Every finding on record at Seagate Rehabilitation And Nursing Center

Based on record review and staff interviews, the facility failed to ensure that each resident was screened for a mental disorder or an intellectual disability prior to admission. This was evident for one resident (Resident #373) of three residents reviewed for Preadmission Screening and Resident Review out of a total sample of 38 residents. Specifically, the Preadmission Screening and Resident Review was not completed for Resident #373 prior to admission to the facility. The findings include: The facility's policy and procedure titled Screen and PASSAR reviewed 08/01/2025, documented that all individuals applying for new admission to the facility must be screened to identify serious mental illness or mental retardation/developmental disability per New York State Department of Health regulations. All applicants who are positive for the Level I criteria will have a comprehensive Level II assessment with determination/recommendations completed prior to admission to the facility. If a resident was identified as having a mental illness and or mental retardation/developmental disability on their admission screen Level I review and met the criterial for categorical determination (convalescent care, seriously physically ill, terminally ill, or provisional emergency admission) requires a length of stay longer than the appropriate physician documented number of days a Screen and Level II Evaluation must be completed. Resident #373 was admitted to the facility on [DATE] with diagnoses that included Rhabdomyolysis (damaged muscle tissue) chronic kidney disease (decline in kidney function) and hypertension (elevated blood pressure).The Minimum Data Set (a resident assessment tool) dated 03/14/2026 documented that Resident #373 was admitted to the facility from an acute hospital, was currently considered by the state Preadmission Screening and Resident Review Level II process to have a serious mental health and or intellectual disability and had an intellectual disability.The Level I Review for possible mental illness and possible mental retardation and developmental disability on the SCREEN DOH-695 form completed on 03/14/2026 documented that Resident #373 had a serious mental illness and had a diagnosis or documented history of mental retardation and or a developmental disability, manifesting itself prior to age [AGE], and is likely to continue indefinitely, resulting in substantial functional limitations in three or more areas of major life activity. The Categorical Determination, item #27, documented that Resident #373 qualified for convalescent care.An Office for People with Developmental Disabilities Preadmission Screening and Resident Review Level II Referral Response Letter dated 03/17/2026 documented that based on information obtained by the Level I Screen, the Patient Review Instrument , and other materials received from the referral entity, an abbreviated Level II Assessment was required to determine eligibility. The Categorical Determination is convalescent care (not to exceed 120 days). Need for specialized services. Services of a lesser intensity, provided through the nursing facility, are recommended. The Nursing facility level of care is needed because the individual's medical condition requires the level of skilled care provided by the facility. There was no documented evidence that the required Preadmission Screening and Resident Review Level II Assessment with determination was completed prior to the Resident #373's admission to the facility on [DATE]. On 07/28/2026 at 10:44 AM, an interview was conducted with the Social Services Director who stated that a Level I Screen is performed prior to a resident being admitted to the facility which will identify if the resident has a developmental disability or a serious mental health diagnosis and requires a Level II review prior to being admitted to the nursing home. The Social Services Director also stated that the Level I screen was completed in the hospital for Resident #373 on 03/14/2026 identifying that they had a developmental disability or mental retardation, and the Preadmission Screening and Resident Review Level II screen then should have been completed by the Office for People with Developmental Disabilities while Resident #373 was in the hospital. The Social Services Director further stated the Level II Determination Screen and Recommendation was completed on 03/17/2026 by the Office for People with Developmental Disabilities after Resident #373 was admitted to the facility on [DATE]. The Social Services Director stated there was some confusion as Resident #373 was not newly diagnosed and the facility should have obtained the Preadmission Screening and Resident Review Level II determination and recommendation prior to the admission to the facility. On 07/29/2026 at 11:32 AM, an interview was conducted with Minimum Data Set Assessor #1 who stated they documented in Section A of the assessment that Resident #373 had an intellectual disability and required a Preadmission Screening and Resident Review Level II Screen Determination. The Minimum Data Set Assessor #1 also stated that the Level II Screen Determination should have been performed prior to Resident #373 being admitted to the facility to ensure their appropriateness for nursing home level of care. On 07/30/2026 at 4:32 PM, an interview was conducted with the Facility Administrator who stated that the Preadmission Screening and Resident Review Level II Screen and Determination for Resident #373 should have been completed and received by the facility prior to admission. The Facility Administrator also stated that the referral was received on a weekday, and the resident was admitted on the weekend and the staff should have waited to receive the determination prior to the admission to ensure that services in the facility were deemed necessary and appropriate for Resident #373 who had an intellectual disability. 10 New York Code, Rules and Regulation 415.11(e)

Number of residents sampled:7Number of residents cited:1 Based on observations, record review and interviews, the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice that were based on the comprehensive assessment, person-centered care plan, and the resident's choice. This was evident for one of seven residents (Resident #129) reviewed for Accidents out of a total sample of 38 residents. Specifically, Resident #129 reported they fell during the early morning hours on 06/27/2026, however, Licensed Practical Nurse #3 did not inform the Registered Nurse Supervisor on duty during the shift. Resident #129 was not assessed until 11:00 AM when Resident #129 directly informed Registered Nurse #3 that they had had a fall earlier in the morning and felt pain to the left side upper back and hip. The findings include:The facility policy and procedure titled Resident Occurrence last revised 01/2026 states that it is the responsibility of all staff to report all incidents and accidents that occur at the facility. All occurrences are investigated in a timely manner and preventive measures are initiated. Staff will notify the Nursing Supervisor immediately when an incident occurs. The Nursing Supervisor will immediately initiate an investigation into all accidents/incidents. The investigation will include written statements from staff members caring for the residents and from people who have knowledge of the event. Resident #129 had diagnoses of colon cancer (uncontrollable growth of cells in the large intestine), prostate cancer (uncontrollable growth of cells in the prostate gland), and Benign Prostatic Hyperplasia (non-cancerous growth of the prostate gland).The Minimum Data Set Assessment (a resident assessment tool) dated 06/24/2026 documented Resident #129 was cognitively intact, had an indwelling catheter, and required substantial assistance for toileting hygiene and toilet transfer.The Comprehensive Care Plan titled Nursing: Urological Functioning: Foley Catheter with effective date of 06/17/2026 included an interventions of toileting every 2-4 hours and as needed.The nursing progress note written by Registered Nurse #3 dated 06/27/2026 documented that the incident was reported at 11:00 AM and Resident #129 alleged they had a fall in the bathroom by the toilet, range of motion noted within residents known limitations, no bruises, redness or swelling. The nursing progress note also documented Resident #129 stated they were ringing the bell for assistance and after no one came, they got up from their bed at 4:15 AM/4:20 AM to empty their foley catheter, lost their balance and fell near the toilet. The nursing progress note further documented the unit nurse reported when they went to Resident #129's room to administer medication around 11:00 AM, Resident #129 reported they fell in their bathroom and they felt pain to the left side upper back. On assessment, no bruises, skin intact, no redness or swelling noted. Resident #129 is able to get up and walk around using their rolling walker. Doctor made aware and ordered a left hip x-ray. Pain medications were administered this morning.The investigation summary dated 06/27/2026 documented that on 06/27/2026 at approximately 11:00 AM, Resident #129 claimed they turned on their call light to have the foley catheter bag emptied between 4:15 AM and 4:20 AM but no one responded to the call light. Resident #129 stated that they got out of bed, lost their balance and fell near the toilet. On assessment by the 6AM-2PM shift Registered Nurse #3, no apparent injury was noted but there was complaint of pain to the left hip. The Doctor ordered an x-ray of the left hip. X-ray results demonstrated no acute fracture, no dislocation, and the joint spaces are normal. The soft tissues are unremarkable. Resident #129 received scheduled Dilaudid 4 milligrams at 3:30 AM and 6:30 AM. The staff who worked overnight stated every time the call light was turned on, the staff responded in a timely manner, and no one observed Resident #129 on the floor. The nurse stated that Resident #129 did not fall. There is no reasonable basis to substantiate allegations of abuse, neglect, mistreatment, misappropriate property, or concerns related to the quality of care provided.On 07/26/2026 at 10:28 AM, Resident #129's Representative was interviewed and stated that Resident #129 has a catheter and approximately three weeks ago, Resident #129 fell when they went to drain the urinary bag by themselves as they kept ringing the call bell and no one answered.On 07/30/2026 at 11:00 AM, Licensed Practical #3 was interviewed and stated that around 4 AM on 06/17/2026, they were informed by the Certified Nursing Assistant #15 that Resident #129 fell. Licensed Practical #3 also stated they felt this was not true as Certified Nursing Assistant #15 had checked on Resident #129 multiple times throughout the shift and observed them in bed. Licensed Practical Nurse #3 further stated that once this incident was brought to their attention, they had gone to Resident #129's room and observed Resident #129 sleeping in bed. Licensed Practical Nurse #3 stated that they had also checked Resident #129 several times throughout the night and had last given pain medications around 3:00 PM/3:30 PM at which time Resident #129 told them not to come back. Licensed Practical Nurse #3 stated that they checked in on Resident #129 a few times during the night following Certified Nursing Assistant #15's reporting of the incident and observed Resident #129 resting in bed. Licensed Practical Nurse #3 also stated that they did not think Resident #129 fell as Resident #129 was observed in bed multiple times, by both them and Certified Nursing Assistant #15. Licensed Practical Nurse #3 stated that they did not inform the Registered Nurse supervisor on duty as they figured Resident #129 was confused and did not think that Resident #129 had actually fallen. Licensed Practical Nurse #3 further stated that if they were certain Resident #129 had fallen, they would have reported it to the Registered Nurse Supervisor.On 07/30/2026 at 1:09 PM, Certified Nursing Assistant #15 was interviewed and stated they could not recall the incident and directed the State Surveyor to their statement.On 07/30/2026 at 11:20 AM, the Assistant Director of Nursing was interviewed and stated that they had completed the investigation for this incident, and they first became aware of this incident on 06/27/2026 around 11:00 AM when Registered Nurse #3 on the unit reported the incident and had already completed the assessment. The Assistant Director of Nursing also stated they reviewed the staff statements but it did not occur to them that Licensed Practical Nurse #3 had not reported the incident to the Registered Nurse earlier in the day, as an assessment had been done by the time it was brought to the attention of the Assistant Director of Nursing around 11:00 AM. The Assistant Director of Nursing further stated that when a resident reports a fall, even if the resident is found in bed and asleep, the incident should still be treated as a fall, and the registered nurse should be informed. The Assistant Director of Nursing stated that Licensed Practical Nurse #3 should have reported the fall to the Registered Nurse Supervisor, so that an assessment could be completed.On 07/30/2026 at 11:30 AM, the Director of Nursing Services was interviewed and stated that if a resident reports a fall, the protocol is that the licensed practical nurse should call the registered nurse supervisor to complete the assessment, and the registered nurse supervisor will then report the incident to the doctor. The Director of Nursing Services also stated that the Licensed Practical Nurse #3 should have reported the fall to the registered nurse supervisor on duty during the shift so that the registered nurse supervisor could complete an assessment. 10 New York Code, Rules and Regulations 415.12

Based on observation, record review, and interviews the facility failed to ensure that an allegation of abuse was reported to the New York State Department of Health. immediately, but no later than two hours after the allegation was made, as required. This was evident in one (Resident #1) of five sampled residents. Specifically, Resident #1's family member alleged that on 06/01/2026, two Certified Nursing Assistants verbally degraded the resident. The family member also alleged that one of the Certified Nursing Assistants snatched the resident's purse, squeezed water on the resident's face, and threw the remaining water on the resident's back. These alleged violations were not reported to the New York State Department of Health. The findings include:The facility's policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, directed staff to report all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property to the Administrator and appropriate officials, including the State Survey Agency, in accordance with state law. The policy further required notification to the Department of Health when there was reasonable cause to believe abuse, mistreatment, or neglect had occurred.Resident #1 had diagnoses including multiple fractures and trauma, coronary artery disease, heart failure, hypertension, peripheral vascular disease, anxiety disorder, osteoarthritis, and atrial flutter.The admission Minimum Data Set assessment dated [DATE] documented Resident #1 was cognitively intact, required extensive assistance with activities of daily living, and exhibited verbal and physical behavioral symptoms.A nursing progress note dated 05/31/2026 documented that the resident's family member notified the facility that Resident #1 was crying following evening care and reported that the Certified Nursing Assistants were not gentle enough during care and that the care caused hip pain. The daughter called 911. The note documented that members of the Fire Department and two police officers responded to the facility.A grievance form dated 06/05/2026 documented that the Social Worker received an email from Resident #1's family member stating that the Certified Nursing Assistants were disrespectful during care. A copy of the e-mail correspondence was attached to the grievance form, it stated that on 06/01/2026, two Certified Nursing Assistants verbally degraded Resident #1 by saying the resident stank. The Certified Nursing Assistants physically handled the resident without consent despite the resident's refusal. When Resident #1 attempted to protect themselves, one of the Certified Nursing Assistants continued to aggressively pull at the resident's bag and snatched their purse. The Certified Nursing Assistant then saturated a washcloth with water from a basin and deliberately squeezed the water on the resident's face and threw the remaining water on the resident's back. The Certified Nursing Assistants then proceed to aggressively change the resident's bed sheets.The facility investigation summary dated 06/05/2026 documented interviews with Certified Nursing Assistants #1 and #2 who provided care on the evening shift. Both stated they found Resident #1 incontinent feces, provided incontinence care, changed the bed linens, and denied mishandling the resident. The investigation concluded with staff re-education regarding resident care, handling, and response times.Record review found no documented evidence that the facility reported the resident's allegation of rough care to the New York State Department of Health.During an interview on 07/02/2026 at 11:23 AM, Resident #1 stated that Certified Nursing Assistants #1 and #2 entered the room and attacked them. They stated Certified Nursing Assistant #1 took a wet washcloth and ringed the water onto their face.During an interview on 07/06/2026 at 1:17 PM, the Director of Nursing stated the allegation was not reported because they do not believe that the allegation occurred as Resident #1 confabulates and a staff member is always present in the resident's room.During an interview on 07/06/2026 at 1:28 PM, the Administrator stated they are in agreement with the Director of Nursing's decision not to report the allegation because Resident #1 had documented behavioral symptoms and episodes of confabulation.10 New York Code of Rules Regulations 415.4

