Every finding on record at Schulman and Schachne Institute for Nursing and Re

Based on observation, record review, and interviews during an Abbreviated Survey (NY00364046), complaint investigation concluded the facility failed to ensure a resident was treated with respect and dignity including the right to be free from physical or chemical restraints imposed for the purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. This was evident for 1 out of 39 residents (Resident #1). Specifically, on several occasions Resident #1's wrists were tied with bed sheets to the bed rails. Certified Nursing Assistant #6 admitted to placing Resident #1 in these restraints and intentionally not removing them to prevent Resident #1 from removing their brief and smearing feces. Resident #1 was restrained for the purposes of discipline or convenience. This resulted in serious harm to Resident #1 that was determined to be Immediate Jeopardy Past Noncompliance. The findings are: The facility's Policy and Procedure titled Physical Restraints was revised on 06/2024. The policy states the facility ascribes to the philosophy of the least restrictive environment for its residents. Restraints will be used only to protect residents' health and safety and to help them attain and maintain their individual levels of physical and emotional function. Residents requiring continued restrains after two weeks, determination will be re-evaluated monthly by the physician and responsible nurse. It will be documented in the resident's medical record, comprehensive care plan, and Nursing Assistant Accountability Record. Resident #1 was admitted to the facility with diagnoses including Hypertension (high blood pressure), Renal Insufficiency (poor function of the kidneys) and Non-Alzheimer's Disease (loss of memory). The Minimum Data Set (an assessment tool), dated 10/02/2024, documented Resident #1 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) score of 12 associated with moderately impaired cognition. The Comprehensive Care Plan titled: At Risk for Victimization dated 09/14/2024 documented Resident #1 was at risk for victimization due to cognitive impairment. The interventions documented to place Resident #1 on one-to-one close monitoring (a person is assigned to always watch the resident), continued visual checks as per protocol and plan of care. A Physician's Order dated 08/02/2024 documented an order to apply hand protector to Resident #1's bilateral hands, remove/release every 2 hours and as needed for 15 minutes to prevent pulling of Perma catheter (flexible tube) located on Resident #1's left front chest wall. Monitor for circulatory impairment. There is no documented evidence the hand protector order was renewed after 08/02/2024. The facility's investigation into an injury of unknown origin concerning Resident #1 was initiated on 12/09/2024. During the investigation Certified Nursing Assistant #5 provided a written statement to the facility dated 12/12/2024. According to their statement, on 10/14/2024 at about 7:02 AM they observed Resident #1 wearing mittens and their wrist tied with a bed sheet to the bed rail. Certified Nursing Assistant #5 wrote they observed Resident #1's family members heading to Resident #1's room, so they ran to the nursing station and notified Licensed Practical Nurse #1 about the restraint. They further wrote Licensed Practical Nurse #1 asked them if they removed the restraint, and they said no. Certified Nursing Assistant #2 also provided a written statement dated 12/12/2024. In the statement Certified Nursing Assistant #2 wrote on 10/15/2024 and 11/15/2024 they observed Resident #1 being restrained with a bed sheet and mittens. They wrote they observed this during their rounds on the 7:00 AM -3:00 PM shift. Certified Nursing Assistant #2 wrote that on both occasions they untied the resident and immediately reported the incidents to Licensed Practical Nurse #1 and #2. License Practical Nurse #1 and #2 worked on the 7:00 AM - 3:00 PM shift. Certified Nursing Assistant #2 wrote that License Practical Nurse #1 and #2 did not check on the resident after they reported the incident. The Facility's investigation concluded restraints were used, and abuse did occur. The facility investigative file contained pictures provided by the family of Resident #1. The photographs revealed the resident being restrained by bed sheets tied to the bed rail. The pictures were not time or date stamped. Licensed Practical Nurse #1 and #2 refused to write statements to the facility. Both denied being informed by Certified Nursing Assistants that Resident #1 was tied to the bed with a bed sheet at any time. Certified Nursing Assistant #6 refused to submit a written statement to the facility. The facility investigative report documented they admitted to the Director of Nursing they used mittens, and bed sheets to restrain the resident because they had been known to smear feces over themself. Resident #1's adult child's personal cell phone with pictures from 12/17/2024 at 1:52 PM was reviewed. Observed: (1) a picture dated 10/14/2024 at 7:40 AM of Resident #1 lying in bed with their left and right hand tied with bed linens to the bed rails; (2) a picture dated 11/02/2024 at 3:35 PM showing Resident #1 lying on their back with right and left hand tied with bed linens to the bed rails; (3) a picture dated 11/09/2024 at 12:11 PM showing Resident #1 lying in bed with a twisted bed linen placed across their midbody and tied to both bed rails. During an interview on 12/17/2024 at 9:41 AM, Resident #1 stated they do not know how they sustained the fracture. Resident #1 stated everyone is nice to them. During an interview on 12/17/2024 at 9:54 AM, Certified Nursing Assistant #2 corroborated what she wrote in her 12/12/2024 statement to the facility. During a telephone interview on 12/17/2024 at 10:58 AM, Certified Nursing Assistant #4 stated they observed Resident #1 with their hands tied to the bed rails on 11/09/2024 on the 3:00 PM - 11:00 PM shift. Certified Nursing Assistant #4 stated they did not report the restraint because they were afraid. During an interview with the Director of Nursing on 12/17/2024 at 12:59 PM, the Director of Nursing stated on 12/09/2024 during their investigation into an incident involving Resident #1 that occurred on 12/04/2024, they learned Resident #1's adult child had observed Resident #1 in restraints. The Director of Nursing stated on 12/10/2024 the adult child showed them (on their cell phone) pictures of the Resident's wrists being tied with a bed sheet to the bed rails on 10/14/2024 at 7:40 AM and on 11/02/2024 at 3:35 PM, and on 11/09/2024 at 12:11 PM with bed sheet across Resident #1's waist and tied to the bed rails. The Director of Nursing stated they interviewed Certified Nursing Assistant #6 who admitted they used pillowcases and sheets to restrain Resident #1's hands to prevent Resident #1 from removing their incontinent brief and smearing feces all over themself. The Director of Nursing stated Certified Nursing Assistant #6 stated they were not wrong for restraining Resident #1. During a telephone interview on 12/17/2024 at 1:45 PM, Resident #1's adult child stated they visited Resident #1 on 10/14/2024 and observed Resident #1's wrists tied with a bed sheet to both side rails at 7:40 AM and that they took pictures with their cell phone. Resident #1's adult child stated they visited Resident #1 on 11/02/2024 at 3:35 PM and Resident #1 had both their wrists tied with a bed sheet to the side rails. Resident #1's adult child stated they visited Resident #1 again on 11/09/2024 at 12:11 PM and Resident #1 had a bed sheet across their waist tied to both side rails. Resident #1's adult child stated they took pictures but did not report the restraints to anyone in the facility because they thought it was okay. During a telephone interview on 12/17/2024 at 3:27 PM, Certified Nursing Assistant #6 stated they put mittens on Resident #1's hands to stop Resident #1 from scratching and playing with their feces. Certified Nursing Assistant #6 stated they removed the mittens when Resident #1 was asleep or was not agitated. Certified Nursing Assistant #6 stated they never used a sheet to tie Resident #1's hands. Certified Nursing Assistant #6 stated they put pillowcases on Resident #1's hands, then put Resident #1's hands into the mittens. During an interview on 12/18/2024 at 4:00 PM, Certified Nursing Assistant #5 corroborated what they wrote in their statement to the facility on [DATE]. During an interview on 12/19/2024 at 4:47 PM, the Administrator stated they received a phone call from the Director of Nursing just after midnight on 12/09/2024 notifying them Resident #1's adult child reported Resident #1 being restrained. The Administrator stated a meeting was held with the adult child, Director of Nursing, Medical Director, and Director of Social Service on 12/10/24 at 11:00 AM. The Administrator stated during the meeting the adult child presented their evidence of Resident #1 being restrained. The Administrator stated the pictures were date and time stamped. The Administrator stated the adult child stated they did not report the restraint to anyone because they were afraid. The Administrator stated they provided education to Resident #1's adult child that advised they should report concerns or issues. The Administrator stated the police were called. The Immediate Jeopardy was determined to have begun on 10/14/2024. The Administrator was informed of the Immediate Jeopardy and provided with the Past Noncompliance Immediate Jeopardy Template on 12/23/2024 at 5:35 PM. Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement prior to the start of this survey. As such, a Plan of Correction is not required for this citation. The facility took immediate corrective actions and was found to be in substantial compliance on 12/12/2024 at 9:00 AM prior to survey initial onsite visit on 12/16/2024 at 9:00 AM. Facility initiated an investigation on 12/09/2024 at 10:40 PM after receiving an x-ray result from the hospital on 12/09/2024. 12/10/2024 at 12:07 AM - Reported to Department Of Health 12/10/2024 - Resident #1 was assigned a staff to do 1:1 supervision (ongoing). 12/10/2024 - 67th Precinct notified. 12/10/2024 - AD HOC QAPI Committee Meeting held (titled Abuse, Neglect, Mistreatment, and Reportable incidents). 12/11/2024 - facility spoke with NYSDOH investigator (name mentioned in documentation) regarding the use of restraint on Resident #1. 12/11/2024 - Attorney General's Office notified via website/phone message. 12/12/2024 - Attorney General's Office Intake Department - spoke with facility Administrator. 12/12/2024 - AD HOC QAPI Meeting held on Resident Safety. 12/12/2024 - Audit conducted to review residents with siderails. Facility suspended 1 Nurse Manager, 2 Licensed Practical Nurses and 5 Certified Nursing Assistants pending investigation outcome. Termination Hearing scheduled for 12/18/2024 at 11:30 AM. 12/10/2024 - Facility in-service (ongoing). Topic: Resident Rights, Abuse, Siderails/Monitoring, Bed Entrapment & Restraint, Reportable Concerns, Pain Management, Managing Difficult Residents, Resident Safety, and Trauma Informed Care. Audits are being conducted on Risk for Abuse started 12/14/2024 on Resident #1's unit for all residents. Policies/Procedures reviewed (no changes made) on Abuse, Entrapment, Reporting, Restraint, Just Culture, Code of Ethics & Conduct. Inservice of all staff was initiated on 12/10/2024. 91% of nursing staff have been in-serviced. Risk for abuse audits started on 12/12/2024 for all residents on Resident #1's unit. All nurses must provide rounding every 2 hours on all shifts/units. Certified Nursing Assistant #3 and #6, License Practical Nurse #1 and #2 were terminated on 12/24/2024. Director of Nursing will continue to in-service the remaining 8% of nursing staff as they report to work. 10 NYCRR 415.4(a)(2-7)

