MEDICAL CONDITION] of left tonsil with large neck nodes and is not a candidate for definitive Chemo ([MEDICAL CONDITION])/RT ([MEDICAL CONDITION] Therapy). Will have [MEDICAL CONDITION] first. if a good response, can be re-evaluated for possible palliative [MEDICAL CONDITION]. The Hematology Consultation dated 3/15/17 documented concern that the resident would not tolerate chemo/[MEDICAL CONDITION]. Impression: Advanced SCC (Squamous Cell [MEDICAL CONDITION]). Recommendation: Port Placement. The re-admission record documented a [DIAGNOSES REDACTED]. The documented onset date was dated 3/28/17. The record further documented the [DIAGNOSES REDACTED]. The Hospital H&P (History and Physical) evaluation dated 4/16/17 documented: Chief Complaint: Rash. History of present illness: [AGE] year old lives in (name of facility) recently diagnosed with [REDACTED]. (February) 2017 which was bx. (biopsy) + (positive) for Sq. Cell Ca. Pt (Patient) p/w (presents with) chief complaint of resh which started April 8th. There was no documented evidence that the resident's left-sided neck mass was further evaluated and/or treatment ordered by the unit Physician after the diagnostic work up that was completed in December 2015 prior to re-evaluation in December 2016. Further, there was a documented increase in the size of the mass, development of necrotic tissue and a [DIAGNOSES REDACTED]. An interview was conducted with the Medical Director on 6/09/2017 at 11:10 AM. The Director stated that she has been working as the Medical Director for the past two weeks and had reviewed the CAT Scan report from December 2015. Based on the written report which was suggestive of a metastatic process, the resident should have been referred for Hematology/Oncology follow-up and evaluation to determine the source of [MEDICAL CONDITION] in a more timely manner. She further stated that the resident should have been monitored on a monthly basis by the attending physician to ensure that the proper care and attention was provided. A review of the facility policy Physician Visits documents the Attending Physician must perform relevant tasks at the time of each visit including a review of the resident's total program of care and appropriate documentation. 415.15 (b) (iii)

Based on observation, record review and staff interviews, during a complaint investigation conducted during the recertification survey, the facility did not ensure that care and services were provided for a resident to attain or maintain the highest practicable physical well-being. Specifically, ongoing assessment, monitoring and medical-surgical follow-up of a mass on the left side of a resident's neck was not provided to the resident in a timely manner. The resident was eventually diagnosed with [REDACTED]. This was evident for 1 of 27 sampled residents reviewed for the provision of care and services. (Resident # 191) Complaint # NY 342 The findings are: On 2/2/17 at 1:56 PM, a complaint was called into the Department of Health hotline alleging that the resident had a baseball sized tumor rapidly growing on the left side of the neck. The complainant stated that nothing was being done and the resident had not been seen by the physician. Resident # 191 is a [AGE] year old was re-admitted to the facility on [DATE] and 4/18/17 with [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] documented intact cognition and extensive assistance of one person for activities of daily living. On 6/5/17 at 1:05 PM, resident was observed lying in bed with head of the bed elevated, greeted surveyor appropriately. Large, red, pink mass noted in the left-side neck area. Resident stated that the mass had been there for some time and denied pain at the site. Resident stated that it [MEDICAL CONDITION], that treatment is done every week and the mass is getting smaller. 06/07/2017 at 3:33 PM, the resident was observed in the day room participating in a Music activity being conducted by facility staff. Resident smiled when greeted. Mass visible in neck area, skin intact, reddish, pink in color. Resident denied pain. The physician progress notes [REDACTED]. The progress note further documented that an x-ray and an ultrasound of the neck was requested. The Licensed Practical Nurse (LPN) progress note dated 9/27/15 at 12:00 AM, documented swelling to the left side of the neck, seen by MD (Medical Doctor), X-ray of the neck, Ultrasound of the neck, Duplex Ultrasound and Carotid Left Side of Neck. The Licensed Practical Nurse (LPN) progress note dated 9/28/15 at 10:44 PM, documented: swelling to left side of neck. Awaiting result of ultrasound. The Carotid Doppler Ultrasonography Report dated 9/28/15 for evaluation of the carotid arteries, documented an incidental finding of a solid mass adjacent to the left mandible (jaw) measuring 3.6 x 3.0 cm (centimeters) of unknown etiology (cause). The physician progress notes [REDACTED]. The progress note further documented that a surgical consultation was requested for further evaluation of the mass. The Physicians Progress Note dated 11/17/15 documented the resident was seen by general surgery for [REDACTED]. An appointment scheduled on 11/20/15 for follow up with general surgery after the CAT Scan result. The Radiology Report dated 12/1/15 documented for CT (Computed Tomography) scan of the soft tissue of the neck was completed w/o (without) contrast (due to poor IV access) to rule out the presence of a mass. The report further documented there was a large 5.8 cm x 3.5 cm left-sided neck mass. The lesion was well-defined with smooth margins, with posterior displacement of the sternomastoid, with anterior, medial and inferior displacement of the submandibular gland. No necrotic adenopathy was identified. The documented impression: Probable large anterior cervical nodal mass. A primary neoplasm is considered less likely. The Physician order [REDACTED]. There was no documented evidence in the medical record that the surgical consult was completed. There was no documentation that the referral for consultation was followed up on by the physician. The Nursing Quarterly Evaluation dated 2/15/16 through 1/14/17 were reviewed and documented: skin intact-no skin alterations. There was no documented evidence that the residents left-sided neck mass was assessed and monitored by the registered and licensed nurses from 2/15/16 through 5/5/17. The Physician H&P's (History and Physicals) dated 3/9/16 to 10/19/16 documented the resident's neck was supple and the skin intact. The Physician H&P dated 6/29/16 documented: neck supple and left neck mass stable. The Physician H&P dated 11/16/16 documented: large mass to left side of neck, hard and non tender, does not disturb swallowing or eating. Plan: Neck mass-not new-patient to follow up with general surgery. The medical record included a document titled Order Listing Report. This report documented that an Ear Nose and Throat consult to evaluate mass to left neck was ordered . The report further documented that the mass was slowly growing and this consult was for one time only for mass to left neck for 14 days. The time period was from 12/14/16-12/28/16. There was no documented evidence that the facility referred the resident for further evaluation after the diagnostic work up completed in December 2015. The medical record documented that the resident was not referred for further evaluation of the left-sided neck mass until December 2016. Further, there was a documented increase in the size of the mass, development of necrotic tissue and a [DIAGNOSES REDACTED]. The Soft Tissue-Neck CT Scan report dated 1/19/17 documented a large necrotic left-sided level two neck mass measuring 6.0 x 6.8 x 6.3 cm. The mass is situated just below the left parotid gland. Impression: 1. Large left-sided level two necrotic mass/lymph node measuring up to 6.8 cm. Suggestive of [MEDICATION NAME] spread. 2. Prominence of left palatine tonsil which may represent primary site of neoplasm. Direct visualization/ENT evaluation is recommended. The [MEDICAL CONDITION] Oncology Consultation dated 3/13/17 documented: [AGE] year old with Stage [MEDICAL CONDITION] of left tonsil with large neck nodes and is not a candidate for definitive Chemo ([MEDICAL CONDITION])/RT ([MEDICAL CONDITION] Therapy). Will have [MEDICAL CONDITION] first, if a good response can be re-evaluated for possible palliative [MEDICAL CONDITION]. The Hematology Consultation dated 3/15/17 documented concern that the resident would not tolerate chemo/[MEDICAL CONDITION]. Impression: Advanced SCC (Squamous Cell [MEDICAL CONDITION]). Recommendation: Port Placement. The re-admission record documented a [DIAGNOSES REDACTED]. The documented onset date was dated 3/28/17. The record further documented the [DIAGNOSES REDACTED]. Review of the physicians orders and medical record documented that the resident was transferred to the hospital on [DATE] for evaluation of a rash that developed after first [MEDICAL CONDITION] treatment. The Hospital H&P (History and Physical) evaluation dated 4/16/17 documented: Chief Complaint: Rash. History of present illness: [AGE] year old lives in (name of facility) recently diagnosed with [REDACTED]. (February) 2017 which was bx. (biopsy) + (positive) for Sq. Cell Ca. Pt (Patient) p/w (presents with) chief complaint of rash which started April 8th. On 6/08/2017 at 1:54 PM, an interview was conducted with the Certified Nursing Assistant (CNA) # 6. The CNA stated that she has worked on the unit for the past two years and as far as she can recall the resident has had a neck mass. The CNA further stated that the resident was more active before starting [MEDICAL CONDITION] and would participate in unit activities. An interview was conducted with the Medical Director on 6/09/2017 at 11:10 AM. The Director stated that she has been working as the Medical Director for the past two weeks and had reviewed the CAT Scan report from December 2015. Based on the written report which was suggestive of a metastatic process, the resident should have been referred for Hematology/Oncology follow-up and evaluation to determine the source of [MEDICAL CONDITION] in a more timely manner. She further stated that the resident should have been monitored on a monthly basis by the attending physician to ensure that the proper care and attention was provided. On 6/09/2017 at 1:47 PM, an interview was conducted with the Registered Nurse/ Nurse Manager (RN/NM ). The RN stated that she is responsible for reviewing the monthly nursing evaluation forms completed by the licensed nurses and had not noticed that the skin condition section was not coded accurately. The residents' left neck mass should have been documented as other with an explanation written in since the resident's condition was not listed on the template. The RN further stated that she reviewed the unit consultation book and was unable to locate the surgical consult that was ordered for follow-up after the CT scan had been performed in December 2015. On 6/09/2017 at 2:33 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the left neck mass was identified in 2015 and a CT scan and x-rays were done. The DON stated that the mass was thought to be benign, the physician signed off on the report and did not make further recommendations. The Physician must have felt that no further work-up was necessary. The mass should have been captured on the nursing evaluation. The nurses are expected to be more familiar with their residents so that situations like this can be avoided. In addition, she added that there have been a number of changes in medical coverage at the facility and ultimately the Medical Director would have been responsible for ensuring that proper follow-up was done. The three physicians who were providing care for the resident during this period were no longer employed at the facility and unavailable for interview. 415.12

Based on staff interviews and record review during an abbreviated survey, the facility did not provide adequate supervision to residents to prevent accidents. This was evident for 1 of 4 residents sampled for supervision (Resident #1). The facility did not provide adequate monitoring and supervision for Resident #1, who has a history of ingesting non-edible objects. Subsequently, Resident #1 ingested Domino (game) pieces, metal screws, and a pen that had to be surgically removed. This resulted in actual harm that is not Immediate Jeopardy. THIS IS A REPEAT DEFICIENCY. Complaint # NY 663 The findings include: Resident #1 was a [AGE] year old male admitted to the facility ' s Neurobehavioral Unit on 8/20/2001 with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented that the resident cognitive skills for daily decision making were moderately impaired. A nurse ' s note dated 1/22/2010 documented that the resident was observed with vomiting and having a loose bowel movement. The resident was transferred to the hospital for an evaluation. The hospital ' s surgical pathology report dated 1/29/2010 documented that one latex glove was removed from the resident ' s stomach. The facility ' s Medical Doctor (MD) ' s note dated 2/1/2010 documented that the resident returned from the hospital, status [REDACTED]. The facility ' s investigation dated 2/1/2010 documented that the resident may have ingested the glove during a medication line after receiving his medication. The MD ' s order dated 2/1/2010 documented that the resident was placed on one-to-one observation for safety. The Comprehensive Care Plan (CCP) for Problem Behavior dated 5/20/2012 documented that the resident had a history of [REDACTED]. The resident ' s medical record from February 2010 to December 2012 revealed that the resident was monitored one-to-one for safety. The medical record also revealed that the resident had no incident related to ingesting non-edible objects. The MD ' s Order dated 1/8/2013 documented that the resident should remain on nursing one-to-one observation for safety. A social worker ' s note dated 1/11/2013 documented that the resident ' s family was notified that one-to-one monitoring for the resident would be discontinued on 1/14/2013. The note documented that the family was concerned about the resident ' s history of ingesting gloves. The social worker told the family that the gloves will be kept out of reach of the resident and that the facility will provide environmental rounds and 15-minute monitoring for safety. The MD ' s order dated 1/14/2013 documented to discontinue one-to-one observation and to place the resident on 15-minute monitoring for safety for seven days. A progress note written by the Director of the Neurobehavioral Unit dated 1/15/2013 documented that a team meeting was held on 1/14/2013. The note documented that the resident was placed on one-to-one monitoring for " Pica " (pattern of eating non-food materials). The note documented that the resident remained stable for the past quarter with no incidents. The resident had no behavior of eating non-food items. The note documented that the family and staff were made aware. The resident was placed on 15-minute monitoring for safety. A psychology note dated 3/5/2013 documented that the facility was conducting environmental rounds to ensure absence of latex gloves to avert ingestion. The note also documented that the resident had not ingested gloves in over one year. The medical record from 1/14/2013 to 10/9/2013 had no documentation of the resident attempting to ingest non-edible objects. The surveyor requested documents for the 15-minute monitoring. The facility provided monitoring sheets that documented that the resident was on 15-minute monitoring in January 2013 and April 2013. A nurse ' s note dated 10/9/2013 documented that the resident was out on pass with his sister at 3:30PM. The note also documented that the resident ' s brother visited the resident in the conference room. The behavioral specialist reported to the nurse that the resident smoked on two occasions with his sister and brother while outside. A nurse ' s note dated 10/10/2013 documented that the resident was found to be lethargic and weak. The resident had a vomiting episode. The MD evaluated the resident and ordered to transfer the resident to the hospital. The hospital record from 10/10/2013 to 11/4/2013 documented that the X-ray result revealed a " metallic screw overlying the left abdomen " and " radiopaque foreign bodies within the stomach. " The hospital ' s neurology consultation documented that the resident was evaluated for ingesting screws and Dominoes. The hospital Patient Review Instrument (PRI) dated 11/4/2013 documented that the resident had a laparoscopic surgery for [REDACTED]. The hospital discharge instructions dated 11/4/2013 documented that the resident needs close observation for ingestion of foreign particles. The facility ' s investigation documented that on 10/10/2013 at 11:45AM Resident #1 was noted to have brown emesis and appeared lethargic. The resident was transferred to the hospital for further evaluation. On 10/11/2013, the hospital notified the facility that the CT (Computerized Tomography) scan of the resident ' s abdomen revealed foreign objects and that the resident may require a surgery. The investigation documented that the hospital reported that during the abdominal surgery in the hospital on [DATE], 9 Domino pieces and one 2-inch screw were extracted from the resident. The facility concluded that there was no clear indication as to when the resident ingested the foreign objects. A nurse ' s note dated 11/4/2013 documented that the resident returned to the facility and was placed back on one-to-one observation. A nurse ' s note dated 11/6/2013 documented that the resident ' s abdomen appeared distended with positive bowel sounds. The facility ' s X-ray report dated 11/6/2013 documented that the resident had distended gas loops of colon. The report documented that a metallic screw was overlying the right lower quadrant. A nurse ' s