Every finding on record at Shaker Place Rehabilitation and Nursing Center

Based on record review and interviews conducted during an abbreviated survey (Case #NY00377666), the facility did not ensure the residents' right to be free from abuse for one (1) (Resident #1) of one (1) resident reviewed for abuse. Specifically, on 4/09/2025 at 2:15 AM, Certified Nurse Aide #1 self-reported that they tapped Resident #1 on their right hand when the resident was combative during a shower. This is evidenced by: See cross references of F-609 and F-610. Resident #1 was admitted to the facility with diagnoses of anxiety disorder (mental health condition characterized by excessive fear or anxiety that interferes with daily activities), cognitive communication deficit (communication difficulties that arise from cognitive impairments), and insomnia (sleep disorder that can make it hard to fall asleep or stay asleep). The Minimum Data Set (an assessment tool) dated 2/10/2025, documented the resident was understood, could understand others, and had moderate cognitive impairments. The facility Policy and Procedure titled, Abuse Prohibition Program, updated 12/2022, documented the facility had procedures in place to screen and train employees, protect residents, and to prevent, identify, investigate and report abuse, neglect, mistreatment, and misappropriation of resident property. Physical abuse included hitting, slapping, pinching, and kicking, controlling behavior though the use of corporal punishment. The Alteration in Plan of Care related to Non-compliance Care Plan initiated 11/20/2024, documented Resident #1 was combative and non-compliant with transfers, ambulation status, showers, and activities of daily living with goal that Resident #1 would not have injury or ill effects from non-compliance. In a Skin Observation Tool dated 4/10/2025 at 2:53 PM, Registered Nurse #1 documented that Resident #1's right dorsal (back of the) hand had a diffuse, irregular fading, light purplish bruise with yellowish edges. It noted that there were four (4) purple bruises in linear fashion to the resident's right upper arm measuring 1.0 centimeters each. The resident's range of motion was within normal limits. The Quality Assurance Investigation Report dated 4/10/2025, documented that Certified Nurse Aide #1 self-reported and admitted to tapping Resident #1's hand when the resident was combative during care. This initially resulted in a reddened area and subsequently a bruise. It was determined that Certified Nurse Aide #1 used their hand to block Resident #1 from hitting them, which caused a bruised area to the resident's right upper arm. The incident was witnessed by Certified Nurse Aide #2. Staff interviews and statements were collected, and an investigation was completed resulting in the termination Certified Nurse Aide #1, Certified Nurse Aide #2, and Registered Nurse #2. It was determined that the staff did not follow facility policy and best practices for management of combative behavior. The report concluded the incident was consistent with physical abuse and it was reported to the Department of Health and the [NAME] County Sheriff's Department. For Quality Assurance, 10 random staff interviews would be conducted weekly for all shifts for one month, and then monthly for 2 months to ensure retention of knowledge of abuse education provided. During an interview on 4/17/2025 at 10:34 AM, Resident #1 stated they did not recall the altercation that occurred with Certified Nurse Aide #1 on 4/09/2025. During a telephone interview on 4/17/2025 at 1:02 PM, Certified Nurse Aide #1 stated they gave Resident #1 a shower around 2:00 AM on 4/09/2025 because they were on the overnight shower schedule. Certified Nurse Aide #1 stated Resident #1 was combative during the shower. Certified Nurse Aide #1 stated they unintentionally tapped the resident's hand and after they finished the resident's care; Certified Nurse Aide #1 reported the incident to Licensed Practical Nurse #1. During a telephone interview on 4/18/2025 at 1:56 PM, Certified Nurse Aide #2 stated Certified Nurse Aide #1 requested they help them with Resident #1's shower on 4/09/2025 because the resident was combative. Certified Nurse Aide #2 stated they assisted by holding the shower hose. They stated during this time, Resident #1 was swatting at Certified Nurse Aide #1. They stated Certified Nurse Aide #1 must have had enough and tapped Resident #1 on the hand and said, stop doing that. They stated it was not in an aggressive way. When asked how Resident #1 responded to the tap, Certified Nurse Aide #2 stated the resident's behavior got worse, swatting Certified Nurse Aide #1 again. During a telephone interview on 4/18/2025 at 9:09 AM, Licensed Practical Nurse #1 stated Certified Nurse Aide #1 approached them around 2:15 AM on 4/09/2025 after giving a shower to Resident #1 and stated they 'lost it' and hit the resident's hand. Certified Nurse Aide #1 informed them that Certified Nurse Aide #2 was with them during the shower. Licensed Practical Nurse #1 stated they instructed Certified Nurse Aide #1 to stay in the office while they checked on Resident #1. They observed a reddened area on Resident #1's hand. They stated that they immediately called Registered Nurse #2 to inform them of the incident and that they would send Certified Nurse Aide #1 to the nursing supervisor's office. Licensed Practical Nurse #1 stated they questioned Certified Nurse Aide #2, who initially denied the accusation until they discovered Certified Nurse Aide #1 had reported themselves. Licensed Practical Nurse #1 further stated that Certified Nurse Aide #2 witnessed Certified Nurse Aide #1 hit Resident #1 in the thigh. Licensed Practical Nurse #1 stated that they sent both Certified Nurse Aides #'s 1 and 2 to the supervisor's office. Licensed Practical Nurse #1 stated Certified Nurse Aide #1 only turned themselves in because they were afraid that Certified Nurse Aide #2 would report them. During an interview on 4/17/2025 at 2:14 PM, Director of Nursing #1 stated Licensed Practical Nurse #1 informed them of the alleged abuse on 4/10/2025 at 8:45 AM, reporting that Resident #1 was resistive to care being provided by Certified Nurse Aide #1, who 'lost it' and tapped the resident's hand. The incident was witnessed by Certified Nurse Aide #2. Certified Nurse Aide #1 self-reported the incident to Licensed Practical Nurse #1. Director of Nursing #1 stated that Licensed Practical Nurse #1 informed Registered Nurse #2 of the incident and sent the two (2) Certified Nurse Aides to the supervisor's office. The Certified Nurse Aides were sent back to the unit to work after speaking with Registered Nurse #2. Per Director of Nursing #1, Registered Nurse #2 denied any knowledge of the alleged abuse and stated they were only made aware that the resident was combative. Director of Nursing #1 stated that they were made aware of the alleged abuse on 4/10/2025 at approximately 8:45 AM, at which time Certified Nurse Aide #'s 1 and 2, and Registered Nurse #2 were suspended and later terminated. They stated a report was made to the Department of Health and to the [NAME] County Sheriff's Department. A skin assessment was completed for Resident #1 and bruising was noted. Their family and the physician were notified of the incident. Director of Nursing #1 stated it was concluded that Certified Nurse Aide #1 did tap Resident #1's hand. As a result, Certified Nurse Aide #1 was terminated. Certified Nurse Aide #2 was terminated because they witnessed the abuse, but did not report it and continued to work. Registered Nurse #2 was terminated because she was informed of the abuse by three (3) different staff members and did not follow the facility policies and procedures for abuse. Director of Nursing #1 stated the facility completed skin assessments for all residents on the unit with no identified concerns. Social work interviewed residents with a Brief Interview for Mental Status score above 8 and called family members for residents with a score of 8 or lower with no concerns reported. Director of Nursing #1 stated they started a house wide education on abuse, and staff could not work until educated. They further stated that even if staff received abuse education prior to the 4/10/2025, they had to be reeducated before working again. During an interview on 4/17/2025 at 2:28 PM, Administrator #1 stated they were notified of the incident on 4/10/2025 at 9:00 AM, and that Director of Nursing #1 immediately started an investigation. Administrator #1 stated Registered Nurse #2 did not seem to handle the situation appropriately, because Certified Nurse Aide #1 was not immediately removed and did not notify the Director of Nursing and Administrator. Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement at the time of surveyor entrance for this survey: On 4/10/2025, conducted skin assessments of all residents on the [NAME] Unit. Facility submitted a report to law enforcement. Incident was reported to the resident's representative and the physician. Social Services conducted interviews with all residents that resided on the [NAME] Unit with a Brief Interview for Mental Status of 8 or greater to confirm that there were no other care concerns. Social Services contacted all resident representatives if the resident's Brief Interview for Mental Status score was lower than 8 to confirm there were no care concerns. Abuse Prohibition Program education was initiated on 4/10/2025 to all staff which included procedures on prevention, identification, investigation and reporting of abuse, neglect, mistreatment, and misappropriate of resident property. Education completed on 4/22/2025. For Quality Assurance, 10 random staff interviews would be conducted weekly for all shifts for one month, and then monthly for 2 months to ensure retention of knowledge of abuse education provided. 10 New York Codes, Rules and Regulations 415.4(b)(1)(i)

Based on record review and interviews conducted during an abbreviated survey (Case #NY00377666), the facility did not ensure that all alleged violations involving abuse were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse, to the administrator of the facility and to other officials including to the State Survey Agency in accordance with State law through established procedures for one (1) (Resident #1) of one (1) resident reviewed. Specifically, Certified Nurse Aide #1 self-reported physical abuse to Resident #1 on 4/09/2025 at approximately 2:15 AM to Licensed Practical Nurse #1. The allegation was reported to the New York State Department of Health on 4/10/2025 at 10:33 AM. This is evidenced by: See cross references of F-609 and F-610. Resident #1 was admitted to the facility with diagnoses of anxiety disorder (mental health condition characterized by excessive fear or anxiety that interferes with daily activities), cognitive communication deficit (communication difficulties that arise from cognitive impairments), and insomnia (sleep disorder that can make it hard to fall asleep or stay asleep). The Minimum Data Set (an assessment tool) dated 2/10/2025, documented the resident was understood, could understand others, and had moderate cognitive impairments. The facility Policy and Procedure titled, Abuse Prohibition Program, updated 12/2022, documented all allegations of abuse should be reported to the Executive Director/designee immediately. If there was suspected abuse, the Executive Director should report immediately, but no later than 2 hours after the allegation was made, if the allegations involved abuse, to other officials (State Survey Agency). During a telephone interview on 4/17/2025 at 1:02 PM, Certified Nurse Aide #1 stated they gave Resident #1 a shower around 2:00 AM on 4/09/2025 because they were on the overnight shower schedule. Certified Nurse Aide #1 stated Resident #1 was combative during the shower and at one point they unintentionally tapped the resident's hand. After they finished the resident's care, Certified Nurse Aide #1 reported the incident to Licensed Practical Nurse #1 at approximately 2:15 AM. The facility Quality Assurance Investigation Report dated 4/10/2025, documented that Certified Nurse Aide #1 self-reported and admitted to tapping Resident #1's hand when the resident was combative during care on 4/09/2025 at approximately 2:00 AM. This initially resulted in a reddened area and subsequently a bruise. A Complaint/Incident Investigation Report documented the incident was reported to the New York State Department of Health on 4/10/2025 at 10:33 AM. During a telephone interview on 4/18/2025 at 9:09 AM, Licensed Practical Nurse #1 stated Certified Nurse Aide #1 approached them on 4/09/2025 around 2:15 AM after giving a shower to Resident #1 and stated they 'lost it' and hit the resident's hand. Certified Nurse Aide #1 informed them that Certified Nurse Aide #2 was with them during the shower. Licensed Practical Nurse #1 observed a reddened area on Resident #1's hand. They stated that they immediately called Registered Nurse #1 to inform them of the incident and sent both Certified Nurse Aides #'s 1 and 2 to the supervisor's office. Licensed Practical Nurse #1 stated they were confused when the aides returned to the unit to finish their shifts. During an interview on 4/17/2025 at 2:14 PM, Director of Nursing #1 stated they were informed of the alleged abuse on 4/10/2025 at 8:45 AM by Licensed Practical Nurse #1. During an interview on 4/17/2025 at 2:28 PM, Administrator #1 stated once they were made aware of the allegation on 4/10/2025 at 9:00 AM, Director of Nursing #1 immediately started an investigation and reported to the Department of Health and to law enforcement. They stated Registered Nurse #1, and Certified Nurse Aide #s 1 and 2 were terminated. 10 New York Codes, Rules, and Regulations 483.12 (c) (1)

Based on record review and interviews conducted during an abbreviated survey (Case # NY00377666), the facility did not ensure alleged violations of abuse were thoroughly investigated for one (1) (Resident #1) of one (1) resident reviewed for abuse. Specifically, Certified Nurse Aide #1 was not removed immediately from resident care when there was an allegation of physical abuse made on 4/09/2025, to prevent further abuse from occurring. Certified Nurse Aide #1 was allowed to finish their shift on 4/09/2025 and also worked 11:00 PM- 7:00 AM shift on 4/09/2025 into 4/10/2025. This is evidenced by: See cross references of F-600 and F-609. The facility Policy and Procedure titled, Abuse Prohibition Program, updated 12/2022, documented the facility should take necessary measures to protect residents from harm or potential abuse during any investigation of an allegation of abuse. The facility should take steps to assure the resident identified as the alleged victim was safe from further incidents. If a staff member was identified as the alleged perpetrator, the staff member's manager, supervising nurse, or executive director should immediately remove the employee from the work area and relocate them to an area of the facility away from resident contact. Once an employee statement was obtained, the employee should be sent home and may be suspended pending investigation. The Quality Assurance Investigation Report dated 4/10/2025, documented that Certified Nurse Aide #1 self-reported and admitted to tapping Resident #1's hand when the resident was combative during care on 4/09/2025 at approximately 2:00 AM. This initially resulted in a reddened area and subsequently a bruise. During a telephone interview on 4/17/2025 at 1:02 PM, Certified Nurse Aide #1 stated they gave Resident #1 a shower around 2:00 AM on 4/09/2025 because they were on the overnight shower schedule. Certified Nurse Aide #1 stated Resident #1 was combative during the shower and at one point they unintentionally tapped the resident's hand. After they finished the resident's care, Certified Nurse Aide #1 reported the incident to Licensed Practical Nurse #1 at approximately 2:15 AM, who then informed Registered Nurse #2. Certified Nurse Aide #1 stated Registered Nurse #2 allowed them to finish their shift, that Resident #1 was removed from their assignment, and that they did not work with Resident #1 the remainder of the shift. Certified Nurse Aide #1 stated they also worked the following 11:00 PM to 7:00 AM shift on 4/09/2025 into 4/10/2025. During a telephone interview on 4/18/2025 at 9:09 AM, Licensed Practical Nurse #1 stated Certified Nurse Aide #1 approached them on 4/09/2025 around 2:15 AM after giving a shower to Resident #1 and stated they 'lost it' and hit the resident's hand. Certified Nurse Aide #1 informed them that Certified Nurse Aide #2 was with them during the shower. Licensed Practical Nurse #1 observed a reddened area on Resident #1's hand. They stated that they immediately called Registered Nurse #1 to inform them of the incident and sent both Certified Nurse Aides #'s 1 and 2 to the supervisor's office. Licensed Practical Nurse #1 stated they were confused when the aides returned to the unit to finish their shifts, and that Registered Nurse #1 said to them Certified Nurse Aide #1 was just overwhelmed. Licensed Practical Nurse #1 stated Certified Nurse Aide #1 worked the following night 4/09/2025 on 11:00 PM -7:00 AM shift. Licensed Practical Nurse #1 stated they did not feel like the other residents were safe and followed Certified Nurse Aide #1 around throughout the shift in attempt to ensure safety of the residents. During an interview on 4/17/2025 at 2:14 PM, Director of Nursing #1 stated the Certified Nurse Aides were sent back to the unit to work after speaking with Registered Nurse #2 on 4/09/2025. Per Director of Nursing #1, Registered Nurse #2 denied any knowledge of the alleged abuse and stated they were only made aware that the resident was combative. They further stated they were made aware of the alleged abuse on 4/10/2025 at approximately 8:45 AM, at which time Certified Nurse Aides #'s 1 and 2, and Registered Nurse #2 were suspended and later terminated. During an interview on 4/17/2025 at 2:28 PM, Administrator #1 stated they were notified of the incident on 4/10/2025 at 9:00 AM, and that Director of Nursing #1 immediately started an investigation. Administrator #1 stated Registered Nurse #2 did not seem to handle the situation appropriately, because Certified Nurse Aide #1 was not immediately removed and did not notify the Director of Nursing and Administrator. 10 New York Codes, Rules, and Regulations 483.12(c)(3)

