Every finding on record at The New Jewish Home, Manhattan

Based on record review and staff interviews, the facility failed to ensure that a person-centered comprehensive care plan was developed and implemented to address the residents' medical, physical, mental, and psychosocial needs. This was evident for one (Resident #3) of six residents reviewed for Abuse. Specifically, the facility did not develop or update the care plan that accurately described care/services to be furnished for a transfer status required Hoyer lift for Resident #3, which created an increase in safety risks as staff rely on active care plans and Kardex to perform the bed-to-wheelchair transfer task.The findings are:The facility's policy and procedure titled, Comprehensive Care Planning and Meetings, last reviewed 07/2026, documented that the facility is to develop and maintain a comprehensive person-centered care plan for each resident to meet the resident's medical, nursing and mental/psychosocial needs that are identified in the comprehensive assessment. It further documented that the Nurse Manager or Registered Nurse Designee updates the Kardex when indicated following the development of the care plan in order to inform the nursing staff across shifts, and they review/update care plans at least quarterly or more frequently as warranted by resident's condition.The facility's policy and procedure titled, Safe Use of Mechanical Lift, last reviewed 01/2026 documented that residents requiring mechanical lift assistance shall be assessed upon admission and when there is a significant change in condition. The care plan shall identify resident's transfer status and indicate when a Hoyer lift is required. Nursing staff shall follow the resident's care plan, utilizing appropriate, safe transfer techniques. Changes in transfer ability shall be reported to licensed nurses and care plan updated as appropriate.Resident #3 was admitted to the facility with diagnoses including non-Alzheimer's dementia (a pattern of mental decline caused by different diseases or conditions), cerebrovascular accident (condition where blood flow to a part of the brain is interrupted or reduced, depriving brain tissue of oxygen and nutrients), and depression (mood disorder that causes persistent sadness, loss of interest, and physical fatigue).The Quarterly Minimum Data Sets (a resident assessment tool) dated 04/25/2024 and dated 09/14/2024 documented Resident #3 had severely impaired cognition and was dependent for chair/bed transfer.The Physical Therapy Discharge summary dated [DATE] documented that Resident #3 is to use Hoyer lift for bed-to-wheelchair transfer.The Activities of Daily Living Care Plan reviewed/updated 09/25/2024 documented that Resident #3 was dependent for chair/bed transfer. There was no documented evidence in the care plan that Resident #3 required the use of a Hoyer lift.The Kardex (nursing instruction) as of 11/28/2024 was reviewed and documentation included that Resident #3 was dependent for chair/bed transfer. There was no documented evidence in the Kardex that Resident #3 required the use of a Hoyer lift.There was no documented evidence that the care plan was updated when Resident #3's transfer status changed to require Hoyer lift as per Physical Therapy discharge recommendation on 05/17/2024.During an interview on 07/21/2026 at 10:35 AM, the Assistant Director of Nursing could not provided when the utilization of Hoyer lift for transfer was initiated for Resident #3. They also stated that the facility investigated an incident where Resident #3 was noted with a skin tear following a bed/chair transfer with Hoyer lift. The Assistant Director of Nursing stated that registered nurse supervisors are responsible for reviewing care plans and ensuing they are followed correctly.During an interview on 07/22/2026 at 11:09 AM, the Rehabilitation Director stated Resident #3 was discharged from physical therapy with the recommendation to use Hoyer lift for bed to wheelchair transfer on 05/17/2024. Unit nurses/certified nursing assistants were informed of the Hoyer lift. The Rehabilitation Director stated that the Hoyer lift should be updated in the care plan and implemented for staff to use by the nursing department.During an interview over the phone on 07/22/2026 at 12:20 PM, Registered Nurse #5 stated that the physical therapist will inform nursing when residents require Hoyer lift. Registered Nurse #5 stated they would update the care plan for use of Hoyer lift, implement in the Kardex and accountability record. Registered Nurse #5 stated they were not aware that Hoyer lift was not implemented in the care plan and Kardex for Resident #3. During an interview on 07/22/2026 at 12:35 AM, the Director of Nursing stated when a resident requires a Hoyer lift, the care plan is updated and implemented in the nursing instructions. Director of Nursing stated the facility's procedure does not require an order for Hoyer lift, so the Hoyer lift is directly implemented in the Kardex and accountability record. The Director of Nursing they could not explain why the use of Hoyer lift was not reflected in the care plan and the Kardex for Resident #3.10 New York Code of Rules and Regulations 483.21 (b)(2)(iii)

Based on interview and record review, the facility failed ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of residential property, are reported immediately to the administrator of the facility and to other officials. This was evident for one (Resident #13) of one resident sampled for Abuse. Specifically, on 10/14/2025 at approximately 9:00 PM Certified Nursing Assistants #8 observed discolorations described as large dark brown spot on Resident #13's arm but failed to report it to the supervising nurse. Additionally, on 10/15/2025 at approximately 8:00 AM, Licensed Practical Nurse #4 was made aware of a discoloration described as a dark bluish spot with smaller red spots on Resident #13's right forearm, but failed to report it to the nursing supervisor immediately. The injury was reported to administration on 10/15/2026 at 2:45 PM. The findings include:The facility policy and procedure titled, Resident Incident/Accident Reporting and Investigation Process, with a review date of 10/2025, documented that resident incident/accidents occurring on premises, along with injuries to residents of unknow origin, are to be investigated and reported in a timely fashion and if there is reasonable cause to believe that such violations or incidents involve abuse or result in serious bodily injury, such shall be reported to the Department of Health no later than two hours after the allegation is made.The facility policy and procedure titled, Abuse/Neglect/Mistreatment-Prevention, Assessment & Reporting of these or other crimes against a resident/client in out care, last revised 10/2025, documented that all staff are to observe and monitor residents to ascertain they are safe and protected. Additionally, the policy documented that it is the responsibility of all staff to report incidents or suspicions of resident abuse, neglect, mistreatment or misappropriation of property which may be prompted by evidence of physical indicators of unknown origin including, but not limited not, bruises and abrasions.Resident #13 had diagnoses that included Alzheimer's dementia, hypertension (high blood pressure), and basal cell carcinoma of the skin (nose, scalp, and neck).The Minimum Data Set 3.0 (a resident assessment tool) assessment dated [DATE] documented that Resident #13 had severe cognitive impairment.A review of care plan titled, Potential for abuse, neglect, mistreatment due to dependence on others with activity of daily living, initiated 07/10/2025 documented interventions including that two staff provide care, to investigate any allegation of abuse, and to monitor resident skin for bruising, skin tears, skin break and injury. An update dated 10/15/2025 documented that Resident #13 was noted with senile purpura (bluish, purplish colored skin due to break in blood vessels that cause discoloration and fragile skin) over right forearm. A review of the care plan titled, Actual Impairment to Skin Integrity of the nose (cancer lesion), right neck, and sacrum, initiated 07/10/2025, documented an update dated 10/15/2025 of senile purpura (bluish, purplish colored skin due to break in blood vessels that cause discoloration and fragile skin) to right forearm with interventions that include applying protective sleeves to forearms and to remove for skin check and hygiene.The electronic medical record was reviewed. There was no documented evidence that any change in skin integrity or condition was noted prior to 10/15/2025 at 1:38 PM.A review of the certified nursing assistant documentation report for 10/2025 revealed Resident #13 skin observation was done on each shift. Code 5 was noted under skin observation tasks, indicating Resident #13 had no new skin issues on the 7:30 AM to 3:30 PM, 3:30 PM to 11:30 PM, and 11:30 PM to 7:00 AM shift on 10/14/2025 and 10/15/2025.A review of the skin check progress note dated 10/15/2025 at 1:38 PM documented by Registered Nurse #2, who is also the wound care nurse, included the observation of a new skin issue all over the right outer forearm. Additionally, the wound was documented as a new wound acquired in-house. A review of the provider wound care note dated 10/15/2025 at 3:31 PM documented Resident #13 was seen for report of bruising. Specifically, nursing reported right arm bruising and Resident #13 reported that someone had wrenched their arm unintentionally. The physical exam revealed right arm, large rectangular purple bruise on dorsal aspect of forearm, thin, delicate skin. Additional documentation included that Resident #13 was an unreliable historian due to dementia.A review of the incident progress note dated 10/15/2025 at 15:41 documented by Licensed Practical Nurse #13 included that Resident #13 was observed with senile purpura on the right forearm. The wound care team assessed and covered Resident #13 arm and the medical doctor was made aware.During an interview on 07/16/2026 at 12:26 PM, Registered Nurse Supervisor #2 stated on 10/15/2025 at around 2:00 PM, Licensed Practical Nurse #4 brought it to the attention of the wound care team that Resident #13 had a bruise on their right forearm that was discovered by Certified Nursing Assistant #9 during morning care rounds. Resident #13 was assessed by the doctor and assessed to have senile purpura (discolored spots of senile purpura as blood spots or skin hemorrhages) associated with fragile, thin skin. Registered Nurse Supervisor #2 was not sure if the senile purpura was a new or previous skin condition but stated that immediate intervention included a medication review; Resident #13 was not on any anticoagulant medication but was prescribed a moisturizer and a protective sleeve.During an interview on 07/17/2026 at 10:40 AM, Certified Nursing Assistant #9 stated on 10/15/2025, they made rounds at 8:00 AM to bring Resident #13 breakfast. Certified Nursing Assistant #9 further stated that when they took off the cover to bring out Resident #13 hands, they observed a discoloration described as a big patch, dark bluish spot, with other little red spots on Resident #13 arm that they had never seen before. Certified Nursing Assistant #9 stated they reported the observation to Licensed Practical Nurse #4 immediately, and about 10 minutes later they showed Licensed Practical Nurse #4 the discoloration on Resident #13's arm. Certified Nurse Assistant #9 did not provide a reason as to why they did not document Resident #13 had a new skin condition on the certified nursing assistance accountability record under the skin observation task.During an interview on 07/17/2026 at 11:29 AM, Certified Nursing Assistant #8 stated they were working on 10/14/2025 on the 3:30 PM to 11:30 PM shift. Certified Nursing Assistant #8 stated that at 09:00 PM, they went in Resident #13's room to provide care when they observed a large, dark brown spot on Resident #13 arm. Certified Nursing Assistant #8 stated that they worked with Resident #13 a few months prior and did not remember any skin issues. Certified Nursing Assistant #8 stated they did not report it to Registered Nurse #10 at the time because they assumed it was old and were under the impression that Registered Nurse #10 had already known and therefore they did not need to report what they had observed. Certified Nursing Assistant #8 stated they do not remember what they had documented in the certified nursing assistant accountability under the skin task observation, if at all.During an interview on 07/17/2026 at 11:51 AM, Licensed Practical Nurse #4 stated that Resident #13 was under their assignment on 10/15/2025. They stated that they assess residents' skin when the certified nursing assistants provide care or activities of daily living for the residents. Licensed Practical Nurse #4 stated that they did not make any observation of Resident #13 skin; they also did not recall the day and time of the incident. Licensed Practical Nurse #4 also stated they do not recall anyone telling them that Resident #13 had a bruise on their arm.Attempts to interview Registered Nurse #10 were unsuccessful.During an interview on 07/17/2026 at 12:45 PM, Assistant Director of Nursing #2 stated on 10/15/2025 at around 2:45 PM, Registered Nurse Supervisor #2 was conducting wound care rounds. During rounds Licensed Practical Nurse #4 reported to Registered Nurse Supervisor #2 that Resident #13 had skin discoloration of unknown origin. Assistant Director of Nursing #2 stated that based on the facility's investigation, it was determined that the bruise was initially identified around 09:00 PM on 10/14/2025 by Certified Nursing Assistant #8, but it was not reported at that time nor during the 11:30 PM to 07:30 AM shift . Assistant Director of Nursing #2 stated initial rounds are to be conducted at the beginning of the 11:30 PM to 7:30 AM shift, incontinent rounds more often, and morning care begins between 4:30 AM and 5:00 AM. Assistant Director of Nursing #2 stated it is the facility policy to report any unusual circumstances that include any new marks on residents' skin. Observation of skin condition is part of the certified nursing assistant accountability task and gets documented and communicated to the nurse. Assistant Director of Nursing #2 did not know why the observation was not documented in the certified nursing accountability task under skin observation.During an interview on 07/23/2026 at 12:08 PM, the Director of Nursing stated that on 10/15/2025 at 2:45 PM, Registered Nurse Supervisor #2 reported to them that Resident #13 had a discoloration on the right forearm. The Director of Nursing stated that the facility policy is that if the staff notice something new, old, or unusual, they are supposed to report it right away to the nurse and the nurse is to report it to the supervisor/manager on duty. Floating staff should not assume if the bruise is new or old and just bring it to the attention of the nurse, and the nurse will make a referral to the covering medical provider. The Director of Nursing did not know why Certified Nursing Assistant #8 did not report their observation. The Director of Nursing stated that the 11:30 PM to 7:30 AM shift was interviewed and no one reported seeing a bruise on Resident #13 arm. Also, the Director of Nursing could not confirm if the nursing staff, including nurses and certified nursing assistants, did an assessment or an observation of Resident #13's skin during the night shift. The Director of Nursing did not know why Licensed Practical Nurse #4 did not report the incident at 8:00 AM when Certified Nursing Assistant #9 reported it.10 New York Codes, Rules and Regulations 483.12(c)(2)-(4)