Based on observation, record reviews, and interviews conducted during an abbreviated survey (2616960, 439261, and 439285), the facility failed to ensure that residents are free from resident-to-resident abuse. This was evident for four (4) of 12 residents (Resident #1, #3, #7, and # 8) sampled for abuse. Specifically, 1) on [DATE] at 9:55 PM, Certified Nursing Assistant #2 discovered Resident #1 lying in bed bleeding from their head after being physically assaulted by Resident #2. Resident #1 was transferred to the hospital and later expired. 2) On [DATE] at 3:45 AM, Resident #4 was observed striking Resident #3 with their cane while Resident #3 was sitting on the floor in Resident #4's bathroom. Resident #3 was later diagnosed with an acute right hip fracture. 3) On [DATE] at 3:21 PM, Resident #7 reported Resident #8 wandered to their room and struck them with their walker. Resident #7 sustained redness under their right eye and complained of pain. This resulted in actual harm and the death of Resident #1, serious injury and harm to Resident #3, and Resident #7 that was Immediate Jeopardy. The findings are: A review of the facility's policy on Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident's Property with an effective date of [DATE] and a review date of [DATE] with no revisions noted, documented the facility shall provide the residents with considerate and respectful care designed to promote the resident's independence and dignity. Each resident has the right to be free from abuse, mistreatment, neglect and misappropriation of property. This includes the identification of residents and the development of intervention strategies to prevent occurrence, monitoring of changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis. 1) Resident #1 was admitted to the facility with diagnoses including major depressive disorder, cerebral infarction (necrotic tissue in the brain), and diabetes.A review of the Minimum Data Set (a resident assessment tool) dated [DATE] documented Resident #1's cognition was severely impaired. A review of the Comprehensive Care Plan for Abuse Prevention dated [DATE] documented interventions to ensure one-to-one social service visits as needed and to encourage the resident to verbalize their feelings. Resident #2 was admitted to the facility with diagnoses including dementia, and cerebral infarction.Resident #2 did not have a Minimum Data Set completed due to being admitted on [DATE].A review of the Comprehensive Care Plan for Abuse Prevention dated [DATE] documented interventions to ensure the resident is asked about preferences for care routines. A review of Resident #2's medical record revealed that the resident was admitted to the facility on [DATE] after an evaluation and four (4) day stay in a hospital psychiatric emergency department. A review of the Hospital Psychiatric Emergency Department Consult report, dated [DATE] at 3:27 PM, revealed Resident #2 was admitted from home to the hospital psychiatric emergency department on [DATE] with history of worsening dementia, being agitated and confrontational with family, being paranoid, and delusional. The chief complaint was aggressive and paranoid behavior. A review of the Hospital Medication Administration Record documented Resident #2 received Olanzapine (an antipsychotic medication used to treat Bipolar and Schizophrenia disorders) 2.5 milligram by mouth on [DATE] at 5:49 PM and 5 milligrams sublingually on [DATE] at 8:00 PM. On [DATE] at 1:08 AM they received Olanzapine 10 milligrams intramuscularly, and at 6:45 PM received an additional 5 milligrams of Olanzapine intramuscularly. The hospital medication discharge orders recommended Depakote Delayed Release 125 milligrams every 12 hours and Olanzapine 2.5 milligram every 12 hours upon discharge to the facility on [DATE]. The facility did not conduct effective monitoring of Resident #2 upon admission. The facility did not develop a baseline care plan for Resident #2 to identify and address potential aggressive behavior towards others.A review of the Physician's Order Activity Detail Report, dated [DATE] through [DATE], revealed there was no written order in the electronic medical record for psychiatric consult. There was an order dated [DATE] for psychotherapy evaluation, however, there was no documented evidence the psychotherapy evaluation was conducted.The facility's investigation dated [DATE] documented that Resident #2 physically assaulted Resident #1 with their wheelchair footrest. On [DATE] at approximately 9:55 PM, Certified Nursing Assistant #2 was conducting rounding and found Resident #1 in their room bleeding fresh, warm blood from their head. Blood was splattered throughout the room. Resident #2 was observed cleaning themself in the bathroom. Licensed Practical Nurse #1 and Registered Nurse Supervisor #1 responded immediately, and First Aid was applied to Resident #1. 911 was called and New York Police Department took over the scene. Resident #1 was transferred to the hospital and subsequently expired on [DATE]. The facility concluded that there was reasonable cause to believe that abuse, mistreatment, neglect, or quality of care concern occurred. A review of the unit hallway video surveillance, dated [DATE] at 9:55:06 PM, revealed Certified Nursing Assistant #2 (incoming shift 10:00 PM-6:00 AM) making rounds and going into Resident #1 and Resident #2's shared room. Certified Nursing Assistant #2 exited the room and called Licensed Practical Nurse #1 who was at the nursing station. From 9:57:01 PM to 9:58:36 PM nursing staff are seen entering and exiting the residents' room. At 9:58:36 PM, Registered Nurse Supervisor #1 went into the residents' room. At 10:18:02 PM, Emergency Medical Services arrived on the unit and went into the residents' room and exited at 10:23:24 PM with Resident #1 on a stretcher. During an interview on [DATE] at 2:30 PM, Certified Nursing Assistant #1 stated they were assigned to Resident #1 and Resident #2 on [DATE] during the 2:00 PM to 10:00 PM shift. Certified Nursing Assistant #1 stated that they arrived on the unit at 1:55 PM and performed rounds. Certified Nursing Assistant #1 stated during rounds they observed Resident #1 sitting in the dayroom and Resident #2 was in their room with family. Certified Nursing Assistant #1 stated after supper at approximately 6:30 PM, they took Resident #1 to their room and provided care to them and put them in their bed. Certified Nursing Assistant #1 stated that they put Resident #1's wheelchair footrest on top of the wheelchair seat, then put the wheelchair into the hallway on one side. Certified Nursing Assistant #1 stated Resident #2 was not ready to go to bed, so they provided care to them and left them sitting in their wheelchair with the footrest attached. Certified Nursing Assistant #1 stated between 8:00 PM and 8:30 PM, they made rounds and Resident #1 was asleep and Resident #2 was still sitting in their wheelchair. There was no unusual behavior. After the incident, Certified Nursing Assistant #1 stated they found one (1) footrest with blood on it and a bloody towel underneath a bag in the drawer of Resident #2's closet (unsure of time). Certified Nursing Assistant #1 also stated while they were looking for the other footrest, the police observed that the window mesh was broken, and they looked out the window and saw the other footrest on the ground. During an interview on [DATE] at 3:00 PM, Certified Nursing Assistant #2, who found Resident #1, stated that while they were performing rounding on Resident #1's unit at approximately 9:55 PM on [DATE], they observed Resident #1 lying in their bed. Certified Nursing Assistant #2 stated they observed blood splattered on the floor and the headboard of Resident #1's bed and they immediately notified Licensed Practical Nurse #1. Certified Nursing Assistant #2 stated they also observed Resident #2 sitting on the toilet making the sign of the cross with their hand. During an interview on [DATE] at 2:00 PM and 10:00 PM, Licensed Practical Nurse #1 stated that they worked with Resident #1 and Resident #2 on [DATE] on the 2:00 PM to 10:00 PM shift. Licensed Practical Nurse #1 stated Resident #2's family was visiting with them in their room on [DATE] during the evening (unsure of time) and nothing unusual went on. Licensed Practical Nurse #1 stated they gave Resident #2 their medication at 5:54 PM and the family left the unit at approximately 7:00 PM. Licensed Practical Nurse #1 stated at 9:51 PM they performed rounds on the unit and observed Resident #1 in bed asleep, while Resident #2 was sitting in a chair (unsure if seated in wheelchair), their right hand resting in their chin and there was no unusual behavior observed. Licensed Practical Nurse #1 stated when they responded to the call of Certified Nursing Assistant #2, they observed Resident #2 sitting on the toilet making the sign of the cross with their hand. During an interview on [DATE] at 2:33 PM, Registered Nursing Supervisor #1 stated on [DATE] at approximately 9:55 PM they were on Resident #1's unit when they were called by Licensed Practical Nurse #1. Registered Nurse Supervisor #1 stated they immediately went to Resident #1 and #2's room where they observed blood splattered on the floor, wall, and closet. Registered Nursing Supervisor #1 stated that Resident #1 was lying on their right side in bed with a blanket pulled up to their chest, and a pillow on top of their head. Registered Nursing Supervisor #1 stated there was a lot of bright red blood and they applied pressure to Resident #1's head. Registered Nursing Supervisor #1 stated 911 was called (not sure of the time) and responded at approximately 10:18 PM, secured the scene, and took over caring for Resident #1. Registered Nursing Supervisor #1 stated they observed Resident #2 sitting on the toilet in the bathroom, and their wheelchair was stationed next to the wall across from their bed. Registered Nursing Supervisor #1 stated they are unsure if the footrests were attached to the wheelchair. Registered Nursing Supervisor #1 stated that when the residents are put in bed, some staff remove some of the footrests and put them on the seat of the wheelchair, and some staff leave the footrest attached to the wheelchair. During an interview on [DATE] at 3:02 PM, Registered Nursing Supervisor #2 stated that they admitted Resident #2 on [DATE] and notified Physician #1 of Resident #2's past medical history and list of medications. They stated they did not see the psychiatric consult information from the hospital emergency department, and that is why they did not put Resident #2 on monitoring. They stated they did not inform Physician #1 of Resident #2's aggressive behavior. They stated the care plans should have been done by the unit manager the following day. During an interview on [DATE] at 5:00 PM, the Director of Nursing stated that Resident #2 used one (1) of the footrests from their wheelchair to assault Resident #1. The Director of Nursing stated the police were called and Resident #2 was taken into custody. The Director of Nursing stated that an investigation was conducted and concluded that there is reasonable cause to believe that abuse, mistreatment, and neglect occurred. The Director of Nursing stated that the admitting Registered Nurse is responsible for thoroughly reviewing the Patient Review Instrument and discharge summary and then sharing that information with the medical doctor. The Director of Nursing stated that all Registered Nurses are responsible for implementing the care plans and Licensed Practical Nurses are responsible for updating them. The Director of Nursing stated that Resident #2 did not exhibit any behavior prior to the incident. During an interview on [DATE] at 1:27 PM, the Administrator stated that they were notified by the Director of Nursing on [DATE] at approximately 10:00 PM that there was an incident in the facility. The Administrator stated that both residents were taken to the hospital, and Resident #2 was taken into police custody while they were in the hospital. The Administrator stated they were informed later that Resident #1 expired in the hospital. The Administrator stated together with the Director of Nursing, they reviewed the video surveillance recording and staff was observed performing rounding on the unit. The Administrator stated that the facility's policy and procedure on footrests storage states that the wheelchair footrests can be left attached or removed and put on top of the wheelchair seat. The Administrator stated that Resident #2 hit Resident #1 with their wheelchair footrest, however, they are not sure if the footrests were attached to Resident #2's wheelchair. 2) Resident #3 was admitted to the facility on [DATE] with diagnoses including vascular dementia, osteoporosis, and arthritis.The Minimum Data Set, dated [DATE], documented Resident #3 had moderately impaired cognition. Section E documented Resident #3 had wandering behavior that occurred one (1) to three (3) days, which placed the resident at significant risk of getting to stairs or outside the facility. The Minimum Data Set also documented the wandering behavior significantly intrudes on the privacy or activities of others. A Behavior Care Plan dated [DATE] documented Resident #3 had behaviors of wandering in rooms related to cognitive impairment and chronic mental illness. Interventions included to eliminate external noise, which may stimulate or initiate behavior, and staff will engage in simple distractions like calm music and emotional support. There was no documented evidence in the care plan identifying intervention for how to monitor Resident #3's wandering behavior. Resident Nursing Instruction Form (contains instructions for Certified Nursing Assistants) dated [DATE] documented wandering behavior; dated [DATE] documented yelling and screaming. The resident was scheduled for behavior monitoring every day from 6:00 AM-2:00 PM, 2:00 PM-10:00 PM, and 10:00 PM- 6:00 AM.A Resident Certified Nursing Assistant Documentation Record dated [DATE] through [DATE] documented Resident #3's wandering behavior, monitored every day from 6:00 AM-2:00 PM, 2:00 PM-10:00 PM, and 10:00 PM- 6:00 AM.A Nursing note dated [DATE] at 8:48 AM by Registered Nurse Supervisor #5 documented it was reported by Certified Nursing Assistant #3 they responded to the noise in Resident #4's room and observed Resident #4 striking Resident #3 with their cane. Resident #3 was observed sitting on the bathroom floor with feet extended. Resident #3 was assessed and noted with pain in the right hip. The Medical Doctor was notified and ordered Tylenol. Resident #3 was transferred to the hospital, and the family was notified.A Physician Order dated [DATE] documented that Resident #3 was ordered Tylenol 325 milligram tablet, give two (2) tablets by oral route as one (1) dose, and transfer to the hospital due to pain in the right hip.A hospital Diagnostic Result of Hip X-ray two (2) views dated [DATE] documented soft tissue swelling, osseous demineralization, and an acute right intertrochanteric fracture (broken hip) with various deformities. A Patient Review Instrument dated [DATE] documented a primary diagnosis of right hip intertrochanteric fracture. Resident #4 was admitted to the facility on [DATE] with diagnoses including psychosis, depression, and anxiety. A Minimum Data Set, dated [DATE], identified Resident #4 as moderately impaired in cognition. A Behavior Care Plan dated [DATE] documented behavior related to cognitive impairment, desire to manipulate, chronic mental illness, and mood state. Interventions included redirecting away from a dangerous situation and separating from the situation through direct intervention by staff. Resident Nursing Instruction Form dated [DATE] documented no behavior, schedule for monitoring every day from 6:00 AM-2:00 PM, 2:00 PM-10:00 PM, and 10:00 PM- 6:00 AM.A Resident Certified Nursing Assistant Documentation Record dated [DATE] through [DATE] documented Resident #4's behavior monitored from 7:00 AM-9:00 AM, 3:00 PM-5:00 PM, and 11:00 PM-1:00 AM.The facility's undated Occurrence Investigation Form documented there was a resident-to-resident physical altercation. Certified Nursing Assistant #3 reported on [DATE] at approximately 3:45 AM, they responded to a noise coming from Resident #4's room. Upon entering the room, Resident #4 was observed striking Resident #3 (who resided in a room next to Resident #4's room) with their cane . Resident #3 was observed sitting on the bathroom floor. Both residents were separated immediately. Resident #3 was assessed with no visible injury but observed guarding their right lower extremity with facial grimaces. Resident #4 refused body assessment. Resident #4 was observed agitated and unable to redirect. Both residents were unable to provide the occurrence of the event. 911 was called and responded. Both residents were transferred to hospital. Resident #3 was readmitted to facility on [DATE] with diagnosis of right hip intertrochanteric fracture. Resident #4 returned to the facility on [DATE] at 6:30 PM with no new orders, and at 7:45 PM was sent back to the hospital due to agitation. During an interview on [DATE] at 4:00 PM, Certified Nursing Assistant #3 stated they worked on [DATE] during the night shift (10:00 PM-6:00 AM) and were assigned to Resident #3. Certified Nursing Assistant #3 stated both residents used to be roommates, but Resident #3 was transferred to the next room (on [DATE]). Certified Nursing Assistant #3 stated Resident #3 was in their bed sleeping prior to taking their break (unsure of the time), and while on the break, they heard a loud sound and went to Resident #4's room and heard Resident #4 asking Resident #3 why they were in their room. Certified Nursing Assistant #3 stated they observed Resident #3 sitting on the bathroom floor. Certified Nursing Assistant #3 stated they do not remember if Resident #4 hit Resident #3 with their cane, but both residents were separated immediately, and they called for assistance. Certified Nursing Assistant #3 stated they conduct their rounds every two (2) hours, but do not document it. During an interview on [DATE] at 1:30 PM, Licensed Practical Nurse #2 stated they worked on [DATE] during the night shift (10:00 PM-7:00 AM). Licensed Practical Nurse #2 stated both residents were in their respective rooms, sleeping prior to the incident. Licensed Practical Nurse #2 stated Resident #3 might get up from bed and go to their previous room (Resident #4's room) because they used to be in that room. Resident #3 was not observed with behavioral symptoms prior to the incident, and Resident #4 had no prior aggressive behavior observed. Licensed Practical Nurse #2 stated they did their rounds every hour, but there was no place to document. Licensed Practical Nurse #2 stated certified nursing assistants document behavior monitoring in their kiosk for both residents. Licensed Practical Nurse #2 stated they were responsible for monitoring the staff and residents in the unit for their safety.Previous Registered Nurse Supervisor #5 is no longer employed in the facility, and their whereabouts were unknown. During an interview on [DATE] at 1:20 PM, Registered Nurse Supervisor #3 stated that the unit nurses are responsible for monitoring the staff and residents in the unit to prevent accidents by doing their rounds. 3) Resident #7 was admitted to the facility on [DATE] with diagnoses including dementia, depression, and psychotic disorder. The Minimum Data Set, dated [DATE], identified Resident #7 as severely impaired in cognition. Resident #7 required supervision/touching assistance with ambulation and other activities of daily living. A Behavior Care Plan with a review date of [DATE] documented Resident #7 with verbal aggression directed towards others related to cognitive impairment. Interventions included redirecting away from dangerous situations, separating from the situation by direct intervention of staff, and ambulating if needed to walk or feel restless/anxious. There was no documented evidence in the care plan of interventions for how to monitor Resident #7's behavior. A Resident Certified Nursing Assistant Documentation Record dated [DATE] through [DATE] documented Resident #7's behavior monitored from 7:00 AM-9:00 AM, 3:00 PM-5:00 PM, and 11:00 PM-1:00 AM.A Nursing note dated [DATE] at 9:25 PM, documented Resident #7 reported Resident #8 wandered into their room and hit them with their rolling walker. Resident #7 observed with redness under their right eye, and Resident #7 complained of pain. Pain medication was administered with relief.Resident #8 was admitted to the facility on [DATE] with diagnoses including dementia, depression, and psychotic disorder.The Minimum Data Set, dated [DATE], identified Resident #8 as severely impaired in cognition. Section E documented that Resident #8's wandering behavior occurred one (1) to three (3) days, which placed the resident at significant risk of getting to a potentially dangerous place. The wandering behavior significantly intrudes on the privacy or activities of others. Resident #8 required supervision/touching assistance with ambulation and other activities of daily living. Resident #8 used a walker device for mobility.A Behavior care plan with a review date of [DATE], documented Resident #8 with wandering, pacing, and combative behavior related to dementia. Interventions to redirect away from a dangerous situation and separate from the situation by direct intervention by staff. A Resident Nursing Instructions Form dated [DATE], with a revised date [DATE], documented with wandering behavior symptoms and to monitor every day at 6:00 AM-2:00 PM, 2:00 PM-10:00 PM, and 10:00 PM-6:00 AM. There was no documented evidence in the care plan of interventions for how staff should monitor Resident #7's wandering behavior.Occurrence Investigation Form (no date) documented on [DATE] at 3:55 PM, Resident #7 reported Resident #8 wandered into their room looking for something, they asked Resident #8 to leave, and Resident #8 hit them with their rolling walker in their right eye. Resident #7 was observed with a red mark near their right eye. The facility reviewed their video surveillance (undated) and observed Resident #8 wandered to Resident #7's room. Resident #8 immediately came out of the room, closing the door as they left. Resident #8 was ambulating in the hallway when Resident #7 came out of their room with their slippers in their hand and struck Resident #8 on their left upper arm. Resident #8 turned around and hit Resident #7 in the face with their walker. Both residents were separated. Registered Nurse Supervisor #4 assessed Resident #7, no other visible injury observed. Resident #7 denies pain and discomfort. 911 was called and responded. Two (2) police officers arrived at the facility and took statements then left without filing any report. Resident #7 was transferred to another unit. The facility's investigation concluded that there was a resident-to-resident physical altercation. Record review of written statement dated [DATE] at 3:45 PM by Certified Nursing Assistant #5 revealed they observed Resident #7 at 2:00 PM walking in the unit hallway, and they assisted them towards the dining room and left. During an interview on [DATE] at 4:04 PM, Registered Nurse Supervisor #4 stated they were informed by the Director of Nursing regarding the resident-to-resident altercation. Registered Nurse Supervisor #4 stated when they arrived on the unit, they observed Resident #7 sitting at the nursing station. Registered Nurse Supervisor #4 stated Resident #7 was observed with redness under their right eye. Registered Nurse Supervisor #4 stated Resident #7 was taken to their room, and a full body assessment was done; no other visible injury was observed. Registered Nurse Supervisor #4 stated it was them and the unit nurses who were responsible for monitoring residents to prevent accidents in the unit. During an interview on [DATE] at 4:30 PM, Director of Nursing stated they were not the Director of Nursing at the time of the above incidents. The previous Director of Nursing, who did the investigation, is no longer employed in the facility, and their whereabouts are unknown. The Director of Nursing stated the supervisors and unit nurses are responsible for monitoring the residents in the unit to prevent accidents and resident-to-resident altercations.On [DATE] at 3:46 PM, Immediate Jeopardy was identified and declared. The Facility's Administrator and the Director of Nursing were notified.The Administrator returned the signed the Immediate Jeopardy Template on [DATE] at 8:40 PM. On [DATE] at 10:01 PM, the facility presented a removal plan that listed the immediate action the facility would take to prevent serious harm from occurring or recurring. The removal plan was accepted on [DATE] at 10:02 PM.On [DATE] the facility had not completed implementation of the removal plan. After discussion it was determined by the facility that plan needed to be revised to include policy revision and further education of staff in behavioral health monitoring. The Administrator presented the updated removal plan on [DATE] at 8:03 PM.The facility updated removal plan was accepted on [DATE]. Based on observation, interview, and record review, the facility completed implementation of the removal plan on [DATE] at 2:00 PM.Immediate Jeopardy was lifted based on the following corrective actions taken by the facility: Policy and Procedure on Abuse, Mistreatment and Neglect dated [DATE] was reviewed with no revision. An Audit was done on [DATE]. The Director of Nursing and Assistant Director of Nursing assessed 70 residents on the third floor with no injuries or signs of abuse. No additional concerns were identified. Facility admission policy dated [DATE], revised on [DATE]. On [DATE], the facility developed a policy titled Resident Rounding-Nursing. It is the policy for all nursing staff that states they are responsible for completing regular rounds of their assigned areas and the facility's common areas, at the start of their shift, twice during the shift, and at the end of their shift, to monitor resident well-being, maintain a safe environment, and respond promptly to resident needs. The facility policy titled Nursing/Rehabilitation/Maintenance dated [DATE] was reviewed/revised on [DATE] to include storage for equipment (including wheelchair/footrests) not being used. Facility-wide inspection was conducted [DATE], by the therapy department, to assess durable medical equipment in residents' rooms that could present a potential safety hazard. Concerns will be addressed accordingly to ensure safety. Three Hundred and Fifty-Eight (358) resident wheelchairs were checked for potential safety hazards. No concerns were found. In-service conducted on [DATE] on Rounding, Call Bells, and Daily Tasks. Lesson plan and sign-in sheets were reviewed/confirmed for staff in-service conducted on Rounding, Call Bells, and Daily Tasks. An Audit done on [DATE] of all new residents admitted within the 30 days prior to the date of the incident ([DATE]) was reviewed by the Regional Nurse/Designee to determine if there were any documented or known behavioral concerns with an adjunct target behavior care plan with individualized monitoring in place. Three residents were admitted on psychoactive medications with physical aggression, anxiety and mood changes. Behavior care plans were developed. Facility policy on Behavioral Health and Dementia dated 06/2025, revised [DATE] to include that the facility will ensure a designated behavior health monitor will be assigned each shift to observe for residents having behaviors such as combative, aggressive impulsive and or assaultive behaviors. Any behaviors negatively affecting others will be documented on the behavioral monitoring log including interventions attempted. All behaviors will be reported to the Registered Nurse for follow up including documentation and notification to physician and psychiatry as needed. The Registered Nurse Supervisor will review and sign the behavior monitoring log each shift. From [DATE] - [DATE] the following staff members received in-service on resident-to-resident abuse/prevention. Listed as follows: Registered Nurse-30 of 30=100%, Licensed Practical Nurses- 38 of 38 = 100%, Certified Nursing Assistants-159 of 169 =94 %, Administration staff - 16 of 16 =100 %, Housekeeping 27 of 30 =90 %, Nursing Administrative 2 of 2 = 100% , Rehab 26 of 26 = 100 %, Dietary 38 of 40 =95 %, Recreation 9 of 10 = 90%, Social Services 5 of 5 = 100 %, Maintenance 6 of 6 = 100 % and Escort 2 of 2 = 100 % On [DATE] the facility completed in-service of all admission staff on changes to the admission policy, including a need to conduct a thorough review of the Patient Review Instrument prior to acceptance of the hospital referral. [DATE] - [DATE] facility staff members including Registered Nurses, Licensed Practical Nurses, and Certified Nursing Assistants were interviewed and stated they received in-service on documentation, reporting of resident's behavior, equipment storage including wheelchair footrests, resident to resident abuse prevention and call bell with no concerns identified. As per the Administrator, the remainder of the staff who did not receive in-services will be in-serviced prior to starting their duties. Staff on vacation or off duty will be in-serviced before going to the unit.It was determined by the State Agency that the facility fully implemented their plan to abate the immediate jeopardy as of [DATE] at 2:00 PM. 10 NYCRR 415.4(b)(1)(i)