Based on observation, record review, and interviews during the recertification survey and an abbreviated survey (Case #NY00307728) from 9/28/2023 to 10/10/2023, the facility did not ensure alleged violations of abuse, mistreatment, neglect, exploitation and misappropriation were thoroughly investigated, and did not immediately put effective measures in place to ensure that further misappropriation of resident property, abuse, neglect, or exploitation would not occur while an investigation was in process. Specifically on 11/26/2022, it was reported to the facility and the Police by Resident #188 and their Family Member (FM) #1 that the resident's credit card was missing, had unknown charges totaling approximately $10,000.00 since 05/2022, and were suspecting misappropriation by a staff member. Subsequently, this had the potential to affect all 235 residents within the facility. This was evidenced by: The facility document titled Abuse Prohibition Policy (APP) dated March 2021, documented the following: - Purpose of the APP was to have procedures in place for screening and training employees regarding protection of residents for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of resident property to ensure that the facility was doing all that was within its control to prevent occurrences. - Abuse prohibition training that was provided to staff was to include, but was not necessarily be limited to, definitions of abuse, neglect, involuntary seclusion, misappropriation of resident property, and/or exploitation; and how to report incidents or allegations of abuse, neglect, involuntary seclusion, misappropriation of property, and/or exploitation. Identification of possible incidents or allegations of abuse, neglect, involuntary seclusion, misappropriation of resident property, and/or exploitation would be facilitated by staff members accepting any report alleging an incident of abuse, neglect, involuntary seclusion, misappropriation of resident property, and/or exploitation from any resident or family member; staff members who receive such an allegation or who observe an incident or believe there may have been a reportable incident shall report the situation immediately to the respective department manager, and/or supervising nurse, and/or the Director of Nursing, and/or Executive Director; if specific allegations or observations of abuse, neglect, involuntary seclusion, misappropriation of resident property, and/or exploitation had been brought to the attention of the department manager or the supervising nurse, the department manager shall immediately report the circumstances to the Director of Nursing, and/or Executive Director; if an allegation concerns a circumstance of unknown origin, the supervising nurse would use clinical judgment to assess whether the possibility of abuse or neglect had occurred and professional judgment to determine whether involuntary seclusion, misappropriation of property, or exploitation had occurred. In those cases, wherein allegations of abuse, neglect, involuntary seclusion, misappropriation of resident property, and/or resident exploitation had been reported to the Director of Nursing/ designee and/or the Executive Director, an investigation of the incident shall commence as soon as practical; initial investigations of allegations may begin immediately and be conducted by the supervising nurse. - Protection: If a staff member had been identified as the alleged perpetrator, the staff members department manager, the supervising nurse, and/or the Executive Director shall immediately remove the employee from the employees' work area and place them in an area of the facility away from all resident contact. Once a statement was obtained from the employee, the employee shall be sent home from the facility and may be suspended pending the outcome of the investigation. Resident #188 was admitted with diagnoses of major depressive disorder, morbid obesity, and atrial fibrillation (an irregular heart rhythm). The Minimum Data Set (MDS, an assessment tool) dated 11/14/2022 documented the resident was able to make themselves understood, understand others, and was cognitively intact. A subsequent MDS dated [DATE] documented a new diagnosis of anxiety disorder for Resident #188. Review of the Comprehensive Care Plans (CCPs) dated from 09/01/2022 to 10/05/2023 for Resident #188 revealed a new care plan was initiated on 02/07/2023 and revised on 02/08/2023 with a problem of the resident having trauma history related to financial abuse by a former caregiver. There was no documented evidence of a CCP for misappropriation found prior to 02/07/2023. The facility's Quality Assurance (QA) Investigative Report, dated 12/29/2022, documented on: - 11/26/2022, Resident #188's daughter FM #1 informed the Director of Nursing (DON) and the Director of Social Work (DSW) #1 believed the resident's credit card had been hacked. Their daughter searched the resident's room that day and was unable to locate the credit card. The Police were notified and initiated an investigation. - 11/26/2022, record review revealed no documented evidence that the incident was reported to the New York State Department of Health (NYSDOH) at the time. - 11/30/2022, Resident #188 reported they believed Certified Nurse Aide (CNA) #1 and CNA #2 were responsible for their missing credit card. - 12/28/2022, two Police detectives arrived at the facility and presented Resident #188 with a photo of CNA #1, whom the resident confirmed. Following an interview with the Police, CNA #1 was suspended, and their access to the building was revoked. Record review revealed no documented evidence of a facility investigation after the allegation was brought to their attention on 11/26/2022. Review of the facility grievance logs dated from 9/01/2022 to 1/30/2023 revealed no documented evidence of complaints or concerns reported by Resident #188, their family or law enforcement related to misappropriation. The Police incident report initiated 11/26/2022 documented the following: - FM #1 called the Police via a landline in the hallway of the facility on 11/26/2022. FM #1 informed Police that since May 2022 they noticed numerous fraudulent charges on Resident #188 credit card amounting to approximately $10,000.00 while the resident was residing at the facility. FM #1 also reported that the most recent charges occurred on 11/25/2022. Resident #188 informed FM #1 that on 11/25/2022 CNA #1 and CNA #2 were caring for the resident. The Resident stated at one point one CNA took the resident out of the room while the other CNA remained in their room with the door closed for an extended period of time. Resident #188 stated they heard one of the CNAs state that they were going to a department store later, which was the same store where the fraudulent charges were subsequently made. - On 11/27/2022, the Police returned to the facility for a follow up interview with Resident #188, who explained to Police there were prior incidents of fraud from four separate credit cards. Resident #188 expressed willingness to press charges. The Police obtained video footage as well as pictures of the incident involving Resident #188's credit card that occurred at the above referenced department store. - On 12/28/2022, the Police returned to the facility to interview Resident #188 with DSW #1 present. After Police provided pictures of the suspect who used the credit card, Resident #188 identified them as CNA #1. Resident #188 stated they did not give CNA #1 permission to use the credit card. The report documented the Police spoke to the Previous Administrator (Admin) #2 to advise them of the incident that had occurred. The facility's staffing assignment sheet dated 11/30/2022 to 12/28/2022 documented CNA #1 was assigned and worked on different units in the facility including Wright, [NAME], [NAME], Case, and [NAME]. The facility's daily punch card dated 11/01/2022 to 1/06/2023 documented CNA #2 worked on 11/28/2022, 11/29/2022, and 11/30/2022 on the [NAME] Unit. Resident #188 resided on [NAME] Unit. The facility's daily punch card dated 11/01/2022 to 01/06/2023 documented CNA #1 worked from 11/26/2022 through 12/28/2022. There was no documented evidence that a written investigation was completed or submitted to NYSDOH as required by regulation. A summary of events dated 12/29/2022 did not include a facility-led investigation had been conducted when the allegation - that CNA #1 may have used Resident #188's credit card - was brought to their attention on 11/26/2022. During an interview on 10/04/2023 at 4:00 PM, DSW #1 stated that the facility was first made aware of the allegation of Resident #188's credit card having been missing on 11/26/2022. DSW #1 stated they, along with FM #1, searched the resident's room on 11/26/2022. When the credit card was unable to be located, FM #1 called the Police. DSW #1 stated they believed the incident required no additional action by the facility. DSW #1 stated there were no case notes or facility investigation and stated they did not document the details of the reported misappropriation. DSW #1 stated the Police returned to the facility on [DATE] with evidence of CNA #1 having used Resident #188's credit card. DSW #1 further stated there was no investigation completed by the facility on 12/28/2022 because CNAs #1 and #2 were no longer employed at the facility at that time. During an interview on 10/04/2023 at 3:25 PM, Registered Nurse Quality Assurance (RNQA) #1 stated they were the responsible person who completed the facility investigation report conducted on 12/29/2022. They further stated FM #1 called Police on 11/26/2022. RNQA #1 stated the facility initiated the investigation on 12/29/2022 after the DON #1 had submitted a report to the New York State Department of Health (NYSDOH) on 12/28/2022. During an interview on 10/04/2023 at 4:53 PM, FM #1 stated some of the fraudulent charges from Resident #188's credit card involved electronic money transfers and in person purchases, none of which had any relation to the resident. FM #1 stated they notified the facility on 11/26/2022 that the credit card charges were not authorized by Resident #188. After DSW #1 and FM #1 searched the room and were unable to locate the credit card, FM #1 called the Police and a report was made. FM #1 stated DSW #1, Registered Nurse Unit Manager (RNUM) #1, and the DON #1 had been made aware of the misappropriation and of whom the resident suspected had taken the credit card on 11/26/2022. FM #1 stated nothing was done until 11/30/2022 when a request was made to remove the CNA #1 and #2 from caring for the resident because Resident #188 expressed fear of retaliation from CNA #1 and #2. CNA #1 and #2 were removed from Resident #188's unit on 11/30/2022, but CNA #1 remained in the facility providing care for other residents. During an interview on 10/04/2023 at 5:36 PM, DON #1 stated they were not aware that Resident #188's credit card had been taken and that FM #1 reported the credit card had been hacked. DON #1 stated Resident #188's family called the Police, and no facility investigation was done because the facility did not identify abuse when they were made aware on 11/26/2022. The DON #1 further stated an investigation was performed but they were unable to locate the facility's investigation. The DON #1 stated CNA #1 was not suspended from work following the allegation of misappropriation on 11/26/2022, and that CNA #1 was reassigned to work on all other units in the facility, except for Resident #188's [NAME] unit. DON #1 stated CNA #1 was suspended on 12/28/2022 and an investigation was initiated when the facility became aware that CNA #1 was being charged with crimes. During an interview on 10/04/2023 at 5:36 PM, DON #1 stated an interview was conducted with CNA #1 when Resident #188 reported their credit card went missing. DON #1 stated CNA #1 admitted to using Resident #188's credit card to make purchases for the resident. DON #1 stated an interview with Resident #188 was conducted, and Resident # 188 admitted allowing CNA #1 to use their credit card to make purchases for them. DON #1 stated the policy for staff using the resident's money or credit cards was not allowed; that policy prohibited staff from using or purchasing any items for residents except for social services. DON #1 stated no disciplinary action was taken against CNA #1 when CNA #1 admitted to ot following policy. During an interview on 10/05/23 at 9:26 AM, Resident #188 stated CNA #1 was their regular aide, and they thought CNA#1 was their friend. Resident #188 stated FM #1 called them about charges to their credit card for things they would never do. Resident #188 stated they initially didn't think the charges were coming from the facility, that they called the bank and was reimbursed for the charges Resident #188 didn't make. Resident #188 stated FM #1 thought it was credit card charges stemming from online purchases but there were subsequent, additional, unaccounted charges. Resident #188 stated there was a charge for thousands of dollars including that for nurses' outfits and shoes. Resident #188 stated they did not authorize the charges and informed the facility the first and third instance when new credit cards were issued. Resident #188 stated FM #1 came to the facility and FM #1 and Resident #1 called the Police. Resident #188 stated Police arrived and brought pictures of CNA #1 buying items including a uniform at a department store with Resident #188's credit card. Resident #188 stated they identified CNA #1 from the pictures. During an interview on 10/05/2023 at 9:35 AM, RNUM #1 stated they did not investigate the allegation of abuse concerning Resident #188's missing credit card. RNUM #1 stated they were aware that Police had been notified and they were told the facility's legal unit was handling the matter. RNUM #1 stated CNA #1 and #2 were moved off the unit where Resident #188 resided, and they had no reason to follow up on the incident. The RNUM stated, they did not check with anyone at the facility to see if the allegation was being investigated or if it had been reported. During an interview on 10/05/2023 at 9:51 AM, CNA #4 stated they did not know if there was a policy but would not purchase anything for residents and would be ethically not something they themselves would do. During an interview on 10/06/2023 at 3:09 PM, Administrator (Admin) #2 stated they believed in November 2022, the family of Resident #188 came to the facility and said that someone, maybe a staff member, was possibly using Resident #188's credit card. Admin #2 stated Resident #188's family said that the resident had possibly given the credit card to the someone, but they weren't sure. Admin #2 stated that they asked CNA #1 in November 2022 if they had used Resident #188's credit card or had been given the credit card and CNA #1 denied it. Admin #2 stated they told DON #1 as a precautionary measure, had no idea what happened, but Admin #2 knew the family said they were going to report it to the Police. Admin #2 further stated that an investigation was completed by Police and that CNA #1 was moved away from Resident #188. Admin #2 stated the had no facts in November 2022 that any wrongdoing was done by CNA #1. Admin #2 further stated the Quality Assurance Person (QA Person) #1 was in the meeting and took notes, but the facility could not locate the notes and that QA Person #1 no longer worked for the facility. Admin #2 further stated the minutes would show that CNA #1 denied everything; Admin #2 only interviewed CNA #1 and could not reach the other accused CNA; Admin #2 did not have knowledge if other residents or staff were interviewed and there were no cameras. Admin #2 further stated that the resident wasn't sure if they gave the credit card or not and the family didn't know who was using it. Admin #2 stated that if it had risen to the level of a reportable event, Admin #2 would have become aware of it, such as when the Police showed up at the facility. Admin #2 stated they assumed Police did their due diligence and Police didn't have an obligation to tell the facility if they charge or don't charge someone with something. Admin #2 stated if the Police did something, they didn't have an obligation to report to the facility, and that if a staff member had been suspended indefinitely and didn't file with their union, the facility didn't have an obligation to follow up. Admin #2 stated in November 2022, the allegation wasn't credible because Admin #2 didn't have facts to support the allegation. Admin #2 further stated that the actions taken by a nursing home were based on the information and investigation and sometimes staff would be suspended, moved to another unit, or sometimes terminated. Admin #2 stated CNA #1 was part of a union and had rights as well as the residents. Admin #2 stated they were trying to weigh each allegation made, the validity of the allegation, and procced to take appropriate action based on the information the facility had. Admin #2 stated they didn't have the facts to suspend CNA #1 or terminate them. Admin #2 further stated the facility took actions to protect all parties, including the staff member, by moving CNA #1 off the unit. Admin #2 further stated there was a quality assurance (QA) meeting that was supposed to have been documented by the QA person. Admin #2 stated DON #1 had looked for it during survey and had access to QA person's computer, but DON #1 couldn't find documentation of the meeting. Admin #2 stated they did not give specific instructions to staff after they spoke to Police, that they could remember. Admin #2 further stated they did not have control over what staff they do on their own time. Admin #2 stated they were not familiar with a facility employee conduct policy and would not be able to speak to what had been done or not done, but that annual abuse and mistreatment trainings were conducted per regulations. During an interview on 10/06/2023 at 9:04 AM, Medical Director (MD) #1 stated they were not aware of the issues Resident #188 reported to Psychology in December 2022 and January 2023, as such issues would be reported to the attending physician's attention and be reported to MD #1 if they believed there was a concern. The attending physician or nurse practitioner would also attend the resident's care conferences. The attendings and nurse practitioners typically did not discuss residents with MD #1 unless there was a roadblock. MD #1 further stated that they had an administrative role at the facility and did not have a resident caseload but was available if required for assistance. 10 NYCRR 415.4(b)(2)

Based on observation, record review, and interviews during the recertification survey from [DATE] to [DATE], the facility did not ensure safe and appropriate labeling of all medications for 3 ([NAME] Unit, [NAME] Unit, and [NAME] Unit) of 3 units for medication labeling and storage. Specifically, the facility did not ensure insulin Kwik pens on the [NAME] Unit, [NAME] Unit, and [NAME] Unit were labeled with the date they were opened, and the expiration dates after opening. Also, the facility did not ensure nursing staff were knowledgeable regarding how to determine insulin expiration dates after opening. This is evidenced by: The Guardian Consulting Services (GCS) grid of Expiration Dates for Open Injectable Diabetic Medication pen expiration dates varied from discard after single use to 56 days, depending on type of insulin pen. Most common expiration was 28 days from opening of insulin pen. There was no documented evidence that the facility inserviced staff on insulin vial and/or insulin pen expiration dates. The facility Insulin Refresher Training PDF did not address insulin vial and/or insulin pen expiration dates. [NAME] Unit During an observation of the medication cart on the [NAME] Unit on [DATE] at 10:25 AM, a lispro Kwik Pen insulin was labeled with the date it was opened. The label on the pen did not include the date of expiration (from the date and time insulin was opened). During an interview with Licensed Practical Nurse (LPN) #4 (who was at the medication cart on the [NAME] Unit) on [DATE] at 10:25 AM, LPN #4 was asked about the expiration date and stated they would calculate the expiration date to be 30 days from date the pen was opened. [NAME] Unit During an observation of the medication cart on the [NAME] Unit on [DATE] at 10:40 AM, an insulin Kwik Pen found in the cart was not labeled with the date the pen was opened. Other insulin Kwik pens labeled with the dates they were opened did not include the date the insulin pen expired after opening. During an interview with LPN #3 (who was on at the medication cart on the [NAME] Unit) on [DATE] at 10:40 AM, LPN #3 was asked to identify the expiration date of the insulin. LPN #3 stated in order to calculate the expiration date, they would use 30 days from the date when opened on all types of insulins. [NAME] Unit During an observation of the medication cart on [NAME] Unit on [DATE] at 11:00 AM, a Kwik Pen insulin pen that was labeled with the date that it was opened did not include the date the pen expired. During an interview LPN #2 stated the use of the insulin pen would expire 30 days after it was opened. Interviews During an interview on [NAME] Unit on [DATE] at 11:30 AM, Unit Manger (UM) #2 stated to determine the expiration date of an insulin pen the LPN would calculate expiration 28 - 30 days from the date opened, depending on the type insulin. UM #2 further stated they would confirm. During an interview with the Director of Nursing (DON) #1 on [DATE] at 11:45 AM, the DON stated the LPN dates insulin when opened and would then calculate expiration 28 - 30 days from the date opened, depending on type insulin. During an interview with Director of Education (DOE) #1, on [DATE] at 11:55 AM, DOE #1 stated insulin expiration dates are determined from Guardian Consulting Services grid of Expiration Dates for Open Injectable Diabetic Medication. DOE #1 stated it was posted on each unit medication room. During an interview and observation on the [NAME] Unit on [DATE] between 9:00 AM and 3:00 PM, the Unit Manager for [NAME] Unit (UM #1) along with LPN #4 were asked if they were familiar with the GCS grid. LPN #4 stated they were providing UM #1 an orientation about the grid as UM #1 had no knowledge of the GCS grid. UM #1 stated the grid was kept in a binder in the medication room. UM #1 was observed pulled grid from inside binder in the [NAME] medication room. The facility Medication Storage Policy stated that bulk medications or multi-use vials would be labeled with the date opened and would expire per manufacturer recommendations; would be discarded according to manufacturer's expiration date. Expired, discontinued and or contaminated medications would be removed from the medication storage areas and disposed of in accordance with facility guideline. 10NYCRR 415.18(e) (,d+[DATE])

Based on observation, record review, and interviews during the recertification survey and an abbreviated survey (Case #NY00307728) from 9/28/2023 to 10/10/2023, the facility did not ensure prompt efforts were made to resolve grievances for 1 (Resident #188) of 1 resident reviewed for grievances. Specifically, the facility did not ensure that complaints regarding Resident #188's missing personal property was acknowledged by the facility and necessary steps towards an appropriate resolution were taken. This is evidenced by: Resident #188: Resident #188 was admitted with diagnoses of major depressive disorder, morbid obesity, and atrial fibrillation (an irregular heart rhythm). The Minimum Data Set (MDS-an assessment tool) dated 11/14/2022 documented the resident was able to make themselves understood, could understand others, and was cognitively intact. The Policy and Procedure (P&P) titled, Procedure for Resident's Missing Items dated 10/2017 documented when a resident reported a missing item to a staff member, a document titled, Missing Item Report would be completed and given to the appropriate department. Review of the facility grievance log dated September 2022 - January 2023 did not include documentation of grievances filed by, or on behalf of, Resident #188. Review of facility missing item reports dated September 2022 - January 2023 did not include documentation of a missing items report filed by, or on behalf, of Resident #188. Review of progress notes dated September 2022 - January 2023, did not include documentation of a report or search for missing items for Resident #188. During an interview on 10/04/2023 at 4:00 PM, the Director of Social Work (DSW) #1 stated that the facility was first made aware of the allegation of Resident #188's credit card having been missing on 11/26/2022. DSW #1 stated they, along with Family Member (FM) #1, searched the resident's room on 11/26/2022. When the credit card was not found, FM #1 called the Police. DSW #1 stated they believed the incident required no additional action by the facility. DSW #1 stated there were no case notes or facility investigation, and sthey did not document the details of the reported misappropriation. DSW #1 stated the Police returned to the facility on [DATE] with evidence of CNA #1 having used Resident #188's credit card. DSW #1 stated they did not initiate an investigation when they became aware of the allegation made by FM #1 on 11/26/2022 because they had no proof that abuse or misappropriation occurred. During an interview on 10/04/2023 at 5:36 PM, the Director of Nursing (DON) #1 stated they were not aware Resident #188's credit card was taken. The Police were notified by the resident's family. No investigation was done, because the facility did not identify abuse when they were made aware on 11/26/2022. During an interview on 10/05/2023 at 9:26 AM, Resident #188 stated they believed they mentioned the missing credit card to a staff member before FM #1 contacted law enforcement but couldn't remember which staff member they told. Resident #188 further stated the staff member then informed Registered Nurse (RN) #1, and RN #1 spoke to them about it. Resident #188 stated they also spoke to DON #1 and DSW #1. During an interview on 10/06/2023 at 2:21 PM, DSW #1 stated they were with Resident #188 when the missing credit card was reported to Police. DSW #1 stated it was their error for not documenting that event or meeting with the resident. DSW #1 stated they believed because Police were involved, it was no longer the responsibility of the facility to investigate anything about the missing credit card. DSW # 1 further stated they did not believe any facility forms were completed because of the incident on 11/26/2022. During an interview on 10/6/2023 at 3:09 PM, Administrator #2 stated they believed Resident #188's family reported to the facility in November 2022 an allegation of someone using the resident's credit card. Administrator #2 further stated a facility report was not made as Administrator #2 was not sure the allegation was credible. 10NYCRR 415.3(c)(1)(ii)

