Every finding on record at Saints Joachim & Anne Nursing and Rehabilitation C

Based on interviews and record review conducted during the Recertification Survey from 04/15/2025 to 04/22/2025, the facility did not ensure residents, or their designated representatives were provided appropriate notification at the termination of Medicare Part A benefits. This was evident for 2 (Resident #67 and Resident #482) of 3 residents reviewed for Beneficiary Notification out of 37 total sampled residents. Specifically, 1). the facility did not ensure that assistive devices were used to make appropriate notification, and 2). the Notice of Medicare Non-Coverage and the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage were not mailed to a resident's representative on the same day the telephone notification was made. The findings are: The facility policy titled Care and Treatment of Residents Medicare Determination for SNF (Skilled Nursing Facility) with an effective date of 01/21 stated that documentation on the Notice of Medicare Non-Coverage letter must include that the resident or designated representative was made aware of their appeal rights and phone number. A copy is given to the resident/designated representative if signed on premises or included in mail to be sent. The policy also stated that the facility is required to provide notification of termination of services/Medicare coverage at least 2 business days before the last covered day. The policy further stated that notices mailed are certified and the receipt of certified mail is stapled to a copy of the letter and maintained in MDS (Minimum Data Set) office. The form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 stated that the form must be delivered at least two calendar days before Medicare covered services end and included the requirement that notification of changes in coverage for an institutionalized beneficiary/enrollee who is not competent, be made to a representative. The instructions also stated that if the provider is personally unable to deliver a Notice of Medicare Non-Coverage to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise them when the enrollee's services are no longer covered. The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on that same date. The instructions further state that use of assistive devices may be used to obtain a signature. 1. The Annual Minimum Data Set assessment dated [DATE] documented that Resident #67 was cognitively intact. The Annual Minimum Data Set assessment also documented that Resident #57 had impaired vision-sees large print but not regular print in newspapers and books. Resident #67 was discharged from Medicare skilled services on 12/19/2024 with 43 benefit days remaining and stayed in the facility. The Notice of Medicare Non-Coverage dated 12/17/2024 documented that Resident #67 resident refused to sign the notice. The Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage dated 12/17/2024 documented that none of Options 1 through 3 were selected and resident refused to sign the notice. On 04/22/2025 at 10:39 AM, Resident #67 was interviewed and stated that they could not read the document since they have not had their reading glasses with them for the entire time they have been at the nursing home. Resident #67 also stated that they would not sign a document that they could not read. There was no documented evidence that Resident #67 was provided with an assistive device so a signature could be obtained when the notice was provided. 2. The Admission Minimum Data Set assessment dated [DATE] documented that Resident #482 was severely cognitively impaired. Resident #482 was discharged from Medicare skilled services on 11/29/2024 with 18 benefit days remaining and stayed in the facility. The Notice of Medicare Non-Coverage documented Resident #482's designated representative was called on 11/27/2024 at 2:00 PM and informed that Resident #482's coverage will end on 11/29/2024 and was mailed to the family. The Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage also documented that it was mailed to family. A copy of a Certified Mail Receipt addressed to Resident #482's designated representative was attached. However, review of the tracking number on USPS.com revealed the message, Label created, not yet in system. There was no documented evidence that the notice was mailed to Resident #482's representative on the same day that telephone notification was made. On 04/22/2025 at 11:31 AM, the Regional Minimum Data Set Coordinator stated that the Minimum Data Set Assessors for the facility were not available, and they were covering for them. The Regional Minimum Data Set Coordinator also stated that once the interdisciplinary team decided which resident would be discharged from Medicare Part A services, the facility had to provide notification that services would be ending at least two days prior to the end date. The Regional Minimum Data Set Coordinator further stated that if a resident was still in the facility, the notification was brought to the resident and explained, and the resident asked to sign it. If the resident refuses to sign, this is indicated on the document. The Regional Minimum Data Set Coordinator stated that they did not know about the circumstances surrounding Resident #67's refusal, but if there were concerns with impaired vision facility staff could have explained to Resident #67 what was in the notice, put it in a larger format, and maybe obtained reading glasses for Resident #67. The Regional Minimum Data Set Coordinator stated that if the resident was no longer in the facility or the resident was cognitively impaired, the facility notified the resident's designated representative by telephone call and mailed the notices to the resident's designated representative by certified mail the same day. The Regional Minimum Data Set Coordinator also stated that the letter is left in the lobby for pick up by the mail carrier. The Regional Minimum Data Set Coordinator further stated that they see that the notices are not documented in the postal services as being mailed out, but they do not know what happened in this instance or how notices are tracked once left for pickup. On 04/22/25 at 12:21 PM, the Administrator was interviewed and stated they would have to check into who supervises the Minimum Data Set staff. The Administrator also stated that they are aware that notices are to be sent out the same day as the telephone notification but was not aware of the issues with resident beneficiary notifications at the facility. 10 NYCRR 415.3(g)(2)(i)

Based on record review and interviews conducted during the Recertification survey from 04/15/2025 to 04/22/2025, the facility did not ensure that resident or resident's representative were offered the opportunity to participate in the revision and/or review of the comprehensive care plan. Specifically, resident and/or resident's representatives were not consistently invited to participate in their care plan meetings. This was evident for 1 (Resident #116) of 2 residents reviewed for Care Plan out of 37 sampled residents. The findings are: The facility policy and procedure titled Care Planning Process with effective date 06/24 stated resident and/or designated representative will be informed of scheduled care plan meetings, including the suggested date and time by the Social Service Department. The policy and procedure also stated that the resident and/or designated representative will be invited to the meeting by phone call, in-person or written invitation. The policy and procedure further stated that the invitation will be documented within the EMR (electronic medical record) and/or a copy of the written invitation maintained by the Social Services Department. The policy and procedure stated that the resident has the right to participate in establishing the expected goals and outcome of care, the type, amount, frequency and duration of care and any other factors related to the plan of care. Resident #116 had diagnoses which included Schizophrenia, Muscle weakness, and Acquired absence of right leg below knee. The Annual Minimum Data Set assessment dated [DATE] documented that Resident #116 was cognitively intact, had no behavior symptoms, and both Resident # 116 and representative participated in the assessment. On 04/15/2025 at 10:42 AM, Resident #116 was interviewed and stated they had been in the facility for about 3 years and had not been invited to any care plan meeting in 2024. Resident #116 also stated they made decision themselves. The written invitations to care plan meeting documented the care conferences were scheduled on 2/28/2024, 5/22/2024, 8/13/2024, and 11/12/2024. The IDT (Interdisciplinary Team) Care Plan Meeting attendance sheet dated 11/12/2024 documented it was for Quarter 3 care plan meeting and was signed by Resident #116. There was no documented evidence in medical records that Resident #116 and/or their designated representative were invited to participate in the review and revision of comprehensive care plans scheduled on 02/28/2024, 05/22/2024 or 08/13/2024 or that they attended these care plans meetings. On 04/18/2025 at 12:27 PM, Registered Nurse #1, who was the unit Nurse Supervisor was interviewed and stated that Resident #116 was alert and oriented to time, place and person, did not refuse care, and made decisions themselves. Registered Nurse #1 also stated the Social Worker was responsible for inviting residents and/or their designated representative to participate in the care plan meetings. On 04/18/2025 at 02:36 PM, the Regional Assistant Director of Social Work was interviewed and stated they were the assigned Social Worker for Resident #116 and the Director of Social Work at the facility. The Regional Assistant Director of Social Work also stated that the Minimum Data Set department schedules the care plan meetings, and the Director of Social Work invites the residents and/or their designated representative to care plan meetings about one week before by written invitations and/or phone calls. The Regional Assistant Director of Social Work further stated that they did not document the care plan meeting invitation in the medical record. The Regional Assistant Director of Social Work also stated they only document if the resident and/or their designated participated in the care plan meeting and then they have the resident and/or their designated representative sign the attendance sheet. The Regional Assistant Director of Social Work further stated that they had no documented evidence in Resident #116's medical record that Resident #116 and/or their representative were invited or attended the care plan meetings scheduled on 02/28/2024, 05/22/2024, and 08/13/2024. 10 NYCRR 415.3(f)(1)(v)

Based on observation, record review, and interviews conducted during the Recertification survey from 04/15/2025 through 04/22/2025, the facility did not ensure that the Minimum Data Set assessment accurately reflected a resident's status. This was evident for 1 (Resident #151) of 5 residents investigated for Accidents, and 1 (Resident #127) of 1 resident investigated for Pressure Ulcers of 37 total sampled residents. Specifically, (1) Resident #151 had documented wandering behavior which was not accurately coded, and (2) Resident #127 had a pressure ulcer that was not accurately coded on the Minimum Data Set assessment. The findings include are: The facility policy titled Minimum Data Set Assessment Version 3.0 effective 06/2024 documented the facility will conduct initially and periodically a comprehensive, accurate, standardize reproducible assessment of each resident's functional capacity. The Minimum Data Set Assessors will interview and observe resident, family and appropriate nursing staff and utilize the facility designated Minimum Data Set Collection Tool based on staff interview, resident observation and interview and medical record review. The Nursing Minimum Data Set is responsible for completion Minimum Data Set 3.0 Section E 0100-1100. The Centers for Medicare Services Resident Assessment Index Version 3.0 Manual October 2024 documented that Section E identified behavioral symptoms in the last 7 days that may cause distress to the resident, or may be distressing or disruptive to facility residents, staff members or the care environment. 1. Resident #151 had diagnoses which included Dementia, Depression, and Difficulty in walking. During multiple observations from 04/16/2025 at 09:32 AM to 04/21/2025 at 04:19 PM, Resident #151 was observed wandering the unit entering other residents rooms and having to be redirected by unit staff. The Annual Minimum Data Set assessment dated [DATE] documented that Resident #151 had no wandering behavior. Nursing progress notes dated January 26, 2025, to January 31, 2025, documented Resident #151 demonstrated wandering behavior. The Physician Progress note dated 01/24/2025 documented that Resident #151 had a history of Dementia, and the chief complaint was Anxiety and wandering. During an interview on 04/18/2025 at 02:21 PM, Licensed Practical Nurse #2 was interviewed and stated when Resident #151 resided on the 4th floor they would walk up and down the hallways, go into other resident's rooms lay on the bed. During an interview on 4/17/2025 at 03:53 PM, Certified Nursing Assistant #8 stated Resident #151 used to walk around the unit from room to room daily. Certified Nursing Assistant #8 also stated that there is a section on the computer for them to document Resident #151's wandering behavior. During an interview on 04/21/2025 at 12:59 PM, the Minimum Data Set Assessor stated they completed the Minimum Data Set Section E for Resident #151 in January 2025. The Minimum Data Set Assessor also stated that the look back period is 7 days before the Assessment Reference Date of 01/31/2025. The Minimum Data Set Assessor further stated that there were notes of Resident #151 wandering documented on 01/25/2025, 01/26/2025, 01/30/2025 and it was their mistake that they missed the notes and did not document wandering behavior on the assessment. During an interview on 4/21/2025 at 03:24 PM, Minimum Data Set Coordinator #2 stated that they reviewed every Minimum Data set assessment before they were uploaded. Minimum Data Set Coordinator #2 also stated that there are notes documenting Resident #151's wandering behavior during the look back period and this was not captured on the January 2025 Minimum Data Set assessment and should have been documented there. Minimum Data Set Coordinator #2 further stated that the only way to accurately check the assessment would be to go through every section of the Minimum Data Set, and it is hard to go through every section to check everyone's work. 44843 2. Resident #127 had diagnoses which included Pressure Ulcer of sacral region, Stage 4, Hemiplegia following cerebral infarction, and Diabetes Mellitus. The Annual Minimum Data Set assessment dated [DATE], documented Resident #127 was severely cognitively impaired, had a diagnosis of Pressure Ulcer of sacral region, Stage 4 and in Section M - Skin Conditions the assessment documented that Resident #127 had no Stage 4 pressure ulcer. The Medical Order dated 11/20/2024 documented to apply Santyl External Ointment 250 unit/gram to wound bed and alginate and cover with silicon dressing every dayshift for Stage 4 pressure ulcer at sacrum. The Consult Form - Wound 2 - V 3 dated 1/7/2025 documented Resident #127 had Stage 4 pressure ulcer to the sacrum. The Consult Form also documented the Stage 4 pressure ulcer at sacrum was measured in size 4 X 4 X 0.6 cm. The Nursing Skin Inspection on Bath/Shower Day dated 12/31/2024 and 01/07/2025 documented Resident #127 had a Stage 4 pressure ulcer at sacrum. The Medical Doctor note dated 12/31/2024 documented Resident #127 had a Stage 4 pressure ulcer on the sacrum which measured 4.2 X 4 X 0.6 cm. On 04/18/2025 at 12:23 PM, Registered Nurse #1 (who was the Nurse Supervisor for the unit) was interviewed and stated that Resident #127 has had Stage 4 pressure ulcer on the sacrum since 01/10/2024 and it was healing slowly. On 04/22/2025 at 10:02 AM, Minimum Data Set Assessor #1 was interviewed and stated they completed the Minimum Data Set assessment dated [DATE], for Resident #127. Minimum Data Set Assessor #1 also stated they reviewed the medical record since last Minimum Data Set assessment and interviewed resident and staff to collect data for the Minimum Data Set assessment. Minimum Data Set Assessor #1 further stated that Resident #127 had a Stage 4 pressure ulcer at sacrum, and they were thinking about something else when completing the Minimum Data Set assessment dated [DATE], for Resident #127. Minimum Data Set Assessor #1 stated they made an error by not coding Stage 4 pressure ulcer in the assessment dated [DATE], for Resident #127. On 04/21/2025 at 12:06 PM, the Regional Minimum Data Set Coordinator was interviewed and stated that the Minimum Data Set assessor was professional staff, and they did not review the accuracy of the Minimum Data Set assessments. The Regional Minimum Data Set Coordinator also stated that their responsibilities were to schedule the Minimum Data Set assessment, make sure the Minimum Data Set assessment was completed and submitted to Centers of Medicare and Medicaid Services in a timely manner. The Regional Minimum Data Set Coordinator had no explanation why the Stage 4 pressure ulcer was not coded on the Minimum Data Set assessment dated [DATE], for Resident #127. 10 NYCRR 415.11(b)