Based on observations, record review, and interviews during an Abbreviated Survey (ID# 2616960), the facility did not ensure a baseline care plan was developed within forty eight (48) hours of a resident's admission and implemented for the resident that includes the instructions needed to provide effective person-centered care that meets professional standards of quality of care. This was evident for one (1) out of twelve (12) residents (Resident #2) sampled for baseline care plan. Specifically, on [DATE], Resident #2 was admitted to the facility with the chief complaint of aggressive and paranoid behavior that was not addressed in a baseline care plan. On [DATE] at 9:55 PM, Resident #2 physically assaulted Resident #1 with their wheelchair footrest, who later expired in the hospital. Additionally, the facility did not provide the resident and their representative with a summary of the baseline care plan. The findings are:The facility's policy and procedure titled Resident's Baseline Care Plan, with review date [DATE], documented it is the facility policy to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality of care. All clinical disciplines review all admission documents and documentation and meets with resident for initial assessment. Completes all sections within 48 hours of admission and makes arrangement to provide written copy of the Baseline care plan to resident and/or family. Review care plan as necessary to ensure care-plan is resident centered and according to the resident's needs and wants.Resident #2 was admitted to the facility on [DATE] with diagnoses of Dementia, Cerebral Infarction, and Hypertension.There was no Minimum Data Set (an assessment tool) completed. Resident #2 was admitted on [DATE].A Hospital Psychiatric Emergency Department Consult report dated [DATE] at 3:27 PM, revealed Resident #2 was admitted from home to the hospital psychiatric emergency department on [DATE] with a history of worsening Dementia, being agitated and confrontational with family, being paranoid, and delusional. The chief complaint was aggressive and paranoid behavior. A review of the Baseline Care Plan dated [DATE], with no completed date, revealed no documented evidence that the chief complaint, aggressive and paranoid behavior, was addressed in the Baseline Care Plan. Review of Resident #2's electronic medical record revealed no documented evidence that the facility provided Resident #2 and their representative with a summary of the baseline care plan.A facility's investigation dated [DATE] documented that Resident #2 physically assaulted Resident #1 with their wheelchair footrest. Resident #1 was transferred to the hospital and subsequently expired on [DATE]. During an interview on [DATE] at 10:15 AM, Resident #2's family member stated they were not given a copy of the baseline care plan or received any documentation from the facility upon Resident #2's admission. The family member stated they were not aware of what a baseline care plan was all about. During an interview on [DATE] at 3:02 PM, Registered Nurse Supervisor #2 stated they admitted Resident #2 on [DATE] and initiated a baseline care plan. Registered Nurse Supervisor #2 stated they never provided a copy of the baseline care plan to Resident #2 of their family member. Registered Nurse Supervisor #2 stated they did not address the behavior because Resident #2 was admitted with no behavior. Registered Nurse Supervisor #2 stated the nurses and social workers are responsible for providing a copy of the baseline care plan to family members. During an interview on [DATE] at 12:51 PM, the Director of Social Work stated either the nurse or they can initiate the baseline care plan upon admission. The Director of Social Work stated they never saw Resident #2 because they sent them to the hospital. The Director of Social Work stated they or the nurse can give a copy of the baseline care plan to the resident or the resident's family member. Director of Social Work, they were not sure if Resident #2's family member received a summary of the baseline care plan.During an interview on [DATE] at 1:18 PM, the Director of Nursing stated the baseline care plan was developed, and it was a template generated in their system. The Director of Nursing stated the baseline care plan must be developed within 48 hours of the resident's admission to the facility. The Director of Nursing stated either the nurse or the social worker can provide a summary of the baseline care plan to Resident #2's family member. The Director of Nursing stated they were not sure if a copy of the baseline care plan was provided to the family member.10 NYCRR 415.11