Based on observation, record review, and interviews during an abbreviated survey (NY00332607), the facility did not ensure that a resident was treated with dignity including being free from physical restraint. This was evident in 1 out of 20 residents reviewed (Resident #1). Specifically, the facility's surveillance camera recording, dated 03/16/2024 at 3:16 AM, showed Resident #1 in their wheelchair being brought into the unlighted dining room by Certified Nursing Assistant #1. Resident #1 was not wearing any clothing or undergarment. While Certified Nursing Assistant #1 was pushing Resident #1's wheelchair, Certified Nursing Assistant #1 used their left hand to hold Resident #1's hands across their chest restricting the movements of Resident #1's hands. Once in the dining room, Certified Nursing Assistant #1 pushed Resident #1's wheelchair against the wall, then used three dining room tables (arranged in a row in front of Resident #1) to pin Resident #1's wheelchair against the wall restricting Resident #1's movements. Resident #1 was left sitting naked, in the dark, in the dining room from 3:16 AM to 5:37 AM when Licensed Practical Nurse #1 entered the dining room and turned on the lights. Licensed Practical Nurse #1 took a (personal) cell phone out of their pocket and took multiple pictures of Resident #1. Licensed Practical Nurse #1 then moved the dining room tables that were restraining Resident #1. This resulted in actual harm to Resident #1 with the potential for serious injury, serious harm, serious impairment, or death to 40 residents on the unit, that was not Immediate Jeopardy. The findings include: The facility's policy on Restraints dated 09/2017 documented Restraint use will be limited to circumstances in which the resident has medical symptoms that warrant such use and only after attempts to use alternatives to restraints have failed. If restraint use is indicated, the least restrictive device will be utilized. Resident #1 was admitted to the facility with diagnoses including of Alzheimer's Disease, Depression, Restlessness, and Agitation. The Minimum Data Set (an assessment tool), dated 03/13/2024, documented Resident #1 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) and scored 2 out of 15, indicating severely impaired cognition. The Summary of Investigation dated 03/16/2024 documented the facility Administrator, Director of Nursing, and IT Director reviewed the video surveillance recording after receiving an anonymous call. The video surveillance review confirmed Resident #1 was sitting in the dining room at 4:30 AM without any clothes on. The video surveillance recording also showed there were three dining room tables in front of Resident #1's wheelchair. The staff were interviewed and stated Resident #1 had a behavior of removing their clothes. Certified Nursing Assistant #1 reported Resident #1 is put in the same position every night, however, most nights Resident #1 was wearing clothes. The Nursing Supervisor was not aware of the incident. The facility investigated the incident and concluded that abuse and neglect had occurred. The Facility Surveillance Camera Recording dated 03/16/2024 at 3:10 AM was reviewed with the Assistant Director of Nursing and Security Manager. The video surveillance recording showed at 3:16 AM Resident #1 in their wheelchair being brought into the unlighted dining room by Certified Nursing Assistant #1. Resident #1 was completely naked. Certified Nursing Assistant #1 used their left hand to hold Resident #1's hands down while pushing the wheelchair with their right hand. Once in the dining room, Certified Nursing Assistant #1 pushed Resident #1's wheelchair against the wall and used three dining room tables (tables positioned in a row) to pin the wheelchair against the wall. Resident #1 was struggling to push the dining room tables but was unable to move the tables. Resident #1 was observed with their arms crisscrossed against their upper body. The edge of the table was touching Resident #1's body just below their breasts. Licensed Practical Nurse #1 entered the dining room at 3:19 AM and offered Resident #1 a cup of liquid which Resident #1 refused. Resident #1 was left sitting naked, in the dark, in the dining room from 3:16 AM to 5:37 AM when Licensed Practical Nurse #1 entered the dining room and turned on the lights. Licensed Practical Nurse #1 took a (personal) cellphone out of their pocket and took multiple pictures of Resident #1. Licensed Practical Nurse #1 put a gown on Resident #1, then moved the dining room tables that were restraining Resident #1. Video ended at 5:40 AM while Licensed Practical Nurse #1 was still with Resident #1. A nursing progress note dated 03/16/2024 at 6:33 AM, by Licensed Practical Nurse #1, did not document that Resident #1 was restrained in the dining room. A medical note dated 03/18/2024 at 8:05 AM documented Resident #1 was seen (at the bedside, calm, and does not recall what happened due to Dementia. Resident #1 denies pain. Small ecchymosis (discoloration of the skin) was found on the left anterior wrist. The surveyor made several attempts to contact Certified Nursing Assistant #1 but was unsuccessful. A certified letter was mailed on 11/06/2024 with no response to date. Certified Nursing Assistant #1 gave a telephone interview to the facility on [DATE] at 4:53 PM. The interview documents every night Resident #1 is in that position and never in their bed. Resident #1 woke up, they took Resident #1 to the bathroom, and put clothes on Resident #1, but Resident #1 pulled the clothes off. The interview also documents Certified Nursing Assistant #1 put Resident #1 in the dining room and sat there with Resident #1 throughout the night and every night. During an interview on 11/07/2024 at 11:41 AM, Licensed Practical Nurse #1 stated they worked on the floor on 03/16/2024 from 11:30 PM - 7:30 AM. Licensed Practical Nurse #1 stated they instructed Certified Nursing Assistant #1 to put a gown on Resident #1 and to remove the restraints when it was first observed at 3:30 AM. Licensed Practical Nurse #1 stated they returned to the dining room (between 5:00 AM and 5:30 AM) and Resident #1 was still restrained and not wearing any clothing. Licensed Practical Nurse #1 stated they did not remove the restraint when it was first noticed because the Certified Nursing Assistants want the nurse to do everything, and they had worked 16 hours. Licensed Practical Nurse #1 stated they waited for the Director of Nursing (before going home) and reported the incident (they do not recall the time). During an interview on 11/08/2024 at 11:29 AM, the Director of Nursing stated they received an anonymous call prior to arriving at the facility regarding Resident #1 being naked in the dining room. The Director of Nursing stated shortly after arriving at the facility they were informed of the incident regarding Resident #1 by Licensed Practical Nurse #1 (not sure of the time). The Director of Nursing stated they reviewed the video surveillance and observed Resident #1 sitting in their wheelchair naked and Certified Nursing Assistant #1 had placed three tables in front of Resident #1 restricting their movement. The Director of Nursing stated Licensed Practical Nurse #1 should have immediately removed the tables and put a gown on Resident #1. During an interview on 11/08/2024 at 11:36 am, the Administrator stated they were notified of the incident by the Director of Nursing on 03/16/2024 (do not recall the time). The Administrator stated they immediately watched the video surveillance recording and called local Law Enforcement. The Administrator stated two Police Officers arrived at the facility during the day shift and watched the video surveillance recording and interviewed staff. The Administrator stated the nursing staff are aware if a resident displays behavior, they are to call the nursing supervisor and notify the medical doctor to get guidance. During an interview on 11/08/2024 at 12:12 PM, Nurse Practitioner #1 stated they were notified of the incident and examined Resident #1 on 03/20/2024 (do not recall the time). Nurse Practitioner #1 stated Resident #1 had no discoloration, bruising, redness, or injury. Nurse Practitioner #1 also stated Resident #1 was evaluated by the psychiatrist and there was no psychosocial harm. Nurse Practitioner #1 also stated Resident #1 has advanced dementia. Nurse Practitioner stated Resident #1 was on Melatonin to help with sleep. 10 NYCHRR 415.4(a) (2-7)

Based on observation, record review, and interviews conducted during an abbreviated survey (NY00332607), the facility failed to protect a resident's right to be free from Abuse. This was evident in 1 of 20 residents reviewed (Resident #1). Specifically, the facility's surveillance camera recording, dated 03/16/2024 at 3:16 AM, showed Resident #1 in their wheelchair being brought into the unlighted dining room by Certified Nursing Assistant #1. Resident #1 was not wearing any clothing or undergarment. While Certified Nursing Assistant #1 was pushing Resident #1's wheelchair, Certified Nursing Assistant #1 used their left hand to hold Resident #1's hands across their chest restricting the movements of Resident #1's hands. Once in the dining room, Certified Nursing Assistant #1 pushed Resident #1's wheelchair against the wall, then used three dining room tables (arranged in a row in front of Resident #1) to pin Resident #1's wheelchair against the wall restricting Resident #1's movements. Resident #1 was left sitting naked, in the dark, in the dining room from 3:16 AM to 5:37 AM when Licensed Practical Nurse #1 entered the dining room and turned on the lights. Licensed Practical Nurse #1 took a (personal) cell phone out of their pocket and took multiple pictures of Resident #1. Licensed Practical Nurse #1 then moved the dining room tables that were restraining Resident #1. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy. The findings include: The Policy titled, Abuse/Neglect/Mistreatment - Prevention, Assessment & Reporting of these or other crimes against a resident/client in our care, dated 11/04/2022 documents the resident/client has the right to be free from verbal, sexual, physical, and mental abuse, corporal punish, involuntary seclusion, misappropriation of property or any other criminal activity. The organization screens and trains employees in the prevention, protection, identification, investigation and reporting of abuse, neglect, mistreatment, misappropriation of resident/clients' property and any other criminal activity. The policy further documents each resident/client has the right to be free from mental abuse. Mental abuse includes, but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident(s). Resident #1 was admitted to the facility with diagnoses that include Alzheimer's Disease, Depression, Restlessness, and Agitation. The Minimum Data Set (an assessment tool), dated 03/13/2024, documented Resident #1 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) and scored 2 out of 15, indicating severely impaired cognition. A Potential for Abuse, Neglect, and Mistreatment Care Plan dated 06/19/2023 documented interventions that included monitor resident's skin for bruising, skin tears, skin break, injury, and report immediately to nurse or designees. The Summary of Investigation dated 03/16/2024 documented the facility Administrator, Director of Nursing and the IT Director reviewed the video surveillance recording after receiving an anonymous call. The video surveillance review confirmed Resident #1 was sitting in the dining room at 4:30 AM without any clothes on. The video surveillance recording also showed there were three dining room tables in front of Resident #1's wheelchair. The staff were interviewed and stated Resident #1 had a behavior of removing their clothes. Certified Nursing Assistant #1 reported Resident #1 is put in the same position every night, however, most nights Resident #1 was wearing clothes. The Nursing Supervisor was not aware of the incident. The facility investigated the incident and concluded abuse and neglect had occurred. The Facility Surveillance Camera Recording dated 03/16/2024 at 3:10 AM was reviewed with the Assistant Director of Nursing and Security Manager. The video surveillance recording showed at 3:16 AM Resident #1 in their wheelchair being brought into the unlighted dining room by Certified Nursing Assistant #1. Resident #1 was completely naked. Certified Nursing Assistant #1 used their left hand to hold Resident #1's hands down while pushing the wheelchair with their right hand. Once in the dining room, Certified Nursing Assistant #1 pushed Resident #1's wheelchair against the wall and used three dining room tables (tables positioned in a row) to pin the wheelchair against the wall. Resident #1 was struggling to push the dining room tables but was unable to move the tables. Resident #1 was observed with their arms crisscrossed against their upper body. The edge of the table was touching Resident #1's body just below their breasts. Licensed Practical Nurse #1 entered the dining room at 3:19 AM and offered Resident #1 a cup of liquid which Resident #1 refused. Resident #1 was left sitting naked, in the dark, in the dining room from 3:16 AM to 5:37 AM when Licensed Practical Nurse #1 entered the dining room and turned on the lights. Licensed Practical Nurse #1 took a personal cellphone out of their pocket and took multiple pictures of Resident #1. Licensed Practical Nurse #1 put a gown on Resident #1, then moved the dining room tables that were restraining Resident #1. Video ended at 5:40 AM while Licensed Practical Nurse #1 was still with Resident #1. A nursing progress note dated 03/16/2024 at 6:33 AM, by Licensed Practical Nurse #1, documented at around 2:00 AM Resident #1 woke up and was trying to get up from the bed. Certified Nursing Assistant #1 put Resident #1 in their wheelchair and moved Resident #1 to the dining room. Resident #1 was screaming. Close monitoring provided by the night shift staff. A medical note dated 03/18/2024 at 8:05 AM documented Resident #1 was seen at the bedside, calm, and does not recall what happened due to Dementia. Resident #1 denies pain. Small ecchymosis was found on the left anterior wrist. The surveyor made several attempts to contact Certified Nursing Assistant #1 but was unsuccessful. A certified letter was mailed on 11/06/2024 with no response to date. Certified Nursing Assistant #1 gave the facility a telephone interview on 03/20/2024 at 4:53 PM. The interview stated every night Resident #1 is in that position and never in their bed. Resident #1 woke up, they took Resident #1 to the bathroom, and put clothes on Resident #1, but Resident #1 pulled the clothes off. The interview also documents Certified Nursing Assistant #1 put Resident #1 in the dining room and sat there with Resident #1 throughout the night and every night. During an interview on 11/07/2024 at 11:41 AM, Licensed Practical Nurse #1 stated they were working on the floor on 03/16/2024 from 11:30 PM - 7:30 AM. Licensed Practical Nurse #1 stated they made rounds at around 1:00 AM and Resident #1 was in bed and was restless, taking off their gown. Licensed Practical Nurse #1 stated they assisted Certified Nursing Assistant #1 to transfer Resident #1 into their wheelchair and then they left Resident #1's room. Licensed Practical Nurse #1 stated at approximately 3:30 AM they observed Resident #1 sitting in their wheelchair naked in the dining room. Licensed Practical Nurse #1 stated they instructed Certified Nursing Assistant #1 to put a gown on Resident #1. Licensed Practical Nurse #1 stated they went back to the dining room between 5:00 AM and 5:30 AM and Resident #1 was not wearing a gown. Licensed Practical Nurse #1 stated they used their personal cell phone to take pictures of Resident #1 to use as evidence. During an interview on 11/08/2024 at 11:29 AM, the Director of Nursing stated they received an anonymous call prior to arriving at the facility regarding Resident #1 being naked in the dining room. The Director of Nursing stated shortly after arriving at the facility they were informed of the incident regarding Resident #1 by Licensed Practical Nurse #1 (not sure of the time). The Director of Nursing stated they reviewed the video surveillance recording and observed Resident #1 sitting in their wheelchair naked and Certified Nursing Assistant #1 had placed three tables in front of Resident #1 restricting their movement. The Director of Nursing stated Licensed Practical Nurse #1 should have immediately moved the tables and put a gown on Resident #1. The Director of Nursing also stated Licensed Practical Nurse #1 should not have used their personal cell phone to take pictures of Resident #1. During an interview on 11/08/2024 at 11:36 am, the Administrator stated they were notified of the incident by the Director of Nursing on 03/16/2024. The Administrator stated they immediately watched the video surveillance recording and called local Law Enforcement. The Administrator stated two Police Officers arrived at the facility during the day shift and watched the video surveillance recording and interviewed staff. The Administrator stated the nursing staff are aware if a resident displays behavior, they are to call the nursing supervisor and notify the medical doctor to get guidance. During an interview on 11/08/2024 at 12:12 PM, Nurse Practitioner #1 stated they were notified of the incident and examined Resident #1 on 03/20/2024. Nurse Practitioner #1 stated Resident #1 had no discoloration, bruising, redness, or injury. Nurse Practitioner #1 also stated Resident #1 was evaluated by the psychiatrist (03/22/2024 at 5:27 PM) and there was no psychosocial harm documented. Nurse Practitioner #1 also stated Resident #1 has advanced dementia. Nurse Practitioner stated Resident #1 was on Melatonin to help with sleep. 10 NYCRR 415 (b)(1)(i)