Based on observation, record review, and interviews conducted during an abbreviated survey (NY00364046), the facility did not ensure that a resident received the necessary care and treatment in timely manner and accordance with professional standards of practices. This was evident in 1 out of 39 residents (Residents #1) sampled. Specifically, a Rewrite Orders Cover Sheet dated 12/05/2024, signed by Licensed Practical Nurse #1 on 12/05/2024, documented x-ray of the left forearm to rule out fracture. A Nursing Progress note dated 12/07/2024 at 3:15 PM documented x-ray was done and result pending. A Nursing Progress note dated 12/09/2024 at 10:40 PM documented x-ray result showed fracture of the midshaft and ulna. Resident #1 to be transferred to the hospital. The x-ray was not done timely, and the results were not obtained in a timely manner. The findings include: The facility's Policy and Procedure titled Provision of Radiology Services, revised 12/2023, documented the facility to ensures efficient provision of services and prompt reporting of test results to the physician or other staff. The policy further documented, Policy Explanation and Compliance Guidelines: (2) final written reports are to be submitted to the nursing home within 48 hours. The Physician Monthly assessment dated [DATE], revealed Resident #1 was assessed by the Medical Doctor. The Medical Doctor also documented will order x-ray of the left forearm to rule out fracture. A form titled Rewrite Orders Cover Sheet dated 12/05/2024 documented x-ray of left forearm to rule out fracture. This form was signed by Licensed Practical Nurse #3 on 12/05/2024 on the 11:00 PM - 7:00 AM shift. Registered Nurse #3 signed the form on 12/07/2024 on the 3:00 PM - 11:00 PM shift. The form was also signed by another nurse on 12/08/2024 on the 7:00 AM - 3:00 PM shift. A Nursing Progress note, by Licensed Practical Nurse #3, dated 12/06/2024 at 6:00 AM documented Resident #1 was seen by the Medical Doctor and an x-ray order was written. A Nursing Progress note dated 12/07/2024 at 3:15 PM, by Registered Nurse #3, documented Resident #1 was accompanied by 2 Certified Nursing Assistants via stretcher for x-ray of left hand to rule out fracture. Resident #1 returned to the unit at 3:54 PM. X-ray was done, and the results are pending. A hospital radiology report dated 12/08/2024 documented status: Final-Result dated 12/08/2024 at 6:01 PM. The report revealed the Physician's Order was faxed to the hospital radiology on 12/06/2024. The order result history report dated 12/08/2024, revealed that x-rays of Resident #1's left forearm were done, and the findings documented there are fractures of the midshaft radius and ulna with mild displacement. No discoloration. Nurse's note dated 12/09/2024 at 10:40 PM documented x-ray results are final and showed fracture of the midshaft radius and ulna with mild displacement. Nursing Supervisor () and the Medical Doctor was notified. Resident #1 to be transferred to the hospital for further evaluation. During an interview on 12/16/2024 at 2:14 PM, Medical Doctor #1 stated they were informed Resident #1 had swelling to their left arm either through the communication book or the floor nurse. Medical Doctor #1 stated they evaluated Resident #1 on 12/05/2024 (do not recall exact time) who was observed with a slight swelling to their left arm. Medical Doctor #1 stated that Resident #1 was able to fold their left arm. Medical Doctor #1 stated Resident #1 did not complain of pain, hence the reason they thought the swelling could have been from a thrombose and that was why they did not order a STAT (immediately) x-ray. Medical Doctor #1 stated they ordered the x-ray on the same night (12/05/2024) they assessed Resident #1. During an interview on 12/16/2024 at 2:40 PM, Licensed Practical Nurse #3 stated Medical Doctor #1 arrived on the unit between 11:00 PM and 11:30 PM on 12/04/2024 and they notified Medical Doctor #1 that Resident #1 had swelling and tenderness to their left arm. Licensed Practical Nurse #3 stated Medical Doctor #1 evaluated Resident #1 and reported to them that the swelling could have been from the graft and that they should give Tylenol to Resident #1 and elevate the extremity. Licensed Practical Nurse #3 stated the following night 12/05/2024 (night shift, 11:00 PM- 7: 00 AM) into 12/06/2024 they informed Medical Doctor #1 that the swelling had persisted, and Medical Doctor #1 ordered an x-ray. During an interview on 12/17/2024 at 12:59 PM, the Director of Nursing stated they received a call from Registered Nurse Supervisor #1 notifying them of Resident #1's x-ray result at approximately 11:30 PM on 12/09/2024. They stated Registered Nurse Supervisor #1 reported that they were searching for the database and retrieved the x-ray results for Resident #1. The Director of Nursing stated they did not receive a call from the radiology department (in the hospital) or a fax of the results. During an interview on 12/19/2024 at 1:20 pm, the Medical Director stated the protocol is for the radiology department to review an x-ray, call the unit and report the findings to the nurse, and then the nurse informs the doctor. The Medical Director stated they investigated why the radiology department did not notify the facility of the x-ray result and the radiology department stated that it is the responsibility of the facility to follow up on their results because they are an outpatient department. 10 NYCRR 415.12

Based on observation, record review and interviews conducted during an Abbreviated Survey (NY00364046), the facility did not ensure that an alleged violation involving abuse, neglect, mistreatment, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility. This was evident in 1 out of 39 residents (Residents #1) sampled. Specifically, on 10/14/2024, 10/15/2024, and 11/15/2024 Certified Nursing Assistants #2 and #5 observed Resident #1's wrists tied with bed sheets to the bed rails and reported it to Licensed Practical Nurse #1 and #2. Neither Licensed Practical Nurse #1 nor #2 reported the restraint to Registered Nurse Supervisor, thus the Administrator was not notified within 2 hours of the allegation being made by the Certified Nursing Assistants. The findings are: The facility's Policy and Procedure titled Abuse, Mistreatment, Neglect, Misappropriation of Resident 's Property was revised on 02/2023. The policy states the facility will protect each resident from abuse, neglect, mistreatment in accordance with State and Federal regulations. The policy further documented that any employee noting any change in the resident's condition shall immediately report the findings and/or concerns to their immediate Nurse Manager or Supervisor. The Nurse Manager or Supervisor will verify the employee's concerns and initiate a resident occurrence report. The Reporting/Response section of the policy states that a report is to be filed if an individual has reasonable cause to believe that a resident has been physically abused, mistreated, or neglected by a staff of this facility and/or by a family member or visitor. Reasonable Cause is defined in the Department of Health Regulations as upon review of the circumstances, there is sufficient' evidence for a prudent person to believe that physical abuse, mistreatment, or neglect has occurred. The policy did not mention who staff should report suspicion of abuse to. The policy only mentioned reporting of change in resident's condition. Resident #1 was admitted to the facility with diagnoses including Hypertension (high blood pressure), Renal Insufficiency (poor function of the kidneys) and Non-Alzheimer's Disease (loss of memory). The Minimum Data Set (an assessment tool), dated 10/02/2024, documented Resident #1 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) score of 12 associated with moderately impaired cognition. The facility's investigation into an injury of unknown origin concerning Resident #1 was initiated on 12/09/2024. During the investigation Certified Nursing Assistant #5 provided a written statement to the facility dated 12/12/2024. According to their statement, on 10/14/2024 at about 7:02 AM they observed Resident #1 wearing mittens and their wrist tied with a bed sheet to the bed rail. Certified Nursing Assistant #5 wrote they observed Resident #1's family members heading to Resident #1's room, so they ran to the nursing station and notified Licensed Practical Nurse #1 about the restraint. They further wrote Licensed Practical Nurse #1 asked them if they removed the restraint, and they said no. Certified Nursing Assistant #2 also provided a written statement dated 12/12/2024. In the statement Certified Nursing Assistant #2 wrote on 10/15/2024 and 11/15/2024 they observed Resident #1 being restrained with a bed sheet and mittens. They wrote they observed this during their rounds on the 7:00 AM -3:00 PM shift. Certified Nursing Assistant #2 wrote that on both occasions they untied the resident and immediately reported the incidents to Licensed Practical Nurse #1 and #2. License Practical Nurse #1 and #2 worked on the 7:00 AM - 3:00 PM shift. Certified Nursing Assistant #2 wrote that License Practical Nurse #1 and #2 did not check on the resident after they reported the incident. The Facility's investigation concluded restraints were used, and abuse did occur. The facility investigative file contained pictures provided by the family of Resident #1. The photographs revealed the resident being restrained by bed sheets tied to the bed rail. The pictures were not time or date stamped. Licensed Practical Nurse #2 refused to write a statement to the facility. Licensed Practical Nurse #2 denied being informed by Certified Nursing Assistants that Resident #1 was tied to the bed with a bed sheet at any time. Certified Nursing Assistant #6 refused to submit a written statement to the facility. The facility investigative report documented they admitted to the Director of Nursing they used mittens, and bed sheets to restrain the resident because they had been known to smear feces over themself. Resident #1's adult child's personal cell phone with pictures from 12/17/2024 at 1:52 PM was reviewed. Observed: (1) a picture dated 10/14/2024 at 7:40 AM of Resident #1 lying in bed with their left and right hand tied with bed linens to the bed rails; (2) a picture dated 11/02/2024 at 3:35 PM showing Resident #1 lying on their back with right and left hand tied with bed linens to the bed rails; (3) a picture dated 11/09/2024 at 12:11 PM showing Resident #1 lying in bed with a twisted bed linen placed across their midbody and tied to both bed rails. During an interview on 12/17/2024 at 9:54 AM, Certified Nursing Assistant #2 corroborated what they wrote in their statement to the facility on [DATE]. Certified Nursing Assistant #2 wrote that they notified Licensed Practical Nurse #1 and #2 on 10/15/2024 and 11/15/2024. During an interview with the Director of Nursing on 12/17/2024 at 12:59 PM, the Director of Nursing stated on 12/09/2024 during their investigation into an incident involving Resident #1 that occurred on 12/04/2024, they learned from Resident #1's adult child that they had observed Resident #1 in restraints. The Director of Nursing stated on 12/10/2024 at 11:00 AM the adult child showed them (on their cell phone) pictures of the Resident's wrists being tied with a bed sheet to the bed rails on 10/14/2024 at 7:40 AM and on 11/02/2024 at 3:35 PM, and on 11/09/2024 at 12:11 PM with bed sheet across Resident #1's waist and tied to the bed rails. The Director of Nursing stated they interviewed Certified Nursing Assistant #6 who admitted they used pillowcases and sheets to restrain Resident #1's hands to prevent Resident #1 from removing their incontinent brief and smearing feces all over themself. The Director of Nursing stated Certified Nursing Assistant #6 stated they were not wrong for restraining Resident #1. During a telephone interview on 12/17/2024 at 1:45 PM, Resident #1's adult child stated they visited Resident #1 on 10/14/2024 and observed Resident #1's wrists tied with a bed sheet to both side rails at 7:40 AM and that they took pictures with their cell phone. Resident #1's adult child stated they visited Resident #1 on 11/02/2024 at 3:35 PM and Resident #1 had both their wrists tied with a bed sheet to the side rails. Resident #1's adult child stated they visited Resident #1 again on 11/09/2024 at 12:11 PM and Resident #1 had a bed sheet across their waist tied to both side rails. Resident #1's adult child stated they took pictures but did not report the restraints to anyone in the facility because they thought it was okay. During an interview on 12/18/2024 at 4:00 PM, Certified Nursing Assistant #5 corroborated what they wrote in their statement to the facility on [DATE]. Certified Nursing Assistant #5 wrote that they notified Licensed Practical Nurse #1 on 10/14/2024. During a telephone interview on 12/19/2024 at 12:01 PM, License Practical Nurse #1 stated they are the regular staff nurse on the unit on the 7:00 AM- 3:00 PM shift and that they have never observed Resident #1 in restraints. Licensed Practical Nurse #1 stated they were never informed by any staff member that Resident #1 was found in restraints. During an interview on 12/19/2024 at 4:47 PM, the Administrator stated they received a phone call from the Director of Nursing on 12/09/2024 (about just after midnight) notifying them Resident #1's adult child reported Resident #1 had been restrained. The Administrator stated a meeting was held with the adult child, Director of Nursing, Medical Director, and Director of Social Service on 12/10/24 at 11:00 AM. The Administrator stated during the meeting the adult child presented their evidence of Resident #1 being restrained. The Administrator stated the pictures were date and time stamped. The Administrator stated the adult child stated they did not report the restraint to anyone because they were afraid. The Administrator stated they provided education to Resident #1's adult child that advised they should report concerns or issues. The Administrator stated the police were called. 10 NYCRR 415.4(b)

