Every finding on record at Salem Hills Rehabilitation And Nursing Center

Based on observations and interviews conducted during the recertification survey from 4/21/2026 to 4/28/2026, the facility did not ensure that food was stored in accordance with professional standards for food safety practice. Specifically, the walk-in freezer and walk-in refrigerator had open and undated items.The findings include:The facility policy and procedure, Food Expiration Dates, Date Marking, Storage, and Disposition of Food Items last reviewed on 10/2/2025, documented the facility shall maintain a standardized system for monitoring manufacturer expiration dates and internal use or discard dates. Food items unreadable, missing date markings must be discarded immediately. No improperly stored food item shall be served or made available for resident consumption. During an initial tour of the kitchen on 04/21/2026 at 9:25 AM, conducted with the Lead Cook, observation of the walk-in freezer revealed an opened and uncovered box of frozen nuggets and a box of frozen eggs stored without expiration dates; and bags of waffles, sweet potatoes and donuts were removed from their original boxes and stored without labels or expiration dates. Observation of the walk-in refrigerator revealed an open bag of grated Parmesan cheese that was not labeled with an expiration date.During an interview on 4/21/2026 at 10:11 AM, the Lead [NAME] stated that they were responsible for storage and labeling of food products in the kitchen and stated that all items must be labeled upon opening with both the date opened and expiration date. The Lead [NAME] was unable to identify the expiration dates of the observed food items.During an interview on 4/21/2026 at 10:53 AM, the Food Service Director stated that in their absence, the Lead [NAME] was responsible for checking stored food items daily for proper labeling and expiration dates. The Food Service Director stated that once a product was opened, staff were required to label it with the date opened and expiration date, and any food item with missing or unreadable labeling must be discarded immediately. 10NYCRR 415.14 (h)

Based on observations, record reviews, and staff interviews conducted during the recertification survey from 4/21/2026 to 4/28/2026, the facility did not ensure residents were assessed for side rails and the resident or resident representative were informed of the risks and benefits of side rails or that they obtained informed consent prior to the installation of side rails for three (3) of five (5) residents (Residents #16, #63, and #77) reviewed for accident hazards. Specifically, Residents #16, #63, and #77 had bilateral side rails on their beds and there was no documented evidence they were assessed for the use of side rails prior to installation. There was no documented evidence that the residents and/or their representatives were informed of the risks and benefits of side rails, or that informed consent was obtained prior to installation of side rails. There were no care plans to address the use of side rails, and no physician orders. The findings are: The facility Side Rail policy revised 8/4/2022 documented upon admission, all residents will be assessed by the licensed nurse for the use of bed rails utilizing the side rail assessment form. Education will be provided to the resident /family regarding the potential risks/negative outcome of its use. A resident may request the use of side rails for their personal security /comfort via signed acknowledgment. The licensed nurse will obtain a physician's order stating the type and medical need. The RN nurse manager is responsible for initiating a specific care plan for use in the comprehensive care plan, The licensed nurse will ensure this use is carried over to the certified nurse aide care card. The interdisciplinary team shall be responsible to review and determine the need quarterly and as needed via the assessment/comprehensive care plan process. The side rail assessment form will be completed in the electronic medical record and reviewed quarterly. 1) Resident #16's diagnoses included orthopedic conditions, non-Alzheimer's dementia, seizure disorder. The 2/2/2025 Minimum Data Set admission assessment documented Resident #16 had severely impaired cognition, no behavioral symptoms, one lower extremity impairment, and no restraints. The resident required partial/moderate assistance with rolling in bed, sit to lying in bed, and sit to stand, and substantial/maximal assistance with transfers. On 4/21/26 at 10:30 AM Resident #16 was in bed, and 2 side rails were observed in the up position on Resident #16's bed. On 4/22/26 at 12:47 PM, 2 side rails were observed in the up position on Resident #16's bed. During record review, the side rail assessment form in Resident #16's physical chart was not completed. During record review, there was no side rail assessment documented in Resident #16's electronic medical record. During record review, there were no physician's orders for Resident #16 for side rails or enablers. The 1/26/2025 Nursing admission Assessment, completed by Registered Nurse #6, documented Resident #16 was able to move all extremities. Physical limitations were not documented either yes or no. The 1/27/2025 Activities of Daily Living Functioning Care Plan documented Resident #16 required assistance of one staff with bed mobility and toilet use. There was no documentation of side rails in the care plan interventions. The 5/9/2025 Nursing admission Assessment, completed by Registered Nurse #9, documented Resident #16 was able to move all four extremities and had no physical limitations. The 2/03/26 Quarterly Minimum Data Set assessment documented Resident #16 had severely impaired cognition, no behavioral symptoms, no physical impairments, no restraints. The resident required dependent assistance with chair to bed transfers, and substantial /maximal assistance with rolling in bed. The current Certified Nurse Aide tasks (care instructions) did not document the use of side rails for Resident #16. On 04/23/2026 at 1:47 PM during an interview and record review with Registered Nurse Unit Manager #2, they stated there was no documentation of consent for the use of side rails and there was no side rail assessment documented for Resident #16. Registered Nurse Unit Manager #2 stated that the use of side rails had not been documented in Resident #16's care plan or certified nurse aide care guide, and there were no physician's orders for side rails. On 04/27/2026 at 1:44 PM during an interview, Registered Nurse #6 stated they completed the nursing admission assessment and baseline care plan on 1/26/2025 for Resident #16. They stated that Resident #16 was able to move and was appropriate for using side rails as enablers. Registered Nurse #6 stated they did not know whether they should have completed a side rail assessment and/or side rail care plan, and they did not ask another nurse as they were not aware it was their responsibility. On 04/28/2026 at 9:55 AM during an interview, Registered Nurse #9 stated they completed the Nursing admission Assessment for Resident # 16 on 5/09/2025 for a readmission. They stated they were aware that residents should be assessed for the use of side rails. They stated the side rail assessment should have been completed on admission, re-admission, and quarterly. They stated they did not know why a side rail assessment was not completed on 5/09/2025 for Resident #16. They stated that on admission and re-admission, another Registered Nurse might have been responsible to complete the side rail assessment, obtain a consent, obtain a physician's order, and initiate a side rail care plan. 2) Resident #63's diagnoses included non-Alzheimer's dementia, malnutrition, and hypertension. The 6/29/2025 Minimum Data Set admission assessment documented Resident #63 had severely impaired cognition, no behavioral symptoms, no physical impairments, and no restraints. The resident required supervision with rolling in bed and sit to stand and transfers and ambulation. On 4/21/26 at 9:51AM and 4/22/26 at 12:48 PM, side rails were observed in the up position on Resident #63's bed. During record review, the side rail assessment form in Resident #63's physical chart was not completed. During record review, there was no side rail assessment documented in Resident #63's electronic medical record. During record review, there were no physician's orders for Resident #63 for side rails or enablers. The 11/16/2025 Nursing admission Assessment, completed by Registered Nurse #7, documented Resident #63 was able to move all extremities and had no physical limitation. The 3/15/26 Minimum Data Set significant change assessment documented Resident #63 had severely impaired cognition and no physical impairments. Resident #63 required dependent assistance with ambulation, and partial/moderate assistance with chair to bed transfers, rolling in bed, lying to sitting in bed, and sit to stand. The 6/23/2025 Activities of Daily Living Functioning Care Plan did not include documentation of the use of side rails for Resident #63. The current certified nurse aide tasks did not include documentation of the presence of side rails for Resident #63. During an interview and record review on 04/23/2026 at 1:50 PM with Registered Nurse Unit Manager #2, they stated there was no documentation of consent for the use of side rails and no side rail assessment was documented for Resident #63. Registered Nurse Unit Manager #2 stated that the use of side rails had not been documented in Resident #63's care plan or certified nurse aide care guide, and there were no physician's orders for side rails. On 04/27/2026 at 4:38 PM during an interview with Registered Nurse #7, they stated they completed the Nursing admission Assessment for Resident #63 when Resident #63 was re-admitted on [DATE]. They stated that Resident #63 had no physical limitations and was able to move all four extremities and was appropriate for side rails as enablers. Registered Nurse #7 stated they should have completed a side rail assessment to determine if side rails were appropriate for Resident #63. Registered Nurse #7 stated they should have notified the resident's family or endorsed to another nurse regarding the use of side rails and asked if they consented to the resident using side rails. Registered Nurse #7 stated they should have discussed the use of side rails with the physician or asked another nurse to do so. Registered Nurse #7 stated they should have initiated a side rail care plan or ask another nurse to do so. 3) Resident #77 was admitted with diagnoses that included multiple sclerosis, seizures and insomnia. The 03/20/2026 admission Minimum Data Set (an assessment tool), documented Resident #77 had moderate cognitive impairment, no behaviors, impairments on both sides of upper and lower extremities, and required substantial/maximal assist with bed mobility and did not walk. The 3/13/26 care plan on Activities of Daily Living functional/rehabilitation potential documented self-care deficit related to physical limitations and medical co-morbidities. The goal was to participate as physically capable in activities of daily living skills. Interventions included but not limited to refer to rehab services as needed provide adaptive equipment as applicable, monitor pain and discomfort, provide time for resident to perform tasks, and provide privacy within individualized safe parameters. The care plan did not document the use of side rails. During an observation on 04/23/2026 at 10:46AM, Resident #77 was observed in bed in supine (lying on their back) position, awake, alert with both side rails up. During an interview on 04/27/2026 at 1:29 PM, Registered Nurse #2 stated that they completed the admission assessment on 03/13/2026 for Resident #77. They reviewed the admission assessment and confirmed that Resident #77 had physical limitation of upper right and upper left extremity and was able to move right upper and left upper extremities. They stated that the physical limitation was because resident was not able to fully extend both upper extremities during the assessment. They stated that they did not assess if Resident #77 was appropriate for use of side rail. They stated that they should have assessed Resident #77 for the use of side rails but did not. During an interview on 04/23/2026 at 2:50 PM, Charge Nurse #5 stated that side rails should be assessed on admission, a consent was needed, the assessment should have been completed by the Registered Nurse. Charge Nurse #5 stated if the resident was cognitively impaired and family requested side rail, a consent form was completed. On 04/24/2026 at 11:28 AM during an interview, the Director of Nursing stated that side rail assessments should have been completed by the Registered Nurse who completed the admission assessment. The Director of Nursing stated that the Registered Nurse Unit Manager was responsible for the quarterly assessments for the continued use of side rails. If side rails were appropriate for the resident, the Registered Nurse who completed the resident's admission was responsible for notifying the resident/family regarding the risks and benefits of the use of side rails. The Director of Nursing stated that if the resident/family consented to the use of side rails, a consent form was completed prior to the use of side rails. The Director of Nursing stated that the next step was the Registered Nurse would notify the physician and enter an order for side rails, then they should initiate a care plan for the use of side rails and update the certified nurse aide care guide of the presence of side rails. On 04/28/2026 at 10:48 AM during an interview, the Rehab Director stated that rehab therapists did not complete side rail assessments. They stated they completed assessments which included assessing for use of side rails for bed mobility and made recommendations to the nursing team regarding transfers, ambulation, positioning, bed mobility, wheelchair positioning, and side rails. They stated they wrote their recommendations in a Physical Therapy Progress Note and flagged it to the 24-hour report for the Nursing staff to see it. 10NYCRR 415.12(h)(1)