Based on observation, record review and interviews conducted during an Abbreviated Survey (NY00336486), the facility failed to treat a resident with respect and dignity and care for a resident in a manner and in an environment that promotes maintenance or enhancement of their quality of life, recognizing each resident's individuality. This was evident for 1 out of 20 residents reviewed (Resident #11). Specifically, 03/16/2024 at 5:17 PM, the facility's surveillance video recording showed Resident #11 sitting in a lounge chair in the hallway. Resident #11 removed their gown and slid themselves from the lounge chair onto the floor. The Facility's surveillance video recording showed that Resident #1 remained on the floor without clothing (only wearing an adult disposable brief) from 5:24 PM to 5:59 PM (35 minutes). Registered Nurse #1 was on the unit and did not immediately assessed Resident #11. Nursing Supervisor #1 assessed Resident #11 and there were no visible injuries. The findings are: The Facility's policy titled Resident Rights, dated 11/2023, documented residents do not leave their individual personalities or basic human rights behind when they move to a long-term care facility. This facility treats each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life and recognizes each resident's individuality. Resident #11 was admitted to the facility on [DATE], with a diagnosis of Dementia, Cerebrovascular Disease, Delirium, and a history of failing. Resident #11 was a new admission, and their Minimum Data Set (an assessment tool) was not completed at the time of the incident. An Incident Report dated 03/16/2024 at 5:17 PM, documented Resident #11 was observed sitting on the floor in front of the nursing station. The Medical Doctor and family were notified at 6:00 PM. A Facility investigation dated 03/16/2024 at 5:17 PM, documented during camera review Resident #11 was seen on the floor in front of the nursing station for an extended period. Resident #11 was observed removing their gown and disposable brief. Although Certified Nursing Assistant #1 tried to cover them with their gown, Resident #1 intermittently removing the gown and cover. Registered Nurse #1 reported that Resident #11 was not transferred back to the chair as they were waiting for the Nursing Supervisor #1 to assess Resident #11. Registered Nurse #1 did not realize that Resident #11 was on the floor for an extended period. Resident #11 was transferred back to the chair after Nursing Supervisor #1 arrived at the unit and assessed Resident #11. The facility determined that there is reasonable cause to believe that abuse, neglect, and mistreatment occurred. A Care Plan for Activity of Daily Living and self-care deficit initiated on 03/15/2024, documented Resident #11 required substantial/maximal assistance with upper body dressing and was dependent on lower body dressing. An Abuse Care Plan dated 03/16/2024, documented Resident #11 slipped from their chair and sat on the floor for an extended period. Interventions included assessing for signs of injury and monitoring skin for bruising and changes in behavior/condition. A Nursing Incident Note, late entry, dated 03/16/2024 at 6:14 PM, written by Registered Nurse Supervisor #1, documented status post fall/behavior follow-up: Resident #11 was observed sitting on the floor in front of the nursing station. The staff placed Resident #11 at the nursing station due to placing themselves on the floor. Resident #11 was confused and not able to recall what happened. A full body assessment was done, and the family was notified. A Facility's Surveillance Video recording dated 03/16/2023 from 5:10 PM to 5:59 PM, reviewed with the Security Supervisor and the Assistant Director of Nursing revealed Resident #11 was transferred from the Hoyer lift to the lounge chair by the nursing office. At 5:17 PM, Resident #11 removed their hospital gown and threw it onto the floor. Resident #11 stood up by holding onto the handrail. Certified Nursing Assistants intermittently attended to Resident #11. At 5:24 PM, Resident #11 slowly slid from the chair to the floor, resting their head on the bottom of the chair. Certified Nursing Assistant #1 and Certified Nursing Assistant #2 were standing by and did nothing then left the scene. Resident #11 continued to lie on the floor in a disposable brief. At 5:29 PM, Certified Nurses Assistants slowly appeared from the dining room and attempted to cover Resident #11, who continued to remove the sheet. At 5:30 PM, Registered Nurse #1 approached Resident #11 and went to the nursing office. At 5:33 PM, Registered Nurse #1 came out of the nursing station and stood by Resident #11 with no interventions. At 5:35 PM, all staff left Resident #11 on the floor and disappeared from camera view. At 5:37 PM, Certified Nursing Assistant #1 made attempts to dress Resident #11, but Resident #11 refused. Certified Nursing Assistant #1 went to sit in the dining room and was watching Resident #11 from a distance. At 5:46 PM, Resident #11 removed the disposable brief and continued laying on the floor completely naked. Certified Nursing Assistant #1 continued sitting in the dining room with no attempts to cover Resident #11. Two more staff passed Resident #11 with no attempts to cover Resident #11. At 5:48 PM, Certified Nursing Assistant #2 covered Resident #11's lower part with a sheet and left. At 5:56 PM, Registered Nurse Supervisor #1 came to the unit and assessed Resident #11. At 5:59 PM, Certified Nursing Assistant #1, Registered Nurse Supervisor #1, and Registered Nurse Supervisor #2 assisted Resident #11 to the sitting position. During a telephone interview on 11/01/2024 at 2:29 PM, Certified Nursing Assistant #1 stated they were assigned to Resident #11 on 03/16/2024 during the 3:00 PM to 11:00 PM shift and did not do anything wrong. Certified Nursing Assistant #1 stated Resident #11 was a new admission, had episodes of behavior, and was removing their clothes despite they tried to cover Resident #11. Certified Nursing Assistant #1 stated Resident #11 put themselves on the floor. Registered Nurse #1 was present, called the Nursing Supervisor, and told them to monitor Resident #11. Certified Nursing Assistant #1 also stated they were watching Resident #11, to ensure they did not hurt themselves. Certified Nursing Assistant #1 further stated they are no longer working in the facility. During a telephone interview on 11/01/2024 at 2:02 PM, Certified Nursing Assistant #3 stated they were not assigned Resident #11 but worked on 03/16/2024 3:00 PM -11:00 PM shift. Certified Nursing Assistant #3 stated around dinner time at around 5:00 PM, Resident #11 had behavior and keep removing their clothes and moving from the chair. Certified Nursing Assistant #3 stated Resident #11 was confused and placed themselves on the floor. Certified Nursing Assistant #3 stated Certified Nursing Assistant #1 was attending to Resident #11. Certified Nursing Assistant #3 stated the Registered Nurse was there and staff should have maintained Resident #11's privacy and moved them from the floor. Certified Nursing Assistant #3 stated the Administration told them they neglected Resident #11 and were fired along with other staff on the unit. During a telephone interview on 11/07/2024 at 1:45 PM Registered Nurse #1 stated they were working on 03/16/2024 7:00 AM to 7:00 PM shift and was assigned to Resident #11. Registered Nurse # 1 stated Resident #11 started lowering themselves to the floor in the dining room, and they told Certified Nursing Assistants to put Resident #11 by the nursing station for observation. Registered Nurse #1 stated they called the Registered Nurse Supervisor two times. Registered Nurse #1 stated Resident #11 removed their gown and put themselves on the floor by the nursing station. Registered Nurse #1 stated Certified Nursing Assistant #1 tried to cover Resident #11 multiple times, but Resident #11 refused. Registered Nurse #1 stated they assigned Certified Nursing Assistant #1 to watch Resident #11 and went to attend to another residents. Registered Nurse #1 stated they did not assess Resident #11 but looked at them while on the floor, and there was no visible injury. Registered Nurse #1 further stated they were waiting for the Nursing Supervisor to come and see what Resident #11 was doing and went to give medications. Registered Nurse #1 stated they don't recall if Resident #11 removed their disposable brief. Registered Nurse #1 stated their actions regarding Resident #11 were not enough. Registered Nurse #1 stated they should have instructed staff to maintain Resident #11 privacy, perform body assessment, and move Resident #11 from the floor. Registered Nurse #1 stated they don't recall when they called the Medical Doctor. During an interview on 11/06/2024 at 1:44 PM, Registered Nurse Supervisor #1 stated they were called by Registered Nurse #1 around 5:00 PM on 03/16/2024, Resident #11 was agitated and restless and tried to stand up and wiggle themselves to the floor. Registered Nurse Supervisor #1 stated they were not told Resident #11 was on the floor for a long period. Registered Nurse Supervisor #1 stated they told Registered Nurse #1 that if the behavior persists, Certified Nursing Assistant #1 should be assigned to monitor Resident #11 and call the doctor. Registered Nurse Supervisor #1 stated about five to ten minutes later, they went to assess Resident #11. Registered Nurse Supervisor #1 stated upon arrival, they saw Resident #11 on the floor by the nursing station, was covered with a bed sheet, and seemed comfortable. Registered Nurse Supervisor #1 stated they asked Registered Nurse #1 and other staff how long Resident #11 was on the floor, and they said just now. Registered Nurse Supervisor #1 stated they assessed Resident #1 with no visible injury noted, and Resident #11 denied any pain, and was transferred to their room. Registered Nurse Supervisor #1 stated they reviewed the camera and thought the staff should have stayed with Resident #11 and made sure they were fully covered. Registered Nurse Supervisor #1 stated it was inappropriate and disrespectful to Resident #11 to leave them naked on the floor for a long period of time. Registered Nurse Supervisor #1 stated it was Registered Nurse #1 responsibility to assess Resident #11 on the floor, make sure their privacy and dignity were maintained, instruct staff to continue to redirect the resident, to cover them, and assist Resident #11 from the floor, call Medical Doctor and notify Registered Nurse Supervisor. During an interview on 11/06/2024 at 4:30 PM, the Director of Nursing stated the Assistant Administrator brought to their attention on 03/19/2024 that they reviewed the video dated 03/16/2024 and observed that Resident #11 was noted on the floor for an extended period of the time. The Director of Nursing stated they reviewed the video and observed Resident #11 was on the floor for an extended period while multiple staff going back and forth with no effort to assist Resident #11. The Director of Nursing stated Registered Nurse #1 was present and was expected to assist and direct staff accordingly to ensure the dignity and safety of Resident #11. The Director of Nursing stated Resident #11 removed their disposable brief and was completely naked. The Director of Nursing stated they did not see any attempts to cover Resident #11 or move them away from heavy traffic (there was a food tract and carts in the area). During a telephone interview on 11/08/2024 at 12:18 PM, Assistant Administrator stated on 03/19/2024, while doing a routine random surveillance check, came across the video where they observed Resident #11 on the floor and reviewed it from the beginning to the time Resident #11 was picked up by Registered Nurse Supervisor #1 and other staff from the floor. The Assistant Administrator stated they called the Director of Nursing immediately, reviewed the video together, and started the investigation. The Assistant Administrator further stated their concern were Resident #11 was on the floor for a long period of time and how staff responded to Resident #11 being on the floor. 10 NYCRR 483.10 (a)(1)

Based on observation, record review, and interviews conducted during the Recertification Survey from [DATE]/ to [DATE], the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety. This was evident during the kitchen and food service observations. Specifically, the walk-in refrigerator and the emergency food storage contained expired food items. The findings are: The facility's policy titled Food and Supply Storage with a last revision date of ,d+[DATE] documented that most, but not all products contain an expiration date. The words 'sell-by', 'best-by', 'enjoy- by', or 'use -by', should precede the date. The 'sell-by is the last date food can be sold or consumed; do not sell products in retail areas or place on patient/trays/resident plates past the date on the product. Foods past the use by, sell-by, best-by or enjoy by date, should be discarded. On [DATE] at 11:30AM, during kitchen observation with the Food Services Director, 2 packets of unfrozen tortillas with expiration date of [DATE] was observed in the refrigerator called the Cook's Box as per the Food Service Director. An interview with the Food Service Director was immediately conducted who stated that the tortillas were being defrosted and that they can use the product 3 months after the expiration date, once its frozen, and that the tortillas was being defrosted at this time. On [DATE] at 02:57 PM, the Emergency Food Storage supply was observed with the Food Services Director. Several cans of chili con carne with beans with an expiration date of ,d+[DATE] was observed. On [DATE] at 03:05 PM, the Food Service Director was interviewed and stated that the executive chef is responsible for checking the expiration dates of the supplies and in their absence, they have the other chefs that does the checking. The Food Service Director stated they do not have a log that indicates if the items are checked or not and was not aware as to when the food supplies were last checked for expiration. The Food Services Director stated that the expired items have a 3-month window that they can still be used after the expired date. The Food Service Director also said that for the emergency supply of food, the stock person would rotate the goods, so as not to have expired items, but no log is kept as to when this occurs. 10 NYCRR 415.14(h)

Based on observation, record review, and staff interviews conducted during the Recertification Survey from 10/31/2024 to 11/07/2024, the facility did not ensure that infection prevention control practices were followed to help prevent the spread, development, and transmission of communicable diseases and infections. Specifically, 1.) The facility did not conduct an annual review of the water management plan, and 2.) Enhanced Barrier Precautions were not maintained during intravenous medication administration through a Peripherally Inserted Central Catheter. The findings are: 1.) The facility policy and procedure titled Legionnaire's Disease: Prevention and Control with a last revision date of October 2024 documented that the Director of Plants Operations will review and update annually the environmental assessment of the water system. A review of the document titled Potable Water Survey, Sampling Program, and Plan that was signed for by the facility owner on 07/08/2019 showed that the facility did not have a recent review of their Water Management Plan in the last 12 months. On 11/04/2024 at 11:30AM, the Director of Maintenance was interviewed and stated that they had scheduled a vendor to review the water management plan and that they would ensure that the water management plan includes all the required components. 48876 2.) The facility policy titled Enhanced Barrier Precautions with a last reviewed date of 05/29/2024 stated that the purpose of the policy was to prevent the spread of novel or targeted multidrug-resistant organisms. The policy stated Enhanced Barrier Precautions refer to the use of gown and gloves during high-contact resident care activities that provide the opportunities for transfer of multidrug-resistant organisms to staff hands. High-contact resident care activities includes device care or use of a device including central lines. Enhanced Barrier Precautions apply to all residents with indwelling medical devices. Resident #130 was admitted to the facility with diagnoses that include Peritoneal Abscess and Pyothorax. The Minimum Data Set assessment dated [DATE] documented that Resident #130 had intact cognition and was receiving intravenous medications. A physician's order dated 10/16/2024 documented Enhanced Barrier Precautions related to the presence of a Peripherally Inserted Central Catheter. A physician's order dated 10/30/2024 documented orders for Ampicillin-Sulbactam Sodium Injection Solution Reconstituted. Use 3 gram intravenously every 12 hours for Eggerthella lenta Bacteremia until 11/19/2024. During medication administration observation on 11/04/2024 at 03:14 PM, Registered Nurse #8 was observed performing intravenous medication administration via a Peripherally Inserted Central Catheter for Resident #130 without wearing a gown. An Enhanced Barrier Precaution sign was posted on the wall outside the resident's door. On 11/04/2024 at 3:20 PM, Registered Nurse #8 was interviewed and stated that they acknowledged the Enhanced Barrier Precautions signage that was posted for Resident #130 and that the precautions were implemented to prevent the spread of multidrug-resistant organisms for all patients with indwelling tubes, catheters, and wounds. Registered Nurse #8 further stated that they should have worn a gown, but they did not because they were nervous. On 11/04/2024 at 03:25 PM, Registered Nurse #7, who was the unit nursing supervisor, was interviewed and stated that Registered Nurse #8 should have worn a gown because they were in close contact providing care for a Resident with an indwelling medical device. On 11/07/2024 at 03:05 PM, The Director of Nursing was interviewed and stated that Enhanced Barrier Precautions have been put in place to prevent transmission of infections and the staff is to read the signage that is posted and follow the directive. The Director of Nursing stated that all staff who are performing care that requires close contact with a resident who has wounds and/or indwelling medical devices must don gloves and gowns. 10 NYCRR 415.19 (a)(1-3)

Based on observation, record review, and interviews conducted during the Recertification Survey from 10/31/2024 to 11/07/2024, the facility did not ensure that resident environment remains as free of accident hazards as is possible. This was evident in 1 (Sutro 2) of 13 units observed. Specifically, a housekeeping cart containing chemical disinfectants, antiseptic sprays, and bleach was observed unattended in the unit corridor with the cabinet door ajar and the keys hanging from the lock. The findings are: The facility policy titled Accidents and Hazards with a reviewed date of 08/2024 documented that it is the policy of the facility to provide residents with an environment free of hazards. The facility policy titled Standard Housekeeping Cart Set-up with a revision date of 10/21/2024 documented that housekeeping carts are to be kept locked at all times. Keys are not to be permitted to be left on the cart or in the lock. The housekeeping cart will be set up in a standardized manner. The set-up guidelines for the contents of the housekeeping cart cabinet includes air freshener, window/glass cleaner, Hydrogen Peroxide Disinfectant or approved disinfectant, furniture polish, cream cleanser/pumice stone if required. The facility policy titled Section: Safety, Chemical Storage with a reviewed date of 10/21/2024 documented that chemicals stored on housekeeping carts shall be in the control of the housekeeper at all times. Carts should remain locked when not in direct control of the housekeeper. On 11/05/2024 at 02:46 PM, the Housekeeper was observed mopping inside Room #S271. The housekeeping cart was observed in the hallway corridor with the door open and the keys hanging out of the lock. The housekeeping cart was not in direct view of the housekeeper. Inside the housekeeping cart cabinet were bottles of chemical disinfectants, bleach, and antiseptic sprays. On 11/05/2024 at 02:48 PM, the Housekeeper was interviewed and stated that they leave the cart in the hallway corridor when they are inside a resident's room. They stated they were supposed to keep the housekeeping cart locked to avoid anyone from getting into the cart and accessing chemicals they could use to cause harm to themselves or anyone else. On 11/06/2024 at 02:50 PM, The Assistant Director of Environmental Services was interviewed and stated that when a housekeeper is mopping a resident's room, the housekeeping cart should be close to them outside the door. The Housekeeping cart should be closed and locked because they cannot physically see it when it is outside the door and a resident can get into the chemicals and harm themselves or others. The Assistant Director of Environmental Services also stated that the housekeeping cart keys should be kept with the housekeeper. 10 NYCRR 415.12(h)(1)

Based on interview and record review conducted during the Recertification Survey from 10/31/2024 to 11/07/2024, the facility did not ensure that all alleged violations involving abuse, neglect, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the New York State Department of Health. This was evident in 2 (Resident #212 and #188) of 7 residents reviewed for Accidents out of 38 total sampled residents. Specifically, 1.) Resident #212 had an unwitnessed incident on 03/04/2024 when Resident was observed on the floor with bleeding to the left leg. X-ray report showed a sub-capital fracture of the right femoral neck with mild displacement. Resident #212 was unable to explain the occurrence. 2.) Resident #188 had an unwitnessed incident on 09/25/2024 when Resident was observed on the floor with discoloration to their right eyebrow. Both incidents were not reported to the New York State Department of Health. The findings are: The facility's policy and procedure titled Abuse/Neglect/Mistreatment-Prevention, Assessment of Reporting with a last revision date of 11/04/2022 documented that for events that take place in the nursing home, if during the investigation identifies that bodily severe injury has occurred and there is reasonable suspicions that abuse, neglect, mistreatment or exploitation is the cause, reports situation within two hours to New York State Department of Health. 1.) Resident #212 was admitted to the facility with diagnoses of Atrial Fibrillation and Non-Alzheimer's Dementia. The quarterly Minimum Data Set assessment dated [DATE] documented Resident #212 cognition as moderately impaired with a Brief Interview of Mental Status score of 11. The resident required substantial assistance with bed mobility and is dependent on transfer. The Comprehensive Care Plan related to Fall initiated on 04/27/2023 documented that Resident #212 is at high risk for falls related to confusion, deconditioning, and unawareness of safety needs. The interventions include to ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance and a low bed in place. The updated fall care plan dated 03/04/2024 documented that Resident #212 had an unwitnessed fall in the afternoon with a visible injury on their left lower leg. A nurse's progress note dated 03/04/2024 at 2:00 PM documented that at 1:24 PM, the nurse on duty called the supervisor and reported that Resident #212 had an unwitnessed fall. The resident was observed sitting on the floor on the right side of the bed. On assessment, the resident had a visible injury, bloody hematoma on the left lower leg measuring 7 centimeter x 6 centimeter. The resident was able to move both extremities. The Nurse Practitioner and the family were made aware. The facility incident report dated 03/04/2024 documented that at 2:16 PM, Resident #212 was noted sitting on the floor on the right side of the bed, head pressed against the enabler, and bleeding from the left leg. The resident was unable to give a description. The physician note dated 03/04/2024 at 3:48 PM documented that the nurse reported that Resident #212 was observed sitting on the floor on the right side of the bed. The resident sustained a bloody hematoma 7x6 cm on the left lower leg. Resident #212 was seen after an unwitnessed fall, with no loss of consciousness, vital signs were stable, and a pain scale of 10. Passive range of motion on both lower extremities, tenderness on hip palpation, no skin ecchymosis on hips. There was a hematoma with a small skin tear on the anterior left lower leg (shin) with small bleeding. A nurse's Progress Note dated 03/05/2024 at 3:08 PM documented that the Nurse Practitioner performed an assessment and ordered Bacitracin ointment for the left shin once a day, as well as an x-ray of the pelvis, hips, and femur. The pelvis and hip radiology results dated 03/05/2024 showed a sub-capital fracture of the right femoral neck with mild displacement. The facility's summary of investigation documented that the plan of care was followed, and there was no reasonable cause to believe that abuse, neglect, or mistreatment had occurred. On 11/07/2024 at 10:04 AM, Assistant Director of Nursing #1 was interviewed and stated they completed the summary of investigation and concluded that Resident #212 was at high risk for falls and that abuse did not occur because the plan of care was followed. They stated that Resident #212 sustained fracture of the femur. Assistant Director of Nursing #1 stated that the incident was not reported to the New York State Department of Health because the fall incident was not a case of abuse and that the fracture was sustained from the fall. On 11/07/2024 at 11:48 AM, the Director of Nursing was interviewed and stated that Resident #212 had a fall in their room and that the resident had a fracture. The Director of Nursing stated they were not aware that unwitnessed fall with major injury should be reported to the Department of Health. 37787 2.) Resident #188 was admitted to the facility with diagnoses of Age-related Osteoporosis, Parkinson's Disease, Dementia with Agitation and Behavioral Disturbances. The Quarterly Minimum Data Set, dated dated dated [DATE] documented Resident #188 had severely impaired cognitive skills. Resident #188 was always incontinent of bowel and bladder. The assessment further documented that Resident #188 was dependent in all activities of daily living. A facility's Accident / Incident Report documented that on 09/25/2024 at 6:45 AM, Resident #188 was observed lying on the right side of their bed and was noticed with a discoloration on the right forehead. Resident was unable to give description. A review of the Accident / Incident Report and employee statements did not indicate any witness to Resident #188's fall occurrence. A nurse's progress notes dated 09/25/2024 at 6:45 AM documented that Resident #188 discoloration on the forehead was 1.5 centimeter x 1.5 centimeter. Cold compress was applied. A comprehensive care plan on unwitnessed fall was initiated for Resident #188 on 09/25/2024 related to the unwitnessed fall with laceration on the right forehead. On 11/06/2024 at 12:33 PM, Registered Nurse #4 was interviewed and stated that Resident #188 was observed on the floor in their room next to their bed with laceration on the right eyebrow. The Registered Nurse further stated that it was not reported because they believe that the laceration was from the fall. On 11/07/2024 at 11:17 AM, the Director of Nursing was interviewed and stated that Resident #118 had an unwitnessed fall on 09/25/2024 and sustained a laceration on the right eyebrow. The Director of Nursing stated that the incident was not reported because there was no reason to believe that abuse, neglect may have happened. 10 NYCRR 415.4(b)(2)