note dated 11/6/2013 documented that the MD ordered to transfer the resident to the hospital due to the distended stomach and the X-ray result that showed a metallic object in the right lower quadrant. The hospital ' s abdominal CT scan dated 11/7/2013 documented that the resident had " foreign bodies seen within the proximal ascending colon (metallic screw) as well as the distal descending colon (pen). " The CT scan result also documented that the foreign body in the descending colon appeared to be protruding through the colonic wall. The hospital transfer sheet dated 11/19/2013 documented that the resident had a primary [DIAGNOSES REDACTED]. The hospital instructed to supervise the resident one-to-one due to incidences of foreign body ingestion. The facility ' s Policy and Procedure on Residents Requiring Increased Supervision with last revision dated April 2012 documented that the MD, licensed nurse or designee will document in the clinical record the circumstance surrounding the need for use of increased supervision and resident ' s response and monitors the resident at frequent intervals until the resident is seen by the MD. The Policy and Procedure documented that the Certified Nursing Assistants (CNA) will document residents ' activity and whereabouts on one-to-one supervision form. A review of the facility ' s Policy and Procedure on Environmental Rounds Protocol with last revision dated October 2013, indicated that " When a resident is identified at risk for harm or injury, a search of his/her room will be conducted to remove any potentially dangerous items ...from the resident ' s room. The policy and procedure also documented " A closet check will be conducted on the top shelves, bottom drawer, including clothing (pockets, sleeves, etc.). " On 11/13/2013 at 3:06PM an interview was conducted with the resident ' s brother. The brother stated that the resident had ingested gloves in the facility in the past. After the gloves were removed by surgery, the facility placed the resident on one-to-one observation. The brother stated that when the new owners came to the facility, the resident was taken off one-to-one observation. He stated that he did not agree with the decision based on the resident ' s history. He stated that the social worker told him that the resident would be kept in the TV (television)/recreational room for close monitoring. He stated that he visited the resident once a week and took him out to the courtyard or stayed with him in the TV room. He stated that he brought Dominoes for the resident about two and a half years ago. He stated that the procedure was for him to play Dominoes with the resident, then give the Dominoes to the staff to be locked up after the visitation. On 11/13/2013 at 3:55PM an interview was conducted with the resident ' s sister. The sister stated that she went to visit the resident on 10/9/2013. She stated that during the visit she gave the resident cookies and juice only. She stated that she did not take the resident off the premises of the facility. She stated that she took the resident out to the front of the building for fresh air. She stated she did not leave the resident alone by himself and that she did not give him Dominoes, screws or a pen or pencil during the visit. On 11/14/2013 at 4:35PM an interview was conducted with CNA #1. CNA #1 stated that she conducted 15-minute monitoring for Resident #1 in the past. She stated that 15-minute monitoring means that the staff are visually observing the residents to know where they are and what they are doing every 15 minutes. She stated that she was very aware that Resident #1 had a tendency to put non-edible objects into his mouth. She stated that whenever she went to the resident ' s room she looked to make sure there were no objects laying around for the resident to swallow. She stated that she was not instructed to check the resident ' s pockets to check for any objects during the monitoring. On 5/5/2014 at 5:40PM an interview was conducted with CNA #3. CNA #3 stated that he conducted 15-minute monitoring for Resident #1 in the past. CNA #3 stated that the resident required monitoring due to his habit of ingesting foreign objects. He stated that the 15-minute monitoring involved making sure that the resident did not do " anything dangerous. " He stated that 15-minute monitoring is " only visual observation. " He stated that he checked the resident ' s body at times to check for non-edible items even though he was not instructed to do so. CNA #3 stated that the resident was able to move around independently in his wheelchair. He stated that the staff did not follow the resident when he needed to use the bathroom. On 5/6/2014 at 11:20AM an interview was conducted with CNA #4. CNA #4 stated that she was assigned to do 15-minute monitoring for Resident #1 in the past. CNA #4 stated that 15-minute monitoring did not involve checking the resident ' s pocket for any non-edible objects that he could swallow. CNA #4 stated that she did not know the resident had Dominoes and that she never saw him with Dominoes. On 5/30/2014 at 3:05PM an interview was conducted with CNA #6. CNA #6 stated that she was regularly assigned to the resident. CNA #6 stated that she recalled conducting 15-minute monitoring in April 2013 as documented in the monitoring sheet, but could not recall doing further 15-minute monitoring during other months. She stated that 15-minute monitoring included going to the resident ' s room and making sure that there were no objects that can be swallowed in his surroundings. She stated that the resident ' s closet was always locked. When asked about the procedure for the resident ' s personal Dominoes, she stated that she was not aware that the resident had his own Dominoes. She stated that she never locked up Dominoes for the resident and that she never saw the resident play with Dominoes. On 5/30/2014 at 4:00PM an interview was conducted with CNA #7. CNA #7 stated that she was regularly assigned to the resident. CNA #7 stated that she conducted 15-minute monitoring for Resident #1 during the month of April 2013 as documented, but could not recall if she was instructed to conduct monitoring during other months. CNA #7 stated that the resident had a history of [REDACTED]. She stated that during the 15-minute monitoring, she made sure that there were no objects in the room that he could swallow and also made sure the electric panels and wires were intact. CNA #7 stated that she never saw the resident with Dominoes. She stated that when the resident was in the recreation room, it was the responsibility of the recreation staff to monitor the resident. On 6/3/2014 at 4:30PM an interview was conducted with CNA #8. CNA #8 stated that she conducted 15-minute monitoring in the past. She stated that the CNAs were instructed to make sure there were no items, such as gloves, in his room. She stated that she never witnessed the resident having his own Dominoes or playing such game. She stated that she had seen the resident coloring with crayons in the past, but she never saw him using a pen or pencil. She stated that she never saw the resident with a metal screw. On 11/14/2013 at 3:45PM an interview was conducted with the Recreational Aide (RA) #1. RA#1 stated that Dominoes is one of the games played in the recreation room. She stated that games are put in the closet and locked away after each use. She stated that she had played Dominoes with the resident in the past. She stated that about 3 months ago, she saw Dominoes in the resident ' s room with his name on it. She stated that she removed the Dominoes from the resident ' s room and brought it to the TV room to play with the resident. She stated that when she looked inside of the box, it appeared that all the Domino pieces were in the box at the time. RA #1 stated that when she brought the game to the TV room, a CNA told her that the resident was not allowed to have Dominoes in his room. RA #1 stated that she was not aware that the resident was not allowed to have Dominoes in his room. On 11/14/2013 at 2:35PM an interview was conducted with RA #2. RA #2 stated that in July 2013 or August 2013 she saw the resident with a box of Dominoes. She stated that the box was not full to the top. She stated that she took the Dominoes away from him, but she did not alert other staff about the possibility of missing Domino pieces. On 5/30/2014 at 4:45PM an interview was conducted with the Senior Recreation Therapist (SRT). The SRT stated that the staff members knew that the resident could " eat anything he grabs. " The SRT stated that he told his recreation staff not to put anything in front of him. The SRT stated that Dominoes was one of the games the recreation staff played with the residents. He stated that he was not aware that the resident had his own Dominoes until the incident happened. On 11/5/2013 at 11:37AM, an interview was conducted with the Registered Nurse Manager (RNM) of the Neurobehavioral Unit. The RNM stated that one-to-one observation worked perfectly for the resident as he had a history of [REDACTED]. She stated that some team members disagreed with the management, but the team had to follow the instruction. The RNM stated that the resident was placed on 15-minute monitoring as ordered by the MD. During a subsequent interview with the RNM on 5/30/2014 at 3:30PM, the RNM was asked about the MD ' s order for 15-minute monitoring for seven days only. The RNM stated that the resident was on 15-minute monitoring beyond the seven days. The RNM stated that the nursing department can implement 15-minute monitoring for a resident even without an MD ' s order. The RNM stated that she could not recall if the resident was continuously on 15-minute monitoring from January 2013 to October 2013. On 11/4/2013 at 1:50PM an interview was conducted with the Director of the Neurobehavioral Unit. She stated that the resident was taken off one-to-one observation since January 2013. She stated that the decision to discontinue one-to-one observation was the Administrator ' s idea. She stated that the resident was placed on 15-minute monitoring checks. She stated that the CNAs were responsible for conducting the 15-minute monitoring. The 15-minute monitoring included checking the resident for his safety and informing the nurse if there were any changes in status. She stated that the CNAs were also responsible for going to the resident ' s room to make sure there were no objects he could swallow. She stated that 15-minute monitoring did not work for this resident based on the fact that the resident ended up swallowing Domino pieces. During a subsequent interview with the Director of the Neurobehavioral Unit on 5/30/2014 at 4:00PM, she stated that the resident continuously received 15-minute monitoring from January 2013 to October 2013. The Director was not able to explain why there was no documentation for 15-minute monitoring, except for January 2013 and April 2013. The Director stated that " it was an assumption " that the resident was continuously on 15-minute monitoring. On 11/13/2013 at 10:30AM an interview was conducted with the MD. The MD stated that the resident was on one-to-one observation for safety reasons, as the resident had a history of [REDACTED]. The MD stated that although he did not support the decision, he wrote an order to discontinue one-to-one observation as he was instructed by the Administrator to do so. The MD stated that based on his clinical opinion, the resident should have stayed on one-to-one observation for safety. On 11/4/2013 at 2:20PM an interview was conducted with the Director of Nursing (DON). The DON stated that the resident continued to receive one-to-one observation in January 2013. The DON was not able to explain how often the resident was observed after January 2013. During a subsequent interview on 11/6/2013, the DON stated that after the Dominoes and a screw were surgically removed from the resident, the resident returned to the facility. The DON stated that two days after he returned to the facility, the resident was transferred back to the hospital because the resident ' s stomach was distended and the X-ray revealed another metallic object in the resident ' s stomach. On 11/4/2013 at 11:45AM an interview was conducted with the Administrator. The Administrator stated that the interdisciplinary team met and decided that the resident could be taken off one-to-one observation. He stated that he did not force the team to discontinue one-to-one observation. 415.12(h)(2)

Based on observation, interviews and record review during an abbreviated survey, the facility did not ensure that the residents received adequate supervision to prevent accidents. This was evident for 1 out of 4 sampled residents (Resident #1). Specifically, a resident on the Neurobehavioral unit sustained a second degree burn on his left arm from the hot steam table in the dining room. This resulted in actual harm that is not Immediate Jeopardy. Complaint # NY 639 The findings include: Resident #1 was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 dated 3/23/2013 documented that the resident was cognitively intact. The Comprehensive Care Plan (CCP) for Falls/Injury initiated on 12/5/2005 and updated 3/2013 documented that the resident was at risk for injuries. The facility ' s interventions included providing an obstacle free and safe environment, assessing resident ' s judgmental status and providing supervision in accordance with needs. The CCP for Dementia/Cognitive Loss initiated on 10/11/2012 documented that the resident had impaired cognitive ability and intellectual functioning as evidenced by impaired decision making, impaired thinking and reasoning, and inappropriate behavior. The updated CCP dated 3/6/2013 documented that the resident ' s cognition was intact, but that the resident had a history of [REDACTED]. The facility ' s interventions included avoiding situations that might precipitate negative behavior and providing direct and simple instructions and cues. The Accident/Incident Report and Investigation dated 3/26/2013 documented that Resident #1 reported on 3/27/2013 that the hot water from the steam table splashed on him and burned his left forearm. The resident ' s left arm was noted with [DIAGNOSES REDACTED] and an open blister at the center. The nurse ' s recommended steps to prevent recurrence were redirecting the resident from touching the steam table and unplugging the steam table after each meal. The Medical Doctor (MD) ' s Progress Note dated 3/27/2013 documented that the resident sustained [REDACTED]. " The MD ordered to send the resident to the emergency room for further evaluation. The Hospital ' s emergency room record dated 3/27/2013 documented that the resident was treated for [REDACTED]. The Burn Clinic consultation dated 4/2/2013 documented that the resident had a second degree burn to the left arm and instructed to discontinue Silvadene cream and apply Bacitracin ointment twice daily. On 6/5/2013 at 10:30 AM the video surveillance of the dining room was viewed. The video revealed that on 3/26/2013, Certified Nursing Assistant (CNA) #1 and residents entered the dining room at around 8:34:04 PM. At 8:34:20 PM, Resident #1 was observed walking towards the refrigerator then reaching over to the steam table next to the refrigerator. CNA #1 was facing the wall preparing snacks with her back towards the resident. At 8:34:31 PM, Resident #1 was observed looking at his left arm. CNA #1 turned around then looked at the resident. At 8:34:53 PM, Resident #1 continued to look at his left arm while leaving the dining room. On 4/10/2013 at 1:45 PM an interview with Resident #1 was conducted. Resident #1 stated that on 3/26/2013 he reached over the table in the dining room and opened the cover of the steamer and got burnt on the arm by the steam. He stated that CNA #1 did not see what happened because she was in the middle of getting snacks out. He immediately told CNA #1 of what happened, but CNA #1 stated that " it was not all that bad. " He stated that he put ice on the injury by himself. He stated that no staff came to evaluate the injury all night and that the burn turned into a blister the following morning. He stated that he reported to the Behavioral Specialist (BS) on 3/27/2013 of what happened in the dining room, then the MD evaluated him. On 6/6/2013 at 11:00 AM an interview was conducted with CNA #1. CNA #1 stated that she was busy preparing snacks when the resident sustained [REDACTED]. She stated that she did not see the resident opening the cover of the steamer. She stated that the resident ' s forearm had a red mark and that she reported it to the Licensed Practical Nurse (LPN) on duty. On 7/10/2013 at 9:15 AM an interview was conducted with the LPN. The LPN stated that CNA #1 told her later during the shift on 3/26/2013 that the resident was trying to " play with the steam table " and that she prevented the resident from getting there. She stated that CNA#1 did not tell her that the resident was injured. The LPN stated that CNA #2 and the BS were supposed to be in the dining room during the snack time to supervise the residents. On 7/10/2013 at 12:30 PM an interview with CNA #2 was conducted. CNA #2 stated that on 3/26/2013, she was not in the dining room when the burn incident occurred because she was going from room to room to tell residents that it was time for snacks. On 7/10/2013 at 11:00 AM an interview was conducted with the BS. The BS stated that on 3/26/2013, he was not in the dining room when the burn incident occurred because he was supervising the medication line at the time. He stated that when medication administration was over, he went to the dining room to help with the snacks. He stated that when he was about to enter the dining room, he saw the resident coming out of the dining room and that the resident told him that he was going back to his room. On 4/10/2013 at 12:00 PM an interview was conducted with the Director of Dietary Services (DDS). The DDS stated that the steam table is used to ensure that food is served warm at all times. She stated that the timer to the steamer is pre-set to automatically turn on one hour prior to the meal service and turn off one hour after the meal service. She stated that it takes over one hour for the steamers to cool down completely. She stated that the steamers were not in use at the time of Resident #1 ' s burn incident. She stated that on 3/26/2013 the dinner ended around 6:00 PM. She stated that she could not explain why the steamer was still hot at 8:30 PM on 3/26/2013. On 4/10/2013 at 10:30 AM an interview was conducted with the Director of Nursing (DON). The DON stated that on 3/26/2013, Resident #1 reached over the table and removed the cover of the steamer to look at what was inside. She stated that the resident sustained [REDACTED]. She stated that CNA #1 did not witness the incident. She stated that CNA #2 and the BS should have been in the dining room during the snack time to supervise the residents. 415.12(h)(2)

