Every finding on record at The Plaza Rehab and Nursing Center

Based on the staff interviews and record review, the facility failed to ensure a resident requiring dialysis received services consistent with professional standards of practice. This was evident for one (Resident #6) of one resident investigated for Dialysis. Specifically, Resident #6, who receives dialysis treatment three times per week, did not receive dialysis treatment on was not provided dialysis treatment as expected on 01/23/2026, and was not rescheduled for treatment due to the facility's failure to communicate and collaborate with the dialysis facility. The findings include:The facility's policy titled, End Stage Renal Disease - Care of Resident, last reviewed 03/2026, documented that on admission licensed nurses will place an order in the electronic medical record for hemodialysis as per schedule confirmed by the hemodialysis center. The policy also documented that the team should attempt to obtain the earliest 24-hour clinically appropriate replacement when treatment was missed (i.e., missed/refused/cancelled/unavailable).Resident #6 was admitted to the facility with diagnoses including diabetes mellitus (chronic condition wherein the body does not produce enough insulin or resists insulin, causing high blood sugar levels), respiratory failure (condition where there is not enough oxygen or too much carbon dioxide in the body), and end stage renal disease (chronic disease where the kidneys are unable to function on their own) with dependence on hemodialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly).The Hospital Discharge summary, dated [DATE], documented Resident #6's medical history included end stage renal disease with dialysis treatment every Monday, Wednesday, and Friday. The Hospital Discharge Summary also included transfer coordination information indicating Resident #6's discharge date set for 01/22/2026 and that that Resident #6 will receive an in-hospital dialysis session on 01/21/2026.The Nursing Evening Shift Report dated 01/22/2026 documented that the facility received a new admission, Resident #6, from the hospital on [DATE] at 09:20PM. The report documented that Resident #6 was non-verbally responsive, unable to make needs known, and had a medical history of end stage renal disease with hemodialysis scheduled every Monday, Wednesday and Friday. It further documented that admitting orders included initial labs and consults that were verified with the doctor and carried out. The report did not indicate that the dialysis facility was contacted.A Physician's Order dated 01/22/2026 documented for Hemodialysis to be done three times a week on Mondays, Wednesdays and Fridays at the dialysis center. The order sis not specify a treatment time.The Nursing Morning Shift Report dated 01/23/2026 documented that Resident #6 had hemodialysis scheduled on Mondays, Wednesdays and Fridays. The report also noted that Resident #6 was status post dialysis completed in hospital prior to admission. The report also included documentation including: 01/26/2026 - Dialysis - Follow Up. The report did not indicate that the dialysis facility was contacted.There was no documented evidence in the medical record that Resident #6 received dialysis treatment on 01/23/2026.A review of Nursing Notes from 01/22/2026 to 01/25/2026 revealed that there was no documented evidence regarding Resident #6's dialysis treatment.A review of the Interdisciplinary Baseline Care Plan, completed 01/23/2026, revealed there was no documentation related to Resident #6's dialysis treatment, including treatment instructions and monitoring parameters for complications.During an interview on 08/24/2026 at 11:45 AM, the Admissions Director stated that Resident #6's referral was accepted for admission by the facility and the dialysis center on 01/08/2026. The Admissions Director further stated that on 01/20/2026, the facility was contacted by the hospital about Resident #6's discharge plan for 01/22/2026. The hospital discharge team indicated that Resident #6 would be dialyzed in the hospital on [DATE] prior to discharge on [DATE]. The Admissions Director stated that updated dialysis documentation was also sent out to the dialysis nurse manager at the dialysis center on 01/20/2026. During an interview on 08/24/2026 at 02:46 PM, Registered Nurse #4 stated that they were working day shift on 01/23/2026 and that they had called the dialysis center for Resident #6's dialysis treatment. Registered Nurse #4 stated that the dialysis center was fully booked and could not accommodate for Resident #6's treatment on 01/23/2026 and 01/24/2026. Registered Nurse #4 further stated that the plan was to monitor Resident #6 during the weekend until Monday's dialysis treatment. Registered Nurse #4 did not document the communication with the dialysis center or the plan in Resident #6's electronic medical record. Registered Nurse #4 could not provide a reason why they failed to document the communication with the dialysis facility. Registered Nurse #4 did not know if Resident #6 received dialysis on 01/26/2026 because their last day of working at the facility was 01/23/2026.During an interview on 08/24/2026 at 12:15 PM, with the dialysis facility's Nurse Manager stated on 01/08/2026, Resident #6's dialysis referral was received and placement for Resident #6 was