Based on observations, record review, and staff interviews conducted during an abbreviated survey (439285), from 09/22/2025 to 10/01/2025 the facility did not ensure that a resident's care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This was evident in one (1) out of twelve (12) residents (Resident #7) sampled. Specifically, Resident #7 had a quarterly assessment conducted on 04/03/2025 and documented on the Minimum Data Set 3.0 ( a resident assessment tool). The resident was assessed as having wandering behavior, and agitation, with severely impaired cognition. The resident's comprehensive care plan was developed on 03/07/2025. On 04/27/2025 Resident #7 had a physical altercation with another resident after wandering in their room. The comprehensive care plan was not reviewed until 09/09/2025. There were no revisions to the interventions after the incident.The findings are:The facility policy titled Care Planning dated 12/11/2024 documented it is the policy of the facility to provide an individualized comprehensive care plan for each resident based on assessments done at the time of admission, quarterly, annually and when there is a change in condition. A Comprehensive care plan will be reviewed and revised as needed upon re-admission(less than 30 days), quarterly and upon significant change. Care plans will be updated to reflect episodic issues/problems as they arise.Resident #7 was admitted to the facility on [DATE] with diagnoses of Dementia, Major Depressive Disorder, and Agitation.The Quarterly Minimum Data Set 3.0 assessment tool dated 04/03/2025 documented Resident #7 has severely impaired cognition. Resident #7 required setup/supervision with all activities of daily living care.A Care plan Behavior as evidenced by wandering, verbal aggression directed towards others and physically abusive dated 03/07/2025 and revised 09/09/2025. Interventions included: we will provide you with reality orientation, we will redirect you away from dangerous situations, and we will separate you from the situation by direct intervention of staff.The care plan was not updated to reflect the resident-to-resident altercation on 04/27/2025. Record review reveals there were no new interventions implemented since 09/21/2024.An Occurrence Investigation Form (no date) documented on 04/27/2025 at 3:55 PM Resident #7 reported Resident #8 wandered into their room looking for something, they asked Resident #8 to leave, and Resident #8 hit them with their rolling walker in their right eye. Resident #7 was observed with red mark near their right eye. Registered Nurse Supervisor #5 was notified. Registered Nurse Supervisor #5 assessed Resident #7, no other visible injury observed. Facility conclusion documented Resident #8 wandered into Resident #7 room and then immediately came out of the room closing the door as they leaves. Resident #8 was ambulating in the hallway when Resident #7 came out of their room with their slippers in their hand and struck Resident #7 on their left upper arm. Resident #7 face was hit with the walker. Both residents were separated. 911 was called and responded. Two Police Officers arrived at the facility and took statement then left without filing any report.A Psychiatry note dated 04/24/2025 documented Resident #7 admitted and treated with worsening dementia, wandering with aggression and agitation.During an interview on 10/07/2025 at 4:04 PM, Registered Nurse Supervisor #5 stated they were informed by Director of Nursing regarding the resident-to-resident altercation. Registered Nurse Supervisor #5 stated when they arrived on the unit, they observed Resident #7 sitting at the nursing station. Registered Nurse Supervisor #5 stated Resident #7 was observed with redness under their right eye. Registered Nurse Supervisor #5 stated Resident #7 was taken to their room and full body assessment done; no other visible injury was observed. Registered Nurse Supervisor #5 stated they wrote their nursing progress note but did not update the behavior care plan. Registered Nurse Supervisor #5 stated the Unit Nurse on the floor was supposed to review and update the behavior care plan.During an interview on 10/07/2025 at 4:11 PM, the Director of Nursing stated that anyone can update the care plan, including Licensed Practical Nurses, once the care plan has been initiated by a Registered Nurse. The Director of Nursing stated the staff member who did the incident report should have updated the care plan.10 NYCRR 415.11(c)(1)