Based upon staff interviews and record reviews it was determined that the medical director: 1) Failed to implement policies and procedures and coordinate the medical and psychiatric care for residents (res) on the neurobehavioral unit that ensures that these residents receive effective and ongoing psychiatric care. 2) Failed to implement polices and procedures pertaining to investigation of resident to resident abuse and sexually inappropriate behaviors. This was evident for 7 of 30 sampled residents and 2 of 6 extended sampled residents.(Residents #12, #13, #14, #19, #20, #21, #23, #33 and #36). This resulted in Immediate Jeopardy to Resident Health and Safety. The findings include but are not limited to: 1) Resident #20, a cognitively impaired individual receiving multiple psychoactive medications was not seen by a psychiatrist from October 2011 through April 2012. During this period the resident had 8 incidents of agitation and /or threatening behavior which included 2 incidents of resident to resident altercations in which the resident was the aggressor. Also, the resident had 1 incident of inappropriate sexual activity in which the resident had questionable ability to consent. The facility was unable to provide the completed comprehensive care plan prior to October 2011 for residents #20. The resident's care plan was not revised to include interventions to prevent further occurrences. 2) Resident #23 is [AGE] year old male with [DIAGNOSES REDACTED]. The Medical Record documented 43 separate incidents of physical altercations in which there was harm with other residents and staff from 11/3/11 through 4/23/12. There is no documented evidence that the care plan was updated and/or revised. 3) Resident #33 is a [AGE] year old male with [DIAGNOSES REDACTED]. The Medical Record documented 8 separate incidents of resident to resident physical abuse from 10/20/11 to 3/19/12. On 2/1/12 nursing documented that the resident was bitten on the chest, neck and arms by another resident. There is no documented evidence that the care plan was updated and/or revised. On 4/20/12 at 5:15PM, the Medical Director was interviewed and stated that her specialty is [MEDICAL CONDITION] neurobehavior. The psychiatrist will see the residents based on nurses informing him which resident needs to be seen. The physicians on the unit reviews the residents [MEDICAL CONDITION] medications. The residents are seen annually by the psychiatrist if there are no concerns. She further stated that the psychiatrist doesn't routinely attend team meetings. When the psychiatrist and/ or psychologist comes to the facility to see and evaluate the residents they should always document every visit. The psychologist who worked here left in early April 2012 and there has been no replacement since. The CNA's undergo skip training which involves what to do if residents agitated and how to hold a resident. Staff received a one day course for 3 to 4 hours, and they were also trained on signs and symptoms of agitation. On 4/27/12 at 1PM, the medical director was again interviewed and stated that she reviews all occurrence/accident and incident reports to determine what caused the occurrence. The medical director stated then she signs the report if she agrees with the actions that have been taken. The medical director stated if she does not agree with actions taken in response to the incident, she verbally brings it to the attention of the director of nursing. The medical director stated that usually the accident / incident reports that come to her attention are adequate and rarely does she make recommendations. She stated that conclusions are written at the bottom of the report. The medical director also stated that Psychiatrists are consultants and they do not see the residents unless the physician orders [REDACTED]. The medical director further stated that in the event of sexual contact between consenting adults, the physician would be required to order testing for sexually transmittable disease (STD). Therefore, an accident / incident report would be necessary. However, there was no documented evidence of an accident / incident report for cognitively impaired resident #20 following the incident of unprotected sexual activity on 10/23/11. The medical director also stated that the social worker uses an assessment tool to determine if residents understand the consequences of sexual contact. However, there was no documented evidence of a social service assessment tool for resident #20. The resident's BIMS score = 6 which indicates that the resident's cognitive status is severely impaired and the resident had sexual contact with another resident on 10/23/11. See F223K, F225K, F226K, F319K, F323K, 415.15(a)

Based on observations, record review and staff interviews, conducted during a recertification survey, 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 to provide a safe envrionment and effectively supervise and monitor residents on the facility's neurobehavioral units. These residents had multiple episodes of behavioral problems including resident to resident altercations; resident to staff altercations; suicidal ideation; suicide attempts; self-mutilation; and inappropriate sexual behaviors. The Administrator also failed to implement facility policies and procedures for monitoring residents with behavioral problems in order to ensure their safety; failed to adequately investigate and report allegations of abuse and neglect; and failed to ensure that resident care plans were reviewed and updated in a timely manner, Furthermore, the Administrator failed to ensure that appropriate psychological services were provided to residents with behavioral problems; failed to coordinate proper medical care; and failed to ensure that the Quality Assurance Committee addressed the problems on the neurobehavioral unit. This was evident for nine (9) out of thirty (30) sampled residents and two (2) out of six (6) residents reviewed as part of the expanded sample (Residents # 9, #12, #13, #14, #19, #20, #21, #22, #23, #33, and #36). This resulted in Immediate Jeopardy to resident health and safety. The findings are: Refer to: F223, F225, F226, F280, F319. F323, F501 and F520. On 04/23/12 at 12:45 PM, the facility's Administrator was interviewed. He stated that the facility did not possess any documentation in connection with the professional certification or relevant training for the Director of the Neurobehavioral Unit. He further stated that the Director of the unit informed him that he had participated in three months of training in 2002, but there was no documentation to support this. The Administrator was re-interviewed on 04/25/12 at 10:10 AM. During this interview the Administrator indicated that he has held his current position since 01/01/12. On 04/25/12, the Administrator stated that the Neurobehavioral Unit has much more staff assigned than the nursing home units. He said, if necessary, he would reassign more staff to the Neurobehavioral Unit if there were numerous residents on 1:1 monitoring. However, he stated he has not found it necessary to add additional staff since he has been employed by the facility. In addition, staffing on the Neurobehavioral Unit has not decreased. At the present time, one Social Worker covers all three units. If there are simultaneous incidents on all three units, a Behavior Specialist and a Nurse will assist the Social Worker and intervene. A document that is signed and dated by the Administrator on 04/23/12 and typed on facility stationery was reviewed. The document is marked "Layoff as of 04/02/12." It contains a list of fifty (50) staff whose employment was terminated. Among those staff being terminated are seven (7) staff assigned to the Neurobehavioral Unit: a coordinator, a psychologist, an assistant social worker, an RN Supervisor and three (3) Registered Nurses. The Administrator also stated that the Quality Assurance Committee reviews and evaluates all incidents and accidents and that this is a continuous process. The television/activity rooms are monitored by staff and video cameras. He said staff should always be present in these rooms when residents are there. The Administrator further stated that, even though incidents are on the increase, all residents are being monitored. He said, "We try to put systems in place to revise the CCP (Comprehensive Care Plans) to protect residents. Nursing and Social Service are responsible for revising the CCP. The DNS (Director of Nursing Services) and I make decisions of what incidents gets called to DOH." 415.26

Based on observations, record review and interviews, the facility did not ensure that the residents' environment remain free of accident hazards. Specifically, 1) a resident with known history of physically aggressive behavior including throwing objects out of his window was found with a closet door propped against the wall in his room and jagged metal hinge exposed on resident's closet where the door was missing, and 2) a resident with known history of suicidal ideation with hazardous items in their room. This was evident for 2 of 18 sampled residents (Residents #101 and #103) and for 2 out of 10 resident units (Unit AB and CD). This resulted in no actual harm with potential for more than minimal harm The findings are: 1) Resident #101 is a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 dated 7/5/12 documented that resident is cognitively impaired. The MDS also documented that resident has physical behavioral symptoms directed towards others (e.g. (for example) hitting, kicking, pushing, scratching, grabbing, abusing others sexually) that have occurred 1 to 3 days over the last 7 days. During the initial tour of the AB unit on 7/13/12 at approximately 10:15 AM, the Registered Nursing Supervisor stated that this resident had a physical altercation with another resident on 7/10/12. She stated that this resident punched another resident in the face on 7/10/12 and has a history of aggressive behavior. At approximately 10:20 AM and again at 4:55 PM on 7/13/12 during a tour of the AB unit, the resident's closet was observed to have a missing door with the jagged metal hinge exposed on the top right corner of the closet. The door was observed propped up on the left side of the closet near the window. The Registered Nurse/ Assistant Director of Nursing was interviewed at approximately 5:00 PM on 7/13/12 and stated that this is the door to the closet. She further stated that the resident ripped the door off and doesn't recall how long ago this happened but that they're waiting for maintenance to fix it. She stated that this resident tends to pull things off the wall and tear things down. The Director of the Neuro Behavior Unit was interviewed at approximately 5:15 PM on 7/13/12 and stated that this is the first he was hearing about the missing closet door. The Director of the Neuro Behavior Unit stated that when something is broken the staff document it in the Maintenance Log Book and the maintenance staff do daily rounds will check the log and make the repairs. 2) Resident #103 is a [AGE] year-old with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that the resident had a Brief Interview of Mental Status (BIMS) score of 9, indicating moderately impaired cognition. The MDS further documented that the resident displayed symptoms of feeling down and having thoughts of being better off dead. The MDS also documented that the resident was on antidepressant, antipsychotic, and antianxiety medication. A Nursing Note dated 7/12/12 at 11PM documented: "...Suicidal Attempt...1:1 (one-to-one) initiated, room searched, belongings taking out for safety. Emotional support given...At 10:45pm resident walked to the nursing station, and reported she tied a shoe lace, around her neck for several minutes because she was depressed about life. Nursing supervisor made aware, MD order patient to be sent to psych awating ambulance service, red mark noted on her neck will continue to monitor." A Nursing Note dated 7/13/12 at 5AM documented: "Resident was sent to psych hospital at 12:50am...returned at 3:04am." A Physician's Note dated 7/13/12 at 7am documented: "Pt seen & (and) examined. Tried to attempt suicide last night by tying a shoelace around her neck because she was depressed. Was sent to psych ER & returned 2 hours later. States she does not have thoughts of suicide at this time...A/P (Assessment and Plan)- ...hx (history) Schizoaffective d/o (Disorder),...s/p (status/post) suicide attempt last night. 1) Suicidal ideation/ hx psychosis: 1:1 observation for safety; psych consult. .. cont (continue) current meds...." The Room Search Checklists dated dated 7/12/12 and 7/13/12 documented that the resident's room had been checked on a every shift by a Behavior Specialist. It also documented: "Target Items: Plastic Bags..." On 7/13/12 at 4:41pm, the resident's room was observed containing the following: two plastic hangers with bras on them hanging in the bathroom shower, one mesh laundry bag (string removed) on the shower floor, 3 bras hanging in the closet, 2 bags with fabric string handles (approximately 12 inches each) and 1 bag with paper string handles in the closet, and one cloth bag with thick fabric handles. On 7/13/12 at 4:45pm, the Registered Nurse Supervisor was interviewed and stated that a room check was done by the Behavior Specialist after the incident on 7/12/12. She further stated that any strings and any objects that the resident can use to harm herself should have been removed. The RNS also stated that the resident is on room checks every shift. On 7/13/12 at 4:55pm, a Behavior Specialist (B-Spec) on the unit was interviewed and stated that room checks are done every shift for this resident. He further stated that when doing room checks thery are looking for food, cigarette butts, sharp objects, metal, glass, and utensils. The B-Spec also stated that they check closets, garbage cans, bathrooms, drawers, under the bed, and under the mattress. He stated that they do look at strings also, but it is specific to whether the resident can have them, which is usually written on the Behavior Plan or discussed in report. He stated that he did learn that the resident is now on 1:1 because she felt like killing herself, but did not receive any new instructions regarding room checks or new restrictions on items she can have. 415.12(h)(1)