Based on observations, interviews, and record review conducted during the Recertification Survey from 04/17/2023 to 04/24/2023, the facility did not ensure that menus were followed. This was evident for 2 of 3 residents reviewed for Food out of 39 sampled residents (Resident #91 and Resident #288) and 182 residents present on 4/17/23. Specifically, 1) Resident # 91 received food items that did not match items on the tray ticket, and 2) Resident #288 reported they were served pork, fried foods and not their preferred foods. In addition, 3) on 4/17/23, the vegetable listed on the posted menu was changed, and residents were not informed. The findings are: The facility policy for Nutrition- Provision of Diet revised 1/10/2018 documented to provide each resident with a nourishing palatable, well balanced regular or therapeutic diet as per primary care provider order. The diet will meet the daily nutritional and specialty die needs of each resident, taking into consideration the cultural, social, religious ethnic needs preferences of each resident and are both safe and appetizing with allergies, intolerance and preferences being considered. 1) Resident #91 had diagnoses of moderate protein calorie malnutrition and dysphagia following cerebral infarction. The Admission Minimum Data Set 3.0 (MDS) date 2/14/2023 documented Resident #91 was moderately cognitively impaired and required extensive assistance x 1 person with eating. On 04/17/2023 at 10:32 AM, Resident #91 was observed sitting in the dining room. The breakfast meal ticket documented the resident should have 2% milk and orange juice on their tray. Resident #91's meal tray was observed with whole milk and apple juice. On 04/18/2023 at 09:31 AM, Resident #91's breakfast tray was observed with 8 oz whole milk and 2 cups of apple juice. The breakfast tray ticket documented the resident should have orange juice and 2 % milk. On 04/20/2023 at 09:34 AM, during breakfast, Resident #91's tray had whole milk, but the tray ticket documented 2% milk. On 04/20/2023 at 12:55 PM, during a lunch observation, Resident #91 was served whole broccoli florets. Lunch tray ticket documented chopped broccoli florets. The Comprehensive Care Plan (CCP) for nutrition as of 2/9/2023 documented Resident #91 required a mechanically altered diet. The CCP further documented the resident had difficulty swallowing, was at risk for weight fluctuations, and had a lack of appetite related to Dementia and altered mental status. The interventions included provide diet and serve as ordered, RD evaluation as needed, and specialized diet. The current physician's orders as of 3/23/2023 documented Resident #91's diet was regular with mechanical soft consistency and regular liquids. On 04/20/2023 at 02:56 PM, CNA #6 was interviewed and stated the meal tray ticket documents what food the resident should receive. The ticket should be correct to ensure the resident receives the right food. On 04/24/2023 at 04:34 PM, the Registered Dietician Eligible (RDE) was interviewed and stated that they spoke to the resident family member and reviewed the menu with the resident's family and obtained their food preferences. Resident #91 does not like spicy food, except for fresh tomato and eats most of food when served. It is important how much the resident consumes of meal to maintain and gain weight. They assist resident to enjoy their meal. There is no individualized menu, and they edit resident meal ticket when needed. 2) Resident #288 had diagnoses of unspecified severe protein calorie malnutrition, adult failure to thrive, and dysphagia unspecified. The Admission MDS dated [DATE] documented Resident #288 was cognitively intact and required supervision and set up help with eating. On 04/17/2023 at 12:09 PM, during an interview with Resident #288 who stated that the food is spicy and they cannot eat beans, peas, cabbage, beef, pork, sauces and mayonnaise. They eat oatmeal and prefer cottage cheese. They stated they have talked to the dietitian about their food preferences. On 04/17/23 from 01:16 PM to 01:22 PM, Resident #288 was given a lunch tray with a tray ticket that documented baked chicken. There was no baked chicken observed. Chicken fried steak was observed on the resident's meal tray. On 04/18/2023 at 09:38 AM, Resident #288 was observed eating breakfast. The resident received apple juice instead of the orange juice listed on the ticket. During a breakfast observation on 04/20/2023 at 09:13 AM, Resident #288's meal ticket documented the resident should receive oatmeal that was not observed on the resident's tray. The current physician's orders, initiated 4/7/2023, documented Resident #288's diet orders as diet regular texture regular liquid consistency. There were no restrictions documented in the diet order. The baseline care plan dated 4/7/2023, documented resident requires a therapeutic diet or modified diet texture, and interventions refer to registered dietitian, resident receives specialized diet the type or consistency of the food ordered to be modified (check with nurse or check orders prior to additional foods). The Care Plan for nutrition initiated on 4/10/2023 documented the resident was below ideal body weight, at risk for weight fluctuations, and had a lack of appetite related to adult failure to thrive and cancer, needed additional nutritional support to promote healing of skin integrity and promote weight gain, The resident had a dietary preference for fish and chicken and a milk intolerance. The interventions included provide diet and serve as ordered and Registered Dietitian (RD) to evaluate as needed. The Nutrition assessment dated [DATE] documented likes a variety of food except sauces, gravy, mayonnaise, dry beans, peas, fried foods, and beef. Lactose intolerant (milk only). Lactaid milk will be given daily. On 04/24/2023 at 02:37 PM, the Dietary Supervisor was interviewed and stated that they check food items on the lunch and dinner trays before they go to the unit to make sure foods are the correct consistencies. The Food Service Director and the cook check the breakfast trays. Residents on a mechanically altered diet cannot get regular diet due to potential for choking. Trays are prepared according to what is on the tray ticket. The 2% milk was not delivered, and residents were given whole milk. The diet is ordered by the doctor. They stated they had tray accuracy training conducted during tray line to correct any tray discrepancies identified and for the evening shift they make the issues identified known, so it is not overlooked. They sometimes write on tray ticket if there are any food substitutions and no changes noted on the menu unless they find out before the menu is printed. The RD does food preferences for residents, and they see residents for food preferences for the weekly menu or as needed to fill out menus for residents. If a resident has a food preference for no fried foods, they would be offered baked food instead, for example if there was fried fish, baked fish would be offered instead. On 04/24/2023 at 05:51 PM, Registered Nurse (RN #4) was interviewed and stated Resident #288 food preferences include dislikes fish and fried foods. We check dinner trays. Call kitchen to ask for alternatives for resident. When not on tray ask for cheese sandwich. Because of culture some residents don't eat foods and for personal reasons and we have to respect this. On 04/24/2023 at 02:56 PM, the Cook was interviewed and stated that they check tray tickets at breakfast. We have to read tray ticket and check off items on the tray ticket. There were no substitutions they were aware of, and they did not run out of milk. On 04/24/2023 at 3:02 PM, the Food Service Director was interviewed and stated that they check the breakfast tray tickets. They will have to check to see if any alternate items were served that differ from the menu posted. On 04/24/2023 at 04:25 PM, the RDE was interviewed and stated Resident #288 has a preference for cereal and eggs. Resident #288 does not touch meat and refused a mechanical soft diet. They do not observe the tray line very often and their last observation was 2 months ago. Resident #288 mentioned cottage cheese and sometimes it is not available. If a resident asks, we serve cottage cheese, but it is not a regular item on the menu. They stated that they are supervised by the Food Service Director who is not a RD. The other RD works on the weekend, and they stay in contact with them. 3) The 2023 Winter Menu (Week 3) for the week of 04/16/2023 to 4/22/2023 documented the lunch menu on 4/17/23 included roasted brussels sprouts. This menu was posted for residents. On 4/17/23 at 1:09 PM -1:37 PM lunch was observed being served in the 6th floor dining room. The lunch trays were observed with California vegetables instead of brussel sprouts. Residents were overheard asking staff about the brussel sprouts. There was no documented evidence the facility informed the residents there were changes to the weekly menu prior to being served at lunch. On 04/24/2023 at 3:02 PM, the Food Service Director was interviewed and stated that they check the breakfast tray tickets. They will have to check to see if any alternate items were served that differ from the menu posted. During an interview on 04/24/2023 at 04:25 PM, the Registered Dietician Eligible (RDE) stated they could not recall if any substitutions were made to the posted menu. 415.4(c)(1-3)

Based on observation, record review and interview conducted during a Recertification survey, the facility did not ensure a clean, comfortable, and homelike environment was maintained. This was evident for 4 of 5 resident floors (Floors 3, 5, 6, and 7). Specifically, resident rooms were observed with broken window blinds (Floors 3 and 5), torn window screens (6th Floor), and missing blinds and privacy curtains (7th floor). Resident wheelchairs had stained cushions (3rd and 6th Floor) and wheel noted with worn tires on both sides with decreased tread chipped paint on oxygen canister holder with a missing screw, wheelchair tires were noted to have multiple decreased rubber tread on bilateral wheels (6th floor). The findings are: The policy titled Maintenance and Cleaning of Rehab Equipment/Devices dated 08/01/2022 documented the facility will provide clean equipment or devices for each resident. To provide appropriate equipment/device necessary to needs of patients that are clean to prevent and control spread of infection. It is the responsibility of all rehabilitation staff with coordination of housekeeping personnel to maintain a clean infection free rehabilitation equipment and devices. The policy titled Wheelchair Issuance and Management dated 08/01/2022 documented wheelchair parts that needs to be fixed and needs to be replaced will be addressed by rehab aide and maintenance department. All requests for broken parts or replacement of parts must be written in maintenance book found in the unit or message can directly relayed to the rehab aide who is transporting residents throughout the day. A maintenance wheelchair book will be in the rehab department for documentation of all wheelchairs fixed by the department. 1) On 04/17/2023 at 10:40 AM - 12:18 PM, during the initial tour room [ROOM NUMBER], 605, 606, and 615 were observed with missing window blind slats or misaligned blinds. room [ROOM NUMBER] had a damaged lower window screen with approximately 1/2 of it is missing. 1) On 04/19/23 at 11:05 AM, Resident #16's recliner was observed with 7 white/cream-colored stains on the seat measuring approximately 3 to 7 inches in length. 2) On 04/19/23 from 12:02 PM to 12:05 PM, the following observations were made on the 7th floor: room [ROOM NUMBER] had no curtains or window treatments. room [ROOM NUMBER] had window blinds with missing slats. room [ROOM NUMBER]B had a privacy curtain hanging off the track. On 04/19/23 at 12:56 PM, the 7th floor main dining room had broken window blinds with the 2 lower slats hanging by a thread. 3) During an observation of the 3rd floor on 04/19/23 at 12:44 PM, Rooms 304B, 306B, and 313 had broken window blinds slats. On 04/21/2023 at 12:55 PM, there were 3 wheelchairs observed in the hallway: 1 wheelchair cushion had white flakes and a white stain measuring 6-inch x 1 inch The 2nd wheelchair for 320B had worn wheels with damaged rubber treads. The 3rd wheelchair cushion had brown stains on the seat. Two recliner seat cushions were noted with stains in 2 separate recliners parked on the unit hallway. On 04/21/2023 at 04:41 PM, a recliner cushion was observed with strands of hair on back rest and 6 white stains on the seat cushion. 4) On 04/21/2023 form 12:20 PM to 12:25 PM, the following observations were made on the 6th floor: room [ROOM NUMBER] had one window blind slat bent up. room [ROOM NUMBER] had window blinds with one slat broken on the right side. room [ROOM NUMBER] window blinds had 2 slats bent on the right side at a 45-degree angle leaning to the right side. On 04/21/2023 at 04:59 PM, the 6th Floor wheelchair for Resident #290 had worn tires on both sides and the wheelchair locks were dusty. A wheelchair with oxygen canister holder was painted green with brown paint visible underneath. The oxygen canister holder was missing a screw from bottom area on the left back wheel. An interview was conducted on 04/24/2023 at 1:07 PM, with 6th floor Housekeeper #1 who stated they clean the windowsills. Maintenance needs to take down the broken window blinds. Housekeeper #1 did not notice chipped window blinds in room [ROOM NUMBER] and confirmed room [ROOM NUMBER] had missing window blind slats on the upper right side. Housekeeper #1 did not notice an issue with the window screen mesh in room [ROOM NUMBER]. If Housekeeper #1 noticed an issue, they would notify their director or maintenance. 37787 During the environmental tour of the 5th floor, the following was observed: - On 04/19/23 at 02:26 PM and on 04/20/23 at 03:20 PM, broken window blind slats in room [ROOM NUMBER]; - On 04/19/23 at 02:27 PM and on 04/20/23 at 03:22 PM, broken window blind slats in room [ROOM NUMBER]; - On 04/20/23 at 03:25 PM and on 04/19/23 at 02:15 PM, broken window blind slats in room [ROOM NUMBER]; and - On 04/19/23 at 04:25 PM and on 04/20/23 at 04 17 PM, broken window blind slats in the wheelchair storage area by the elevator On 4/21/2023 at 4:22 PM, 5th floor Certified Nursing Assistant (CNA) #7 was interviewed and stated they make rounds on the unit but did not notice the broken window blinds in resident rooms. If CNA #7 noticed the broken blinds, they would have called maintenance. On 04/24/23 at 10:59 AM, The Director of Housekeeping was interviewed and stated that maintenance takes care of the blinds. Housekeeping sends email notification to maintenance if they see broken window blinds. On 04/24/2023 at 02:38 PM, the Director of Engineering and Security (DES) was interviewed and stated maintenance operates on a work order system and staff must place a work order to get window blinds fixed. They can leave a message for the DES, and staff can verbally tell maintenance staff. The DES is aware resident rooms have broken window blinds and an order was placed for replacement blinds. The order was declined because of credit. On 04/24/2023 at 03:08 PM, the Rehabilitation Assistant was interviewed and stated that housekeeping is in charge of cleaning the wheelchairs in the hallway. The rehab department staff try to clean resident wheelchairs sometimes. On 04/24/2023 at 04:16PM, the Director of Rehabilitation (DOR) was interviewed and stated a maintenance book is available if a recliner or wheelchair needs to be repaired. Maintenance performs visual rounds on resident equipment daily. The DOR was aware there were issues with some wheelchairs and just ordered new replacements this week. 415.12(h)(1) (2)