Based on observation, record review and interviews during the recertification survey from 4/21/2026 through 4/28/2026, the facility did not ensure residents had the right to a dignified dining experience for one (1) (Resident #67) of four (4) residents reviewed for dignity. Specifically, the Certified Nurse Aide was observed standing over Resident #67 while assisting the resident with their meal. The findings include:The facility policy titled Dignity and Assistance During Dining or Feeding last date reviewed 7/10/2025, documented that staff providing feeding assistance shall sit at eye level with the resident whenever possible.Resident #67 was admitted to the facility with diagnoses including hereditary and idiopathic neuropathy, depression and malnutrition.The Minimum Data Set (resident assessment) dated 2/6/2026 documented Resident #67 had moderately impaired cognition and functional limitation in range of motion, with impairment in both upper extremities. Resident #67 was dependent on staff for eating.The Comprehensive Care Plan, Potential for Altered Nutritional Status dated 7/30/2025, documented provide necessary encouragement and assist during meals to optimize intake.During observations on 4/21/2026 at 1:02 PM and 1:17 PM Resident #67 was in bed during the lunch meal. Certified Nurse Assistant # 16 was standing over the resident while providing feeding assistance.During an interview on 4/21/2026 at 1:19 PM Certified Nurse Assistant # 16 stated they assisted Resident #67 with feeding and stated they were standing over the resident at the time. Certified Nurse Assistant # 16 stated they were aware that they should sit at eye level with the resident while providing feeding assistance. 10 NYCRR 415.5 (d) (1)(i)

Based on observations, record reviews and interviews conducted during the recertification survey from 04/21/2026 to 04/28/2026, the facility did not ensure a person-centered comprehensive care plan was developed and/or implemented for two (2) of seven (7) residents (Resident #93 and #87) reviewed for activities of daily living. Specifically, 1) for Resident #93 a care plan was not developed for refusal of nail care. 2) for Resident #87 a comprehensive care plan was not developed to address the use of side rails.Findings include: 1. Resident # 93 had diagnoses including cerebral infarction, dysphagia and essential hypertension. The facility policy, Nail Care, revised 04/10/2025 documented in order to maintain the resident's dignity, prevent injury and infection, fingernails are to be maintained in a clean, short, well- manicured condition. The quarterly Minimum Data Set (an assessment tool) dated 04/04/2026 documented Resident #93 had impaired cognition, had no rejection of care, and had other behavioral symptoms not directed towards others. The Activities of Daily Living Care plan dated 07/01/2025 documented nail care to be done weekly or as needed as per resident's preference and the resident was dependent on staff for personal hygiene. The Behavior Problem care plan dated 03/ 08/ 2026 documented that the resident was noted to play with feces, spreading it on linens and throwing it. During observations on 04/21/2026 at 2:21 PM, 04/22/2026 at 9:16 AM, 04/24/2026 at 9:23 AM, and 04/27/2026 at 9:37 AM, the resident had fingernails that were long and dirty. During an interview on 04/28/ 2026 at 9:59 AM, Certified Nurse Aide #11 stated the resident's nails were very long. They stated that the resident did not let them cut their nails and the resident fought them if they attempted to give nail care. Additionally, Certified Nurse Aide #11 stated that they asked the therapist to help with the nail care and the resident still refused. They stated that they had made nursing aware. During an interview on 04/ 28/ 2026 at 11:59 AM, Registered Nurse #13 stated that the certified nursing aides performed nail care for the residents, and it was done on shower days twice a week. They stated that if a resident refused nail care, they would reapproach the resident at a later time. They stated if the resident continued to refuse nail care, they would pass it on to the next shift so that they could attempt to render the nail care. Registered Nurse #13 stated that the resident refused nail care by pulling their hands away and raising their hands up. They stated that the certified nursing aide told them that the resident refused nail care and they told the charge nurse but did not write a progress note. They stated that not rendering nail care could result in infection for the resident. During an interview on 04/28/2026 at 12:24 PM Registered Nurse Unit Manager #2 stated that nail care was done routinely with showers and as needed. They stated that if a resident refused nail care, it would be passed on in report for staff to try again. They stated they were aware that Resident # 93 refused nail care. They stated that they did not document this in the progress notes and there was not a refusal of care plan for Resident #93 and there should have been 2. Resident #87 had diagnoses including non-traumatic brain dysfunction, non-Alzheimer's dementia and depression. The Minimum Data Set (resident assessment) dated 3/27/2026 documented Resident #87 had severely impaired cognition and was dependent on staff for all functional abilities. The Restraint and Side Rail assessment dated [DATE] documented Resident #87 did not have the ability to get in and out of bed independently with a side rail and required assistance. Side rails were utilized to enable positioning in bed. Review of the physician's orders and comprehensive care plan revealed no evidence that an order for side rails was obtained, nor that a comprehensive care plan was developed or implemented to address the use of side rails. During observations on 4/21/2026 at 10:34 AM, 11:01 AM and 12:46 PM and on 4/22/2026 at 10:09 AM and 12:47 PM, Resident #87 was in bed with two (2) one-half side rails in the raised position. During an interview on 4/27/2026 at 4:46 PM, Registered Nurse #14 stated that Resident #87 was unable to make significant movement in bed independently, however, if prompted, the resident could reach for and grab the side rail. Registered Nurse #14 stated they were responsible for completing the admission assessment but were not responsible for obtaining physician's orders or initiating care plans, stating that the nursing supervisor would be responsible for initiating care plans. During an interview on 4/27/2026 at 5:02 PM, Licensed Practical Nurse Evening Supervisor # 15 stated that obtaining physician orders and initiating care plans were outside of their scope of practice. Licensed Practical Nurse Evening Supervisor #15 stated that the admission registered nurse was responsible for contacting the physician and obtaining orders and for initiating both baseline and comprehensive care plans, including evaluation of the need for said rails. During an interview on 4/27/2026 at 9:40 AM, the Director of Nursing stated that the admission nurse was responsible for completing admission assessment, initiating the baseline care plan, and developing the comprehensive care plan. The Director of Nursing stated that if the admission nurse did not complete or initiate required care plans, the next registered nurse who was taking care of the resident would be responsible to review, initiate, and complete the care plans. 415.11(c)(1)

Based on observations, record review, and interviews conducted during the recertification survey from 04/21/ 2026 to 04/28/2026, the facility did not ensure each resident who was unable to carry out activities of daily living received the necessary care and services to maintain good personal hygiene for one (1) of seven (7) residents (Resident #25) reviewed for activities of daily living. Specifically, Resident #25, required dependent assistance with activities of daily living was observed sitting in a wet soiled diaper.Findings include:The facility policy Activities of Daily Living, last reviewed on 11/ 07/ 2023, documented residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.Resident # 25 had diagnoses including Parkinson's disease with dyskinesia, cerebral infarction and functional quadriplegia.The quarterly Minimum Data Set (an assessment tool) dated 04/08/2026 documented the resident had impaired cognition, was frequently incontinent of bowel and bladder and was dependent on staff for toileting hygiene.The comprehensive care plan Activities of Daily Living dated 04/08/23 documented Resident #25 required extensive assistance of 2 staff members for toileting.During an observation on 04/21/2026 at 11:30 AM, Resident # 25 was sitting in their wheelchair in the dining room. During an observation on 04/ 21/ 2026 at 3:49 PM, Resident #25 was sitting in the same exact spot as the previous observation.During an interview on 04/ 21/ 2026 at 3:49 PM, Certified Nurse Aide #12 stated they were going to change the resident after dinner. At the surveyor's prompting, Certified Nurse Aide #12 took Resident # 25 to their room and checked the resident for incontinence. At 4:06 PM Certified Nurse Aide #12 stated that the resident's brief was wet and contained a bowel movement.During an interview on 04/24/2026 at 2:40 PM, Certified Nurse Aide #11 stated they were assigned to Resident #25 on 04/21/2026 and got them out of bed between 9:30 AM and 10:00 AM. They stated that the resident was in the day room for most of the day. They stated that they asked Resident #25 if they needed to use the bathroom before taking their lunch break and stated that the resident declined toileting at around 1:30 PM. Certified Nurse Aide #11 stated that they did not remember if they checked the resident after returning from their lunch break. They stated that they usually checked residents two to three times every shift and that sometimes Resident #25 was alert and able to request toileting and other days they were too confused to request toileting.During an interview on 04/ 28/ 2026 at 11:46 AM Registered Nurse #13 stated that all the residents should be toileted every two hours. They stated that the residents who were alert would tell staff when they need to be changed. They stated that residents who were not alert would be checked by a certified nurse aide by bringing them to their room to make sure that their briefs were not soiled. Registered Nurse #13 stated they did rounds to make sure residents were being changed by checking the resident's brief and helping residents who needed to be toileted. They stated that Resident#25 usually was toileted after lunch and checked throughout the day.During an interview on 04/ 28/ 2026 at 12:31 PM Registered Nurse Unit Manager #2 stated that all residents should be toileted every two hours and as needed. They stated they could tell when residents needed to be changed by checking their briefs in the shower room, sensing an odor or if the resident appeared restless. They stated that there were residents who could verbalize if they need to be changed. Registered Nurse Unit Manager #2 stated that they did not feel it was inappropriate to ask a cognitively impaired resident about toileting; however, if they refused, staff should always follow up and take them to a private area to check their brief. 415.12(a)(3)