Based on observations, record review and staff interviews, the facility failed to consistently provide a safe environment and supervision of residents with histories of self injurious behavior, inappropriate sexual behavior and suicidal ideation. Specifically, the facility lacked consistent monitoring and supervision of residents, resulting in repeated physical altercations, suicidal attempts and self mutilations. The facility failed to evaluate interventions to prevent recurrences and failed to maintain an environment that was free of accident hazards. This was evident for 7of 30 sampled residents and 2 of 6 residents in the extended survey. (Residents #12, #13, #14, #19, #20, #21, #23, #33 and #36). This resulted in actual harm that is Immediate Jeopardy to Resident Health and Safety and Substandard Quality of Care. The findings include, but are not limited to: 1) Resident # 23 is a [AGE] year old male with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE], documents that the resident has moderately impaired cognition. The Brief Interview for Mental Status (BIMS) score is 9, with fluctuating presence of inattention and disorganized thinking, presence of hallucinations, delusions, physical, verbal and other socially inappropriate behavior displayed 1 to 3 days, during a seven-day period preceding the MDS. The Interdisciplinary progress notes from 10/22/2011 to 4/24/2012 and the Notes of Behavior Incident from 11/3/11 to 4/22/2012, document that resident #23 had 23 incidents of physical aggression, involving 9 peers. One peer, resident #34, was repeatedly involved in six different incidents with resident #23. In addition, during the same period, the resident attempted to hit peers and/or staff or displayed physically threatening behavior on 36 occasions. The majority of the aforementioned altercations occurred in the hallway, dining room, and/or smoking room, during the day and evening hours, when according to MQAC investigation reports, 6-10 staff were present. The Comprehensive care plan (CCP) for problem behavior dated 4/18/2011, documents as " expected outcome "that the resident will demonstrate fewer episodes of verbal & (and) physical aggression, not harm self or others, minimize risk of injury ... " and includes interventions as " ongoing assessment of behavior pattern, administer medications as ordered, assess response to medication, anticipate needs/interests, implement motivational strategies, provide adequate exercise, engage in activities that reduce frustration and support needs, provide individual counseling, redirect negative behaviors, not to wait on med (medication) line, physical aggression c (with) peer keep at arm distance at all times ..., orient to his own room, to be rewarded with sports trading cards if no reported aggression during day/evening." The behavioral care plan does not document evidence of implementation of new behavioral strategies or address the monitoring/supervision for this resident. The "Residents to be kept at arms distance" list (undated) for AB wing documents the name of resident #23 and resident #22 and does not include res (resident) # 34. The CCP for problem behavior with a revision date of 11/1/2011 documented, " Monthly CCP- ... Reinforcer is in place for good behavior. Continue with + (positive) verbal cues. " The Note of behavioral incident (NBI) dated 11/3/11 documents, " attempted to kick nurse " and " threatened the peer #22 to set his hair on fire." On 11/9/2011 the psychiatrist documents " paranoid and anxious ...coherent, not a management problem ....close observation, provide support ... " The (MQAC) report dated 11/12/2011, documents that at 7 PM, resident #23 pushed peer #E, who was seated in his wheelchair, toward resident #34. Resident #34 fell and hit his head on resident #E's wheelchair. The Medical Doctor (MD) documented on 11/13/2011, that resident # 34 complained of pain on R (right) frontal side on his head and mild L (left) arm pain. On 11/15/2011 at 8:25 AM, the MQAC documents that resident #23, while being redirected by the behavioral specialist, hit resident #34 on the top of his head. The MQAC documented that resident #23 was redirected and counseled. Instructed res. (resident) to keep distance from peer. Ativan was administered for agitation. The CCP dated 11/15/11, for problem behavior, documents that a behavioral meeting was held, " continues to show periodic episodes of aggression/paranoia, verbal outbursts. Psychiatric evaluation ...increased neuroleptic dose. Behavior intervention plan modified targeting above behavior with + (positive) reinforcement of picture celebrities provided once a week for daily reinforcement will continue ... " On 1/7/2012 the MQAC documents that at 8:40 AM, the resident got out of his chair, during breakfast in the dining room and slapped resident #34 in the back of his head. " Resident was counseled and kept at least at arms length from peer. " On 1/11/2012 the MQAC report documents that at 8:35 PM, the resident hit resident # 34 in the arm for no apparent reason. The MQAC documents "Was the resident supervised at the time of injury?" a check mark is noted in the no response. " both residents separated and counseled. " On 1/8/2012, the MQAC (Memo to Quality Assurance Committee) report documents that at 4 PM in the dining room, the resident slapped resident #22 on the back of his head and per MQAC the resident was not supervised at the time of occurrence. Action taken: "separated and counseled." On 1/8/2012, the CCP for problem behavior was updated to reflect the occurrence and documents, " continue CCP. " There were no new interventions to address the resident's need for supervision/monitoring. On 1/10/2012, the Memo to Quality Assurance Committee (MQAC) report documents that at 4:25 PM in the hallway, the resident became agitated and hit resident # 22 on his arm. Action taken: " separated and counseled." On 1/17/2012, resident #23 was seen by the psychiatrist who documented " ...behavior improved from before ...developing cognitive deficits, please orient him before telling him to do something, continue behavioral management. " On 1/17/2012 the nursing note documents " Resident #23 attempted to hit peer # 34 for no apparent reason. Redirected and counseled ...will continue to monitor for safety." The CCP for problem behavior was updated on 1/17/2012 documents " ... Cont. (continue) emotional support. Reinforcer in place." On 1/22/2012 the nursing note documents, " Peer (initials- #F) reported to nursing supervisor that resident allegedly choked her yesterday. " The resident was sent to the Psychiatric emergency room (ER) and readmitted several hours later, placed on 1:1 monitoring until 1/23/12. The MQAC dated 1/22/2012 documents, " He (resident) stated that he put his fingers on resident F (initials) neck, but denies choking her ...camera review done- residents were not near each other. Allegation unfounded. " On 1/24/2012 the NBI note documents at 8:50 AM, the resident (#23) walked during breakfast pass the peer #F and grazed her leg ... " counseled and redirected. " At 11:55AM attempted to strike peer in the hallway. At 6;34 PM the resident attempted to kick the Behavioral Specialist. On 1/25/2012 the NBI documents at 8:40 AM " Resident (#23) was in the dining room and got up from his seat, walked up to the resident (name of resident #34) with a plastic knife in his hand and put the knife to resident (initials) # 34's neck. Resident was immediately escorted away... to another area of the unit where the plastic knife was confiscated and discarded. Informed that he cannot assault other residents." " Per medicine" note dated 1/25/2012, " resident transferred to Psych ER ...having both homicidal and suicidal ideations." Upon readmission to the facility on the same day, the resident was transferred to unit K, 15 minutes monitoring was continued, and the Resident Care Profile was updated with " No plastic knives at meals for safety. " On 1/27/2012 the psychiatrist documents, " sent to ER for hallucinating and agitation ...memory poor, impulse control questionable, I/J (insight and judgment poor) " Risperdal was increased to 3 mg in the morning and 4 mg at night. On 2/5/2012, the nursing note documents that the resident hit a male peer # G on his head, in the smoking room, for no reason. The resident was escorted to his room, placed on 1:1 monitoring and sent to psychiatric ER. After readmission from the hospital on the same day, the 1:1 observation was continued. On 2/9/2012, the nursing note documented that resident #23 was transferred back to unit AB. On 2/9/2012, the social worker note documented " Resident agreed to move to AB unit resident much calmer and in control. l (Intervention) Requested to go back to AB unit. All in agreement and notify." On 2/12/2012 the nursing note documents that the resident attempted to hit resident #22, after redirection. The medical record for the period of 2/13/12 to 2/29/12, documented that resident #23 had two incidents of resident to resident aggression, and two incidents of hitting staff. Resident # 23 was also noted to have six incidents of increased agitation. The behavior observation form for February 2012, documented that resident #23 had 38 behavioral episodes and was physically aggressive 13 times. On 2/17/2012, the psychiatrist documented decreasing the resident's medication Abilify to 10 mg orally in the morning and at hour of sleep, Risperdal was tapered off, and Latuda 40 mg orally daily was added. There is no documented evidence that there were any attempted changes to resident #23's behavioral modification program. There is no documented evidence that resident #23 was seen by the psychiatrist after 2/17/2012. The CCP for falls on 2/22/2012 documents, " ...increased agitation past 3 months. Seen and evaluated by (name of the psychiatrist) medications adjusted, hit some people including staff. Plan of care reviewed and continue the plan of care. " The medical record for the period of 3/01/12 to 3/13/12, documented that resident #23 had six incidents of physical aggression towards other residents and three incidents involving staff. The Monthly Medical Doctor (MD) note dated 3/19/2012 documents, " He (the resident) was stable this month. " On 4/2/2012, the NBI note documents that the resident became threatening to resident #22. The medical record documented that on 4/10/12, 4/18/12 and 4/20/12, resident #23 had three incidents of physical aggression towards his peers. Per MQAC dated 4/12/2012, the resident (#23) pushed resident #22 to the floor, while he (resident #23) was passing by. The intervention included counseling and keeping at the distance from the peer. The Monthly MD (medical doctor) note dated 4/16/2012 documents, " Resident was mentally more stable this month. " On 4/22/2012 the nursing note documents that the resident engaged in verbal altercation with resident # 34 and attempted to hit him. When redirected, the resident attempted to hit staff. On 4/24/2012 at 1:10 PM the Behavioral Specialist was interviewed and stated that all behavioral specialists receive training on how to deal with the residents who are displaying agitation and aggressive behaviors. The BS stated that there are usually 2 specialists on the unit during the day, except when one specialist goes out with a resident as an escort. The BS stated that he has been in-serviced to always monitor the areas with the greatest concentration of the residents, like dining room, medication room, smoking room, and the hallways during transition. He stated that routinely, the resident displaying aggressive behavior is counseled and escorted to the quiet area to calm down. The BSs will document the residents' behavior and forwards the note to the BS Supervisor, and notifies nursing. The BS stated that resident # 23 displays, at times unpredictable behaviors. He further stated that staff try to anticipate the residents' actions and to keep the residents apart from certain peers. He stated that there is no specific list of the residents that need to be kept apart. On 4/24/2012 at 4:48 PM, the evening shift Licensed Practical Nurse was interviewed and stated she was in-serviced on how to deal with the residents on behavioral unit. Routinely, the LPN stated, there are 6 CNAs and 1-2 behavioral specialists on the evening shift. The LPN stated that the BS is usually in the area when she administers medications to the residents and the BSs are also in the dining rooms during meals. The LPN stated staff try to anticipate residents' behavior. The LPN stated that if she cannot manage the resident's behavior, she would call a behavioral specialist for assistance. The nurse was not aware if there was documentation to keep certain residents apart from another. On 4/24/2012 at 5:30 PM, the Behavioral Specialist on evening shift was interviewed and stated that the BSs usually receive report from the previous shift at 3 PM, and monitor the highest areas of concentration of residents (usually the hallway) while the residents are transitioning. One BS is also present in the dining room during snacks (at 3:30PM) and dinner (5PM) and in the smoking room at 6-6:30 PM. Also, the BS is usually with the nurse during medication pass. He further stated that when something is going on, the staff is aware and it is verbally communicated which residents should not be near each other. At times, the BS stated, it is impossible to prevent conflict, particularly for the residents with unpredictable behavior. If the Resident hits a peer, the residents are separated, the nurse assesses the resident and initates an occurrence report, the MD is notified, as well as the family. The level of supervision could be increased to 15 minutes monitoring or 1:1 monitoring. On 4/25/2012 at 9:45 AM the Medical Doctor was interviewed and stated that the resident has history of aggressive and unpredictable behavior. He further stated that he has not referred the resident to the psychiatrist since February 2012, as the psychiatrist was on vacation and the resident was relatively stable during that period. " I told him not to be agitated ...my perception is that he is doing better now on Latuda. " The Coordinator of Behavioral Specialists (CBS) was interviewed on 4/25/2012 at 10:30 AM and stated that routinely A/B and C/D units have 2 behavioral specialists each and the unit K has 1 behavioral specialist on day and evening shift, while at night, all the units share one behavioral specialist. Per the facility's protocol, the CBS stated, the BSs document all residents' behaviors (physically, verbally abusive, socially inappropriate) and interventions they implemented. The CBS stated he compiles information for each individual resident and documents monthly statistics, looking for trends. The CBS stated it is his responsibility to update the care plan on basis of recommendations of the interdisciplinary team, which meets after occurrences and per schedule. The CBS stated that the Behavioral CCP is not necessarily updated after each altercation with new interventions. The CBS stated that resident #23 was provided with photographs, as a reinforcement for each day without altercation and was followed by the psychiatrist. The CBS stated that the resident is very aggressive, unpredictable, and forgetful and it is very difficult to come up with effective interventions to prevent his behavior, but he did " improve " in the last couple of months. The CBS was not aware if there is a list maintained documenting the names of the residents who should be kept " at arms distance. " On 4/25/2012 at 11:05AM, the Director of the behavioral program was interviewed and stated that the purpose of all three specialized units, is to manage the behavioral issues of the residents who have primary psychiatric diagnoses, in order to stabilize and transfer to the less restrictive environment. The Director stated that the residents on A/B unit present with increased cognitive impairment in relation to the other units. " We are all watching them. " He continued stating that the episodes of physical and verbal abuse and inappropriate behaviors, are sporadically occurring in spite of staff's monitoring and usually the level of supervision is increased, for the residents with problem behaviors from routine 30 minutes to 15 minutes monitoring and 1:1 monitoring, as needed to minimize occurrences. The Director stated that the purpose of behavioral statistics for each resident and of the MQAC investigations, is to establish causes and trends, so that appropriate interventions could be care planned to prevent future occurrences. The Director stated that they maintain the log book of the behavioral occurrences for each unit and these are being reviewed by the Occurrence Review Committee. In spite of all efforts, the repeat altercations between the peers are at times unavoidable, due to the impulsivity and unpredictability of some residents. The Director concluded, that in spite of the transition of ownership, on the behavioral units, " it's been pretty quiet in last 30 days. " On 4/25/2012 at 11:30 AM, the Licensed Master Social Worker (LMSW) was interviewed and stated she covers all of the behavioral units (A/B, C/D, K) by herself, as the social work assistant is no longer employed since 4/2/2012. The LMSW stated that as a member of the interdiciplinary team, she participates in the care plan meetings and gives suggestions related to behavioral management of the residents displaying aggressive behaviors. The SW further stated that various interventions were implemented for this resident, like daily outings (in the past), psychiatry follow up, unit change, photographs of sports and music stars, as reinforcement for good behavior. However, the SW continued, the resident is impulsive and unpredictable, which makes it difficult for behavioral specialists to protect the other residents. Also, the resident has a short attention span and does not engage for long in any activity. The SW was not aware if there was a list of the residents communicating to staff from which residents to keep the resident # 23 apart. She stated that the nurse verbally communicates to staff the residents who should not be kept together and staff memorizes these residents. 2) Resident #13 is a [AGE] year old female with [DIAGNOSES REDACTED]. The Minimal Data Set 3.0 dated 1/21/12 documented a BIMS (Brief Interview for Mental Status) score of 14 which indicates that the resident is cognitively intact. On 4/13/12 at 12:18 PM, during the lunch meal observation, the resident was observed to ask the CNA (Certified Nurse Assistant) for some hot sauce. The CNA directed the resident to get the hot sauce from the refrigerator. The resident was observed to remove a glass bottle of hot sauce from the refrigerator. The resident went to the dining table and poured the hot sauce on her meal. The resident placed the glass bottle on the table between her and resident #12 (resident #13 threw a hamper at resident #12 on 4/6/12). The unit manager was present in the dining room and the surveyor brought to the nurse manager's attention that the glass bottle of hot sauce was on the resident's meal table. The unit manager immediately removed the bottle. The notes of behavior incident and interdisciplinary progress notes dated 10/4/11 to 12/31/11, documented 3 incidents of Resident #13 hitting/punching other residents, and throwing water pitchers at other residents. The interdisciplinary notes dated 10/4/11 documented that resident #13 reported that she had oral sex with another male resident on 10/2/11. The physician order [REDACTED].(unprotected sex)...Q (every) 15 min (minutes) round for safety..." There is no documented evidence that resident #13 was monitored every 15 minutes from 10/4/11 to 11/9/11, as ordered by the physician on 10/4/11. The comprehensive care plan (CCP) for problem behavior, (actual) initiated 3/2/06 and revised 11/11/10 and 2/1/12, documented that the resident had physical aggression/verbal aggression. There is no documented evidence that incidents from 10/4/11 to 12/31/11 were addressed in the CCP. The interdisciplinary progress note dated 1/2/12 at 11PM documented "...Suicidal Ideation... Resident was found by staff attempting to asphyxiate herself c (with) a scarf on her neck. Resident then attempted again c laundry bag. o (no) redness 0 visible injury. 