Based on observation, interview, and record review, conducted during the recertification and abbreviated survey (Case #NY00307728) from 9/28/2023 to 10/10/2023, the facility did not ensure residents were free of abuse, neglect, exploitation, and misappropriation of resident property for 1 (Resident #188) of 14 residents reviewed for abuse, neglect, exploitation, and misappropriation of resident's property. Specifically, for Resident #188, the facility did not ensure the resident's credit card was free from misappropriation by a Certified Nurse Aide (CNA #1) who used the credit card without permission to purchase goods not intended for the resident from September 2022 through November 2022. The facility did not ensure to protect the resident's right to be free from any type of abuse and neglect, that results in or has the likelihood to result in physical harm, psychosocial harm, or the likelihood of psychosocial harm, pain, or mental anguish associated with the willful misappropriation of the resident's credit card by a facility CNA. Also, the facility did not ensure to assess the effect of the misappropriation on the resident's psychosocial wellbeing to determine whether there was psychosocial harm or the likelihood to result in psychosocial harm when they were notified of the allegation of misappropriation on 11/26/2022. Subsequently, the failure of the facility to notify the psychologist of the incident of misappropriation resulted in a delay of psychological care. This is evidenced by: A facility document titled Abuse Prohibition Policy (APP) dated March 2021, documented the following: The purpose of the APP is to have procedures in place for screening and training employees regarding protection of residents for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of resident property to ensure that the facility is doing all that is within its control to prevent occurrences. Particularly, misappropriation of the resident's property is defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of the resident's belongings or money without the resident's consent. Exploitation is defined as the act of taking advantage of a resident for personal gain using manipulation, intimidation, threats, or coercion. The facility corporate compliance policy states the facility corporate compliance committee shall perform regular and periodic monitoring of current employees to ensure continuing compliance with facility employment standards and regulatory requirements. Should an employee be subject to a finding by a court of law that may place them in question to continue to practice within the employee's profession, the corporate compliance committee shall report such judicial determinations (if known by the facility) to the applicable state professional licensing agency. Resident #188 was admitted with diagnoses of major depressive disorder, morbid obesity, and atrial fibrillation (an irregular heart rhythm). The Minimum Data Set (MDS - an assessment tool) dated 11/14/2022 documented the resident was able to make themselves understood, could understand others, and was cognitively intact. Resident #188 lived in a private room and had their credit card located in drawer with a lock provided by the facility. Review of progress notes and the Comprehensive Care Plans (CCPs) dated from 09/01/2022 to 10/05/2023 provided no documented evidence that a psychosocial assessment was completed for Resident #188 addressing the victimization or exploitation the resident was subjected to. CCP initiated 02/07/2023 documented Resident #188 had financial abuse by former caregiver, with goal for resident to verbalize feelings and emotional state through next review date, and interventions to allow the resident time to answer questions and to verbalize feelings, perceptions, and fears. A CCP for alteration in psychosocial wellbeing as evidenced by guilt, anger, fear, or stress regarding safety of personal property at the facility was dated 10/6/2023, with no previous CCPs for alteration in psychosocial wellbeing regarding safety of personal property. There was no documented evidence in progress notes reviewed from 9/01/2022 to 01/06/2023 of psychosocial assessments for the misappropriation and exploitation that occurred from 9/2022 to 12/28/2022 to Resident #188. A Social Worker (SW) progress note dated 12/02/2022 from 09:42 AM to 10:07AM documented the following: Resident #188 continued to exhibit intact temporal orientation, was independent in their decision making. Some decisions affected by their anxiety and fear, but mood status was being supported. The resident was not documented as showing any impairment to memory or recall. The resident had documented altered mood states of depression and anxiety. Although the resident was not reporting any symptoms with PHQ-9 (PHQ-9 - one module of the Patient Health Questionnaire and includes nine short questions designed to help healthcare professionals identify signs or symptoms of depression) score, Resident #188 was documented to have been seeking support from both the psychiatric Nurse Practitioner and psychologist. The resident would continue to be monitored by nursing and social services for any changes in mood status. A SW progress note dated 12/05/2022 at 12:04 PM documented the following: Resident #188 was reviewed in an Interdisciplinary Team meeting. The resident had been diagnosed with a dual diagnosis of anxiety and depression and was seeking support from both the psychiatric Nurse Practitioner (NP) and the psychologist; with family actively involved with the residents care daily. A SW progress note dated 12/28/2022 at 2:00 PM documented the Director of Social Work (DSW) #1 was present at the time the Police spoke with Resident #188 about their missing credit card. Record review did not include documented evidence that monitoring of Resident #188 had occurred by nursing or social services for signs and symptoms of increased anxiety or depression related to the misappropriation from 11/26/2022 through 1/30/2023. Record review of staffing logs documented that Certified Nurse Aides (CNAs) #1 and #2 had access to the resident's room from 09/01/2022 through 11/30/2022. CNA #1 had continued access to the resident's room from 11/30/2022 to 12/28/2022 when they continued to work at the facility on multiple units. Review of facility complaint summary dated 12/29/2022 documented Family Member (FM) #1 filed a complaint with the Police on 11/26/ 2022 2023. FM #1 indicated Resident #188 lived at the facility and stated they had been victim of misappropriation by facility staff of the Resident's personal credit card. The Quality Assurance (QA) Investigative Report dated 12/29/2022 documented the following: -11/26/2022, FM #1 informed the Director of Nursing (DON) #1 and DSW #1 they believed the resident's credit card had been hacked. FM #1 searched the resident's room that day and was unable to locate the credit card. Police were notified, and they initiated their investigation. -11/30/2022, Resident #188 reported they believed CNA #1 and CNA #2 were responsible for the missing credit card. -12/28/2022, two Police detectives arrived at the facility and presented Resident #188 with a photo of CNA #1, whom the resident confirmed. Following an interview with the Police detectives, CNA #1 was suspended, and their access to the building was revoked. - 01/06/2023, as an addendum, the facility received charge/conviction report from the Division of Criminal Justice Services with the following information as related to CNA #1. Charges included unlawful possession of personal identification information (3rd degree), identity theft (2nd degree), grand larceny (4th degree) and criminal possession of stolen property (4th degree). Review of the facility grievance logs dated from 9/01/2022 to 1/30/2023 did not include any interaction, complaints, or concerns reported by Resident #188, FM #1, or Police related to the misappropriation that occurred to Resident #188 from 09/2022 through 1/30/2023. Police Incident Report initiated 11/26/2022 at 12:43 PM documented video footage and pictures provided by the department store that showed the suspect (CNA #1) using the victim's (Resident #188's) credit card to purchase $47.28 worth of miscellaneous clothes. On 12/28/2022, Police showed the pictures of the suspect (CNA #1) who had used the credit card to Resident #188, and Resident #188 identified suspect as CNA #1. When asked if they gave permission for CNA #1 to use the credit card, Resident #188 said no. The 11/26/2022 12:43 PM police incident report witness statement by Resident #188 detailed all prior incidents of fraud from their four separate credit cards. FM #1 stated they sent an email containing the reports of money missing from Resident #188's checking account in a digital document. During an interview on 10/05/23 at 9:26 AM, Resident #188 stated CNA #1 regularly took care of them as their regular aide. Resident #188 stated they found CNA #1 and #2 to be nice and thought the three of them were friends. Resident #188 stated that on 11/26/2022, their credit card was found to have unauthorized charges on it by FM #1. The FM #1 came to the facility and with the help of the DSW #1, a search for the resident's credit card was conducted. They were unable to locate the card and FM #1 called the Police. The resident had three prior occasions starting in September 2022 where charges were made to their credit card, for thousands of dollars but didn't believe it was staff. The resident started to notice CNA #1 and CNA #2 would distract them bringing the resident out of the room and one or the other would go back to the room and if the resident asked to go back to the room, they would create a reason why they couldn't go back. Once Resident #188 believed it was the two CNAs who had befriended and cared for them that were responsible for the misappropriation, they reported this to the DSW, DON #1, and the Registered Nurse Unit Manager (RNUM) #1. Resident #188 stated nothing was done until four days later when family requested CNA #1 and #2 be removed from care of Resident #188 because they weren't comfortable with the CNAs caring for the resident. Resident #188 stated they continued to be anxious and was reluctant to discuss the incident because they didn't want to get anyone in trouble. Resident #188 stated they felt bad and guilty about reporting the incident, and they felt the facility made them feel that they were the one at fault for the incident by not always locking up their belongings in their room. Resident #188 stated CNA #1 remained in the facility for a month until Police finished their investigation. Resident #188 further stated they identified CNA #1 after a video of the CNA #1, wearing a facility uniform, and using Resident #188's credit card was presented to the resident for identification. Resident #188 stated they knew something was wrong because large amounts of nursing clothing had been purchased. Resident #188 stated at no time did they ever give anyone permission to use their credit card. Resident #188 stated DSW #1 was present when Police had Resident #188 identify who was using their credit card, and that they identified CNA #1 as the person they had reported as involved in the misappropriation of their card a month earlier. During an observation/interview on 10/05/23 at 09:26 AM, Resident #188 was observed lying in their bed watching television. Resident #188 stated they felt conflicted about having to identify CNA #1 to the Police and had residual feelings of guilt. Resident #188 stated they were informed CNA #1 still had family that worked at the facility, and Resident #188 felt badly that they, themselves, were affecting an entire family. Resident #188 stated they felt betrayed because all along they were being lied to and stolen from by staff including CNA #1. During an interview on 10/04/2023 at 3:25 PM, the Registered Nurse - Quality Assurance (RNQA) #1 stated that around Thanksgiving in 2022, Resident #188's FM #1 reported they believed the resident's credit card had been hacked. FM #1 searched the resident's room, and when the card was not found, they called the police. After the police were called, the facility did nothing further related to this matter. No investigation or interviews were performed, and the facility did not report the incident to the New York State Department of Health (NYSDOH) until 12/28/2022. RNQA #1 further stated the facility did not follow up on these things the way they should have, and stated that they were not sure if Resident #188 had suffered any harm because RNQA #1 compiled the report from a review of the Don #1 facility-reported-incident submission to NYSDOH on 12/28/2022. RNQA #1 stated they did not have any firsthand knowledge of the incident and that no corrective actions for the resident's psychosocial well-being was conducted. During an interview on 10/04/2023 at 4:00 PM, DSW #1 stated the facility was first made aware of the incident on 11/26/2022, and that Resident #188 credit card had been missing. FM #1 and DSW #1 searched the room on 11/26/2022. When the credit card was unable to be located, FM #1 called the police. DSW #1 stated they did not assess the resident or update Resident #188's care plan when they became aware of the allegation. DSW #1 stated they believed the incident required no additional action by the facility. DSW #1 stated there were no case notes or updates to Resident #188's care plan from 11/26/2022 to 12/28/2022. During an interview on 10/4/2023 at 5:36 PM, DON #1 stated family member of Resident #188 contacted Police on 11/26/2022 concerning the missing credit card, and once that was done, no further follow up with Resident #188 was done by the facility. DON #1 stated CNA #1 and CNA #2 had been assigned to other units in the facility on 11/30/2022 and were not removed from resident care. DON #1 further stated CNA #1 and #2 were reassigned to work on all other units in the facility, except Resident #188's unit. DON #1 stated CNA #2 never returned to work after being reassigned, but CNA #1 continued to work at the facility caring for other residents throughout the building until Police finished their investigation and CNA #1 was arrested. DON #1 stated CNA #1 was suspended and access to the building was restricted. During an interview on 10/05/2023 at 9:35 AM, RNUM #1 stated they did not investigate the allegation of abuse concerning Resident #188's missing credit card. RNUM #1 was aware there had been issues with the resident credit card but until CNA #1 and CNA #2 were moved off the unit RNUM #1 stated they hadn't spoken with the resident. RNUM #1 stated they believed they had a conversation with FM #1, and once the staff was removed, RNUM #1 didn't get involved. RNUM #1 stated the police had been notified and they were told facility's legal unit was handling the matter. RNUM #1 stated CNA #1 and #2 were moved off the unit where Resident #188 resided. RNUM #1 stated they had no reason to follow up on the incident and did not check with anyone at the facility to see if it was being investigated or if it had been reported. During a telephone interview on 10/05/2023 at 4:00 PM, Police Detective #1 stated they responded to the facility 11/26/2022 and met with Resident #188 who reported a stolen credit card. The resident believed staff were involved and named two CNAs at the facility they believed were responsible for the misappropriation. DSW #1 and FM #1 were present at the time of the interview. Later it was determined by using video, CNA #1 was observed at a store using the residents credit card. When it was determined CNA #1 was involved the detectives returned to the facility and the resident was shown a picture of the suspect. The resident made a positive identification, and the suspect was identified as CNA #1. The detectives met with Administrator #2 and reported the findings to the facility. CNA #1 was arrested and charged with a Felony and three other charges. CNA #2 was not interviewed by Police Detective #1 and had left the faciity on [DATE]. Police Detective #1 stated attempts to reach or interview CNA #2 were not successful. During a telephone interview on 10/06/2023 at 9:04 AM, the Medical Director (MD), stated they were not aware of the issues Resident #188 reported to Psychology in December 2022 and January 2023; that these would be reported to the attending physician's attention and be reported to them if they believed there was a concern. The attending physician or nurse practitioner also attended Resident #188's care conferences. During a telephone interview on 10/06/2023 at 10:00 AM, Psychologist #1 stated they were familiar with Resident #188. Psychologist #1 had been contacted by the social worker in January 2023 to come see Resident #188, but by the time Resident #188 was seen, it appeared to be resolved. There were two people involved and the Resident #188 stated the people had been arrested. Psychologist #1 stated that usually the nurse manager or social worker would relay any concerns to the psychologist. Psychologist #1 stated that initially Resident #188 believed it was an online [NAME] but then it was discovered staff took the credit card and the facility had not made Psychologist #1 aware of the gravity of the issue. Psychologist #1 stated that they guessed Resident #188 had reported that their card was stolen for the second time but Psychologist #1 would have addressed it earlier had they known credit card misappropriation had occurred four times. Psychologist #1 further stated Resident #188 had good cognition, could manage their credit cards, and Psychologist #1 never had concerns about Resident #188 managing their own money. Psychologist #1 stated they were not briefed by the facility about any of the allegations, incidents, or misappropriation. Psychologist #1 stated that had they known, they would have worked to protect Resident #188. Psychologist #1 further stated it would have been important for them to know about this when it happened as it would have helped them understand Resident #188's issues with trust and anxiety. Psychologist #1 stated that if they were aware of staff involvement, they would have addressed the issues that staff had exploited the resident, even if the staff were no longer caring for Resident #188 directly. Psychologist #1 stated the social worker contacted them on the morning of 10/06/2023 and wanted them to see Resident #188 because they were distressed. Psychologist #1 stated Resident #188 declined to meet with Psychologist #1 on 10/03/2023 and was going to try to see them 10/06/2023 in the afternoon. Psychologist #1 stated it would have been important for them to know back in November 2022 these details of the incidents so they could have addressed any concerns, anxiety or emotions Resident #188 may have been experiencing. Psychologist #1 stated usually the social worker brings concerns to them. Psychologist #1 stated that the facility had their phone number, email, and that they visited the facility two days a week. Psychologist #1 further stated there was no barrier to the facility getting in touch with Psychologist #1, and that Psychologist #1 reviewed the Medical Doctor's notes before seeing a resident, but most of the communication came from the social worker or the nurse manager. Psychologist #1 further stated medical issues were communicated to the nurse manager and psychosocial issues were communicated to the social worker. During an interview on 10/10/2023 at 2:10 PM, DSW #1 stated the interview with Resident #188 conducted on 10/05/2023 demonstrated continued anxiety and fear over the credit card theft that occurred in November 2022. DSW #1 stated Resident #188 stated bringing the matter up again caused them increased anxiety, and when DSW #1 was talking with Resident #188, sometimes the sunflowers would hit the window and the noise of it would jolt the resident. DSW #1 further stated that Resident #188's reaction prompted them to assure the resident that the building was safe, and security monitored who enters and leaves the building. DSW #1 stated they did not document the day the credit card was reported missing because Resident #188 was with their family. DSW #1 stated they were with Resident #188 when the Police showed the resident the picture of the person to identify. DSW #1 further stated they had met with the resident several times and it was DSW #1's error that they didn't document on it. DSW #1 stated their thought process was that Police were involved and the matter was out of their hands. DSW #1 stated the resident had been significantly affected by this, and they should have spoken to the psychologist sooner. 10 NYCRR 415.4(b)(1)(i)

Based on observations, interviews, and record reviews conducted during the recertification and abbreviated survey (Case #NY00307728) from 9/28/2023 to 10/10/2023, the facility did not ensure each resident was free from misappropriation of resident property and exploitation for 1 (Resident #188) of 14 residents reviewed. Specifically, the facility did not ensure that staff did not make unauthorized purchases on Resident #188's credit cards and did not take appropriate action to resolve the misappropriation of Resident #188's personal property. This is evidenced by: A Policy and Procedure (P&P) titled Abuse Prohibition Program dated March 2021 documented the following: procedures were in place for screening and training employees, protection of residents and for the prevention, identification, investigation and reporting of abuse, neglect, mistreatment, and misappropriation of resident property to ensure that the facility was doing all that was within its control to prevent occurrences. The facility shall implement oversight procedures designed to facilitate the prevention of abuse, neglect, involuntary seclusion, misappropriation of resident property, and/or exploitation. The policy defined Misappropriation of Resident Property as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings, or money without the resident's consent. The policy defined Exploitation as the act of taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats or coercion. Resident #188: Resident #188 was admitted to the facility with diagnoses of major depression, morbid obesity, and atrial fibrillation. The Minimum Data Set (MDS - an assessment tool) dated 11/14/2022 documented the resident was able to make themselves understood, understand others, and was cognitively intact. Resident #188 lived in a private room and had their credit card located in their drawer with a lock. The Quality Assurance (QA) Investigative Report dated 12/29/2022 documented the following: -11/26/2022, Family Member (FM) #1 informed the Director of Nursing (DON) #1 and Director of Social Work (DSW) #1 they believed the resident's credit card had been hacked. FM #1 searched the resident's room that day and was unable to locate the credit card. Police were notified, and they initiated their investigation. -11/30/2022, Resident #188 reported they believed Certified Nurse Aide (CNA) #1 and CNA #2 were responsible for the missing credit card. -12/28/2022, two Police detectives arrived at the facility and presented Resident #188 with a photo of CNA #1, whom the resident confirmed. Following an interview with the Police detectives, CNA #1 was suspended, and their access to the building was revoked. - 01/06/2023, as an addendum, the facility received charge/conviction report from the Division of Criminal Justice Services with the following information as related to CNA #1. Charges included unlawful possession of personal identification information (3rd degree), identity theft (2nd degree), grand larceny (4th degree) and criminal possession of stolen property (4th degree). Police Incident Report initiated 11/26/2022 at 12:43 PM documented video footage and pictures provided by the department store that showed the suspect (CNA #1) using the victim's (Resident #188's) credit card to purchase $47.28 worth of miscellaneous clothes. On 12/28/2022, Police showed the pictures of the suspect (CNA #1) who had used the credit card to Resident #188, and Resident #188 identified suspect as CNA #1. When asked if they gave permission for CNA #1 to use the credit card, Resident #188 said no. During an observation/interview on 10/05/23 at 09:26 AM, Resident #188 was lying in their bed watching television. The resident stated they felt conflicted about having to identify CNA #1 to the Police and had residual feelings of guilt. Resident #188 stated they were informed CNA #1 still had family that worked at the facility, and Resident #188 felt badly that they, themselves, were affecting an entire family. The resident also stated how they thought staff members were nice to them because they liked Resident #188. Resident #188 stated they felt betrayed because all along they were being lied to and stolen from by staff including CNA #1. During an interview on 10/04/2023 at 4:00 PM, DSW #1 stated the facility was first made aware of the incident on 11/26/2022, and that Resident #188 credit card had been missing. FM #1 and DSW #1 searched the room on 11/26/2022. When the credit card was unable to be located, FM #1 called the police. DSW #1 stated they did not assess the resident or update Resident #188's care plan when they became aware of the allegation. DSW #1 stated they did not initiate an investigation when they became aware of the allegation made by FM #1 on 11/26/2022 at the time of searching Resident #188's room. DSW #1 stated they had no proof that abuse, or misappropriation occurred. DSW #1 further stated they believed the allegation required no additional action by the facility because Police were investigating the matter. DSW #1 stated there were no case notes or updates to Resident #188's care plan from 11/26/2022 to 12/28/2022. During an interview on 10/4/2023 at 4:53 PM, FM #1 stated between 9/19/2022 and 9/30/2022, charges to Resident #188's credit card #1 were reported in the amount of $2,141.68. FM #1 cancelled credit card #1, and Resident #188 received credit card #2 shortly thereafter. FM #1 stated between 10/3/2022 and 10/07/2022, charges to Resident #188's credit card #2 totaling $2,506.17 were reported (these charges were electronic; the card was not swiped). Credit card #2 was cancelled and Credit card #3 was issued. FM #1 stated between 10/27/2022 and 10/28/2022, $206.00 of charges were accrued on Resident #188's credit card #3. The card was shut down immediately by FM #1, and Credit Card #4 was issued. When FM #1 was notified Credit Card #4 was being used without authorization and a purchase at a department store had occurred on 11/25/2022, FM #1 informed the facility of the unauthorized use and charges to the card on 11/26/2022. The DSW #1 and FM #1 searched Resident #188's room. The credit card was missing. The FM #1 stated initially they hadn't suspected staff but after the last charge in person for $46.85, it became clear that it was someone at the facility because large amounts of nursing gear had been purchased. FM #1 stated some of the money that was misappropriated from Resident #188's credit cards had been re-distributed to various mobile banking sites with no relation to the resident by way of electronic money transfers and in-person purchases. FM #1 stated that they asked the facility about the updates on the investigation. FM#1 further stated that CNA #1 was moved to another unit at FM #1's request. It was reported to FM #1 that on 12/28/2022, Police showed Resident #188 a picture of a person using the credit card at a local department store, and Resident #188 identified the person as CNA #1. During an interview on 10/05/2023 at 9:26 AM, Resident #188 stated that after the first time money went missing on the credit card, they thought their identity was stolen. Resident #188 stated by the fourth occurrence they reported their concerns to the Registered Nurse Unit Manager (RNUM) #1, DSW #1, and DON #1 after the card was missing on 11/26/2022. Police were notified after a room search done by the Director of Social Work (DSW) #1 and FM #1 determined the credit card was gone. Resident #188 stated Police were called and a police report was completed. Resident #188 stated they did not receive any updates from the facility regarding their credit card allegation, and CNA #1 remained in the facility for a month until Police finished their investigation. Resident #188 stated they told RNUM #1 when they found out that CNA #1 was still working at the facility and told RNUM #1 that they were uncomfortable. Resident #188 further stated that RNUM #1 told them that they understood but couldn't speak on it anymore because the matter was with the facility's the legal department. Resident #188 further stated the RNUM #1 informed her that never would have guessed CNA #1 had done it either. Resident #188 further stated they identified CNA #1 after a video of the CNA #1, wearing a facility uniform, and using Resident #188's credit card was presented to the resident for identification. Resident #188 stated they knew something was wrong because large amounts of nursing clothing had been purchased. Resident #188 stated at no time did they ever give anyone permission to use their credit card. Resident #188 stated DSW #1 was present when Police had Resident #188 identify who was using their credit card, and that they identified CNA #1 as the person they had reported as involved in the misappropriation of their card a month earlier. Resident #188 stated that Police informed them CNA #1 would be arrested and they would need to press charges. Resident #188 pressed charges against CNA #1 but still was unaware of the outcome for CNA #2 who had left the facility after Police were notified. During an interview on 10/05/2023 at 4:00 PM, Police Detective #1 stated two Police deputies responded to the facility and met with Resident #188 who reported a stolen credit card on 11/26/2022. The resident believed staff was involved and named two CNAs at the facility who they thought were responsible for the misappropriation. The DSW #1 and FM #1 were present at the time of the interview. Later it was determined by using video, CNA #1 was observed at a store using the credit card confirmed to be Resident #188's. When it was determined CNA #1 was involved, Police returned to the facility on [DATE] and the resident was shown a picture of the suspect. Police Detective further stated Resident #188 made a positive identification of the suspect as CNA #1. Police met with Administrator #2 and reported the findings to the facility. CNA #1 was arrested and charged with a Felony and three other charges. CNA #2 was not interviewed by Police Detective #1 and had left the faciity on [DATE]. Police Detective #1 stated attempts to reach or interview CNA #2 were not successful. 10NYCRR 415.4(b)