Based on observation, record review, and interviews conducted during the Recertification Survey from 10/31/2024 to 11/07/2024, the facility did not ensure drugs and biologicals were stored in accordance with professional standards of practice for 1 of 13 units (2nd Floor Sutro Building). Specifically, the facility medication cart was not kept locked or under direct observation of authorized staff. The findings are: The facility policy and procedure titled Storage and Discard Dating of Drugs and Biologicals, effective date 01/04/2023, documented that all medications and other drugs, including treatment items, shall be stored in a locked cabinet, cart, or room inaccessible to residents and visitors. During medication administration, the nurse will lock the cart if they step out of visual range. Drugs shall be inaccessible only to authorized personnel. On 11/05/2024 at 2:05 PM, an unlocked medication cart was observed in the hallway corridor of the 2nd floor unit of the Sutro building adjacent to the unit dining room. The medication cart was unattended and was out of the sight of Licensed Practical Nurse #1 who was observed exiting Room #S271. On 11/05/2024 at 2:09 PM, Licensed Practical Nurse #1 was observed returning to the medication cart and was interviewed. Licensed Practical Nurse #1 stated that the medication cart was unlocked because they went to care for Resident #48 in Room #S271 who was asking for help. Licensed Practical Nurse #1 further stated that they should have locked the medication cart prior to attending to Resident #48 because anything could have been taken from the medication cart by anyone which could have potentially cause harm to the facility residents and others. On 11/06/2024 at 4:13 PM, Registered Nurse #1, who was the nursing supervisor, was interviewed and stated that the medication cart should always be locked even if the nurses turn their back to the cart, they should push the lock close. Registered Nurse #1 stated that if a resident needs help, the nursing staff should lock the medication cart before leaving it unattended. Registered Nurse #1 further stated that if the medication cart is unlocked and unattended, residents, staff or visitors can go through the medication cart, take the medications, and harm themselves or others. On 11/07/2024 at 8:03 AM, The Director of Nursing was interviewed and stated that the standard is for the medication cart to be locked before the nurse leaves it unattended. 10 NYCRR 415.18 (e)(1-4)

Based on interviews and record review conducted during the Recertification Survey from 10/31/2024 to 11/07/2024, the facility did not ensure residents, or their designated representatives were provided appropriate notification at the termination of Medicare Part A benefits. This was evident in 2 (Resident #402 and Resident #403) of 3 residents reviewed for Beneficiary Notification out of 38 total sampled residents. Specifically, the facility did not ensure that Notice of Medicare Non-Coverage were mailed to the residents' representatives on the same day telephone notification was made. The findings are: The facility policy titled Medicare Beneficiary Notice for Non-Coverage of Service with a last revision date of 01/03/2024 documented that residents / representatives are notified in writing when a decision of Medicare non coverage is made a minimum of 2 days' notice before the last covered Medicare day. The facility policy also documented a copy of annotated Notice of Medicare Non-Coverage should be mailed to the resident's appointed or authorized representative the day telephone contact is made. The Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 states that the form must be delivered at least two calendar days before Medicare covered services end and included the requirement that notification of changes in coverage for an institutionalized beneficiary/enrollee who is not competent be made to a representative. The instructions also stated that if the provider is personally unable to deliver a Notice of Medicare Non-Coverage to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise them when the enrollee's services are no longer covered. The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on that same date. The instructions also state that when direct phone contact cannot be made, the notice should be sent to the representative by certified mail, return receipt requested. 1) Resident #402 was discharged from Medicare skilled services and was discharged home on 05/22/2024. The Notice of Medicare Non-Coverage documented that Resident #402's designated representative was called on 05/20/2024 and was informed that Resident #402's coverage will end on 05/22/2024. There was no documented evidence that the notice was mailed to Resident #402's representative on the same day that telephone notification was made. 2) Resident #403 was discharged from Medicare skilled services on 09/09/2024. The Notice of Medicare Non-Coverage documented that Resident #403's designated representative was called and informed that Resident #403's coverage will end on 09/09/2024. There was no documented evidence that the notice was mailed to Resident #403's representative on the same day that telephone notification was made. On 11/06/2024 at 04:04 PM, the Director of Minimum Data Set & Managed Care was interviewed and stated that residents who will be discharged from Medicare Part A services are given at least 48 hour notice and that their right to appeal is explained. They stated that if a resident is cognitively intact, they ask them to sign the Notice of Medicare Non-Coverage. They stated that if a resident is cognitively impaired to make decisions, they notify the resident's designated representative, and that the Finance Department will mail them the notice afterwards. The Director of Minimum Data Set & Managed Care stated that Residents #402 and #403 did not sign the Notice of Medicare Non-Coverage. They stated that although Residents #402 and #403 were both cognitively intact, they had advised the staff to contact their designated representatives about their discharge from Medicare Part A services. On 11/07/2024 at 10:07 AM, the Account Receivable Manager was interviewed and stated they are responsible for mailing the Notice of Medicare Non-Coverage to the designated representatives. The Account Receivable Manager further stated they had no evidence to prove if the Notice of Medicare Non-Coverage was actually mailed to the designated representatives. On 11/07/2024 at 10:27 AM, the Administrator was interviewed and stated the Minimum Data Set Coordinator was responsible for providing Notice of Medicare Non-Coverage to residents and/or their designated representatives to review and sign before discharging them from Medicare Part A. The Administrator also stated they should mail, email, or use other methods to send the Notice of Medicare Non-Coverage to the designated representative on the day they notified the designated representative and keep a proof of it. 10 NYCRR 415.3(g)(2)(i)

Based on observation, interview, and record review conducted during the recertification survey from 10/16/2023 to 10/26/2023, the facility did not ensure residents' environment received adequate supervision and assistive devices to prevent accidents. This was evidenced for 3 of 3 residents (Resident #162, #243, and #336) reviewed for smoking out of 39 total sampled residents. Specifically, Resident #162 did not have a completed Smoking Safety Evaluation (SSE), was identified as a safe smoker despite a documented incident of smoking in their room on 10/10/2023. Resident #243's Smoking Safety Evaluation (SSE) documented they had incidents of lighting their cigarettes outside of the Designated Smoking Area (DSA). Resident #336 had an incident of smoking in the building on 5/15/2023 and was found smoking 2 packs of cigarettes simultaneously on 7/14/2023 and continued to be identified as a safe smoker. This resulted in Substandard Quality of Care that was Immediate Jeopardy (IJ) with the likelihood for serious injury, serious harm, serious impairment, or death to all residents smoking unsafely without adequate assessment and supervision. The findings are: The facility Smoking Policy dated 9/2023 documented they were a No Smoking facility and acknowledged a small subset of residents were admitted prior to the implementation of this policy and will be permitted to smoke. Approved smokers smoked only in designated areas. Administration was responsible for establishing smoking policies and ensuring all staff, residents, and visitors were aware. Nursing screened residents for smoking status upon admission and referred smokers to the Social Worker (SW) to complete a Smoking Safety Evaluation (SSE). Nursing referred unsafe smokers to the SW. The SW completed the SSE for smokers on admission and as needed, counseled unsafe smokers on the facility policy, and ensured those residents did not have access to smoking materials. Occupational Therapy (OT) assessed the residents' ability to smoke safely, Housekeeping (HK) ensured ashtrays were in the smoking area, and the Interdisciplinary Team (IDT) conducted team meetings to review resident compliance with the smoking policy. 1.) Resident #162 was admitted [DATE] and diagnosed with dementia, chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and nicotine dependence. Medical Doctor Orders (MDO) dated 9/27/2023 documented Resident #162 would receive oxygen at 2 liters per minute (LPM) as needed for hypoxia (an absence of enough oxygen to sustain bodily functions). The Annual Minimum Data Set 3.0 (MDS), an assessment, dated 04/14/2023 documented Resident #162 was a tobacco smoker. The MDS assessment dated [DATE] documented Resident #162 was cognitively intact. The Comprehensive Care Plan (CCP) related to smoking initiated 08/17/2023 documented Resident #162 would not suffer injury from unsafe smoking and included interventions to instruct the resident about facility policy on smoking locations, times, and safety concerns. Resident #162 could smoke unsupervised and was able to light their own cigarette and keep a lighter at their bedside. The CCP was updated 10/10/2023 and documented Resident #162 was found smoking in their room with an oxygen tank. Resident #162 was told they need to smoke outside to be considered a safe smoker and expressed understanding. There was no documented evidence of an evaluation by OT stating Resident #162 was a safe smoker. On 8/17/2023, SW #1 documented on an SSE that Resident #162 was a smoker. There was no documented evidence the Resident followed the facility smoking policy regarding the Designated Smoking Area (DSA), and there were no documented smoking safety notes. There was no documented evidence the SSE section for care planning was completed. A SW Note dated 10/09/2023 documented a care plan meeting was held, Resident #162 was not in attendance, and Resident #162 continued to be a safe smoker. The Security Guard Log dated 10/10/2023 documented Resident #162 was found smoking in their room with oxygen in use. A SW Note dated 10/10/2023 documented Resident #162 was found smoking in their room and was counseled. There was no documented evidence that SW #1 completed a reassessment SSE for Resident #162 after unsafe smoking was identified on 10/10/2023. On 10/18/2023 at 10:42 AM, Resident #162 was interviewed in their room, was not oriented to time and place, and stated they have been in the facility for 2 or 3 days. Resident #162 brought their cigarettes to the facility from where they previously resided and smoked outside in the DSA twice a day. Resident #162 was unable to recall where they previously resided and stated they had no family or friends. On 10/18/2023 at 11:33 AM, Resident #162 was observed using their rollator (a type of walker with wheels and a seat) and physical assistance from the security guard to enter the back patio. The security guard left Resident #162 and reentered the facility. Resident #162 stopped halfway down the path leading to the DSA. Resident #162 smoked the cigarette outside of the DSA and dropped the lit cigarette butt onto the ground next to the pathway. During an immediate interview, Resident #162 stated they knew they were not supposed to smoke in that area and should not drop cigarette butts on the ground. Resident #162 lit another cigarette, smoked it, dropped the lit cigarette on the ground, and walked back into the facility. There were 6 other cigarette butts observed on the ground among dry leaves. On 10/18/2023 at 5:50 PM, Resident #162 was observed sitting alone on their rollator outside of the DSA under a wooden canopy near the entrance to the patio. A No Smoking sign was posted on the wooden pillar next to the resident. Resident #162 smoked a cigarette and dropped the lit cigarette butt onto the patio. Resident #162 lit another cigarette, smoked it then discarded the cigarette in the manner as the first. There were no fire extinguishers, smoking blankets, or smoking aprons in addition to no staff observed on the patio. On 10/19/2023 at 9:10 AM, Security Guard (SG) #1 was interviewed and stated they were responsible for ensuring residents smoke in the DSA. The security camera showed residents walking on their way to the DSA. There was a camera located in the DSA, but it did not work, and SG #1 was unable to view the residents in the DSA. On 10/19/2023 at 9:17 AM and 2:11 PM, the Assistant Administrator (AA) was interviewed and stated they were made aware Resident #162 smoked in their room and the IDT team met to discuss the incident. Resident #162 was remorseful, was educated and counseled, promised not to smoke in their room again, and a decision was made not to take the resident's cigarettes and lighter. The AA did not know who saw Resident #162 smoking in their room. There were cameras in the DSA and security monitored the cameras. There was no documented evidence of IDT meeting notes regarding a re-assessment of Resident #162 as a safe smoker. On 10/18/2023 at 3:06 PM, Certified Nursing Assistant (CNA) #1 was interviewed and stated they are assigned to Resident #162 and knows that Resident #162 is a smoker. CNA #1 is not aware of Resident #162 smoking in their room and stated, if Resident #162 had an incident of smoking in their room, it was not on CNA #1's shift and CNA #1 never heard of it. On 10/19/2023 at 9:16 AM, SW #1 was interviewed and stated they were the SW for Resident #162 since 12/2022, and the resident was on the smoking list. Resident #162 held onto their cigarettes and lighter. The Assistant Administrator (AA) informed SW #1 that the unit clerk reported Resident #162 smoked in their room. SW #1 stated they spoke with RN #1 about the incident and counseled the resident. If Resident #162 was not found smoking in the DSA and was not extinguishing their cigarettes in the ashtray, the IDT or someone from Administration would inform them. SW #1 did not know the reason an SSE was not completed for Resident #162 prior to 8/2023. SW #1 stated they made an error when they did not fully complete the SSE in 8/2023. SW #1 stated Resident #162 was still a safe smoker, and an SSE was not completed despite the incident of Resident #162 smoking in their room on 10/10/2023. The SW stated they were responsible for completing the SSE along with input from OT and the IDT. Additionally, SW #1 stated the SSE was completed if there was an incident of unsafe smoking or a significant change in a resident's condition. The smoking CCP was updated quarterly, and the SSE was not done quarterly. The smoking policy did not address whether residents can maintain possession of their cigarettes and lighting materials and was determined on a case-by-case basis. Cognitive and physical ability were the determining factors for whether a resident held on to their smoking materials. The DSA was located outside, and the smoking hours were from 8:00 AM to 8:00 PM. On 10/23/2023 at 12:57 PM, the Director of Nursing (DON) was interviewed and stated on 10/10/2023, it was reported that there was a strong smell of smoke from Resident #162's room. Security responded and went to the unit. The nurse on the unit entered the resident's room and did not see the resident smoking but smelled smoke in the room. The resident was counseled on not smoking in the room and Resident #162 stated, I'm sorry. The oxygen concentrator was on, and Resident #162 was lying in bed. SW #1 was notified to counsel Resident #162 on the smoking policy and not to smoke in their room. The DON stated that SW #1 met with the IDT and concluded Resident #162 was a safe smoker because they were cognitively intact and had no previous smoking incidents. Resident #162 verbalized agreement and was not reassessed with the SSE. The smoking CCP was updated. The incident occurred at change of shift and nursing communicated to all other shifts. Resident #162 was monitored with purposeful rounding every 2 hours. There was no documented evidence defining purposeful rounding and there was no documented evidence Resident #162 was monitored every 2 hours. On 10/23/2023 at 2:23 PM, the Administrator was interviewed and stated on 10/10/2023, there was a smell of smoke on Resident #162's unit and staff immediately responded. The nurse on the unit went to Resident #162's room and did not observe the resident smoking. The notification that there was a smell of smoke went out to the other departments and SW #1 went to speak with Resident #162. The IDT met to determine if Resident #162 was still a safe smoker. There was no documented evidence there was an IDT meeting conducted regarding a re-assessment of Resident #162 as a safe smoker. On 10/24/2023 at 10:18 AM, Resident #162 was interviewed and stated they do not remember which staff spoke to them about a smoking incident in their room. They were told not to smoke in their room because they used oxygen. They have not spoken with SW #1, did not have a care plan meeting, and thought someone left a paper about smoking in their room for them. Resident #162 stated they go outside to smoke and traveled to the store to buy their own cigarettes. Resident #162 stated they did not know where they were and needed to get to Astoria, NY where they lived. Resident #162 stated they did not know how they will get home and felt totally lost. 2.) # 243 was admitted to the facility on [DATE] with diagnoses of aphasia (a language disorder affecting a person's ability to communicate), and Cerebral Vascular Accident (CVA) with left hemiplegia (one sided paralysis or weakness). The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #243 was severely cognitively impaired, sometimes understands, and was sometimes understood. The Comprehensive Care Plan (CCP) related to Smoking initiated 04/25/2023 and last reviewed 09/19/2023 documented Resident #243 did not require supervision while smoking. The SSEs dated 4/25/2023 and 7/13/2023 documented a safety smoking note that Resident #243 was assessed by the IDT and was a safe smoker; however, nothing was checked off on these SSEs, including the section regarding whether Resident #243 followed the smoking policy. The SSE dated 09/19/2023 documented Resident #243 followed the facility policy on location and time of smoking, had occasions where they lit a cigarette on their route to the DSA but is redirectable and continued to be reeducated, and was identified as a safe smoker. There wase no documented evidence that the SSE for 4/25/2023 and 7/13/2023 were completed. On 10/18/2023 at 10:50 AM, Resident #243 was observed smoking outside of the DSA. There were no staff observed with the Resident. On 10/18/2023 at 3:26 PM, RN #3 was interviewed, and stated residents were assessed upon admission for smoking and referred to SW for an SSE. A safe smoker was someone who can light their own cigarette, transfer themselves independently on and off the unit, and follow direction. The IDT determined whether a smoker was safe or unsafe. Smokers were supposed to be supervised in the DSA. Resident #243 did not follow direction and became easily agitated and aggressive. Resident #336 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (disrupted blood supply and restricted oxygen to the brain), chronic obstructive pulmonary disease, and nicotine dependence. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #336 was cognitively intact and required the assistance of 2 people to perform activities of daily living (ADL). The CCP related to mood and behavior initiated 3/20/2023 documented Resident #336 was noncompliant with smoking protocols and lights up cigarettes outside of the DSA. Interventions included monitor and document Resident #336's behavior. The CCP was revised on 7/14/2023 and documented Resident #336 was observed with 2 packs of cigarettes lit up in the garden. No new intervention was added at the time of the incident. The CCP related to smoking initiated 3/28/2023 documented Resident #336 had new functional deficits that required smoking reassessment on 5/15/2023. Interventions were added 7/14/2023 to check Resident #336 for extra cigarettes when they go to smoke. There is no documented evidence SW completed an additional SSE for Resident #336 as required for the change in functional deficits. There was no documented evidence of an evaluation by OT stating Resident #336 was a safe smoker. A Nursing Behavior Note dated 7/14/2023 documented [Resident #336] was found with two packs of cigarettes in the garden which they lit. As a result, these cigarettes had to be extinguished. Resident #336 was told this was unacceptable, should only have one pack of cigarettes in their possession, and should only smoke 1 cigarette at a time. The Assistant Director of Nursing (ADON) reported they would involve the resident's SW. SW Note dated 7/17/2023 documented SW #1 met with Resident #336 and reinforced safe smoking practices. Resident #336 reported they understood. There was no documented evidence of an SSE re-assessment following unsafe smoking. On 10/18/2023 at 4:03 PM, the Director of Social Work (DSW) was interviewed, and stated SWs were responsible for completing the SSE and CCPs for smokers. Once a resident was identified as a smoker, the SW educated the resident that this was a nonsmoking facility. Smoking cessation was offered. The SSE was completed when a smoker was identified, quarterly, and upon significant change. When a safe smoker was determined to be cognitively intact, OT would evaluate their motor skills. The SSE should be done before a resident was allowed to start smoking in the DSA. The SW was responsible for filling out the assessment with the information from the IDT. The smoker needed to be able to go to the DSA independently with no supervision and no one staying with them. Each smoker was provided with verbal education regarding the location of the DSA. There was no smoking contract. If smokers were noncompliant, they were counseled by the SW, and it was documented in a progress note. There was no documented evidence of an IDT meeting regarding Resident #336 after the incident of unsafe smoking. There was no documented evidence of an evaluation by OT after the incident of unsafe smoking. On 10/19/2023 at 9:16 AM, SW #1 was interviewed, and stated they were informed by the AA that Resident #336 had an incident on 7/14/2023 where they were found with 2 packs of lit cigarettes in the garden. Resident #336 also had an incident of smoking in the building on 5/15/2023 and an SSE was not completed at that time. A CCP meeting was held with the resident at the time and Resident #336 was reeducated not to smoke in the building. The plan was for Resident #336 to get assistance from staff to go to the garden to smoke. SW #1 completed Resident #336's SSE dated 10/16/2023 and determined Resident #336 was still a safe smoker. On 10/20/2023 at 3:48 PM, Immediate Jeopardy (IJ) was identified and declared. The facility Administrator and Director of Nursing were notified. On 10/24/2023 at 11:30 AM a removal plan was implemented, and Immediate Jeopardy was lifted based on the following corrective actions taken by the facility: -Resident #162's Smoking care plan was updated on 10/20/2023. A Smoking Agreement was signed by the resident and dated 10/20/2023. An SSE was completed on 10/21/2023. The facility's investigation regarding the smoking incident on 10/10/2023 was completed on 10/22/2023. -3 sampled safe and 3 unsafe smoking residents were reviewed, and the SSEs were completed on 10/20/2023 - 10/23/2023. Smoking Care Plans were updated between 10/20 -10/23/2023. All Smoking Agreements were reviewed with and signed by the smoking residents on 10/20/2023. -Lesson plans on Resident Smoking Policy and attendance sign-in sheets documented 72% (429 of 597) of all staff in-serviced, including Nursing = 70%, Security/Smoke Monitor = 100%, and Social Work = 78%, by 10/24/2023 at 11:00 AM. -Multiple observations conducted from 10/21/2023 to 10/24/2023 revealed smoking monitor in place, sign on the patio door with the smoking times of 8AM to 8PM, log of smoking residents being kept by the smoke monitor, updated list of unsafe and safe smokers available on all units and with the smoke monitor, patio clean and free of cigarette butts, 2 ashtray receptacles in the designated smoking area, and a fire extinguisher and smoking blanket available in the designated smoking area. -The revised smoking policy and procedure dated 10/20/2023 was reviewed and included: smoking protocols and rules, specific smoking hours, supervision of smokers by the smoking monitor, location of cigarettes and lighting materials, smoking apron availability, the smoking assessment frequency and determining factors for safe and unsafe smokers, and staff response related to smoking-related incidents. Based on observation, interview and record review conducted on 10/25/2023, the facility fully implemented the IJ Removal Plan, and the IJ was removed as of 10/24/2023 at 11:30 AM. 10 NYCRR 415.4(a)(2-7) 19546 43350