confirmed for dialysis treatment at the center. The dialysis facility's Nurse Manager stated they were notified of Resident #6's pending date of admission via email from the Admissions Director on 01/20/2026. The dialysis facility's Nurse Manager stated that it was facility staff's responsibility to call the dialysis center to coordinate treatment time upon Resident #6's admission to the facility. The dialysis facility's Nurse Manager stated they did not receive any call from facility staff regarding Resident #6's treatment on 01/23/2026 nor the following day on 01/24/2026. Dialysis Nurse Manager stated that if Resident #6 was admitted during the evening on 01/22/2026, the facility staff should have called the dialysis center on 01/23/2026 to coordinate time/schedule for Resident #6 to ensure that the treatment is not missed.During an interview on 08/24/2026 at 01:10 PM, the Medical Doctor stated Resident #6's stay was short and over a weekend. The Medical Doctor stated they were not contacted to reconcile admission orders since Resident #6 was admitted late at night. The Medical Doctor stated that they may get notified when a resident's condition changes requiring hospitalization for urgent dialysis but usually don't get notified of missing dialysis treatment. They further stated that if Resident #6 missed their scheduled dialysis session, the plan would be to schedule a make-up session the following day.During an interview on 08/24/2026 at 04:15 PM, the Assistant Director of Nursing stated that nurse managers/supervisors is responsible for communicating with the dialysis center to schedule and coordinate treatment times. The Assistant Director of Nursing stated they were not aware of any issue related to Resident #6 as Registered Nurse #4 never reported any issues regarding Resident #6 to the Assistant Director of Nursing.During an interview on 08/24/2026 at 03:2PM, the Director of Nursing stated they did not know if there was any issue related to Resident #6's dialysis schedule because there was no reported issue from staff about Resident #6.10 New York Code Rules and Regulations 415.12

Based on observation, record review, and interviews conducted during an Abbreviated Survey (2622908), 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 for one 1(Resident #1) out of 3 residents reviewed for accidents. Specifically, Resident #1 complained of pain to their right arm on 09/18/2025 and Xray results showed a non-displaced fracture of the right proximal humeral shaft. Resident #1 was unable to explain the occurrence. The incident was not reported to the New York State Department of Health within 2 hours of the Xray results. The findings are: The Facility policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property reviewed 08/2025 documented Abuse allegations (abuse, neglect, exploitation, or mistreatment, including injuries of unknown source without clinical baseline and misappropriation of resident property) are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two (2) hours after the allegation is 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 or result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facility) in accordance with State Law through established procedures.Resident #264 had diagnoses of Non-Alzheimer's Dementia, Chronic Diastolic Heart Failure, and Polyneuropathy. The Annual Minimum Data Set, dated [DATE] documented Resident #1 had severely impaired cognition and required maximal assist with upper body dressing, personal hygiene, and roll left and right. Resident #1 was dependent of staff with the remainder of Activity of Daily Living care. Resident #1 was always incontinent of urine and bowels.The Comprehensive Care Plan related to pain effective 10/24/2021 and last updated 09/19/2025 documented Resident #1 will not verbalize pain/discomfort related to fragility of bone related to diagnosis of fracture and moderate osteoporosis x 90 days. Interventions included on-going assessment of the resident's pain with emphasis on the onset, location, description, intensity of pain and alleviating and aggravating factors and monitor side effects and adverse reactions resulting from interventions rendered.The Accident Investigation dated 09/19/2025 at 5:30PM documented Resident #1's next of Kin reported resident complained of right arm pain with movement on 09/18/2025. Certified Nursing Assistant #1's statement who worked 7:00 AM to 3:00PM on 09/18/2025 documented Resident #1 complained of, pain all over their body but not too much and they reported this to Licensed Practical Nurse #1. Nurse Practitioner #1 was notified on 09/18/2025 and ordered a right upper extremity Xray. The Accident investigation revealed this pain was not a result from Activity of Daily Living activity or a fall. On 09/19/2025 an Xray result of the right shoulder showed an acute nondisplaced fracture of the right proximal humeral shaft. Nurse Practitioner #1 ordered to transfer Resident #1 to the emergency room for further medical evaluation and management, and Resident #1 was sent to the emergency room at 5:33 PM.The Administrative Determination completed 10/09/2025 documented on 09/19/2025, at approximately 5:30 PM, a report was received from Registered Nurse #3 who was the supervisor on duty that Resident #1's right shoulder X-ray result revealed a non-displaced fracture of the right