Based on observation and interviews conducted during the Recertification Survey from 06/26/2024 to 07/03/2024, the facility did not ensure that garbage and refuse were disposed of properly. Specifically, garbage was not properly contained outside of the facility. The blue trash compactor/dumpster was not covered and there were various types of garbage lying on the ground. There was an overflow of various metal objects from the open dumpster. The findings are: The facility policy and procedure titled Compactor Usage with the effective date of 03/07/2022 documented that waste removal vendor removes and disposes waste related to municipal waste and recycling waste. During an observation on 06/28/2024 at 08:30 AM, there was a blue compactor observed with the lid open. On top of the blue dumpster was observed to have red colored substance, gray colored crutch, old food (green pepper) and blue rubber gloves. There were flies noted in the area. Trash was scattered on the ground around the dumpster area and there was white colored standing water. Also noted to the right side of the trash compactors were 10 red biohazard containers. Located on the ground next to the red biohazard containers are six (6) empty beer cans in a black plastic bag, six (6) empty glass beer bottles, 10 cigarette butts, suitcase, 2 televisions, printer, and a disc producer. Located in the garbage area is an old oil drum and an opened bag of rock salt placed on the ground. There were four (4) back boards tied to the fence of the garbage area. An open trash container used for metal items was observed. There were bedside table trays, mechanical lifts, chairs, 2 shopping carts, metal cabinets, open paint cans, aluminum pans, two (2) back boards, thirty-three (33) containers of biohazard boxes filled with needles. One (1) large blue dumpster was observed open and filled with trash. During an interview on 06/28/2024 at 9:00 AM, the Housekeeping Supervisor stated they are not sure who is responsible to keep the garbage area clean. During an interview on 06/28/2024 at 11:02 AM, the Director of Building Services/Corporate Director stated they have a big facility and everyone between the hospital, nursing home and clinics are responsible for the garbage. The grounds keeping department is the one that is supposed to clean the grounds around the garbage. During an interview on 07/01/2024 at 10:12 AM, the Assistant Administrator stated that the Director of Building Services is responsible for the trash compactor area and the grounds keeping staff is responsible for the other trash such as the metal items. During an interview on 07/02/2024 at 10:30 AM, the Building Services Employee stated their job is to keep the compactor area clean. They stated that lids are supposed to be closed on the trash compactor and supposed to be free of debris. They stated they are responsible to clean around the perimeter of the garbage area to sweep and pick up any debris on the ground. 10 NYCRR 415.14(h)

Based on observation, record review, and interviews during the Recertification survey from [DATE] to [DATE], the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was identified during the Dining and Kitchen Tasks. Specifically, 1) During the initial tour of the kitchen, opened and undated package of food were observed in the walk-in freezer. 2) the walk-in refrigerator was noted with juice spills, and 3) the walk-in refrigerator had food on the shelf past the best buy date. The findings are: The facility policy titled Food and Nutrition Sanitation Program with a last revised date of ,d+[DATE] documented that the purpose of the policy was to maintain a clean, safe, and effective environment of care and to prevent the transmission of disease-carrying organisms. Each employee will be designated daily to clean and sanitize all areas throughout the department. Cleaning equipment, walls, floor, and storage areas routinely with appropriate cleaning solution and sanitizing agents will prevent and significantly reduce the spread of harmful organisms. The facility policy titled Food, Supplies, and Equipment Procurement with a last revised date of ,d+[DATE] documented that it is the policy of the Food and Nutrition Services Department to design and implement a mechanism to ensure the safe and accurate purchase, receipt and check-in of food and nutrition item. The Executive Chef is responsible for the procurement of food, supplies, and equipment. Food items must be within their expiry date. An initial tour of the kitchen was completed on [DATE] at 09:30 AM with the Food Services Director. The following were observed: walk-in freezer had an open plastic bag of frozen fish patties on top of a cardboard box. Refrigerator #1 (meat refrigerator) was observed with red meat juices lying on the bottom of a gray table and on the floor of the refrigerator. Refrigerator #2 (dairy refrigerator) was observed with three (3) 48 ounces of ricotta cheese on the shelf with a best buy date of [DATE]. Six (6) 48 ounces of ricotta cheese on the same shelf was noted with best buy date of [DATE]. During an interview on [DATE] at 09:30 AM with the Food Service Director, they stated the staff had not gotten a chance to clean up the red meat juices and they do not know why there was an open bag of fish patties in the freezer. They stated that cleaning is the responsibility of all the staff to keep the kitchen clean. During an interview on [DATE] at 11:31 AM with the Store Room Inventory staff, they stated they are responsible for the storeroom and that they rotate the products and items and check for the expiration dates. They stated the garbage person is responsible for cleaning the floors, refrigerator, and freezer when there is a spill and there is more than one person that covers that area at any given time. During an interview on [DATE] at 11:40 AM with the Lead Cook, they stated that the kitchen staff is responsible for checking the refrigerators and freezers to make sure that the food is fresh, and no expired food remains in the refrigerator. 10 NYCRR 415.14(h)

Based on record review and interview conducted during the Recertification Survey from 06/26/2024 to 07/03/2024, the facility failed to develop and implement an effective discharge planning process that focuses on the resident's discharge goals. This was evident for 3 (Residents #136, #44, and #291) of 35 total sampled residents. Specifically, an individualized discharge care plan was not developed for Residents #136, #44, and #291. The findings are: The facility's policy titled Planned Transfer and Discharge with a reviewed date of 02/2023 stated that the social worker documents the resident's/designated representative's plan/request to return home or to another skilled nursing facility in the medical record, the assessment section, the coordinated care plan and the progress notes. The facility's policy titled Comprehensive Care Plan with a reviewed date of 12/2023 stated that every comprehensive care plan meeting must include a review and discussion of discharge planning. 1.) Resident #136 had diagnoses of Congestive Heart Failure, Hypertension, and Diabetes. The Minimum Data Set assessment dated [DATE] documented that the Resident had intact cognition. A review of Resident #136's comprehensive care plan revealed no documented evidence that a discharge care plan had been developed. During an interview on 06/26/2024 at 3:42 PM, Resident #136 stated they requested the social worker for help to be discharged in an apartment and they were told that Resident #136's family had to look for the apartment. During an interview on 07/03/2024 at 10:56 AM, Social Worker #4 stated Resident #136 had no active discharge plan because the Resident need homecare and had no housing. The Social Worker stated that there had been no discussion with Resident #136 about their discharge. During an interview on 07/02/2024 at 11:51 AM, the Director of Social Services stated discharge planning for each resident begins on admission and that discharge options must be discussed and documented in the medical record. The Director of Social Services stated a discharge care plan must be initiated for every resident. 45351 2.) Resident #44 had diagnoses of Seizure Disorder, Hyperlipidemia, and Hypertension. The Minimum Data Set assessment dated [DATE] documented Resident #44 had intact cognition and that Resident participated in the assessment process and would like to talk about possibility leaving the facility and returning to the community. A review of Resident #44's comprehensive care plan revealed no documented evidence that a discharge care plan had been developed. 3.) Resident #291 had diagnoses of Thyroid Disorder and Myotonic Dystrophy. The Minimum Data Set assessment dated [DATE] documented resident had intact cognition. The Social Services assessment dated [DATE] documented Resident #291 wanted to be transferred to another facility and gave a list of facilities. The review of medical record revealed there was no documented evidence Resident #291's transfer request made on 11/14/2023 was ever submitted and follow up was ever made to inform resident on the progress of transfer request. The Social Service assessment dated [DATE] documented Resident #291's goal was to remain in the facility and resident did not have active discharge planning occurring. A review of Resident #291's comprehensive care plan revealed no documented evidence that a discharge care plan had been developed. During an interview on 06/26/2024 at 9:52 AM, Resident #291 stated they requested a transfer to another facility some time last year, but Resident does not know if the application were submitted. During an interview on 07/02/2024 at 11:50 AM, Registered Nurse #5 stated Resident #291 had requested a few times about transferring to another facility and that the social worker was aware of the request. During an interview on 07/03/2024 at 10:49 AM, the Social Worker Assistant stated Resident #291 requested a transfer and gave a list of potential facilities some time last year. They stated they sent Resident #291's information last year but they cannot recall if they followed up with the facilities. The Social Worker Assistant stated Resident #291 gave them another list of facilities this year where they would want to be transferred to but have not submitted the application to any of these facilities. During an interview on 07/02/2024 at 3:34 PM, The Director of Social Services stated Resident #291 requested transfer to other facilities in November 2023 as per the medical record, but the Resident's transfer request was never carried out by the social work assistant. The Director of Social Services stated they were not able to locate the discharge care plan for Resident #291 and Resident #44 upon review of their medical record. They stated that the social worker who is assigned to the resident is responsible for initiating a discharge care plan. 10 NYCRR 415.11(d)(3)

Based on observation, interview, and record review conducted during the Recertification and Complaint (NY00311959) Survey from 06/26/2024 to 07/03/2024, the facility did not ensure that food were served at an appetizing temperature during meal service. This was evident for 2 units observed during dining observation. Specifically, food served during lunch meal service were not maintained at palatable and appetizing temperatures. The findings are: The facility's policy and procedure titled Dining and Meal Policy dated 11/2023 documented it was the policy of the facility to serve meals to meet the nutritional needs of residents. The facility's policy on Food and Nutrition Service dated 11/2023 documented it is the policy of the facility to provide meals to residents as scheduled to meet their nutritional requirements and to develop a mechanism that will ensure safe and accurate preparation and distribution of food products. The meal service time for lunch is 12:00 PM to 1:00 PM. 1. Resident #27 was admitted to the facility with Coronary Artery Disease, Hypertension and Hemiplegia. The Annual Minimum Data Set, dated dated dated [DATE] documented resident had intact cognition. On 06/27/2024 at 10:43 AM, Resident #27 stated meals are delivered to their room. The food is often served unappetizing and not hot enough. 2. Resident #261 was admitted to the facility with Depression, Respiratory Failure and Diabetes Mellitus. The Quarterly Minimum Data Set, dated dated dated [DATE] documented that resident had intact cognition. On 06/26/2024 at 11:07 AM, Resident #261 stated the meals were often served late and food is cold. On 06/28/2024 at 12:38 PM, Resident #261 was observed in the room, waiting for their lunch meal. On 07/01/2024 from 12:06 PM to 12:59 PM, food delivery cart arrived on Unit 2 North. The staff distributed the trays in the dining room and then distributed meal trays to residents in their room. On 07/01/2024 at 12:59 PM, test tray was conducted and revealed the following temperatures: chicken noodle soup 146.5 degrees Fahrenheit, a cup of hot water for tea 117.8 degrees Fahrenheit, spaghetti with sauce 148.5 degrees Fahrenheit, baked chicken 132.9 degrees Fahrenheit, broccoli 118.8 degrees Fahrenheit. On 7/2/2024 from 11:40 AM to 12:32 PM, food delivery cart arrived on Unit 3 North. The staff distributed the trays to the residents in the dining room and residents' rooms. On 07/02/2024 at 12:32 PM, test tray was conducted on Unit 3 North. The food temperatures were: meatloaf 115.5 degrees Fahrenheit, stuffing 154.4 degrees Fahrenheit, and mustard greens 147 degrees Fahrenheit. On 07/03/2024 at 11:35 AM, the Food Service Director stated the food temperatures measured on 7/1/2024 and 7/2/2024 were inconsistent and some items were below the optimal temperature for hot foods. Food Service Director stated some hot foods depending on the density are harder to maintain the temperature; however, the temperature should be at least above 135 degrees Fahrenheit. Food Service Director stated the food cart is delivered to dining room at 11:45 AM, starts meal delivery around 12:00 PM and should not take no longer than 30 minutes from start time. Food Service Director stated the staff took about 1 hour which is longer than expected to deliver the meals to the residents. When foods are kept long on the food cart, the temperature and quality may not be maintained. Food Service Director stated they have been using this food delivery system for more than [AGE] years; therefore, the equipment may also need maintenance to ensure they are working properly. On 7/3/2024 at 1:31 PM, Administrator stated they were made aware of the food temperature issue yesterday. Administrator further stated the facility will need to review the current food delivery system and look further into improving the food quality and temperature for the residents. 10 NYCRR 415.14(d)(1)(2)