Based on record review and interviews conducted during the recertification and extended recertification survey from 10/16/2023 through 10/26/2023, the facility did not ensure an Infection Preventionist (IP) with specialized training was designated to be responsible for the facility's Infection Prevention and Control Program (IPCP). This was evident during the review of the Infection Control Task. Specifically, the facility's designated IP did not have documented evidence of completing specialized infection prevention and control training. The findings are. The Centers for Medicare and Medicaid Services (CMS) memo titled Center for Clinical Standards and Quality/Quality, Safety & Oversight Group. Ref: QSO-19-10-NH dated 3/11/19 documented Specialized Infection Prevention and Control Training for Nursing Home Staff in the Long-Term Care Setting. Effective 11/28/19, the final requirement includes specialized infection prevention and control training for the individual(s) responsible for the facility's IPCP. The course is approximately 19 hours long and comprises 23 modules and submodules. The facility's policy and procedure, titled, Nursing Homes: Infection Control Plan with a revised date of 6/2021, documented that the IP is a registered professional nurse who has a baccalaureate degree, works at least part time with basic training in infection control. He/she maintains a knowledge base of current infection prevention and control information through peer-networking, internet access, published literature and/or professional meetings and continuing education. He/she chairs the Infection Control Committee and participates in Quality Assurance and Performance Improvement (QAPI). The facility's IP's certificate of training dated 9/2/2021 documented that the IP had successfully completed Modules 1- 15 of the Centers for Disease Control and Prevention (CDC) Nursing Home Infection Preventionist Training Course which is comprised of 23 modules. On 10/23/2023 at 4:17 PM, the Infection Control Preventionist (ICP) was interviewed and stated they became the facility's IP on 1/31/2023 and the facility never requested an IP completion certificate. The ICP also stated that they just realized their ICP training was not completed when the completion certificate was requested by the State Surveyor. The ICP further stated they completed the Respiratory module and received the completion certificate after taking the test today. On 10/26/2023 at 12:49 PM, the Director of Nursing Services (DNS) stated that they thought the ICP had their IP Certificate of Completion before starting at this facility. The DNS further stated the ICP completed one of the missing modules a few days ago. 415.19

Based on observations and interviews conducted during the Recertification survey from 10/16/2023 to 10/26/2023, the facility did not ensure that a safe, functional, sanitary, and comfortable environment was provided for residents, staff, and the public. This was evident during observation of the Library/Activity Room and the facility outdoor Patio/Garden. Specifically: 1). The Garden Area contained tables that were in disrepair, had broken furniture, banister, tiles, blinds, and umbrellas; and 2). The Library Room was observed in disrepair with signs of water damage, black and green colored substance on the wood paneling, peeling plaster, and mis-hung book shelves. The findings are: 1. On 10/18/2023 at 11:33 AM, the following was observed on the outdoor Patio/Garden: a. 3 of 5 umbrellas that were broken and had holes in the cloth, b. 1 broken plastic chair in the smoking area and 4 chairs near the patio entrance that were heavily worn with warped wood causing the chairs to lean off center. c. 4 of 4 tables that were warped, scratched, and crumbling and broken off at the edges. The top of one of the tables was loose and able to be pulled off the metal frame holding it up. d. The banister to the stairs leading from the upper portion of the back patio to the lower landing had black tape around part of the frame holding the wooden frame to metal poles. A portion of the wooden frame of the handrail broke apart and fell off when grabbed for support. e. An erected structure on the lower portion of the back patio had metal poles with a green tarp wrapped around to create the appearance of a [NAME]. The green tarp was attached using bungee cords. The roof of the structure had flexible wooden blinds pulled over the top and were falling off creating a large opening in the roof. The blinds were not affixed to the structure and were hanging down the side of the structure. Another section of blinds was lying on the floor next to the structure. There was a metal bench and table and another chair contained inside of the structure. 19546 2). On 10/26/23 at 10:29 AM the following was observed in R 1 Library Room: a. Warped wood paneling, signs of water damage, musty odor, rows of books directly underneath the warped wood paneling were layered with a black spotty substance and a slimy green substance. b. The ceiling above the alcove was observed with signs of water damage, brownish stains, and peeled plaster. c. Multiple book shelves containing books were slanted and hanging off the hooks. On 10/26/23 at 1:43 PM, an interview was conducted with the Director of Support Services (DSS) who stated that they are responsible for managing the environment. The DSS also stated that staff report furniture that might appear dangerous or need to be removed and they focused on upkeep of the grounds. Staff clean the furniture in the garden, mostly during the spring and summer and Housekeeping staff is responsible for cleaning the Library Room. The Environmental Committee make random and weekly rounds to ensure that staff are doing their jobs. There was a leak in the Library some time ago and some books had to be removed. The Recreational Therapeutic staff use the Library Area together with the residents. The DSS further stated that they do not enter the Library Room, however they occasionally see staff using the duster to clean off the shelves. Housekeeping staff remove all the trash and clean the outside perimeter of the building. They periodically check for debris. They report cigarette butts in the garden and loose branches that should not be there. Maintenance is responsible for repairs or for discarding broken furniture. 415.29