Based on observation, record review and interviews conducted during the Recertification and Complaint Survey (NY00325830 & NY00337223) from [DATE] to [DATE], the facility did not ensure that there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility reported low weekend staffing and 1 star staffing rating for Fiscal Quarter 3, 2024 as confirmed by a review of the Daily Staffing and the Payroll Based Journal (PBJ) Staffing Data Report. This was evident for 2 of 2 residents reviewed for Sufficient and Competent Nurse Staffing out of a sample of 38 residents. The findings include but are not limited to: The facility Staffing policy and procedure dated [DATE], last reviewed [DATE] documented that the facility maintains adequate staffing on each shift to ensure that resident's needs and services are met; licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services; Certified Nursing Assistants are available on each shift to provide the needed care services of each resident as outlined on the resident's comprehensive care plan. The New York State Department of Health Intake #NY00325830 dated [DATE] with the Addendum dated [DATE] documented that Resident #97 complained of unsafe staffing in the facility, most of the time, it is throughout the building during the day, with ,d+[DATE] Certified Nursing Assistants on each unit instead of 5; Residents are not getting the care they deserve; residents who are bed bound or can't ring the call bell are not changed frequently and left soiled. The complainant also stated that their unit does not consistently have a nurse, when the regular evening shift nurse takes vacation or has a day off, they would have no nurse, and they have to wait up to two hours for a nurse to come from another unit to give them medication. The New York State Department of Health Intake #NY00325830 dated [DATE] documented that the Representative for Resident #443 complained that residents were left sitting in the hallway in wheelchairs throughout the day, and there was a distinct smell of urine which led them to believe that residents were not being changed. The Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Quarter 3, 2024 ([DATE]- [DATE]) documented the facility triggered for low weekend staffing and 1 star staffing rating. The Facility assessment dated [DATE] documented that the facility capacity was 360 beds and average daily census was 353 residents. The Facility Assessment also documented that the overall facility staff needed to ensure a sufficient number of qualified staff were available to meet each resident's needs were: 6AM-2PM: Certified Nursing Assistants ,d+[DATE], Licensed Practical Nurses 10, and Registered Nurses 5, and Unit Managers 5. 2PM-10PM: Certified Nursing Assistants ,d+[DATE], Licensed Practical Nurses/Registered Nurses 10, and Registered Nurse Supervisors 2. 10PM -6AM: Certified Nursing Assistants 22, Licensed Practical Nurses/Registered Nurses 10, and Registered Nurse Supervisors 1. The Daily Staffing Sheet reviewed for the weekends dated from [DATE], to [DATE], documented that the day and evening shifts were short of one Certified Nursing Assistant per unit on multiple occasions. Resident #163 was admitted to the facility with diagnoses that included Cerebrovascular Accident and Diabetes Mellitus. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #163 had intact cognition. On [DATE] at 09:50 AM, Resident #163 was interviewed and stated that they are not getting adequate care because of the shortage of staff. Resident #163 also stated that there are only 3 Certified Nursing Assistants every day instead of 5, and they are not able to respond to the residents' needs in a timely manner. Resident #97 (NY00325830) was admitted to the facility with diagnoses that included Cerebral Palsy, Depression and Diabetes Mellitus. The Annual Minimum Data Set, dated dated dated [DATE] documented that Resident #97 had intact cognition. On [DATE] at 10:31 AM, Resident #97 was interviewed and stated that residents on the unit require a lot of care, but there are not enough staff to take care of the resident's needs. Resident #97 also stated that most of the time, especially on weekends and on the evening shift they do not have enough staff to take care of them, and sometimes there was no nurse to give them their medications on time, especially when the regular evening nurse was not working. On [DATE] at 09:30 AM, Resident #443's Representative (NY00337223) was interviewed and stated that their parent had since died , however Resident #443 had multiple pressure ulcers, could not verbalize their needs, and they felt that Resident #443 had not received proper care and was not being changed regularly. On [DATE] at 02:34 PM, an interview was conducted with Certified Nursing Assistant #1 who stated that they work the 2 PM to 10 PM shift and had not seen the charge nurse for their shift since they arrived on the floor at 2 PM and did not meet the outgoing nurse so was not given an update on the residents before beginning their shift. Certified Nursing Assistant #1 also stated that this happens all the time and sometimes when there is no nurse the supervisor comes to cover the floor. Certified Nursing Assistant #1 further stated that they work every other weekend, and there are supposed to be 4 Certified Nursing Assistants but most of the time there are only 3 Certified Nursing Assistants to work on the unit. On [DATE] at 02:39 PM, Certified Nursing Assistant #2 was interviewed and stated that they reported to the unit at 2:00 PM today, but they have not seen a nurse on the unit yet, and this happens frequently when their regular nurse is off, and a charge nurse will be sent to the unit later in the shift. Certified Nursing Assistant #2 also stated that they work every other weekend and most of the time 3 Certified Nursing Assistants work instead of 4. Certified Nursing Assistant #2 further stated that if the residents are asking for their medication, they will call on the evening supervisor to come and help. On [DATE] at 02:44 PM, Certified Nursing Assistant #3 was interviewed and stated that they have not seen any nurse to cover the unit for today. Certified Nursing Assistant #3 also stated that they work every weekend and many times they are short staffed on the evening and night shifts where they only get 3 Certified Nursing Assistants instead of 4, and on the night shift when there should be 2 Certified Nursing Assistants to work they sometimes only have 1 Certified Nursing Assistant. Certified Nursing Assistant #3 further stated that if multiple residents need help at the same time, they try to pay attention to the resident that needs the most help first and then they would assist the other residents. On [DATE] at 02:49 PM, an interview was conducted with Certified Nursing Assistant #4 who stated that they worked the 6 AM to 2 PM today and will be staying for the 2 PM to 10 PM shift to make the 4th Certified Nursing Assistant on the evening shift. Certified Nursing Assistant #4 also stated that they work every other weekend on the day shift, and most of the time when any of the regular Certified Nursing Assistants called out, they always work with 4 staff instead of 5. On [DATE] at 11:08 AM, an interview was conducted with Licensed Practical Nurse #1 who stated that they work the 6 AM to 2 PM shift every other weekend, and there are always 4 Certified Nursing Assistants instead of 5 on most weekends. Licensed Practical Nurse #1 also that the residents suffer a little bit as there are a lot of totally dependent residents on the floor that need assistance to be fed which can take a long time so often some residents are fed late because they cannot all be fed at the same time. Licensed Practical Nurse #1 further stated that sometimes there is no nurse relieve them at the end of their shift, so they either have to wait an extra 15 to 30 minutes, have the evening supervisor relieve them and take the keys or just wait until another nurse is sent to relieve them if the supervisor is not available to collect the keys. On [DATE] at 11:26 AM an interview was conducted with Registered Nurse #1 that works the 6 AM to 2 PM shift on the unit. Registered Nurse #1 stated that 5 Certified Nursing Assistants are scheduled to work, but sometimes 4 will work if 1 was pulled out for escort, or if 1 calls out. Registered Nurse #1 also stated that it will take the staff a lot of time to give care to the resident when they work short, and some residents will have to wait a longer for care to be provided. Registered Nurse #1 further stated that most of the residents require total care, but they always encourage the staff to do their best to meet the residents' needs. On [DATE] at 12:31 PM, the Corporate Staffing Manager was interviewed and stated that the facility has a par level which is consistent all the time and they always meet with the Administrator and the Director of Nursing to review staffing based on the resident's census and residents' acuity level. The Corporate Staffing Manager also stated that for the evening and weekends call outs, the supervisor on duty will reach out to staff to try to get someone to come in. The Corporate Staffing Manager further stated that there is a staffing agency that the facility works with, and if there are any problems with staffing the supervisor can reach out, in addition there are per-diem staff that can be called if needed. On [DATE] at 01:13 PM, an interview was conducted with the Director of Nursing who stated that they meet daily with the Administrator, Staffing Coordinator, and Human Resources staff to review staffing, discuss the needs of the building, review the schedule, and if any shortage is noted they try to fill in the staff. The Director of Nursing also stated that the facility does sometimes have staff call outs and they recently did a job fair as they are trying their best to have adequate staffing. Director of Nursing further stated that there was a supervisor to cover the unit that was reported by the surveyor without a nurse on [DATE], they were told that the supervisor just stepped out to attend to another urgent issue when the surveyor was there. Director of Nursing stated that they are not sure what happened to the nurse on the unit that day, but they were told that a supervisor went to the unit to take over the unit until the nurse was around. On [DATE] at 2:39 PM, the Administrator was interviewed and stated that when staff, residents, or residents' family member bring workload concerns to them they try to review the staffing for that day and make sure that their complaints are addressed properly. The Administrator also stated that the facility is trying to ensure that resident's care is not negatively affected due to shortage of staff. The Administrator stated that their labor relations committee and Quality Assurance Agency committee discuss the staffing problem regularly to ensure there is adequate staffing for the residents' care. The Administrator further stated that they make sure that they do not start the shift without adequate staffing, and never go below critical levels. 10 NYCRR 415.13(a)(1)(i-iii)

Based on observation, record review, and interviews conducted during the Recertification survey from 10/21/2024 to 10/28/2024, 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 #287) of 6 residents reviewed for Activities out of 38 sampled residents. Specifically, Resident #287 was not provided with activities that met their cultural preferences and were in their preferred language. The findings are: The facility policy titled Therapeutic Recreation programs Scope of Services dated 6/17/2024 documented the activities program reflects the cultural interests of resident population and provides opportunities for continual enjoyment in areas of former leisure interests. The policy also documented that leisure programs were to enhance the social, emotional, intellectual, physical, creative, and spiritual wellbeing of the resident population. Resident #287 had diagnoses which included Heart Failure, Chronic Obstructive Pulmonary Disease, Diabetes Mellitus. The Annual Minimum Data Set assessment dated [DATE] documented Resident # 287 was severely impaired in cognition and their preferred language was Cantonese. The Annual Minimum Data Set assessment also documented it was very important for Resident #287 to do their favorite activities. The Annual Minimum Data Set assessment further documented only Resident #287's representative participated in the assessment. On 10/21/2024 at 10:47 AM, Resident #287's Representative was interviewed and stated Resident #287 was Taishanese and Cantonese speaking only and liked to watch Cantonese television channels when they were in the community. Resident #287's Representative also stated they were not aware if the facility had Cantonese television channels available for Resident #287. Resident #287's Representative further stated there was no television set in Resident #287's room and they did not observe that Resident #287 had been provided with any other device to watch television programs in their preferred language. Resident #287's Representative stated they participated in the care plan meeting for Resident #287 and told the staff that Resident #287 liked to watch television programs in Cantonese language. During an observation of Resident #287's room on 10/21/2024 at 11:01 AM, no television set or other device was observed. From 10/21/2024 at 10:13 AM to 10/28/2024 at 09:23 AM, multiple observations were made of Resident #287 sitting in their wheelchair in the dining room with no ongoing activities and the television in the dining room was playing an English-language station. Resident #287 was also not provided or offered alternate activities in their preferred language. The Comprehensive Care Plan titled Activities: Activities/Socialization initiated on 05/15/2023 and last updated 8/13/2024 documented one of the goals for Resident #287 was to spend their leisure time watching television. The Quarterly/Annual/Significant Change Assessments - IDT (Interdisciplinary Team) dated 8/13/2024 documented Resident #287 enjoyed watching TV/DVDs/Videos. The facility document titled Complimentary Television Channels listed that the facility provided 50 television channels. Two channels (46 and 49) broadcasted in Spanish, three channels (4, 5, 6) broadcasted in Russian, and the remaining channels broadcasted in English. There was no documented evidence that a resident centered activity program that incorporated Resident #287's interests, hobbies, and cultural preferences, which is integral to maintaining and/or improving a resident's physical, mental, and psychosocial well-being, and independence, was implemented. On 10/25/2024 at 09:46 AM, Certified Nursing Assistant #11 was interviewed and stated Resident #287 was alert with episodes of confusion and did not speak English. Certified Nursing Assistant #11 also stated that Resident #287 had breakfast in the dining room every day and stayed there until going back to bed in the evening. Certified Nursing Assistant #11 further stated that the television in the dining room played English-language programs all the time and there were no Asian television channels at the facility. Certified Nursing Assistant #11 stated that Resident #287 did not watch the television in the dining room and there was no television set in Resident #287's room. On 10/25/2024 at 10:50 AM, Recreation Therapist #2 was interviewed and stated they did the admission, quarterly, and annual recreation assessment for Resident #287. Recreation Therapist #2 also stated that Resident #287's Representative was interviewed regarding Resident #287's activity preferences during the assessment and they were aware that Resident #287's preference was to watch Cantonese language television. Recreation Therapist #2 further stated that the facility only provided English and Spanish language television channels for residents, and Resident #287 did not understand English or Spanish. Recreation Therapist #2 stated that there was no television set in Resident #287's room and the television in dining room played English channels all day and they were not able to explain how Resident #287 might view programs in their preferred language. On 10/25/2024 at 11:08 AM, the Director of Recreation was interviewed and stated that the facility only had English and Spanish language television channels. The Director of Recreation also stated they had devices like iPad for residents to watch video programs in their preferred language. The Director of Recreation further stated that they were not sure if any such device had been provided to Resident #287 so they could watch television programs in their preferred language or if Resident # 287 was able to navigate these alternative devices. The Director of Recreation stated they were not aware that Resident #287's was not being provided activities in their preferred language. 10 NYCRR 415.5(f)(1)