Based on observation, interview, and record review conducted during the recertification and abbreviated survey (NY00323734) from 5/9/24 to 5/16/24, the facility did not ensure adequate supervision was provided and that the resident's environment remained as free of accidents hazards as possible for 3 of 7 residents (Residents #89, #72, and #3) reviewed for accidents. Specifically,1) Resident #89 did not receive 1:1 supervision as per plan of care, resulting in a fall, 2) Resident #72 had multiple oral medications and eye drops (left by nursing) in their room on a dementia unit with twelve residents with wandering behaviors, and 3) Resident #3 had medicated creams (left by nursing) in their room on a dementia unit with twelve residents with wandering behaviors. The findings are: The facility policy and procedure, titled Accident Prevention/Falls last revised 12/15/2023 documented it was the policy of the facility to provide adequate supervision, assistance, and assistive devices to prevent accidents. 1. Resident #89 was admitted with diagnoses including but not limited to non-Alzheimer's dementia, anxiety disorder, and mood affective disorder. The Quarterly Minimum Data Set (an assessment tool) dated 8/16/23 documented severely impaired cognition. The resident required 1-person limited assistance with ambulation. The care plan titled Risk for Falls documented on 9/3/23 the resident had a fall and sustained a hematoma (solid swelling of clotted blood) to the left side of the forehead and was sent to the emergency room . The 9/4/23 care plan note documented the resident was placed on 1:1 upon return from the emergency room . The 9/5/23 care plan note documented the resident was to remain on 1:1 observation for 2 more days. The Incident / Accident Report dated 9/5/23 documented, 'resident identified as at risk for incident /accident due to dementia, self-care deficit, history of falls dependent with activities of daily living'. The incident / accident report documented an unwitnessed fall at 10:35 PM. On 5/15/24 at 4:25 PM during an interview, the Director of Nursing stated Resident #89 was on 1:1 supervision upon return from the hospital on 9/4/23 after a fall and was supposed to be on 1:1 supervision for 3 days from 9/4/23 to 9/7/23. The Director of Nursing stated that when Resident #89 had another fall on 9/5/23, the resident was on 1:1 supervision, but the certified nurse aide who was providing 1:1 supervision had stepped away from Resident #89. The Director of Nursing stated that the Registered Nurse and Licensed Practical Nurse Supervisor had educated the certified nurse aide who was assigned to provide 1:1 supervision of Resident #89 not to leave Resident #89 unsupervised, and to ask for assistance or relief if needed. On 5/15/24 at 4:30 PM during an interview, Staff #21 (Registered Nurse) who was on duty 9/5/23 at the time of Resident #89 fall stated the certified nurse aide who was assigned to do 1:1 supervision for Resident #89 had stepped away from the resident and when they returned to the resident's room they found the resident on floor of their room. The Registered Nurse stated the certified nurse aide who was assigned to do 1:1 supervision of Resident #89 had been educated to stay with the resident at all times and to ask for assistance or relief if they needed to step away, but the certified nurse aide had not asked for assistance or relief. On 5/16/24 at 8:20 AM during an interview, Staff #13 (Licensed Practical Nurse Supervisor) stated they were on duty on 9/5/2023 on the 3-11 evening shift. They stated the certified nurse aide who was assigned to 1:1 supervision of Resident #89 had stepped out of the resident's room. They stated the certified nurse aide who was assigned to 1:1 supervision of Resident #89 had been educated by them and by the Registered Nurse on duty not to leave the resident unsupervised at any time, and to ask for relief if needed. On 5/16/2024 at 8:30 AM during an interview, Staff #17 (certified nurse aide) who was assigned to 1:1 supervision of Resident #89 stepped out of Resident #89 room. They stated they did not ask another staff for assistance or for relief prior to leaving the room. They stated the registered nurse on duty had explained to them not to leave Resident #89 alone, and to ask for assistance or relief if needed. 48847 2. The facility policy titled Medication Administration dated 1/02/2019 and reviewed on 03/12/2024 documented the goal was to ensure safe and accurate medication administration, to stay with the resident until medication was swallowed, and to never leave medication at the bedside. Resident #72 was admitted with diagnosis including but not limited to Alzheimer's disease, major depressive disorder, and shared psychotic disorder. The Quarterly Minimum Data Set (resident assessment tool) dated 4/17/23 documented that Resident #72 had severely impaired cognition, required extensive with toileting, limited assistance with transfers, was independent with eating and bed mobility and had no behaviors or rejection of care. The care plan titled Cognitive Patterns; Dementia dated 8/21/21 documented staff will remind resident to maintain daily schedule, offer resident simple choices, provide cues and assistance as needed. On 05/09/24 at 10:32 AM, Resident #72 was observed in their room. Two almost full bottles of Latanoprost eye drops were observed on the resident's bed side table. One bottle was filled on 11/7//23 and the other was filled on 3/21/24. On 05/10/24 at 09:57 AM, Resident #72 was observed in their room sitting in a chair. There were two medicine cups containing multiple oral medications, and 2 almost full bottles of Latanoprost eyedrops were observed on the bed side table. Resident #72 stated they didn't know when the medications were put on their table and stated they did not know when to take them. Resident #72 stated they took them when they felt like it. They're only vitamins. On 05/10/24 at 03:28 PM, Resident #72 was observed in their room. One medicine cup with multiple oral medications was observed on the bedside table (Seroquel (antipsychotic) 2.5 mg, Seroquel 12.5 mg, Aldactone (water pill) 25 mg, folic acid (vitamin) 1 mg, Diltiazem (blood pressure medicine) CD 240 ER 24 hr, Lasix (water pill) 40 mg, Eliquis (blood thinner) 5 mg x 2, gabapentin (anticonvulsant) 100 mg, Atorvastatin (cholesterol medication) 20 mg, and Aricept (dementia medication) 5 mg) and Latanoprost (eye drops). On 05/10/24 at 03:35 PM, the Assistant Director of Nursing was observed removing the oral medications from Resident #72's bed side table and at 3:40 PM provided the sureveyor a list with names for the medications that had been removed from the residents room. On 05/10/24 at 04:00 PM, the Assistant Director of Nursing stated they were told by Staff #12 (Licensed Practical Nurse) that the medications were left in the room unattended due to Resident #72 stating they were going to take the medication. The Assistant Director of Nursing stated that it was unacceptable and not good practice for nurses to leave medications unattended at residents' bedside and that Resident #72 was not capable of self-administering medication. The Assistant Director of Nursing stated that the medications found in the Resident #72 room were a mixture of day and evening shift medications and that if a resident refused medications, the nurse should have taken the medications out of the resident's room, written a nurses note, and notified the doctor. During an interview on 05/10/24 at 04:24 PM, Staff #12 (Licensed Practical Nurse) stated they did leave medications in Resident #72's room and that they were aware that medications should never be left unattended. Staff #12 (Licensed Practical Nurse) stated that they should always make sure residents take their medications and if a resident refused, they should report to the charge nurse and document. Review of all Care Plans revealed that there were no care plan in place for self-medication administration. During an interview with on 05/15/24 at 12:25 PM, Staff #22 (Registered Charge Nurse) stated that oral medications should never be left in the residents' rooms because it was a safety hazard and if a resident refused medications, the nurse should re-approach, and if the resident continued to refuse, the nurse should remove medications from the room, document, and make the registered nurse aware. Staff #22 stated that there were a lot of residents who wandered on the unit who may wander into rooms. Staff #22 stated that leaving oral medications in a resident room was a safety issue. During an interview on 05/16/24 at 10:45 AM, the Director of Nursing stated that it was unsafe to leave medications in a resident's room and that the nurse should have ensured that the resident took the medications. The Director of Nursing stated if the resident refused, the nurse should not have left the medications unattended. During an interview on 05/16/24 at 12:41 PM, the Nurse Practitioner stated they were made aware of oral medications being left unattended in Resident #72's room. The Nurse Practitioner stated Resident #72 was not psychologically intact to self-administer their own medications and would not advise them to administer their own medications. The Nurse Practitioner stated that it was harmful to leave medications in the residents' room because there were residents who wandered. The Nurse Practitioner stated Resident #72 did not know what the medications were and would not know how to consume them. 3. Resident #3 was admitted with diagnosis including but not limited to bilateral primary osteoarthritis of knee, polymyalgia rheumatica, and primary osteoarthritis of shoulder. The Comprehensive Minimum Data Set, dated dated dated [DATE] documented that Resident #3 had intact cognition, required moderate assist with toileting, transfers, and bed mobility, and was independent with eating. Review of all Care Plans revealed that there were no care plan in place for self-medication administration. On 05/09/24 at 11:08 AM and 5/10/24 at 10:11 AM Resident #3 was observed in their room. Multiple tubes of medicated creams which included: Clobetasol (steroid), Lotrimin ultra (anti-fungal), hemorrhoidal ointment, miconazole nitrate (anti-fungal) 2% topical cream were observed on their nightstand. Resident #3 stated that the creams were left by the nurse and either the nurse applied the creams, or they applied the creams. On 05/10/24 at 03:14 PM, Resident # 3 was observed with multiple tubes of medicated creams on their nightstand. Resident #3 stated that they were in the process of ordering new creams because the applicator was not sanitary. Resident #3 stated that some of the creams were for gynecological problems and stated that the nurses left the creams in their room. On 05/13/24 at 02:54 PM, Resident #3 was observed in their room. Clobetasol cream was observed on the resident's nightstand dated 4/25/24. Resident #3 stated the nurses previously removed the creams but then gave it back. During an interview on 05/10/24 at 04:00 PM, the Assistant Director of Nursing stated that creams should never be left in a resident's room unless they have an order to self-apply and stated that they were not sure if Resident #3 was able to self-apply creams/ointments. During an interview on 05/10/24 at 04:24 PM, Staff #12 (Licensed Practical Nurse) stated that the creams had been in Resident #3's room for a while and was unsure if there was a physician order to self-apply. During an interview on 05/13/24 at 02:55 PM, Staff #12 (Licensed Practical Nurse) stated that Resident #3 could not self-apply Clobetasol and that the nurses must apply it. Staff #12 (Licensed Practical Nurse) stated that Resident #3 should not have had that Clobetasol in their room and stated that they thought that it had been removed. Staff #12 (Licensed Practical Nurse) stated that creams should be kept locked away in the treatment cart and stated that oral medications were not safe to keep in residents' room due to residents who wander on the unit. During an interview on 05/16/24 at 10:45 AM, the Director of Nursing stated medications and creams must be stored away in the locked medication and treatment carts. During interview on 05/16/24 at 12:41 PM, the Nurse Practitioner stated that they didn't know that an official self-medication administration assessment was required and was just going off what the nurses told them about the resident being able to apply their own creams. The Nurse Practitioner stated the first time that they assessed Resident #3 to self-apply creams was on 5/14/24, and when they assessed them, they did not want them to be confused with the two creams (Clotrimazole and Clobetasol) because one is to applied to the Resident's face and the other is for the Resident's vaginal area. The Nurse Practitioner stated that when nursing staff showed them the bags with the creams that were left in the resident's room, they were shocked because the resident could get confused about which cream is for which body. The Nurse Practitioner stated the nurses should have been applying the Clobetasol cream and it should not have been left in the room, due to safety concerns. 10NYCRR 415.12