Based on observation, record review and interviews during the recertification survey and an abbreviated survey (Case #NY00307728) from 9/28/2023 to 10/10/2023, the facility did not ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including misappropriation of resident property, were reported immediately, but no later than 2 hours after the allegation was made for 1 (Resident # 188) of 4 residents reviewed for abuse. Specifically, the facility did not ensure Resident #188's allegation made on 11/30/2022 that Certified Nurse Aides (CNAs) #1 and #2 were involved in the unauthorized use of their credit card was reported in a timely manner to the New York State Department of Health (NYSDOH). This is evidenced by: Resident #188 Resident #188 was admitted to the facility with diagnoses of congestive heart failure (CHF), major depression, and morbid obesity. The Minimum Data Set (MDS - an assessment tool) dated 11/14/2022, documented the resident was able to make themselves understood, could understand others, and was cognitively intact. The policy and procedure (P&P) titled Abuse Prohibition Program, dated March 2021, documented incidents of suspected abuse, neglect, and misappropriation of resident property would be promptly reported to the NYSDOH. The Quality Assurance (QA) Investigative Report dated 12/29/2022 documented the following: -11/26/2022, Family Member (FM) #1 informed the Director of Nursing (DON) #1 and Director of Social Work (DSW) #1 they believed the resident's credit card had been hacked. FM #1 searched the resident's room that day and was unable to locate the credit card. Police were notified, and they initiated their investigation. -11/30/2022, Resident #188 reported they believed Certified Nurse Aide (CNA) #1 and CNA #2 were responsible for the missing credit card. -12/28/2022, two Police detectives arrived at the facility and presented Resident #188 with a photo of CNA #1, whom the resident confirmed. Following an interview with the Police detectives, CNA #1 was suspended, and their access to the building was revoked. - 01/06/2023, as an addendum, the facility received charge/conviction report from the Division of Criminal Justice Services with the following information as related to CNA #1. Charges included unlawful possession of personal identification information (3rd degree), identity theft (2nd degree), grand larceny (4th degree) and criminal possession of stolen property (4th degree). During an observation/interview on 10/05/23 at 09:26 AM, Resident #188 was lying in their bed watching television. The resident stated they felt conflicted about having to identify CNA #1 to the Police and had residual feelings of guilt. Resident #188 stated they were informed CNA #1 still had family that worked at the facility, and Resident #188 felt badly that they, themselves, were affecting an entire family. The resident also stated how they thought staff members were nice to them because they liked Resident #188. Resident #188 stated they felt betrayed because all along they were being lied to and stolen from by staff including CNA #1. During an interview on 10/04/2023 at 3:25 PM, the Registered Nurse - Quality Assurance (RNQA) #1 stated around Thanksgiving in 2022, Resident #188's daughter reported they believed the resident's credit card had been hacked. The daughter searched the resident's room, and when the card was not found, they called the police. After the police were called, the facility did nothing further related to this matter. They did not initiate an investigation, and did not report the incident to the NYSDOH until 12/28/2022. The facility did not follow up on these things the way they should have. During an interview on 10/06/2023 at 04:00 PM, the DSW stated the facility was aware of the unauthorized purchases on Resident #188's credit card in November 2022, and the resident's daughter had called the police. Although their duties did not include reporting facility incidents, they spoke with the DON a couple of times about this incident after it occurred in November 2022 and did not know why it had not been reported at the time. During an interview on 10/04/2023 at 05:35 PM, the DON stated they became aware of the concerns related to the misappropriation of Resident #188's credit card in November 2022. On 11/26/2022, Resident #188's family reported the credit card had been hacked, and they reported the incident to the police. A few days later, Resident #188 reported they believed CNA #1 and CNA #2 were responsible for their missing credit card. The DON stated there was a facility investigation at the time, but it was not documented anywhere. The incident was not reported to the NYSDOH until 12/28/2022, when police arrived at the facility and informed them of a criminal investigation related to misappropriation of Resident # 188's credit card involving CNA #1. During an interview on 10/06/2023 at 3:09 PM, Administrator #2 stated in November 2022, Resident #188's family reported someone may have been using the resident's credit card, and a staff member may have been involved. They and RNQA #2 met with CNA #1, and they denied any involvement in this incident, but they were not sure where the notes regarding that interview were since they were taken by RNQA #2, who no longer worked at the facility. 10 NYCRR 415.4(b)(2)

Based on observation, record review, and interviews during the recertification survey from [DATE] to [DATE], the facility did not ensure residents received respiratory care consistent with professional standards of practice and the comprehensive person-centered care plan for 1 (Resident #31) of 6 residents reviewed for respiratory care. Specifically, the facility did not ensure Resident #31 had a physician's order for the use of continuous oxygen therapy recieved via nasal cannula and did not ensure the comprehensive care plan (CCP) included interventions related to the use of oxygen between [DATE] - [DATE]. This is evidenced by: Resident #31: Resident #31 was admitted to the facility with diagnoses of obstructive sleep apnea, COVID-19, and generalized anxiety disorder. The Minimum Data Set (MDS - an assessment tool) dated [DATE] documented the resident was able to make themselves understood, able to understand others, and was cognitively intact. The policy and procedure (P&P) titled Oxygen Therapy dated ,d+[DATE] documented oxygen would be administered by physician order via oxygen cylinder or oxygen concentrator unit. The oxygen order must include type of administration (nasal cannula or face mask), number of liters per minute, humidified/non-humidified, continuous, or as needed (PRN) administration, indications for use, and specific parameters if the flow rate was determined by the resident's blood oxygen as determined by the pulse oximeter. The P&P titled Comprehensive Care Planning and Baseline CCP, dated ,d+[DATE], documented a CCP would be individualized for each resident/patient using a person-centered approach. All disciplines were responsible for reviewing the plan of care and documenting goals, interventions, monitoring notes and updating as needed. The comprehensive care plan (CCP), titled Altered Respiratory Status reviewed on [DATE], did not include documentation the resident used a nasal cannula for supplemental oxygen. A review of physician orders are as follows: - [DATE], documented apply oxygen 2 - 4 liters per minute (LPM) to maintain an oxygen saturation greater than 90% for 2 weeks. Call the provider if requiring greater than 2 LPM. The order was discontinued on [DATE]. - [DATE] - [DATE], the physician orders did not include an order for supplemental oxygen via nasal cannula. Progress notes dated [DATE] - [DATE] did not include documentation the resident was using a nasal cannula. During observations on: - [DATE] at 03:06 PM, the resident was using oxygen at 4 liter (L) via nasal cannula. - [DATE] at 10:35 AM, the resident was using oxygen at 4L via nasal cannula. - [DATE] at 09:59 AM, the resident was using oxygen at 4L via nasal cannula. - [DATE] at 12:20 PM, the resident was using oxygen at 4L via nasal cannula. During an interview on [DATE] at 09:59 AM, Resident #31 stated they had been using oxygen via nasal cannula continuously during the day over the past several days. During an interview on [DATE] at 12:44 PM, Licensed Practical Nurse (LPN) #2 stated residents needed to have a physician's order before they were put on continuous supplemental oxygen via nasal cannula. Orders consisted of the oxygen delivery device being used, which was typically a nasal cannula, the liter flow, and any parameters for monitoring the resident's oxygen level. When residents were on oxygen, it was normally checked at least once a shift and documented on the Medication Administration Record (MAR), and any concerns would be reported to the physician. Resident #31 was currently using 4L of oxygen via nasal cannula. There was no order for the oxygen, but there should have been. Residents using a nasal cannula should also have that documented in their care plan. During an interview on [DATE] at 12:57 PM, Registered Nurse Unit Manager (RNUM) #4 stated oxygen should not be used without a physician order. They were not sure why Resident #31 had oxygen in place without an order; they would look into it. During an interview on [DATE] at 08:45 AM, RNUM #4 stated facility policy regarding oxygen was that residents required a physician order with the type of administration device, number of liters per minute, whether the oxygen was continuous or PRN (PRN - as the need arises), indications for use, and parameters for use if necessary. RNUM #4 stated Resident #31 had an order for oxygen that expired on [DATE]; the order should have been renewed, but the Nurse Practitioner did not realize it expired and it was missed. RNUM #4 stated during the time the resident was receiving oxygen without an order, nursing could have potentially realized the resident was receiving oxygen and they were not documenting their oxygen levels on the MAR at least once a shift which could have possibly led to realizing there was no order for the oxygen. When a resident was on oxygen via nasal cannula, that should be part of their CCP. During an interview on [DATE] at 11:03 AM, the Director of Nursing (DON) #1 stated when residents were using oxygen via nasal cannula, they needed to have a physician's order. Residents who were using supplemental oxygen via nasal cannula should have had it included in their CCP. 10 NYCRR 415.12(k)(6)

Based on record review and interviews conducted during an abbreviated survey (Case #'s NY00283709 and NY00305004), the facility did not ensure each resident received adequate supervision to prevent accidents for 2 (Resident #'s 1 and #2) of 2 residents reviewed for accidents. Specifically, for Resident #1, who was non-ambulatory, was care planned as at risk for falls. Resident #1 had been restless, agitated, and was found attempting to transfer themselves. The facility did not ensure Resident #1 was provided with supervision to prevent falls on 9/19/2022. The resident was found lying on the floor in the lounge area with their face in a pool of blood. Subsequently, the resident was transferred to the hospital sustaining diagnoses of a right forehead laceration (a tear in the skin), a right orbital fracture (occurs when one or more of the bones around the eyeball break), a maxillary sinus (facial bone) fracture, a nose fracture, and a fracture to their right 5th finger. Resident #2, was non-ambulatory, and was care planned as a risk for falls due to confusion and gait balance problems. The facility did not ensure Resident #2 was provided with supervision to prevent falls on 6/22/2022 when the resident was found lying on the floor in the lounge area with a laceration on their head. Subsequently, Resident #2 was transferred to the hospital with a subsequent diagnosis of a fracture to the right humerus (upper arm bone). This resulted in actual harm to Resident #1 and #2 that was not immediate jeopardy. This was evidenced by: The Policy and Procedure (P&P) titled Fall Prevention Program documented it was the facility's policy to act in a proactive fashion to identify and assist those residents who may have the potential to be at risk for falls, to plan preventative strategies and facilitate as safe an environment as possible. The Policy and Procedure (P&P) titled Safety and Supervision of Residents stated the facility strives to make the environment as free from accident hazards as possible. Resident safety, supervision, and assistance to prevent accidents were facility-wide priorities. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Resident supervision was a core component of the systems approach to safety. Resident #1: Resident #1 was admitted to the facility with diagnoses of dementia, history of falling, and diabetes. The Minimum Data Set (MDS, an assessment tool) dated 9/15/2021, documented the resident could be understood and could usually understand with severe cognitive impairment for decisions of daily living. The Comprehensive Care Plan (CCP), for Limited Physical Mobility, initiated on 11/4/2018 and revised on 9/22/2021, documented the resident had limited physical mobility related to the disease process of dementia. The interventions in place included an alert that the resident was non-ambulatory, bed mobility with extensive 1-person assistance, transfers with extensive 1-person assistance with a mechanical lift (lift used to assist residents from a sitting position to a standing position) and gait belt. The CCP titled The resident is at risk for falls related to confusion, gait/balance problems, unaware of safety needs. initiated on 8/12/2018 and revised on 11/21/2022, documented interventions to include, but not limited to; place call light within reach and encouraging resident to use it as needed, bed in lowest position, bilateral landing mats on left and right side of bed, anticipate and meet the resident's needs. The Fall Risk assessment dated [DATE] documented Resident #1 with intermittent confusion. They have had 3 or more falls in the past 3 months. Resident #1 was chairbound and documented as non-ambulatory. The Fall Risk assessment dated [DATE] documented Resident #1 was disoriented to person, place, and time. They have had 3 or more falls in the past 3 months. Resident #1 was chairbound and documented as non-ambulatory. The facility's investigative report, dated 9/20/2021, documented, Resident #1 sustained a fall from their wheelchair on 9/19/2021 at 10:15 AM. They were lying on their face, in a pool of blood. There was a laceration on the resident's right eyebrow that measured 6 cm x 3 cm x 2 cm. The right eyebrow, nose, and laceration were bleeding profusely. In the investigative report, Registered Nurse Manager (RNM) #3 documented, they were called to the unit immediately. When they arrived, Resident #1 was lying face down on the floor with a large amount of blood in their hair and on the floor. Pressure and ice were applied to the laceration and nose. Medical Doctor (MD) #1 was called immediately because RNM #3 was unable to control the bleeding. Resident #1 denied hip pain, the right leg did appear somewhat rotated, as well as right 5th finger appeared slightly swollen. Certified Nurse Aide (CNA) #5's statement, dated 9/21/2021 at 8:00 AM, documented during morning care, Resident #1 was sitting on the side of the bed trying to get up. Resident #1 was washed, dressed, and sat in their wheelchair. At 10:00 AM, Resident #1 was in the lounge talking to other residents. After breakfast, Resident #1 was wandering around, in their wheelchair, trying to go into other resident rooms. Resident #1 was found in another resident's room just before attempting to transfer from their wheelchair into a straight chair. Resident #1 was restless and agitated and stated they wanted to get out of here. Resident #1 was taken back to the lounge area. CNA #5 and CNA #4 left the lounge area, to go and assist another resident when they heard the nurse calling for help. CNA # 5 went to check the lounge area and found the resident on the floor, lying face down on their stomach and face. They were bleeding. The CNA assignment sheets, for all three shifts on 9/19/2021, were reviewed. The CNA assignment sheet for the 11:00 PM- 7:00 AM shift documented a scheduled 1:1 supervision for an unidentified resident. The assignment sheet for 3:00 PM- 11:00 PM shift documented lounge monitors were assigned in 30-minute increments. The 7:00 AM-3:00 PM shift assignment sheet on 9/19/2021, did not document assigned lounge monitors for the lounge area. Resident #2: Resident #2 was admitted to the facility with diagnoses of right pelvic fracture, disorder of bone density and structure, and Alzheimer's Disease. The Minimum Data Set (MDS, an assessment tool) dated 6/15/2022, documented the resident could sometimes be understood and could sometimes understand others with severe cognition deficit for decisions of daily living. Resident #2 required extensive, two- person physical assistance with bed mobility, transfers, dressing, and toilet use, and was totally dependent with 1-person physical assist with locomotion on and off the nursing unit. The CCP for At Risk for Falls, dated 6/8/2022, documented Resident #2 at risk for falls due to confusion and gait/balance problems. The interventions included attempting to anticipate and meet the resident's needs, making sure the call light within reach and encourage the resident to use it for assistance as needed, bed in the lowest position, check to ensure resident's needs are met every 2-3 hours due to inability to understand how to use call bell even with prompt signs, encourage use of non-skid socks at all times including hour of sleep, ensure the resident is wearing appropriate footwear, landing mats on both sides of resident's bed, offer toileting and/or check and change every 2-3 hours, physical therapy (PT)/ occupational therapy (OT) to screen as needed, and Resident #2 to wear arm protectors at all times except during care. In the Health Status Note dated 6/8/2022 at 9:40 PM, written by Licensed Practical Nurse (LPN) #4 documented Resident #2 was admitted to the facility as a high fall risk. In the Health Status Note dated 6/9/2022 at 3:34 PM, written by LPN #5 documented on day 2 of admission, Resident #2 was alert and would yell out. They tried to get up and walk on their own. They were placed in the lounge area to be monitored. In an Incident Note, dated 6/22/2022 at 6:40 PM, written by Registered Nurse (RN) #4 documented Resident #2 was found lying on the floor, in the lounge area, on their right side. Resident #2 was in the fetal position (position where the back is curved, the head bowed, and the limbs are bent and drawn up to the torso) complaining of pain in their arm and shoulder. Resident #2 said I was trying to help people. The resident sustained 3 cm x 1 cm laceration on the back of their head. A Health Status Note dated 6/23/2022 at 2:14 AM, RN #5 documented Resident #2 sustained a fracture to the right humerus (upper arm bone) per hospital documentation. The facility's Investigative Report, dated 6/23/2022, documented that on 6/22/2022 at 5:45 PM, Resident #2 sustained an unwitnessed fall in the lounge, their right shoulder and clavicle were deformed, and they were in pain. Resident #2 also had a laceration to the back of their head, they were sent to the emergency room (ER), and subsequently diagnosed with a non-displaced right humerus fracture. The Investigation Statement, dated 6/22/2022 at 6:08 pm, written by LPN #3, documented they saw Resident #2 just prior to the fall sitting in a chair in the lounge area. LPN #3 heard someone yelling for help and stated they hurried and ran to the area. They observed Resident #2 already lying on the floor with their right-side arm bent backwards. An untimed statement by RNS #1 dated 6/23/2022, documented they were called to the lounge. Resident #2 was laying on the floor on their right side. They were in the fetal position complaining of pain in their arm and shoulder. When asked what happened, the resident stated they were trying to help people. The resident had a 3 cm x 1 cm size laceration on the back of their head. Further review of the facility investigation documented Resident #2 was noted to have stood unassisted, in the lounge area, took a few steps and fell . There was no documented evidence a CNA was assigned to the Lounge Monitor CNA Assignment Sheet on 6/22/2022 for 7:00 AM- 3:00 PM and 3:00 PM - 11:00 PM shifts. Interviews: During an interview on 12/20/2022 at 4:43 PM, CNA #2 stated residents in the lounge area were supervised in 30-minute increments. CNA #2 stated there was no schedule for who was supervising and when. They stated it was discussed among the CNA staff and they did not document the supervision. CNA #2 stated supervision was not logged or documented. During an interview on 12/21/2022 at 10:25 AM, LPN #1 stated that residents in the lounge area are supervised in 30-minute increments and was documented on the unit assignment sheet. The assignment sheets are kept for a long time in case something needs to be verified and they are collected by the night supervisor and stored in a file cabinet. During an interview on 12/21/2022 at 10:45 AM, CNA #4 stated that the residents in the lounge area were monitored and supervised by a CNA assigned to the lounge area during that time. CNA #4 stated there was an assignment sheet that documents who was assigned and when. The CNA #4 was assigned to the lounge area at the time of interview. The assignment sheet breaks the assignment down into 30-minute increments. CNA #4 reviewed the assignment sheet and stated how the assignments were read, they pointed out that they were assigned to the lounge area from 10:30 AM to 11:00 AM. CNA #4 stated that they periodically round on all residents to see if they need anything, if the resident was non-ambulatory, they round more frequently on the resident. When there were changes and updates to a resident's care plan, they were communicated to the CNAs during the shift change meetings and then an updated care plan was placed behind the door in the resident's room. During an interview on 12/21/2022 at 3:35 PM, the Director of Nursing (DON) reviewed the unit assignment sheets but could not confirm if there was supervision in the lounge area, on 9/19/2021. The DON stated there was not always supervision available. The DON also stated the facility had cameras, in every lounge area, that were monitored by security. They would call the unit or overhead page the unit if they think there may be potential for a resident to harm themselves. During an interview on 12/21/2022 at 4:15 PM, RN #2 stated that supervision in the lounge area was done in 30-45-minute increments, but it was not always available. RN #2 stated when supervision was not available, the staff should be doing safety checks every 30-45 minutes. During an interview on 12/22/2022 at 3:30 PM, Licensed Practical Nurse (LPN) #2 stated they were floated to the [NAME] (nursing unit where Resident #1 resided) that day, to help with medications. Resident #1 was seated in the lounge area, and administered Resident #1 their medication. LPN #2 stated they left the unit and when they came back, RNM #3 was working on the resident. LPN #2 stated there was supposed to be supervision in the lounge area at all times. The CNAs are assigned 30 minutes increments on the assignment sheet. LPN #2 stated there were 3 CNAs on the unit that day and CNA #5 was the CNA that was supposed to be supervising the area when they left the unit. During an interview on 12/22/2022 at 4:15 PM, RNM #3 stated they were called to the [NAME] unit. When they got there, Resident #1 was laying on their stomach, on the floor, and in a lot of blood. Stated they checked the vital signs and stabilized the resident. There was a considerable amount of bleeding. RNM #3 stated that they checked for fractures, and the fingers on the resident's right hand appeared injured. The RNM #3 stated CNA #5 was assigned to monitor the lounge and had walked away from the lounge because a call light was on. They stated the lounge was supposed to be supervised at all times, if there were enough staff available and if there were not enough staff, then they can't supervise the lounge area. During an interview on 1/18/2023 at 3:43 PM, the Medical Director (MD) stated they were not familiar with Resident #1 because they don't treat the residents. The MD stated they were only in the facility for administrative purposes. They stated the only information they had on Resident #1 was that the resident fell in the lounge, had facial fractures, and a fractured pinky. The MD also stated they were not familiar with Resident #2. The lounges were monitored by security, the nurse managers office, and staff. The MD stated the lounge was not monitored on a 24-hour basis. The nurse managers were not always in their offices and were also on the floors doing walk-throughs. The MD stated security cameras were monitored by the security guards who would call the nurse supervisors when they see a potential problem. During an interview on 1/18/2023 at 2:14 PM, the Administrator (ADM) stated that they were not familiar with Resident #1 or Resident #2. The ADM stated there was no way they can have designated monitors to supervise the lounge area. The nurse managers can see through the windows in their office, security monitors the lounge areas through the camera system and staff walk through the area periodically. The administrator stated for non-ambulatory resident's, the facility is a restraint- free environment. The residents are reminded to ask for help. We cannot put fifty people on 1:1 supervision. During a subsequent interview on 1/19/2023 at 3:40 PM, the DON stated that the care plans were reviewed quarterly by the nurse manager, Interdisciplinary Team (IDT), or Quality Assurance (QA), depending on the situation. In order to identify interventions that are suitable for each resident, they look at the situation or incident that occurred and discuss it during the morning meeting. The DON stated, that when care-planned interventions were updated, a report was given from shift to shift and when the Kardex (CNA Care Plan) was updated. The DON stated that fall assessments were conducted on admission, quarterly, on every fall, and with significant changes. The Nurse Manager conducts the fall assessments, and the RN will conduct an assessment during fall incidents and updates the interventions in the care plan. During an interview on 2/3/2023 at 2:05 PM, the Senior Security Guard, located at the front desk, stated that there are cameras throughout the facility. The screens are located at the front desk, and security was able to monitor the hallways and the lounge areas. During an interview on 2/6/2023 at 9:31 AM, the Security Guard Manager (SM), stated there are cameras in the lounge area. There was at least one security guard at the front desk that can monitor the cameras. If an incident was witnessed on the camera, the security guard will complete a report and submit it to the security manager. The security manager confirmed, on 2/6/2023 at 11:01 AM, security did not submit a report for Resident #1's fall incident on 9/19/2021 and for Resident #2's fall incident on 6/22/2022. 10 NYCRR 415.12(h)(1)