0 SOB (shortness of breath). Resident became combative throwing objects... Ativan IM (intramuscularly injection) PRN (whenever necessary) given. Medication effective. Resident transferred to Psych ER (psychiatric emergency room ) at 6:55 PM. Resident returned to unit at 9PM. Psych ER ordered to maintain 1:1 (one to one) observation....Continue to maintain 1:1 + (and) provide safety." The comprehensive care plan dated 1/4/12 was not revised to address the resident's suicide attempt and did not document an evaluation of the resident's need for supervision/monitoring. During the brief tour on 4/26/12 at 12:20PM, the resident's room was observed to contain a laundry bag, with a draw string and a long scarf like head band (approximately 12 inches in length). The charge nurse was immediately interviewed and stated that this resident is monitored for altercations with other residents. She further stated that she was not aware the resident had attempted to harm herself. She also stated that she does not know of the items resident tried to harm herself with. The charge nurse stated she will remove all items, that the resident could potentially harm herself with, from the resident's room for safety. The interdisciplinary progress notes and the notes of behavior incidents dated 2/4/12 to 4/21/12 documented one incident of self-injurious behavior and 12 incidents of the resident punching/pushing other residents, throwing a hamper at another resident, throwing a piece of the exit sign at another resident and grabbing a lighter from the smoke cart. Two of these incidents involved attacking and throwing items at resident #12. The comprehensive care plan for problem behavior revised 2/1/12 to 4/4/12, documented that the resident displayed targeted behaviors that consisted of verbal and physical aggression toward peers. The interventions were to "...Resident encouraged to inform staff of any problems she may have with her peers. Cont. c emotional support along c + verbal cues..." These interventions were not revised to address the resident's continued behavior. The CCP did not evaluate the resident's need for supervision /monitoring. On 4/27/12 at 11:50AM, the assigned CNA (CNA#1) was interviewed and stated that she is not aware of the residents who have a history of sexual encounter/inappropriateness, and suicidal ideations. She further stated that resident #13 is monitored for aggressive behaviors, but we do not document these incidents. On 4/27/12 at 12:15PM, the unit Registered Nurse supervisor was interviewed and stated that she is aware of the resident's sexual encounters. She further stated that when a resident has a suicidal ideation items that resident can use to harm self should be removed. She stated that she was not aware of the items that needed to be removed for this resident. 3) Resident #36 is a [AGE] year old female with [DIAGNOSES REDACTED]. The Minimal Data Set 3.0 ((MDS) dated [DATE] documented a BIMS (Brief Interview of Mental Status) score of 9 which indicates that the resident has moderate impairment in cognition. The integrated progress notes and the notes of behavior incidents dated 7/4/11 to 4/15/12, documented that the resident had 16 incidents of self injurious behavior, including banging her head, punching and scratching self and 16 incidents of behaviors, such as pulling the fire alarm, punching/scratching other residents, verbal altercations and removing her clothing. The physician's orders [REDACTED]. There is no documented evidence that the resident was monitored while on 1:1 observation from 8/19/11 to 8/27/11. There is no documented evidence that the resident was monitored every 15 minutes on 8/4/11, 8/10/11 and 8/11/11. The physician's orders [REDACTED]...15 mins (minutes) rounds for safety..." There is no documented evidence that the resident was being monitored every 15 minutes on 10/19/11 and on 10/20/11, the monitoring from 7am to 9:45am, the 15 minutes rounds form has an X mark with no documentation of the resident's whereabouts noted. On 10/21/11, the monitoring from 7am to 2:45pm, the 15 minutes rounds form has a X mark with no documentation of the residents whereabouts. On 10/21/11 the next entry by nursing documented "... Res was reported by peer( initials of peer) to staff seen having having sexual intercourse with peer (initials of peer) in his room. She was redirected and counseled. sup (supervisor) made aware... O (no) further behaviors noted. Continue to monitor." The nurse's note on 10/22/11 at 2:30pm documented "....Resident was agitated threatening the nurse and staff. Scratching her face punching herself tripping staff. Verbally redirected x (times) 3 with no success. Resident threw soda bottle at staff. IM PRN Ativan given then sent to Psych ER.... 1:1 observation put in place for safety..." The physician's telephone order dated 10/22/11 "... Sent to Psych ER for eval of suicidal and homicidal ideation. Place on 1:1 observation. On 10/24/11 at 10:30am, the physician order [REDACTED]. q (every) 15 minutes rounds. On 10/24/11, there are numerous discrepancies noted in documentation of the resident's location. On one side of the sheet, the resident was being monitored every 15 minutes from 7am to 10:15am. At 10:30am and 10:45am, staff initials are noted and the letter "G" indicating that the resident is in "Group," according to the facility ledger, then at 11:00am and 11:15am, the staff initials are noted with the letter "G" indicating the resident's location. On the other side of this same sheet, is the date 10/24/11, with an a X mark noted for the time period of 7am to 10:15am. The sheet has the same initials with resident's location "TV" for 10:30am and 10:45am, there is no code on the ledger to reference these letters. At 11:00am and 11:15am, different initials are noted indicating "TV" for the location of the resident. In the evening from 5:00pm to 7:00pm, the initials of one staff person is noted indicating the resident's location, however, on the the other side of the sheet, for the same time period, initials of two different staff are noted indicating the resident's locations, in particular at 6:30pm and 7:00pm, the documentation has the resident in two different locations, at the same time. On 10/31/11 nursing documented, " ... 8:10p, Resident Highly Agitated...Resident Stated Through hand Gesture That Resident Wanted To Kill Herself. A Bathrobe Tie Was Removed From Neck.... Resident Transferred To Psych ER@ (at)8:40p..." On 2/11/12 nursing documented " ... resident became highly agitated and removed all her clothes and tied her Bra around her neck and scratched both her hands/arms. The jogging bra was removed.... MD ordered 1;1 for observation for safety. Resident ready to ER for suicide Ideation. All potential objects have been removed for safety...." The CCP for Problem Behavior dated 3/6/11 to 4/4/12, documented that the resident displays verbal and physical aggression, socially inappropriate behaviors toward peers, staff, and to provide emotional support, positive verbal cues, and that resident's reinforcers are in place. It further documented interventions that were noted to be last updated on 11/15/10, that the resident earns the right to attend weekly cooking reinforcers group, when behavior is appropriate. There is no documented evidence of an effective and an individualized plan of care for monitoring/supervision , self inflicted injuries, victimization and suicidal ideations, in which to prevent and protect the resident from mental, physical and psychosocial harm. On 4/27/12 at 11:50AM, the assigned CNA (Certified Nurse Assistant) was interviewed and stated that she is not aware of the residents who have history of sexual encounter/inappropriateness, and suicidal ideation. She further stated that she was not given any specific instructions to monitor this resident, but she just knows she needs to be monitored for safety by making sure all her needs are being met. On 4/27/12 at 12:15PM, the unit nursing supervisor was interviewed and stated that she is aware of the resident's sexual encounters. She then stated everytime something like this happens a wing change, blood work, psychology evaluation, sexual transmitted disease education, community meetings, and 1:1 observations is done, but she does not know if these were done for this resident. She further stated that when a resident has suicidal ideation, things that resident can use to harm self should be removed and she does not know what was removed for this resident. On 4/27/12 at 12:30PM, the resident was interviewed and stated, via sign language interpreter, that her peer (same male peer found in sexual engagement on 10/21/11 and in sexual engagement with resident #13) comes in her room every time to have sex. The resident stated, through the interpreter, that she consented to having sex with the other resident. She (resident #36) has concerns about her abdomen and is telling the doctor and staff she is pregnant and wants to go to the GYN (Gynecologist), but no one is doing anything for her. The resident also stated, via the interprete,r that no one educated her on sexual transmitted diseases. On 4/27/12 at Approximately 1PM, the registered social worker was interviewed and stated that she is aware that the resident had sexual intercourse with more than one resident. We provide her with education and counseling for inappropriate sexual behavior with other residents. We do not give her condoms. The resident is at risk, because she is having unprotected sex. She understands the education, when it's translated by the sign language consultant. She further stated that most of her behaviors of suicidal ideations and self injury, stem from her being banned from going into male residents' rooms. 415.12(h)(1)(2)

Based upon observation, staff interviews and record reviews, it was determined that the facility failed to ensure that residents' care plans are revised and updated following incidents of resident to resident abuse, inappropriate sexual contact, self mutilation and sucidal.ideations. This was evident for 7 of 30 sampled residents and 2 of 6 residents in the extended survey. (Residents #12, #13, #14, #19, #20, #21, #23, #33 and #36). This resulted in Immediate Jeopardy to Resident Health and Safety. The findings include but are not limited: 1) Resident #23 is [AGE] year old male with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE], documents that the resident has moderately impaired cognition. The Brief Interview for Mental Status (BIMS) score is 9, with fluctuating presence of inattention and disorganized thinking, presence of hallucinations, [MEDICAL CONDITION], physical, verbal, and other socially inappropriate behavior displayed 1 to 3 days, during a seven-day period preceding the MDS. The Medical Record documented 43 separate incidents of physical altercations in which there was harm with other residents and staff from 11/3/11 through 4/23/12. There is no documented evidence that the care plan was updated and/or revised. The Coordinator of Behavioral Specialists (CBS) was interviewed on 4/25/2012 at 10:30 AM and stated that routinely A/B and C/D units have 2 behavioral specialists each. The CBS stated it is his responsibility to update the care plans on basis of recommendations of the interdisciplinary team, which meets after occurrences and per schedule. The CBS stated that the Behavioral CCP is not necessarily updated after each altercation with new interventions. 2) Resident #33 is a [AGE] year old male with [DIAGNOSES REDACTED]. The Minimal Data Set (MDS) 3.0 dated 1/02/12 documented a BIMS (Brief Interview for Mental Status a score of 11of 15, which indicates that the resident has moderate impairment in cognition. The Medical Record documented 8 separate incidents of resident to resident physical abuse from 10/20/11 to 3/19/12. On 2/1/12 nursing documented that the resident was bitten on the chest, neck and arms by another resident. There is no documented evidence that the care plan was updated and/ or revised. 3) Resident #20 is a [AGE] year old male with [DIAGNOSES REDACTED]. [MEDICAL CONDITION], dementia secondary to [MEDICAL CONDITION], rule out [DIAGNOSES REDACTED] and chronic [MEDICAL CONDITION] infection. From 10/2/11 through 4/10/12 the resident had 8 incidents of agitation and /or threatening behavior which included 2 incidents of resident to resident altercations in which the resident was the aggressor. Also during this period, the resident had 1 incident of inappropriate sexual activity in which the resident had questionable ability to consent. The facility was unable to provide the complete comprehensive care plan prior to October 2011 for resident # 20. The resident's care plan was not revised to include interventions to prevent further occurrences. On 4/27/12 at 10AM, the neurobehavioral unit coordinator was interviewed and confirmed that the resident's inappropriate sexual behavior is not documented in the current available comprehensive care plan. The neurobehavioral unit coordinator stated that the resident does not have that many episodes of physical aggression towards peers and this was an adequate comprehensive care plan for this resident. 4) Resident #19 is a [AGE] year old male with [DIAGNOSES REDACTED]. The annual MDS 3.0 completed on 10/25/11,documents that the resident is assessed as having short and long term memory problems and cognitive skills for daily decision making was moderately impaired. A review of the Quality Assurance Committee Supervisor's reports and nurses' progress notes from 9/27/11 thru 3/5/12, revealed that resident #19 was involved in a total of 25 episodes of physical aggression against peers, specifically punching in the face, head, the midline and torso, some resulting in injury. There is no documentation of care plan revision to include interventions to prevent further occurrences. On 4/24/12 at 10AM, the assistant director of nursing (ADON) was interviewed and stated that comprehensive care plans are updated only if an incident results in injury. The ADON stated that regarding the incident where the resident punched a peer in the nose causing bleeding, was referred to the occurrence review committee. The occurrence review committee meets every Monday to determine if the comprehensive care plan is adequate for both provoked and unprovoked behaviors. See F319 and F323 415.11(c)(2)(i-iii)

Based on observation, record reviews and staff interviews, the facility failed to operationalize and implement their written policies and procedures that prohibit mistreatment, neglect and abuse of residents. The facility failed to implement policies to protect residents from abuse, neglect and mistreatment recurrence of harm. The facility failed to report these abuses to the appropriate authorities and failed to implement interventions designed to minimize these behaviors in order to prevent recurrence Specifically, the facility failed to investigate multiple incidents of resident to resident altercations, some of which resulted in injuries (Residents #13, #19, #20, #22, #23, #33); incidents of suicidal ideation and suicide attempts (Resident #13); acts of resident self-mutilation (Resident #14); instances of inappropriate sexual behavior by residents (Residents #9, #20 and #36); injuries of unknown origin (Resident #22); and increased agitation with threatening behaviors (Resident #23). This was evident for 7 of 30 sampled residents and 2 of 6 residents in the expanded sample. This resulted in actual harm that is Immediate Jeopardy to resident health and safety and Substandard Quality of Care for all residents on the facility's behavioral unit. The findings include but are not limited to: A review of the facility's Policy and Procedure for Abuse Prevention, with a revised date of 9/06, documents that "All alleged or suspected incidents of abuse, neglect...will be thoroughly investigated and findings documented in a report format...abuse: the willful infliction of injury with resulting physical harm, pain, or mental anguish...Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Neglect occurs when facility staff fails to monitor and/or supervise the delivery of resident care and services to assure that care is provided as needed....The Interdisciplinary team will continue to provide individualized care plans that identify risk factors of residents....The Comprehensive Care Plan will be reviewed, revised and updated as needed...Investigation: copies of all occurrence reports are submitted to the Administrator for review...the investigative process will include statements from staff, witnesses, residents and medical record review...Investigative report will summarize the findings and outcome as well as note any corrective action or follow up...Protection: If another resident: assess situation as to safety of all residents and address through care planning process. Facility will report any incident and/or violation where abuse, neglect...is suspected." The resident to resident Abuse Policy with a revised date of 2/01 documented...."This facility protects its residents from abuse, neglect....in accordance with federal and state regulations. All alleged or suspected occurrences of abuse between residents will be thoroughly investigated and findings documented in a report format. The facility shall make every effort to prevent abuse from occurring between residents....Interdisciplinary team will hold comprehensive care plan meeting to review involved residents care plans and revise if needed." The Occurence Reporting - Resident/Patient/Client Policy with a revision date of 2/06 documented "An occurence Report Form and Occurence statements are completed for all allegations of violations involving mistreatment, neglect, or abuse, including injuries of unknown source...includes a summary of the incident, including all written and verbal statements, notes on the scope of the investigation, a conclusion, and the plan for prevention of recurrence". 