Based on observation, record review and interview conducted during the recertification survey from 5/9/2024 to 5/16/2024, the facility did not ensure each resident was treated with respect and dignity in an environment that promotes maintenance of their quality of life for 2 of 3 residents (Resident #33 and #105) reviewed for dignity. Specifically, 1, Resident #33 was observed on several occasions wearing socks with name labels that were visible on the outside of both socks, and 2, Resident #105 was noted with photographs depicting the resident in positioning devices on the wall above the head of the bed and visible from the door. The findings are: Policy and Procedure reviewed 4/18/2024 documented all residents have a right to a dignified existence including the right to privacy and confidentiality. 1. Resident #33 was admitted with diagnoses including Alzheimer Disease, Cancer and Depression. The 4/2/24 Quarterly Minimum Data Set documented Resident #33 was rarely/never understood, used a wheelchair, was dependent for upper and lower body dressing, putting on/taking off footwear, and personal hygiene. During observation on 5/10/24 at 11:11 AM, 5/10/24 at 12:45 PM and 5/13/24 at 12:20 PM, Resident #33 was observed in the unit dayroom with pink socks on both feet. Name labels (resident name) were clearly visible on the outside of both socks. During an interview on 5/13/24 at 12:54 PM Staff #8 (Licensed Practical Nurse) stated it was policy that clothing items required name labels, if the facility did the residents laundry. Staff #8 stated that name label/s should be on the inside of socks, to avoid the name being visible to others. Staff #8 stated the visible name labels were a privacy and dignity issue. During an interview on 5/13/24 at 1:05 PM Staff #6 (Certified Nurse Aide) stated Resident #33's socks were labeled on the outside by the laundry staff. Staff # 6 stated that because Resident #33 did not wear shoes, the name labels on the socks were visible. Staff #6 stated they never reported to nursing that the name labels were visible on the outside of Resident #33's socks. During an interview on 5/13/24 at 1:30 PM Staff #7 (Licensed Practical Nurse Charge Nurse) stated that socks were labeled on the outside because most residents wore foot coverings/shoes. Staff #7 stated Resident #33 did not wear shoes. Staff #7 stated they were not aware that Resident #33's socks were labeled on the outside. Staff #7 stated they saw the concern as this was a dignity issue. 47626 2. Resident #105 was admitted with diagnoses including Dementia, Major Depression, and Glaucoma. The 3/31/24 Minimum Data Set documented Resident #105 had impaired cognition, and was dependent for all activities of daily living. During observation on 05/09/24 at 10:24 AM, 05/13/24 at 12:19 PM, and 05/14/24 at 10:09 AM, there were 2 photographs taped to the wall above Resident #105's bed. The photographs depicted the resident both in the wheelchair and in bed with a positioning device in place. The photographs were visible from the door and could be viewed by the resident's roommate and visitors. During an interview on 05/14/24 at 11:14 AM, Staff #23 (Physical Therapist) stated they posted the photographs behind the bed so the certified nurse aide understood the positioning device and how it should be placed. During an interview on 05/14/24 at 11:25 AM, the Director of Rehabilitation stated the photographs with the positioning devices should have been placed on the inside of the closet door, and should not be on the wall behind the bed. During an interview on 05/14/24 at 11:27 AM Staff #24 (Registered Nurse) stated the certified nurse aides used the photographs on the wall above the bed depicting the positioning device to show them how to use the positioning device. Staff #24 stated it was also on the care guide. 10NYCRR: 415.3 (d)(1)(i)

Based on observation, record review and interview conducted during the recertification survey from 5/9/24 to 5/16/24, the facility did not ensure that the call bell system was accessible for 1 of 5 residents (Resident #123) reviewed for environment. Specifically, multiple observations revealed that the call bell designated for Resident #123, was not within the resident's reach. The findings are: Resident #123 was admitted with diagnosis including but not limited to major depressive disorder, overactive bladder, and poly-osteoarthritis. The Risk for Falls care plan dated 4/5/24 documented interventions including answering calls for assistance promptly and call bell to be within reach. The Admission Minimum Data Set ( resident assessment tool) dated 4/11/24 documented Resident #123 had intact cognition, required setup with eating, was dependent with toileting and transfers, and required extensive assist with bed mobility. Furthermore, the Admission Minimum Data Set, dated dated dated [DATE] documented Resident #123 had impairments on both sides, upper and lower extremities, and sometimes felt lonely and isolated. On 05/09/24 at 11:12 AM, Resident #123 was observed in their room sitting in their wheelchair on the left side of their bed and the call bell was observed on the right side on the bed. Resident #123 attempted to reach for the call bell and was unable to stretch their left arm across the bed to reach the call bell. Resident #123 stated that that they could not reach the call bell and they needed it closer. Resident #123 stated that staff never leave the call bell within reach and that they needed it close to them so that they would be able to call for assistance. On 05/10/24 at 10:06 AM, Resident #123 was observed in their room sitting in wheelchair and their call bell was observed on the floor behind their wheelchair. Resident #123 stated that when the call bell was on the floor, they could not reach it. During an interview on 05/13/24 at 03:11 PM, Staff #14 (Certified Nurse Aide) stated that Resident #123 could use the call bell and that all residents should have call bells within reach for safety. During an interview 05/15/24 at 12:22 PM, Staff #22 (Registered Charge Nurse) stated that residents must always have calls bells within reach. Staff #22 stated that staff must ensure that the call bells were within resident reach whenever the resident was in their room, whether in bed or in their wheelchair. During an interview on 05/15/24 at 12:47 PM, the Director of Nursing stated that all call bells should be within reach of residents and that it was not acceptable for the call bells to be on the floor or not within resident reach. The Director of Nursing stated that Resident #123 was alert and oriented and was able to make their needs known. The Director of Nursing stated that was even more reason why their call bell should be within reach. 10 NYCRR 415.5(e)(1)

Based on observation, interview and record review conducted during the recertification survey from 5/09/24-5/16/2024, it was determined that for one (Resident #3) of seven residents reviewed for accidents, the facility did not ensure a comprehensive care plan that included measurable goals and interventions based on resident assessment was provided to maintain the resident's highest practicable physical well-being. Specifically, Resident #3 did not have a care plan in place for self-medication administration. The Findings Are: Resident #3 was admitted with diagnosis including but not limited to bilateral primary osteoarthritis of the knee, polymyalgia rheumatica, and primary osteoarthritis of the shoulder. The Comprehensive Minimum Data Set, dated dated dated [DATE] documented that Resident #3 had intact cognition, required moderate assist with toileting, transfers, and bed mobility, and was independent with eating. On 05/09/24 at 11:08 AM, Resident #3 was observed in their room and multiple tubes of medicated creams (clobetasol [corticosteroid], Lotrimin ultra [antifungal], hemorrhoidal ointment, miconazole nitrate [antifungal] 2% topical cream) were observed on their nightstand. On 05/10/24 at 10:11 AM, Resident #3 was observed in their room. Multiple tubes of medicated creams (clobetasol, lotrimin ultra, hemorrhoidal ointment, and miconazole nitrate 2% topical cream) were on the resident's nightstand. Resident #3 stated that the creams were left by the nurse and either the nurse applied them, or they applied them. On 05/10/24 at 03:14 PM, Resident #3 was observed in their room. Multiple tubes of medicated creams were on the nightstand. Resident #3 stated that they were in the process of ordering new creams because the applicator was not sanitary. Resident #3 stated that some of the creams were for gynecological problems and stated that the nurses left the creams in their room. On 05/13/24 at 02:54 PM, Resident #3 was observed in their room. Clobetasol cream was observed on the resident's nightstand dated 4/25/24. Resident #3 stated that the nurses previously removed the creams but then gave them back. There was no evidence in the medical record documenting that a self medication administration care plan had been put in place. During an interview on 05/10/24 at 04:00 PM, the Assistant Director of Nursing stated that creams should never be left in a resident's room, unless an order for self-application was in place. The Assistant Director of Nursing stated that they were not sure if Resident #3 was able to self-apply creams/ointments or if a care plan was in place. During an interview on 05/13/24 at 04:09 PM, the Director of Nursing stated that prior to 5/12/24, there was no care plan in place for medication self-administration. During an interview with on 05/15/24 at 12:25 PM, Staff #22 (Registered Charge Nurse) stated that updates to the care plan must be done when a change happens, and that care plans were updated quarterly and as needed. Staff #22 stated that there should be a care plan in place for Resident #3 to self-administer medications. 10 NYCRR 415.11(c)(1)