Based on record review and interview conducted during the Recertification and Complaint survey (NY00313269) from [DATE] and [DATE], the facility did not ensure that residents' comprehensive care plans (CCPs) were reviewed and revised by the interdisciplinary team after each assessment and as needed. This was evident for 3 out of 39 sampled residents (Residents #19, #16 and #134). Specifically, (1) Resident #19's Advance Directive CCP was not reviewed and revised when their code status was changed to Do Not Resuscitate (DNR) and after the quarterly assessment; (2) Resident #16's CCP related to Anemia and gastrointestinal (GI) bleeding was not reviewed and revised to reflect a change in the resident's status after hospitalization ; and (3) Resident #134's elopement risk CCP was not reviewed and revised for 6 months. The findings are: The facility policy titled Care Plan Process and Development last revised ,d+[DATE] documented the CCP process is reviewed at least quarterly, upon significant change in condition, revised to ensure its effectiveness in attaining the specific goals, and address the resident specific problems, concerns and/or needs. Upon review and revision of the care plan, the date of review/revision is to be recorded on the care plan. 1.) Resident #19 had diagnoses of non-Alzheimer's dementia, Depression and Psychotic Disorder The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #19's cognition as severely impaired, required the limited assist of one person for bed mobility, transfers, and eating and the resident required supervision of one person physical assistance for toilet use. The CCP for Advanced Directives (AD), initiated [DATE], documented that the resident had AD orders for Cardiopulmonary resuscitation (CPR) to be initiated to honor Resident #19's full-code wishes. A quarterly care plan note dated [DATE] documented that a care plan meeting was held with the Resident #19's family, and AD remains the same: DNR, Do Not Intubate (DNI). A Physician's Order, initiated [DATE], documented Resident #19 had AD orders for DNR and DNI. There was no documented evidence the CCP related to ADs had been reviewed and revised when Resident #19's AD status changed to DNR and DNI. There was no documented evidence that the CP was revised upon MDS assessments dated [DATE] and [DATE]. On [DATE] at 12:11 PM Social Worker (SW) #1 was interviewed and stated that the ADs are reviewed with the resident's family during the care plan conference. SW #1 stated they were responsible for updating the AD CCP which should have been updated for Resident #19 quarterly and as needed and revised to reflect the current AD status. 45988 (2) Resident #16 was admitted to the facility with diagnoses of GI hemorrhage and acute posthemorrhagic anemia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #16 had severe cognitive impairment and required extensive assistance of two persons for most daily activities. On [DATE], a complainant reported to the New York State Department of Health (NYSDOH) (NY00313269) Resident #16 was transferred to the hospital, received multiple blood transfusions, and was diagnosed with a duodenal ulcer. The resident returned to the facility on [DATE]. On [DATE] at 10:50 AM, Resident #16 was interviewed and stated they lost a lot of blood while hospitalized recently. A CCP related to anemia and GI bleed effective [DATE] and last reviewed [DATE] documented Resident #16 will be free of signs and symptoms of anemia such as pallor, dizziness, activity intolerance, and resident's blood work will be within normal limits. Interventions included monitor for signs and symptoms of anemia, notify the physician of findings, labs as ordered, and activity as tolerated with frequent rest periods. A Nursing Note dated [DATE] documented Resident #16 was found unresponsive to verbal commands and was transferred to the hospital. A Physician's Order dated [DATE] documented Resident #16 was to receive Pantoprazole 40 mg by mouth every 12 hours for gastroesophageal reflux disease (GERD). A Physician's Note dated [DATE] documented Resident #16 was readmitted after a hospitalization for gastrointestinal hemorrhage and several blood transfusions due to GI bleeding. The CCP related to anemia and GI bleed was not updated to reflect the resident's recent hospitalization requiring several blood transfusions following a gastrointestinal hemorrhage. The CCP was not updated upon MDS assessment dated [DATE]. On [DATE] at 12:43 PM, Registered Nurse (RN) #2 was interviewed and stated that Resident #16 had no prior history of GI bleed upon transfer to the hospital. RN #2 further stated that the MDS department does the care planning for residents. On [DATE] at 10:49 AM, the MDS Coordinator was interviewed and stated that when a resident comes back from the hospital, a new baseline care plan is generated. Any new issues are supposed to be added if they were not triggered from the initial assessment. Right now, the care plans are put in by the MDS coordinators, Director of Nursing (DNS), Assistant DNS (ADNS), and nurses on the floor. The MDS Coordinator stated Resident #16's CCP related to anemia and GI bleed had not been updated since [DATE] and did not reflect Resident #16's hospitalization or MDS assessments. (3) Resident #134 had diagnoses of non-Alzheimer's dementia and anxiety. The MDS assessment dated [DATE] documented Resident #134 had severe cognitive impairments and did not have a wander/elopement alarm. On [DATE] at 11:36 AM and [DATE] at 10:51 AM, Resident #134 was observed wandering on the unit and an audible alarm was triggered when the resident approached the elevator. A Comprehensive Care Plan (CCP) related to elopement risk initiated [DATE] and updated through [DATE], documented Resident #134 repeatedly looks for the exit doors and a wanderguard was placed on their left ankle. An Elopement Risk Assessment, completed [DATE], documented Resident #134 was at high risk for elopement Wandering/Elopement Potential, and a wanderguard was placed upon admission. A Physician's Order dated [DATE] documented wanderguard placement to Resident #134's left ankle and continuous visual checks during each shift. There was no documented evidence Resident #134's CCP related to elopement risk was reviewed or revised after [DATE]. On [DATE] at 10:28 AM the MDS coordinator was interviewed and stated CCPs can be initiated by nursing and MDS Coordinators if there is a new issue. The MDS Coordinator stated the CCP for Resident #134 elopement risk was added on [DATE]. The MDS coordinator stated they are still fine tuning the new electronic medical record system. On [DATE] at 3:53 PM the DNS was interviewed and stated care planning is discussed during interdisciplinary team meetings. Each discipline is responsible for updating care plans. There are care plan reviews every quarter. The maximum time between reviews is within the quarter. The staff makes sure the care plans correlate with the condition the resident has. The facility switched to a new electronic medical record system. The new system generates the care plan automatically. 415.11(c)(2) (i-iii)

Based on observations, interviews, and record review conducted during the recertification survey from [DATE] to [DATE], the facility did not ensure biologicals were stored in accordance with professional principles. This was evident for 1 (6th Floor medication room) of 5 medication storage areas reviewed. Specifically, 1) emergency medications were stored in a plastic emergency box missing the tamper proof seal. The findings are: The undated pharmacy policy titled Emergency Boxes (EBOX) documented each E-box will be locked with a tamper resistant lock indicating if the box has been opened. Each box that is opened is sent to the Nursing office for return to the pharmacy for replenishment. Each box sent to the nursing office will be replaced immediately with a current in date box (swing box). On [DATE] at 12:47 PM - 01:00 PM, the medication room on the 6th floor was observed with Licensed Practical Nurse (LPN) # 1. The red emergency medication box was unlocked and did not have a tamper proof seal. When the box was opened, the emergency medications and two intact tamper proof seals were inside #s 5796015, 5796016. The broken tamper proof seal for the emergency box was noted on the counter. On [DATE] at 1:00 PM, LPN #1 was interviewed and stated the emergency box should be sealed for safety because any staff can access the medications. LPN #1 stated that they usually look at it, and that the supervisor also checks the emergency box. They stated they have never used the emergency box. During an interview on [DATE] at 1:21 PM, the Registered Nurse Supervisor (RN #3) stated the emergency box was last checked by the pharmacy on [DATE]. They stated the emergency box was sealed yesterday. The pharmacy consultant was here in [DATE]. RN #3 stated they were working on [DATE] and all emergency boxes were checked and seals intact. If a medication in the box is used, the nurse has to fill out the bottom of the paper and the box is put in the nurses' office so that it can be sent back to the pharmacy and replaced with a new one. Nursing staff should check the emergency box every morning to make sure the medications are not expired by looking at the attached medication list. The emergency box checks are not documented anywhere by nursing but when a medication is used it is initialed on the inventory sheet for the box. On [DATE] at 5:37 PM, the Director of Nursing (DON) was interviewed and stated they found several emergency boxes with open tamper seals which may have popped from being too tight. DON stated that after the issue was identified that the seals were checked and found to be broken. The pharmacy always provides locked emergency boxes to the facility. 415.18(e)(,d+[DATE])

Based on record review and interviews during the Recertification survey from 04/17/23 and 04/24/23, the facility did not ensure that laboratory services were provided timely to meet resident needs for 1 (Resident #19) of 5 residents reviewed for Unnecessary medications. Specifically, laboratory (lab) blood work [Complete Metabolic Profile (CMP) and Complete Blood Count (CBC) with differentials, Lipids, B12, Folate, Thyroid -stimulating hormone (TSH), and Hemoglobin A1c] ordered for Resident #19 on 3/30/2023 and 04/19/23 was not done. The finding is: The facility's policy titled Laboratory- Specimen Collection, last reviewed 07/2022, documented that the facility will be responsible to contract with a laboratory to provide diagnostic laboratory services. The referrals for laboratory tests will be made by the Attending physician/Nurse Practitioner, or on the recommendation of a consulting physician. The policy also documented that the resident care manager/charge nurse on each floor will put the tests request into the Lab book and in the EMR (Electronic Medical Record) Resident #19 was admitted [DATE] with diagnoses which included non-Alzheimer's dementia, Depression, and Psychotic Disorder. The Quarterly Minimum Data Set 3.0 (MDS) dated [DATE] documented the resident had severely impaired cognition and required the limited physical assistance of one person for bed mobility, transfers, and eating. The resident required supervision with one person's physical assistance for toilet use. A Physician's order dated 03/30/23 documented CMP and CBC with differentials, LIPIDS, B12, Folate, TSH, HgA1C. A Registered Nurse's (RN) note dated 03/30/23 documented that telephone order (T/O) from the physician for labs: CMP and CBC with differential lipids, hgba1c, B12, folate, TSH, on 3/31/23 A physician's note dated 04/05/23, documented that Resident #19 was seen to follow up on multiple medical problems as below, pending labs with lipids and pending Hgba1c, for diabetic diet. A physician's note dated 04/15/23, documented that Resident #19 was seen on 4/15 to follow up on multiple medical problems as below, pending labs with lipids and discussed with nurse on the unit, and pending Hga1c. A Physician's order dated 04/19/23 documented CMP and CBC with differentials, LIPIDS, B12, Folate, TSH, HgA1C. A Registered Nurse's (RN) note dated 04/19/23 documented that telephone order(T/O) from the physician for labs CMP and CBC with differential Lipids, B12, Folate, TSH, HgA1C , to be done on 4/20/23. There was no documented evidence that the blood was collected, and that lab work was ever completed. On 04/24/23 at 12:07 PM, RN #1 was interviewed and said that when labs are ordered, the person who receives the order, writes the order in the EMR (electronic medical record), then places it lab in the lab book that is located on the units. A requisition is generated for the lab, so that when the lab technician comes to draw blood for the labs, the requisition is signed off. The lab results would then be in the EMR as it is interfaced with the results. RN #1 said that in the case of Resident #19, they do not know why the lab was not done, and that it was missed on both occasions by the nurses. RN #1 called the lab during the interview, and the lab reported they did not receive any requisitions for Resident #19 for the dates noted. On 04/24/23 at 12:17 PM, the Director of Nursing (DON) was interviewed and stated that the Staff would follow up on the labs ordered, since the results can be found in the EMR. The DNS also said its the floor nurses' responsibility to ensure that the labs are completed as ordered and follow up on the results. DNS said that in the case of Resident #19, the labs were not carried out as ordered, and the lab book should have documentation when a lab is ordered. The DNS also said that the Physicians should also follow up when a lab is ordered. 483.50(a)