Based on observation, record review, and interviews conducted during the Recertification Survey from 06/26/2024 to 07/03/2024, the facility did not ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This was evident for 1 (Resident # 69) of 1 resident reviewed for position/mobility. Specifically, there were multiple observations of Resident #60 without the left-hand carrot in place as per Occupational Therapy and physician orders. The findings are: The facility policy titled Adaptive Equipment/Assistive Feeding Devices with a revised date of 11/2023 documented that the rehabilitation department will provide residents requiring a splint, adaptive equipment, or assistive feeding device. The nurse will write instructions for use of the device and add updates to the care plan. Resident # 69 had diagnoses of Cerebral Vascular Accident, Dementia, and Hemiplegia. The Minimum Data Set assessment dated [DATE] documented that Resident #69 was moderately cognitively impaired and required substantial/maximal assistance of 1 person to complete Activities of Daily Living and had functional limitation in range of motion on upper extremity. The Department of Rehabilitation Medicine Assistive Devices / Adaptive Equipment form dated 05/31/2023 documented that Resident #69 had been provided with a splint, left hand carrot to be worn daily as tolerated to prevent further hand tightening. To remove for hygiene and skin inspection. Physician orders dated 02/11/2024 documented splint to be worn to both upper extremities at all times and remove during range of motion and skin care and hygiene. The Occupational Therapy endorsement form dated 02/09/2024 documented splint for both upper extremities to be worn at all times; remove during range of motion, skin care, and hygiene. A Comprehensive Care Plan related to contracture dated 04/05/2024 documented contracture of the left hand. The facility interventions include to provide range of motion as recommended, to monitor use of splints/devices; left hand carrot to be worn daily as tolerated and to remove for hygiene, skin infection and as needed. Review of Resident #69's care plan did not indicate Resident's refusal to wear the carrot splint. On 06/26/2024 at 12:30 PM and on 06/28/2024 at 12:15 PM, Resident #69 was observed sitting in the dining room with left hand contracture and without a left hand carrot in place. An interview was conducted on 06/28/2024 at 11:36 AM with Registered Nurse #2, who stated that Resident #69 had orders to clean the left hand and place the carrot. They stated that Resident #69 refuse to wear the carrot and would remove it when placed on their hand. An interview was conducted on 06/28/2024 at 12:10 PM with Licensed Practical Nurse #2, who stated that Resident #69 has left hand contracture and was ordered to use a carrot splint but Resident #69 keeps removing the carrot. An interview was conducted on 06/28/2024 at 12:16 PM with Certified Nursing Assistant #5, who stated that Resident #69 is supposed to wear a carrot splint for their hands. An interview was conducted on 06/28/2024 at 12:20 PM with Registered Nurse #3, who is also the Nursing Supervisor for the unit, stated that Resident #69 is supposed to wear a carrot splint on their left hand; they were not aware that Resident #69 has not been using the carrot splint. 10 NYCRR 415.12 (e)(2)

Based on observation, record review, and interview conducted during the Recertification and Complaint Survey (NY00341538), the facility did not ensure that the resident environment remains as free of accident hazards as is possible; and received adequate supervision to prevent accidents. This was evident for 1 (Resident #237) of 5 residents investigated for Accidents, out of 38 total sampled residents. Specifically, on 05/07/2024, Resident #237 sustained a fall when Certified Nursing Assistant #11 transferred Resident #237 using a mechanical lift without assistance from another staff. The findings are: The facility policy titled Mechanical Lift with a last reviewed date of 02/2020 documented that all residents must be lifted or transferred according to the determined procedure as stated in the resident care plan. A mechanical lift shall be used appropriately to facilitate transfers of residents as required. At least 2 people shall be present during transferring with the lift. Resident #237 had diagnoses of Hypertension, Hyperkalemia, and Non-Alzheimer's Dementia. The Minimum Data Set assessment dated [DATE] documented that Resident #237 had moderately impaired cognition. The assessment further documented that Resident #237 had impairment in both upper and lower extremities and was dependent for transfers, toileting, and bathing activity. A care plan for self-care deficit inability to transfer was initiated on 12/27/2023 for Resident #237. The care plan documented that Resident had impaired ability to move independently secondary to wheeled, chair fast, inability to shift weights, loss of voluntary movements. The facility interventions include providing passive range of motion, and to provide a supportive and safe environment. The Certified Nursing Accountability Record for Resident #237 dated May/June 2024 documented that the Resident required assistance of two persons for assistance using a mechanical lift for transfers. The nursing progress notes dated 05/07/2024 at 7:00 PM by Registered Nurse #7, documented that at approximately 6:25 PM, the nurse went to the unit to assess Resident #237. Upon arrival Resident was observed on the floor supine next to bed with the mechanical lift next to the Resident. Resident #237 was noted with a 2 centimeter laceration to the forehead. Resident was unable to give account of occurrence secondary to cognitive impairment. The note documented that as per staff, Resident #237 slid from the canvas during transfer with a mechanical lift. The doctor was informed and ordered to transfer the resident to the hospital. The laceration was cleaned with normal saline and cold compress was applied. The nursing progress notes dated 05/08/2024 at 8:15 AM documented that Resident #237 returned to the facility. The Resident was status post fall, laceration to their left forehead remained intact with no bleeding, mild swelling noted, denied pain. The hospital emergency room after visit summary dated 05/07/2024 documented that Resident #237 had a diagnosis of unspecified fall, with forehead laceration, closed with glue. The computed tomography scan showed no evidence of cervical spine fracture or subluxation and no acute findings in the head/brain. A written statement by Certified Nursing Assistant #11 dated 05/07/2024 documented that they were preparing Resident #237 to transfer from recliner chair back to bed. The written statement documented, Certified Nursing Assistant called for help and while waiting, raised the Resident up from the recliner chair and the Resident shifted and slid from the canvas. The facility Internal Investigation Report form completed by the Director of Nursing documented that on 05/07/2024, the supervisor was called to the unit to assess a resident post fall. Resident was unable to give an account due to cognitive impairment. Staff reported that while waiting for help, they transferred Resident #237 with a mechanical lift from the chair and the resident slid off the canvas. The investigation concluded that the staff was made aware of the dangers of using a Hoyer Lift without assistance and most important of calling for help, and waiting until help arrives. The facility investigation report also documented that the incident was an accident which could have been avoided. On 07/02/2024 at 09:47 AM, Resident #237 was interviewed and stated they remember they had a fall when 1 staff transferred them and that they hit their head and went to the hospital. On 07/01/24 at 03:45 PM, an interview was conducted with Certified Nursing Assistant #11. They stated that Resident #237 was on their assignment on the evening shift of 05/07/2024. The stated they took Resident #237 to their room and called for help to transfer the resident. The Certified Nursing Assistant was not able to specifically say who they asked for assistance. They stated that they were setting up the Resident for transfer by placing the recliner close to the bed. Certified Nursing Assistant #11 stated they did not try to transfer Resident #237 alone with a mechanical lift, and that Resident #237 had a canvas underneath and was moving and shaking and fell out of the chair on their left side. On 07/03/2024 at 12:52 PM, the Director of Nursing Services was interviewed and stated that the incident that occurred on 05/07/2024 was an accident that could have been avoided if the staff followed the plan of care of having two staff for mechanical lift transfer. 10 NYCRR 415.12 (h)(2)

Based on observation, record review, and interviews conducted during the Recertification Survey from 06/26/2024 to 07/03/2024, the facility did not provide an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. This was evident for 1 (Resident #365) out of 38 total sampled residents. Specifically, Resident #365 was not provided with a television or other device to watch their preferred programs. The findings are: The facility policy titled Departmental Scope of Service with Policy Number TR-001.5 for Therapeutic Recreation Department and implemented and revised date 12/23 documented the service provision is made available to all members of the resident population, and is based on individual resident assessment, treatment planning, interests, preferences, and needs. Resident #365 had diagnoses of Multiple Sclerosis, Arthralgia, and Unspecified Fall. The Minimum Data Set assessment dated [DATE] documented Resident #365 had severely impaired cognition. The assessment also documented Resident #365 found it very important to do their favorite activities. From 06/26/2024 at 10:29 AM to 07/01/2024 at 03:32 PM, there were multiple observations of Resident #365 in their bed and in wheelchair in the hallway on the unit with no ongoing activities. There was no television or other device observed being provided to Resident #365 to watch their preferred television programs. The Comprehensive Care Plan related to leisure needs that was initiated on 12/21/2023 and was last updated on 06/16/2024 documented that Resident #365 was a loner by lifestyle preference and preferences included watching television. The interventions included to involve in preferred activities and provide support to improve motivation. The initial recreation assessment dated [DATE] documented it was very important for Resident #365 to do their favorite activities including to watch television. It also documented the current leisure interests for Resident #365 included to watch television in their own room. The quarterly recreation assessment dated [DATE] and 6/16/2024 documented Resident #365 was intact in memory and their current leisure preferences included watching television. There was no documented evidence Resident #365 was provided a television set or other alternative device to watch their favorite television programs in their room. On 06/25/2024 at 10:29 AM, Resident # 365 was interviewed and stated they were admitted to the facility for several months and was not able to watch their favorite sport program on television in their room. Resident #365 also stated there was a television installed on the wall in front of the roommate's bed and they were not able to watch it from their bed. Resident #365 further stated they did not have activities to do in their room and would like to watch sport program on television at any time they liked as when they were in the community. On 07/01/2024 at 12:18 PM, the Certified Nursing Assistant #1 was interviewed and stated Resident #365 did not have television or activities in the room. On 07/01/2024 at 02:37 PM, the Recreation Therapy Specialist was interviewed and stated they did the initial and quarterly recreation assessment for Resident #365. The Recreation Therapy Specialist also stated the current leisure interest for Resident #365 was to watch television in their room. The Recreation Therapy Specialist stated they were not sure if Resident # 365 was able to watch the television installed on the roommate's side. The Recreation Therapy Specialist went to Resident #365's bed with State Surveyor and confirmed Resident #365 was not able to watch the television from their bed. On 07/01/2024 at 03:24 PM, the Assistant Director of Recreational Therapy was interviewed and stated they provided the residents with their preferred activities as per assessments indicated. The Assistant Director of Recreational Therapy further stated all residents should be able to watch their favorite television programs in their room at any time if this was their preferences. The Assistant Director of Recreational Therapy had no explanation why no follow up or other alternative was made to address Resident #365's interest of watching television in the room as indicated in the recreation assessment. 10 NYCRR 415.5(f)(1)