Based on observation, record review and interview conducted during the recertification survey from 5/9/24 to 5/16/24, the facility did not ensure 1 of 3 residents (Resident #57), reviewed for positioning, received treatment and care in accordance with professional standards of practice. Specifically, Resident #57 was observed on multiple occasions sitting in their wheelchair without their footrest extender. The findings are: The facility policy titled, Wheelchair and Positioning Devices, reviewed 8/15/2023 documented it was the policy of the rehabilitation department to determine and provide the appropriate wheelchair and positioning devices for residents. Resident #57 had diagnoses which included depression, dementia, and spinal stenosis, The Activities of Daily Living Functioning Care Plan dated 1/24/23 documented the resident required 1-person extensive assistance with locomotion in wheelchair and 2-person dependent assistance with transfers. The Quarterly Minimum Data Set (resident assessment tool) dated 2/25/24 documented Resident #57 had severely impaired, impairment on both upper and lower extremities, and required dependent assistance with activities of daily living including transfers and locomotion. The 3/11/24 physician's order for physical therapy documented evaluate footrests, resident's feet were not staying on footrests. The 3/12/24 occupational therapy note documented footrest extender placed / adjusted on bilateral leg rests with positive effect. Maintaining bilateral feet on footrests. On 5/9/24 at 10:33 AM, Resident #57 was observed in their wheelchair in the second-floor day room. Resident #57's feet were observed on the floor. Resident #57 was observed grimacing when the Assistant Director of Nursing repositioned their feet onto the wheelchair footrests. On 5/9/24 at 12:42 AM, Resident #57 was observed in the first floor dining room eating lunch with their guardian. Resident #57's feet were observed on the floor, not on their wheelchair footrests. On 5/9/24 at 12:43 AM during an interview, the resident's guardian stated the staff were supposed to put a device on Resident #57 wheelchair footrests, so their feet don't fall off the wheelchair footrests. On 5/10/24 at 11:02 AM, Resident #57 was observed sitting in their wheelchair in the second-floor day room, with no footrest extender in place to their wheelchair footrests. On 5/10/24 at 11:05 AM, a footrest extender was observed on the floor in Resident #57 room. On 5/13/24 at 12:30 PM during an interview, Staff #4, (Registered Nurse) stated they were aware that Resident #57 should have a footrest extender in place to their wheelchair footrests, but they were not aware that the resident did not have the footrest extender in place on 5/9/24 and 5/10/24. On 5/13/24 at 12:38 PM during an interview, Staff #5 (Certified Nurse Aide) stated they were responsible for the resident's care on Thursday 5/9/24. They stated they were aware that the resident required a footrest extender to their wheelchair footrests, but they forgot to apply it on Thursday 5/9/24. They stated they did not tell the nurse that it was not in place. On 5/13/24 at 1:28 PM during an interview, the Assistant Director of Nursing stated it was the certified nurse aide's responsibility to apply the footrest extender when they transfer the resident to their wheelchair. They stated the nurses were responsible to supervise the certified nurse aides. On 5/13/24 at 2:37 PM during an interview, the Director of Rehab stated the footrest extender was added to prevent the resident's feet from sliding off their wheelchair footrests. On 5/14/24 at 1:10 PM during an interview, Staff #11 (Certified Nurse Aide) stated they were responsible for the resident's care on Friday 5/10/24. They stated they were not aware that the resident required a footrest extender to their wheelchair footrests. They stated they floated to the unit and were not a regular on the unit. They stated they did not see the footrest extender in the resident's room. 10NYCRR 415.12

Based on observation, record review and interview conducted during the recertification survey from 5/9/2024 to 5/16/2024, the facility did not ensure that residents received treatment and services to prevent pressure ulcers for 2 of 8 residents (Residents #105 and #33 ) reviewed for pressure ulcers. Specifically, 1)Resident #105 was observed without a thigh cushion to off load their heels as ordered by the physician, and 2) Resident #33 who was assessed at high risk for pressure ulcers was observed on multiple occasions with their right heel resting on the metal wheelchair foot rest. The findings are: 1. Resident #105 was admitted with diagnoses which included dementia, depression, and glaucoma. The physician order dated 3/5/2024, documented during supine (lying on back) in bed put heels up cushion under thighs, and black skill care abductor-contracture cushion between lower legs and feet, except for during skin care and hygiene. The Braden Scale completed on 3/25/2024 documented the resident was a moderate risk for pressure ulcers. The Annual Minimum Data Set (an assessment tool) dated 3/31/24 documented Resident #105 had impaired cognition, was dependent with all activities of daily living, was at risk for pressure ulcers, and had no pressure ulcers. During observation on 05/10/24 at 9:52 AM and 05/14/24 at 10:11 AM, Resident #105 was lying in bed on their back. There was no abductor pillow between the legs and feet; there was no cushion under the thighs and the heels were not elevated off the mattress. The under thigh cushion was observed on the chair in the room. The care plan titled Skin integrity: At risk for Skin Breakdown with a 5/7/24 review date, documented interventions during supine in bed included a heels up cushion under thighs and black skil care abductor-contracture cushion between the lower legs and feet except for skin care and hygiene. The May 2024 certified nurse aide care guide documented to off load heels. During an interview on 05/14/24 at 11:35 AM, Staff #25 (Certified Nurse Aide) stated they normally used the positioning devices and off loaded the heels when Resident #105 was in bed. Staff #25 stated they did not know why the positioning cushion was not there today. Staff #25 stated sometimes the resident kicked off the positioning devices. During an interview on 05/16/24 11:15 AM, Staff #7 (Licensed Practical Nurse Manager) stated the resident needed their heels to be offloaded because the resident was at high risk for pressure ulcers. Staff #7 stated the certified nurse aide should off load the resident's heels. If the resident was not tolerating it they should let the nurse know. Staff #7 stated they were not aware the resident had been kicking off the positioning cushion. 39308 2. The facility policy and procedure titled Skin Integrity/Prevention of Pressure Ulcers with a 12/13/23 review date documented the policy was intended to serve as a guideline for the prevention of pressure ulcers in high risk residents/ decrease the risk of pressure ulcers and included encourage/assist with mobility in bed and in wheelchair. Resident #33 was admitted with diagnoses including Alzheimer Disease, Cancer and Depression. The 3/19/24 physician order documented physical therapy evaluation and treatment to assess and provide positioning device to both lower extremities when in bed due to the resident crossing both lower extremities, at risk for skin breakdown. The 3/19/24 physical therapy evaluation/treatment plan documented referral plan establish a wearing time and schedule for the knee separator to both lower extremities in bed and out of bed secondary to the resident crossing the lower extremities, placing them at risk for skin breakdown. The 3/27/24 Braden Assessment documented a score of 11(high risk) The 4/2/24 Quarterly Minimum Data Set documented Resident #33 was rarely/never understood, had 1 sided upper and lower functional limitations, used a wheelchair, was dependent for chair to/bed transfers, upper and lower body dressing, putting on/taking off footwear, was at risk for developing pressure ulcers, had no pressure ulcers, and was receiving 5 days of physical therapy. The care plan titled At Risk for Skin Breakdown with a 4/3/24 review date documented interventions including physical therapy/occupational therapy evaluation for appropriate preventive positioning device/s or equipment. The 4/17/24 physical therapy discharge summary documented the resident tolerated the knee separator to both lower extremities when in bed up to 80% of the time. The 4/18/24 physical therapy note documented discontinue from skilled therapy services as of 4/17/24 use knee separator to both lower extremities 8 hours as tolerated in bed. Observation on 5/10/24 at 11:00AM, Resident # 33 was in the unit dayroom/dining room sitting in their wheelchair with both legs elevated and without shoes. The left foot/lower leg was crossed over the right ankle/foot. The heel of the right foot was resting/pressing against the top corner of the metal foot rest. At 11:11 AM the Assistant Director of Nursing adjusted the placement of Resident # 33's sheet. At 11:18 AM Staff # 9 (Licensed Practical Nurse) wheeled Resident #33's wheelchair to a near by table. During the above observation/s there were no attempts to reposition Resident #33's feet/offload the right heel. Observation on 5/10/24 at 12:45 PM, Resident #33 was in the unit dayroom/dining room sitting in their wheelchair with both legs elevated and without shoes. The left foot/lower leg was crossed over the right ankle/foot. The heel of the right foot was resting against the top corner of the metal foot rest. Observation on 5/13/24 at 11:35 AM, Resident # 33 was in the elevator/sitting in their wheelchair with both legs elevated and without shoes while being escorted by facility staff. The left foot/lower leg was crossed over the right ankle/foot. The heel of the right foot was resting against the top corner of the metal foot rest. Observation on 5/13/24 at 12:20 PM, Resident # 33 was sitting in their wheelchair with both feet elevated and without shoes while being assisted with their lunch meal. The left foot/lower leg was crossed over the right ankle/foot. The inner right foot was pressed against the inner left metal foot rest. The heel of the right foot was pressed against the top corner of the metal foot rest. During an interview on 5/13/24 at 1:05 PM, Staff # 6 (Certified Nurse Assistant) stated if they positioned Resident #33's foot the resident always crossed the left foot over the right foot. Staff #6 stated Resident #33 did not have a foot rest cushion to offload the heels and did not look comfortable. Staff #6 stated that this was the normal position for Resident #33 but they had not discussed/reported the positioning to nursing/therapy. During an interview on 5/13/24 at 1:16 PM Staff #7 (Licensed Practical Nurse Charge Nurse) stated Resident #33 always rested the left leg over the right foot and they were not aware that the right heel was pressing against the metal foot rest. Staff #7 stated Resident #33 was at risk for skin breakdown if the right heel was resting against the metal foot rest. Upon checking the residents positioning at the time of interview, Staff #7 stated the residents right heel and right inner foot were resting on the metal foot rest/s. Staff # 7 stated they did see the concern. During an interview on 5/13/24 at 1:28 PM the Director of Rehabilitation stated both leg rests on Resident #33's wheelchair should elevate evenly and go back down. The Director of Rehabilitation stated that since the wheelchair foot pedals were metal and Resident #33 did not wear shoes they were at risk for areas of pressure. The Director of Rehabilitation stated that if the unit staff had positioning concerns, the unit nurse should reach out to rehabilitation via referral to request an evaluation and the reason for the evaluation. The Director of Rehabilitation stated they would need to make adjustments to Resident #33's wheel chair positioning/ foot rests. 10NYCRR 415.12(c)(1)