Based on observations, record review and interviews, during the Recertification survey the facility did not ensure each resident received food that accommodated resident's allergies, intolerances, and preferences. This was evident for 2 of 39 residents sampled for dining observations. (Resident #91 and Resident #288). Specifically, (1). Resident #91's menu did not follow the resident's preferences, and (2). the food preferences of Resident #288 were not honored when the resident expressed a preference for cottage cheese, oatmeal and whose meal ticket specified food dislikes gravy, sauces, fried foods, beef, beef stew. The findings include: The facility policy for Nutrition- Provision of Diet revised 1/10/2018 documented to provide each resident with a nourishing palatable, well balanced regular or therapeutic diet as per primary care provider order. The diet will meet the daily nutritional and specialty die needs of each resident, taking into consideration the cultural, social, religious ethnic needs preferences of each resident and are both safe and appetizing with allergies, intolerance and preferences being considered. 1) Resident #91 had diagnoses of moderate protein calorie malnutrition and dysphagia following cerebral infarction. The Admission Minimum Data Set 3.0 (MDS) date 2/14/2023 documented Resident #91 was moderately cognitively impaired and required extensive assistance x 1 person with eating. On 04/17/2023 at 10:32 AM, Resident #91 was observed sitting in the dining room. The breakfast meal ticket documented the resident should have 2% milk and orange juice on their tray. Resident #91's meal tray was observed with whole milk and apple juice. On 04/18/2023 at 09:31 AM, Resident #91's breakfast tray was observed with 8 oz whole milk and 2 cups of apple juice. The breakfast tray ticket documented the resident should have orange juice and 2 % milk. On 04/20/2023 at 09:34 AM, during breakfast, Resident #91's tray had whole milk, but the tray ticket documented 2% milk. On 04/20/2023 at 12:55 PM, during a lunch observation, Resident #91 was served whole broccoli florets. Lunch tray ticket documented chopped broccoli florets. The Comprehensive Care Plan (CCP) for nutrition as of 2/9/2023 documented Resident #91 required a mechanically altered diet. The CCP further documented the resident had difficulty swallowing, was at risk for weight fluctuations, and had a lack of appetite related to Dementia and altered mental status. The interventions included provide diet and serve as ordered, RD evaluation as needed, and specialized diet. The current physician's orders as of 3/23/2023 documented Resident #91's diet was regular with mechanical soft consistency and regular liquids. On 04/20/2023 at 02:56 PM, CNA #6 was interviewed and stated the meal tray ticket documents what food the resident should receive. The ticket should be correct to ensure the resident receives the right food. On 04/24/2023 at 04:34 PM, the Registered Dietician Eligible (RDE) was interviewed and stated that they spoke to the resident family member and reviewed the menu with the resident's family and obtained their food preferences. Resident #91 does not like spicy food, except for fresh tomato and eats most of food when served. It is important how much the resident consumes of meal to maintain and gain weight. They assist resident to enjoy their meal. There is no individualized menu, and they edit resident meal ticket when needed. 2) Resident #288 had diagnoses of unspecified severe protein calorie malnutrition, adult failure to thrive, and dysphagia unspecified. The Admission MDS dated [DATE] documented Resident #288 was cognitively intact and required supervision and set up help with eating. On 04/17/2023 at 12:09 PM, during an interview with Resident #288 who stated that the food is spicy and they cannot eat beans, peas, cabbage, beef, pork, sauces and mayonnaise. They eat oatmeal and prefer cottage cheese. They stated they have talked to the dietitian about their food preferences. On 04/17/23 from 01:16 PM to 01:22 PM, Resident #288 was given a lunch tray with a tray ticket that documented baked chicken. There was no baked chicken observed. Chicken fried steak was observed on the resident's meal tray. On 04/18/2023 at 09:38 AM, Resident #288 was observed eating breakfast. The resident received apple juice instead of the orange juice listed on the ticket. During a breakfast observation on 04/20/2023 at 09:13 AM, Resident #288's meal ticket documented the resident should receive oatmeal that was not observed on the resident's tray. The current physician's orders, initiated 4/7/2023, documented Resident #288's diet orders as diet regular texture regular liquid consistency. There were no restrictions documented in the diet order. The baseline care plan dated 4/7/2023, documented resident requires a therapeutic diet or modified diet texture, and interventions refer to registered dietitian, resident receives specialized diet the type or consistency of the food ordered to be modified (check with nurse or check orders prior to additional foods). The Care Plan for nutrition initiated on 4/10/2023 documented the resident was below ideal body weight, at risk for weight fluctuations, and had a lack of appetite related to adult failure to thrive and cancer, needed additional nutritional support to promote healing of skin integrity and promote weight gain, The resident had a dietary preference for fish and chicken and a milk intolerance. The interventions included provide diet and serve as ordered and Registered Dietitian (RD) to evaluate as needed. The Nutrition assessment dated [DATE] documented likes a variety of food except sauces, gravy, mayonnaise, dry beans, peas, fried foods, and beef. Lactose intolerant (milk only). Lactaid milk will be given daily. On 04/24/2023 at 02:37 PM, the Dietary Supervisor was interviewed and stated that they check food items on the lunch and dinner trays before they go to the unit to make sure foods are the correct consistencies. The Food Service Director and the cook check the breakfast trays. Residents on a mechanically altered diet cannot get regular diet due to potential for choking. Trays are prepared according to what is on the tray ticket. The 2% milk was not delivered, and residents were given whole milk. The diet is ordered by the doctor. They stated they had tray accuracy training conducted during tray line to correct any tray discrepancies identified and for the evening shift they make the issues identified known, so it is not overlooked. They sometimes write on tray ticket if there are any food substitutions and no changes noted on the menu unless they find out before the menu is printed. The RD does food preferences for residents, and they see residents for food preferences for the weekly menu or as needed to fill out menus for residents. If a resident has a food preference for no fried foods, they would be offered baked food instead, for example if there was fried fish, baked fish would be offered instead. On 04/24/2023 at 05:51 PM, Registered Nurse (RN #4) was interviewed and stated Resident #288 food preferences include dislikes fish and fried foods. Call kitchen to ask for alternatives for resident. When not on tray, ask for cheese sandwich. On 04/24/2023 at 3:02 PM, the Food Service Director was interviewed and stated that they check the breakfast tray tickets. They will have to check to see if any alternate items were served that differ from the menu posted. On 04/24/2023 at 04:25 PM, the RDE was interviewed and stated Resident #288 has a preference for cereal and eggs. Resident #288 does not touch meat and refused a mechanical soft diet. They do not observe the tray line very often and their last observation was 2 months ago. Resident #288 mentioned cottage cheese and sometimes it is not available. If a resident asks, we serve cottage cheese, but it is not a regular item on the menu. They stated that they are supervised by the Food Service Director who is not a RD. The other RD works on the weekend, and they stay in contact with them. On 04/24/2023 at 02:37 PM, the Dietary Supervisor was interviewed and stated that they check food items on the lunch and dinner trays before they go to the unit to make sure foods are the correct consistencies. The Food Service Director and the cook check the breakfast trays. They sometimes write on tray ticket if there are any food substitutions and no changes noted on the menu unless they find out before the menu is printed. The RD does food preferences for residents, and they see residents for food preferences for the weekly menu or as needed to fill out menus for residents. If a resident has a food preference for no fried foods, they would be offered baked food instead, for example if there was fried fish, baked fish would be offered instead. On 04/24/2023 at 04:25 PM, the RDE was interviewed and stated Resident #288 has preference for cereal and eggs. Do not touch meat. Refused mechanical soft diet. They do not observe the tray line very often and their last observation was 2 months ago. They do not recall if any substitutions to the menu were made. Resident #288 mentioned cottage cheese and sometimes not available and offered on regular menu. If a resident asks, we serve cottage cheese, and it is not a regular item on the menu. They stated that they are supervised by the Food Service Director who is not a Registered Dietitian (RD). The other RD works on the weekend, and they stay in contact with them. 415.14(d)(4)

Based on staff interview and record review conducted during the recertification survey, the facility did not ensure that person-centered care plans with measurable goals, time frames and interventions were developed to address resident's concerns. Specifically, there was no documented evidence that the comprehensive care plan included measurable goals, objectives and interventions to address a resident with behavior that included verbal abuse and rejection of care. This was evident for 1 of 6 residents reviewed for Unnecessary Medications out of a sample of 29 residents. (Resident # 57). The findings are: The facility policy and procedure titled Care Plans Process and Development reviewed 12/2019 documented under the section policy to provide care necessary for each resident to reach his/her highest practicable physical, mental and psychosocial well-being. The policy further stated based on a discipline-specific clinical assessment, a care plan will be developed for each resident in order to have a systematic blueprint of the resident problem/need, a measurable goal for each problem/need and the itemized interventions determines to be necessary to achieve the measurable specific and individualized goals. Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] documented the resident was cognitively intact and required extensive assistance of one to two persons for Activity of Daily Living (ADL's). Resident care plan titled Behavior symptoms 7/21/2020 and last updated 7/22/2020 evidenced by verbally abusive, resist treatments/medications, resists ADL assistance care, deterioration in problem behavior, Delusions, Hallucinations related to Unstable or debilitating condition/disease, mood state, New environment, resident has episodes of behavior problem toward staff, yelling, screaming, verbally abusive, cursing, threatening, attempting to scratch, rejection of care (medications, ADL care) despite much advise and counseling, risk and benefits explained. There were no documented goals or interventions and the care plan was documented as incomplete. On 09/10/20 at 11:31 AM, resident was observed lying in his bed in no distress. Resident reported feeling fine today and verbalized no issues or concerns. On 09/11/20 at 10:23 AM, resident observed lying in bed in no distress. Denied any issues or concerns. The Medication Administration Record [REDACTED]. Nursing behavior progress notes dated 9/12/2020 documented verbal behaviors of screaming at others, cursing at others which had significant impact on resident's care and significantly interfere with resident's participation in activities/Social/Environment and behavior had gotten worse from last assessment. Non-Pharmacological interventions included redirect and explaining to resident medical interventions. Nursing progress notes dated 7/20/20 to 9/12/2020 documented resident refusal of care despite several attempts and resident's verbally aggressive behavior toward staff. Medical progress notes dated 9/9/2020 documented examined resident and resident was educated on the need to adhere to plan of care of changing dressing, adhering to ADL care. Plan discussed with nursing. Psychiatry consult dated 7/9/2020 documented mood calm and appropriate in wheelchair. On Trazadone 50 mg at nights, [MEDICATION NAME] 5mg, [MEDICATION NAME] 75 mg TID. Diagnosis: [REDACTED]. Continue use in accordance with relevant current standards of practice and any attempt at dose reduction will likely impair residents' function or exacerbate the underlying psychiatric condition. Resident is on lowest dose to control symptoms. Recommendations: D/C Trazadone. Start [MEDICATION NAME] 15 mg QHS for Depression. Recommendation completed as ordered. Psychiatry consult dated 9/1/2020 documented appetite good, out of bed in wheelchair, sleep adequate, yelling screaming, refusing care, verbally abusive to staff. Resists ADL's. Current medications: [REDACTED]. Non-pharmacological interventions tried: redirection, diversional activities. Oriented x 3 with recurrent [MEDICAL CONDITION]. Assessment of GDR: Continue use in accordance with relevant current standards of practice and any attempt at dose reduction will likely impair residents' function or exacerbate the underlying psychiatric condition. Resident is on lowest dose to control symptoms. No new recommendations. On 09/14/20 at 09:43 AM, an interview was conducted with Certified Nursing Assistant (CNA #1) assigned to Resident #57. CNA #1 stated the resident required extensive assistance with his ADL care and frequently refused care and to have incontinence briefs changed. CNA #1 also stated the resident lies in bed and makes demands of staff and becomes angry shouting at staff and using profanity when needs are not met immediately. CNA#1 further stated she makes multiple attempts to provide care to the resident and if resident does not accept care, she informs the nurse and incoming shift. On 09/14/20 at 11:04 AM, an interview was completed with the Nursing Supervisor (NS). The NS stated the resident had multiple behaviors and seemed to get very upset when pain medication was not given on time and needs were not met immediately. The NS also stated all the nurses on the unit, including himself are responsible for completing the care plans and he is not sure what happened. Once a care plan is initiated the nurse should compete the care plan by activating the care plan and ensure that goals and interventions are entered. The NS further state the interdisciplinary team meets and reviews all the care plans and he is not sure how this care plan was missed. On 09/14/20 at 11:15 AM, an interview was conducted via phone with Registered Nurse (RN #2) who works per diem at the facility and was responsible for completion of MDS assessments and care plans. RN stated she usually individualizes care plans and could not explain what happened why she did not complete the behavior care plan, except to say she may have been distracted. RN stated in developing a care plan she usually communicates with the supervisor on the unit and reads all the progress notes about the resident to ensure appropriate goals and interventions are added and did not know how she had failed to complete this care plan. On 09/15/20 at 10:54 AM, an interview was conducted with the Director of Nursing Services (DNS). The DNS stated that care plans are initiated when a resident is admitted and as needed. DNS stated the RNs are responsible for initiating the care plan and stated the behavior care plan was started by the MDS nurse and it is unclear why the care plan was not completed. The DNS further stated that the only system in place for monitoring of care plans involved review of care plans at morning report. A system where care plan initiation and implementation could be tracked by supervisors and the DNS would be created moving forward. 415.11 (c)(1)