Based on observation, interviews, and record review conducted during the Recertification and Complaint (NY00340955) Survey from 06/26/2024 to 07/03/2024, the facility did not ensure that a resident who is unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene. This was evident for 1 (Resident # 69) of 35 total sampled residents. Specifically, Resident #69 did not receive staff assistance for nail trimming and was observed with thick, long, discolored fingernails. The findings are: The facility policy titled Activities of Daily Living with a revised date of 06/2024 documented that a program of activities of daily living (ADL) is provided to residents to prevent disability and promote resident's function at maximum level of independence. The ability of each resident to meet the demands of daily living is assessed by a registered nurse, occupational therapist, and/or physical therapist. Hygiene was included in the policy explanation and compliance guidelines. Resident # 69 had diagnoses of Cerebral Vascular Accident and Dementia. The Minimum Data Set assessment dated [DATE] documented that Resident #69 had moderately impaired cognition and required partial/moderate assist with toileting, personal hygiene, and grooming. On 6/26/2024 at 12:30 PM, Resident #69 was observed sitting in the dining room eating lunch. Resident's left hand was contracted, with long, thick and brownish/yellowish nails observed curled into resident's left hand. The Comprehensive Care Plan Titled Self Care Deficit- Dressing and Grooming that was initiated on 04/05/2024 documented that Resident #69 required assistance with personal hygiene associated with grooming. The facility interventions include to clip and clean nails regularly in accordance with preference and safety. The Certified Nursing Assistant Accountability Records from April 2024 to May 2024 had no documentation about nail care for Resident #69. The nursing progress notes dated 11/01/2023 to 06/26/2024 had no documentation that Resident # 69's fingernails were cleaned and trimmed. During an interview on 06/28/2024 at 12:16 PM, Certified Nurse Assistant #5 stated Resident #69 needs total care. They stated that Resident #69's nails need to be trimmed by a podiatrist because they are too long. They stated they did not report to the nurse that Resident #69's nails need to be trimmed. During an interview on 06/28/2024 at 12:10 PM, Licensed Practical Nurse #2 stated that Resident #69 requires total care and that they were not aware of Resident #69's long nails. During an interview on 06/28/2024 at 12:20 PM, Registered Nurse # 3, who was the nursing supervisor, stated they were not aware of Resident #69's long nails. They stated that the Certified Nursing Assistants are supposed to cut the resident's nails unless it is beyond their training to cut the nails, then a podiatry consult is placed. 10 NYCRR 415.12(a)(3)

Based on observation, interviews, and record review during an abbreviated survey (Case #NY00332762, NY00332416) the facility did not ensure that the resident's representative was notified of changes to a resident skin. This was evidenced in one of three residents sampled (Resident #1). Specifically, on 01/29/2024, Resident #1' s designated family member was visiting Resident #1 and saw healing abrasions to the front of the legs below the knees (shins). The family member was not aware of the skin changes. The Findings are: The facility's policy titled, Change in Resident Condition, dated 8/2023, documented Circumstances Requiring Notification are: 1. Accidents resulting in injury 2. Potential to require physician intervention. Resident #1 was admitted on [DATE], with diagnoses include Dementia, (memory loss), Cerebrovascular Accident (a stroke) with Left side weakness, and Seizures. Resident #1 was non-verbal, legally blind, and aphasic (unable to speak). The Minimum Data Set (MDS-tool used to determine level of care required) dated 12/16/2023, documented Resident #1 was dependent for all activities of daily living and was non-ambulatory (unable to walk). The Brief Interview for Mental Status (BIMS-a scored tool used to determine cognition) documented Resident #1 was severe cognitively impaired. Nursing Progress notes dated 01/19/2024 and 01/27/2024 to 01/31/2024 revealed no documented evidence of changes in Resident #1's skin. A Nursing Progress Note, by Registered Nurse #2, dated 01/29/2024 during the 7 AM to 3 PM shift, documented, Resident #1's adult child visited and expressed concerns regarding Resident #1's skin to both legs. Resident #1's skin was assessed and noted with healing lacerations to both shins. The right shin was six centimeters by one-centimeter dry skin area, the Left shin had dry healing scabs. The Skin Check Form dated 01/26/2024 to 01/29/2024 documented G for good skin on Resident #1's skin check form for all shifts. On 01/29/2024 during the 7 AM to 3 PM shift, the skin check form documented B for broken skin, with no indication as to where the skin was broken. The Physician 's progress note dated 1/29/2024, documented resident with linear abrasions on both shins, no erythema, no bleeding, no discharge. Apply Bacitracin topically and cover with dry sterile dressing for seven days. The Results of the X-ray of the right and left leg dated 01/31/2024, documented no evidence of fractures or soft tissue swelling. During a telephone interview on 06/11/2024 at 11:32 AM, the assigned Certified Nursing Assistant #1 who works the 3 PM to11 PM shift but was assigned to work the 7 PM to 3 PM shift on 01/29/2024, stated they never saw any injuries or skin changes on Resident #1 prior to 01/29/2024. The skin changes were observed during care on the morning of 01/29/2024, there were long lines on each of the Resident #1's leg and they were dry, hard scabs, no swelling, no bleeding. Certified Nursing Assistant #1 stated they forgot to tell the assigned nurse, License Practical Nurse #1 on the dayshift. The family member arrived, saw the Resident #1's legs, and spoke with the Nursing Supervisor. During telephone interview on 06/11/2024 at 1:55 PM, the Registered Nurse / Unit Manager #1 stated they were at the nurses' station with Registered Nurse #1 when the family member expressed their concern. Resident #1 was assessed by the Unit Manager #1 and Registered Nurse #1 and observed the healing abrasions on both shins. The Unit Manager #1 acknowledge and concluded that the injuries may have occurred within 72 hours and the family member was upset because they did not get a call from the facility to inform them of Resident #1's skin changes. During an interview on 06/07/2024 at 6:30 PM, the Director of Nursing and the Administrator, stated that it is not acceptable that the Certified Nursing Assistants who provided care to Resident #1 did not observe that Resident #1's legs had wounds or injury at the front of the legs below the knees. 10 NYCRR 415.3(e)(2)(ii)(b)

Based on observation, record review and interviews during an abbreviated survey (Case # NY00296995), the facility did not ensure that the resident had the right to be free from physical abuse. This was evident for 1 out of 4 residents reviewed (Resident #1). Specifically, on 06/05/2022 at 8:40 AM, Resident #1 stated that the Food Service Staff, the Dietary Aide #1 (FSS #1) hit them in their face. On 06/05/2022 at 10:51 AM, Registered Nurse #1 (RN #1) assessed Resident #1 and there was a small cut to the left nose with redness and swelling to the left side of the face. The FSS #1 was immediately suspended. The findings are: The Facility's Policy titled Abuse, Mistreatment, Neglect, Misappropriation of Resident's Property dated 02/2022, documented that the facility shall provide residents with considerate and respectful care designed to promote resident's independence and dignity. Each resident will be protected from abuse, neglect, mistreatment or misappropriation of property in accordance with State and Federal regulations. This includes the facility's identification of residents, whose personal histories render them at risk for abusing other residents and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior and reassessment of the interventions on a regular basis. Resident #1 was admitted to the facility with diagnoses of Rhabdomyolysis (a breakdown of muscle tissue), and Below the Knee Amputation (BKA). The Minimum Data Set (MDS, a resident assessment tool) dated 04/13/2022, documented Resident #1's. Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 15, indicated cognitively intact status. Resident #1 required supervision with all activities of daily living (ADL). The Risk Care Plan for Abuse revised on 06/05/2022, documented intervention to encourage the resident to verbalize fears and feelings, teach resident to report incident, monitor resident for signs and symptoms of abuse, bruises, and social withdrawal. The Facility's investigative report dated 06/05/2022 at 8:40 AM, documented that it was reported that there was a verbal dispute between Resident #1 and the FSS #1 in the dining room. Resident #1 stated that they passed gas, and the FSS #1 asked them to apologize. The resident then reacted by throwing the butter bowl at the FSS #1. The FSS #1 then punched Resident #1 to the left side of the face. Resident #1 sustained an abrasion to the left side of the nasal bridge with redness and swelling. The New York Police Department (NYPD) and Medical Doctor (MD) were notified. NYPD responded and interviewed Resident #1 and the staff. No reports were filed as Resident #1 did not want to file a police report. Based on interviews, observation and record review, the evidence indicated that the FSS #1 hit Resident #1 to the face resulting in a small cut to the lateral nose, with mild pain to the left jaw. The Nursing progress note dated 06/05/2022 at 10:51 AM, written by RN #1, documented that License Practical Nurse #1 (LPN #1) reported that the resident was arguing with a Dietary Aide (FSS #1) in the dining room, and they observed a small skin break on the resident's nose. This was immediately reported, and the resident was assessed. The resident was observed to have an abrasion to the left side of their nose, measuring 0.3 centimeters (cm) x 0.1 cm with slight swelling. Resident was alert and oriented times three and was interviewed about the occurrence. The resident stated that they were hit in their face by the FSS #1. The resident explained that they and the food service worker got into an argument because they, the resident passed gas and the food service worker told resident to say excuse to them and resident did not. The resident stated that they were upset, and they grabbed and threw the container with the butter at the FSS #1. The resident stated, at that point the worker started throwing punches and they punched them in their face. The resident stated that they were hit on their nose and on the left side of their face. During an interview on 03/06/2023 at 10:54 AM, Resident #1, stated that they had breakfast in the dining room. Resident #1 stated that after breakfast they were wheeling themselves to empty their food tray. Resident #1 stated that as they were wheeling themselves they passed gas. Resident #1 stated that the FSS#1 was in front of them. Resident #1 stated that FSS #1 turned around and told them to apologize. Resident #1 stated that they refused because everyone passed gas and they did not see it as a big deal. Resident #1 stated that they had a small container of butter on the tray. Resident #1 stated that they took the small container of butter and threw it at FSS #1. Resident #1 stated that it hit the FSS #1 in their face. Resident #1 stated that FSS #1 turned around and punched them on the left side of their face. Resident #1 stated that they had a little swelling and mild pain. Resident #1 stated that the facility called the NYPD and was interviewed by NYPD. Resident #1 stated that they refused to pressed charges because it was not a big deal. During an interview on 03/06/2023 at 10:58 AM, Registered Nurse (RN) #1 stated that they were on the unit at the nursing station when they heard a noise and responded. They observed Resident #1 and FSS #1 arguing, but did not see when FSS #1 punched Resident #1. RN #1 stated that when they got closer to Resident #1, they observed redness. RN #1 stated that they did a body assessment and Resident #1 was noted with redness, swelling and a small cut to their left nose. RN #1 stated that they immediately reported the incident to the FSS #1's Supervisor. RN #1 stated that they make rounds on the unit to monitor residents and staff to ensure that no abuse occurred. During an interview on 03/06/2023 at 12:45 PM, Certified Nursing Assistant (CNA #1) #1 stated that they were serving the breakfast tray when they heard a noise close to the dining room area. CNA #1 stated that they did not see FSS #1 punched Resident #1, but they were arguing. CNA #1 stated that they informed FSS #1 that they should not be arguing with Resident #1. CNA #1 stated that other staff heard the noise and came to see what was happening. CNA #1 stated that they persuaded FSS #1 to leave the unit. CNA #1 stated that FSS #1 left the unit immediately. During an interview on 03/06/2023 at 2:37 PM, FSS #1 stated that they were the dietary transporter for the day. FSS #1 stated that they went to the unit and was making rounds to see what supplies the staff needed on the unit. FSS #1 stated that Resident #1 was wheeling themselves with a tray in their lap going to the garbage bin. FSS #1 stated that Resident #1 was behind them. FSS #1 stated that Resident #1 passed gas and they informed Resident #1 to apologized. FSS #1 stated that Resident #1 used profanity to them and then threw a container of butter at them. FSS #1 stated that the container hit them in their face. FSS #1 stated that they did not punched Resident #1 in their face. FSS #1 stated that they do not know how Resident #1 sustained the swelling and cut to their face. FSS #1 stated that NYPD was called and interviewed them and left. FSS #1 stated that they received in-service on abuse prevention. During an interview on 03/06/2023 at 3:00 PM, the Director of Food Services (DFS) #1 stated that they received a call from RN #1. DFS #1 stated that they went to the unit and interviewed Resident #1. DFS #1 stated that while talking to Resident #1 they observed redness and swelling to their face. DFS #1 stated that they initiated an investigation. The DFS #1 stated that FSS #1 was suspended pending the outcome of the investigation. The DFS #1 stated that the investigation was substantiated and FSS #1 was terminated. The DFS #1 stated that they make daily rounds and spoke with the residents on the unit. DFS #1 stated that they also provided abuse prevention in-service to the staff. During an interview on 03/06/2023 at 4:00 PM, Director of Nursing (DON) stated that they were informed of the incident by RN #1. The DON stated that Resident #1 was interviewed, and a body assessment was done. The DON stated that Resident #1 was noted with a small cut to their left nose. The DON stated that NYPD was called immediately. The DON stated that Resident #1 and FSS #1 were interviewed by NYPD. The DON stated that Resident #1 refused to pressed charges and NYPD left. The DON stated that FSS #1 was immediately suspended and later terminated from the facility. The DON stated that MD was called and order bacitracin oinment to the area daily for five days. The DON stated Resident #1 was placed on neurological assessments for 48 hours. Staff members were provided with re-education of abuse prevention. The DON stated that the nurses and the nursing supervisor are responsible to make rounds and monitoring the residents and staff on their unit. The DON stated that the incident was discussed in QAPI meeting and interventions were put in place to prevention abuse. Based on the following corrective actions taken, there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance with this specific regulatory requirement prior to and during the time of this survey. A Plan of Correction was not required for this citation. The facility took corrective actions and was found to be in substantial compliance on 06/15/2022 prior to the onsite visit on 03/06/2023. Resident #1 body assessment was done. The facility called local law enforcement. Policy and Procedure on Abuse was reviewed, and no changes were required. The food service staff was terminated. All staff was re-in-service on the abuse policy. The facility has 311 staff members and in-service. 100 percent (%) Random audit with residents on abuse prevention was done on 10/03/2022, 11/14/2022 and 12/05/2022. Quality Assurance and Performance Improvement (QAPI) dated 6/15/2022. Interviews conducted on 03/03/2023 and 03/06/2023 with (6 CNAs, 4 LPNs 3 RNSs, 4 food service staffs, 2 housekeepers) revealed that staff was knowledgeable about the abuse policy. 10 NYCRR 415.4(b)(I)(i)