Based on observation, record review, and staff interview during the recertification survey from 5/9/24 to 5/16/24, the facility did not ensure that needed services, care and equipment were provided to assure that a resident with limited range of motion and mobility maintained or improved function based on the resident's clinical condition for 1 of 3 residents (Resident #89) reviewed for position and mobility. Specifically, Resident #89 was observed on 3 occasions without a right resting hand splint in place as ordered by the physician to prevent further contractures. Findings include: The facility policy & procedure titled Splinting reviewed 2/12/24 documented the purpose, indications, treatment procedure, and wearing schedules of splints. Resident #89 had diagnoses which included primary osteoarthritis, non-Alzheimer's dementia, and frontotemporal neurocognitive disorder. The medical note dated 1/11/24 documented Resident #89 was seen for slight swelling to right hand/fingers. Decreased range of motion to the right hand, wrist, and fingers. Minimal swelling noted, no tenderness. Passive range of motion and stretching performed with resistance. The occupational therapy evaluation & plan of treatment for certification period 1/11/24-2/9/24 documented stiffness of right upper extremity. Contracture: functional limitations present due to contracture. Skilled therapy is needed to address possible right hand/digit contractures. Resident #89 noted with guarding/facial grimacing upon range of motion techniques to right hand digits. Skilled occupational therapy services to assess the need for splinting devices and decrease painful condition of upper extremity. The occupational therapy treatment encounter note dated 1/26/24 documented schedule developed to wear resting hand splint at all times and be removed for skin checks/hygiene. Patient and caregiver training included resting hand splint wearing schedule. The physician's order dated 1/26/24 documented apply right resting hand splint to right hand, to be worn at all times, remove for skin checks and hygiene. The Quarterly Minimum Data Set (resident assessment tool) dated 2/16/24 documented the resident had severely impaired cognition, an impairment to the upper extremity on one side, and required dependent assistance with activities of daily living including transfers and locomotion in wheelchair. The care plan titled Activity of Daily Living Function last updated 2/16/2024 documented apply right hand resting splint to right hand to be worn at all times, remove for skin checks and hygiene. On 5/9/24 at 10:36 AM, 5/10/24 at 11:00 AM, and 5/10/24 at 4:07 PM Resident #89 was observed in their wheelchair in the 2nd floor day room. No right resting hand splint was observed. On 5/13/24 at 12:25 PM during an interview, Staff #3, (Certified Nurse Aide) stated that on 5/9/24, they did not apply the resident's right hand resting splint because it was dirty and needed to be cleaned. They stated they did not tell the nurse. On 5/13/24 at 12:30 PM during an interview, Staff #4, (Registered Nurse) stated they were not aware that Resident #89 was not wearing their right hand resting splint on 5/9/24. Staff #4 stated that on Friday at approximately 12:00 PM, the Assistant Director of Rehabilitation took the resident's resting hand splint to be washed and did not bring a replacement device. On 5/13/24 at 1:28 PM during an interview, the Assistant Director of Nursing stated they were not aware that Resident #89 did not have the right hand resting hand splint in place on Thursday 5/9/24. On 5/13/24 at 1:38 PM during an interview, the Assistant Director of Rehabilitation stated they removed the right handing resting hand splint from Resident #89 hand on Friday in the early afternoon to be washed. They stated they did not apply a replacement device in the interim, and stated they should have applied a replacement device for Resident #89's contracture management. On 5/13/24 at 2:37 PM during an interview, the Director of Rehabilitation stated Resident #89's right hand resting hand splint was issued for decreased range of motion and contracture to the resident's right hand, and to prevent further contracture. 10NYCRR: 415.12(e)(2)

Based on observation, interview, and record review during the recertification survey from 5/9/24 to 5/16/24, the facility did not properly establish and/or maintain an infection prevention and control program designed to provide a safe and sanitary environment. Specifically, 1) the facility did not ensure that an infection surveillance plan based on facility assessment was implemented for identifying, tracking, and monitoring infections, communicable diseases, and outbreaks, 2) the facility water management plan had not been reviewed or updated since 2019, and 3) staff did not perform proper hand hygiene during dining for Resident #21. The findings are: The facility policy and procedure titled Infection Control Program dated 1/12/2010 and last reviewed 4/2/2024, documented a surveillance program was essential to the prevention and control of infection within the facility. Its purpose was to detect and record nosocomial infections in order to institute effective control measures. Data was recorded on resident surveillance reports and infection line listing reports. 1. The infection tracking logs documented infections that were being tracked for the month of November 2023. There was no documentation during December 2023 or January through May 2024 that could be reviewed for infection onset dates, signs and symptoms, lab tests/results, isolation, and outbreak potential. During an interview on 5/15/24 at 10:34 AM, the Assistant Director of Nursing Infection Preventionist stated they began tracking infections when resident conditions were discussed during morning report. They stated the facility used the McGreer model for tracking which included symptom-based data. They stated the information was put on a line list but stated they had not done a line list for infections in a long time because they were bogged down with other duties. They stated they were just getting back into it now. The Assistant Director of Nursing stated they knew they should be doing a line list so they could see where infections were in the facility. 2. The facility Legionella water management plan dated December 16, 2019, documented implementation of the plan was intended to prevent disease and injury associated with potable water systems in buildings. Emphasis was on preventing Legionella infection and other clinically significant environmental source pathogens. During an interview on 5/16/24 at 11:13 AM the Facility Engineer stated they were responsible for the program and updates to the environmental risk assessments. The Engineer stated they did not know the water management plan needed to be reviewed annually. The Engineer stated nothing changed so they did not think it needed to be reviewed yearly. During an interview on 5/16/24 at 10:30 AM the Administrator stated they were aware the water management plan needed to be updated annually and the Engineer was responsible for the assessment and updating the water management plan. The Administrator stated they did not know why it had not been done. 39308 3. The policy and procedure titled Hand Washing with a review date of 4/25/24 documented hands must be washed before passing trays/handling food, and during performance of duties. Resident #21 was admitted with diagnoses including but not limited to Type 2 Diabetes Mellitus, Parkinson's Disease, and Alzheimer Dementia. The Annual Minimum Data Set (a resident assessment tool) dated 03/24/24 documented Resident #21 had a Brief Interview of Mental Status score of 99, indicating the resident was unable to complete the interview, and received set up assistance for eating. The 1/19/24 care plan titled Activities of Daily Living intervention documented limited assistance x 1 for feeding. During a 5/13/24 at 12:01 PM observation Resident #21 was in the unit dining room sitting in a wheelchair. Staff #10 (Physical Therapist) repositioned Resident #21's chair away from the table and began to perform lower extremity exercises. At 12:06 PM, Resident #21's meal tray was placed on the table in front of them. At 12:10 PM, Staff #10 completed the lower extremity exercises and reattached Resident #21's wheelchair leg/foot rests. Staff #10 then repositioned Resident #21's chair to face the table. Without washing or sanitizing their hands, Staff #10 touched and opened Resident #21s bread packet, and utensil packet. Staff #10 asked the resident if they wanted a clothing protector, and Staff #10 went to get a clothing protector and placed it on the resident. Staff #10 without washing or sanitizing their hands opened the milk carton and held the opened straw. During an interview on 5/13/24 at 2:50 PM, Staff #10 stated they were aware of the facility infection control policy and stated infection control was always reviewed with staff. Staff #10 stated that they had missed washing their hands and could have run to the sink. Staff #10 stated that before touching food/assisting with meal tray set up, hands should be washed, and they needed to develop that habit. 10NYCRR 415.19