Based on record review and interview, during an abbreviated survey (NY 460), the facility did not ensure an allegation of abuse was reported immediately, not later than 2 hours, to the administrator and to the State Agency. In addition, the results of the investigation were not reported to the Administrator and the New York State Department of Health (NYSDOH) within 5 working days of the incident. Specifically, the facility received an allegation of physical abuse from a witness on 4/27/18, and the allegation was not reported to the administrator and State Agency until 5/8/18. The investigation was not completed until 5/9/18. This was evident for 1 of 2 residents reviewed for Abuse (Resident #19). The findings include: Resident # 19 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had impaired cognition. The resident had [DIAGNOSES REDACTED]. The resident required the extensive assist of two persons for transfers, and the extensive assist of one person for bed mobility. The Comprehensive Care Plan (CCP) for Self-Care Deficit initiated 8/6/13, last reviewed 6/8/18, documented the resident currently required the extensive assist of one person for toileting and transfers. The CCP review note prior to the allegation dated 4/3/18 documented the resident required limited to extensive assist with Activities of Daily Living (ADLs). The CCP further documented the resident required the limited assist of one person for toileting and transfers prior to 5/1/18. The Complaint/Grievance form dated 5/2/18, completed by the Social Worker (SW), documented the SW received a telephone call from the wife of a resident (Witness). The Witness reported that she observed a Certified Nursing Assistant (CNA #2) push a resident and did not want that CNA caring for her mother. The Statement written by the Witness dated 5/2/18 documented that she observed CNA #2 in the day room taking Resident #19 to the bathroom. Resident #19 became upset and tried to rise from the wheelchair (w/c) when CNA #2 forcefully pushed the resident back into the w/c. The Witness spoke to the Registered Nurse Supervisor (RNS) about the incident the following day, 4/29/18. The Statement written by the Registered Nurse Supervisor (RNS) documented that the RN was approached by the Witness on 4/27/18 at approximately 3:00 PM in the supervisor's office. The RN was just about to do the staffing at the time. The Witness described CNA #2 and stated that CNA #2 was not nice and very rough with a resident, pushing the resident to sit down. The Witness told her that she does not think CNA #2 should be working in the facility. The RN attempted to inform the Assistant Director of Nursing (ADON), but was unable to find him. She then went on to complete the staffing and got caught up with other work duties. She forgot to call the ADON. On 5/1/18, she remembered the complaint when she saw CNA #2 checking the schedule. She asked CNA #2 what happened on 4/26/18. CNA #2 told her, I was covering the dining room and the resident (Resident #19) kept trying to stand up. She redirected the resident several times to sit down, but she continued to stand up. She then went over to the resident who became combative, and she put her to sit down. While taking the resident to the bathroom, she attempted to stand up, so she pulled her from behind down in the wheelchair. The RN asked CNA #2 to write a statement and leave it with the 3-11 Supervisor. On 5/2/18, the RN received a call from the ADON about the complaint. The RN had completely forgotten about the situation and apologized for not following-up in a timely manner. The Statement written by CNA #2 dated 5/3/18 documented that on 4/26/18 she was supervising residents in the day room when Resident #19 asked to use the bathroom. She was not able to take the resident immediately because she was the only aide in the room. Resident #19, who is not allowed to walk on her own, attempted to walk to the bathroom. CNA #2 tried to sit the resident back in her chair when she began flailing her arms and yelling, causing a commotion in the dining room. The nurse came to assist and she took the resident to the bathroom as requested. The HERDS NH Incident Form, the incident form used by the facility to report incidents to NYSDOH, was submitted to NYSDOH on 5/8/18. The Witness reported the allegation to the RNS on 4/27/18, but the RNS did not report the allegation to anyone. The allegation of abuse was not reported immediately, not later than 2 hours, to the administrator and State Agency. The facility did not report the allegation to NYSDOH until 5/8/18. The Investigation Summary written by the ADON dated 5/9/18 documented the 4/26/18 camera footage from 5:00 PM to 6:30 PM was reviewed. CNA #2, two other CNAs, and the Licensed Practical Nurse (LPN) were in the day room supervising dinner. Dinner ended around 6:28 PM. One CNA exited the dining room. The LPN was observed coming in and out of the dining room. CNA #2 and another CNA were in the dining room. At 6:30 PM Resident #19 was observed trying to get out of her w/c. CNA #2 was observed forcefully pushing the resident down by placing her two hands on the resident's shoulders repeatedly. The Witness was observed in the dining room at the time. The Summary documented the interviews completed. CNA #2 was removed from the work schedule and later terminated. All nursing staff were re-educated on abuse, neglect, and mistreatment. The summary conclusion documented: Based on the statements, interviews and surveillance camera footage and investigation findings, there is sufficient evidence to conclude that abuse, neglect, and mistreatment occurred. The summary was reviewed by the Director of Nursing (DON). The results of the investigation should be reported to the administrator and NYSDOH within 5 working days. The facility did not begin to investigate the allegation until 5/2/18, and the investigation was not completed until 5/9/18. The results of the investigation were not available to report timely. The results should have been reported to the administrator and NYSDOH by 5/2/19. On 9/13/18 at 1:00 PM, CNA #2 was interviewed via telephone. CNA #2 stated that she recalls the incident being in the afternoon while she was supervising the dining room alone. Resident #19 was not allowed to walk or stand up on her own. She asked the resident to sit in the chair because she was supervising the dining room by herself and could not help the resident. As Resident #19 was getting up from the chair, CNA #2 stated she pressed on the resident's shoulders to sit her down and lower her back into the wheelchair. CNA #2 stated she was not assigned to the resident at the time. She held onto the back of the chair and asked the resident to sit. The resident is Spanish speaking and does not speak fluent English so there is a communication barrier. The LPN came into the room due to the commotion created by the resident yelling and refusing to stay seated. Resident #19 is a very quiet resident, but whenever she was not understood, she would become dramatic. That is what had happened that evening. The incident was reported by another resident's family member. The CNA stated she was interviewed by the ADON, and a few days later she spoke with the DON and was told that she was terminated. The DON also informed her that the incident would be reported to the state and she would be contacted. On 09/13/18 at 12:23 PM, Resident #19's daughter was interviewed. The daughter stated that she did not witness the incident; it was reported to her by the wife of another patient. She stated that she put in the complaint and provided her name. She did not report the incident to the police. The daughter stated that the facility told her that CNA #2 was fired. She believed the incident occurred in the community room. Her mother wanted to go to the bathroom, and CNA #2 pushed her down. The daughter stated the facility did an investigation, and it took 10 days to complete the process. She believed CNA #2 was suspended right away then terminated later after the investigation. On 09/13/18 at 01:26 PM, the ADON was interviewed. He stated that if an allegation is brought to his attention, he collects statements, conducts interviews, and reviews the medical records related to the case. He further stated he also involves the family members. The ADON stated that he does in-services for the entire facility. If there is something that is reportable, the DON will report it to the state. The ADON stated that he monitors everything daily. He stated that he started his investigation immediately upon learning of the allegation on 5/2/18, and he viewed the surveillance footage with CNA #2. CNA #2 was not able to defend her actions, and she kept saying that she was in the dining room alone despite the footage showing that there were 3 staff members in the dining room. The ADON stated that he could see the resistance of what CNA #2 did to Resident #19, but CNA #2 denied pushing Resident #19 in a forceful manner. On 5/2/2019 at 10:30 AM, the DON was interviewed. The incident occurred on 4/26/2018 according to the documentation. The Witness reported the incident to the RNS on 4/29/18 and the family member on 5/2/18. The RNS remembered the allegation on 5/1/2018 when she saw CNA #2, and she asked CNA #2 about what happened on 4/26/18. On 5/2/2018, the RNS received a call from the ADON asking about the complaint, and the RNS stated that she had forgotten to report it and apologized. The DON stated that the date written on the RNS statement (4/26/18) is not the date it was written. The DON stated that the ADON started the investigation on 5/2/18, and the investigation was completed on 5/9/18. She reported the incident to the State Agency on 5/8/18 at 9:33 AM upon returning from a conference upstate. The DON stated that she was concerned that the RNS forgot to report the allegation to the administration. She further stated that she reported the incident late because she did not return to work until 5/8/18, and she decided to report the incident late rather than not report it at all. She stated that any abuse, neglect, mistreatment, and misappropriation of property should be reported to the State agency within 24 hours, and the abuse can be reported by herself or any other staff member. She stated that the facility has the hotline number posted by the elevator on each floor. All employees are screened prior to hiring and educated about abuse, but the incident still happened. The facility policy documents that all abuse should be reported within 24 hours and investigated promptly and thoroughly. 415.4(b)(1)(ii)

Based on record review and interview during an abbreviated survey (NY 460), the facility did not ensure that a resident was free from abuse. Specifically, a resident was repeatedly forcefully pushed down into the chair to prevent them from getting up and going to the bathroom. This was evident for 1 of 2 residents reviewed for abuse (Resident #19). The finding is: The policy and procedure for Abuse dated 4/2014 documented all reports of resident abuse or neglect should be promptly and thoroughly investigated by facility management. Resident # 19 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had impaired cognition. The resident had [DIAGNOSES REDACTED]. The resident required the extensive assist of two persons for transfers, and the extensive assist of one person for bed mobility. The Comprehensive Care Plan (CCP) for Self-Care Deficit initiated 8/6/13, last reviewed 6/8/18, documented the resident currently required the extensive assist of one person for toileting and transfers. The CCP review note prior to the allegation dated 4/3/18 documented the resident required limited to extensive assist with Activities of Daily Living (ADLs). The CCP further documented the resident required the limited assist of one person for toileting and transfers prior to 5/1/18. The Complaint/Grievance form dated 5/2/18, completed by the Social Worker (SW), documented the SW received a telephone call from the wife of a resident (Witness). The Witness reported that she observed a Certified Nursing Assistant (CNA #2) push a resident and did not want that CNA caring for her mother. The Statement written by the Witness dated 5/2/18 documented that she observed CNA #2 in the day room taking Resident #19 to the bathroom. Resident #19 became upset and tried to rise from the wheelchair (w/c) when CNA #2 forcefully pushed the resident back into the w/c. The Witness spoke to the Registered Nurse Supervisor (RNS) about the incident the following day, 4/29/18. The Statement written by the Registered Nurse Supervisor (RNS) documented that the RN was approached by the Witness on 4/27/18 at approximately 3:00 PM in the supervisor's office. The RN was just about to do the staffing at the time. The Witness described CNA #2 and stated that CNA #2 was not nice and very rough with a resident, pushing the resident to sit down. The Witness told her that she does not think CNA #2 should be working in the facility. The RN attempted to inform the Assistant Director of Nursing (ADON), but was unable to find him. She then went on to complete the staffing and got caught up with other work duties. She forgot to call the ADON. On 5/1/18, she remembered the complaint when she saw CNA #2 checking the schedule. She asked CNA #2 what happened on 4/26/18. CNA #2 told her, I was covering the dining room and the resident (Resident #19) kept trying to stand up. She redirected the resident several times to sit down, but she continued to stand up. She then went over to the resident who became combative, and she put her to sit down. While taking the resident to the bathroom, she attempted to stand up, so she pulled her from behind down in the wheelchair. The RN asked CNA #2 to write a statement and leave it with the 3-11 Supervisor. On 5/2/18, the RN received a call from the ADON about the complaint. The RN had completely forgotten about the situation and apologized for not following-up in a timely manner. The Statement written by CNA #2 dated 5/3/18 documented that on 4/26/18 she was supervising residents in the day room when Resident #19 asked to use the bathroom. She was not able to take the resident immediately because she was the only aide in the room. Resident #19, who is not allowed to walk on her own, attempted to walk to the bathroom. CNA #2 tried to sit the resident back in her chair when she began flailing her arms and yelling, causing a commotion in the dining room. The nurse came to assist and she took the resident to the bathroom as requested. The Investigation Summary written by the ADON dated 5/9/18 documented the 4/26/18 camera footage from 5:00 PM to 6:30 PM was reviewed. CNA #2, two other CNAs, and the Licensed Practical Nurse (LPN) were in the day room supervising dinner. Dinner ended around 6:28 PM. One CNA exited the dining room. The LPN was observed coming in and out of the dining room. CNA #2 and another CNA were in the dining room. At 6:30 PM Resident #19 was observed trying to get out of her w/c. CNA #2 was observed forcefully pushing the resident down by placing her two hands on the resident's shoulders repeatedly. The Witness was observed in the dining room at the time. The Summary documented the interviews completed. CNA #2 was removed from the work schedule and later terminated. All nursing staff were re-educated on abuse, neglect, and mistreatment. The summary conclusion documented: Based on the statements, interviews and surveillance camera footage and investigation findings, there is sufficient evidence to conclude that abuse, neglect, and mistreatment occurred. The summary was reviewed by the Director of Nursing (DON). On 9/13/18 at 1:00 PM, CNA #2 was interviewed via telephone. CNA #2 stated that she recalls the incident being in the afternoon while she was supervising the dining room alone. Resident #19 was not allowed to walk or stand up on her own. She asked the resident to sit in the chair because she was supervising the dining room by herself and could not help the resident. As Resident #19 was getting up from the chair, CNA #2 stated she pressed on the resident's shoulders to sit her down and lower her back into the wheelchair. CNA #2 stated she was not assigned to the resident at the time. She held onto the back of the chair and asked the resident to sit. The resident is Spanish speaking and does not speak fluent English so there is a communication barrier. The LPN came into the room due to the commotion created by the resident yelling and refusing to stay seated. Resident #19 is a very quiet resident, but whenever she was not understood, she would become dramatic. That is what had happened that evening. The incident was reported by another resident's family member. The CNA stated she was interviewed by the ADON, and a few days later she spoke with the DON and was told that she was terminated. The DON also informed her that the incident would be reported to the state and she would be contacted. On 09/13/18 at 12:23 PM, Resident #19's daughter was interviewed. The daughter stated that she did not witness the incident; it was reported to her by the wife of another patient. She stated that she put in the complaint and provided her name. She did not report the incident to the police. The daughter stated that the facility told her that CNA #2 was fired. She believed the incident occurred in the community room. Her mother wanted to go to the bathroom, and CNA #2 pushed her down. The daughter stated the facility did an investigation, and it took 10 days to complete the process. She believed CNA #2 was suspended right away then terminated later after the investigation. On 09/13/18 at 01:26 PM, the ADON was interviewed. He stated that if an allegation is brought to his attention, he collects statements, conducts interviews, and reviews the medical records related to the case. He further stated he also involves the family members. The ADON stated that he does in-services for the entire facility. If there is something that is reportable, the DON will report it to the state. The ADON stated that he monitors everything daily. He stated that he started his investigation immediately upon learning of the allegation on 5/2/18, and he viewed the surveillance footage with CNA #2. CNA #2 was not able to defend her actions, and she kept saying that she was in the dining room alone despite the footage showing that there were 3 staff members in the dining room. The ADON stated that he could see the resistance of what CNA #2 did to Resident #19, but CNA #2 denied pushing Resident #19 in a forceful manner. On 5/2/2019 at 10:30 AM, the DON was nterviewed. The incident occurred on 4/26/2018 according to the documentation. The Witness reported the incident to the RNS on 4/29/18 and the family member on 5/2/18. The RNS remembered the allegation on 5/1/2018 when she saw CNA #2, and she asked CNA #2 about what happened on 4/26/18. On 5/2/2018, the RNS received a call from the ADON asking about the complaint, and the RNS stated that she had forgotten to report it and apologized. The DON stated that the date written on the RNS statement (4/26/18) is not the date it was written. The DON stated that the ADON started the investigation on 5/2/18, and the investigation was completed on 5/9/18. She reported the incident to the State Agency on 5/8/18 at 9:33 AM upon returning from a conference upstate. The DON stated that she was concerned that the RNS forgot to report the allegation to the administration. She further stated that she reported the incident late because she did not return to work until 5/8/18, and she decided to report the incident late rather than not report it at all. She stated that any abuse, neglect, mistreatment, and misappropriation of property should be reported to the State agency within 24 hours, and the abuse can be reported by herself or any other staff member. She stated that the facility has the hotline number posted by the elevator on each floor. All employees are screened prior to hiring and educated about abuse, but the incident still happened. The facility policy documents that all abuse should be reported within 24 hours and investigated promptly and thoroughly. On 09/14/18 at 12:54 PM, the DON was interviewed. The DON stated that on 5/8/2018, she was informed by the ADON that on 5/2/18 the Director of Social Services (SW) gave a formal complaint to him. In the complaint, the SW received a phone call from Resident #19's daughter who stated that she was informed by another resident family member (Witness) that she observed CNA #2 grab Resident #19 forcefully from the back and pull her back onto the chair before transporting her to the bathroom. The ADON started the investigation process on 5/2/18 by collecting written statements from the perpetrator, and he also interviewed the family member that saw the incident. The DON stated that written statements were collected from all staff that were present during the shift, and the resident's medical record was reviewed. She stated that the Witness, RNS, and CNA #2 were interviewed on 5/3/18, and the resident's daughter was interviewed on 5/4/18. All staff from the unit were interviewed. The DON stated the camera footage from the dining room was viewed by management, but she did not see too much of the video. The ADON reported that CNA #2 was observed forcefully pushing the resident down by placing her two hands on Resident #19's shoulders repeatedly. The witness person was observed in the dining room at the time. Also, CNA # 5 was observed in the dining room, and the LPN was observed coming in and out of the dining room. The DON further stated that CNA #2 was taken off the assignment and not allowed to work. CNA #2 was terminated on 5/8/2018 for the allegation of abuse. On 5/2/2019 at 10:30 am, the DON was re-interviewed. The incident occurred on 4/26/2018 according to the documentation. The Witness reported the incident to the RNS on 4/29/18 and the family member on 5/2/18. The RNS remembered the allegation on 5/1/2018 when she saw CNA #2, and she asked CNA #2 about what happened on 4/26/18. On 5/2/2018, the RNS received a call from the ADON asking about the complaint, and the RNS stated that she had forgotten to report it and apologized. The DON stated that the date written on the RNS statement (4/26/18) is not the date it was written. The DON stated that the ADON started the investigation on 5/2/18, and the investigation was completed on 5/9/18. She reported the incident to the State Agency on 5/8/18 at 9:33 AM upon returning from a conference upstate. The DON stated that she was concerned that the RNS forgot to report the allegation to the administration. If the allegation was reported timely, the CNA would not have continued to work. CNA #2 would have been removed from duty pending investigation sooner. The ADON removed CNA #2 from work on 5/3/18 after he found out what was going on. The DON stated the facility should have ensured residents were subject to any further potential abuse, and the CNA should not have been working with the residents. She further stated that she reported the incident late because she did not return to work until 5/8/18, and she decided to report the incident late rather than not report it at all. She stated that any abuse, neglect, mistreatment, and misappropriation of property should be reported to the State agency within 24 hours, and the abuse can be reported by herself or any other staff member. She stated that the facility has the hotline number posted by the elevator on each floor. All employees are screened prior to hiring and educated about abuse, but the incident still happened. The facility policy documents that all abuse should be reported within 24 hours and investigated promptly and thoroughly. 415.4(b)(1)(i)