Based on interviews and record review conducted during the Recertification and Complaint (NY 442 and NY 027) Survey from 09/07/2022 to 09/13/2022, the facility did not ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegations were made to the New York State Department of Health (NYSDOH). This was evident for 3 (Resident #536, # 105, and # 586) of 3 residents reviewed for Abuse out of 38 sampled residents. Specifically, 1) Resident # 536's right thigh fracture of unknown origin was not reported to the NYSDOH (NY 442); and 2) a resident-to-resident altercation involving Resident # 105 and #586 was not reported to the NYSDOH within 2 hours of occurrence (NY 027). The findings are: The facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident's Property last reviewed 1/10/2022 documented alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries from an unknown source, 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 and to the NYSDOH in accordance with State Law through established. 1) Resident #536 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #536 had moderately impaired cognition and required 2 people to assist with activities of daily living. Nursing Note (NN) dated 2/19/2021 documented resident noted slid down wheelchair, Occupational Therapy (OT) referral completed to evaluate for possible recliner. An A/I Report dated 2/19/2021 documented Resident #536 slid self from the wheelchair in the dining area and was observed lying on their right side on the floor. The fall was unwitnessed, and no injury was noted. On 2/22/2021, staff reported resident was screaming during care and noted with swelling and discoloration to right lower extremity. The A/I report documented the fall was unwitnessed and no statement was collected from the staff who observed the resident on the floor, and did not conclude abuse, neglect and or mistreatment was excluded. The undated DNS Summary attached to the A/I documented a Certified Nursing Assistant (CNA), who no longer works at the facility, reported Resident #536 was found lying on the right side fidgeting a bit but appeared comfortable. The resident was monitored until the morning of 2/22/2021. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Radiology Report dated 2/22/2021 documented x-ray of Resident #536 right femur showed acute mildly displaced oblique fracture of distal femoral shaft below level of hardware. NN dated 2/22/2021 documented resident was transferred to the hospital for evaluation. There was no documented evidence Resident #536's unwitnessed fall and subsequent fracture of right femur were reported to the NYSDOH within 2 hours of occurrence. On 09/12/22 at 04:05 PM, the Assistant Director of Nursing Services (ADNS) #3 was interviewed and stated they worked in the facility at the time of Resident #536's incident on 2/19/21 but was not responsible for completing and/or reporting A/I investigations to the NYSDOH. After initially stating they do not recall Resident #536's right thigh fracture, ADNS #3 stated, while the resident was in the hospital, they informed Resident #536's daughter the facility did not know the cause of resident's injury. The A/I Investigation Summary was reviewed, and it was assumed Resident #536 fell based on the information provided. ADNS #3 did not know the reason this incident was not reported to the NYSDOH. On 09/13/22 at 01:05 PM, the Director of Nursing Services (DNS) was interviewed and stated they were not employed by the facility on 2/19/21. Nursing Supervisors report all incidents to the DNS to determine if the incident needs to be reported to the NYSDOH. Investigations into injuries of unknown origin must be thoroughly investigated, reported to the proper authorities by the DNS or Administrator, and rule out abuse, neglect, or mistreatment. The facility has a process in place and the DNS does not know what occurred with the reporting of the investigation into Resident #536's incident. On 09/13/22 at 12:34 PM, an interview was conducted with the Administrator who stated the Administrator and the current DNS equally share reporting responsibilities. The former DNS usually discussed A/I Investigations with the Administrator prior to the Administrator signing off on the investigations. The former DNS discussed Resident #536 had an injury that was of known origin because the resident likely fell . The Administrator does not recall the specifics of the A/I investigation for Resident #536's right thigh fracture nor the reason the case was not reported to the NYSDOH. Resident # 105 (NY 027) had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident # 105 was severely cognitively impaired and did not display physical/verbal behavioral symptoms within the previous 7 days. Resident #586 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident # 586 was severely cognitively impaired and did not display physical/verbal behavioral symptoms within the 7 previous days. The Accident/Incident (A/I) Report dated 1/21/2022 documented, on 1/20/2022 at 12:30PM, Resident # 105 reported their roommate, Resident # 586, hit Resident #105 twice with a cane on the left hand while they were in their shared room. Residents #105 and #586 were separated and there was no evidence of injury following assessment of Resident #105. Aspen Complaint Tracking System (ACTS) documented the Assistant Director of Nursing (ADNS) reported a resident-to-resident altercation between Resident #105 a Resident #586. The incident took place on red on 01/20/2022 at 12:30 PM and the online submission email documented the incident was submitted to Department of Health on 1/21/2022 at 7:18 PM, more than 24 hours after the incident occurred. On 09/09/22 at 11:25 AM, the Assistant Director of Nursing Service (ADNS) # 1 was interviewed and stated the Administrator and Director of Nursing Services (DNS) are responsible for reporting allegations of abuse to DOH and had access to system used for reporting. The resident-to-resident altercation between Resident #105 and Resident #586 was considered possible resident physical abuse and reported to the NYSDOH on 1/21/2022. The facility should have reported the incident to the NYSDOH within 2 hours after the allegation was made. ADNS #1 does not recall what caused the delay in reporting. On 09/09/22 at 11:36 AM, the DNS was interviewed and stated the ADNS, the Administrator, and the DNS became aware of the incident involving Resident #105 and Resident #586 and decided it was reportable to the NYSDOH. The incident should have been reported to the NYSDOH within 2 hours of the incident. The DNS stated they were unable to recall what delayed the facility's reporting to the NYSDOH. On 09/09/22 at 11:52 AM, the Administrator was interviewed and stated the incident between Resident # 105 and Resident # 586 happened on 1/20/2022 was considered possible physical abuse and the facility had to report it to the NYSDOH within 2 hours of occurrence. The Administrator was unable to explain the delay in reporting. 415.4 (b)(2)

Based on record review and interviews conducted during the Recertification and Complaint (NY 442) Survey, the facility did not ensure that all alleged abuse and neglect were thoroughly investigated. This was evident for 1 (Resident #536) of 5 residents reviewed for Accidents out of 38 sampled residents. Specifically, nursing staff documented Resident #536 was found on the floor and the facility Accident/Incident (A/I) investigation did not contain witness statements necessary to rule out abuse or neglect. The findings are: The facility policy titled Accident Reports last revised on 09/01/2022 documented all A/Is are investigated properly, to determine if any abuse occurred and to determine possible cause and interventions to prevent the accident/incident from reoccurring. The facility policy titled Abuse, Mistreatment, Neglect Exploitation and Misappropriation of Resident Property last revised 1/10/2022, documented the Nursing Supervisor will initiate the A/I report and begin the investigation, notify the Director of Nursing Services (DNS), and include statements from all parties involved (resident involved, family members and other residents and staff). Resident #536 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #536 had moderately impaired cognition and required 2 people to assist with activities of daily living. Nursing Note (NN) dated 2/19/2021 documented resident noted slid down wheelchair, Occupational Therapy (OT) referral completed to evaluate for possible recliner. An A/I Report dated 2/19/2021 documented Resident #536 slid self from the wheelchair in the dining area and was observed lying on their right side on the floor. The fall was unwitnessed, and no injury was noted. On 2/22/2021, staff reported resident was screaming during care and noted with swelling and discoloration to right lower extremity. The A/I report documented the fall was unwitnessed and no statement was collected from the staff who observed the resident on the floor, and did not conclude abuse, neglect and or mistreatment was excluded. The undated DNS Summary attached to the A/I documented a Certified Nursing Assistant (CNA), who no longer works at the facility, reported Resident #536 was found lying on the right side fidgeting a bit but appeared comfortable. The resident was monitored until the morning of 2/22/2021. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Radiology Report dated 2/22/2021 documented x-ray of Resident #536 right femur showed acute mildly displaced oblique fracture of distal femoral shaft below level of hardware. NN dated 2/22/2021 documented resident was transferred to the hospital for evaluation. There was no documented evidence the facility gathered statements from all actual witnesses and conducted a thorough investigation into Resident #536 unwitnessed fall on 2/19/21 and subsequent fracture on 2/22/21. On 09/13/22 at 01:05 PM, an interview was conducted with DNS who stated they were not working at the facility at the time of this incident and is not familiar with Resident #5367's incident on 2/19/21. The Nursing Supervisor (NS) is informed when an incident occurs, assesses the resident and environment, informs the Medical Doctor (MD), and informs the family. NS completes the incident report and carries out orders the doctor may give (i.e., x-ray, blood work, etc.), writes progress notes, and inform DNS to see if the incident needs to be reported to New York State Department of Health (NYSDOH). The investigation must rule out abuse, neglect, or mistreatment as being a factor in the resident's incident. On 09/13/22 at 12:34 PM, the Administrator was interviewed and stated they cannot recall the specifics of Resident #536's investigation into unwitnessed fall and subsequent fracture. No explanation was provided for missing witness statements in the A/I. 415.4 (b) (3)

Resident #266 Position, Mobility Based on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure a resident with limited range of motion received treatment and services to maintain or improve mobility. This was evidenced by 1 (Resident #266) of 1 residents reviewed for Mobility out of 38 sampled residents. Specifically, Resident #266 was observed on multiple occasions without elbow splint in place in accordnace with the physician order. The findings are: The facility policy titled Splints/Orthoses/Prostheses dated 8/17/2022 documented the nursing department will take responsibility for applying and removing devices. Resident #266 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #266 was severely cognitively impaired and did not document use of splinting devices. On 09/08/22 at 11:21 AM and 09/09/22 at 11:54 AM, Resident #266 was observed without a left elbow splint in place. Comprehensive Care Plan (CCP) related to activities of daily living was initiated 1/27/2022 and documented Resident was to have a left hand [NAME] or carrot at all times. Medical Doctor Order (MDO) dated 5/4/22 documented Resident #266 was ordered to receive left elbow splint be worn at all times. On 09/09/22 at 11:54 AM, the Certified Nursing Assistant (CNA) #1 was interviewed and sated Resident #266 never had a left elbow splint documented on the CNA Accountability Record (CNAAR) and CNA #1 never applied a elbow splint. Rehab usually gives the CNAs training on devices and it is reflected in the CNA record. On 09/09/22 at 12:11 PM, the Assistant Director of Nursing (ADNS) was interviewed and stated Resident #266 never had a left elbow splint in place. On 09/09/22 at 12:39 PM, the Occupational Therapist (OT) was interviewed and stated they assessed Resident #266 and the resident now does not need the left elbow splint. The OT cannot recall Resident #266 wearing a left elbow splint when the OT has made rounds on the units. On 09/13/22 at 12:34 PM, Registered Nurse #2 was interviewed and stated they never saw a MDO for Resident #266 to have a left elbow splint at all times. Resident #266 never received the splint. 415.12(e)(2)

Based on observations, interviews, and record review conducted during a Recertification and Complaint (NY 442) Survey, the facility did not ensure A resident who is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. This was evident for 1 (Resident #312) of 1 residents reviewed for Mood/Behaviors out of 38 total sampled residents. Specifically, the CCP related to Resident #312's cognition was not reviewed and revised to address the resident calling out for mama. The findings are: The facility policy titled Care Planning dated 12/14/2021 documented individualized CCPs for each resident based on assessments done at the time of admission, quarterly, annually, and when there is a change in condition. CCPs will be updated to reflect interval problems as they arise. Resident #312 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/08/22 at 11:10 AM, Resident #312 was observed in a geri-chair in the dining area crying out mama and speaking in Russian loudly. Resident attempted to get out of the geri-chair and staff redirection unsuccessful. Resident #312 was provided with juice, received staff interaction, and was involved in a musical activity but continued to cry out loudly. On 09/08/22 at 03:16 PM, 09/09/22 at 10:25 AM, 09/12/22 at 10:37 AM, 09/12/22 at 04:35 PM, and 09/13/22 at 10:20 AM, Resident #312 was observed in a geri-chair, in dining area with several other residents during musical activities, crying out mama loudly. The CCP related to Behavior Etiology: [CONDITION(S)] Disorder initiated 3/10/2022 and last revised 8/25/2022 documented Resident #312 resists all care, is combative, refuses to eat, has verbal aggression directed towards others and the behavior is related to cognitive impairments. Interventions to address Resident #312's behavior include give time to relax, eliminate external noise and stimulation, redirect, and provide reality orientation. Update dated 8/25/2022 documented the plan of care was still applicable and continued. The CCP related to Cognitive Loss/Dementia was initiated 3/10/2022 and did not document and dates of review. Resident #312 was disoriented, had a limited attention span, and impaired cognition due to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing progress notes dated 8/11/2022 and 8/12/2022 documented Resident #312 had episodes of yelling and screaming and was being closely monitored. Psychiatry Consult dated 8/18/2022 documented staff presented Resident #312 as screaming and calling out for their ''mother''. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident uncooperative with behavioral disturbances. Staff to continue with non- pharmacological therapy such as reality orientation, music therapy, and arts one-to-one interactions. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented evidence the interdisciplinary team reviewed and revised Resident #312's CCP to include person-centered interventions to address verbally disruptive behaviors related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/13/22 at 10:47 AM, Certified Nursing Assistant (CNA) #3 was interviewed and stated they were assigned to Resident #312. Resident has a behavior of screaming mama very loudly. Resident #312 speaks Russian, and the CNA cannot understand what the resident says. CNA #3 offers Resident #312 food or juice to calm them down, but nothing works. Resident #312 is calm when in the dining room and then the yelling starts because there are people around. On 09/13/22 at 11:11 AM, an interview was conducted with License Practical Nurse (LPN) #1 who stated they redirect Resident #312's verbally disruptive behaviors by talking to the resident and holding the resident's hands. LPN #1 writes notes on Resident #312's behavior and the Registered Nurse (RN) updates the resident's CCPs. On 09/13/22 at 11:20 AM, an interview was conducted with RN Manager #3 who stated Resident #312 has a behavior of calling out mama. Staff redirects the resident by offering something to eat, assess for pain, talking to the resident, musical and recreation activity in the dining area, and changing the resident. RN #3 stated spoke with the resident's daughter and the daughter stated this is an ongoing behavior. RN #3 stated the behavior CCP is in place but did not update the CCP to put the specific behaviors of the resident related to dementia. RN#3 stated did document verbal outburst but stated did not have interventions of what the staff need to do to distract the behaviors. RN #3 stated did not have a chance to update the CCP and will do so going forward. On 09/13/22 at 01:07 PM, an interview was conducted with Director of Nursing Services (DNS). DNS stated the LPN can updated CCP for behaviors as well as falls, and RN can initiate as well as updated the CCP. DNS stated if a resident has ongoing behaviors as new behaviors it must be implemented in the CCP. DNS stated if an incident such as a fall the supervisor may update, but the team meets to review the incident and updated the CCP with interventions specific to the resident. DNS stated aware of the resident on the Dementia units with behaviors and stated monitors by the team, by discussing and ensuring intervention are in place. 415.11(c)(2)