1). Resident #20 is a [AGE] year old male with [DIAGNOSES REDACTED]. [MEDICAL CONDITION], dementia secondary to [MEDICAL CONDITION], rule out [DIAGNOSES REDACTED], chronic [MEDICAL CONDITION] infection. From 10/2/11 through 4/10/12, the resident had 8 incidents of agitation and /or threatening behavior which included 2 incidents of resident to resident altercations in which the resident was the aggressor. Also during this period, the resident had 1 incident of inappropriate sexual activity in which the resident had questionable ability to consent. The facility did not implement their abuse protocol in that their was no investigation into the episodes of altercations and sexual activity. On 4/24/12 at 10AM & 5PM and 4/25/12 at 10AM, the Assistant Director of Nursing was interviewed and stated that there was no accident, incident, occurrence report for the incident of oral sex. The sexual encounter occurred between 2 consenting adults. "This is their home so they had the right for the sexual encounter." Also, the DON was unable to find this incident in the comprehensive care plan. Concluding the resident is a consenting adult is contrary to the BIMS score (6) and the psychiatrist evaluation "alert and oriented X 0. On 4/27/12 at 1PM the medical director was interviewed and stated that if sexual contact occurs between 2 consenting adults, the attending physician would have to order testing for sexual transmitted disease (STD). Therefore an occurrence report would be necessary. On 4/23/12 at 5PM and 4/26/12 at 11:30AM the social worker was interviewed and stated that she did not write a note pertaining to the sexual behavior on 10/23/11. However, the 2 residents are consenting adults. The psychologist uses a screening tool to determine the resident's ability to consent for sexual activity. However, the facility was unable to provide a copy of the psychological screen. On 10/23/12 the medical record documents that resident #20 who has a history of chronic [MEDICAL CONDITION] infection, reportedly engaged in unprotected sexual activity. The resident's ability to consent to sexual activity is questionable due to cognitive impairment. However, there is no formal investigation of this incident. On 2/18/12 and 3/15/12 the resident was involved in resident to resident altercations which resulted in injury to a resident on 3/15/12. The investigations were not complete,did not discuss the cause of the altercations, did not form conclusions and did not develop preventive measures as per facility policy. None of the incidents were reported to the NYS State Department of Health in accordance with State Law. 2). Resident #33 is a [AGE] year old male with [DIAGNOSES REDACTED]. The annual MDS 3.0 completed on 10/12/11 indicates a BIMS score = 14 which indicates that the resident is cognitively intact. From 10/20/11 - 3/19/12, the resident had 7 incidents of agitation and/or resident to resident altercations. During 3 of the incidents, the resident was a victim. During one of the resident to resident altercations, the resident was injured, required treatment in the hospital emergency room and required follow up medical care. During the incident involving injury, the resident was also an aggressor. The incidents included such events as attempts to elope, destruction of property, physical punching of peers, sustained bites ( from [MEDICAL CONDITION].resident), and falls. None of these incidents were reported to the NYS Department of Health as per State Law. There is no documented evidence that the facility implemented their abuse protocol, as the incidents were not thoroughly investigated, did not contain interviews from staff on all 3 shifts. The investigations lacked conclusions and did not result in revisions to the behavior plan. In addition, the investigations were not reviewed by the Medical Director, Nursing and the Administrator. 3). Resident #36 is a [AGE] year old female with [DIAGNOSES REDACTED]. The Minimal Data Set 3.0 ((MDS) dated [DATE] documented a BIMS score of 9 which indicates that the resident has moderately impaired cognition. The Interdisciplinary Progress Notes dated from 6/29/11-4/22/12 revealed that the resident exhibited at least 25 episodes of maladaptive behaviors such as suicidal ideation and attempts, inappropriate sexual behavior (sexual relations and stripping naked), self injurious head banging and cutting, increased agitation, resident to resident altercations with injuries and threatening to kill other residents. There is no documented evidence that these incidents were thoroughly investigated, that attempts were made to identify behavioral triggers, did not contain interviews from staff on all three shifts and the investigations lacked a conclusion and preventive measures as per facility policy. None of these incidents were reported to the NYS Department of Health in accordance with State Law. 415.4 (b)

Based on record reviews and staff interviews, the facility failed to ensure that incidents were thoroughly investigated. Specifically, there was no documented evidence of conclusions, administrative staff review, interviews of witnesses/staff, and interview of residents involved in these incidents and the incidents were not reported to the state agency. This was evident for 11 of 30 sampled residents (Residents #12, #13, #14, #19, #20, #21, #22, # 25, #28, #33, and #36). This resulted in immediate jeopardy to resident health and safety and substandard quality of care. The findings include but are not limited to: The Occurence Reporting - Resident/Patient/Client Policy with a revision date of 2/06 documented "An occurence Report Form and Occurence statements are completed for all allegations of violations involving mistreatment, neglect, or abuse, including injuries of unknown source...includes a summary of the incident, including all written and verbal statements, notes on the scope of the investigation, a conclusion, and the plan for prevention of recurrence". The resident to resident Abuse Policy with a revision date of 2/01 documented...."This facility protects its residents from abuse, neglect....in accordance with federal and state regulations. All alleged or suspected occurences of abuse between residents will be thoroughly investigated and findings documented in a report format. The facility shall make every effort to prevent abuse from occuring between residents". On 4/27/12 at 12:45PM the Assistant Director of Nursing was interviewed and stated that she is responsible for the A/I occurences. The system of the facility is that the Manager/supervisor enters information on a tracking sheet in a binder. "I get them out of book and review them for completion" and ensure that MD and supervisor completes their portions and that all statements are collected. The Supervisor completes the supervisory investigative report. If A/I is res to res abuse then there would be a summary. She further stated that she was aware of all residents (Residents #12,#13, #14, #19, #20, #21, #22, #23, #33 and #36) who were transfered to the emergency room (ER) for various incidents of striking out, unruly/uncontrolled behaviors, res to res/staff altercations. Res would go to psychiatic ER for their behaviors and the ER may or may not give recommendations. Upon res return to facility, the resident will be placed on a 1:1 and a team meeting would be held to make decisions on further interventions. Team meeting notes would be documented sporadically. The neurobehavior unit team meets twice a day, in morning and afternoon from Monday through Friday and there is no documentation of this meeting. There are no meetings on weekends. On Monday, the team would review everything that happened from Friday night to Sunday evening and there is no documentation of this meetings. 1) Resident #19 is a [AGE] year old male with [DIAGNOSES REDACTED]. The annual MDS 3.0 completed on 10/25/11 documents that resident is assessed as having short and long term memory problems and cognitive skills for daily decision making is moderately impaired. A review of the Quality Assurance Committee Supervisor's reports and nurses progress notes from 9/27/11 thru 3/5/12 revealed that resident #19 was involved in a total of 25 episodes of physical agression against peers specifically punching in the face, head, the midline and torso, some resulting in injury. For all 25 incidents, the investigations either were totally lacking, were incomplete, had no conclusion, no new preventive measures and/or lacked review by the Medical Director, Nursing and the Administrator. The Assistant Director of Nursing was interviewed on 4/25/12 at 1:00pm and stated that occurrence review committee meets every Monday to determine if the comprehensive care plan is adequate for both provoked and unprovoked behavior. However, the facility was unable to provide a copy of the occurrence review committee documentation. 2) Resident #20 is a [AGE] year old male with [DIAGNOSES REDACTED]. [MEDICAL CONDITION], dementia secondary to [MEDICAL CONDITION], rule out [DIAGNOSES REDACTED], chronic [MEDICAL CONDITION] infection. On 8/2/11 a psychiatry note documents that the resident was "alert and oriented X 0." From 10/2/11 through 4/10/12 the resident had 8 incidents of agitation and /or threatening behavior which included 2 incidents of resident to resident altercations in which the resident was the aggressor. Also during this period, the resident had 1 incident of inappropriate sexual activity in which the resident had questionable ability to consent. The annual MDS 3.0 completed on 10/12/11 indicates a "Brief Interview for Mental Status Score"(BIMS) = 06 which indicates severe cognitive impairment. On 10/23/11 at 2PM a "note of behavior incident" documents: "Resident admitted that peer . . . performed an oral sexual act on him. When asked by the nurse... peer announced act in hallway prior to . . . being questioned by LPN (licensed practical nurse). "Outcome (how incident was resolved): resident was educated by staff on sexual safety. " The next social worker note was on 2/22/12 which documented a room change for the resident. On 3/27/12 a "social worker quarterly note" does not document the 10/23/11 sexual incident. On 4/24/12 at 10AM & 5PM and 4/25/12 at 10AM, the Assistant Director of Nursing was interviewed and stated that there was no accident, incident, occurrence report for the incident of oral sex. The sexual encounter occurred between 2 consenting adults. "This is their home so they had the right for the sexual encounter." On 4/27/12 at 1PM the medical director was interviewed and stated that if sexual contact occurs between 2 consenting adults, the attending physician would have to order testing for sexual transmitted disease (STD). Therefore an occurrence report would be necessary. On 10/23/11 the medical record documents that resident #20 who has a history of chronic [MEDICAL CONDITION] infection, reportedly engaged in unprotected sexual activity. The resident's ability to consent to sexual activity is questionable due to cognitive impairment. However, there is no formal investigation of these incidents. 3). Resident #33 is a [AGE] year old male with [DIAGNOSES REDACTED]. The annual MDS 3.0 completed on 10/12/11 indicates a BIMS score = 14 which indicates that the resident is cognitvely intact. From 10/20/11 - 3/19/12, the resident had 7 incidents of agitation and/or resident to resident altercations. During 3 of the incidents, the resident was a victim. During one of the resident to resident altercations, the resident was injured, required treatment in the hospital emergency room and required follow up medical care. During the incident involving injury, the resident was also an aggressor. The incidents included such events as attempts to elope, destruction of property, physical punching of peers, sustained bites ( from [MEDICAL CONDITION].resident), and falls. None of these incidents were reported to the NYS Department of Health as per State Law. There is no documented evidence that the incidents was thoroughly investigated, did not contain interviews from staff on all 3 shifts. The investigations lacked conclusions and did not result in revisions to the behavior plan. In addition, the investigations were not reviewed by the Medical Director, Nursing and the Administrator. 4) Resident #36 is a [AGE] year old female with [DIAGNOSES REDACTED]. The Minimal Data Set 3.0 ((MDS) dated [DATE] documented a BIMS score of 9 with moderate impairment and that this resident requires supervision while ambulating on/and off unit, dressing and eating. The Interdisciplinary Progress Notes dated from 6/29/11 to 4/22/12 revealed that the resident exhibited at least 25 episodes of maladaptive behaviors such as suicidal ideation and attempts, inapropriate sexual behavior (sexual relations and stripping naked), self injurious head banging and cutting, increased agitation, resident to resident altercations with injuries and threatening to kill other residents. There is no documented evidence that these incidents were thoroughly investigated, that attempts were made to identify behavioral triggers, contained interviews from staff on all three shifts and the investigations lacked a conclusion and preventive measures as per facility policy. None of these incidents were reported to the NYS Department of Health in accordance with State Law. 415.4 (b)(1)(ii)

Based on record reviews and staff interviews, the facility failed to ensure that residents were free from verbal, sexual, physical and mental abuse. Specifically, 8 of 72 residents (Res) on the facility's neurobehavioral unit had multiple episodes of behavioral problems including resident to resident altercations ( res #12 #19 #20 #21 #23,#33 ); and allegations of inappropriate sexual behaviors (res #13 #20 #36). The facility failed to protect all residents from abuse. The faciility failed to implement interventiions to prevent recurrence of abuse. This was noted for 8 of 72 residents who reside on the neurobehavioral units AB, CD, and K. This resulted in actual harm that is immediate jeopardy to resident health and safety and substandard quality of care. The findings include but are not limited to: The resident to resident Abuse Policy with a revision date of 2/01 documented...."This facility protects its residents from abuse, neglect....in accordance with federal and state regulations. All alleged or suspected occurences of abuse between residents will be thoroughly investigated and findings documented in a report format. The facility shall make every effort to prevent abuse from occuring between residents". 1) Resident #19 is a [AGE] year old male with [DIAGNOSES REDACTED]. The annual MDS 3.0 completed on 10/25/11 documents that the resident is assessed as having short and long term memory problems and cognitive skills for daily decision making is moderately impaired. A review of the Quality Assurance Committee Supervisor's reports and nurses' progress notes from 9/27/11 thru 3/5/12, revealed that resident #19 was involved in a total of 25 episodes of physical aggression against peers. Specifically, punching in the face, head, the midline and torso; some resulting in injury. For all 25 incidents, there was no documented evidence that the facility implemented interventions to prohibit the recurrence of abuse. The Assistant Director of Nursing was interviewed on 4/25/12 at 1:00pm and stated that the occurrence review committee meets every Monday to determine if the comprehensive care plan is adequate for both provoked and unprovoked behaviors. However, the facility was unable to provide a copy of the occurrence review committee documentation. 2). Resident #20 is a [AGE] year old male with [DIAGNOSES REDACTED]. [MEDICAL CONDITION], dementia secondary to [MEDICAL CONDITION], rule out [DIAGNOSES REDACTED], chronic [MEDICAL CONDITION] infection. On 8/2/11, a psychiatry note documents that the resident was "alert and oriented X 0." There was no psychiatric evaluation of resident #20 from September 2011 through April 2012. From 10/2/11 through 4/10/12, the resident had 8 incidents of agitation and /or threatening behavior which included 2 incidents of resident to resident altercations in which the resident was the aggressor. Also during this period, the resident had 1 incident of inappropriate sexual activity in which the resident had questionable ability to consent. The annual MDS 3.0 completed on 10/12/11 indicates a "Brief Interview for Mental Status Score"(BIMS) = 06 which indicates severe cognitive impairment. On 10/23/11 at 2PM a "note of behavior incident" documents: "Resident admitted that peer . . . performed an oral sexual act on him. When asked by the nurse... peer announced act in hallway prior to . . . being questioned by LPN (licensed practical nurse). "Outcome (how incident was resolved): resident was educated by staff on sexual safety. " The next documented social worker note was on 2/22/12 and there was no documented evidence of the 10/23/11 sexual incident. On 3/27/12 a "social worker quarterly note" does not document the 10/23/11 sexual incident. On 4/24/12 at 10AM & 5PM and 4/25/12 at 10AM, the Assistant Director of Nursing was interviewed and stated that there was no accident, incident, occurrence report for the incident of oral sex. The sexual encounter occurred between 2 consenting adults. "This is their home so they had the right for the sexual encounter." On 4/27/12 at 1PM, the medical director was interviewed and stated that if sexual contact occurs between 2 consenting adults, the attending physician would have to order testing for sexual transmitted disease (STD). Therefore an occurrence report would be necessary. On 4/23/12 at 5PM and 4/26/12 at 11:30AM the social worker was interviewed and stated that she did not write a note pertaining to the sexual behavior on 10/23/11 as, the 2 residents are consenting adults. The psychologist uses a screening tool to determine the resident's ability to consent for sexual activity. The facility was unable to provide a copy of the psychological screen. 3). Resident #33 is a [AGE] year old male with [DIAGNOSES REDACTED]. The annual MDS 3.0 completed on 10/12/11 indicates a BIMS score = 14 which indicates that the resident is cognitively intact. From 10/20/11 - 3/19/12, the resident had 7 incidents of agitation and/or resident to resident altercations. During 3 of the incidents, the resident was a victim. During one of the resident to resident altercations, the resident was injured, required treatment in the hospital emergency room and required follow up medical care. During the incident involving injury, the resident was also an aggressor. The incidents included such events as physical punching of peers, and sustained bites ( from [MEDICAL CONDITION].resident), and falls. There is no documented evidence of interventions to address the recurrence of abuse and interventions to protect this resident from further abuse. On 4/27/12 at 11AM, the behavior specialist coordinator was interviewed and stated that the resident only receives positive reinforcement for appropriate behavior. The resident will receive emotional support from the staff along with positive verbal cues. The behavior specialist coordinator indicated that he is responsible to write entries into the problem behavior care plan. 415.4(b)