Based on record review and interview, conducted during the abbreviated survey (NY 460), the facility did not ensure that further potential abuse was prevented while an allegation of abuse was being investigated. In addition, the allegation of abuse was not investigated or reported to the administrator and New York State Department of Health (NYSDOH) within 5 working days. Specifically, a Witness reported an allegation of physical abuse to the facility on [DATE] to the Registered Nurse Supervisor (RNS). The RNS did not report the allegation or initiate an investigation. The Certified Nursing Assistant (CNA) accused of the alleged abuse was not removed from assignment immediately after the allegation was received, nor was she removed from assignment after the Assistant Director of Nursing (ADON) initiated the investigation on 5/2/18. In addition, the investigation was not completed until 5/9/18. This was evident for 1 of 2 residents reviewed for Abuse (Resident #19). The findings are: The policy and procedure for Abuse dated 4/2014 documented all reports of resident abuse or neglect should be promptly and thoroughly investigated by facility management. Resident # 19 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had impaired cognition. The resident had [DIAGNOSES REDACTED]. The resident required the extensive assist of two persons for transfers, and the extensive assist of one person for bed mobility. The Comprehensive Care Plan (CCP) for Self-Care Deficit initiated 8/6/13, last reviewed 6/8/18, documented the resident currently required the extensive assist of one person for toileting and transfers. The CCP review note prior to the allegation dated 4/3/18 documented the resident required limited to extensive assist with Activities of Daily Living (ADLs). The CCP further documented the resident required the limited assist of one person for toileting and transfers prior to 5/1/18. The Complaint/Grievance form dated 5/2/18, completed by the Social Worker (SW), documented the SW received a telephone call from the wife of a resident (Witness). The Witness reported that she observed a Certified Nursing Assistant (CNA #2) push a resident and did not want that CNA caring for her mother. The Statement written by the Witness dated 5/2/18 documented that she observed CNA #2 in the day room taking Resident #19 to the bathroom. Resident #19 became upset and tried to rise from the wheelchair (w/c) when CNA #2 forcefully pushed the resident back into the w/c. The Witness spoke to the Registered Nurse Supervisor (RNS) about the incident the following day, 4/29/18. The Statement written by the Registered Nurse Supervisor (RNS) documented that the RN was approached by the Witness on 4/27/18 at approximately 3:00 PM in the supervisor's office. The RN was just about to do the staffing at the time. The Witness described CNA #2 and stated that CNA #2 was not nice and very rough with a resident, pushing the resident to sit down. The Witness told her that she does not think CNA #2 should be working in the facility. The RN attempted to inform the Assistant Director of Nursing (ADON), but was unable to find him. She then went on to complete the staffing and got caught up with other work duties. She forgot to call the ADON. On 5/1/18, she remembered the complaint when she saw CNA #2 checking the schedule. She asked CNA #2 what happened on 4/26/18. CNA #2 told her, I was covering the dining room and the resident (Resident #19) kept trying to stand up. She redirected the resident several times to sit down, but she continued to stand up. She then went over to the resident who became combative, and she put her to sit down. While taking the resident to the bathroom, she attempted to stand up, so she pulled her from behind down in the wheelchair. The RN asked CNA #2 to write a statement and leave it with the 3-11 Supervisor. On 5/2/18, the RN received a call from the ADON about the complaint. The RN had completely forgotten about the situation and apologized for not following-up in a timely manner. The Statement written by CNA #2 dated 5/3/18 documented that on 4/26/18 she was supervising residents in the day room when Resident #19 asked to use the bathroom. She was not able to take the resident immediately because she was the only aide in the room. Resident #19, who is not allowed to walk on her own, attempted to walk to the bathroom. CNA #2 tried to sit the resident back in her chair when she began flailing her arms and yelling, causing a commotion in the dining room. The nurse came to assist and she took the resident to the bathroom as requested. The Raw Punch Report, a payroll timecard report, covering the time period of 4/1/2018 to 5/31/2018, documented CNA #2 worked the evening shift on 4/26/18, 4/28/18, 4/29/18, 5/1/18, 5/2/18, and 5/3/18. CNA #2 worked 5 days after the allegation was reported to the RNS on 4/27/18. The HERDS NH Incident Form, the incident form used by the facility to report incidents to NYSDOH, was submitted to NYSDOH on 5/8/18. The Investigation Summary written by the ADON dated 5/9/18 documented the 4/26/18 camera footage from 5:00 PM to 6:30 PM was reviewed. CNA #2, two other CNAs, and the Licensed Practical Nurse (LPN) were in the day room supervising dinner. Dinner ended around 6:28 PM. One CNA exited the dining room. The LPN was observed coming in and out of the dining room. CNA #2 and another CNA were in the dining room. At 6:30 PM Resident #19 was observed trying to get out of her w/c. CNA #2 was observed forcefully pushing the resident down by placing her two hands on the resident's shoulders repeatedly. The Witness was observed in the dining room at the time. The Summary documented the interviews completed. CNA #2 was removed from the work schedule and later terminated. All nursing staff were re-educated on abuse, neglect, and mistreatment. The summary conclusion documented: Based on the statements, interviews and surveillance camera footage and investigation findings, there is sufficient evidence to conclude that abuse, neglect, and mistreatment occurred. The summary was reviewed by the Director of Nursing (DON). The results of the investigation should be reported to the administrator and NYSDOH within 5 working days. The facility did not begin to investigate the allegation until 5/2/18, and the investigation was not completed until 5/9/18. The results should have been reported to the administrator and NYSDOH by 5/2/18. On 9/13/18 at 1:00 PM, CNA #2 was interviewed via telephone. CNA #2 stated that she recalls the incident being in the afternoon while she was supervising the dining room alone. Resident #19 was not allowed to walk or stand up on her own. She asked the resident to sit in the chair because she was supervising the dining room by herself and could not help the resident. As Resident #19 was getting up from the chair, CNA #2 stated she pressed on the resident's shoulders to sit her down and lower her back into the wheelchair. CNA #2 stated she was not assigned to the resident at the time. She held onto the back of the chair and asked the resident to sit. The resident is Spanish speaking and does not speak fluent English so there is a communication barrier. The LPN came into the room due to the commotion created by the resident yelling and refusing to stay seated. Resident #19 is a very quiet resident, but whenever she was not understood, she would become dramatic. That is what had happened that evening. The incident was reported by another resident's family member. The CNA stated she was interviewed by the ADON, and a few days later she spoke with the DON and was told that she was terminated. The DON also informed her that the incident would be reported to the state and she would be contacted. On 09/13/18 at 12:23 PM, Resident #19's daughter was interviewed. The daughter stated that she did not witness the incident; it was reported to her by the wife of another patient. She stated that she put in the complaint and provided her name. She did not report the incident to the police. The daughter stated that the facility told her that CNA #2 was fired. She believed the incident occurred in the community room. Her mother wanted to go to the bathroom, and CNA #2 pushed her down. The daughter stated the facility did an investigation, and it took 10 days to complete the process. She believed CNA #2 was suspended right away then terminated later after the investigation. On 09/13/18 at 01:26 PM, the ADON was interviewed. He stated that if an allegation is brought to his attention, he collects statements, conducts interviews, and reviews the medical records related to the case. He further stated he also involves the family members. The ADON stated that he does in-services for the entire facility. If there is something that is reportable, the DON will report it to the state. The ADON stated that he monitors everything daily. He stated that he started his investigation immediately upon learning of the allegation on 5/2/18, and he viewed the surveillance footage with CNA #2. CNA #2 was not able to defend her actions, and she kept saying that she was in the dining room alone despite the footage showing that there were 3 staff members in the dining room. The ADON stated that he could see the resistance of what CNA #2 did to Resident #19, but CNA #2 denied pushing Resident #19 in a forceful manner. On 5/2/2019 at 10:30 AM, the DON was nterviewed. The incident occurred on 4/26/2018 according to the documentation. The Witness reported the incident to the RNS on 4/29/18 and the family member on 5/2/18. The RNS remembered the allegation on 5/1/2018 when she saw CNA #2, and she asked CNA #2 about what happened on 4/26/18. On 5/2/2018, the RNS received a call from the ADON asking about the complaint, and the RNS stated that she had forgotten to report it and apologized. The DON stated that the date written on the RNS statement (4/26/18) is not the date it was written. The DON stated that the ADON started the investigation on 5/2/18, and the investigation was completed on 5/9/18. She reported the incident to the State Agency on 5/8/18 at 9:33 AM upon returning from a conference upstate. The DON stated that she was concerned that the RNS forgot to report the allegation to the administration. She further stated that she reported the incident late because she did not return to work until 5/8/18, and she decided to report the incident late rather than not report it at all. She stated that any abuse, neglect, mistreatment, and misappropriation of property should be reported to the State agency within 24 hours, and the abuse can be reported by herself or any other staff member. She stated that the facility has the hotline number posted by the elevator on each floor. All employees are screened prior to hiring and educated about abuse, but the incident still happened. The facility policy documents that all abuse should be reported within 24 hours and investigated promptly and thoroughly. On 09/14/18 at 12:54 PM, the DON was interviewed. The DON stated that on 5/8/2018, she was informed by the ADON that on 5/2/18 the Director of Social Services (SW) gave a formal complaint to him. In the complaint, the SW received a phone call from Resident #19's daughter who stated that she was informed by another resident family member (Witness) that she observed CNA #2 grab Resident #19 forcefully from the back and pull her back onto the chair before transporting her to the bathroom. The ADON started the investigation process on 5/2/18 by collecting written statements from the perpetrator, and he also interviewed the family member that saw the incident. The DON stated that written statements were collected from all staff that were present during the shift, and the resident's medical record was reviewed. She stated that the Witness, RNS, and CNA #2 were interviewed on 5/3/18, and the resident's daughter was interviewed on 5/4/18. All staff from the unit were interviewed. The DON stated the camera footage from the dining room was viewed by management, but she did not see too much of the video. The ADON reported that CNA #2 was observed forcefully pushing the resident down by placing her two hands on Resident #19's shoulders repeatedly. The witness person was observed in the dining room at the time. Also, CNA # 5 was observed in the dining room, and the LPN was observed coming in and out of the dining room. The DON further stated that CNA #2 was taken off the assignment and not allowed to work. CNA #2 was terminated on 5/8/2018 for the allegation of abuse. On 5/2/2019 at 10:30 am, the DON was re-interviewed. The incident occurred on 4/26/2018 according to the documentation. The Witness reported the incident to the RNS on 4/29/18 and the family member on 5/2/18. The RNS remembered the allegation on 5/1/2018 when she saw CNA #2, and she asked CNA #2 about what happened on 4/26/18. On 5/2/2018, the RNS received a call from the ADON asking about the complaint, and the RNS stated that she had forgotten to report it and apologized. The DON stated that the date written on the RNS statement (4/26/18) is not the date it was written. The DON stated that the ADON started the investigation on 5/2/18, and the investigation was completed on 5/9/18. She reported the incident to the State Agency on 5/8/18 at 9:33 AM upon returning from a conference upstate. The DON stated that she was concerned that the RNS forgot to report the allegation to the administration. If the allegation was reported timely, the CNA would not have continued to work. CNA #2 would have been removed from duty pending investigation sooner. The ADON removed CNA #2 from work on 5/3/18 after he found out what was going on. The DON stated the facility should have ensured residents were subject to any further potential abuse, and the CNA should not have been working with the residents. She further stated that she reported the incident late because she did not return to work until 5/8/18, and she decided to report the incident late rather than not report it at all. She stated that any abuse, neglect, mistreatment, and misappropriation of property should be reported to the State agency within 24 hours, and the abuse can be reported by herself or any other staff member. She stated that the facility has the hotline number posted by the elevator on each floor. All employees are screened prior to hiring and educated about abuse, but the incident still happened. The facility policy documents that all abuse should be reported within 24 hours and investigated promptly and thoroughly. 415.4(b)(1)(ii)