Based on observation, interview, and record review conducted during an abbreviated survey (NY00309380), the facility did not ensure that 1 out of 12 sampled residents (Resident #1) was free from abuse and mistreatment. Specifically, Housekeeper (HK #1) was witnessed by HK #2 on 01/24/2023 cursing at Resident #1 and aggressively repositioned Resident #1. Facility Video footage of the incident was reviewed on 02/01/2023 and HK #1 was observed speaking to the resident and aggressively repositioned Resident #1's wheelchair. Resident #1 was observed agitated and flaring their hands as HK #1 moved them towards a table with other residents in the day room. The findings are: The facility policy entitled Abuse Prevention/Prohibition effective 01/28/2021, revised on 01/25/2023 documented that all residents will be free from abuse and mistreatment. Any allegation of abuse will be investigated thoroughly and reported to the New York State Department of Health (NYSDOH) as required. Resident #1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, Type 2 Diabetes Mellitus, Hypertension, and anxiety disorder. The Minimum Data Set (MDS, an assessment tool) dated 11/30/2022 documented that the resident had short term and long-term memory problems and had moderate impairment with cognitive skills for daily decision making. Resident#1 required extensive 1-person physical assistance for transfer, and locomotion off the unit; limited 1-person physical assistance for locomotion on the unit. The facility video footage of the incident with no audio was reviewed on 02/01/2023 at 11:44 AM by NYSDOH surveyors in the presence of the facility administrator. On the video footage that was dated 01/24/2023 at 7:15 PM, HK #1 was observed speaking to Resident #1. Resident #1 appeared agitated. HK #1 was observed aggressively pushing resident #1's wheelchair towards a table with other residents. Resident #1 was observed resisting with arms flailing attempting to hit HK #1. The Recreation Aide (RA) was observed seated at the table with other residents. The table with the RA appeared to be within hearing distance, with a view of the interaction between HK #1 and Resident #1, before the resident was moved to the table. HK #2 (witness #1 - who reported the incident) was observed standing at the entrance of the day room. The Facility Incident Report dated 01/25/2023 and Facility Investigation Summary dated 01/29/2023 was reviewed on 02/01/2023. The facility reported that on 01/24/2023 at 7:15 PM, Housekeeper (HK #2) informed the facility that while in the day room they observed HK #1 curse at Resident #1 telling them to shut up several times and then aggressively repositioned resident #1's wheelchair towards a table where other residents were watching a movie. The Director of Nursing (DON) with a Licensed Practical Nurse (LPN) completed a physical assessment of Resident #1 on 01/25/2023 with no negative findings. A written interview dated 01/25/2023 at 4:15 PM conducted by Human Resources (HR) with HK #1 was reviewed. HK #1 stated they were assisting Resident #1 because the resident was yelling and trying to hit HK #1. HK #1's interview documented they moved Resident #1, but they do not recall anything that was uttered to resident #1. HR informed HK#1 that his/her employment was terminated effective 01/25/2023. During a telephone interview conducted with HK #1 on 02/09/2023 at 10:57 AM, HK #1 stated that they do not recall anything that happened during the alleged event, and they were already terminated so there was no point in discussing the incident. HK #1 stated that the facility provided them in-service on abuse prevention and how to care for residents with dementia. HK #1 stated that interacting with residents is not part of their required job responsibilities. Attempted to call HK #2 on 02/09/2023 at 10:56 AM was unsuccessful. HK #2's written statement about the incident dated 01/25/2023 was reviewed. HK #2 documented that on 01/24/2023 around 7 to 7:30 PM as they were cleaning the 3rd floor day room with HK #1. HK #2 documented that Resident #1 became agitated and HK #1 had an exchange of words with resident #1 including cursing at the resident telling them to shut up several times. As resident #1 tried to roll themselves away, HK #1 grabbed the wheelchair and pushed resident #1 aggressively towards the table and the resident #1 resisted by trying to hit HK #1. During an interview conducted with Housekeeper Lead (HKL) on 02/01/2023 at 1:43 PM, the HKL stated they spoke to HK #2 around 9:30 PM on 01/24/2023 from home. HKL stated HK #2 informed them that HK #1 was talking to resident #1 who repeatedly wanted to go to bed, and HK #1 was cursing at the resident and manhandled Resident #1. During an interview on 02/01/2023 at 12 PM with the RA, the RA denied witnessing the cursing and the aggressive behavior of HK #1 towards Resident #1 on 01/24/2023. RA stated they were watching a movie with the other residents. The RA stated they had no recollection of anything inappropriate on 01/24/2023 as written in their statement. However, when they watched the video footage on 01/26/2023 it was clear that it should have been reported. During an interview conducted 02/01/2023 at 1:58 PM with the Director of House Keeping and Laundry (DHL), the DHL stated that all HK staff received abuse prevention training via a computer programming called Relias. The DHL stated that HK #1 had no discipline since his/her employment. DHL stated that the facility does not tolerate abuse and HK #1 was terminated right away. The DHL stated it is not possible for HK #1 to have had any other interaction with other residents because HK #1 and HK #2 were working the whole building together the entire evening and left at the same time (4 PM to 9 PM). 415.4(b)(I)(i)

Based on interviews and record reviews conducted during an abbreviated survey (NY00309380), the facility did not ensure an alleged violation involving abuse was reported to the New York State Department of Health (NYSDOH) within 2 hours of occurrence. This was evident for 1 out of 12 residents (Resident #1) reviewed for abuse and mistreatment. Specifically, the facility reported a staff-to-resident abuse that occurred on 01/24/2023 at 7:30 PM to the NYSDOH on 01/26/2023 at 2:18 PM. The findings are: The Facility Policy entitled Abuse Prevention/Prohibition effective 01/28/2021, revised on 01/25/2023 documented that all residents will be free from abuse and mistreatment. Any allegation of abuse will be investigated thoroughly and reported to the NYSDOH within the required timeframe. Resident #1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, Type 2 Diabetes, Hypertension, and anxiety disorder. The Minimum Data Set (MDS, an assessment tool) dated 11/30/2022 documented that the resident had short term and long-term memory problems and had moderate impairment with cognitive skills for daily decision making. The Facility Incident Report dated 01/25/2023 and the Facility Investigation Summary dated 01/29/2023 was reviewed. The facility reported that on 01/24/2023 at 7:15 PM, Housekeeper (HK#2) informed the facility that while in the day room they observed HK #1 cursed at Resident #1 telling them to shut up several times and then aggressively repositioned the residents' wheelchair towards a table where other residents were watching a movie. HK#2 reported the incident to their immediate supervisor, the House Keeping Lead (HKL) at around 7:45 PM via text. The Administrator initiated an investigation upon learning of the incident from the Director of House Keeping and Laundry on 01/25/2023 at 9:30 AM (DHL). The facility reported the incident to the NYSDOH on 01/26/2023 at 2:18 PM. During an interview conducted with HKL on 02/01/2023 at 1:43 PM, HKL stated they got a text from HK #2 while in class around 7:45 PM on 01/24/2023. HKL was able to speak to HK #2 around 9:30 PM on 01/24/2023 when they got home. HKL stated they were trained on abuse prevention and was aware to report incidents of abuse immediately, but they were already home at the time. HKL stated they reported the incident to the Director of Housekeeping at 8 AM on 01/25/2023. HKL stated they were re-in serviced on abuse reporting after the incident. During an interview conducted with the DHL on 02/01/2023 at 1:58 PM, the DHL stated that they received the report from HKL on 01/25/203 at 8 AM and they reported to the Administrator. The DHL stated that HK #1 had no discipline on their record since employment. The DHL stated that HK #1 was terminated right away. During an interview on 02/01/2023 at 4:20 PM conducted with the Administrator, the Administrator stated that because of the delayed reporting of the HKL, the facility policy on abuse prevention and reporting has been revised. The portion on reporting now includes reporting to the immediate supervisor, to the nursing manager, the department manager, the DON, or Administrator immediately. All staff were re-inserviced on the revised policy. 415.4(b)(2)

Based on record review and interview conducted during the recertification survey, the facility did not ensure that the attending physician acted upon the pharmacy consultant's recommendations regarding each resident's medications. This was evident for 1 of 6 residents reviewed for Drug Regimen Review. (Resident #77). The findings are: Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 10/11/18 Admission MDS (Minimum Data Set- an assessment tool) indicated Resident #77 had cognitive impairment and received antipsychotic and anticoagulant therapies for the look back period of 7 days. The 4/8/19 Quarterly MDS indicated Resident #77 had cognitive impairment and received antipsychotic, antidepressant and anticoagulant therapies for the look back period of 7 days. Review of the physician's orders [REDACTED]. The Pharmacy Medication Regimen Review dated 3/10/19 indicated the following; antipsychotic medications are associated with metabolic, cardiovascular, neurological and anticholenergic adverse consequences and to order a lipid panel and HgbA1C. The physician response to the pharmacy review indicated he would order this lab work. There was no documented evidence in the medical record that the resident's physician had ordered these lab tests per the pharmacy consultant's recommendations. In an interview on 5/31/19 at 10:09 AM with Registered Nurse manager (RN #1) she stated that after checking the electronic medical record she could not locate documentation to indicate the physician had ordered the lipid panel and HgbA1C. She further stated that the physicians check the pharmacy regimen reviews regularly and then notify nursing of any new orders. 415.18(c)(2)

Based on observation, interview and record review conducted during the recertification survey the facility did not ensure that residents received care and treatment in accordance with professional standards of practice in order to meet the resident's physical, mental, and psychological needs. Specifically, the facility did not ensure that positioning devices were applied per physician's orders [REDACTED]. (Resident #63). The findings are: Resident #63 was admitted to the facility with [DIAGNOSES REDACTED]. The 9/24/18 Annual MDS (minimum data set: an assessment tool) indicated that Resident #63 was cognitively impaired and required total assist of 2 for bed mobility and transfers and had unilateral functional limitation of the upper extremity. The 4/5/19 Quarterly MDS indicated Resident #63 was cognitively impaired and required extensive assist of 2 for bed mobility, total assist of 2 for transfers and had unilateral functional limitation of the upper and lower extremities. Review of the physician's orders [REDACTED]. 8/1/17- wears skil care relief boot (has a bar to help modify the rotation of the hip) for the left leg when out of bed (OOB) in HTR (recliner) chair. Review of the comprehensive care plan revealed: ADL function interventions include; 1/22/19 left hip abduction pillow in w/c between knees. The care plan did not include the 8/1/17 use of the skil care relief boot for the left leg when in HTR chair. Observations revealed; 5/24/19 at 3:25 PM the resident was seated in the recliner with her right lower leg crossed over her left lower leg. 5/24/19 at 12:18 PM and 5/30/19 at 11:06 AM the resident was observed resting in the recliner chair with both legs elevated on the foot rest. During the above observations Resident #63 did not have the hip abductor pillow or the left leg skil care relief boot in place. In an interview with Resident #63 on 5/30/19 at 11:07 AM she stated she had used a pillow between her legs (which tended to become dislodged) and a boot on her left leg but she had not been using them lately . She further stated she had occasional pain in the left hip. During an interview on 5/30/19 at 11:30 AM with the Registered Nurse manager (RN #1) she stated she was not aware the resident had not been using the skil care relief boot to the left leg or the abductor pillow. She stated the Certified Nursing Assistant (CNA #1) had never reported that the resident refused to use the positioning devices. During an interview on 5/30/19 at 11:43 AM with CNA #1 she stated the resident did not always want her to apply the hip abductor pillow or the left leg skil care relief boot and that she had reported this to a nurse. During an interview on 5/30/19 at 1:20 PM with the Physical Therapist (PT) she stated the left skil boot was for positioning more naturally to keep the left hip comfortable and the abductor pillow would allow for continued abduction of the legs/hips. She further stated the staff had just informed her the resident was not using the left leg skil care relief boot and the hip abductor pillow. 415.12