Based on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure an effective pest control program was maintained. This was evident for 1 (6th floor) of 7 residential floors in 1 of 2 facility buildings. Specifically, there were multiple observations of roaches infestation in resident rooms on the facility's 6th floor. The findings are: The facility policy titled Building Services: Pest Control dated 1/2022 documented the facility will control control pest infestations throughout all areas of the Medical Center by contracting with a qualified pest management company and establishing a service schedule. On 06/15/22 at 03:45 PM, 5 roaches were observed walking on the floor of Room 634 on the 6th floor residential unit. On 06/16/22 at 01:24 PM, 06/17/22 at 01:00 PM, and 06/21/22 10:18 AM, observations of several live and dead roaches were observed in Room 636. The roaches were observed crawling up the walls and on resident belongings in the room. The 6th Floor Pest Control Log from 3/31/22 to 5/30/22 did not document pest concerns related to roach infestation. The Pest Control Log documented roach infestation was observed and addressed in Room 636 and 630 on 5/31/22 and in Room 600 and 605 on 6/02/22. On 06/16/22 at 03:42 PM, the Building Services Manager (BSM) was interviewed and stated they did observe roaches living amongst the residents belongings in Room 636. At the time of the interview, the BSM attempted to enter the room but Resident #27, who was present in Room 636, asked the BSM and Surveyor to leave. The BSM stated nursing staff and the BSM log pest control concerns in the Pest Control Log and the facility's contracted pest control company comes in to address the logged concerns. Pest control contact information was made available to the nursing staff on the 6th floor if they had immediate concerns with infestation. The facility had issues with their previous pest control company and hired a new company. The pest control company applies a gel to resident rooms to address any infestation and nursing staff have been educated re: preventing infestation by removing food and dirty linen from resident rooms. Residents are also educated mot to leave food in their bedside tables. On 06/16/22 at 04:34 PM, the Assistant Administrator was interviewed and stated pest control services are available 5 days a week and the 6th Floor infestation is a known concern due to a resident with hoarding behavior who resides on the unit. The facility has become more aggressive in their approach to 6th floor infestation. On 06/17/22 at 02:15 PM, the Housekeeper was interviewed and stated Resident #27 in Room 636 hoards clothing and food and does not allow the housekeeping staff to remove items from the room. The roach infestation in Room 636 has not improved and there are roaches on the walls, in the drain, and throughout the room. The BSM was made aware of the roach infestation on the 6th floor. On 06/17/22 at 04:38 PM, Licensed Practical Nurse (LPN) #2 was interviewed and stated Resident #27 in Room 636 closes their door and does not provide nursing staff access to their room. Resident #27 orders outside food and stores food in their bedside table and sometimes blocks their door with a bin to prevent staff from entering. 415.29(j)(5)

Based on observation, record review, and interview conducted during the recertification survey, the facility did not ensure a comprehensive care plan (CCP) was developed to meet a resident's medical, nursing, mental, and psychosocial needs. This was evident for 2 (Resident #27, Resident #67) of 38 sampled residents. Specifically, 1) Resident #27 was observed with hoarding behavior and documented refusals of medications without a developed CCP to address the behaviors; and 2) there was no documented evidence a CCP related to [CONDITION(S)] Drug Use was developed for Resident #67 who receives antipsychotic and anti-depressant medication. The findings are: The facility policy titled Interdisciplinary Person-Centered Care Planning dated 05/2022 documented to ensure effective implementation of a comprehensive person-centered care plan for each resident which includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs that are identified in the comprehensive assessment. 1) Resident #27 was admitted to the facility with Diabetes, Hypertension, and [CONDITION(S)]. The Quarterly Minimum Data Set, dated dated dated [DATE] documented Resident #27 was cognitively intact. On 06/16/22 at 01:24 PM, 06/17/22 at 01:00 PM, and 06/21/22 10:18 AM, observations of several live and dead roaches were observed in room [ROOM NUMBER] where Resident #27 resided. There were observations of large bags of resident clothing and belonging, and clean and dirty linen. There was no documented evidence a CCP related to Resident #27's hoarding behavior was developed or implemented. On 06/16/22 at 03:42 PM, the Building Services Manager (BSM) was interviewed and stated Resident #27 is a known hoarder of blankets, towels, and personal belongings to the extent that Resident #27 cannot walk around the entire room. Resident #27 also hoards food that attracts flies and roaches. At the time of the interview, Surveyor and BSM attempted to enter Resident #27's room and was asked to leave by the resident. On 06/16/22 at 04:34 PM, The Assistant Administrator was interviewed and stated Resident #27 has hoarding behavior that has been a problem for a while and the facility has attempted to address the issue more aggressively. On 06/17/22 at 02:15 PM, the Housekeeper was interviewed and stated Resident #27 does not let the Housekeeper throw out items and watches them while they clean the room. The Housekeeper noticed the roach infestation in Resident #27's rooms and informed the BSM. Resident #27 stuffs clothes and food under their bed and in other areas of the room and will not allow the Housekeeper to remove the food. Resident #27 displays hoarding behavior so the Housekeeper mops around their belongings. On 06/17/22 at 04:38 PM, Licensed Practical Nurse (LPN) #2 was interviewed and stated Resident #27 keeps their door closed and sometimes places a bin in front of it to prevent staff from entering. Staff do not enter Resident #27's room out of respect for their privacy. Nursing staff is aware that Resident #27 orders outside food, does not allow staff to keep the food in the refrigerator, and keeps the food in their bedside table. LPN #2 stated CCPs related to behavior are initiated by the night nurse and kept in a binder at the nursing station. LPN #2 was unable to provide documented evidence the facility created a CCP related to hoarding behavior for Resident #27. On 06/21/22 at 11:14 AM, the Director of Nursing (DON) was interviewed and stated when a resident has an identified concern, then a care plan should be initiated. The Registered Nurses are responsible for initiating the CCPs; however, there is no nursing supervisor currently assigned to Resident #27's unit to ensure CCPs are developed. Hoarding behavior is an identified concern that should have a correlating CCP to address the behavior. 2) Resident #67 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] and 5/10/2022 documented Resident #67 was cognitively intact and received antipsychotic and antidepressant medications. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . June 2022 Medical Administration Record documented Resident #67 received [MEDICATION(S)] tablet 50 mg at bedtime and [MEDICATION(S)] 50mg daily as ordered by the Physician. There was no documented evidence a CCP related to [CONDITION(S)] Drug Use was developed or implemented for Resident #67. On 06/17/22 at 12:35 PM, Registered Nurse (RN) #3 was interviewed and stated CCPs were developed by the nursing staff on the unit and kept in a CCP binder. The nursing supervisor for a different unit is currently covering the 6th floor where Resident #67 resides. CCPs related t [CONDITION(S)] Drug Use were not developed for Resident #67. On 06/17/22 at 02:34 PM, RN #4 was interviewed and stated they were covering the 6th floor but was unfamiliar with Resident #67. 415.11(c)(1)

Based on interviews and record review conducted during the recertification survey, the facility did not ensure a resident diagnosed with dementia, received the appropriate treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. This was evident for 1 (Resident #67) of 3 residents reviewed for Dementia Care. Specifically, the facility did not develop a comprehensive care plan (CCP) related to dementia for Resident #67 who was diagnosed with dementia. The findings are: The facility policy titled Interdisciplinary Person-Centered Care Planning dated 05/2022 documented to ensure effective implementation of a comprehensive person-centered care plan for each resident which includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs that are identified in the comprehensive assessment. Resident #67 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) dated [DATE] and 5/10/2022 documented Resident #67 was cognitively intact and was diagnosed with non-Alzheimer's dementia. Psychiatry Consult dated 4/7/2022 documented rule out (R/O) Lewy body dementia. Nursing Notes dated 3/23/2022 and 3/29/2022 documented Resident #67 refused medications. The Medical Doctor Note dated 5/18/2022 documented Resident #67 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] There was no documented evidence a CCP related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 06/17/22 at 12:35 PM, Registered Nurse (RN) #3 was interviewed and stated they update and implement CCPs located in a binder on the unit. The Nursing Supervisor is responsible for reviewing the CCP binders but there is currently no Nursing Supervisor assigned to the Resident #67's unit. The facility decided to switch from electronic medical record CCPs in 4/2022 and now write CCPs by hand and place them in the binder. RN #3 was unable to provide documented evidence a CCP related to dementia was developed for Resident #67. On 06/17/22 at 02:34 PM, RN #4/Nursing Supervisor was interviewed and stated they are covering the 6th floor and was not familiar with the residents on Resident #67's unit. A On 06/21/22 at 11:14 AM, the Director of Nursing (DON) was interviewed and stated residents with identified concerns should have a coinciding CCP initiated. The RN initiates the CCP, and RNs or LPNs can update them. The RNs are not able to view the same diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #67 was cognitively intact and did not require a CCP related to their dementia diagnosis. The DON stated the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 415.12