Based on record review and staff interviews, the facility's quality assessment and assurance committee failed to identify issues that required quality assessment and assurance activities; and failed to develop, identify and implement appropriate plans of action. Specifically, the quality assessment and assurance committee failed to develop and implement a plan of action to address ongoing incidents of resident to resident altercations resulting in injuries, suicidal ideation, suicide attempts, self-mutilation and inappropriate sexual behaviors for the residents on the neurobehavioral units. This was evident for 7 of 30 sampled residents and 2 of 6 residents in the expanded sample. Residents #12, #13, #14, #19, #20, #21, #23, #33, and #36. The findings include but are not limited to: 1) Resident #23 is [AGE] year old male with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documents that the resident has moderately impaired cognition. The Medical Record documented 43 separate incidents of physical altercations in which there was harm with other residents and staff from 11/3/11 through 4/23/12. There is no documented evidence that the care plan was updated and/or revised from 11/3/11 to 4/23/12. A thorough investigation was not conducted for each incident. 2) Resident #13 is a [AGE] year old female with [DIAGNOSES REDACTED]. The Minimal Data Set (MDS) 3.0 dated 1/21/12 documented a BIMS (Brief Interview for Mental Status) a score of 14 out of 15 which indicates that the resident is cognitively intact. The MDS further documented that the resident requires supervision with no set up assist for ambulation on/off unit, dressing, eating, and personal hygiene. The Medical Record documented incidents of behavior including inappropriate sexual behavior, suicidal ideation, self mutilation and resident to resident physical abuse from 10/2/11 through 4/12/12. There is no documented evidence that the care plan was updated and/ or revised. A thorough investigation was not conducted for each incident. 3) Resident #33 is a [AGE] year old male with [DIAGNOSES REDACTED]. The Minimal Data Set (MDS) 3.0 dated 1/02/12 documented a BIMS (Brief Interview for Mental Status a score of 11 of 15 which indicates that the resident has moderate impairment in cognition. The Medical Record documented 8 separate incidents of resident to resident physical abuse from 10/20/11 to 3/19/12. On 2/1/12 nursing documented that the resident was bitten on the chest, neck and arms by another resident. There is no documented evidence that the care plan was updated and/ or revised. A thorough investigation was not conducted for each incident. There is no documented evidence that appropriate plans of action were implemented to correct identified resident behavioral issues. The Director of Nursing was interviewed on 4/25/12 at 10:30 AM and stated that the staff is aware of these behavioral problems and the most recent incidents occurred on the weekends when the activity staff is limited. She further stated that residents have been experiencing anxiety recently due to transitions in staffing. The Medical Director was interviewed on 4/26/12 at 3:25 PM and stated that lately the facility has not been working on Quality Assurance due to the transition of the new owners. She continued to state that the facility was aware there was an increase in aggressive behavior exhibited by the residents on the neurobehavioral units. The Administrator was interviewed on 4/27/12 at approximately 1:00 PM and stated that he came to work at the facility in January 2012. He stated that he did identified that there behavioral problems on the neurobehavioral unit by reviewing the Accident Incident (A/I) Reports. He continued to stated that he started trending the reports to see the times of the occurrences and at this time the facility is aware of the numerous behavioral incidents on the neurobehavioral units. 415.27(a-c)

Based on record reviews and staff interviews, the facility failed to ensure that residents who displayed mental and psychosocial adjustment difficulty received appropriate treatment and services to maintain and improve psychosocial functioning as evidenced by: failure to provide ongoing psychiatric re-evaluations and effective behavioral interventions for residents on a neurobehavorial units who exhibited multiple episodes of agitation, physical aggression, [MEDICAL CONDITION], self mutilations and sexual activity. This was evident for 7 of 30 sampled residents and 2 of 6 residents in the expanded sample. (Residents #12, #13, #14, #19, #20, #21, #23, #33 and #36) This resulted in actual harm that is Immediate Jeopardy to Resident Health and Safety and Substandard Quality of Care. The findings include but are not limited to: 1) Resident # 23 is a [AGE] year old male with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documents that the resident has moderately impaired cognition. The (Brief Interview for Mental Status) BIMS score is 9, with fluctuating presence of inattention and disorganized thinking, presence of hallucinations, [MEDICAL CONDITION], physical, verbal, and other socially inappropriate behavior displayed in 1 to 3 days during a seven-day period preceding the MDS. The MDS assessment further documents that the resident requires staff supervision for walking in the corridor, locomotion on and off unit. The Comprehensive care plan (CCP) for problem behavior dated 4/18/2011 documents as " expected outcome " that the resident will demonstrate fewer episodes of verbal & (and) physical aggression, not harm self or others, minimize risk of injury ... " and includes interventions as " ongoing assessment of behavior pattern, administer medications as ordered, assess response to medication, anticipate needs/interests, implement motivational strategies, provide adequate exercise, engage in activities that reduce frustration and support needs, provide individual counseling, redirect negative behaviors, not to wait on med (medication) line, physical aggression c (with) peer keep at arm distance at all times ..., orient to his own room, to be rewarded with sports trading cards if no reported aggression during day/evening." The Interdisciplinary progress notes from 10/22/2011 to 4/24/2012 and the Notes of Behavior Incident from 11/3/11 to 4/22/2012, documents that resident #23 had 23 incidents of physical aggression involving 9 peers. One peer, resident #34 was repeatedly involved in six different incidents with resident #23. In addition, during the same period, the resident attempted to hit peers and/or staff or displayed physically threatening behavior on 36 occasions. The Residents to be kept at arms distance list (undated) for AB wing documents the name of resident #23 and resident #22 and does not include res (resident) # 34. On 10/22/11 at 8:35pm, the nursing note documents that the resident had a physical altercation with peer in the hallway "....will continue to monitor." On 10/29/11 at 12:00pm, the nursing note documents that the resident was involved in a verbal altercation with peer #22 "...admitted to pushing another resident's wheelchair (W/C) into resident # 22's right leg...Continue to monitor." The CCP for problem behavior, with a revision date of 11/1/2011, documented " Monthly CCP- ... Reinforcer is in place for good behavior. Continue with + (positive) verbal cues. " The Note of behavioral incident (NBI) dated 11/3/11 documents, " attempted to kick nurse " and " threatened the peer #22 to set his hair on fire." On 11/9/2011 the psychiatrist documents, " paranoid and anxious ...coherent, not a management problem ...increase [MEDICATION NAME] to 1mg (milligrams) AM (morning) and 2 mg PO (orally) @ (at) HS (hour of sleep) ...close observation, provide support ... " The NBI note 11/9/11 attempted to hit peer, staff intervened. The (MQAC) report dated 11/12/2011, documents that at 7 PM, resident #23 pushed (initials of peer) who was seated in his wheelchair, toward peer # 34. Resident #34 fell and hit his head on the resident's (initials of peer) wheelchair. The Medical Doctor (MD) documented on 11/13/2012, that resident # 34 complained of pain on R (right) frontal side on his head and mild L (left) arm pain. On 11/15/2011 at 8:25 AM, the MQAC documents that the resident #23, while being redirected by the behavioral specialist, hit peer # 34 on the top of his head. The MQAC documented that resident #23 was redirected and counseled. Instructed res. (resident) to keep distance from peer. [MEDICATION NAME] was administered for agitation. The CCP dated 11/15/11 for problem behavior, documents that a behavioral meeting was held " continues to show periodic episodes of aggression/paranoia, verbal outbursts. Psychiatric evaluation ...increased neuroleptic dose. Behavior intervention plan modified targeting above behavior with + (positive) reinforcement of picture celebrities provided once a week for daily reinforcement will continue ... " On 11/16/2011, the psychiatrist recommended resident #23's medication be increased to [MEDICATION NAME] 2 mg orally in the morning and at hour of sleep and continuation of behavioral management. The Therapeutic Recreation Leader documented on 11/16/2011, " Resident (#23) frequently becomes verbally/physically aggressive toward staff (esp. - especially female) and peers for 0 (no) apparent reason. His moods fluctuate from kind and docile to violent and aggressive c (with) increased lability. " On 1/7/2012 the MQAC documents that at 8:40 AM, the resident got out of his chair, during breakfast in the dining room and slapped peer #34 in the back of his head. "Resident was counseled and kept at least at arms length from peer. " On 1/8/2012 the CCP for problem behavior was updated to reflect occurrence and documents " continue CCP. " On 1/10/2012 the Memo to Quality Assurance Committee MQAC report documents that at 4:25 PM in the hallway, the resident became agitated and hit resident # 22 on his arm. Action taken: " separated and counseled." On 1/17/2012, resident #23 was seen by the psychiatrist who documented " ...behavior improved from before ...developing cognitive deficits, please orient him before telling him to do something, continue behavioral management. " On 1/17/2012 the nursing note documents " Resident #23 attempted to hit peer # 34 for no apparent reason. Redirected and counseled ...will continue to monitor for safety." The CCP for problem behavior was updated on 1/17/2012 and documents " ... Cont. (continue) emotional support. Reinforcer in place." On 1/22/2012 the nursing documents " Peer (initials) reported to nursing supervisor that resident allegedly choked her yesterday. " The resident was sent to the Psychiatric emergency room (ER) and readmitted several hours later, placed on 1:1 monitoring until 1/23. The MQAC dated 1/22/2012 documents " He (resident) stated that he put his fingers on resident F (initials) neck, but denies choking her ...camera review done- residents were not near each other. Allegation unfounded. " On 1/23/11 the NBI note documents " very disruptive, screaming, yelling, cursing and threatening to hit peers, threaten staff members ...escorted to less stimulating area (his room), verbal counseling ...will continue to monitor for safety. " On 1/24/2012 the MQAC report documents that the resident (#23) pushed the behavior specialist from behind at 7:40 AM, then threw himself to the floor ... the resident agitated and combative ... escorted to his room ...small scratch on left ear and scant bleeding. " On 1/24/2012 the NBI note documents at 8:50 AM, the resident (#23) walked during breakfast past the peer(initials) and grazed her leg ... " counseled and redirected. " At 11:55AM, attempted to strike peer in the hallway. At 6:34 PM, the resident attempted to kick the Behavioral Specialist. On 1/25/2012, the NBI documents at 8:40 AM, " Resident (#23) was in the dining room and got up from his seat, walked up to the resident (name # 34) with a plastic knife in his hand and put the knife to resident (initials) # 34's neck. Resident was immediately escorted away... to another area of the unit where the plastic knife was confiscated and discarded. Informed that he cannot assault other residents." " Per medicine" note dated 1/25/2012, " resident transferred to Psych ER ...having both homicidal and [MEDICAL CONDITION]." Upon readmission to the facility on the same day, the resident was transferred to the unit K, 15 minutes monitoring was continued, and the Resident Care Profile was updated with " No plastic knives at meals for safety. " On 1/27/2012 the psychiatrist documents " sent to ER for hallucinating and agitation ...memory poor, impulse control questionable, I/J (insight and judgment poor) " [MEDICATION NAME] was increased to 3 mg in the morning and 4 mg at night. On 2/1/2012 nursing notes document that the resident attempted to hit behavioral specialist. On 2/5/2012, the nursing note documents that the resident hit a male peer # G on his head, in the smoking room, for no reason. The resident was escorted to his room, placed on 1:1 monitoring and sent to psychiatric ER. After readmission from the hospital on the same day, the 1:1 observation was continued. On 2/9/2012 the nursing note documented that resident #23 was transferred back to unit AB. On 2/9/2012 the social worker note documented, " Resident agreed to move to AB unit resident much calmer and in control. l (Intervention) Requested to go back to AB unit. All in agreement and notify." On 2/12/2012, the nursing note documents that the resident attempted to hit resident #22, after redirection. The medical record for the period of 2/13/12 to 2/29/12, documented that resident #23 had two incidents of resident to resident aggression, and two incidents of hitting staff. Resident # 23 was also noted to have six incidents of increased agitation. The behavior observation form for February 2012 documented that resident #23 had 38 behavioral episodes and was physically aggressive 13 times. On 2/17/2012, the psychiatrist documented decreasing the resident's medication [MEDICATION NAME] to 10 mg orally in the morning and at hour of sleep, [MEDICATION NAME] was tapered off, and [MEDICATION NAME] 40 mg orally daily was added. There is no documented evidence that there were any attempted changes to resident #23's behavioral modification program. There is no documented evidence that resident #23 was seen by the psychiatrist after 2/17/2012. Review of the communication book for the psychiatrist documents no residents were referred to the psychiatrist. The Resident Care Profile and the unit list of residents to be kept at arms distance document, " Keep at arms distance from peer's initials ( resident #22). Resident #22 engaged in at least 5 altercations with resident #23 since 10/22/2011. The CCP for falls on 2/22/2012 documents, " ...increased agitation past 3 months. Seen and evaluated by (name of the psychiatrist) medications adjusted, hit some people including staff. Plan of care reviewed and continue the plan of care. " The medical record for the period of 3/01/12 to 3/13/12 documented that resident #23 had six incidents of physical aggression toward other residents and three incidents involving staff. The Monthly Medical Doctor (MD) note dated 3/19/2012 documents, " He (the resident) was stable this month. " On 4/2/2012 the NBI note documents that the resident became threatening to resident #22. The medical record documented that on 4/10/12, 4/18/12 and 4/20/12, resident #23 had three incidents of physical aggression towards his peers. Per MQAC dated 4/12/2012, the resident pushed resident #22 to the floor, while he(resident #23) was passing by. The intervention included counseling and keeping at the distance from the peer. The Monthly MD (medical doctor) note dated 4/16/2012 documents, " Resident was mentally more stable this month. " On 4/22/2012, the nursing note documents that the resident engaged in verbal altercation with resident # 34 and attempted to hit him. When redirected, the resident attempted to hit staff. The undated, "The Residents to be kept at arms distance list" for AB wing does not include resident # 34, with whom resident # 23 had 6 altercations with or female resident (initials) with whom the resident also had at least 2-3 altercations. The behavioral care plan does not document evidence of implementation of new behavioral strategies or address the monitoring/supervision for this resident. On 4/24/2012 at 1:10 PM the Behavioral Specialist (BS) was interviewed and stated that all behavioral specialists receive training on how to deal with the residents who are