Based on observations, interviews and record review conducted during the Recertification survey from 9/07/22 to 9/13/22, the facility did not ensure residents received accurate assessments. This was evident for 2 (Resident #235 and Resident #337) of 38 total sampled residents. Specifically, 1) The Minimum Data Set 3.0 (MDS) assessment for Resident #235 did not accurately reflect the resident's use of a wander guard (WG) device; and 2) Resident #337 was discharged home and the MDS assessment documented Resident #337 was discharged to the acute hospital. The findings are: The facility policy titled MDS dated [DATE] documented MDS Registered Nurse (RN) will be responsible for section P (Restraints and Alarms). All disciplines that make entries on the MDS attests to the accuracy of the items. The MDS Coordinator (MDSC) is not attesting to accuracy of the assessments. 1) Resident # 235 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/07/22 at 12:03 AM, 09/08/22 at 09:33 AM, and 09/09/22 at 02:04 PM, Resident # 235 was observed wearing a WG on their right lower extremity while walking around at the unit. The MDS dated [DATE] documented Resident # 235 was severely cognitively impaired and had wandering behavior 4-6 days out of the last 7 days. The MDS did not document the WG/elopement alarm observed on Resident #235's right lower extremity. The physician ordered initiated 06/03/2022 documented Resident #235 to have WG to their right leg. Nursing Note (NN) dated 6/3/2022 documented WG was placed to Resident # 235's right lower extremity. On 09/09/22 at 02:33 PM, the MDS Assessor (MDSA) was interviewed and stated they are responsible for completing the MDS section that documents resident alarm use. The MDSA stated it was an error that Resident #235's WG use was not documented on the MDS dated [DATE]. 2) Resident #337 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #337 was cognitively intact and was discharged to an acute hospital. The Medical Discharge Summary assessment dated [DATE], documented that Resident #337 was discharged to home. Nursing Note dated 6/16/2022 documented Resident #337 was discharged home today via private bus with all personal belongings. The MDS dated [DATE] did not document Resident #337 was discharged to their home in the community. On 09/12/22 at 05:19 PM an interview was conducted with the MDSA who stated they are responsible for reviewing completed MDS assessments for accuracy and/or mistakes. Resident #337's MDS was checked for accuracy, and it must be a mistake that Resident was not documented as being discharged home. On 09/12/22 at 03:35 PM and 09/09/22 at 02:19 PM, the MDSC was interviewed and stated they review MDS assessments to ensure they are completed and do not review MDS assessments for accuracy. 415.11(b)

Based on observation, interviews and record review conducted during an abbreviated survey (NY 612), the facility did not ensure that each resident receives adequate supervision to prevent accidents. This was evident in 1 out of 3 residents sampled (Resident #1). Specifically, on 07/15/2020, Resident #1 reported that Certified Nursing Assistant #1 (CNA #1) hit his head on the bedrail during care. Resident #1 complained of pain to the left side of his head. Record review revealed that Resident #1 required assistance of two (2) people for bed mobility. On 07/15/2020, CNA #1 did not follow Resident #1's plan of care. The Findings Include: The Facility's Policy and Procedures on Accident/Incidents-Risk Management dated 5/20/2019 documented that an Accident is an unexpected, unintended event that can cause a resident body injury and incident as an unexpected, unintended event that can cause a resident superficial or no injury. Resident #1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, a resident assessment tool, dated 06/26/2020, revealed that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determined attention, orientation and ability to recall information) score of 11/15 (00-7 severe impairment, 08-12 moderate impairment and 12-15 cognitively intact). Review of Resident #1's Activity of Daily Living (ADL) Care Plan dated 06/19/2020, documented that Resident #1 required assistance of 2 people for bed mobility and transfer. Review of the Resident Nursing Instructions dated 06/19/2020, revealed that Resident #1 required 2 persons assistance with bed mobility; turning and positioning when in bed. Review of the Nurse's Progress Note dated 07/15/2020 at 3:19 p.m. documented that Resident #1 reported during morning care, CNA #1 was rude, was rough with him and banged his forehead on the bedrail. Resident #1 stated that he was rude to CNA #1. Resident #1 was assessed, and no visible injury was noted. Resident #1 complained of headache on a scale of 5/10 and pain medication was given. CNA #1 was removed from the assignment. Review of the Facility's Accident and Incident Report dated 07/15/2020 documented that on 07/15/2020 between 8:00 a.m. to 8:30 a.m., Resident #1 reported to staff that CNA #1 was rough during care. Resident #1 stated that CNA #1 banged his forehead on the bedrail and threw a towel over his face. [MEDICATION NAME] was given for pain. Resident #1 and CNA #1 cursed at each other. Review of the Physician's Progress Note dated 07/16/2020 documented that Resident #1 was examined after possibly sustaining an injury. Resident #1 complained of left side headache. No neuro deficit was noted. Review of the Medication Administration Record [REDACTED] During an interview with the Registered Nurse Supervisor (RNS) on 09/01/2020 at 10:45 a.m., the RNS stated that Resident #1 reported that while CNA #1 was providing care to him, the CNA banged his head on the bedrail and threw a towel in his face. The RNS stated that she assessed the resident with no visible injury. Upon inquiry, the RNS stated that the Charge Nurse on the unit supervised the CNAs and ensures that the CNAs are following the residents plan of care. During a follow-up interview with the RNS on 09/22/2020 at 1:50 p.m., the RNS stated that the Charge Nurse informed her of Resident #1's allegation. The RNS stated that she spoke with Resident #1 and the resident allegation remained the same. The RNS stated that she assessed Resident #1 with no visible injuries, but that the resident complained of headache. The nurse on the unit administered [MEDICATION NAME] 5mg-325mg tablet. Resident #1 was reassessed, and the pain scale was 0/10. During an interview with CNA #1, who was assigned to Resident #1 on 07/15/2020, on 09/03/2020 at 11:00 a.m., CNA #1 stated that Resident #1 got upset and started cursing and using inappropriate language to her. CNA #1 stated that she provided care to Resident #1 without assistance of another staff member. The CNA stated, she turned Resident #1 and as she was pulling the soiled bedsheet from under the resident, Resident #1's head accidently hit the bedrail. During an interview with the Director of Nursing Service (DNS) on 09/01/2020 at noon, the DNS stated that Resident #1 informed the Social Worker (SW) that during morning activities of daily living (ADL) care, CNA #1 was rude, was rough with him, banged his forehead on the bedrail and threw a towel over his face. The DNS stated that Resident #1 and CNA #1 cursed at each other. The DNS stated that Resident #1 had an order for [REDACTED].#1 complained of headache and pain medication was administered. During a follow-up interview with the DNS on 09/22/2020 at 2:30 p.m., she stated that CNA #1 did not follow Resident #1's plan of care. She stated that the License Practical Nurse (LPN) and the Unit Manager are responsible for supervising the CNAs to ensure that the CNAs follow the residents plan of care. 415.12(h)(1)

Based on observation, interviews and record review conducted during an abbreviated survey (NY 612), the facility did not ensure that each resident receives adequate supervision to prevent accidents. This was evident in 1 out of 3 residents sampled (Resident #1). Specifically, on 07/15/2020, Resident #1 reported that Certified Nursing Assistant #1 (CNA #1) hit his head on the bedrail during care. Resident #1 complained of pain to the left side of his head. Record review revealed that Resident #1 required assistance of two (2) people for bed mobility. On 07/15/2020, CNA #1 did not follow Resident #1's plan of care. The Findings Include: The Facility's Policy and Procedures on Accident/Incidents-Risk Management dated 5/20/2019 documented that an Accident is an unexpected, unintended event that can cause a resident body injury and incident as an unexpected, unintended event that can cause a resident superficial or no injury. Resident #1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, a resident assessment tool, dated 06/26/2020, revealed that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determined attention, orientation and ability to recall information) score of 11/15 (00-7 severe impairment, 08-12 moderate impairment and 12-15 cognitively intact). Review of Resident #1's Activity of Daily Living (ADL) Care Plan dated 06/19/2020, documented that Resident #1 required assistance of 2 people for bed mobility and transfer. Review of the Resident Nursing Instructions dated 06/19/2020, revealed that Resident #1 required 2 persons assistance with bed mobility; turning and positioning when in bed. Review of the Nurse's Progress Note dated 07/15/2020 at 3:19 p.m. documented that Resident #1 reported during morning care, CNA #1 was rude, was rough with him and banged his forehead on the bedrail. Resident #1 stated that he was rude to CNA #1. Resident #1 was assessed, and no visible injury was noted. Resident #1 complained of headache on a scale of 5/10 and pain medication was given. CNA #1 was removed from the assignment. Review of the Facility's Accident and Incident Report dated 07/15/2020 documented that on 07/15/2020 between 8:00 a.m. to 8:30 a.m., Resident #1 reported to staff that CNA #1 was rough during care. Resident #1 stated that CNA #1 banged his forehead on the bedrail and threw a towel over his face. [MEDICATION NAME] was given for pain. Resident #1 and CNA #1 cursed at each other. Review of the Physician's Progress Note dated 07/16/2020 documented that Resident #1 was examined after possibly sustaining an injury. Resident #1 complained of left side headache. No neuro deficit was noted. Review of the Medication Administration Record [REDACTED] During an interview with the Registered Nurse Supervisor (RNS) on 09/01/2020 at 10:45 a.m., the RNS stated that Resident #1 reported that while CNA #1 was providing care to him, the CNA banged his head on the bedrail and threw a towel in his face. The RNS stated that she assessed the resident with no visible injury. Upon inquiry, the RNS stated that the Charge Nurse on the unit supervised the CNAs and ensures that the CNAs are following the residents plan of care. During a follow-up interview with the RNS on 09/22/2020 at 1:50 p.m., the RNS stated that the Charge Nurse informed her of Resident #1's allegation. The RNS stated that she spoke with Resident #1 and the resident allegation remained the same. The RNS stated that she assessed Resident #1 with no visible injuries, but that the resident complained of headache. The nurse on the unit administered [MEDICATION NAME] 5mg-325mg tablet. Resident #1 was reassessed, and the pain scale was 0/10. During an interview with CNA #1, who was assigned to Resident #1 on 07/15/2020, on 09/03/2020 at 11:00 a.m., CNA #1 stated that Resident #1 got upset and started cursing and using inappropriate language to her. CNA #1 stated that she provided care to Resident #1 without assistance of another staff member. The CNA stated, she turned Resident #1 and as she was pulling the soiled bedsheet from under the resident, Resident #1's head accidently hit the bedrail. During an interview with the Director of Nursing Service (DNS) on 09/01/2020 at noon, the DNS stated that Resident #1 informed the Social Worker (SW) that during morning activities of daily living (ADL) care, CNA #1 was rude, was rough with him, banged his forehead on the bedrail and threw a towel over his face. The DNS stated that Resident #1 and CNA #1 cursed at each other. The DNS stated that Resident #1 had an order for [REDACTED].#1 complained of headache and pain medication was administered. During a follow-up interview with the DNS on 09/22/2020 at 2:30 p.m., she stated that CNA #1 did not follow Resident #1's plan of care. She stated that the License Practical Nurse (LPN) and the Unit Manager are responsible for supervising the CNAs to ensure that the CNAs follow the residents plan of care. 415.12(h)(1)