FACILITY Resident Assessment Based on staff interview and record review conducted during a recertification and abbreviated survey, the facility did not ensure that each portion of the Minimum Data Set (MDS) assessment accurately reflect the resident's status. This was evident for 2 residents out of 38 sampled residents. (Resident # 11, Resident #207). Specifically, Resident #11's Annual MDS assessment inaccurately documented that Resident #11 received Insulin for seven days while in the facility. Resident #207's Annual MDS assessment did not accurately document that the resident received [CONDITION(S)] three times weekly while a resident. The findings are: The facility's Policy titled Completion of MDS 3.0 dated last reviewed 10/2021 documented residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop interdisciplinary care plan. The Policy further documented According to Federal regulations, the facility conducts initially and periodically a comprehensive accurate and standardize assessment for each resident, and Persons completing part of the assessment must attest to the accuracy of the section they completed. 1) Resident #11 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Annual Minimum Data Set (MDS) Assessment 3.0 dated 02/07/2022 documented resident with Long-term and Short-term memory problem. No memory recall, and severe cognitive impairment. MDS Section N0350 titled Insulin Part A. documented the resident received insulin for seven (7) days. The MDS did not accurately document the resident status. A review of the resident's entire medical record from the MDS assessment reference dates was completed. There was no documented evidence that the resident received any insulin, and no documented evidence that insulin was administered while a resident in the facility. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Medication Administration Record(MAR) dated February 2022 had no documented evidence that the resident received Insulin Injections for the above assessment period, and no documented evidence that the resident received insulin injections during the month of February 2022. On 06/16/22 at 11:21 AM, an interview was conducted with Minimum Data Set Assessor (MDSA), Other Staff #6. The MDSA stated when completing the MDS conducts a complete chart review which includes, review of the progress notes, the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDSA stated the resident did not receive any insulin during this assessment period. The MDSA stated this was an oversite, and an error and takes full responsible for this error. MDSA also stated he/she was inserviced to double check documentation when completing the MDS, and this was just an error. On 06/16/22 at 11:24 AM, an interview was conducted with The Director of Clinical Assessment (DCA). The DCA stated he/she is responsible for reviewing all MDS assessments and supervises all the MDSAs. The DCA stated he/she monitors the MDSAs by reviewing all the residents that are due for review in the Comprehensive Care Plan meetings (CCP) and meeting weekly with the MDSAs to review with them what is going on with each resident up for review. The DCA stated he/she reviews the entire MDS, including Section N. The DCA stated also review the MDS for accuracy, by checking the documentation of the assessors, but stated unfortunately this was missed. The DCA stated all staff are inserviced and instructed to do a double review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The DCA stated this was an unfortunate oversite. Resident #207 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) dated [DATE] and 3/31/2022 documented Resident #207 was cognitively intact. The MDS did not document Resident #207 was receiving Hemodialysis treatment. MDS does not include that the resident is receiving [CONDITION(S)]. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The comprehensive care plan (CCP) related to Hemodialysis treatment was initiated 4/8/22 and documented interventions to address Resident #207 receiving Hemodialysis three times weekly. On 06/21/22 at 10:00 AM, MDS Coordinator #2 was interviewed and stated they assess residents and are responsible for completing the section related to Hemodialysis therapy. The MDS Director reviews the MDS before it is submitted. If there is missing or incorrect information in the MDS, MDS Coordinator #2 will inform their supervisor so a correction can be made. On 06/21/22 at 10:23 AM, the Director of Clinical Reimbursement (DCR) was interviewed and stated meets with the MDS Coordinators weekly to review resident assessment information. Resident #207 was not documented as receiving Hemodialysis on the MDS assessments due to an oversight. The MDS Coordinator was contacted to revise Resident #207's MDS assessments to include [CONDITION(S)] treatment. 415.11(b)

Based on interviews and records review conducted during the recertification and complaint survey (NY 220), the facility did not ensure that an alleged violation involving Abuse was reported to the New York State Department of Health (NYSDOH) within the acceptable timeframe. Specifically, one allegation of resident to resident abuse, involving Resident #211 and #231, was not reported within 2 hours. This was evident for 2 of 4 residents reviewed for Abuse (Resident #211 and #231). The findings are: The facility policy titled Abuse, Mistreatment, Neglect, Misappropriation of Resident's Property effective 1/1/94 and reviewed 2/22 documented any case in which abuse, neglect, mistreatment or misappropriation of resident's property has been identified via the investigation, or a conclusion cannot be drawn will be reported promptly to the State Department of Health for further investigation. Resident #211 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident # 211 had severely impaired cognition and required supervision to total assistance of one person for Activities of Daily Living (ADLs). A Nursing Note dated 1/16/2021 documented Resident #211 was ambulating in the hallway when Resident #231 tried to take Resident #211's pillow out of his hands. When resident #211 refused to release the pillow, resident #231 punched resident #211 in the nose before staff could intervene. Resident #211 had a large nosebleed, and an ice pack was applied. Resident # 231 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #231 had severely impaired cognition and required supervision to extensive assistance of one person for Activities of Daily Living (ADL). The Accident/Incident Report was initiated 1/16/2021 and documented the facility investigated the incident between Resident #211 and #231. The investigation was completed and signed 1/16/21 by the Assistant Director of Nursing (ADNS). A confirmation email from NYSDOH documented the facility submitted the incident to the NYSDOH on 1/17/2021 at 1:51 PM. An interview was conducted on 6/17/22 at 11:42 AM with the ADNS who stated I was previously told we notify NYSDOH within 24 hours. We just learned we have 2 hours to notify NYSDOH. This incident happened on 1/16/21 at 11:30 AM. NYSDOH was notified on 1/17/21 at 1:51 PM. An interview was conducted on 6/21/22 at 11:55 AM with the Director of Nursing (DON) who stated suspected abuse should be reported to the NYSDOH within 24 hours. The resident to resident altercation should have been reported within 24 hours. The incident happened on 1/16/21 at 11:30 AM and was reported on 1/17/21 at 1:51 PM. The facility received the x-ray results on 1/17/21, indicating resident #211's nose was fractured. Incidents resulting in serious bodily injury must be reported within 2 hours after forming the suspicion. All other incidents must be reported within 24 hours. 415.4(b)(1)(i)

Based on record review and interviews conducted during the Recertification and Complaint survey from 6/13/2022 to 6/21/2022, the facility did not ensure, to the extent practicable, that residents were involved in developing the comprehensive care plan and making decisions about their care. Specifically, the facility did not ensure that residents were afforded the opportunity to participate in the Comprehensive Care Plan (CCP) meeting. This was evident for 1 of 3 residents reviewed for Participation in Care Planning out of a sample of 38 residents (Resident # 319). The findings are: The facility policy titled Interdisciplinary Person Centered Care Planning with original date 07/1995 and last revised date in 05/22 documented under Procedure section 1) The Interdisciplinary Plan of Care is based on the initial person centered Comprehensive Assessment, and will be formulated and finalized at the Interdisciplinary meeting after the completion of the 1.1 Admission/Readmission MDS, 1.2 Quarterly MDS, 1.3 Annual MDS, 1.4 MDS for Permanent Significant Changes; section 4) Social Workers are responsible for the coordination of the discharge plan and its documentation on the Interdisciplinary Care Plan. He/she shall be responsible for including residents and family or health care proxy to attend ICP meetings via written correspondence; section 6) The Director of Nursing/designee/Director of Social Work has the responsibility for the implementation and coordination of the Interdisciplinary Care Planning process. Resident # 319 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Date Set 3.0 (MDS) dated [DATE] documented Resident # 319 had BIMS score 15, was able to understand others and made self understood, and both Resident # 319 and representative participated in the assessment. On 06/13/22 at 11:46 PM, Resident # 319 was interviewed and stated they were admitted to the facility on [DATE], and they were not invited to the initial care plan meeting with the interdisciplinary team (IDT). Resident # 319 also stated they made decision for themselves. The Admission Care Plan Meeting was scheduled on 1/20/2022 as documented in the section Plan of Care. It did not document that Resident # 319 and/or representative attended the meeting. The Social Worker notes from 1/5/2022 to 1/28/2022 in the medical record were reviewed and there was no documented evidence that Resident # 319 and/or their designated representative were invited to the initial care plan meeting scheduled on 1/20/2022. On 06/16/22 at 10:04 AM, Registered Nurse (RN) # 2 was interviewed. RN # 2 stated the Social Worker (SW) was responsible for inviting residents to the care plan meeting and documenting the invitation in the medical record. RN # 2 also stated residents were invited to initial, quarterly, annual, significant change, and upon request care plan meetings. RN # 2 stated Resident # 319 was alert and oriented x 3, made decision themselves, and participated in their assessments. RN # 2 also stated they were unable to recall if Resident # 319 attended the initial CCP or not. On 06/16/22 at 10:16 AM, Social Worker (SW) was interviewed and stated they were responsible to invite residents and/or representative to care plan meetings for initial, quarterly, significant change, annual, and as needed care plan meeting. SW also stated they invited cognitively intact residents face to face on the unit and documented the invitation in the SW note. SW stated Resident # 319 was cognitively intact and should be invited to all care plan meetings. SW checked the medical record and was unable to locate any documented evidence that Resident # 319 was invited to the initial care plan meeting scheduled on 1/20/2022. SW stated they were not the SW for Resident # 319 in January 2022 and were unable to explain why Resident # 319 was not invited to the initial care plan meeting. On 06/16/22 at 11:16 AM, Director of Social Work & Behavioral Health (DSWBH) was interviewed. DSWBH stated the residents were invited to initial, quarterly, annual, significant change, and as requested care plan meeting. DSWBH also stated it was primarily the SW's responsibility to invite resident and/or representative to the care plan meetings and document the invitation in the medical record. The DSWBH further stated residents/representatives were invited to care plan meeting typically 2 weeks in advance. The DSWBH checked the medical record and was unable to locate any documented evidence that Resident # 319 or their representative were invited to or attended the initial care plan meeting on 1/20/2022. The DSWBH stated they were unable to explain why Resident # 319 or representative was not invited to the initial care plan meeting. 415.11(c)(2)(i-iii)