Based on observations, interviews and record reviews conducted during the Recertification Survey, the facility did not ensure prompt efforts were made to resolve a grievance for 4 (Resident #'s 56, 143, 170, and #446) of 4 residents reviewed for grievances. Specifically, for Resident #'s 56, 143, 170, and #446, the facility did not ensure there was documented evidence that the resident's complaints that Resident #596 had entered their rooms during the night, startled them from their sleep, and was observed going through their personal belongings and for Resident #56, had left the room with resident #56's personal belongings, was acknowledged by the facility and that the facility was actively working toward providing resolution to their complaints. This is evidenced by the following: The Policy & Procedure titled Concern and Comment Guidelines dated 12/2016 documented; It is our policy to support, encourage and promote resident's rights including the right to an easy use and responsive grievance and suggestion procedure without fear of reprisal. To offer a method for the residents to voice suggestions, concerns, and comments in order to improve the quality of life and to make sure there is resolution. The Director of Social Work/Designee is deemed the facility's Grievance Officer. All verbal or written suggestions or grievances will be directed to the Grievance Officer for coordination and initial investigation. During the investigation, immediate action to prevent further potential violations of any resident right will be taken if warranted. The Concern and Comment/recommendation will be completed and entered into the log kept in the Social Work Department. The issue will be referred to the appropriate department for resolution. After completion by the designated department the form will be returned to the Grievance Officer for review and signature. Resident #56 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment) dated 4/9/2021, documented the resident's cognition was intact. Resident #143 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment) dated 5/7/2021, documented the resident's cognition was intact. Resident #170 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #446 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment) dated 6/23/2021 documented the resident's cognition was intact. Resident #596 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During observations on 6/23/2021, 6/24/2021, 6/25/2021, 6/28/2021, and 6/29/2021, Resident #596 was monitored by an Activity staff member and one or more of the nursing students assigned to the unit during the day shift in the dining room and activity area. During an interview on 06/23/2021 at 11:00 AM, Resident #143 stated they were frightened of Resident #596 who wandered and came into their room on the night shift. Resident #143 stated Resident #596 came in their room last night, 6/23/2021 at 3:00 AM. Resident #143 opened their eyes to see Resident #596 standing over them and looking down at Resident #143 lying in bed. Resident #143 reported the incident to staff but did not remember which staff member it was reported to. During a Resident Council Group Interview on 06/24/2021 at 10:40 AM, the following residents expressed concerns regarding Resident #596: Resident #56 stated Resident #596 came into their room at 4:00 AM and took personal belongings from the room. Resident #56 had to hide personal belongings because Resident #596 would wander in the room and take items that belonged to Resident #56. Resident #56 stated the staff were aware of this happening, but the staff had not done anything about Resident #596's wandering. Resident #170 and Resident #446 stated Resident #596 wandered into their room in the middle of the night. The staff were aware, and stated the staff were looking to transfer Resident #596 to another facility. Resident #170 was not aware of any interventions the facility put in place to stop Resident #596 from wandering in their rooms. During an interview on 06/29/2021 at 10:27 AM, Resident #446 stated they did not want to complain, but wanted the staff to know that Resident #596 was coming into their room at night. The resident stated it startled me when I woke up at 3:00 AM and there Resident #596 was, standing over me. The staff did not ask if I wanted to make a formal complaint. The resident did not remember what staff member it was reported to. The following progress notes were documented in Resident #596's medical record: -6/17/2021 at 4:09 AM, the resident was sitting in the wheelchair going in and out of other rooms earlier in the shift and was assisted back to bed. -6/17/2021 at 1:25 PM, the resident was out of bed to the wheelchair. The resident was wandering in and out of other residents' rooms and the writer attempted to redirect and resident became upset. - 6/17/2021 at 7:55 PM, the resident was confused and anxious since family left after visiting and was going into other residents' room agitating other residents. - 6/19/2021 3:55 PM, a nursing supervisor documented many residents were complaining on unit regarding Resident #596 being up all night and wandering in and out of their rooms startling them. The resident was confused and suffering from [CONDITION(S)], as noted, and documented by nursing staff. The Medical Doctor (MD) was updated regarding this and an order was obtained to increase [MEDICATION(S)] (most commonly used for [CONDITION(S)]) to 6 milligrams (mg) at HS (bedtime). - 6/23/2021 at 3:35 AM, the resident was sleeping on the start of shift, got up and was walking around, going in other residents' rooms, arguing with staff and residents, seeking exit doors. The note documented [MEDICATION(S)] (antianxiety) order complete. MD called and renewed order for 7 days, given at 1:00 AM with some effect. - 6/25/2021 at 3:16 PM, the Interdisciplinary Team (IDT) met for the resident's initial care conference. A resident representative attended, and nursing reported that the resident was medically stable, wandered and had picked up items that did not belong to the resident. During an interview on 06/24/2021 at 01:36 PM, the Director of Social Work (DSW) stated they had no written grievances for the last three months to show the survey team. The facility had not had any resident or family complaints in the last three months. During an interview on 06/25/2021 at 10:50 AM, Registered Nurse Supervisor (RNS) #2 stated one of the nurses brought to my attention that some of the residents had complained about Resident #596. The residents felt startled when Resident #596 came into their rooms. RNS #2 spoke with Resident #446 who told RNS #2 that they did not want to get Resident #596 in trouble, that Resident #596 woke them up in the middle of the night and had been startled that Resident #596 had entered their room. RNS #2 stated if there were only 1 or 2 residents complaining, the staff would use stop signs on the doors to prevent Resident #596 from going into the other resident rooms, but there were too many residents to use stop signs. RNS #2 was not aware of anything that was being done so far to stop the behavior of Resident #596, but the Physician and the Unit RN were made aware. If a resident had a complaint or grievance and wanted to speak to the RN Supervisor, the facility had a Quality Assurance (QA) document/statement form the staff could complete. RNS #2 stated we would ask the resident if they wanted the complaint to be formal or informal, if the resident chose an informal complaint then the staff did not fill out the QA form. If it was informal and something one of the staff could take care of the staff would take care of it without filling out a form. RNS #2 would not always document a complaint. During an interview on 06/28/2021 at 02:24 PM, the DSW stated grievances started with a complaint to a Registered Nurse Supervisor or unit nurse, they would ask the resident if they wanted to make a formal complaint. Grievances were formal and we address resident grievances when we get them. When staff are told of a resident concern, they ask the resident if they want to make it a formal complaint or keep it informal. If the complaint was informal and the staff member can handle it, they would fix it, then pass it on to Social Work. If the complaint was formal, the grievance form would be completed and sent to Social Work. Written grievances would normally come to morning report and would be discussed at the meeting. The DSW stated the complaints about Resident #596 should have been a written Grievance Report. If there was no written report the IDT may not know about a concern/complaint during morning report. If a nurse received an informal concern/complaint that nurse would report it to the next nurse. The DSW did not know how or where the nurse would document an informal concern/complaint. The DSW was only aware of Resident #446 making a complaint about Resident #596 but did not document it and had not spoken to Resident #446 about it. The DSW stated the Grievance Process had been done this way since the DSW started working for the facility in 2017. The complaints about Resident #596 by other residents were something the IDT should have been aware of. The DSW stated missing items reports were filled in for everything that was reported missing and then forwarded to the Social Work. The DSW was not aware of Resident #56's missing items. The DSW stated when residents, who resided on the same unit as Resident #596, reported a personal item was missing, DSW would check Resident #596's room first. The DSW stated that recently, a cell phone was reported missing by a resident and the DSW found it in the room of Resident #596. During an interview on 06/28/2021 at 2:59 PM, RNS #1 stated RNS #1 was not aware residents were complaining about Resident #596 until Thursday 6/22/2021. There should have been a meeting to discuss the complaints and what could be done to prevent the problem. Staff would redirect the resident as needed, but RNS #1 was not aware of any other interventions. During an interview on 06/29/2021 at 10:15 AM, Certified Nursing Assistant (CNA) #3 stated if a resident complained about anything the staff listened to the resident, then reported what the resident told them to the Nurse Manager or other nurse. The CNA stated that CNA's did not write on any forms for resident complaints, but CNA's let a nurse know and the nurse would deal with whatever the problem was. If a resident was wandering in other rooms, the CNA's would redirect the resident out of the room. CNA #3 stated Resident #596 tried to go into Resident #170's room this morning and CNA #3 stopped the resident from going in. During an interview on 06/29/2021 at 10:30 AM, CNA #2 stated if a resident made a complaint CNA's would tell the nurse about it and the nurse would talk to the resident. The CNA was not sure what was done after that. CNA #2 stated the staff saw Resident #596 wandering and going in and out of other residents' rooms. The staff redirected residents when they saw them entering other residents' room. The CNA stated for missing items the process was the same and they would let the nurse know and the nurse would take care of it. During an interview on 06/29/2021 at 11:31 AM, the Director of Nursing (DON) stated the DON was not aware of the residents' complaints about Resident #596 and would have wanted to know what had been going on. The DON stated the DON would have fixed it. The DON stated last night the DON and Social Worker put victim care plans in place for those residents who complained about Resident #596's wandering and put stop signs on their doors to prevent Resident #596 from entering their rooms. If DON was aware of a complaint, there would be a conversation with the resident who complained to see if anything could have been done to fix it. If a resident complained that someone was coming into their room, the DON would ask if they felt safe, would offer to do a formal complaint, would ask if they would like a room change and the DON would investigate the complaint. The DON was not aware of missing items being found in Resident #596's room, including the missing cell phone. The DON stated that when an item is reported missing, they begin a search for that item immediately. The DON stated that listening to and addressing a resident's concern is always the best practice. During an interview on 06/29/2021 at 11:46 AM, the Administrator (Adm) stated the Adm was aware of the resident's wandering and that staff had been redirecting Resident #596. The Adm stated grievance forms were on every unit and the staff were educated on the Grievance Process. The Adm stated the Adm would have to speak to those involved in the complaint process to determine what had transpired. 10NYCRR 415.3(c)(1)(ii)

Based on observation, record review and interviews conducted during the recertification survey, the facility did not ensure the development and implementation of comprehensive person-centered care plans (CCP's), that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs, for 6 (Residents #48, 53, 57, 102, 156, and 183) of 35 residents reviewed. Specifically: for Residents #48 and 57, the facility did not ensure a care plan was developed to address the resident's needs related to the use of psychoactive medications; for Resident #53, the facility did not ensure a care plan was in place to address that the resident was performing catheter care; for Resident #102, the facility did not ensure measurable objectives and interventions were included in the care plan that addressed the resident's hoarding of perishable food items; for Resident #156, the facility did not ensure that care plan interventions for constant observation was implemented for a resident who wanders off the unit; and for Resident #183, the facility did not ensure that a comprehensive care plan was developed that addressed transmission-based precautions. This is evidenced by: Resident #48: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had moderately impaired cognition, could understand others and could make self understood. A physician order [REDACTED]. A physician order [REDACTED]. A physician order [REDACTED]. During a record review on 04/24/19 at 01:10 PM, the comprehensive care plan did not address the use of [MEDICAL CONDITION] medications. Resident #57: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], assessed the resident could understand, make self understood, and had intact cognitive skills. A physician's orders [REDACTED]. During an interview on 4/29/19 at 10:09 AM, the Nursing Supervisor reported there was no care plan for anxiety or for the use of psychoactive medications and there should be. During an interview on 4/29/19 at 11:49 PM, the Director of Nursing reported, any resident that is on psychoactive meds should have a care plan to address their needs related to medication use. Resident #183: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severe cognitive impairment, could usually understand others and could usually make herself understood. An observation on 4/23/18 at 10:51 AM, a Contact Precautions sign was noted posted outside of the resident's room. A physician order [REDACTED]. During a record review on 4/25/19 at 11:36 AM, the comprehensive care plan did not include documentation that addressed transmission-based precautions for MDRO. During an interview on 4/29/19 at 2:42 PM, the Assistant Director of Nursing stated the resident was on contact precautions for MDRO in her urine and there should be a care plan in place that addressed contact precautions. 10 NYCRR 514.11(c)(1)

Based on record review and interview during a recertification survey, the facility did not ensure that before it transferred a resident to a hospital or the resident goes on therapeutic leave, the nursing facility provided written information to the resident or resident representative that specified the duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility, for 1 (Residents #175) of 2 residents reviewed for hospitalization . Specifically, the facility did not ensure there was documented evidence that the resident and the resident's representatives were notified in writing of the bed hold policy when the residents were admitted to the hospital. This is evidenced by the following: Resident #175: The resident was admitted to the nursing home on 9/18/17 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having intact cognitive skills for daily decision making. It documented that the resident understood and was understood by others. The Facility Hospital Transfer forms dated 1/22/19, 2/15/19, 3/15/19, and 3/22/19, documented that the resident was transferred to the hospital. During an interview on 4/25/19 at 12:12 PM, Registered Nurse Manager (RNM) #1 stated that when when a resident went to the hospital the nurse sending the resident, would fill out the transfer notice and give it to the Social Worker (SW). They did not do anything with the bed hold. During an interview on 4/25/19 at 1:54 PM, the SW stated she was not aware the bed hold policy notice had to be sent, so it was not being provided to the resident or the resident representative. 10NYCRR 415.3(h)(4)(i)(a)