Based on observation, record review, and interviews conducted during the recertification and extended survey from 10/16/2023 to 10/26/2023, the facility did not ensure an ongoing activities program was provided to meet the interests of and support the physical, mental, and psychosocial well-being of the resident for 3 (Residents #25, #252, and #366) of 6 residents reviewed for Activities. Specifically,1) Resident #25, a Spanish speaking resident, expressed they did not like the activities to the psychiatrist, and there was no follow-up to ensure Resident #25's needs were reassessed to ensure activities that met their interests were provided, 2) Resident #252, a resident with severely impaired cognition, was observed for extended periods without meaningful activities, and 3) Resident #366, who has severely impaired cognition, was observed multiple times in bed with no meaningful activities. The findings are: The facility policy and procedure revised 9/1/23 titled Therapeutic Recreation Program-Scope documented the facility strives to sustain each resident's dignity and meaningful engagements. The recreation programs will be broad enough in appeal and content to give each person opportunities to participate. Activities are an integral part of the daily life. They will be age appropriate and reflect individual interests and cultural backgrounds. Both group and individual engagements will be offered. Activities are designed to enhance meaning in resident's lives and support vitality and purpose. 1) Resident #25 had diagnoses of bipolar disorder and personality disorder. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #25 is Spanish speaking, needs an interpreter, is cognitively intact, and feels down and depressed. The Annual MDS dated [DATE] documented Resident #25 found it very important to listen to music, keep up with news, do favorite activities, and attend religious services. Resident #25 found it somewhat important to have books and magazines, do group activities, and get fresh air. On 10/17/2023 at 10:47 AM, Resident #25 was interviewed and stated the only activity available to them is their television. Resident #25 stated they are bored and depressed because no one interacts with them, visits them, or invites them to activities they can participate in. Resident #25 stated they desire group activities with Spanish speaking residents they can communicate and converse with. The Comprehensive Care Plan (CCP) related to activities, initiated 4/6/2023, documented Resident #25 was independent with meeting emotional, intellectual, physical, and social needs. Interventions included Resident #25 being introduced to residents with similar backgrounds, invited to scheduled activities, provided a program of activities that is of interest and empowers the resident by encouraging choice and self-expression, and encouraged and supported in activities of leisure such as watching television and listening to music. The Recreation assessment dated [DATE] documented Resident #25 tolerated one-to-one (1:1) visits in their room, enjoyed listening to music, watching movies, and attending Catholic services. The Psychiatry Consult dated 6/23/2023 documented Resident #25 was lonely, did not like the activities offered, and reported the movies offered are not appropriate. Psychiatry Consult dated 7/18/2023 documented Resident #25 was lonely and irritable, and the resident wished staff would talk to them more. The recommendation was to engage Resident #25 in activities. The Recreation assessment dated [DATE] and 9/21/2023 documented Resident #25 tolerated one-to-one (1:1) visits in their room, enjoyed listening to music, watching movies, and attending Catholic services. Psychiatry Consult dated 9/8/2023 documented Resident #25 appeared enthusiastic to retry connecting with a Recreation Volunteer (RV) and the plan was discussed with the team. A Nurse Practitioner (NP) Note dated 9/11/2023 documented the NP will discuss a RV for Resident #25 with the Recreation Department again. The Activities Log for October 2023 documented Resident #25 was involved in 1 ball game, 1 current events review, and 1 music activity. There was no documented evidence 1:1 visits or religious activities were provided to Resident #25. On 10/25/2023 at 05:27 PM, Certified Nursing Assistant (CNA) #25 was interviewed and stated Resident #25 has reported they are depressed, and they come out of their room and walk up and down the hallways to get exercise. There are no activities on the unit. The only time CNA #25 sees activities on the unit is when pet therapy is provided. There are a lot of activities provided downstairs in the main activity area, but Resident #25 has not gone to the off-unit activities. On 10/26/2023 at 12:35 PM, Therapeutic Recreation Aide ([NAME]) #3 was interviewed and stated they were assigned to Resident #25 before the resident was moved off their unit in October 2023, and [NAME] #3 completed Resident #25's Recreation Assessments. Resident #25 enjoys listening to music and sometimes enjoys reading the Spanish newspaper. Resident #25 was introduced to 2 other Spanish speaking residents and the Latin Club. Resident #25 attended the Latin Club and stayed for a bit but then left. When there are concerts or movies on the calendar that Resident #25 enjoys, the resident might come down. Resident #25 mostly enjoys talking to other people, and [NAME] #3 used to visit with the resident when they were on [NAME] #3's assigned unit. [NAME] #3 no longer visits with Resident #25 and Resident #25's new [NAME] does not speak Spanish. The 1:1 visits are not scheduled, tracked, or documented. There is only an activity log for off-unit activities. [NAME] #3 does not have any involvement with the RV program, and assigning a RV to Resident #25 was not part of the resident's CCP. RVs can provide 1:1 visits with residents, but there are no Spanish speaking RVs, so no one was assigned to Resident #25. Resident #25 expressed the desire for more interaction, and [NAME] #3 encouraged Resident #25 to come down to the off-unit activities. Resident #25 did not enjoy interacting with the other residents downstairs, and [NAME] #3 tried to visit with Resident #25 more often. The nurse on the unit communicated that Resident #25 needed more attention and support, and [NAME] #3 tried to provide this to the resident when they were on their assigned unit. On 10/26/2023 at 03:16 PM, the Therapeutic Recreation Director (TRD) was interviewed and stated the Activities Log documents activities that have been identified as appropriate for residents according to their [NAME]. The Recreation Department establishes resident preferences, types of activities they prefer, and if residents want to spend their time socializing. With this information, the [NAME] chooses the types of activities that will benefit the resident. The 1:1 visits are scheduled and appear on the Activity Calendar. There are different types of 1:1 activities such as intellectual, conversational, pet visits, and music strollers. Some TRAs are documenting activities with residents by hand because the new computer system to track activities was introduced in 9/2023. If the TRAs do not save their work in the computer program correctly, it disappears. The Activity Calendar does not reflect on-unit activities, but there are a lot of 1:1 visits and materials provided to residents who choose to stay in their room. These 1:1 visits cannot be logged because they are not scheduled on the Activity Calendar. RVs are transporters and escorts. Some RVs are capable of being trained to chat with residents. The TRD did not recall ever assigning a RV to Resident #25 or receiving a request for Resident #25 to have a RV visit with them. On 10/26/2023 at 12:18 PM, the Psychiatrist was interviewed and stated if they have concerns during their evaluations that involve other departments, the Psychiatrist documents the concerns in their note. The nurse or the Medical Doctor (MD) will review the Psychiatry notes and act as the dispatcher to ensure the Psychiatrist recommendations are communicated with the other departments. Resident #25 is very lonely, has no family, and has anxiety. The Psychiatrist set Resident #25 up with the Recreation Department for a volunteer to visit with the resident, but Resident #25 did not find the volunteer to be compatible. The Psychiatrist spoke with the MD and was informed the Recreation Department would attempt to set Resident #25 up with another volunteer. 44842 2) Resident #252 had diagnoses of Dementia, Epilepsy, and Cerebral aneurysm. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #252 had severely impaired cognition. 10/17/23 11:00 AM to 11:27 AM, Resident #252 was observed sitting in a chair by the nurse's station. The television by the nurse's station was off, and music was playing from a speaker. There was no activity programming in progress. On 10/18/23 at 11:55 AM, Resident #252 was observed sitting in a chair by the nurse's station. There was no activity programming in progress. Nail Spa was scheduled for 11:00 AM On 10/20/23 at 10:06 AM, Resident #252 was observed lying in bed with their eyes open. There was no television or music on, and there were no staff members in the room. On 10/24/23 at 10:01 AM, Resident #252 was observed sitting in a chair by the nurse's station. Another resident was sitting in the same area. There was no activity programming in progress. On 10/24/23 at 11:10 AM, Resident #252 was observed sitting in the day room. A Certified Nursing Assistant (CNA) was also sitting in the room. The television was on, and there was no activity programming in progress. On 10/24/23 from 01:25 PM to 3:00 PM, Resident #252 was observed sitting in a chair across from the nurse's station with 3 other residents. There was music playing. There was no activity programming in progress. Balloon Toss was scheduled for 3:00 PM. On 10/25/23 at 04:25 PM, Resident #252 was observed sitting in a chair by the nurse's station with 5 other residents. There was music playing on a speaker. There were 9 other residents sitting in the dayroom with the television was on, and there was no activity programming in progress. Table Games were scheduled to begin at 3:30 PM. On 10/26/23 at 10:05 AM, Resident #252 was observed sitting in a chair by the nurse's station with 5 other residents. There was no music or television playing. There were 6 residents sitting in the day room with the television on, and there was no activity programming in progress. On 10/26/23 at 10:58 AM, Resident # 252 was observed sitting in a chair by the nurse's station with music playing on a speaker. There was no activity programming in progress. The Comprehensive Care Plan (CCP) relating to Activities, initiated 3/27/23, documented Resident #252 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits. The goal was for the resident to maintain involvement in cognitive stimulation, social activities such as bingo, coffee break, and casino as desired. Interventions included invite/escort the resident to scheduled activities and introduce the resident to residents with similar background, interests, and encourage/facilitate interaction. The Unit Activity Calendar for Resident #252's unit dated 10/16/23 to 10/26/23 documented 1:1 Visits with at 10:00 AM and Music at 11:00 AM on Mondays, Current Events at 11:45 AM and Balloon Toss at 3:00 PM on Tuesdays, nail spa at 11:00 AM and Table Games at 3:30 PM on Wednesdays, Chit Chat at 11:30 AM and Bingo at 3:30 PM on Thursdays, and 1:1 Visit (Music Therapy) at 11:00AM and Socials/Party/Special Events at 4:00 PM on Fridays. The Activities assessment dated [DATE] documented Resident #252 has advanced dementia, was very social, and needed to be escorted to off-unit activities. Resident enjoyed 1:1 interactions and small on/off unit music groups. Also, resident engaged in 1:1 interactions with Therapeutic Recreation staff and peers of their choice, and they participated in casino night, pet therapy, of- unit special events, and loved to have coffee. The review of the recreation Multi-Day Participation Report from 10/16/23 to 10/26/23 revealed Resident #252 attended 1:1 Visit (Music Therapy) on 10/20/23 and Bingo on 10/26/23. On 10/26/23 at 10:08 AM, CNA #17 was interviewed and stated Resident #252 was confused and usually walks back and forth from the nurse's station to the dining room. The residents mostly sit around the nurse's station with nothing to do. CNA #17 further stated the facility could do better with their activity program. In the past there were more activities on the Dementia unit. On 10/26/23 at 10:33 AM, Licensed Practical Nurse (LPN) #9 was interviewed and stated sometimes the residents watch television or listen to music at the nurse's station and in the dayroom. Once in a while, someone comes and plays the piano in the day room or recreation escorts residents to activities. This floor has less activities than other floors. LPN #9 further stated that more entertainment would be good for the residents. On 10/26/23 at 10:59 AM, the Registered Nurse Manager (RNM) #2 was interviewed and stated before the pandemic there were a lot more activities on the dementia unit. Those residents who wander pace up and down the hallway and others just sit by the nurse's station or in the day room the majority of the day. There is not a lot of interaction on this unit. The CNAs and nurses try to entertain and engage the residents. A music therapist comes in sometimes and plays songs suited for their generation, and a volunteer comes and paints residents' nails on Wednesdays. The RNM #2 further stated they don't see much more than that which is kind of sad. On 10/26/23 at 11:15 AM the Therapeutic Recreation Aide ([NAME]) #2 was interviewed and stated the activities on Resident #252's unit usually start at 11:00 AM. Right now, recreation does coloring, meditation, and a little bit of chit chat. Recreation also provides activity or sensory stimulation through auditory, music, coloring, painting, and watching the Price is Right and Let's Make a Deal. [NAME] #2 stated they put music on through a speaker and provide a Spanish or English newspaper upon arriving to the unit. Once residents are done eating their breakfast, the nursing staff helps support by putting on music or television programs which they enjoy, and that entertains the residents until [NAME] #2 arrives on the unit. 39136 3.) Resident #366 was admitted with diagnoses that include Alzheimer's Disease and Dementia. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #366's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of 0. The MDS documented that according to Resident #366's family, it was very important for the resident to have books and magazines to read, listen to music, do things with a group of people, and go to religious services. On 10/18/23 at 9:16 AM, Resident #366 was observed sleeping in bed. On 10/18/23 at 11:16 AM, Resident #366 was observed resting in bed. The TV was on very low. On 10/20/23 at 11:32 AM, Resident #366 was observed resting in bed with the TV on. On 10/23/23 at 10:01 AM, Resident # 366 was observed resting in bed awake with the TV on. On 10/24/23 at 2:43 PM, Resident #366 was observed sleeping in bed with a newspaper on the bedside table away from the resident unopened. On 10/25/23 at 9:54 AM, Resident #366 was observed resting in bed. The TV was on, and the same newspaper was on the bedside table away from the resident, unopened. A Comprehensive Care Plan (CCP) related to Activities initiated on 8/28/23 documented that Resident #366 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to Dementia. The interventions include ensuring that the activities the resident attends are compatible with physical and mental capabilities, with known interests and preferences, and inviting the resident to scheduled activities. The Unit Activity Calendar for Resident #366's unit dated 10/16/23 to 10/26/23 documented current events at 10:30 AM, coloring and meditation at 2:30 PM on Mondays, Bingo on the unit at 2:30 PM on Tuesdays, 1:1 visit at 10:30 AM, and nail/hand spa at 3:30 PM on Wednesdays, music at 1:30 PM and Bingo at 3:30 PM on Thursday, and current events at 11:30 AM and brain games at 3:00 PM on Friday. The Activity note dated 9/7/23 at 12:00 PM documented that Resident #366 can make all their needs and preferences known and attend to their independent leisure routine of choice. The Activities Calendar from 9/26/23 to 10/26/23 documented that Resident #366 participated in the following activities: One on one visit - 10/18/23, Brain games -10/20/23, Coloring/meditation 10/9/23 and 10/23/23, Current events - 10/2/23, 10/16/23, 10/20/23, and 10/23/23, and Nail/hand Spa - 10/18/23. Resident #366 attended two activities from 9/26/23 to 10/15/23, prior to the start of the NYS DOH survey. The progress notes dated 9/8/23 to 10/26/23 had no documented evidence that Resident #366 participated in any activities. On 10/24/23 at 2:53 PM, Certified Nursing Assistant #22 (CNA #22) was interviewed and stated that Resident #366 is given a pencil to draw when the resident is out of bed in the dining room. The recreation aide on the unit leave a newspaper at the bedside for the resident, but CNA #22 has not seen the resident reading it. Resident #366 is taken out of bed in the afternoon. In the morning, Resident #366 stays in their room, and the CNAs turn the TV on. On 10/24/23 at 3:03 PM, Therapeutic Recreation Aide #1 (TR #1) was interviewed and stated they were assigned to 2 units. They do 1:1 visit in the morning, but they did not do it today because they were on their other unit. TR #1 gave Resident #366 a newspaper in the morning for current events. They had Bingo at 2:00 PM, but the resident did not participate. They do a 1:1 visit, with the residents on the unit and asked the residents if they needed anything and turned on the TV. On 10/25/23 at 12:35 PM, Registered Nurse Manager #1(RNM #1) was interviewed and stated that Resident #366 sometimes gets activities. They give Resident #366 a newspaper, but the resident cannot read it. They are working on getting Resident #366 an audiobook. Resident #366 stays in the bed and watches TV. Resident #366 participates in activities in the dining room when the resident is out of bed. They are trying to do more activities on the unit. On 10/26/23 at 9:45 AM, the Therapeutic Recreation Director (TRD) was interviewed and stated Resident #366 gets a newspaper in the morning for current events. The unit's activity program starts at 10:45 AM, and they also do an event in the afternoon. Resident #366 participates in activities in the afternoon when the resident is out of bed. 415.11(C)(2) (i-iii)

Based on observation, interviews, and record review conducted during the Recertification Survey from 10/16/23 thru 10/26/23, the facility did not ensure the resident's right to a safe, clean, comfortable, and homelike environment. This was evident for 2 of 12 Units, (R6 and Sutro3). Specifically, 1) a) Unit R6 - room [ROOM NUMBER]a-was observed with linear broken plaster and paint on room walls. b) room [ROOM NUMBER] with rusty bathroom radiators were missing metal covers, exposing the inner pipes and were layered with dirt and debris. c) Corridor toilet across from room [ROOM NUMBER] had loose ceiling tiles and the call bell was wrapped around the grab bar in the toilet room. e) room [ROOM NUMBER] - loose cable wires. f) room [ROOM NUMBER]b- Crusty thick layered brownish stains on the base of the IV pole. The feeding pump was dusty and with scattered brown stains and streaks. g) room [ROOM NUMBER]a-wheelchairs heavily layered with dirt, dust and debris. 2) a) Sutro 3 room [ROOM NUMBER] noted with warped discolored and missing floor files. b) puddle of rust colored liquid pooled on 2 tiles. The findings are: The facility policy and procedure for Cleaning of Resident Equipment, effective July 2018, revised date May 2021, documented, To ensure medical equipment is properly cleaned and sanitized during use .or as required for infection control .equipment includes, suction machines, feeding pumps and poles, blood pressure cuffs and machines, wheelchairs, medication carts, oxygen concentrators, pulse oximeters and mechanical lifts. Wheelchairs mechanical lifts, IV pools, treatment and medication carts undergo cleaning on a continuous schedule by housekeeping. 1) On 10/17/23 - 10/26/23 the following were observed on Unit R6 between 8:00AM - 11:00AM: a. room [ROOM NUMBER]: loose cable wire upon room door entrance. b. room [ROOM NUMBER]a: wheelchair and wheel spokes layered with dirt and debris. c. room [ROOM NUMBER]b: wheelchair and wheel spokes with layered dirt, dust and debris. Missing right anti-tipper. d. room [ROOM NUMBER]a: wheelchair and wheel spokes with layered dirt, dust and debris. e. room [ROOM NUMBER]b: IV pole and base infusing Enteral feeds with thick layer of brownish substance. The pole had multiple brownish stains and dirt. The feeding pump layered dust and brownish stains. The floor underneath the pole with multiple areas of brownish stains. f. room [ROOM NUMBER]a: Wall behind the room chair with long linear and deep area of broken plaster and missing paint. g. room [ROOM NUMBER]: Rusty radiator in the room bathroom, missing bottom metal cover, exposed inner piping layered with dirt and dust. h. Corridor bathroom located across room [ROOM NUMBER]: loose ceiling tile in toilet area. Call bell wrapped around the grab bar in toilet area. On 10/26/23 at 08:35AM Licensed Practical Nurse (LPN) # 11 was interviewed and stated that housekeeping staff are always on the unit to keep the unit clean. LPN # 11 stated, the housekeeping department is responsible for cleaning the tube feeding poles and wheelchairs. On 10/26/23 at 08:40AM Housekeeper # 3 was interviewed and stated that I am a floater. My routine is to dust mop the corridors, dining room, staff and corridor bathrooms and nurses station. After 9:00AM, I begin to clean the residents rooms. Housekeeping is responsible for cleaning the IV poles when they are not being used. The pole is placed in the storage room on the unit. I make daily checks of the storage room and check for any resident equipment that is stored and needs cleaning. Wheelchairs are maintained by the housekeeping department. There is a housekeeper assigned for this job, during the hours of the 11:00PM - 8:00AM shift. There is a wheelchair cleaning schedule. I am responsible for reporting anything that is broken or needs repair to the unit nurse or my supervisor. 40686 2) On 10/16/23 at 09:32 AM and 10/17/23 at 11:55 AM, Room Sutro 361 was observed with Resident #61 lying in bed. There was a large section of warped, discolored and missing floor tiles by the head of the resident's bed and adjacent to the wall. A small puddle of rust-colored liquid was pooled on top of 2 of the tiles without an apparent source. On 10/26/23 at 1:43PM the Director of Support Services was interviewed and stated that Support Services covers, Housekeeping/Environmental services. I am responsible for managing several departments that include: Central Supply, Laundry and Environment Services. My role is important because all residents, all staff and all visitors should have a safe, clean, homelike and meaningful environment. As the Director I ensure that my staff are cleaning and sanitizing the environment on a daily basis. The resident rooms , hall corridors, ancillary and surface areas are all are wiped down with EPA recommended germicidal wipes and sprays. The high touch surfaces are also cleaned, such as grab bars, handrails, doorknobs, elevator buttons grab bars, doorknobs. We measure our performance by an audit tool that is used during rounds. Its a check off list of environmental areas to observe for. We have one housekeeping staff that is assigned to clean wheelchairs during the night shift. The staff are made aware of the wheelchairs that are on the cleaning schedule for their units so that the wheelchairs can be removed from the room and placed outside the door. 415.5(h)(2)