Based on observation, interviews and record review conducted during an abbreviated survey (NY 323), the facility did not ensure that the resident was free from abuse. This was evident in 1 out of 3 residents sampled (Resident #1). Specifically, on 03/07/2022, on the evening shift, Licensed Practical Nurse (LPN) #1 witnessed CNA #1 yelling and using profanity (F-word) at Resident #1. CNA #1 was not removed immediately from Resident #1's assignment. CNA #1 continued on Resident #1's assignment until security escorted CNA #1 off the unit approximately 10:15PM. The findings are: Review of the facility's policy and procedure entitled Abuse, Neglect, Mistreatment, Misappropriation of Resident's Property reviewed in 02/2022 documented: Each resident will be protected from abuse, neglect, or misappropriation of property in accordance with State and Federal regulations. The facility shall ensure the screening and training of employees for the prevention, identification, investigation and reporting of abuse, mistreatment, neglect, and misappropriation of resident's property. Staff member accused of abuse, neglect, mistreatment, or misappropriation of property by any resident, family member, visitor or other parties will be required to meet with the Administrator and/or designee for a thorough review of facts as best as can be ascertained. Resident #1 was initially admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15/15, indicating intact cognition. The MDS documented that Resident #1 required total dependence of 2 persons for bathing/showers. A Comprehensive Care Plan (CCP) titled Risk for Abuse/Neglect was initiated on 01/03/2022 documented interventions for staff to assist Resident #1 to develop familiar and trusting relationships, approach in a calm manner, monitor interactions with peers and remove from potential danger. An Occurrence Investigation Report dated 03/10/2022 documented that Resident #1 reported that after returning from [CONDITION(S)] on 03/07/2022 at 7:30 PM, he/she asked CNA #1 to give him/her a shower and CNA #1 refused stating that Resident #1's shower was in the morning. An argument ensued and Resident #1 reported that CNA #1 punched him/her in the face. Based on the collection and review of information, CNA #1 suggested a bed bath instead of a shower and Resident #1 became upset. When Resident #1 was being transferred back to bed by CNA #1 and LPN #1, Resident #1 became combative towards CNA #1 and began striking CNA #1 with his/her fist. CNA #1 stated that he/she held Resident #1's hand, moving them back to Resident #1's body to prevent further strikes. Resident #1 was safely transferred back to bed and after staff exited the room, Resident #1 called 911 to report that CNA #1 punched him/her in the face. Upon assessment, a linear scratch was noted on the resident's right facial area. The injury likely occurred when Resident #1 became combative and was inadvertently scratched when CNA #1 moved Resident #1's arm back towards his/her body. There is no evidence that CNA #1 willfully abused Resident #1. CNA #1 was removed from duty and suspended for 3 days. Facility wide re-in-services was given on Abuse and Showers. A review of Nursing Progress Note, written by RN #1, dated 03/08/2022 at 12:42 AM documented that after returning from break, the writer was informed by Resident #1 that the assigned CNA #1 hit him/her in his/her face and refused to give him/her a shower. Upon observation, Resident #1 had a 5 cm x1cm abrasion on the right-side of the face, no bleeding observed. Facial area cleaned with normal saline then zinc and clean dressing applied. Resident #1 denied pain and was verbally aggressive. Resident #1 also called the Police and told them that he/she was hit in the face by staff member. Covering Supervisor and the Physician were informed. A review of Physician's Progress Note dated 03/08/2022 at 5:26 PM documented that Resident #1 was in bed, alert and responsive, in no acute distress. Resident #1 had a linear abrasion to the right maxillary area of face consistent with oxygen tubing, no [CONDITION(S)]/discharge-can apply topical [MEDICATION(S)]. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Administration instructions: clean abrasion to right maxillary area with normal saline and apply [MEDICATION(S)] ointment two times a day. A review of the Treatment Administration Record documented that [MEDICATION(S)] ointment packet 1 gram was applied externally 2 times daily to Resident #1's right maxillary area from 03/09/2022 at 9:30 AM to 3/18/2022 at 5:00 PM. A review of Psychiatry Consult dated 03/09/2022 at 11:26 AM documented that Resident #1 was seen for aggression towards staff. Resident #1 reported that a staff member was hard on him/her after Resident #1 requested a shower. The resident claimed that the staff member became angry and slapped him/her which prompted Resident #1 to slap the staff member back. The resident stated that he/she had a scheduled time to receive his/her shower but on Monday instead of receiving shower in the morning, he/she was scheduled to have it in the afternoon. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 03/21/2022 at 10:25 AM, Resident #1 stated that sometimes the staff give him/her shower too early, around 8:00 AM. Resident # 1 stated that he/she did not receive his/her scheduled shower during the day shift on 03/07/2022. Resident #1 stated that CNA #2 gave him/her a bed bath instead of a shower. Resident #1 said that he/she returned from [CONDITION(S)] on 03/07/2022 at about 7:30 PM and requested a shower since his/her skin was scratching him/her. Resident #1 stated that CNA #1 cursed him/her using profanity. Resident #1 stated that CNA #1 said I'm not giving you no F .ing shower and I don't give a dam. Resident #1 stated that LPN #1 assisted CNA #1 to transfer him/her back to bed then LPN #1 left the room. Resident #1 stated that while he/she was in the bed and was pressing the call bell, CNA #1 told him/her not to ring the bell. Resident #1 stated that CNA #1 tried to grab the call bell from his/her left hand. Resident #1 reported that he/she resisted and tried to grab CNA #1's right hand off from his/her left hand. Resident #1 said that he/she cursed CNA #1 and told CNA #1 to kiss his/her ass. Resident #1 stated that CNA #1 responded kiss your family ass and punched Resident #1 in the face under the right eye. Resident #1 stated there was bruising under his/her right eye. Resident #1 stated there was discoloration under the right eye with tearing. Resident #1 stated that he/she received the shower there days later. During an interview on 03/21/2022 at 2:40 PM, CNA #1 stated that he/she was assigned to Resident #1 during the evening shift on 03/07/2022. CNA #1 stated that he/she was previously assigned to Resident #1 about 2 times before and found Resident #1 to be a little demanding. CNA #1 stated as soon as Resident #1 was wheeled off the elevator on return from [CONDITION(S)], Resident #1 stated that he/she must get a shower because he/she did not get a shower during the day shift. CNA #1 stated that he/she asked LPN #1 if Resident #1 could have had a shower due to his/her [CONDITION(S)] shunt on his/her left arm. and LPN #1 told him/her that he/she was not sure if Resident #1 could have had a shower. CNA #1 stated that he/she asked RN #1 if Resident #1 could have had a shower and RN #1 stated that he/she was not sure due to Resident #1's shunt. CNA #1 stated that RN #1 instructed him/her to give Resident #1 a bed bath instead of a shower. CNA #1 stated that he/she transported Resident #1 to his/her room to transfer Resident #1 to bed and Resident #1 stated that he/she was not going back to bed. CNA #1 stated that Resident #1 began flaring Resident #1's hands, moving and kicking. CNA #1 stated that he/she held Resident #1's hands away from CNA #1 to prevent the resident from hitting him/her. CNA #1 stated that LPN #1 came in the room, and they both used the draw sheet and transferred Resident #1 back to bed. CNA #1 said that he/she positioned Resident #1 in bed and the resident became calm. CNA #1 stated that after he/she positioned the resident in bed, he/she observe the scratch on the resident's face. CNA #1 stated that after dinner, he/she went to give Resident #1 a bed bath and the resident refused the bed bath. CNA #1 stated that Resident #1 received only perineal care on 03/07/2022. CNA #1 stated that he/she told Resident #1 that the resident has a scratch on the face and the resident accused him/her of punching the resident in the face. CNA #1 stated that he/she did not try to take the resident's call bell from the resident. CNA #1 stated that he/she reported to RN #1 that he/she observed a scratch mark on Resident #1's face. CNA #1 said the Police were in the facility around 10:15 PM and security came and escorted him/her off the unit. CNA #1 stated that he/she was suspended for 3 days. During an interview on 03/21/2022 at 3:15 PM, LPN #2 stated that he/she floated to the unit and was assigned to Resident #1. LPN #2 stated that Resident #1 asked him/her if Resident #1 could get a shower and he/she told the resident yes. LPN #2 stated that CNA #1 came to him/her and asked if Resident #1 could have a shower since Resident #1 had a [CONDITION(S)] shunt on the arm. LPN #2 stated that he/she told CNA #1 to cover Resident #1's arm with plastic and to give the resident a shower. LPN #2 said he/she continued with his/her assignment and did not follow up regarding the shower. LPN #2 stated that the Police came to the unit later in shift (can't recall time) and stated that Resident #1 was punched in the face by a staff member. LPN #2 stated that he/she referred the Police to the charge nurse (RN #1). LPN #2 stated that he/she observed a long scratch mark from the side of Resident #1's right eye to the cheek. During an interview on 03/21/2022 at 3:50 PM, LPN #1 stated that he/she was not assigned to Resident #1 on 03/07/2022. LPN #1 stated that he/she was sitting at the nurse's station when Resident #1 was wheeled up at the desk on stretcher from [CONDITION(S)]. LPN #1 stated that he/she heard the resident asked about taking a shower because the resident's skin was itching. LPN #1 stated that the resident reported not receiving a shower on the day shift. LPN #1 stated that CNA #1 came to the nursing station and told the resident that he/she was not giving the resident a shower. LPN #1 stated that CNA #1 told the resident that the resident should have had the shower on the day shift. LPN #1 stated that Resident #1 continued to ask for a shower and CNA #1 wheeled Resident #1 to the resident's room. LPN #1 stated at around 7:30 PM, while CNA #1 was wheeling the resident to the room, Resident #1 was yelling and cursing. LPN #1 stated that he/she heard the yelling escalated between Resident #1 and CNA #1. LPN #1 stated that he/she heard CNA #1 using the profanity (F-word) to Resident #1. LPN #1 stated that Resident #1 swung a fist at CNA #1 and CNA #1 shoved Resident #1's hand away. LPN #1 stated that he/she did not see CNA #1 hit Resident #1 and that he/she assisted CNA #1 in putting Resident #1 in bed (does not recall time). LPN #1 said that he/she left the room to continue with his/her assignment. LPN #1 stated that he/she notified RN #1 of the incident. During an interview on 04/27/2022 at 10:29 AM, the Director of Nursing (DON) stated that the facility concluded that the scratch on Resident #1's face was not a result of staff to resident abuse. The DON stated that LPN #1 witnessed Resident #1 was physically aggressive and Resident #1's scratch could have occurred during the aggressive episode. The DON said he/she was not aware that CNA #1 cursed Resident #1. During an interview on 05/25/2022 at 3:15 PM, Supervisor #1 stated that he/she was covering Supervisor on 03/07/2022 during the evening shift. Supervisor #1 stated that he/she responded to the unit on 03/07/2022 around 9:00 PM, after the Police arrived on Resident #1's unit. Supervisor #1 stated that he/she interviewed Resident #1 and the resident said that CNA #1 punched the resident in the face. Supervisor #1 stated that he/she assessed the resident and observed a linear scratch mark on the right side of the resident's face. Supervisor #1 stated there was no active bleeding, but the scratch appeared new. Supervisor #1 stated that he/she removed CNA #1 from duty pending the investigation outcome. During an interview on 06/02/2022 at 3:45 PM, Registered Nurse #1 (RN #1) stated that he/she was the charge nurse of the unit on 03/07/2022 during the evening shift. RN #1 stated that he/she did not recall seeing Resident #1 when Resident #1 returned from [CONDITION(S)]. RN #1 said he/she did not hear Resident #1 requesting a shower at the nurse's station on 03/07/2022. RN #1 stated that CNA #1 asked him/her if Resident #1 could have a shower and he/she told CNA #1 that it was not a problem for Resident #1 to have a shower. RN #1 stated that LPN #1 did not report to him/her that CNA #1 yelled at and used profanity towards Resident #1. RN #1 said CNA #1 did not inform him/her that Resident #1 had a scratch on Resident #1's face. RN #1 stated that he/she did not go to Resident #1 until during rounds when he/she returned from break. RN #1 said he/she could not recall what time he/she returned from break. RN #1 stated that during rounds (does not recall time) Resident #1 told him/her that CNA #1 punched Resident #1 the face and refused to shower the resident. RN #1 stated that he/she observed a scratch on Resident #1's face. RN #1 stated that he/she did not remove CNA #1 from duty because the Police and Supervisor #1 were already on the unit. 415.4(b)(1)(i)