Based on observation , record review and staff interviews, the facility did not provide medically -related services to attain the highest practicable physical, mental and psychosocial well -being of each resident. Specifically, resident #27 was observed in a hospital gown; subsequent observations of closet and drawers revealed that resident did not have any clothing. The Resident has resided in the facility for 5 months and the facility staff did not provide the resident with clothing. This was evident for 1 of 3 residents reviewed for dignity out of a sample of 62 residents. (Resident # 27) The finding is: The facility policy and procedure on clothing states: prior to and upon admission , the admissions coordinator will review the clothing policy and it is recommended that two weeks of clothing be provided upon admission. Assigned certified nursing assistant (CNA ) will advise unit social worker if there is a need for additional clothing. Resident # 27 was admitted to the facility on [DATE]. The Minimum Data Set 3.0 (MDS ) assessment dated [DATE] identified the resident with severely impaired cognition and completely dependent to staff in all his activities of daily living, including dressing, toileting and transfers. The comprehensive care plan (CCP ) dated 06/02/2018, identified that the resident has a self care deficit and requires total assist in dressing. One of the interventions was to encourage the resident to make choices related to clothing preferences. On 09/10/2018 at 01:18 PM the resident was observed in his room seated in his gerichair, with trachea connected to a ventilator and a peg tube with feeding infusing through a pump dressed in a hospital gown. The resident was alert but non responsive to verbal cues. The resident's closet and drawers were observed empty of any personal clothing or belongings. The Registered Nurse (RN) in charge of the unit was interviewed on 09/11/208 at 12:00 PM. The RN stated that when a resident has no personal clothing the Certified Nurses Assistant (CNA) can go to the laundry room to get clothing, because the facility has donated clothes. After the interview with the RN the resident was observed on 09/12/2018 at 11:00 AM in his room, seated in his gerichair, dressed in a clean T-shirt and pants. Both feet and lower extremities were covered with a stockinet. On 09/12/2018 at 11:30 AM the CNA assigned to the resident was interviewed. When asked why the resident was wearing a stockinet instead of socks. The CNA stated, He has no clothing, everyone knows that. That is why he was dressed in his gown and now we got some pants and shirts from the laundry. On 09/ 13/2018 at 11:30 AM the Director of Social Work (DSW) was interviewed. The DSW stated, We have some donations in the laundry room. The DSW further stated that the traveling clothing store come to the facility where the residents and family can buy clothing. The DSW said that the CNA on the unit is supposed to let SW department know and then they will contact the family. The DSW stated that she contacted and spoke with the resident's wife who said as soon as she gets his clothing from the previous skilled nursing home she would bring them in to the facility. 415.5 (g)(1)(i-xv)

Based on observation , record review and staff interviews during the recertification survey the facility did not ensure that each resident is treated with respect, dignity and cared for in a manner that promotes or enhances his quality of life and recognizing resident's individuality. Specifically, resident #27 was observed in a hospital gown; subsequent observations of closet and drawers revealed that resident did not have any clothing. Facility staff did not provide the resident with clothing. This was evident for 1 of 3 residents reviewed for dignity out of a sample of 62 residents. (Resident # 27) The finding is: The facility policy and procedure on clothing states: prior to and upon admission , the admissions coordinator will review the clothing policy and it is recommended that two weeks of clothing be provided upon admission. Assigned certified nursing assistant (CNA ) will advise unit social worker if there is a need for additional clothing. Resident # 27 was admitted to the facility on [DATE]. The Minimum Data Set 3.0 (MDS ) assessment dated [DATE] identified the resident with severely impaired cognition and completely dependent to staff in all his activities of daily living, including dressing, toileting and transfers. The comprehensive care plan (CCP ) dated 06/02/2018, identified that the resident has a self care deficit and requires total assist in dressing. One of the interventions was to encourage the resident to make choices related to clothing preferences. On 09/10/2018 at 01:18 PM the resident was observed in his room seated in his gerichair, with trachea connected to a ventilator and a peg tube with feeding infusing through a pump dressed in a hospital gown. The resident was alert but non responsive to verbal cues. The resident's closet and drawers were observed empty of any personal clothing or belongings. The Registered Nurse (RN) in charge of the unit was interviewed on 09/11/208 at 12:00 PM. The RN stated that when a resident has no personal clothing the Certified Nurses Assistant (CNA) can go to the laundry room to get clothing, because the facility has donated clothes. After the interview with the RN the resident was observed on 09/12/2018 at 11:00 AM in his room, seated in his gerichair, dressed in a clean T-shirt and pants. Both feet and lower extremities were covered with a stockinet. On 09/12/2018 at 11:30 AM the CNA assigned to the resident was interviewed. When asked why the resident was wearing a stockinet instead of socks. The CNA stated, He has no clothing, everyone knows that. That is why he was dressed in his gown and now we got some pants and shirts from the laundry . 415.5 (a)

Based on observations and interviews the facility did not ensure that sanitary conditions were maintained in kitchen to prevent food borne illness related to food storage and cold food holding temperatures on the tray line. This was evident on observations conducted during the Kitchen Tour. The findings are: 1) On 1/11/17 at 10:15 AM during the tour of the kitchen dry store room area, multiple boxes containing food were stored directly on the floor after delivery. There were nine rows of boxes containing different foods on the floor. In total, there were fifty-nine boxes containing canned sweet potatoes, canned tomatoes, farina, potato granules, Cheerios and other cereals. There were twelve cases of soda cans and five cases of juice stored on the floor. A second observation was conducted on 1/13/17 at 3:00 PM. There were two small narrow palettes placed in the center of the store room. On 1/11/17 at 10:20 AM the Food Service Supervisor (FSS) was interviewed and stated that the facility receives food deliveries four times a week and the delivered food items are left on the floor of the store room. Later the store room staff puts them away in the proper places. We do not have additional palettes for all of the delivered items to be placed on which is why the food boxes are left on the floor. I will have to order some more palettes. On 1/11/17 at 10:30 AM the Food Service Director (FSD) was interviewed and stated that the delivery person comes early and always leaves them on the floor and the store room staff puts them away afterwards. She will order some more palettes. I will rearrange the racks to fit so the delivery man can leave them on the racks. The facility policy, revised 8/26/16 for Dry storage areas documents that all (food) items must be stored at least 6 inches off the floor. 2) On 1/13/17 at 12:00 noon , the tray line was observed. The cold foods did not meet the temperature guidelines as follows: Pureed peach 50 degrees F (Fahrenheit) The peaches were stored on a tray in the truck near the trayline and not refrigerated or placed on ice to maintain cold temperature. Ham and Cheese sandwich 65 F -Two trays of twenty-six ham and cheese sandwiches were placed on trays in the truck near the trayline, On 1/13/17 at 12:20 PM the Food Service Worker (FSW ) was interviewed and stated that there is no space in the reach-in refrigerator where sodas and juices are stored, which is why the sandwiches were left on the truck. The meat sandwiches were brought out around 11:40 AM to the tray line area from the refrigerator and the tray line service finishes by 1:45 PM to 2:00 PM for a two hour time period. The FSW further stated that she does not know why the sandwiches were not refrigerated. On 1/13/17 at 12:25 PM the Food Service Director (FSD ) was interviewed and stated that she has trained and reinforced the policy with the staff and added that the staff does not listen and that it was difficult to get them to follow procedures. On 1/17/17 at 4:00 PM the FSD came by and communicated that , she had An order was placed for another refrigerator that came in yesterday. Now there are two refrigerators for tray line use and meal service for cold foods. The facility policy, revised 8/25/16 for 'Sanitation and Food safety' documents: Cold foods will be maintained at 41 F and below. 3) On 1/11/17 at 10:30 AM during the tour of the kitchen, an area across from the pot washing station, was a large puddle of spilled water from the pot washing. On 1/11/17 at 10: 35 AM the Food Service Supervisor (FSS) was interviewed and stated that they have a problem with water puddling daily. The staff have to sweep off the water every day, a few times a day, to keep the floor clean and dry. The drain had been closed over a year. Last year the Department of Environmental Protection Agency ( DEP) made a visit and told them to close this drain. Since then we have a problem with water puddling. On 1/11/17 at 10: 40 AM the Food Service Director (FSD) was interviewed and stated that they have been having the water puddle problem for few months, have discussed with Environmental/Maintenance services. On 1/11/17 at 10:45 AM , the Director of Maintenance was interviewed and stated that the DEP told them to close the drain and was unable to explain the rationale for the closure. 415.14(h)

Based on interviews and record review during an abbreviated survey, the facility did not provide a written notice of transfer or discharge when residents were transferred to the hospital. This was evident for 4 out of 4 sampled residents (Residents #1, #2, #3, #4). Complaint ID # NY 555 The findings include: 1) Resident #1 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 dated 4/27/2014 documented that the resident ' s cognitive skills were severely impaired. A nurse ' s note dated 5/8/2014 documented that the resident was transferred to the hospital for restless, agitated, and aggressive behavior. A review of Resident #1 ' s medical record revealed no documented evidence that the resident was provided with the transfer/discharge notice with the appeal rights information when the resident was transferred to the hospital on [DATE]. 2) Resident #2 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS 3.0 dated 5/5/2014 documented that the resident made decisions in daily life with modified independence. A nurse ' s note dated 5/4/2014 documented that the resident was transferred to the hospital for [MEDICAL CONDITION] exacerbation and Hemoptysis (coughing up of blood). A review of Resident #2 ' s medical record revealed no documented evidence that the resident was provided with the transfer/discharge notice with the appeal rights information when the resident was transferred to the hospital on [DATE]. 3) Resident #3 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS 3.0 dated 5/9/2014 documented that the resident was moderately impaired in cognitive skills for daily decision making. A nurse ' s note dated 5/9/2014 documented that the resident was observed with crackles upon auscultating the lung sounds. The resident was transferred to the hospital for further evaluation. A review of Resident #3 ' s medical record revealed no documented evidence that the resident was provided with the transfer/discharge notice with the appeal rights information when the resident was transferred to the hospital on [DATE]. 4) Resident #4 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse ' s note dated 5/7/2014 documented that the resident was transferred to the hospital due to shortness of breath. A review of Resident #4 ' s medical record revealed no documented evidence that the resident was provided with the transfer/discharge notice with the appeal rights information when the resident was transferred to the hospital on [DATE]. The facility ' s undated Policies and Procedure for discharges were reviewed. The policies did not stipulate that all residents who are discharged or transferred to the hospital are provided with a transfer/discharge notice. On 4/10/2015 at 11:40AM, an interview was conducted with the Director of Social Work (DSW). The DSW stated that hospital discharges do not require residents be provided with transfer/discharge notice with appeal rights information. She stated that the residents were only provided with a bed hold notification letter for hospital transfers. On 10/1/2015 at 11:35AM an interview was conducted with the Director of Admissions (DOA). The DOA stated that for planned discharges to the community, the social worker provides the notice of transfer/discharge with appeal rights information. The DOA stated that for hospital transfers, the nurses should send the notice of transfer/discharge. On 10/8/2015 at 10:40AM an interview was conducted with the Admission ' s Coordinator (AC). The AC stated that the bed hold notification letter is mailed to the resident ' s family once the resident gets admitted to the hospital. The AC stated that the facility does not provide a notice of transfer/discharge when residents are transferred to the hospital. 415.3(h)(1)(iii)(a-c)