Based on observation, record review, and interviews conducted during the recertification and extended survey from 10/16/23 through 10/26/23, the facility did not ensure that residents had the rights to reside and receive services with reasonable accommodation of needs and preferences for 1 of 1 resident (Resident #30). This was evident for 1 of 1 resident reviewed out of 38 residents. Specifically, Resident #30, who needs special equipment for a shower, did not receive it. The findings Include: The facility policy and procedure titled; Quality of Life Accommodation of Needs, last revised on June 2023, documents, the facility's environment and staff behaviors are directed towards assisting the resident in maintaining and or achieving independent functioning, dignity, and well-being. The resident's needs and preferences, including the need for adaptive devices and modification to the physical environment, shall be evaluated upon admission and reviewed on an ongoing basis. Resident #30 was admitted to the facility with diagnoses including; Paraplegia and Pressure Ulcer of the Sacral Region Stage 4. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented Resident #30's cognition as intact with a Brief Interview for Mental Status (BIMS) score of 15. The resident requires extensive assistance of two persons in bed mobility, transfer, and personal hygiene. On 10/16/23 at 12:12PM, Resident #30 was interviewed and stated that they were not getting a shower because they had a wound on the buttocks and would not be able to sit on the shower chair. They last had a shower over a year ago. On 10/18/23 and 10/25/23 at 9:45AM and 10:05AM, Resident #30 was observed lying in bed with water in a basin on the bedside table. Interdisciplinary Rehab Screen Note dated 9/22/23 at 4:57PM documented that, as per Resident #30, they have been requesting a shower not a bed bath. Staff stated that due to the complexity of the wound, they would like to receive training to provide showers safely. It is documented that they will request Physical Therapy/Occupational Therapy sessions for assistance with showers and instruct the staff on how they can safely provide these. The Certified Nursing Assistant Accountabilty Record (CNAAR) dated October 2023 documented Resident #30 was bathed on 10/4/2023 and 10/7/2023 with physical assist in part of bathing from one person. The CNAAR documented the resident refused a bath on 10/11/23, 10/14/23, and 10/25/25, and a bath was not applicable to the resident on 10/18/23 and 10/21/23. On 10/26/23 at 10:00AM, Resident #30 was interviewed and stated that they did not shower because there is only a regular shower chair available, which hurts the resident's wound. Resident #30 further stated the staff informed the supervisor that they refused showers, but the showers were never offered. On 10/25/23 at 12:28PM, Registered Nurse Manager #3 (RNM #3) was interviewed and stated, that Resident #30 does not take showers because the resident refuses. They met with the therapist, and they were going to show the resident how to transfer to the shower chair. The therapist came, but the resident refused. On 10/26/23 at 12:42PM, Certified Nursing Assistant #14 (CNA #14) was interviewed and stated that they give Resident #30 warm water in a basin with soap, and the resident uses it to wipe themselves. Resident # 30 does not get showers because of the ulcer on the buttocks. They are supposed to get the resident something, but CNA #14 does not know if it is a chair or something to shower the resident with. CNA #14 has not seen it and does not know if they have it. Resident #30 has a big ulcer and cannot sit on the shower chair. It will be uncomfortable for the resident to sit on the shower chair. On 10/26/23 at 1:27PM, the Occupational Therapist (OT) was interviewed and stated that they evaluated Resident #30 a few weeks ago to evaluate the resident for bed bathing. Resident #30 will need specialized equipment for the shower room. The resident is a good candidate for bathing in bed. Because of the sacral wound and several medical issues, the resident cannot use the shower chair. Resident #30 will require a pressure relief surface on the shower chair. On 10/26/23 at 2:25PM, the Director of Nursing was interviewed and stated that there is a schedule for showers for the resident, but the resident refuses to shower most of the time. They are unaware that Resident #30 needs special equipment for showering. Nobody brought it to their attention that Resident #30 cannot use the shower chair. They would have purchased a shower chair to accommodate the resident's needs. They could have explored and looked for an alternate solution. 415.5(e)(1)

Based on record review and staff interview during the recertification, abbreviated (NY00326962) and extended survey conducted from 10/16/23 through 10/26/23, the facility failed to report all alleged violations involving Abuse, Neglect, including injuries of unknown source, to the New York State Department of Health (NYSDOH), within 2 hours after the allegation was made. This was evident for 1 (Resident #79) of 10 residents reviewed for Abuse out of 38 total sampled residents. Specifically, on 3/20/23 and 3/22/23, Resident #79 reported to the Social Worker and the Physical Therapist that they were handled roughly by staff. The facility reported the incident to NYSDOH on 10/26/23. The findings are: The facility's policy and procedure titled Abuse/Neglect/Mistreatment-Prevention, Assessment & Reporting with last revised date 6/4/21 documented resident has the right to be free from verbal, sexual, physical, and mental, corporal punishment, involuntary seclusion, misappropriation of property, or any other criminal activity. The facility will comply with New York State and Federal regulations for screening, training, preventing, identifying, reporting and investigation any reasonable suspicion of such abuses or other criminal activity. Resident #79 was admitted with diagnoses of Anxiety Disorder and Depression. The quarterly Minimum Data Set (MDS) dated [DATE] documented resident #79's cognition as moderately impaired. The facility Accident and Incident Report dated 3/22/23 documented that Resident #79 reported that they were physically abused by two Certified Nursing Assistants (CNAs) on 3/22/23 in the early morning. The Comprehensive Care Plan (CCP) related to Abuse initiated on 3/22/23 documented that Resident #79 alleged that two staff members beat them up. The intervention includes assessing the resident for any injuries, removing the resident from the current night shift CNA assignment, and giving emotional support. A psychiatry consult note dated 3/24/23 at 1:00 PM documented that Resident # 79 was seen for significant issues of alleging staff are rough with them. As per the resident, they were beaten up by 2 CNAs this morning between a quarter to and 6:30 AM. A review of the Nursing Home Facility Incident Report documented that the facility reported the incident to NYSDOH on 10/26/23 at 12:00 PM. On 10/26/23 at 9:16 AM, the Director of Nursing (DON) was interviewed and stated that they became aware of the alleged abuse incident on 3/20/23. The DON stated that Resident # 79 reported that they were handled roughly by two staff members to the Social Worker on 3/20/23. The resident was examined, and there were no signs or symptoms of abuse. Resident #79 was referred to the psychiatrist and was provided emotional support. The DON stated they investigated the incident and concluded that abuse did not occur. The DON stated they did not report the abuse allegation to NYSDOH because the team agreed it was not a case of abuse. The DON stated they were responsible for reporting abuse allegations to NYSDOH. 10 NYCRR 415.4(b)(2)

Based on observations, interviews and record reviews conducted during the recertification survey (FJ4G11) the facility did not ensure that a resident's advance directive was implemented. This was evident for 1 of 35 residents (Resident #345) reviewed for Advance Directives. Specifically, Resident #345's advance directive for Do Not Resuscitate/Do Not Intubate was not ordered after readmission from the hospital. The findings are: The facility's policy and procedure entitled Advance Directives/Advance Care Planning, last reviewed 09/27/2017, documented that the physician documents the resident's/representative's advance care directives on the Medical Orders for Life-Sustaining Treatment (MOLST) form and orders all advance directives at the time of admission. Resident #345 was readmitted on [DATE] with diagnoses which include Peripheral Vascular Disease and Hypertension. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #345 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) of 3 out of 15. A MOLST form with orders for Do Not Resuscitate/Do Not Intubate (DNR/DNI) was signed by the designated representative on 01/29/2023. The MOLST form was in Resident #345's paper chart. A physician's order recap report dated 03/01/2023 documented an order for DNR/DNI was in place and renewed each month through September 2023. The order was discontinued on 09/19/2023 because the resident was discharged . A Nursing Note dated 09/19/2023 at 10:47 PM, documented the unit nurse received a call from the resident's family member informing them Resident #345 was admitted to the hospital following an outpatient surgical procedure . As per protocol, the resident was discharged from the facility as of that date and time. The Nursing admission assessment dated [DATE] at 8:35 PM documented Resident #345 was readmitted to the facility. The assessment did not contain information regarding Resident #345's Advance Directives or code status. A Medical Assessment completed by the Nurse Practitioner (NP) dated 9/30/2023 contained no information regarding Resident #345's Advance Directives or code status. A Comprehensive Medical assessment by the physician on 10/13/2023 documented a MOLST form was not seen. There was no documented evidence DNR/DNI was ordered after the resident was readmitted on [DATE]. On 10/23/2023 at 11:39 AM, Licensed Practical Nurse (LPN) #3 was interviewed and stated that usually when a resident is admitted or readmitted to the facility, the doctor or covering NP will assess them and activate all their orders. The LPN stated, Whoever was here when this resident came back didn't input their MOLST again. I would think that the doctor would see the MOLST in their chart and act on it. On 10/24/2023 at 2:14 PM, NP #1 was interviewed and stated that they became responsible for Resident #345 as of October 1st, and they did not readmit Resident #345. The NP #1 stated that a returning resident usually has their MOLST form pre-loaded into the electronic medical record and would have come back with their hospital paperwork reflecting their resuscitation status. The resident would usually be wearing a bracelet from the facility clearly identifying them as DNR. The NP #1 said they did not notice that the resident's DNR order was missing. On 10/24/2023 at 2:27 PM, NP #2 was interviewed and stated they were the admitting practitioner at the time Resident #345 was readmitted . The NP #2 said that they were doing weekend evening coverage at that time, and their priority was to make sure the resident's medications were reordered. The NP #2 stated the primary physician would discuss the advance directives with the resident later and reorder accordingly unless it appeared to them that the resident might not survive the night. If this was the case, then advance directives became the priority, but Resident #345 was a stable admission. On 10/26/2023 at 10:58 AM, the Attending Physician (MD #1) was interviewed and stated that it is the doctor's responsibility to make sure a resident's advance directives are reordered when the resident is readmitted from the hospital. Resident #345 switched insurance plans as of 10/01/2023 and therefore had a new medical team, which included NP #1 and MD #1. The resident's hospital discharge paperwork listed Resident #345 as a full code. MD #1 stated they wanted to know the resident better before discussing advance directives. When the DOH survey began, the physician stated that they began going over their resident charts, noted the absence of a MOLST order, and spoke with the resident about their wishes. Despite their cognitive impairment, Resident #345 was clear about not wanting any resuscitation or intubation but because they had not personally signed their own MOLST, the physician then called the family member who confirmed that they were in agreement with DNR. The physician stated, It should have been done when they first came back, but it was chaos with one team exiting and another team entering, and it wasn't picked up. 415.4(e)(2)(iii)

Based on observation, interview, and record review conducted during the recertification survey from 10/16/2023 to 10/26/2023, the facility did not ensure to promote a resident's right to self-determination through support of resident choice. This was evidenced for 1 (Resident #294) of 39 total sampled residents. Specifically, Resident #294 preferred to eat breakfast and brush their teeth after being taken out of bed and was observed in bed after breakfast had already been served. The findings are: Resident #294 was diagnosed with hemiplegia and hemiparesis of right side following nontraumatic intracerebral hemorrhage and dysphagia. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #294 had mild cognitive impairment, required extensive assistance of 1 person for dressing, limited assistance of 1 person for eating, and extensive assistance of 1 person for personal hygiene. On 10/17/2023 at 09:26 AM, Resident #294 was observed lying in bed with their breakfast tray untouched and out of reach on the bedside dresser. Their toothbrush was on the windowsill in a small basin and appeared dry and unused. Resident #294 stated they need assistance with transferring from the bed, meal tray setup, and setup with brushing their teeth. Resident #294 stated they prefer not to eat until being transferred out of bed to their wheelchair. During an interview conducted on 10/17/2023 at 12:16 PM Resident #294's Significant Other (SO), stated the Certified Nursing Assistants (CNA) do not brush the resident's teeth. The SO arrived today to find Resident #294's toothbrush dry and their teeth unbrushed. On 10/25/2023 at 12:28 PM, Resident #294 was observed in their wheelchair and CNA #3 was finishing making the resident's bed. Toothbrush on windowsill, dry and appears unused. Resident #294 stated at the time of the observation that they needed to wait over an hour for the CNA to attend to them and take them out of bed. The Comprehensive Care Plan (CCP) related to Activity of Daily Living (ADL) self-care deficit initiated 2/7/2023 and last reviewed 10/18/2023 documented Resident #294 was able to feed self and perform oral hygiene only with setup help and is given substantial assistance for transferring. The CCP related to oral/dental health initiated 3/20/2023 documented Resident #294 can perform oral hygiene with setup help and supervision. There was no documented evidence Resident #294's preference to be out of bed and in their wheelchair to eat breakfast and brush their teeth was honored. During an interview on 10/25/2023 at 12:31 PM, CNA #3 stated that they were aware that Resident #294 would not eat breakfast while in bed. Breakfast was served at 8:15 AM. CNA #3 did not transfer Resident #294 until after breakfast is served to everyone on the unit. This morning, CNA #3 started to provide care to the resident and was told the Nurse Practitioner (NP) wanted to see the resident so they left Resident #294 in bed and attended to another resident. CNA #3 was not made aware once the NP saw the resident and did not return until later to finish Resident #294's ADL care. Resident #294 did not have breakfast or brush their teeth yet today. CNA #3 has not asked or attempted to get Resident #294 out of bed before breakfast is served so they can eat when breakfast comes onto the unit. Resident #294 did not brush their teeth this morning, but CNA #3 stated they would get the resident to brush their teeth now. During an interview on 10/26/2023 at 01:19 PM, Registered Nurse (RN) #5 stated that Resident #294 has a preference to come out of bed before they eat breakfast. Staff try to accommodate resident choice and preference. The preference should be documented in the CCP. Resident #294 and their SO verbally informed RN #5 of their preference to eat breakfast when out of bed. All CNAs knew to brush a resident's teeth after the resident ate their meal. 10 NYCRR 415.5(b)(1-3)

Based on observation, interviews and record review conducted during an abbreviated survey, (NY 396) on 08/05/2020, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents. This was evident for 1 out 3 residents sampled (Resident #1). Specifically, The Resident Care Summary (instructions for certified nurse aide care) documented that Resident #1 was non-ambulatory and required a wheelchair for mobility. Certified Nursing Assistant #1 (CNA #1) ambulated Resident #1 to and from the bathroom without the use of a wheelchair. As a result, the resident was lowered to the floor and sustained Traumatic Tri-malleolar (breaks in three sides) [MEDICAL CONDITION] ankle. This resulted in actual harm that is not Immediate Jeopardy. The findings include: The facility's Policy and Procedure on Falls Prevention and Management dated 05/05/2015 documented that it is the facility's policy to assess all residents for risk for falling and implement person centered prevention plans as necessary. The Rehab Therapist screens the resident for rehab needs upon admission. Based on the findings, the Rehab Therapist makes recommendations to the interdisciplinary team regarding Activities of Daily Living (ADL) assistance and the use of assistive devices indicated for the resident to function with optimal safety. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) was not completed since Resident #1 was 2 days post admission. The Cognition Assessment on 07/01/2020 documented that Resident #1 was cognitively intact. A Fall Risk assessment dated [DATE] documented a score of 10 which indicated that Resident #1 was at a high risk for falls. The Risk for Falls Care Plan (CP) dated 07/01/2020, documented Resident #1 was at risk for falls related to decreased strength, endurance, balance strength, unsteady gait, impaired Activity of Daily Living (ADLs), [MEDICAL CONDITION] and dizziness. The interventions included: place call light within resident's reach, anticipate and meet needs, skilled Physical Therapy 5-7 times weekly and provide a safe environment. The Resident Care Summary dated 07/01/2020 documented Resident #1 required total assistance of two (2) staff members for transfer. Resident #1 was non-ambulatory and required assistance of 1 person for wheelchair mobility and extensive assistance for toileting. The Physical Therapy (PT) initial assessment dated [DATE] documented Clinical Impressions: Resident #1 required total assistance with transfers and ambulation due to obesity, decreased strength, endurance and balance. Walking not attempted due to medical conditions or safety concerns and dependent with toileting. The ADL Deficit related to weakness CP, initiated on 07/02/2020, documented interventions to provide extensive assistance of 1 person with toileting and locomotion with wheelchair. The Nursing Progress Note dated 07/03/2020 at 7:40 a.m. documented Resident #1 was lowered to the floor by CNA #1 during a.m. care. The Charge Nurse and Nursing Supervisor informed. Bilateral lower extremities [MEDICAL CONDITION] noted. Range of Motion unchanged. Resident #1 was assisted back to bed. The Nurse Practitioner's (NP) Progress Note dated 07/03/2020 at 9:38 a.m. documented Resident #1 was seen and examined at the bedside. Resident #1 had left ankle swelling, [DIAGNOSES REDACTED] (abnormal redness of the skin) and pain to light palpation. A STAT x-ray of Resident #1's left ankle was ordered. The Nursing Progress Note dated 07/03/2020 at 3:25 p.m. documented Resident #1 was evaluated by the NP. The x-ray result showed that Resident #1 had a [MEDICAL CONDITION] ankle and an order was given to transfer the resident to the hospital. The x-ray results dated 07/03/2020, documented Resident #1 had a [MEDICAL CONDITION] Distal Fibula and Medial Malleolus with disruption of the Left Ankle Mortise. The Facility's Occurrence Investigation Summary dated 07/03/2020 documented Resident #1 lost her balance while ambulating from the bathroom with CNA #1. CNA #1 lowered Resident #1 to the floor as the resident was too heavy. Resident #1 was assessed with [REDACTED]. The resident was participating in therapy and was able to ambulate. The emergency room Discharge documents dated 07/04/2020 revealed a Computed Tomography Scan of Resident #1's left ankle without contrast and x-ray of the left ankle, results showed Traumatic Tri-malleolar [MEDICAL CONDITION] ankle. Orthopedic Clinic on 07/09/2020 at 9:00 a.m. for operative planning. Recommendation made for [MEDICATION NAME]-[MEDICATION NAME] 5-325mg tablet, 1 tablet orally every 6 hours as needed for severe pain. The Nursing Progress Note dated 07/04/2020 at 7:30 a.m. documented that Resident #1 returned from the hospital with below knee cast to the left ankle Tri-malleolar Fracture in place. The Registered Nurse Supervisor (RNS) was interviewed on 09/04/2020 at 8:25 a.m. and she stated that that Resident #1 was observed lying on the floor in her room. CNA #1 was in the room with Resident #1. CNA #1 stated that while she was ambulating Resident #1 from the bathroom to the bed, Resident #1 lost her balance and began falling. CNA #1 reported that she tried to prevent Resident #1 from falling by lowering the resident to the floor. The RNS stated that Resident #1 was assessed with [REDACTED]. The Physician was notified and an order for [REDACTED].#1 had a fracture and the resident was transferred to the hospital. CNA #1 was interviewed on 09/04/2020 at 10:50 a.m. and stated, on the morning of 07/03/2020, Resident #1 requested to go to the bathroom. CNA #1 stated that she offered Resident #1 the bedpan and that the resident refused. On inquiry, CNA #1 verbalized that she was aware that Resident #1 was non-ambulatory, but that Resident #1 informed her that she ambulated with the walker during the day. CNA #1 stated that Resident #1 sat at the edge of the bed and insisted on walking to the bathroom. CNA #1 stated that she gave Resident #1 the walker and walked behind the resident to the bathroom. After Resident #1 completed her toilet task, Resident #1 had difficulty getting up from the toilet. CNA #1 verbalized that she called the Licensed Practical Nurse (LPN) for assistance and the LPN assisted with getting Resident #1 off the toilet. After the LPN assisted with getting the resident off the toilet, the LPN left the room. Resident #1 was almost at the bedside when the resident suddenly lost balance and began to fall. CNA #1 stated that she lowered Resident #1 to the floor. On inquiry, CNA #1 stated that she did not inform the Charge Nurse that Resident #1 wanted to walk to the bathroom. CNA #1 stated that she did not receive any training on ambulating Resident #1. The Licensed Practical Nurse was interviewed on 10/01/2020 at 2:05 p.m. and stated that she could not recall Resident #1 and the incident. She added that she floats on several units. Nurse Practitioner #1 was interviewed on 10/01/2020 at 2:15 p.m. and stated that she assessed Resident #1 after the incident on 07/03/2020, prior to hospital transfer. Resident #1 had left ankle swelling, redness and pain. She ordered x-ray of the left ankle but did not review the results. The Director of Rehabilitation was interviewed on 10/01/2020 at 2:25 p.m. and stated that she became aware of PT#1's note dated 07/02/2020 at 8:43 p.m. during the investigation of the incident. She further stated that for any changes to be made to a resident's plan of care, the Physical Therapist must demonstrate to the CNA and nurse, inform the nurse then document the changes in status. She further stated that a change in a resident's treatment plan is not usually made until after 3-5 days of therapy, depending on the resident. The former Director of Nursing (DON) was interviewed on 10/01/2020 at 3:12p.m and stated that whenever there is a change in a resident's physical status: the Physical Therapist would queue the order in the electronic medical record, nurses would transcribe the order, then update the CNA Nursing Instructions. Upon inquiry, she stated that there was no order for Resident #1 to ambulate. 415.12(h)(2)