Based on observation, record review and interview conducted during the recertification survey, the facility did not ensure that the comprehensive care plan was revised for 1 of 5 residents (#63) reviewed for positioning and mobility. Specifically, the care plan was not updated to address the use of a left leg skil care relief boot. The findings are: The 9/24/18 Annual MDS (Minimum data Set-an assessment tool) indicated Resident #63 was cognitively impaired and required total assist of 2 staff for bed mobility and transfers. It further documented the resident had unilateral functional limitation of the upper extremity. The 4/5/19 Quarterly MDS indicated that Resident #63 was cognitively impaired, required extensive assist of 2 staff for bed mobility and total assist of 2 staff for transfers and had unilateral functional limitation of the upper and lower extremity. physician's orders [REDACTED]. Review of the comprehensive care plan documented: ADL function effective 2/2/17 did not include the 8/1/17 use of the skil care relief boot for the left leg when in HTR chair. During multiple observations between 5/23/19 and 5/30/19 Resident #63 did not have the left leg skil care relief boot in place. During an interview on 5/30/19 at 11:30 AM with the Registered Nurse manager (RN #1) she stated she was unable to locate the intervention for the use of the left leg skil care relief boot on the care plan. 415.11(c)(2)(i-iii)

Based on record review and interview conducted during the recertification survey and an abbreviated survey (complaint #NY 018) the facility did not ensure that a care plan was developed with person-centered goals and interventions to address the use of medications for 2 of 6 residents (Residents #88 and #29) reviewed for unnecessary medications and did not ensure that the plan of care was implemented for 1 of 2 residents ((Resident #374) reviewed for injuries of unknown origin. Specifically, 1) Resident #88 did not have a plan of care to address the use of a pancreatic enzyme replacement medication (Creon); 2) the plan of care for Resident #29 did not address the use of a [MEDICAL CONDITION] medication; and 3) the activities of daily living plan of care for Resident #374 was not implemented as written to prevent accidents/injuries. The findings are: 1. Resident #88 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. The order was initiated on [DATE]. Review of the comprehensive care plan revealed no evidence of a plan of care to address the use [MEDICATION NAME] the treatment for [REDACTED]. The care plan entitled Potential for Altered Nutritional Status related to poor intake and weight loss was reviewed and revealed the following; An update to the care plan dated [DATE] indicated there was a plate watch done and the resident was not consuming the required number of calories. [DATE] update: Wt. 122 lbs. Significant weight loss (10% x 30 days), decline in intake. [DATE] update: Care plan meeting with family. Resident refusing meals . Resident stated she just doesn't want to eat. [DATE] update: Intake poor despite staff encouragement. The Registered Nurse(RN)- unit manager was interviewed on [DATE] at 11:15 AM regarding care issues related to the use [MEDICATION NAME] the fact that the resident's food intake is declining. She stated there is no care plan for the use of Creon. 2. Resident #29 was a [AGE] year-old male with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. A review of the resident's current plan of care revealed no measurable goals and interventions to address [MEDICAL CONDITION] and the ongoing use of [MEDICATION NAME]. In an interview with the RN-unit manager on [DATE] at 12:05 PM she stated that no care plan was developed to address [MEDICAL CONDITION] and/or the ongoing use of [MEDICATION NAME]. 3. (Complaint #NY 018) Resident #374 was a [AGE] year-old female with [DIAGNOSES REDACTED]. The resident expired in (MONTH) 2019. According to the MDS dated [DATE], the resident was moderately impaired for decision making, had long and short-term memory problems and required total assistance of two persons for bed mobility, transfers and toileting. The Activities of Daily Living care plan initiated on [DATE] and in effect at the time of the [DATE] MDS noted that the resident was dependent on staff for all activities of daily living and required two persons to assist with the Hoyer lift during transfers. Multiple nursing notes during (MONTH) (YEAR) and (MONTH) (YEAR) revealed that the resident was resistive to care. Additionally, a nurses note dated [DATE] showed that the resident was placed on 72-hour observation due to an ecchymosis (bruise) on her nose. On [DATE] the Nurse Practitioner (NP) documented the following: Asked to examine resident for discoloration of the nose. The nasal bridge presents with a small ecchymosis and mild swelling. The resident did not allow the writer to examine her nose and became physically aggressive, swinging her arms and throwing punches at the writer. The NP concluded that the bruise was self-inflicted. On [DATE] the Director of Nursing (DON) completed an investigation to determine the cause of this injury. The conclusion of the investigation was that the cause of the injury could not be determined. However, during this investigation one of the certified nurse aides (CNA#2) was interviewed and stated that during care of the resident on [DATE] she transferred the resident unassisted without the use of the Hoyer lift. On [DATE] at 11:10 AM the surveyor interviewed CNA #2. She denied that the resident's nose came in contact with any object during the transfer. Additionally, the CNA also stated that she knew that the resident's plan of care included the assistance of two persons with the use of the Hoyer lift. She failed to do this because no staff were available to assist with the transfer. She did not ring the call bell for assistance. The facility was found to have identified and corrected it's self reported noncompliance with implementation of a care plan as it related to the use of a Hoyer/mechanical lift prior to survey. Specifically: the facility provided documented evidence that CNA #2 was disciplined and other CNAs across all shifts were in-serviced on the use of mechanical lifts and the importance of implementing a resident's plan of care related to the use of a mechanical lift. The facility reported that on [DATE], 2 days after the discovery of the injury, rounds were made on all shifts and staff were interviewed on the protocol for the use of mechanical lifts and the implementation of a resident's plan of care. The staff members' responses demonstrated that they were aware that care plans should be implemented as written, that Hoyer/mechanical lifts should be used with the assistance of two persons and that the incident with CNA #2 was isolated. -Accident Incident Reports for the past three months were reviewed and there were no accidents/incidents related to failure to use a mechanical lift. Additionally the transfer of one resident whose plan of care included the use of a mechanical lift for transfers was observed. No problems were noted. - Based on interviews with eight CNAs on [DATE] and [DATE] about neglect (which includes failure to provide services) and/or the use of mechanical lifts, they were knowledgeable about the necessity of providing residents with required services and/or the importance of using a mechanical lift with the assistance of two persons when indicated according to the resident's plan of care. 415.11(c)(1)

Based on observation, record review and staff interviews conducted during an abbreviated survey (NY 616), the facility failed to protect one of three residents reviewed for abuse from staff to resident abuse/mistreatment (Resident #1). Specifically, Certified Nurse Aide #1 (CNA #1) reported that she held the resident's hands in response to being slapped by the resident. Video surveillance showed the resident slapping CNA #1. CNA #1 then grabbed and held the resident by her right wrist. The resident then used her left hand and slapped CNA #1 in the face. CNA #1 then grabbed and held the resident's left wrist while continuing to hold the right wrist firmly. The resident's wrists were held for approximately 35 seconds without attempt by the CNA to move away from the resident. The findings are: Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS (Minimum Data Set, a resident assessment and screening tool) dated 6/26/18 revealed that Resident #1 was moderately cognitively impaired, with a BIMS (Brief Interview for Mental Status) score of 99, exhibited no physical behavioral symptoms directed at others such as hitting and kicking but did exhibit some verbal symptoms towards others such as cursing and screaming. A Care Plan for Behavioral Symptom Status dated 6/27/18 addressed behaviors of being resistive to cares and physically abusive to staff with interventions including to redirect negative behaviors, honor preference in care routines, explain procedures prior to, and allow time to de-escalate and re-approach. A Facility Accident and Incident Report dated 8/14/18, Investigation Summary signed by the Director of Nursing on 8/17/18 and staff statements revealed that, on 8/14/18 at approximately 5:15 PM, CNA #1 requested an employee incident report and alleged that Resident #1 slapped her on both sides of her face. After video surveillance was viewed the investigation revealed a physical exchange that lasted approximately 35 seconds. Resident #1 was seen slapping CNA #1 on the right buttock and CNA #1 was seen immediately turning around and grabbing Resident #1 by the right wrist. At that point Resident #1 slapped CNA #1 in the face with her left hand and CNA #1 then grabbed the left wrist of Resident #1 while holding the right wrist as well, speaking directly in her face. The Unit RN Supervisor assessed Resident #1 and found no signs and symptoms of injuries and no negative findings. CNA #1 submitted a written statement of the incident dated 8/14/18, as part of the facility investigation, that stated the resident slapped CNA #1 in the face so to protect herself she held the resident's right hand. The resident then slapped CNA #1 again using her left hand, so CNA #1 held both of the resident's hands and told her not to do that and to go away. The video surveillance was reviewed and revealed actions by Resident #1 and CNA #1 that were consistent with the account documented in the facility report. No attempt by CNA #1 to move away and distance herself from the resident was observed. CNA #1 was interviewed on 1/23/19 at 12:45 PM and stated that Resident #1 slapped her in the face. She then grabbed Resident #1's right hand to protect herself. The resident used her left hand to slap her again. She then stated that she grabbed both Resident #1's hands and told her not to do that. The Unit RN Supervisor was interviewed 1/23/2019 at 4:00 PM and stated CNA #1 reported to her around 5:00 PM on that day that Resident #1 slapped her on the left and then the right side of her face. CNA #1 reported that she grabbed Resident #1's hands to prevent her from continuing to be hit. She assessed CNA#1 and Resident #1 for injuries and then reported it to the Director of Nursing. 415.4(b)(1)(ii)