Based on observation, interviews, and record reviews during a recertification survey, the facility did not ensure the assessment accurately reflected the resident's status for five (Resident #'s 22, 27, 52, 102, and #183) of thirty-five residents reviewed for accuracy of resident assessments. Specifically, for Resident #'s 22, 27 and #52, the facility did not ensure the Minimum Data Set (MDS) accurately reflected the residents' status related to the use of anticoagulant medication; for Resident #102, the facility did not ensure the MDS accurately reflected the resident's status related to locomotion on the unit; for Resident #183, the facility did not ensure the MDS accurately reflected the resident's status related to the use of antibiotics and a [DIAGNOSES REDACTED]. This is evidenced by: The Policy and Procedure titled RAI (Resident Assessment Instrument)- Completion of the RAI Process, last revised 08/2017, documented the facility would designate an employee(s) to serve as MDS Coordinator(s) to coordinate and oversee the RAI process and the department head for each department was responsible for ensuring that assessments were completed in a timely manner and according to procedure and the RAI manual. Resident #27: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had moderately impaired cognition, could understand others and could make self understood. The MDS documented the resident received an anticoagulant 7 out of 7 days during the look back period. The Centers for Medicare & Medicaid Services' RAI 3.0 Instruction Manual documented that antiplatelet medications such as aspirin/extended release, and [MEDICATION NAME] ([MEDICATION NAME]) were not to be coded as an anticogulant medication. A physician order [REDACTED]. A physician order [REDACTED]. The medical record did not include documentation that the resident received an anticoagulant medication during the 7 day look back period. During an interview on 04/29/19 at 09:38 AM, the MDS Coordinator #12 stated aspirin and [MEDICATION NAME] should not be coded as an anticoagulant. She stated it would be inaccurate to code aspirin or [MEDICATION NAME] as an anticoagulant on a resident's MDS. Resident #102: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident had moderately impaired cognition, could understand others and could make self understood. The Comprehensive Care Plan (CCP) for Activities of Daily Living (ADL), last updated on 3/13/19, documented the resident was independent with wheelchair mobility. The Certified Nursing Assistant (CNA) care card documented the resident was independent with wheelchair mobility. The MDS dated [DATE], documented the resident self-propelled his wheelchair independently in his room once or twice. The CCP for Activities of Daily Living (ADL), last updated on 3/13/19, documented the resident was independent with wheelchair mobility. The Certified Nursing Assistant (CNA) care card documented the resident was independent with wheelchair mobility. During an interview on 4/29/19 at 9:41 AM, Register Nurse Unit Manager #3 stated the resident self propelled independently in the wheelchair in his room daily, and should have been coded as independent instead of coding that the activity only occured once or twice. Resident #183: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident had severe cognitive impairment, could usually understand others and could usually make self understood. The MDS documented the resident did not have a urinary tract infection [MEDICAL CONDITION] over the 30 day look back period and did not receive an antibiotic medication during the 7 day look back period. A physician order [REDACTED]. The Medication Administration Record [REDACTED]. A nurse practitioner note dated 12/21/18, documented the urine culture results were obtained showing MRDO E-coli (multi-drug resistant organisms Escherichia coli) and will be treated with [MEDICATION NAME] for 3 weeks. During an interview on 04/29/19 at 09:38 AM, the MDS Coordinator #12 stated based on the look back period for the resident's MDS, it would not be accurate to document that the resident did not have a UTI if she was diagnosed with [REDACTED]. During an interview on 04/30/19 at 11:40 AM, the Director of MDS stated the resident's MDS dated [DATE] was coded inaccurately for antibiotic use and UTI diagnosis. She stated the MDS should have been coded for 2 days of antibiotic use and should have coded that the resident had a UTI. 10NYCRR415.11(b)

Based on observations, record review, and interviews during a recertification survey the facility did not ensure that services provided or arranged by the facility, as outlined by the comprehensive care plan, were provided by qualified persons in accordance with each resident's written plan of care, for one (Resident #163) of 2 residents reviewed for oxygen use. Specifically, the facility did not ensure that the liter flow of oxygen was set by staff who were qualified to do so. This is evidenced by: Resident #163: The resident was admitted to the nursing home on 3/28/19 with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having severely impaired cognitive skills for daily decision making. It documented that the resident understood and was understood by others. During an observation on 4/23/19 at 9:25 AM, Certified Nursing Assistant (CNA) #3 changed the oxygen (O2) tank for the resident. The CNA turned on the O2 liter flow and asked the resident if she could feel the O2 coming from the cannula. During an interview on 4/25/19 at 10:48 AM, CNA #3 stated that when the gauge on the O2 tank got into the red zone they will change the tank out. The amount of liters the resident was on was documented in the nurse's treatment book on the treatment cart. CNA #3 usually changed O2 tanks a couple times a week, and if he was floated to another unit, he would change the O2 tank, if that nurse wanted him to. During an interview on 04/25/19 at 11:14 AM, CNA #1 stated if a nurse was really busy they would ask the CNA to change an O2 tank for a resident, and they would. CNA #1 would find out how many liters to set the gauge at in the nurse's treatment book. During an interview on 4/25/19 at 12:07 PM, Registered Nurse Manager (RNM) #1 stated that only the nurses and Respiratory Therapists (RT's) were qualified to change oxygen and set the liter flow rate. She was not aware that the CNAs were doing that, and to her knowledge O2 was considered a medication and was a nursing responsibility. During an interview on 4/25/19 at 2:27 PM, the Director of Nursing stated that regulating the O2 was supposed to be done by a nurse or a RT. She was not aware until today that CNAs were changing the O2 and setting the liter flow rate. She stated that was out of their scope of practice. 10NYCRR 415.11(c)(3)(ii)

Based on record review and interviews during a recertification survey, the facility did not ensure that residents who required [MEDICAL TREATMENT] received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #81) of one resident reviewed for [MEDICAL TREATMENT]. Specifically, for Resident #81, the facility did not ensure the resident received ongoing assessments of their condition and monitoring for complications after [MEDICAL TREATMENT] treatments received at a certified [MEDICAL TREATMENT] facility and did not ensure that comprehensive care plans developed to address [MEDICAL TREATMENT], were person-centered and met the individual needs of the resident. This is evidenced by: Resident #81: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact, could understand others and could make self understood. The Policy and Procedure (P&P) titled [MEDICAL TREATMENT], last revised 9/2018, documented to monitor the resident's pre and post [MEDICAL TREATMENT] weights as recorded in the [MEDICAL TREATMENT] communication book or designated location; to observe the resident after returning from each [MEDICAL TREATMENT] treatment and document in the nursing progress notes their tolerance of the procedure, meals taken, dressing condition, and any other pertinent information as indicated; and to monitor for changes in mental status and report changes to the physician immediately. The Comprehensive Care Plan for [MEDICAL TREATMENT], last revised 3/15/19, documented the resident received [MEDICAL TREATMENT] (HD) related to end stage [MEDICAL CONDITIONS]. The interventions included to monitor vital signs per facility policy, and did not include the location and contact information for the [MEDICAL TREATMENT] center. The facility policy did not include a policy for obtaining or monitoring the resident's vital signs. Finding #1: The facility did not ensure the resident received ongoing assessments of their condition or monitoring for complications after [MEDICAL TREATMENT] treatments. The Weights and Vital Signs summary for the 22 [MEDICAL TREATMENT] days between 3/2/19 - 4/20/19 documented that vital signs were taken on 2 of the 22 [MEDICAL TREATMENT] days. Physician orders did not include an order for [REDACTED].>Nursing Progress Notes for 22 [MEDICAL TREATMENT] days from 3/02/19 to 4/20/19 did not include documentation of assessments for complications after [MEDICAL TREATMENT] treatments or monitoring of vital signs. The [MEDICAL TREATMENT] Communication Book dated from 3/02/19 to 4/20/19, did not include any written communication from the facility to the [MEDICAL TREATMENT] center and did not include an area for the facility to document an assessment or vital signs to communicate with the [MEDICAL TREATMENT] center. During an interview on 4/29/19 at 10:32 AM, Licensed Practical Nurse (LPN) #3 stated the [MEDICAL TREATMENT] center did vital signs on the resident after [MEDICAL TREATMENT]. She stated that nursing could write in the book to communicate with [MEDICAL TREATMENT] if the resident was having a [MEDICAL TREATMENT]-related issue. She stated nursing only monitored the resident's [MEDICAL TREATMENT] site but did not monitor vital signs before or after [MEDICAL TREATMENT]. During an interview on 4/29/19 at 2:43 PM, the Assistant Director of Nursing (ADON) stated the nursing staff documented when the resident was back in facility from [MEDICAL TREATMENT], but did not complete an assessment or take vital signs upon the resident's return. During an interview on 4/29/19 at 3:50 PM, the Director of Nursing (DON) stated it depended on the resident as to how much monitoring the facility did for a resident receiving [MEDICAL TREATMENT]. It was not the facility policy to take vital signs every time a resident returned from [MEDICAL TREATMENT]. She stated vital signs were taken once a month for all residents and that taking vital signs upon return from [MEDICAL TREATMENT] did not ensure the resident would not have a medical event a few hours later. The DON reviewed the current [MEDICAL TREATMENT] policy that did not address vital signs and stated she would take a better look at the [MEDICAL TREATMENT] policy now. Finding #2: The facility did not ensure the comprehensive care plan to address [MEDICAL TREATMENT] was person-centered and met the individual needs of the resident. The P&P titled Vital Signs, dated 5/2018 documented that all vital signs would be checked as per the physician orders and the order would include routine frequency and parameters if indicated and to document vital signs in the medical record. Physician order dated 6/18/18 documented the resident received [MEDICAL TREATMENT] at the [MEDICAL TREATMENT] center three times a week on Tuesday, Thursday, Saturday with a pick-up time at 3:00 PM, an appointment time at 4:00 PM, and a return time at 7:00 PM. Physician orders did not include an order for [REDACTED].>During an interview on 4/29/19 at 3:50 PM, the Director of Nursing (DON) stated vital signs were taken once a month for all residents and staff could refer to the vital sign policy if needed. During an interview on 4/30/19 at 8:59 AM, the Assistant Director of Nursing (ADON) stated the [MEDICAL TREATMENT] center location and contact information should be included in the physician orders and on the [MEDICAL TREATMENT] care plan. She reviewed the resident's orders and care plan and stated the information was not in either place, but should be. She stated she would update the order and care plan to include that information to make it easily accessible to staff. 10NYCRR 415.12

Based on record review and interviews during a recertification survey, the facility did not ensure that residents were free from unnecessary [MEDICAL CONDITION] medications for one (Resident #53) of five residents reviewed for [MEDICAL CONDITION] medications. Specifically, the facility did not ensure that the psychiatrist's recommended [MEDICAL CONDITION] medication reduction was implemented. This is evidenced by: Resident #53: The resident was admitted to the nursing home on 6/27/07, with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having intact cognitive skills for daily decision making. It documented that the resident understood and was understood by others. A physician (MD) order dated 2/22/19, documented the resident was to receive [MEDICATION NAME] (antipsychotic medication) 5 mg; give 2 tablets one time a day at 8:00 PM. A Psychiatric Periodic Evaluation dated 4/4/19, documented to decrease [MEDICATION NAME] dose to 5 mg once daily at night. The Medication Administration Record [REDACTED]. Review of physician orders did not include documentation of a physician order orders for the recommended decreased dose of [MEDICATION NAME]. During an interview on 4/25/19 at 11:40 AM, Registered Nurse Manager (RNM) #1 stated when a resident gets seen by the psychiatrist, the MD decides whether the recommendation would be followed by signing the consult. If the MD was not in agreement he would write his rationale at the bottom of the consult; whoever was in change at that time was supposed to implement the changes. RNM #1 stated the orders were missed. During an interview on 4/29/19 at 2:06 PM, the MD stated when staff got consults for his residents, he had them notify him immediately so he could implement the changes. This resident was followed by a healthcare service provider (named), so they would make the changes. During an interview on 4/29/19 at 2:25 PM, the Health Care Providers Nurse Practitioner stated that because the health care provider (named) followed this resident, the recommendations should have come to her to implement the recommended changes as she was there every day. When the psychiatry consult was received the nurse should have put it in the healthcare service provider (named) communication book for her to address, but that never happened. 10NYCRR 415.12(1)(2)(ii)

Based on observation, record review and interviews during the recertification survey, the facility did not ensure the facility stored, prepared, and distributed food in accordance with professional standards for food service safety. Specifically, the facility did not ensure equipment was clean and the chemical solution in the three compartment sink was maintained at the correct concentration. This is evidenced by: Finding #1 During an observation on 4/23/19 at 8:27 AM, the stove and side of the ovens were soiled with grease and debris. During an interview on 4/23/19 at 8:27 AM, the Food Service Director (FSD) stated the cooks were responsible for cleaning the stove and ovens, and the equipment should have been cleaned. Finding #2 A chemical sanitizer testing guide documented the concentration of the chemical sanitizer (Oasis 146 Multi-Squat Sanitizer) in the three compartment sink was to be between 150-400 parts per million (ppm) between 65-75 degrees Fahrenheit. During an observation on 4/23/19 at 8:56 AM, the sanitizer in the three compartment sink tested greater than 400 ppm after the temperature was confirmed to be in range with a calibrated thermometer. During an interview on 4/23/19 at 8:56 AM, the FSD stated the sanitizer should have been less than 400ppm, and it was over 400ppm. 10NYCRR415.14(h)

Based on record review and interview during the recertification survey, the facility did not ensure a policy was developed regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. Specifically, the facility did not ensure the policy included a process for assisting residents in accessing and consuming the food if a resident was unable to do so on his/her own and the facility did not provide information for family and visitors on safe food preparation and handling practices. This is evidenced by: A Policy and Procedure (P&P) titled Food Distribution to Residents documented for safety and sanitation purposes that families were encouraged to bring food that can be consumed in one setting and did not require storage. The P&P did not include safe food handling and storage practices, and did not include information regarding residents that can't access and consume foods on his/her own. During an interview on 4/29/19 at 1:45 PM, the Food Service Director (FSD) stated they encourage one time use of foods brought into the facility, and there were no additional policies for food brought in from home. 10 NYCRR 415.14(h)