Based on Facility's surveillance camera footage, observation, staff interviews, and record review during an abbreviated survey (NY 910), the facility failed to adequately supervise a resident to prevent elopement. This was evident in 1 out of 8 residents sampled (Resident #1). Specifically, there was no documented monitoring instructions for a resident with prior elopement attempts; the staff did not respond in a timely manner when the door alarm was activated; and staff did not identify the source of 2 different door alarm activations. Subsequently, on 07/09/2019, Resident #1 activated the exit door alarms on two separate units and successfully eloped undetected from the facility. Resident #1 was found on an 11-foot-high scaffolding, which was covering the sidewalk along the front of the facility, putting the resident at risk for injury harm, impairment or death. This resulted in Immediate Jeopardy (IJ) and Substandard Quality of Care to resident health and safety. The findings include: The facility policy on Manhattan Safety and Security - Alarms with a revised date of 04/04/2019 states that all resident floor stairwell doors are audibly alarmed to prevent unauthorized egress. Upon activation of a stairwell door alarm, it is the responsibility of all staff assigned to a unit to respond to the alarm. Whenever a stairwell door alarm is activated a staff member must check to see who has gone through the door before disarming the alarm. If it is not evident who breached the alarm, the staff member must check one flight up and one flight down in order to identify the person. In the event, the person is not identified, security is called to intervene. The facility policy and procedure on Unsafe Wandering/Elopement Prevention Program with an effective date of (MONTH) (YEAR) states that all residents who have demonstrated wandering behavior to or following admission will be assessed for their risk of elopement and have an appropriate interdisciplinary plan of care developed. The policy defined elopement as the ability of a resident to successfully leave the nursing facility unsupervised and unnoticed and enter into harm's way. The policy also states that the Certified Nursing Assistant (CNA) checks for the placement of Wander-guard sensor device each shift and using a transmitter, checks the Wander-guard functioning once a day, at 2-hour intervals documents on Elopement/Unsafe Wanderer Monitoring tool the location of each resident and informs the nurse if resident risk behavior increases. The nurse places resident with increased risk behavior on Visual Check Monitoring for a minimum of 72 hours using the Resident Visual Check Sheet and informs the interdisciplinary team that the resident is on 30-minute visual checks. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, resident assessment tool) dated 07/08/2019 documented that Resident #1 had a Brief Interview for Mental Status (BIMS) and scored 6/15 associated with severe impairment in cognition (00-07 severe impairment, 08-12 moderate impairment, and 12-15 cognitively intact). Resident #1 required extensive assist of one with transfer, walk in room, and walk in corridor. Section [NAME] of the MDS dated [DATE] documented that Resident #1 was assessed with [REDACTED]. An Elopement Risk assessment dated [DATE] documented that Resident #1 was assessed and scored 1 point, denoting low risk for elopement. Review of the nursing note dated 07/03/2019 at 7:08AM documented that Resident #1 attempted to the leave the floor several times and Wander-guard was applied to Resident #1's right ankle. Review of the nursing note dated 07/04/2019 at 2:08AM documented that after the Wander-guard was placed on Resident #1's right ankle, the resident still tried to leave the floor and asked for scissors to cut the Wander-guard off. Record review revealed that the facility did not update Resident #1's Elopement Risk Assesmsent to reflect on the attempted elopements. Review of Resident #1's Care Plans (CP), revealed that no CP was put in place to address wandering or monitoring of Resident #1 after the Wander-guard was placed on the resident's right ankle. Review of the Resident Care Summary revealed no instructions for the CNAs regarding Resident #1's attempts to leave the unit and Wander-guard placement. No monitoring instructions for elopement were noted. Review of the nursing note dated 07/09/2019 at 8:14 PM documented that the Registered Nurse Supervisor (RNS) informed the staff that Resident #1 was found on the scaffolding at 6:20 PM. Prior to the incident, the resident was sitting on the chair next to his bed in his room around dinner time. Resident #1 was unable to state what happened but stated that he climbed a tree. 911 was called and brought Resident #1 to the hospital. Surveyor #1 together with Surveyor #2 and the Assistant Administrator (AA) viewed the recorded surveillance camera footage of buildings and floor locations on 07/23/2019 at 11:12AM. Time stamped shown on the camera footages were actual. Resident #1 was observed on 07/09/2019 at 6:00 PM in building 1 on the 3rd floor. Building 1, 3rd floor camera footage revealed that on 07/09/2019 at 6:00 PM, Resident #1 walked out of his room and exited the west exit door leading to the stairwell (as per observation, the west exit door is 15 steps away from Resident #1's room). At 6:01:06 PM, CNA #1 exited the same exit door; re-entered 11 seconds (6:01:17) later and deactivated the alarm. Building 1, 1st floor camera footage showed on 07/09/2019 at 6:06 PM, Resident #1 entered the unit from the west exit door coming from the stairwell. Four minutes later, at 6:10 PM, the camera showed Licensed Practical Nurse #2 (LPN #2) exited the 1st floor west exit door; and re-entered 6 seconds later and deactivated the alarm. Resident #1 entered Building 2 through a connecting door. The basement laundry room camera footage showed that on 07/09/2019 at 6:14 PM, Resident #1 exited the basement through an opened roll down gate. The rolling gate leads to a small yard that was still inside the facility's building perimeter. The camera in the small yard that was positioned to face the alley that leads to the street, showed that on 07/09/2019 at 6:15 PM, Resident #1 untied a ladder that was secured to the fence. After untying the ladder, Resident #1 leaned the ladder against a metal gate and at 6:16 PM, Resident #1 climbed the ladder and made his way up onto the 11-foot-high scaffolding at 6:19 PM. Building tour was conducted on 07/23/2019 at 11:25 AM with the AA and Surveyor #2. It was noted during the tour that there was a panel at the nursing station that shows which door alarm was triggered (East or West). When the door opens without disengaging or pushing the buttons, the alarm activates and can be heard throughout the hallway and the nursing station. The unit elevators are equipped with a Code Alert sensor, the elevator will not move when a resident with a Wander-guard boards unless the code is entered. It was also noted during the tour that the door connecting Building 1 and Building 2, on the 1st floor did not have an alarm and as confirmed by the AA, there was no surveillance camera positioned to face the connecting door. Tour of the security station on 07/23/2019 at 12:00 PM, revealed that a computer system to monitor Code Alert sensor (Wander-guard system) activation was in place. When a Wander-guard alarm is activated, it sends a signal to the security computer alerting security that a Wander-guard alarm is activated. The resident's name, Wander-guard ID number and location of the activated alarm would appear on the computer screen. The security computer for 07/09/2019, did not show that Resident #1 activated the Wander-guard alarm system. The Administrator was interviewed on 07/22/2019 at 3:06 PM and stated that she was walking along the street in front of the building at around 6:15 - 6:20 PM when she heard footsteps. She came around and observed Resident #1 up in the scaffolding. The resident told the Administrator that he was trying to go home. LPN #1 was interviewed on 07/22/2019 at 4:14 PM and stated that prior to the incident, Resident #1 kept packing his bags and was upset stating that he wanted to leave. A Wander-guard was applied to Resident #1. LPN #1 stated that she does not remember if Resident #1 was put on monitoring or visual checks for elopement. CNA #2 was interviewed on 07/22/2019 at 4:26 PM and stated that on 07/09/2019, a little before 6:00 PM, the exit door alarmed on the 3rd floor. CNA #1 checked the exit door on the West side of the unit, and she checked the other exit door on the East side of the unit and did not see anyone. CNA #2 stated that she did not call security and she was not aware that the security guard needed to be notified when an alarm is activated on the unit. So, after checking the exit door, CNA #2 continued handing out dinner trays and RN #1 continued passing medications. Upon inquiry, CNA #2 stated that they do not check Wander-guard placement on the residents. The staff will know if a resident is wearing a Wander-guard and if it is functioning when a resident approaches the elevator and activates the Wander-guard alarm system. CNA #2 stated that she is familiar with Resident #1 and that the resident was not on monitoring or visual checks. CNA #3, who was assigned to Resident #1 on the day shift on 07/09/2019, was interviewed on 07/22/2019 at 4:30 PM. CNA #3 stated that Resident #1 had a Wander-guard, but that Resident #1 was not on monitoring or visual checks for elopement. CNA #1 was interviewed on 07/22/2019 at 4:38 PM and stated that she was assigned to Resident #1 on 07/09/2019 on the 3rd floor evening shift. CNA #1 stated that she was not aware that Resident #1 was an elopement risk and that he should have been wearing a Wander-guard. Resident #1 was not on monitoring or visual checks for elopement. She had no reason to check Resident #1's whereabouts. CNA #1 stated that she last saw Resident #1 on 07/09/2019 at about 5:45 PM when she served him supper. At around 6:00 - 6:10PM (did not look at her watch), the medication nurse (RN #1) instructed her to go and check the exit door because the alarm went off. CNA #1 affirmed that she ran to the exit door (on the West side of the unit), went up and down the stairs and that she did not see anybody. CNA #1 reported that when she went back to the unit and notified RN #1 that she did not see anybody, the RN said okay. Upon inquiry, CNA #1 stated that the security was not notified that an exit door alarm was activated on the unit. LPN #2 was interviewed on 07/23/2019 at 4:56 PM and stated that she responded to the west exit door alarm in building 1 on the 1st floor at around 6:00 PM. LPN #2 stated that she looked up and down the stairwell but did not see anyone, then went back and reset the exit door alarm. LPN #2 stated that she did not notify security that the exit door alarmed. LPN #2 stated that she is not aware that security must be notified if a stairwell door alarm is activated. The Unit Manager (UM) was interviewed on 07/23/2019 at 1:26 PM and stated that prior to the incident, Resident #1 had incidents of trying to get in the elevator. Wander-guard was applied on Resident #1 and he was placed on 2-hourly monitoring because of his exit-seeking behavior. Resident #1 was placed on 15-minute checks after the incident. The UM stated that when an exit door alarms, the staff must check one flight up and one flight down to see if there was any resident in the stairwell. The UM stated that there is no need to notify security because it might have been a staff who activated the alarm. The RNS was interviewed on 07/22/2019 at 4:55 PM and stated that Resident #1 was not on monitoring or visual checks. The RNS stated that residents who are at risk for elopement and showing signs of increased exit seeking behavior must be placed on 30-minute visual checks. The RNS also stated that Resident #1 should have been placed on 30-minute monitoring the moment he verbalized that he wanted to go home. The RNS stated that on the day of the incident, she was notified by the Associate Director of Nursing (ADON) at around 6:10 PM that Resident #1 was on the scaffolding. When Resident #1 was brought down safely by the police and was placed on the stretcher, the RNS checked Resident #1's extremities and did not find the Wander-guard. The Associate Director of Nursing (ADON) was interviewed on 07/23/2019 at 1:49 PM and stated that whereabouts of residents at risk for elopement are checked every 2 hours. The ADON stated that on the day of the incident at around 6:00 PM, the Administrator notified her that Resident #1 was on the scaffolding. The ADON stated that when Resident #1 was brought from the scaffolding by the police, the staff checked Resident #1 and the resident was not wearing a Wander-guard. Security Officer #1 (SO #1), who was on duty on 07/09/2019 at the time of the incident, was interviewed on 07/23/2019 at 5:30 PM and stated at around 6:00PM, the Administrator notified him that Resident #1 was on the scaffolding. SO #1 also stated that the nursing staff did not notify him that the exit door alarms were activated on the units. Upon inquiry, SO #1 stated that when a Wander-guard alarm is activated, the location, Wander-guard number, and the resident's name would appear on the computer screen. Resident #1did not activate the Wander-guard alarm system on 07/09/2019. SO #2 was interviewed on 07/23/2019 at 5:45 PM and stated that the nursing staff did not notify him that the alarms were activated on the units. The Vice President (VP) for Clinical Excellence who was the interim Director of Nursing when the elopement incident occurred was interviewed on 07/26/2019 at 1:23 PM. The VP stated that the incident was investigated and that the incident is not considered an elopement because Resident #1 was found in the building property and he was not harmed. The Administrator was interviewed on 07/23/2019 at 6:00 PM and stated Resident #1 exited the facility through the roll down gate in the basement near the laundry room. Resident #1 was able to take a ladder that was secured on the fence and used that ladder to get to the scaffolding. The Administrator stated that when she did the investigation, she did not review the surveillance camera in Building 1, 1st floor and she was not aware that it took 4 minutes for the LPN to respond to the alarm. The Administrator also stated that when the exit door on the unit alarms, the staff is supposed to notify security and the charge nurse if nobody was seen in the stairwell. Immediate Jeopardy (IJ) was identified, declared, and the facility Administrator notified on 07/24/2019 at 5:03 PM. The survey team declared the immediacy of the IJ had been abated after receiving an acceptable corrective action plan from the facility on 07/24/2019 at 7:40 PM. The survey team declared that the IJ was removed on 07/29/2019 at 3:30 PM based on the following corrective actions taken by the facility: 1. The facility implemented a revised policy on Safety and Security - Alarms on 07/24/2019. The facility added steps in the procedure such as: nursing must initiate a head count on the unit with documentation of location for all residents with a high risk for elopement. 2. The facility implemented a revised policy on Safety and Security: Missing and Wandering Resident's on 07/24/2019. The facility revised the procedure on the event that there is a missing resident. The nurse on the unit will activate a Code Silver Alert from the unit by pressing *94 from the nursing unit phone and announce overhead CODE SILVER ALERT and unit name. (The previous policy dated 08/31/2018 documented that the nurse on the unit will call security and have security announce Code Silver Alert on the overhead paging system). 3. The facility developed and implemented staff education on the revised policies. The staff education started on 07/24/2019 and will be ongoing until 100% of the staff is achieved (301/365 nursing staff were in-serviced). The staff that are not in-serviced (i.e. per diem, on leave of absence, on vacation) will be educated on the first day they return to work. 4. A Drill Guideline on stairwell alarm response and Code Silver Alert was developed by the facility on 07/26/2019 and was included in the staff education process. 415.12(h)(2)