Based on observations, record reviews, and staff interviews, the facility did not ensure that the food is palatable and served at the proper temperature to ensure resident satisfaction. This was evident on the tray line where cold food holding temperatures were not meeting the standards. This resulted in no actual harm with potential for more than minimal harm. The findings are: On 10/21/13 at 12:20 PM, the tray line was observed and temperatures were taken in the kitchen. Cold foods temperatures were as follows: Fruit Cocktail 50 degrees Fahrenheit (F) (in open reach in refrigerator by tray line) Peaches 65 F (in trays on Cart) Cranberry Juice 50 F (in trays on Cart) Milk 40F (inside refrigerator) On 10/21/13 at 12:30 PM the Food Service Director was interviewed and stated that she was aware the cold foods temperatures need to be below 40F; Kitchen is warm and the cold temperature do not hold up. The facility policy dated 8/1/13 for " Food safety and Sanitation " documents: " All cold foods are to be maintained and served at a temperature of 41 F or below. Temperatures should be taken periodically to assure cold foods stay below 41 F. " 415.14 (d) (1) (2)

Based on record review and interview, the facility did not ensure that policies and procedures that prohibit neglect were implemented. Specifically, (1) a nurses aide did not report a fall that occurred during a transfer not done in accordance withe the plan of care, and (2) the incident was not thoroughly investigated and reported to the state agency. This was evident for 1 of 2 residents reviewed for Abuse (Resident #117). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. The finding is: Resident #117 is a [AGE] year-old with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had severely impaired cognition (Brief Interview of Mental Status score of 5 out of 15). The MDS further documented the resident required extensive assist of two persons for transfers. The Comprehensive Care Plan for "At Risk for Accidents/Falls/Injury" dated 9/10/13 included the intervention of 2 staff assist with transfers. The Certified Nursing Assistant (CNA) Accountability for October 2013 documented the resident required extensive assist of 2 persons for transfer. A Nursing Note dated 10/11/13 documented: "Charge Nurse was informed by Medication Nurse that Mr. (NAME REDACTED) was very upset and was complaining that he fell while being transferred to his chair. CNA assigned was called and questioned about the claims the resident made. CNA stated that while he was transferring the resident he was too heavy for him and his buttock touched the floor. Resident is an Extensive Assist transfer with 2 Persons, Supervisor made aware. Call placed to (Physician) to inform him of incident with the resident. Resident stated that he has no pain or discomfort at this time, body check done and no signs of discoloration noted, resident is able to flex and extend all extremities, no swelling noted to body at this time, call placed to resident's wife...". A Physician's (MD) Note dated 10/11/13 documented the resident was examined for a "near fall" episode. The note further documented: "A&P(Assessment and Plan) Fall- no actual fall occurred, no signs of injury seen, no acute complaints reported- for fall precautions". The Incident Report dated 10/11/13 documented the resident stated he fell while being transferred by nursing staff. The report further documented the facility determined that there was no abuse, neglect, or mistreatment. The Investigation dated 10/11/13 documented: "Staff was instructed to follow facility policy to transfer resident with required amount of staff...Resident care plan was not followed. Staff transfer resident by himself and transfer required two person assistance. Disciplinary action was taken. Staff was re-inserviced immediately". There was no documented evidence that a statement was taken from the Licensed Practical Nurse (LPN) who initially spoke to the resident about the incident. There was no documented evidence that the neglect was reported to the Department of Health (DOH). The Facility policy for "Resident Abuse, Neglect, Mistreatment, Involuntary Seclusion and Misappropriation of Property" dated 11/10 documented: "...All alleged or suspected incidents of abuse neglect, mistreatment or misappropriation of resident's property will be thoroughly investigated and findings documented in a report format...Any case in which...neglect...has been identified via the investigation, or a conclusion cannot be drawn, will be reported promptly to the New York State Department of Health for further investigation...Definitions...Neglect: Failure to provide timely, consistent, safe, adequate and appropriate services, treatment, and/or care to a resident. This includes...activities of daily living...". On 10/24/13 at 11:37 AM, the Registered Nurse (RN) was interviewed and stated that on the date of the fall she attended an inservice meeting in the morning. She stated that when she returned to the unit around 12:15pm, the medication nurse informed her that the resident was upset and arguing in English and Creole and saying that the person that took care of him made him fall on the floor. The RN further stated that she asked the resident if he fell and he responded "yes" and denied having pain. She also stated that she asked the CNA what happened, and the CNA informed her that during a transfer done alone, he sat the resident on the floor because the resident was too heavy to hold up. She stated that she informed the supervisor and physician and started the incident report. On 10/24/13 at 12:51 PM, the CNA was interviewed and stated that he transferred the resident from the bed to wheelchair (w/c) by himself because he thought the resident required one person assist instead of two. He further stated that resident was agitated and when he realized he could not bear the resident's weight, he lowered the resident to the floor. The CNA stated that he moved the resident back to the bed and then transferred him to the w/c. He stated that at the time, he was not thinking and automatically picked the resident up. The CNA stated that he did not see the nurse on the floor at that time and began helping another resident. He stated that he should have told the nurse immediately about the fall, and he should not have moved the resident until he was assessed by the nurse. He stated that he has been re-inserviced on abuse, neglect, and mistreatment. The CNA also stated that he has also been instructed to read the CNA Accountability before providing care to the residents. On 10/24/13 at 2:08 PM, the Licensed Practical Nurse (LPN) was interviewed and stated that the resident was agitated and mumbling in the dining room so she spoke to him in Creole to see what was wrong. She further stated that the resident told her that one of the aides dropped him and hit him. She stated that the resident was very upset, and when she asked him which CNA did this, he pointed to a CNA in the room that did not work with him. The LPN stated that she reported the information to the RN. On 10/25/13 at 12:33 PM, the Registered Nurse Manager (RNM) who completed the investigation was interviewed and stated that statements are taken from all immediate staff for an investigation. She further stated that she did not notice that the LPN did not complete a statement for the investigation when she reviewed all the information. She stated that she did ask the resident what happened the next day, and he said he fell . The RNM stated she knew the CNA did not follow the plan of care, but she did not feel it was neglect. She stated that she re-inserviced the CNA on abuse and suspended him because she knew it was serious. The RNM stated that the CNA is per diem and staff are aware that he should be monitored. The CNA has not been re-assigned to the resident's floor. On 10/25/14 at 12:02 PM and 2:51 PM, the Director of Nursing (DON) was interviewed and stated the investigation should have contained a statement written by the LPN who initially spoke to the resident about the incident. She further stated that she was never told that the resident stated he was hit, and she would immediately look into what the LPN told the surveyor so that it can be investigated. She stated that the incident was neglect and the team discussed reporting it to DOH, but they concluded that since there was no negative outcome of injury or fracture it was sufficient to re-inservice and suspend him. The DON stated that she spoke to the resident (in Creole) and the LPN to clarify what was meant when the resident stated he was hit. The DON stated that the resident hit his arm and leg when he fell . He did not get hit by the CNA. 415.4(b)

Based on record review and interview, the facility did not ensure that an allegation of neglect was thoroughly investigated and reported to the state agency within 5 days. This was evident for 1 of 3 allegations reviewed for the Abuse Prohibition Protocol (Resident #117). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. The finding is: Resident #117 is a [AGE] year-old with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had severely impaired cognition (Brief Interview of Mental Status score of 5 out of 15). The MDS further documented the resident required extensive assist of two persons for transfers. The Comprehensive Care Plan for "At Risk for Accidents/Falls/Injury" dated 9/10/13 included the intervention of 2 staff assist with transfers. The Certified Nursing Assistant (CNA) Accountability for October 2013 documented the resident required extensive assist of 2 persons for transfer. A Nursing Note dated 10/11/13 documented: "Charge Nurse was informed by Medication Nurse that Mr. (NAME REDACTED) was very upset and was complaining that he fell while being transferred to his chair. CNA assigned was called and questioned about the claims the resident made. CNA stated that while he was transferring the resident he was too heavy for him and his buttock touched the floor. Resident is an Extensive Assist transfer with 2 Persons, Supervisor made aware. Call placed to (Physician) to inform him of incident with the resident. Resident stated that he has no pain or discomfort at this time, body check done and no signs of discoloration noted, resident is able to flex and extend all extremities, no swelling noted to body at this time, call placed to resident's wife...". A Physician's (MD) Note dated 10/11/13 documented the resident was examined for a "near fall" episode. The note further documented: "A&P(Assessment and Plan) Fall- no actual fall occurred, no signs of injury seen, no acute complaints reported- for fall precautions". The Incident Report dated 10/11/13 documented the resident stated he fell while being transferred by nursing staff. The report further documented the facility determined that there was no abuse, neglect, or mistreatment. The Investigation dated 10/11/13 documented: "Staff was instructed to follow facility policy to transfer resident with required amount of staff...Resident care plan was not followed. Staff transfer resident by himself and transfer required two person assistance. Disciplinary action was taken. Staff was re-inserviced immediately". There was no documented evidence that a statement was taken from the Licensed Practical Nurse (LPN) who initially spoke to the resident about the incident. There was no documented evidence that the neglect was reported to the Department of Health (DOH). On 10/24/13 at 11:37 AM, the Registered Nurse (RN) was interviewed and stated that on the date of the fall she attended an inservice meeting in the morning. She stated that when she returned to the unit around 12:15pm, the medication nurse informed her that the resident was upset and arguing in English and Creole and saying that the person that took care of him made him fall on the floor. The RN further stated that she asked the resident if he fell and he responded "yes" and denied having pain. She also stated that she asked the CNA what happened, and the CNA informed her that during a transfer done alone, he sat the resident on the floor because the resident was too heavy to hold up. She stated that she informed the supervisor and physician and started the incident report. On 10/24/13 at 12:51 PM, the CNA was interviewed and stated that he transferred the resident from the bed to wheelchair (w/c) by himself because he thought the resident required one person assist instead of two. He further stated that resident was agitated and when he realized he could not bear the resident's weight, he lowered the resident to the floor. The CNA stated that he moved the resident back to the bed and then transferred him to the w/c. He stated that at the time, he was not thinking and automatically picked the resident up. The CNA stated that he did not see the nurse on the floor at that time and began helping another resident. He stated that he should have told the nurse immediately about the fall, and he should not have moved the resident until he was assessed by the nurse. He stated that he has been re-inserviced on abuse, neglect, and mistreatment. The CNA also stated that he has also been instructed to read the CNA Accountability before providing care to the residents. On 10/24/13 at 2:08 PM, the Licensed Practical Nurse (LPN) was interviewed and stated that the resident was agitated and mumbling in the dining room so she spoke to him in Creole to see what was wrong. She further stated that the resident told her that one of the aides dropped him and hit him. She stated that the resident was very upset, and when she asked him which CNA did this, he pointed to a CNA in the room that did not work with him. The LPN stated that she reported the information to the RN. On 10/25/13 at 12:33 PM, the Registered Nurse Manager (RNM) who completed the investigation was interviewed and stated that statements are taken from all immediate staff for an investigation. She further stated that she did not notice that the LPN did not complete a statement for the investigation when she reviewed all the information. She stated that she did ask the resident what happened the next day, and he said he fell . The RNM stated she knew the CNA did not follow the plan of care, but she did not feel it was neglect. She stated that she re-inserviced the CNA on abuse and suspended him because she knew it was serious. The RNM stated that the CNA is per diem and staff are aware that he should be monitored. The CNA has not been re-assigned to the resident's floor. On 10/25/14 at 12:02 PM and 2:51 PM, the Director of Nursing (DON) was interviewed and stated the investigation should have contained a statement written by the LPN who initially spoke to the resident about the incident. She further stated that she was never told that the resident stated he was hit, and she would immediately look into what the LPN told the surveyor so that it can be investigated. She stated that the incident was neglect and the team discussed reporting it to DOH, but they concluded that since there was no negative outcome of injury or fracture it was sufficient to re-inservice and suspend him. The DON stated that she spoke to the resident (in Creole) and the LPN to clarify what was meant when the resident stated he was hit. The DON stated that the resident hit his arm and leg when he fell . He did not get hit by the CNA. 415.4(b)(1)(ii)