Based on record reviews and staff interviews conducted during the recertification survey, the facility did not ensure that residents participated in the development, review and revision of the Comprehensive Care Plan (CCP). Specifically, residents were not invited to comprehensive and quarterly care plan meetings. This was evident for 3 of 3 residents reviewed for Participation in Care Planning (Residents # 39, 234, 287) out of a sample of 38 residents. The findings are: 1). Resident #39 was admitted with [DIAGNOSES REDACTED]. Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition. Physician order [REDACTED]. On 11/04/19 at 02:53 PM, an interview was conducted with Resident # 39 who stated he has not been invited to care plan meetings. Resident #39 stated meetings only happened for physical therapy and he could not recall the last time he attended a care plan meeting. Review of the care plan meeting attendees tab in the Sigma Care Electronic Medical Record (EMR) contained no documented evidence that resident was in attendance at the Annual care plan meeting held on 11/13/18 and the Quarterly care plan meetings held on 2/12/19, 5/14/19, 8/13/19. The Care Plan Meeting Details dated 11/13/18 to 8/13/19 revealed there was no documented evidence that Resident #39 had been invited to the care plan meetings. On 11/07/19 at 10:55 AM, an interview was conducted with the Social Worker (SW #5) who stated resident is invited verbally to all care plan meetings a few days before the meeting and the resident goes to [MEDICAL TREATMENT], so we try to accommodate that. SW #5 also stated Resident #39 gave verbal notice that he does not want to attend the care plan meetings. SW #5 stated the invitation and response by the resident was not documented in the system. Care plan meetings for the 4th floor is on Tuesdays beginning at 11 am and the resident goes to [MEDICAL TREATMENT] on Tuesdays and returns to facility in the afternoon maybe around 1. If Resident # 39 is too tired after [MEDICAL TREATMENT] and chooses to reschedule the CCP meeting, we accommodate that. SW #5 further stated when the resident attends the CCP meeting their name is added as an attendee. 2). Resident #234 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition. On 11/04/19 at 02:53 PM, an interview was conducted with Resident #234 who stated she could not recall attending a care plan meeting during the 4 years she has resided in the facility. Review of the care plan meeting attendees tab in the Sigma Care Electronic Medical Record (EMR) contained no documented evidence that resident was in attendance at the Quarterly CCP meetings held on 11/13/18, 02/12/19, 06/04/19, 07/16/19, 10/01/19 and Significant Change CCP meeting held on 03/05/19. The Care Plan Meeting Details dated 11/13/18 to 10/01/19 contained no documented evidence that Resident #234 had been invited to the care plan meetings. On 11/07/19 at 11:27 AM, an interview was conducted with SW #2. SW #2 stated Resident #234 is invited to the Annual, Significant Change and Quarterly CCP meeting verbally on Thursday or Friday in the week before CCP meetings scheduled on a Tuesday. SW#2 stated the resident verbally refuses, and states does not feel good or does not want to attend. SW #2 stated the invitation and response by the resident was not documented. 3). Resident #287 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition. On 11/05/19 at 10:16 AM, an interview was conducted with Resident #287 who stated he attended one care plan meeting last year. Review of the care plan meeting attendees tab in the Sigma Care Electronic Medical Record (EMR) contained no documented evidence that resident was in attendance at the Quarterly CCP meetings held on 10/23/18, 01/15/19, 07/16/19, 10/15/19 and Annual CCP meeting held on 4/16/19 The Care Plan Meeting Details dated 01/15/19 to 10/15/19 contained no documented evidence that Resident #234 had been invited to the care plan meetings. On 11/07/19 at 11:42 AM, an interview was conducted with SW #2 who stated the residents are invited verbally to Annual and Significant Change and Quarterly care plan meeting. SW #2 stated the resident verbally refused to attend the CCP meetings, but the response of the resident was not documented in the medical record. On 11/07/19 at 12:15 PM, an interview was conducted with SW #5 who stated the resident was verbally invited to Annual, Significant Change and Quarterly CCP meetings and Resident #287 responded verbally if he was or was not going to attend. SW #5 stated Resident #287 is informed of the meeting on Wednesday or Thursday of the week prior to the meeting. On 11/07/19 at 12:52 PM, an interview was conducted with the Director of Social Work (DSW) who stated within a week before the CCP meeting a SW will verbally invite the residents to CCP meetings and the resident responds verbally. For residents attending [MEDICAL TREATMENT], we adjust to their schedule. The DSW stated the CCP meeting is scheduled a day before or after so that everyone gets an equal opportunity to attend their CCP meetings. CCP meetings would not be scheduled on the days of [MEDICAL TREATMENT] because we want the residents to attend. The DSW also stated a resident's refusal or agreement to attend the CCP are documented in the progress notes. The DSW further stated it was identified three to four months ago that invitations and resident responses were not being documented in written form and SWs are now to document if a resident wishes to attend or refuses to attend the CCP meeting. The DSW stated that residents are invited to all care plans including 14 days post admission, annual, quarterly and significant change CCP meetings. The DSW stated she monitors the process by printing out a list of scheduled CCP meetings the week before, ensures that follow up calls are done and that residents are invited, and their responses are documented. 415.11(c)(2)(i-iii)

Based on observations, record review, and staff interview conducted during the Recertification survey, the facility did not ensure that when the use of restraints is indicated, the facility used the least restrictive alternative for the least amount of time and documented ongoing re-evaluation of the need for restraints. Specifically, there was no documented evidence that the ongoing need for an abdominal binder was re-evaluated and behaviors necessitating use were documented. This was evident for 1 of 1 resident reviewed for Restraints (Residents #200) out of a sample of 38 residents. The findings are: The facility's policy and procedure Restraints-Use of revised 10/7/19 documented medical symptoms that warrant the use of restraints will be documented in the resident's medical record, ongoing assessments, and care plans. Resident #200 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented resident with severe impairment with short/long term memory problems and no behaviors were exhibited. The MDS further documented other restraints in bed and in chair/out of bed. On 11/06/19 at 04:10 PM, an abdominal binder was observed as the resident rubbed her stomach when the binder was touched by RN #1 and on 11/07/19 at 11:15 AM, resident was observed receiving tube feeding and as RN #1 adjusted the binder and resident moved her left hand towards the area. No pulling or tugging at the tubing was observed. Physician order [REDACTED]. Care plan for Physical Restraint use (Abdominal Binder) effective 6/8/17 documented goal is to remain accident/incident free. Interventions included apply physical restraint per MD order, assess potential to decrease and or eliminate restraints, monitor response to restraint. Care plan notes dated 6/12/17 to 4/17/19 did not document attempts by the resident to pull on the G- tube. Interdisciplinary Physical Restraint Assessment created on 01/21/19 completed on 3/17/19 documented the resident's response to the use of this restraint as positive. Interdisciplinary Physical Restraint Assessment were documented in the system as being created on 4/17/19, 5/17/19, 7/10/19, 9/09/19 and 10/20/19, however all assessments were documented as being completed on 11/07/19. Each assessment documented that the resident continued to pull on her GT tube however, there was no documented evidence of when these attempts occur. Medical progress notes dated 01/02/19 to 10/02/19 did not address the use of the abdominal band. On 11/07/19 at 03:34 PM, an interview was conducted with Registered Nurse (RN #1). RN#1 stated the interdisciplinary assessment for restraints included looking to see if the resident is pulling, tugging, scratching, and/or rubbing at the site, putting her hands underneath the clothing which will show that the resident continued to require the use of the restraint. RN #1 stated when the abdominal binder is released, the resident makes attempts to pull at the site. The resident is monitored/observed frequently while in the room and at the nursing station. RN#1 also stated during the past month the resident was observed to be doing the above behaviors, but the behaviors were not documented in the system. RN#1 further stated the Certified Nursing Aide's (CNA) reported when the abdominal binder was released the resident made attempts to pull on the GT tube. Every three months the restraint assessment appears in the EMR and I or another RN complete the assessment. On 11/07/19 at 04:10 PM, an interview was conducted with CNA #1. CNA#1 stated she had not observed the resident pulling or attempting to pull on the GT tubing when the abdominal band is released while the resident is sitting in the chair or is in bed. CNA#1 further stated Resident #200 hands are placed above the sheet while in bed and resident has been observed pulling on the sheet or her night gown but not on the binder or tubing. On 11/08/19 at 10:34 AM, an interview was conducted with the Nurse Practitioner (NP). The NP stated as the patient is confused and pulls out peg tube, the abdominal binder is primarily for safety and secondary as a restraint. The NP stated from time to time the abdominal binder is removed and when it is noticed that the resident starts pulling or touching the tubing the abdominal binder is put back. The NP stated staff are reporting that resident continues to play with the tube and touches and tries to pull the tube when the abdominal binder is off. The resident is redirected, and the tube will be covered with clothing or with the diaper. The NP could not recall the last time the resident was observed pulling on the GT tube or the length of days the abdominal binder was off and was not able to show in the record documentation of when these behaviors occurred. 415.4(a)(2-7)

Based on record review and staff interviews conducted during the recertification survey, the facility did not ensure assessment accurately reflected the resident status. Specifically, a resident with short-term and long-term memory problem was captured on the MDS as having no problem with memory. This was evident of 1 out 1 one resident reviewed for Closed Record -Death out of a sample of 38 residents. (Resident #283). The findings are: Resident #283 was admitted to facility with [DIAGNOSES REDACTED]. The facility document entitled Policy and Procedure: Subject: Minimum Data Set 3.0 dated effective 6/25/2019 documented under the section entitled Procedure for Completion: All disciplines that make entries on the MDS 3.0 are responsible to sign and date the sections they completed. The signature indicates that the section was reviewed and attest to the accuracy of the items. Significant Change Minimum Data Set ((MDS) dated [DATE] documented in Section C 0700 resident with short and long-term memory OK- memory OK. The MDS also documented the resident had moderately impaired cognitive skills for decision-making. Quarterly MDS assessments dated 2/4/19, 5/25/19, 8/7/19, and 9/18/2019, documented resident with short-term and long-term memory problem, able to recall staff names/faces, and was moderately impaired-decisions poor, cues/supervision required. The Comprehensive Care Plan entitled Dementia Cognitive Loss related to Dementia, Long Term Memory Problems, Short Term Memory Problem, impaired cognition, Impaired decision making, impaired thinking/reasoning revised on 9/25/2019 documented the following interventions: Provide consistent routine; Provide resident appropriate orientation; Recognize and reinforce positive behaviors; stimulate long term memory. Social Services Significant Change Assessment progress note dated 9/25/2019 documented resident cognitive status as alert, confusion present. Orientation to person and short-term memory poor, and long- term memory poor. On 11/07/19 at 10:53 AM, an interview was conducted with the MDS Coordinator (MDSC). MDSC stated the Social Worker is responsible for completing Section C the cognitive section, but she ensures the documentation is correct by looking at the Social Worker assessment which was completed on 9/25/2019. The MDSC stated the Social Worker assessment note was correct, the resident had long and short-term memory problems, but the information entered on the MDS was a data entry error. MDSC stated she is responsible for ensuring that the MDS documentation is correct before submitting but is unsure how this error occurred. This was an entry error and the MDS will be modified immediately. On 11/07/19 at 12:05 PM, an interview was conducted with Social Worker (SW #1). SW#1 stated she completes a cognitive assessment for the resident before completing the MDS, which she did and documented the assessment in the resident chart on 9/25/2019. SW #1 also stated when she assessed the resident at the time his Brief Interview for Mental Status (BIMS) score was 99 and the resident had short and long-term memory impairment. This was just a data entry error. I just clicked on the wrong answer. 415.11(b)

Based on observations and interviews the facility did not ensure that garbage was disposed of properly. this was evident during the initial tour observation of the kitchen. Findings are; During initial tour of the kitchen on 2/12/2018 between 7:30 AM and 8:30 AM the following were noted: 1) Two grease drums and one chemical drum observed with dirt build up, grease and stained with brown food and liquid, as well as dust. 2) Within the kitchen; located at the back exit door towards the compactor garbage disposal area there were empty boxes, paper and other garbage and debris in front of the juice refrigerator. On 02/13/2018 at 2: 5 PM DFS (Director of Food Services) was interviewed. The DFS stated there is a cleaning person who cleans daily, different items each day and oven cleaning weekly. There should be no garbage stored inside the kitchen, garbage should be taken out constantly and daily to the outside compactor. I do not have an answer as to why those items were missed and and garbage left inside the kitchen. The facility's Policy and Procedures for Cleaning Work Area documented the following: Stoves, including ovens are broken down and cleaned once a week--general cleaning of above is done daily On 02/14/18 12:17 PM Kitchen Employee #1 was interviewed. He stated that he comes in at 12:00 PM and he has to clean the entire kitchen including floors all stoves, freezers, ovens, steamers. All the left over food and food items from lunch and dinner he has to cover, label and put in refrigerator and or freezer. He also has to take out garbage, clean table tops including steamers and soup kettle. Each day there are also specific focus cleaning of specific kitchen items example stoves and ovens. On 02/15/2018 at 2:55 PM the Administrator was interviewed. The Administrator stated two people are supposed to be assigned to clean the kitchen every day and everyone in the kitchen helps. 415.14(h)

Based on observations and interviews the facility did not ensure food was stored in accordance with professional standards for food service safety. Specifically, Leftover foods were observed unlabeled and not dated and stored in the refrigerator. This was observed during the initial tour of the kitchen. Findings are: During the initial tour of the kitchen between 7:30AM and 8:30AM on 2/12/2018 left over food items were observed in the walk in refrigerator. The items were one plate of fish with lettuce and tomato, and one small pan of scrambled eggs. Neither of which were dated, or labeled. The facility's policy and procedures regarding Storing Leftovers documented the following: Left over foods and prepared perishables must be labeled and dated as to date of preparation. Food should not be kept longer than 48 hours. On 02/12/2018 at 7:55AM The kitchen supervisor was interviewed. She stated all food items must be dated and labeled prior to refrigerated and kept for only 48 hrs. On 02/15/2018 at 3:18PM DFS (Director of Food Services) was interviewed . He stated without the food items being dated or labeled it was not possible to determine when the food was prepared. All foods must be labelled date and put in refrigerated and kept for 48 hrs 415.14(h)