Based on observations, record review, and interviews during a recertification survey and an abbreviated survey (Case #NY 737), the facility did not ensure that the residents environment remained as free of accident hazards as is possible; and each resident received adequate supervision and assistance devices to prevent accidents for three of eleven residents reviewed. Specifically, for two (Resident #'s 215 and 222 ) of eight residents reviewed for smoking, the facility did not ensure adequate supervision was provided to Resident #215, a supervised smoker, when the resident was found in the smoking area unsupervised and that the resident was assessed for Smoking Safety annually. Additionally, the facility did not ensure preventative measures were taken to prevent accident hazards after Resident #222 was found smoking in his room on 12/23/15. A smoking assessment was not completed until 1/4/16, a careplan to address smoking was not implemented until 2/16/16 and a behavior careplan for smoking in his room was not developed until 4/11/16. Also, the facility did not ensure the designated locked space for smoking materials remained locked. Additionally, the facility did not ensure that each resident receives adequate supervision to prevent accidents for one (Resident #229) of three (Resident #'s 229, 177 and #232) residents reviewed for accidents. Specifically, the facility did not provide adequate supervision for Resident #229 who wandered unsupervised (without 1 stand by guard (SBG) for ambulation, and 1 SBG for locomotion as documented on the resident's care plan and without contact guard (CG) for locomotion (ambulation) as documented on the care card ) on two occasions (2/19/16 at 8:00 pm and 11:50 pm) into the room of a resident (Resident #177) with a care plan for aggressive behaviors towards residents who enter his room. This resulted in a resident-to-resident physical altercation where Resident #229 fell and fractured her wrist. This is evidenced by: Finding #1 The facility did not ensure that the residents environment remained as free of accident hazards as is possible and that each resident received adequate supervision for two (Resident #'s 215 and 222) of eight residents reviewed for smoking. A facility Policy titled, Resident Smoke Program dated 8/7/14 documented that it was the policy of the facility to develop a program designed to assure those residents who smoked did so in a safe and prudent manner; an assessment would be completed by the Occupational Therapist (OT) or Registered Nurse (RN) on all residents upon admission, annually and with any significant change in condition, and that residents would be identified as being an independent or supervised smoker; nursing staff would establish a method of distribution to dispense smoking materials to those residents that require supervision while smoking; and Residents who required supervision while smoking would do so only in the line of site of a designated staff member and the only designated smoking area for residents was in the smoking room in the South lounge. Resident #215 The resident was admitted to the nursing home on 2/9/01 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as having moderately impaired cognitive skills for daily decision making. It documented that the resident usually understood and was usually understood by others. During an observation on 4/20/16 from 7:45 am - 9:20 am, the drawer that contained resident smoking materials had a lock that was in the locked position, holding the drawer ajar. The drawer was labeled, keep locked. Resident Smoking Safety Assessments (RSSA) dated 12/8/14 and 2/16/16 documented that the resident was to be a supervised smoker and should wear and an apron. There was no documented evidence of an assessment for 2015. A Comprehensive Care Plan (CCP) for Smoking dated 9/4/15 documented that the resident was to follow the supervised smoking policy and that the safety of the resident and others would be maintained. An undated CCP for Smoking documented that the resident was to have a complete smoking assessment annually, that he was a supervised smoker, that staff were to hold his smoking materials and that the residents' smoking times were the units scheduled times (10:00 am, 2:00 pm, 4:00 pm, and 7:00 pm). The Certified Nursing Assistant (CNA) Care Plan dated 2/24/16, documented that the resident wore a roam alert bracelet on the left wrist and was to be kept in a supervised area. A Nursing Progress note dated 4/17/16 at 10:00 pm documented that the resident left the unit without a staff escort for smoking and was brought back without incident. An Accident Incident Report form dated 4/17/16 at 6:50 pm, documented that the resident left the unit without supervision to smoking room, and the attached staff statement by the CNA who discovered the resident, documented that the resident was noted coming down the hall with no supervision and had taken cigarettes. It documented that the unit nurse was called. During an interview on 4/19/16 at 10:30 am, the Registered Nurse on the resident's unit stated that he was aware that the resident left the unit and that the resident could have followed someone on the elevator or at times the elevator worked without pushing a code. During an interview on 4/19/16 at 2:00 pm the CNA who found the resident stated that she was taking a smoker down to smoke and told the CNA monitoring the dining room that the resident was not to go down for a smoke at this time per his care plan. The CNA stated that she was down stairs a couple minutes and saw the resident coming down the hall without an escort to the smoking lounge. The CNA stated that the resident stole his cigarettes from the nursing station and brought them with him and that the resident came down the elevator and must have known the code. Additionally the CNA stated that because the resident wears a wandergard bracelet, security had to be called to alert them that his alarm was going to sound. During an interview on 4/21/16 at 1:20 pm the Registered Nurse Manager (RNM) stated that she was responsible for the care planning and that the care plan should have been dated and that OT was responsible for doing the smoking assessments. The RNM stated that when an incident happened the nurse on the unit or the supervisor was supposed to start the incident report and that during morning meeting the team went over the 24 hour reports and any Incident/Accident reports. During an interview on 4/21/16 at 1:20 pm the RNM stated that she was not aware until the DOH surveyor told her, that the resident went downstairs with cigarettes and that the elevator does not always need a code to use it. Additionally the RNM stated that Incident Reports are discussed at morning meeting that is attended by department heads. During an interview on 4/21/16 at 1:40 pm the OT stated that the smokers should have been reassessed yearly. During an interview on 4/21/16 at 2:00 pm the Licensed Practical Nurse (LPN) stated that she was aware that the resident went downstairs alone, but not that the resident had cigarettes. The LPN stated that the cigarettes and lighters are locked in the drawer and taken out by the nurse who had the keys. The LPN stated that sometimes there was a lighter available in the drawer and sometimes there was not. The LPN stated that she prepped the cigarettes ahead of time and kept them in her cart but that someone may have taken them out and left them at the nursing station, but that she did not do this because the resident was very impulsive and would take them. Resident #222 The resident was admitted to the nursing home on 12/22/15 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as having intact cognitive skills for daily decision making. It documented that the resident understood and was understood by others. The Admission Nursing Profile dated 12/22/15 at 10:45 am documented that the resident was a smoker but did not have any cigarettes to do an evaluation at that time. A Nursing Progress note dated 12/23/15 at 11:00 pm documented that 15 minute safety checks initiated due to the resident refusing to hand in cigarettes and lighter. A Nursing Progress note dated 12/24/15 at 7:00 am documented that at 6:15 am it was suspected that the resident was smoking in his room/bathroom, It documented a strong smell of cigarette smoke could be smelled all the way to the nursing station. The Nursing Supervisor was notified and security came to the unit and that the DON was notified. Resident Care Conference Notes dated 1/4/16 and signed by 5 members of the interdisciplinary team documented that the resident was very delusional related to his schizoaffective diagnosis, and that he had one incident of unsafe smoking but has since has abided by smoking policy. Resident Smoking Safety Assessments (RSSA) dated 1/4/16 (13 days after the resident was admitted ) documented that the resident demonstrated independent ability to manage smoking on this date and that nursing was aware. A CCP for Smoking dated 2/17/16 (56 days after the resident was admitted ) documented that staff were to hold his smoking materials. There was no documentation as to the resident smoking in his room or refusing to turn over his smoking materials. An evaluation dated 4/11/16 documented that the resident smoked only in designated areas. A CCP for Behavior dated 4/11/16 (3 ½ months after the incident) documented that the resident was smoking in his bathroom in January of 2016 (only documented incident was December 2015). It documented that smoking supplies to be left with staff. During an interview on 4/21/16 at 1:20 pm the RNM stated that she was responsible for the care planning and that the residents smoking care plan should have been put in place prior to 2/17/16. The RNM stated that during the quarterly care plan meetings the team will discuss areas that should be care planned and put them in place at that time. The RNM stated that when an incident happened the nurse on the unit starts the I&A and each shift the supervisor picks the incident reports up. The Quality Assurance Nurse (QAN) looks them over then will send an email if anything further was needed. During morning report the team goes over the 24 hour reports and any Incident/Accident reports. During an interview on 4/21/16 at 1:20 pm the RNM stated that she didn't know about the resident smoking in his room because she did not work here at the time. During an interview on 4/21/16 at 2:00 pm the LPN #1 stated that she did hear about the resident smoking in his room and thought it was because he was not reported as a smoker and had his own smoking materials so staff did not find out until the resident smoked. During an interview on 4/21/16 at 2:15 pm LPN #2 stated that she was aware of the incident but did not know the resident was a smoker prior to the incident. During an interview on 4/20/16 at 9:20 am the Registered Nurse Manager (RNM) stated that she did not know that the drawer was unlocked and that the medication nurses have the keys. When the RNM asked the Licensed Practical Nurse (LPN) and the Registered Medication Nurse (RMN), in close proximity to the DOH surveyor they both stated that they did not leave the drawer unlocked and the RMN told the NM that it must have been left unlocked by the night shift. Finding #2 The facility did not ensure that each resident receives adequate supervision to prevent accidents for one (Resident #229) of three (Resident #'s 229, 177 and #232) residents reviewed for accidents. Resident #229: The resident was admitted to the facility from home on 2/19/16, with a [DIAGNOSES REDACTED]. At the time of admission, the resident was assessed by the RN (registered nurse) as being alert and oriented to person only. A Comprehensive Care Plan (CCP) entitled Cognitive Loss dated 2/19/16, documented the resident has impaired cognition and exhibits: short term memory deficit, long term memory deficit, and impaired decision making ability. A Fall Risk Assessment completed by the RN on 2/19/16 at 2:50 pm, documented a score of 10, and documented in the assessment instructions, that if the score is above 10, the resident should be considered at potential risk of falls. A CCP entitled Falls, dated 2/19/16, documented the resident was at risk for falls or injury related to: confusion, unaware of safety needs/poor judgement, medications effecting blood pressure, psychoactive medications, and incontinence/urgency. A CCP entitled ADL's (activities of daily living) dated 2/19/16, documented SBG (standby guard) for transfer, 1 SBG for ambulation, and 1 SBG for locomotion. Additionally, transfer, ambulation, and locomotion were revised to supervision. The CCP revision did not include documentation of the date, time, initials, or the reason for the revisions. The Physical Therapy Recommendations to Nursing report dated 2/19/16, documented limited assist x1 for transfers and ambulation, and for other, documented, keep in monitored area. A CNA (Certified Nursing Assistant) Care Plan (instructions for resident's care) dated 2/19/16, documented the resident was cognitively impaired, a 1 person assist and contact guard for locomotion, and was a 1 person assist for transfers. The top of the CNA Care Plan documented keep in monitored area. Additionally, the box for up & about was marked, however, the box for enc. (encourage) to stay in monitored area was not marked. Review of the Nursing Progress Note dated 2/19/16 at 10:30 pm, written by LPN #4 (Licensed Practical Nurse), revealed the resident was a new admission, was alert, verbal, with confusion, and had difficulty following simple direction. The progress note documented the resident was out of bed and ambulating about hallway in and out of other's rooms. The progress notes also documented the resident redirects easily, is restless, does not stay in one spot long, continues to ambulate about the unit at this time, and constant redirecting at this time to keep from entering other resident's rooms. Review of the Accident/Incident (A&I) Form dated 2/19/16 at 11:50 pm, revealed that a staff member heard a thud and saw resident (#229) on the floor outside of Resident #177's room. Resident #177 stated, I threw her out. Resident #229 had complaint of severe pain in her right wrist, and there was swelling noted in the right wrist and forearm. The A&I documented the resident was a limited assist x1 for ambulation, and the root cause of the occurrence was documented as unpredictable behavior of another resident. The SBAR (situation, background, appearance, review and notify) Communication form from nursing to the physician dated 2/20/16 at 12:30 am, documented that the resident fell , had pain in the right arm/hand and was unable to move it, and the resident displayed non-verbal signs of pain documented as grimacing; stating It hurts so bad; guarding. Further review of the form revealed the physician ordered the resident to be sent to the emergency room for X-rays and appropriate treatment. The Nursing Home Transfer form dated 2/20/16 (no time), documented was knocked to the floor by another resident, the resident was alert and totally confused, and the resident was independent for ambulation and transfer. Review of a statement written by the RN Charge nurse on 2/20/16, regarding the resident-to-resident altercation on 2/19/16 with Resident #229 and #177, revealed that the resident (#229) stated He (Resident #177) pushed me down, at the time of the incident. A Nursing Progress Note dated 2/20/16 at 11:30 am, written by the Director of Nursing (DON) documented that a call was received from the resident's daughter informing the facility that the resident was discharged home with family and has a right wrist fracture. A Nursing Progress Note date 2/21/16 at 1:30 am, written by the Registered Nurse Supervisor (RNS) documented an addendum to 2/19/16 at 11:15 pm that included documentation that the resident was up and about, wandering up and down halls, going into other resident's rooms, easily re-directed, and made no attempts to leave the unit. Review of a statement dated 2/22/16, written by the Physical Therapist, regarding the resident-to-resident altercation on 2/19/16 with Resident #229 and #177, revealed the resident was screened by the Physical Therapist upon arrival to the facility to implement initial unit care plan status. The statement documented; It was recommended limited assist to be provided for transfers/ambulation until full PT (physical therapy) evaluation completed the following day. Given res (resident) demo (demonstration) of confusion and in new, unfamiliar environment - limited assist was recommended for maximal safety. The Investigative Report dated 2/23/16, documented that on 2/19/16 at 11:50 pm, the Charge RN who was at the nurses' desk, heard a thud and observed Resident #229 on the floor outside of Resident #177's room, and when staff went to investigate what happened, Resident #177 stated, I threw her out. The conclusion of the report documented, unwitnessed accident; the resident was found on the floor in front of Resident #177's room, staff heard a thud and responded. Resident #177: The resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented a Brief Interview for Mental Status of 8/15; moderate cognitive impairment. A CNA (Certified Nursing Assistant) Care Plan dated 12/27/15, documented I do not like residents in my room, try to keep them out. I can be aggressive when my space is invaded The CNA Care Plan documented under mentation I am confused. Additionally, an update on 12/30/15 documented Velcro stop sign at the doorway and an update on 2/6/16 documented tap bell to be on over bed table at bedside at all times to alert staff to residents entering his room. A CCP (Comprehensive Care Plan) entitled Mood & Psychosocial Wellbeing dated 1/13/16, documented little tolerance for others, and poor insight. One of the approaches/interventions was documented as tap bell available on over bed table to alert staff to resident entering room. Review of the CCP entitled Behavior dated 2/1/16, revealed documented clinical issues: resident has hx (history) of being aggressive, confrontational with other residents and documented behavioral triggers: other residents entering his room or what he perceives to be his interpersonal space. One of the approaches/interventions on the CCP documented tap bell available on the over bed table to alert staff to a resident entering his space. Review of the CCP entitled Psychotropic Medications dated 2/1/16, documented an approach/intervention of redirect resident if agitation is noted. Resident has history of needing his own private space. A CCP entitled Disruptive Behavior dated 2/2/16 and updated on 2/25/16, documented that the resident was involved in disruptive behavior physically or verbally to co-resident secondary to: poor reasoning skills. The CCP documented the resident was refusing to leave the mesh barrier on the door. Some of the approaches/interventions on the CCP included: resident will use tap bell to notify staff that a resident has entered his room, Q15 minute safety checks 7am-3pm & 3pm-11pm, Q 1 hr. safety checks 11pm-7am only, mesh barrier will remain across room doorway to deter wanderers from entering room, and door sensor placed on interior of doorway to alert for people entering and exiting room. A CCP entitled Aggressor rewritten on 2/3/16 documented a problem as physical aggression towards another resident. A CCP update dated 2/19/16, documented for evaluation not met- resident became aggressive with another resident. Review of an Acute Visit note dated 2/8/16, written by the NP (nurse practitioner), revealed a follow-up on the resident's threatening behavior. The note documented that the resident was minimizing and guarded, and he tends to deny things most of the time. It also documented for assessment, that the resident was recently involved in an altercation with other residents in the unit, and he easily reacts to negative situations related to his mild hypervigilance, and mild paranoia. Review of the Acute Visit note written by the NP on 2/18/16, revealed that it was a follow-up on the resident behavior that was documented as threatening, aggression, hypervigilance, and mild paranoia. Additionally, it documented that the resident continues to minimize his behaviors, and he is still guarded. An Accident and Incident Report (A&I) dated 2/19/16 at 11:50 pm, documented a resident-to-resident altercation. It documented that a staff member heard a thud down the hall and observed a female resident (#229) on the floor outside of Resident #177's room, and Resident #177 stated, I threw her out. Additionally, it documented had been in his room latter part of the shift. The root cause of the occurrence was documented as lack of control over impulsiveness, behavior. The resident was sent to the hospital ER (emergency room ) for evaluation of behavior. The SBAR Communication form dated 2/20/16 at 2:00 am, documented assaulted female resident and it was indicated on the form that this has occurred before this, several times. It documented pushed female resident to floor causing injury. Additionally, it documented the resident was calm shortly after the incident, does not understand the wrong doing of the situation, and insists he never hurt anyone. A Nursing Progress Note written by the RNS (Registered Nursing Supervisor) on 2/21/16 at 1:45 am, documented an addendum to 2/19/16 at 8:00 pm, that another resident had attempted to enter his room and he wanted staff assistance. The other resident was redirected, and the RNS praised the resident for his positive behavior, encouraging him to continue this way. Review of the Monthly Note dated 2/25/16, written by the NP (Nurse Practitioner), revealed the following treatment plan. The resident demonstrated increased periods of aggressive behaviors towards other residents and earlier in the month was evaluated by Psychiatry, and started on Depakote. The resident reportedly feels threatened in his personal space and as a result has lashed our aggressively at others, initially using his cane. A door mesh was put in place to discourage others from entering the resident's room in error, and a system was put in place where the resident would ring a bell, if his space was in jeopardy, and staff would respond to intervene. It was documented on 2/20/16, that a new resident with dementia reportedly wandered into the resident's room, the resident (#177) rang the bell, and staff responded and corrected the situation. Additionally it documented However, on the second occurrence, (Resident #177) assaulted the elderly female resident and she sustained a wrist fracture. During an interview on 3/2/16 at 9:45 am with PT (Physical Therapist) #1, she stated that limited assist x1 equals contact guard, which is using a gait belt with hands on the resident. She stated that she is not sure why keep in monitored area was written for Resident #229, but generally they would write that so the resident could be kept in an area so that he/she could be monitored. However, the resident always has a choice of where they want to be. After PT #1 reviewed Resident #229's CNA Care Plan and PT 's recommendations on 2/19/16, she stated The locomotion interventions are consistent with PT recommendations. During an interview on 3/2/16 at 10:55 am with OT (Occupational Therapy) #1, she stated that SBG (standby guard) and limited assist are the same. She stated that standby guard means that you need to be standing right next to the resident. She stated that the CCP for ADLs and the CNA Care Plan gets updated by PT. She stated that the PT recommendation is the initial recommendation before the evaluation. She stated that no PT evaluation was done. During an interview on 3/2/16 at 11:02 am, with the Director of PT, she stated that when the resident (#229) came into the facility, the therapist did a screen, and the resident was scheduled for a full evaluation the next day. She stated that contact guard means you have a hand on the person. She stated that the physical therapist who did the initial screen should have made the resident supervision with redirection as needed, because the resident did not have any balance issues. She stated that the therapist checks updated CCP on the PT recommendation, tells the nurse, and then the nurse writes it on the CNA Care Plan or the therapist does it, if the nurse is busy. She stated She fell because she was pushed by another resident, not because she had a balance issue. She stated Making her a contact guard is not what we usually do. During an interview on 3/2/16 at 11:08 am with OT #2, he stated that he saw Resident #229 in her room, she walked a few doors down and back, and then came back into the room. He stated that she was steady on her feet. He stated the family said she was a wandering risk, supervision was needed, and she was exit seeking. He stated there were no balance issues noted. During an interview on 3/2/16 at 11:37 am. with RN #2, he stated that keep in a monitored area means to keep the resident where there is an LPN, CNA, or other staff present, like the lounge, etc. During an interview on 3/2/16 at 11:40 am with LPN #4, she stated keep in a monitored area means to keep in area where they could be watched, and stated Need to keep your eyes on her. She stated that contact guard means hands on the resident, 1 assist; they need 1 person to help them ambulate. She stated that contact guard was not necessary for Resident #229. She stated that on the day of the incident she worked the 3pm - 11pm shift and stated the family was here until 8:00pm. She stated that from 8:00 pm - 1100 pm, she caught the resident wandering in and out of rooms while she was passing medications. She stated that she kept the resident with her as much as possible and reported to the night nurse that the resident was all over the place. LPN #4 stated If she went into his room, he definitely pushed her. When asked if Resident#177 knows how to use the tap bell, she stated He knows what he is doing. He's just a bully. During an interview on 3/2/16 at 12:55 pm, with the Social Worker (SW) #2, she stated that Resident #177 took the stop sign off his door and after that was given a tap bell. She stated that she talked to the resident about using the tap bell instead putting his hands on people. She stated the resident knows what he is doing. She stated that it was her understanding that he used it appropriately the first time, but wasn't sure about this time. She stated that when she interviewed Resident #177, he stated that Resident #229 wandered into his room twice, and stated he guided her out. She stated that although Resident #229 didn't need to be contact guard for ambulation because she was steady on her feet, the nursing staff should be following what is on the care card. When asked about monitoring the resident, SW #2 stated She should have been in their view at all times. During an interview on 3/2/16 at 1:33 pm with CNA #2, she stated that keep in monitored area means We need to see them, and points to her eyes. She stated that contact guard means that they need to be right next to the resident. During an interview on 3/2/16 at 1:33 pm, with Resident #177, he stated that Resident #229 came into his room three times. He stated that the first two times she left, and stated The third time, I gently took her by the arm to escort her out, she took a couple of steps and fell . She was a nuisance, that's all. When asked if Resident #229 said anything when she came into the room, he stated Not that I recall. The resident stated I don't think anything else needs to be done about people coming in my room. During an interview on 3/2/16 at 1:50 pm, with the Registered Nurse Manager (RNM) #2, she stated that Nursing fills out the CNA Care Plan at the time of admission. She stated that locomotion on the CNA Care Plan is determined by the recommendation from PT. She stated that contact guard would be used for residents with balance issues, and stated that you would stand by the resident and watch them. In regards to keep in monitored area, RNM #2 stated We would want to keep them somewhere where staff could see them. She stated that supervision means just keeping an eye on them due to behavioral reasons, dementia, etc. She stated that if staff were concerned about Resident #229's wellbeing and safety, she would expect them to get her into the lounge with a LPN or CNA, and stated she would expect the LPN to call the Nursing Supervisor. She stated that Resident #177 has a long standing pattern of violence towards others, and he doesn' t always yell. She stated if He (Resident #177) believes that someone is invading his space, he would be apt to push him out the door. During an interview on 3/2/16 at 3:00 pm, with the Psychiatry NP regarding Resident #177, he stated that the resident can make his own decisions and he knows what he is doing. He stated the resident has good recall, tends to minimize things, is manipulative and guarded. The NP stated that the resident is capable of hurting someone and has had episodes in the past. He stated that the resident does not like his space invaded, and if any resident wanders in his room he can be a danger to them. He stated that the resident would not admit to pushing the resident, even if he did, because he downplays everything. The NP stated that the resident's behaviors can be managed, but appropriate care planning should be done. During an interview on 3/3/16 at 10:20 am with the RNS, she stated that on the day of the resident-to-resident incident, at 8:00 pm the resident (#229) wandered down the hall, near Resident #177's doorway. The RNS stated that she was by the nurse station when she heard Resident #177 yelling Hey, hey, hey! She stated that she went right down there and praised him for letting staff know and reinforced that he can come to them or use the tap bell. When asked if the tap bell was effective, she stated that she could not answer that and stated that Social Services suggested the tap bell. She stated that Resident #229 was easily redirected and that she was not sure if she got all the way into his room. She stated that on the following shift, the resident (#229) was found on the floor in front of Resident #177's room. Regarding the CNA Care Plan for Resident #229 dated 2/19/16, she stated that she completed the CCP entitled ADLs and the CNA Care Plan, and that it was in the resident's closet before 11:00 pm on the day the resident was admitted . She stated that the CNAs know to look in the closet, and it was part of their orientation. When asked for a definition of keep in a monitored area, she stated, Keep the resident in lounge, with staff in the lounge, at the nurse station with staff; anywhere they can see her. Regarding contact guard, she stated, Somebody with her the entire time. The RNS stated that she saw the PT recommendation, and verbally communicated to a CNA that she needed the bathroom and was a 1 assist. During an interview on 3/3/16 at 1:55 pm with CNA #3, she stated that keep in a monitored area means that you have to keep watching them, contact guard means that you need to be right next to the person, and 1 assist means they need help; 1 person. During an interview on 3/3/16 at 2:00 pm, with CNA #4, he stated locomotion 1 assist means that 1 person helps, contact guard means you have physical hands on the resident