displaying agitation and aggressive behaviors. The BS stated that there are usually 2 specialists on the unit during the day, except when one specialist goes out with a resident as an escort. The BS stated that he has been in-serviced to always monitor the areas with the greatest concentration of the residents, like dining room, medication room, smoking room, and the hallways during transition. He stated that routinely the resident displaying aggressive behavior, is counseled and escorted to the quiet area to calm down. The BS will document the resident's behavior and forwards the note to the BS Supervisor, and notifies nursing. The BS stated that resident # 23 displays at times unpredictable behaviors. He further stated that staff try to anticipate the residents' actions and to keep the residents apart from certain peers. He stated that there is no specific list of the residents that need to be kept apart. On 4/24/2012 at 4:48 PM, the evening shift Licensed Practical Nurse was interviewed and stated she was in-serviced on how to deal with the residents on behavioral unit. Routinely, the LPN stated, there are 6 CNAs and 1-2 behavioral specialists on the evening shift. The LPN stated that the BS is usually in the area when she administers medications to the residents and the BSs are also in the dining rooms during meals. The LPN stated staff try to anticipate residents' behavior. The LPN stated that if she cannot manage the resident's behavior, she would call a behavioral specialist for assistance. The nurse was not aware if there was documentation to keep certain residents apart from another. On 4/24/2012 at 5:30 PM, the Behavioral Specialist on evening shift was interviewed and stated that the BSs usually receive report from the previous shift at 3 PM, and monitor the highest areas of concentration of residents (usually the hallway) while the residents are transitioning. One BS is also present in the dining room during snacks (at 3:30PM) and dinner (5PM) and in the smoking room at 6-6:30 PM. Also, the BS is usually with the nurse during medication pass. He further stated that when something is going on, the staff is aware and it is verbally communicated which residents should not be near each other. At times, the BS stated, it is impossible to prevent conflict, particularly for the residents with unpredictable behavior. If the Resident hits a peer, the residents are separated, the nurse assesses the resident and initates an occurrence report, the MD is notified, as well as the family. The level of supervision could be increased to 15 minutes monitoring or 1:1 monitoring. On 4/25/2012 at 9:45 AM the Medical Doctor was interviewed and stated that the resident has history of aggressive and unpredictable behavior. He further stated that he has not referred the resident to psychiatrist since February 2012 as the psychiatrist was on vacation and the resident was relatively stable during that period. " I told him not to be agitated ...my perception is that he is doing better now on [MEDICATION NAME]. " The Coordinator of Behavioral Specialists (CBS) was interviewed on 4/25/2012 at 10:30 AM and stated that routinely A/B and C/D units have 2 behavioral specialists each and the unit K has 1 behavioral specialist on day and evening shifts, while at night, all the units share one behavioral specialist. Per the facility's protocol, the CBS stated, the BSs document all residents behaviors (physically, verbally abusive, socially inappropriate) and interventions they implemented. The CBS stated he compiles information for each individual resident and documents monthly statistics, looking for trends. The CBS stated it is his responsibility to update the care plan on basis of recommendations of the interdisciplinary team, which meets after occurrences and per schedule. The CBS stated that the Behavioral CCP is not necessarily updated after each altercation with new interventions. The CBS stated that resident #23 was provided with photographs as a reinforcement for each day without altercation and was followed by the psychiatrist. The CBS stated that the resident is very aggressive, unpredictable, and forgetful and it is very difficult to come up with effective interventions to prevent his behavior, but he did " improve " in the last couple of months. The CBS was not aware if there is a list maintained documenting the names of the residents who should be kept " at arms distance. " On 4/25/2012 at 11:05AM, the Director of the behavioral program was interviewed and stated that the purpose of all three specialized units is to manage the behavioral issues of the residents who have primary psychiatric [DIAGNOSES REDACTED]. The Director stated that the residents on A/B unit present with increased cognitive impairment in relation to the other units. " We are all watching them. " He continued stating that the episodes of physical and verbal abuse and inappropriate behaviors, are sporadically occurring in spite of staff's monitoring and usually the level of supervision is increased for the residents with problem behaviors from routine 30 minutes to 15 minutes monitoring and 1:1 monitoring as needed to minimize occurrences. The Director stated that the purpose of behavioral statistics for each resident and of the MQAC investigations is to establish causes and trends so that appropriate interventions could be care planned to prevent future occurrences. The Director stated that they maintain the log book of the behavioral occurrences for each unit and these are being reviewed by the Occurrence Review Committee. In spite of all efforts, the repeat altercations between the peers are at times unavoidable, due to the impulsivity and unpredictability of some residents. The Director concluded that in spite of the transition of ownership, on the behavioral units " it's been pretty quiet in last 30 days. " On 4/25/2012 at 11:30 AM the Licensed Master Social Worker (LMSW) was interviewed and stated she covers all of the behavioral units (A/B, C/D, K) by herself, as the social work assistant is no longer employed since 4/2/2012. The LMSW stated that as a member of the interdiciplinary team, she participates in the care plan meetings and gives suggestions related to behavioral management of the residents displaying aggressive behaviors. The SW further stated that various interventions were implemented for this resident, like daily outings (in the past), psychiatry follow up, unit change, photographs of sports and music stars as reinforcement for good behavior. However, the SW continued, the resident is impulsive and unpredictable, which makes it difficult for behavioral specialists to protect the other residents. Also, the resident has a short attention span and does not engage for long in any activity. The SW was not aware if there was a list of the residents communicating to staff from which residents to keep resident # 23 apart. She stated that the nurse verbally communicates to staff the residents who should not be kept together and staff memorizes these residents. On 4/25/2012 at 5 PM the Certified Nursing Assistant was interviewed and stated that he works on-call 2-3 evenings or nights per week. He stated that usually he is able to talk to resident #23. He further stated that if resident #23 is not cooperative, and if he cannot manage resident #23's behavior, he calls the behavioral specialist for assistance. 2) Resident #20 is a [AGE] year old male with [DIAGNOSES REDACTED]. [MEDICAL CONDITION], dementia secondary to [MEDICAL CONDITION], rule out [DIAGNOSES REDACTED] and chronic [MEDICAL CONDITION] infection. The annual MDS 3.0 completed on 10/12/11 indicates a "Brief Interview for Mental Status Score" (BIMS) = 06 indicating severe cognitive impairment. On 9/6/11 a psychiatry consultation documented that the resident was alert and oriented X 1 (times one). There was no psychiatric evaluation for resident #20 from September 2011 through April 2012. From 10/2/11 through 4/10/12, the resident had 8 incidents of agitation and /or threatening behavior, which included 2 incidents of resident to resident altercations, in which the resident was the aggressor. Also during this period, the resident had 1 incident of inappropriate sexual activity, in which the resident had questionable ability to consent. On 10/23/11 at 3PM, a nursing note documents: "P (problem) resident had sexual encounter with (resident #9). . . . . I (intervention) nurse counseled with some success. E (evaluation) Continue to monitor. " On 10/23/11 at 11PM, the nursing note documents "P: F/U (follow up) sexual encounter with peer. (resident #9). I: Resident was counseled and monitored. E: No sexual encounters or behavior noted on this shift." On 10/23/11 at 2PM, a "note of behavior incident" documents: "Resident admitted that peer . . . performed an oral sexual act on him. When asked by the nurse . . .peer announced act in hallway prior to . . . being questioned by LPN (licensed practical nurse). "Outcome (how incident was resolved): resident was educated by staff on sexual safety. " On 10/25/11 at 1:50PM, a physician's note documents: Resident has unprotected sex with peer . . . Blood urine tests are ordered. Counseling about safe sex education given.. On 11/30/11 a psychology note documents: "met with resident. Resident discussed interpersonal issues. Coping strategies were discussed. . . " There was no psychiatric evaluation of resident #20 following the incident of sexual activity on 10/23/11. There is no documented evidence of a comprehensive care plan to address this resident's sexual activity. The next social worker note was on 2/22/12 and documented a room change for the resident. On 3/27/12 a "social worker quarterly note" does not document the 10/23/11 sexual incident. On 3/6/12, the comprehensive care "Problem behavior" documents: "Monthly CCP. Resident displayed 1 targeted behavior this month pushing his peer causing his peer to fall to the ground. Continue to give resident positive verbal cues and counseling " There was no new behavioral interventions to address the resident's continued physical aggression. On 4/20/12 at 11AM, the psychiatrist was interviewed via phone and asked about the use of multiple psycho active medications and frequency of visits for resident #20. He stated that the neurobehavioral unit residents have severe problems with impulse control, agitation and [MEDICAL CONDITION]. The medications control the impulses and allow the resident to sleep. Even with multiple medications it is difficult for them to remain stable. Over 90% of residents have 4 -5 medications. Most of the time, when we try to adjust or wean the medications, the resident decompensates with devastating results. The psychiatrist stated that he comes to the unit and sees the residents twice a week. He believes he saw resident #20 last month. On 4/20/12 at 3PM, the neurobehavioral unit director was interviewed and was unable to find any psychiatry evaluations for resident #20, after September 2011. He stated that psychiatrists see the residents at least once a year. The psychologist sees the resident in between. The neurobehavioral unit director also stated that the resident was seen by a psychiatrist in the ER, which is adequate psychiatric evaluation. On 4/20/12 at 3:30PM the attending physician was interviewed about Resident #20's psychiatry consultation. The physician stated that resident #20 is stable and does not require a psychiatry consultation. If the resident is agitated psychiatry is called. The attending physician also stated that "I don't touch psychoactive medications." He leaves this to the psychiatrist. On 4/23/12 at 5PM and 4/26/12 at 11:30AM, the social worker was interviewed and stated that she did not write a note pertaining to the sexual behavior on 10/23/11. However, the 2 residents are consenting adults. The social worker further stated that the psychologist uses a screening tool to determine the resident's ability to consent for sexual activity . However, the facility was unable to provide a copy of the psychological screen. On 4/24/12 at 10AM & 5PM and 4/25/12 at 10AM, the assistant director of nursing was interviewed and stated that the sexual encounter occurred between 2 consenting adults. "This is their home so they had the right for the sexual encounter." Also, the DON (Director of Nursing) was unable to find this incident in the comprehensive care plan. On 4/27/12 at 1PM, the medical director was interviewed and stated that if sexual contact occurs between 2 consenting adults, the attending physician would have to order testing for sexual transmitted disease (STD). Therefore an occurrence report would be necessary. 3) Resident #19 is a [AGE] year old male with [DIAGNOSES REDACTED]. The annual MDS 3.0 completed on 10/25/11 documents that resident is assessed as having short and long term memory problems and cognitive skills for daily decision making is moderately impaired. A review of the Quality Assurance Committee Supervisor's reports and nurses' progress notes from 9/27/11 thru 3/5/12, revealed that resident #19 was involved in a total of 25 episodes of physical aggression against peers. Specifically punching in the face, head, the midline and torso, some resulting in injury. For all 25 incidents, there was no documented evidence that the facility implemented new/revised behavioral interventions to prohibit the recurrence of physical aggression toward other residents. On 10/25/11 the "evaluation of comprehensive care plan" for "problem behavior" indicates: "Resident has exhibited numerous targeted behaviors for this period. Resident unprovokingly attacks staff and peer and throws himself to the floor. Resident to be kept at arms distance from his peers and is to stay out of stimulating areas. Continue with positive verbal cues and counseling." On 11/22/11, the evaluation of comprehensive care plan for problem behavior indicates: "Resident has 2 documented behavior noted yelling at peers and staff and making inappropriate remarks continue with verbal cues and counseling. " On 12/22/11 the comprehensive care plan for problem behavior indicates: "Resident has displayed 3 targeted behaviors this month displayed. . . .Continue to keep resident in a less stimulating area. Continue with verbal cues and techniques. " On 1/4/12 at 2PM, nursing documented: "Increased agitation. Verbally redirected, [MEDICATION NAME] IM 2mg/ml given as PRN escorted to his room several times. Resident noted with increased agitation throws himself on floor attempted to hit B spec / peer. Refused verbal cues. IM 2mg [MEDICATION NAME] given as PRN order with good effect. . . On 1/5/12, the evaluation of comprehensive care plan for falls injury indicates: 1/5/12 resident hit one peer in the back and slapped another in the face. Resident moved to a private room for safety. On 1/5/12 at approximately 8:40PM, " Memo to Quality Assurance committee Supervisor's Investigative report" , indicates "resident hit peer on the back while they were standing by the exit door. . . . Revised care plan measures: Continue with above interventions. Additional comments: Continue with above interventions, keep resident at least at arms length from peers. On 1/5/12 at 8:45PM, " Memo to Quality Assurance Committee Supervisor's Investigative report indicates: "resident slapped peer in the face while both residents were alone in the room." . . . . " Interventions from care plan in place prior to occurrence: "Q 15 min rounds, falling star program, helmet when out of bed for safety with transfer and ambulation. Revised care plan measures: continue with above interventions, resident moved to private room. On 1/24/12, the evaluation of comprehensive care plan for problem behavior indicates: "Resident has displayed an increase in targeted behavior this month. Resident has become physically aggressive toward peers on numerous occasions this period. Psych follow up because of increased behaviors. Continue emotional support." The behavioral interventions implemented on 10/25/11 were continued,without revision, despite the resident's increased physical aggression. On 1/27/12 at 9:40AM, nursing documented: "According to CNA resident came out of his room and punched peer in his nose for no apparent reason causing his nose to bleed. Resident was escorted to his room and verbally counseled about his behavior and nursing supervisor made aware. " On 1/31/12, psychiatry documented: "Interviewed patient. Patient was agitated for no reason and punched peer (2 residents) and tried to choke social worker. Patient at this point in room asleep. Verbal, calm and coherent. Plan: Increase morning dose of [MEDICATION NAME] from 25mg to 50mg. Continue to stabilize, close observations, separation from those other residents. " On 1/31/12, the evaluation of comprehensive care plan for problem behavior indicates: "Behavior meeting, reviewed resident recent behavior, aggressive stricking out at peers and staff. Seen by psychiatrist on today, increase [MEDICATION NAME], monitor resident, escort to his room at first sign of agitation. Keep at arms length from peers." On 3/22/12, the evaluation of comprehensive care plan for problem behavior indicates resident has had a decrease in targeted behaviors (2). Medication change noted on 2/28/12, continue with verbal cues and counseling. On 4/27/12 at 10AM the behavior specialist coordinator was interviewed and stated that he updates the care plan for behavioral issues. He stated that the resident displayed physically aggressive behavior toward peers and staff and the resident's behaviors are unprovoked. He stated that the resident is escorted to a less stimulating environment. The resident was seen by psychiatrist. The comprehensive care plan 1/31/12 and 2/21/12 entry indicates to escort to his room at first sign of agitation. Keep at arms length from peers. Continue with positive verbal cues and counseling. He stated that these care plans were adequate. 415.12(f)(1)