Based on record review and staff interview during complaint investigation (#NY 996), the facility did not ensure that the resident environment remained as free of accident hazards as is possible and that each resident received adequate supervision to prevent accidents. Specifically, Resident #4 was admitted to the facility on [DATE] at approximately 11:20 am with a feeding tube for dysphasia (difficulty in swallowing). On 5/4/15, the day of admission, the resident received a lunch meal tray delivered to his room by a facility Certified Nursing Assistant (CNA). A facility housekeeper was witnessed exiting the resident's room with a lunch tray in which most of the food was gone and within a short time later the resident developed symptoms of aspiration (when solids or liquids that should be swallowed into the stomach are instead breathed into the respiratory system) and was transferred to the hospital where the resident's primary [DIAGNOSES REDACTED]. This resulted in actual harm that is not immediate jeopardy. This is evidenced by: Resident #4 The resident was admitted to the facility on [DATE] from diagnosed with [REDACTED]. The resident's cognition had not been assessed. Nurses' note dated 5/4/15 at 11:20 am signed by the Registered Nurse Manager (RNM ) #2 documented that the resident was admitted to to the facility, oriented to his room and transferred to bed with the assistance of two (2) staff. Nurses note dated 5/4/15 at 2:00 pm signed by the RNM #2 documented that she was alerted that the resident received a lunch tray. A housekeeper was witnessed exiting the resident's room with a lunch tray in which most of the food was gone. The resident was assessed with [REDACTED]. Nurses note dated 5/4/15 at 2:30 pm documented that the resident's physician was notified and examined the resident, noted slight congestion in the upper airways but his lungs were clear. Nurses note dated 5/4/15 at 3:00 pm documented that the resident was noted with an oxygen saturation of 91 - 93% on room air, his hands noted to be dusky in color, both arms shaking, oxygen was provided to the resident and 911 was called for transfer to the hospital. The Hospital Discharge Summary documented that the resident was admitted to the hospital on [DATE] with a history of dysphasia with a feeding tube in place and ate food at the nursing home when given a tray. Upon admission, the resident's primary [DIAGNOSES REDACTED]. The resident was stabilized and returned to the nursing home on 5/7/15. During an interview on 5/18/15 at 2:30 pm, RNM #2 stated that the resident had been admitted to the facility at about 11:20 am, she was aware that the resident had a feeding tube and should have no food or drink by mouth. RNM #2 stated before she could see the resident to conduct the full nursing assessment, she was alerted that the resident was given a lunch tray and had consumed most of the food on the lunch tray. RNM #2 stated that the physician was notified, evaluated the resident in no apparent distress however, a short time later the resident was noted with symptoms of aspiration and transferred to the hospital for treatment. The RNM #2 stated that Certified Nurse's Assistant #1 (CNA #1) gave the resident a lunch tray without checking with the nursing staff first. During an interview on 5/21/15 at 12:20 pm the resident's physician stated that she was called to the unit and informed that the resident was admitted just prior to lunch, was mistakenly given a lunch tray and had consumed much of the tray. The physician stated that she assessed the resident and thought that he might be able to clear the food that he had ingested, however, after a short time, he began to show signs of distress and was transferred to the hospital. The resident's physician stated that usually the facility obtains basic care needs, including diet, from the transferring provider and that information should be shared with the care providers at the facility. The physician stated that the whole initial admission process needs to be looked into so that this does not happen again. During an interview on 5/21/15 at 1:00 pm, CNA #1 stated that the resident was admitted to the facility just before lunch time and was placed on her assignment. CNA #1 stated that another CNA told her to give the resident a tray so she did so and did not question it. CNA #1 stated that she brought the tray to the resident. CNA #1 stated that there was no ticket on the tray and that she did not think anything of it. CNA #1 stated she later found out that the resident had a feeding tube and should not have received a lunch tray. During an interview on 5/21/15 at 1:45 pm, CNA #2 stated that she was working with CNA #1 on 5/4/15 when the resident was admitted to the facility. CNA #2 stated that she passed by the lunch cart, where there was a lunch tray with no meal ticket on it and told CNA #1, I think that is your new resident's tray. CNA #2 stated that the nurses did not give the CNAs report on the new resident so they did not know that the resident had a feeding tube and should not have gotten a lunch tray. During a follow-up interview on 5/23/15 at 2:40 pm, RNM #2 stated that she did not provide a report to the CNAs assigned to the resident prior to or upon his arrival to the facility. RNM #2 stated that the CNAs are expected to ask the nurse if there is question about a resident's care but that the CNAs should also be given information on new admissions. During an interview on 5/23/15 at 4:00 pm, Licensed Practical Nurse #1 (LPN) stated that this resident was on her assignment when he arrived to the facility on [DATE]. LPN #1 stated that she observed a housekeeper exiting the resident's room with a lunch tray, and alerted RNM #2 that the resident was given a lunch tray and had consumed most of it. LPN #1 stated that prior to the resident's admission, RNM #2 had informed her of the anticipated new admission and had reported that the resident had a feeding tube and so when the housekeeper exited with the eaten lunch tray she was very concerned. LPN #1 stated that she had not given report to any of the CNAs about the resident's diet prior to the incident. 10NYCRR415.12(h)(1)

Based on medical record review, interview and observations during a complaint investigation (#NY 573), the facility did not ensure that the resident's environment remained as free of accident hazards as is possible and that residents received adequate supervision and assistance devices to prevent accidents for ten of twenty-eight residents reviewed. As a result one resident's (#4) neck became wedged between the mattress and side rail and she required RESCUE BREATHING (a life saving measure to deliver breaths to someone who is not breathing adequately on their own.) and hospitalization for treatment of [REDACTED]. This resulted in actual harm that is not immediate jeopardy. This is evidenced by the following:Resident #4:The resident was admitted on [DATE] diagnosed with [REDACTED]. The Brief Mini Mental Status (BIMS) dated 11/7/14 assessed the resident with no cognitive impairments. The resident required extensive assistance for bed mobility, activities of daily living and transfers. This assessment further noted that the use of the siderail/enabler was not identified to be utilized for mobility or transfer. Resident #4's Comprehensive Care Plan dated 5/16/14 for Physical Restraints documented the use of bilateral upper side rails for independent positioning in bed. The care plan documented that the facility restraint evaluation protocol/policy will be followed for the goal of safety and independent positioning.The resident's "I Centered Certified Nurses Assistant (CNA) Care Plan" dated 11/28/14 documented "I do not have any restraints." Physical Therapy Plan of Care dated 12/1/14 documented that the resident's current bed mobility ability for rolling side to side required a maximum assistance of two care givers and from a laying position to a sitting position and visa verse, the resident was dependant and required 100% assistance.Occupational Therapy Plan of Care - Evaluation only dated 12/1/14 documented that the resident's current bed mobility ability was independent (requiring no assistance, no assistive devices or extra time to roll from side to side). Accident and Incident Report dated 12/11/14 at 7:20 am documented that the resident was found by CNA #1 between the upper left side rail and mattress. The resident's head was turned to the left side, facing the door and the rest of her body from her torso down was in a prone position and propped on her right elbow. Resident was assisted to the floor by staff and then placed on her back. The resident was assessed as unresponsive with agonal respirations, periods of blank stare, in and out of consciousness with eyes rolling back and forth. The resident was assisted in RESCUE BREATHING for at least five minutes then placed on a non rebreather mask until paramedics arrived. Resident was noted with a 2 inch long by 1/4 inch wide reddened area at the base of her chin. During an interview on 12/12/14 at 1:45 pm, the hospital physician who received the resident on the morning of 12/11/14 stated that she was advised by Emergency Medical Technicians that according to facility staff, the resident became entrapped between her bed mattress and and side rail. The hospital physician stated that the resident was admitted to the hospital for treatment of [REDACTED]. During an interview on 12/12/14 at 2:30 pm, the Director of Nursing (DON) stated that she was currently investigating an incident in which the resident was found unresponsive with her head stuck between her mattress and the left side bed rail. The DON stated the preliminary investigation revealed that the resident's comprehensive plan of care documented bilateral side rails, however, the CNA care card did not indicate bilateral side rails in use. The DON further stated that interviews with nursing staff revealed that the resident's functional abilities became somewhat inconsistent since August 2014. The resident was recently hospitalized , returned to the facility on [DATE] and was assessed by physical therapy, and there is no mention of the use bed rails. The DON stated that Occupational Therapy also evaluated the resident on the same day and documented that Resident #1 was independent. The DON stated she is unaware of why these two evaluations significantly conflict.During an interview on 12/13/14 at 7:50 am, the DON stated that none of the residents currently in the facility use side rails as a restraint. The DON stated that she searched for a policy and procedure that would address the assessment and use of siderails as a bed mobility or positioning device, to no avail. The DON stated Resident #4's care plan references the facility restraint evaluation protocol/policy, but the residents siderails were not a restraint. Observation of the resident's room on 12/13/14 9:15 am, revealed the the bed frame with attached siderails/enablers on both sides of the bed. The mattress measured 6 inches in height, and was supple to touch. The mattress lacked firmness and density on the perimeter of the siderail/enabler site. Compression of the mattress resulted in a gap in the space between the siderail/enabler and the mattress, which allowed the resident's head to become entrapped. The use of this type mattress in combination with the siderail/enabler exacerbated the risk of entrapment. During an interview on 12/13/14 at 9:45 am, the Physical Therapist (PT) sat on the resident's mattress that was on the resident's bed at the time of the incident and stated that it felt squishy, that the mattress compressed in comparison to the other bed in the same room. The PT stated that she is not responsible for the particular mattress on a particular bed. The PT stated that on 12/1/14 when she evaluated the resident, she did not recommend side rails for the resident, but side rails were a goal to increase the resident's bed mobility. The PT stated that nursing staff had reported that the resident would move about her bed and at one point sat on the edge of the bed on her own, but in therapy, Resident #1 could not repeat the ability. During an interview on 12/15/14 at 9:30 am, CNA #1 stated that she is familiar with the resident and the resident has used side rails on her bed for as long as she can remember.During an interview on 12/15/14 at 9:45 am, CNA #2 stated that she is the current care giver for the resident who has used side rails for a very long time. CNA #2 stated that on 12/11/14 at approximately 7:20 am, she observed the resident with her head between her mattress and the side rail and the resident appeared unconscious. CNA #2 stated she immediately called for assistance and along with CNA #1 and LPN #1, assisted in releasing the resident from between the mattress and side rail. During an interview on 12/17/14 at 10:10 am, the Occupational Therapist (OT) stated that he evaluated the resident on 12/1/14 and assessed her to be independent with bed mobility. Then OT stated that he is aware that the resident was inconsistent with her abilities and sometimes, residents in general will perform tasks differently for different people. The OT stated that if he documented that the resident was independent, she was able to move in her bed without any physical assistance. 10 NYCRR 415.12(h)(2)

Based on medical record review, interview and observations during a complaint investigation (#NY 573), the facility did not ensure that the resident's environment remained as free of accident hazards as is possible and that residents received adequate supervision and assistance devices to prevent accidents for ten of twenty-eight residents reviewed. As a result one resident's (#4) neck became wedged between the mattress and side rail and she required RESCUE BREATHING (a life saving measure to deliver breaths to someone who is not breathing adequately on their own.) and hospitalization for treatment of [REDACTED]. This resulted in actual harm that is not immediate jeopardy. This is evidenced by the following:Resident #4:The resident was admitted on [DATE] diagnosed with [REDACTED]. The Brief Mini Mental Status (BIMS) dated 11/7/14 assessed the resident with no cognitive impairments. The resident required extensive assistance for bed mobility, activities of daily living and transfers. This assessment further noted that the use of the siderail/enabler was not identified to be utilized for mobility or transfer. Resident #4's Comprehensive Care Plan dated 5/16/14 for Physical Restraints documented the use of bilateral upper side rails for independent positioning in bed. The care plan documented that the facility restraint evaluation protocol/policy will be followed for the goal of safety and independent positioning.The resident's "I Centered Certified Nurses Assistant (CNA) Care Plan" dated 11/28/14 documented "I do not have any restraints." Physical Therapy Plan of Care dated 12/1/14 documented that the resident's current bed mobility ability for rolling side to side required a maximum assistance of two care givers and from a laying position to a sitting position and visa verse, the resident was dependant and required 100% assistance.Occupational Therapy Plan of Care - Evaluation only dated 12/1/14 documented that the resident's current bed mobility ability was independent (requiring no assistance, no assistive devices or extra time to roll from side to side). Accident and Incident Report dated 12/11/14 at 7:20 am documented that the resident was found by CNA #1 between the upper left side rail and mattress. The resident's head was turned to the left side, facing the door and the rest of her body from her torso down was in a prone position and propped on her right elbow. Resident was assisted to the floor by staff and then placed on her back. The resident was assessed as unresponsive with agonal respirations, periods of blank stare, in and out of consciousness with eyes rolling back and forth. The resident was assisted in RESCUE BREATHING for at least five minutes then placed on a non rebreather mask until paramedics arrived. Resident was noted with a 2 inch long by 1/4 inch wide reddened area at the base of her chin. During an interview on 12/12/14 at 1:45 pm, the hospital physician who received the resident on the morning of 12/11/14 stated that she was advised by Emergency Medical Technicians that according to facility staff, the resident became entrapped between her bed mattress and and side rail. The hospital physician stated that the resident was admitted to the hospital for treatment of [REDACTED]. During an interview on 12/12/14 at 2:30 pm, the Director of Nursing (DON) stated that she was currently investigating an incident in which the resident was found unresponsive with her head stuck between her mattress and the left side bed rail. The DON stated the preliminary investigation revealed that the resident's comprehensive plan of care documented bilateral side rails, however, the CNA care card did not indicate bilateral side rails in use. The DON further stated that interviews with nursing staff revealed that the resident's functional abilities became somewhat inconsistent since August 2014. The resident was recently hospitalized , returned to the facility on [DATE] and was assessed by physical therapy, and there is no mention of the use bed rails. The DON stated that Occupational Therapy also evaluated the resident on the same day and documented that Resident #1 was independent. The DON stated she is unaware of why these two evaluations significantly conflict.During an interview on 12/13/14 at 7:50 am, the DON stated that none of the residents currently in the facility use side rails as a restraint. The DON stated that she searched for a policy and procedure that would address the assessment and use of siderails as a bed mobility or positioning device, to no avail. The DON stated Resident #4's care plan references the facility restraint evaluation protocol/policy, but the residents siderails were not a restraint. Observation of the resident's room on 12/13/14 9:15 am, revealed the the bed frame with attached siderails/enablers on both sides of the bed. The mattress measured 6 inches in height, and was supple to touch. The mattress lacked firmness and density on the perimeter of the siderail/enabler site. Compression of the mattress resulted in a gap in the space between the siderail/enabler and the mattress, which allowed the resident's head to become entrapped. The use of this type mattress in combination with the siderail/enabler exacerbated the risk of entrapment. During an interview on 12/13/14 at 9:45 am, the Physical Therapist (PT) sat on the resident's mattress that was on the resident's bed at the time of the incident and stated that it felt squishy, that the mattress compressed in comparison to the other bed in the same room. The PT stated that she is not responsible for the particular mattress on a particular bed. The PT stated that on 12/1/14 when she evaluated the resident, she did not recommend side rails for the resident, but side rails were a goal to increase the resident's bed mobility. The PT stated that nursing staff had reported that the resident would move about her bed and at one point sat on the edge of the bed on her own, but in therapy, Resident #1 could not repeat the ability. During an interview on 12/15/14 at 9:30 am, CNA #1 stated that she is familiar with the resident and the resident has used side rails on her bed for as long as she can remember.During an interview on 12/15/14 at 9:45 am, CNA #2 stated that she is the current care giver for the resident who has used side rails for a very long time. CNA #2 stated that on 12/11/14 at approximately 7:20 am, she observed the resident with her head between her mattress and the side rail and the resident appeared unconscious. CNA #2 stated she immediately called for assistance and along with CNA #1 and LPN #1, assisted in releasing the resident from between the mattress and side rail. During an interview on 12/17/14 at 10:10 am, the Occupational Therapist (OT) stated that he evaluated the resident on 12/1/14 and assessed her to be independent with bed mobility. Then OT stated that he is aware that the resident was inconsistent with her abilities and sometimes, residents in general will perform tasks differently for different people. The OT stated that if he documented that the resident was independent, she was able to move in her bed without any physical assistance. 10 NYCRR 415.12(h)(2)

Based on record review and interview the facility did not ensure that acceptable parameters of nutrition such as body weight was maintained for one (#'s 49) of eight residents reviewed during the extended recertification survey. Specifically, the facility did not assess a significant weight loss in a timely manner, did not notify the physician (MD) of the significant weight loss in a timely manner, and lacked timely implementation of an intervention to address the significant weight loss. The resident required hospitalization . This resulted in actual harm that is not immediate jeopardy. This is evidenced by the following: Resident # 49 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident had impaired long and short term memory and impaired decision making skills. The MDS also documented the resident's weight as 184 lbs and the resident required the limited assistance of one staff for eating. The resident's Comprehensive Care Plan prior to 1/14/11 was requested by the surveyor several times on 2/28/11, and was not produced. The Nutrition assessment dated [DATE] documented the resident's nutritional needs as: 2000 kilocalories, 84 grams of protein and 2500 cc of fluids a day and a calorie count was in progress. The goal was to maintain weight at 184 lbs +/- 5 lbs. The plan was to do weekly weights and monitor intake at meal rounds. The resident's Weight Record documented: 11/22/10=180.6 lbs, 12/7/10=176.6 lbs, 12/13/10=175.2 lbs, 12/20/10=173.8 lbs, 1/3/11=159.2 lbs (a significant wt loss of 8.4 %) with a reweigh of 160.4 lbs on 1/11/11 and a post hospital readmission weight of 160.4 lbs on 1/17/11. The dietary progress note dated 11/26/10 documented a kilocalorie count showed the resident was consuming less than 65% of the estimated needs, was refusing some meals, and had lost 4 lbs. The note documented that 8 ounces of Ensure Plus would be provided at 10:00am, 2:00 pm and 8:00 pm. The last dietary note in the medical record was dated 12/27/10 and documented variable acceptance of the Ensure Plus at 10:00 am and 2:00 pm and 100% acceptance at 8:00 pm. There was no mention of weight loss. The Certified Nurses Aide (CNA) Flow Sheet record of meal intake documented: for Dec '10 there were 81 meals consumed (there were 10 blanks on the record). There was consumption at the 100% level 3 times, at the 75% level 14 times, at the 50% level 22 times, at the 25 % level 28 times and at the 0 % level 19 times. The Jan '11 consumption record documented for the 13 days prior to hospitalization : there were 31 meals consumed (there were 8 blanks for meals). There was no consumption at the 100% and 75 % level; there was consumption at the 50 % level 8 times, at the 25 % level 18 times and at the 0% level 8 times. From 1/1/11 to 1/12/11 there was no documentation in nursing notes that the resident had poor food/fluid intake. There was no plan initiated to address the poor meal intake noted on the CNA flow sheets. There was no documentation in any physician progress notes [REDACTED]. The Physician Visit notes of 1/10/11 do not document the significant weight loss. No action was taken to address the significant weight loss by the physician. The nurses notes dated 1/11/11 documented the resident appeared to be very weak and slightly shaky. The nurse's notes dated 1/13/11 at 11:00 am documented the physician was made aware the resident was very unsteady on his feet and his legs were buckling. The physician was informed of the resident's decreased appetite and that he was hardly eating or drinking and the physician ordered blood work. The nurse's notes at 1:00 am on 1/14/11 documented the resident was going to get up and was lowered to the floor. His eyes rolled up, he had pursed blue lips and he was unresponsive, oxygen was started and the physician was notified. The resident was sent to the hospital and admitted with a [DIAGNOSES REDACTED]. During an interview on 2/24/11 at 10:14 am the Dietitian (RD) stated she addressed the weight loss in a weight change assessment on 1/13/11. She said she usually looks at weights just after they are done, in this case on 1/4/11. She said she put the resident on grape drink on 1/6/11 because the resident was refusing the ensure however it is not the same calorie/nutrient level. The RD stated the facility only uses ensure supplements, nothing else. The RD also stated she was not aware the CNA flow sheets documented meal intake and she was not reviewing them. The RD stated the Diet Technicians were laid off at the end of December leaving 2 RD's for the facility. During an interview on 2/24/11 at 9:15 am the Registered Nurse Manager (RNM) was asked what was done to address the significant weight loss found on 1/3/11. The RNM stated she notified the physician but could not state when that occurred. The RNM stated there was no Physician Worksheet (filled out by nursing to address resident concerns with the physician) that noted the weight loss for the physician to address. During an interview on 2/24/11 at 9:40 am the physician stated he did not remember if he was informed of the weight loss or not. The physician stated if it was not on the Physician Visit note then he probably was not notified. 10NYCRR415.12(i)(1)