proximal humeral shaft. The day before, on 09/18/2025 Nurse practitioner #1 was informed Resident #1 complained of right arm pain. Nurse Practioner #1 assessed resident at bedside, no distress noted, no swelling, no discoloration, no tenderness on palpation, no warmth, with no overt signs of infection. Nurse practitioner #1 ordered Tylenol 650 milligrams by mouth every 8 hours as needed, and a right upper extremity X-ray. Based on an interview with the next of kin who was at the bedside, they stated that Resident #1 expressed they had pain. Resident #1 did not have any incidence of falls and due to confusion was not able to give an account on the occurrence. Nurse practitioner #1 reviewed the X-ray results on 09/19/2025 and ordered to send Resident #1 to the hospital for further medical evaluation. Resident #1 was transferred to the emergency room on [DATE], at 5:33 PM and came back to the facility in stable condition on 09/20/2025 at 3:12 AM accompanied by their next of kin. Resident #1 returned with a sling on their right arm, with a prescription for Oxycodone 5 milligrams by mouth every 8 hours for 10 days and an orthopedic follow up visit scheduled on 09/29/2025. Resident #1 is at high risk for spontaneous fractures based on their diagnosis and past medical history including but not limited to right shoulder arthritis, diffuse osteopenia throughout the bones, right shoulder decreased osseous mineralization established in 2021, vitamin D deficiency, chronic kidney disease, Type 2 Diabetes Mellitus, pain disorder, polyneuropathy, and hypothyroidism. There is no cause to believe any alleged resident abuse, exploitation, or neglect regarding Resident #1 has occurred. The Webform submission email confirmation form dated 09/20/2025 at 10:34 PM documented the Nursing Home Facility Incident Report successfully submitted on 09/20/2025 at 10:32 PM. There was no documented evidence the facility reported Resident #1's injury of unknown source, to the New York State Department of Health within 2 hours of the reported Xray results.On 11/04/2025 at 4:07 PM, the [NAME] President of Clinical Services was interviewed and stated they reported the incident to the department of Health on 09/20/2025 at 10:32 PM. They did not report this incident within 2 hours because this incident was not abuse by clinical presentation so there was no suspicion of a crime. The fracture was nondisplaced, there was no impact, and Resident #1 had clinical diagnosis of decreased mineralization, moderate Osteoporosis, Osteopenia, and moderate Osteoarthritis which puts them at risk of spontaneous fractures. The [NAME] President of Clinical Services also stated once there is a determination of an unknown injury they report the incident to the Department of Health.On 11/04/2025 at 4:26 PM, the Administrator was interviewed and stated the [NAME] President of Clinical Services reported the incident to them once they discovered the Xray results of a nondisplaced fracture. The investigation was completed, and they did a review and there was no skin opening, no bruising, and no impact. Clinical indications were that Resident #1 has Osteoporosis, Osteopenia, and Osteoarthritis and the fracture could be attributed to their diagnosis. The Administrator also stated, when there is an allegation of abuse, neglect, misappropriation, and serious bodily injury it is reported to the Department of Health in 2 hours. If the allegation does not involve abuse, suspicion of a crime, and doesn't involve serious bodily injury then the incident is reportable in 24 hours. The Administrator further stated the fracture could be pathological since Resident #1 has Osteoporosis. If there was a true fall there has to be some kind of bruising. Since there was no bodily injury and no suspicion of crime then this incident was reportable in 24 hours. 10 NYCRR 415.4(b)(2)

Based on record review, and interviews during the Recertification Survey conducted from 04/29/2025 to 05/06/2025, the facility did not ensure medical records were complete and accurately documented in accordance with accepted professional standards and practices. This was evident for 1 (Resident #640) of 3 residents reviewed for Skin Condition out of total 38 sampled residents. Specifically, the medical record did not contain evidence that Resident #640 received wound treatment as ordered on multiple days. The findings are: The facility's policy and procedure titled Wound Care Treatment Plan reviewed 3/2025 documented that the facility is to assess all residents and develop a plan of care that will prevent the development of wounds or provide the healing of existing wounds. Resident #640 was admitted with diagnoses that included Diabetes Mellitus, Hyperlipidemia, and Depression. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #640 was cognitively intact and had a surgical wound. The Care Plan titled Skin Integrity initiated 08/22/2024 and reviewed on 02/19/2025 documented that Resident #640 has surgical wound, and right trans metatarsal amputation. Interventions included apply local treatments as ordered, monitor for signs and symptoms of infection, perform wound care rounds weekly, report any skin changes, and wound care consult as needed. The Physician Order dated 12/04/2024 documented to cleanse wound with Dakin's Solution 0.25%, pat dry, cut black foam to fit wound, apply transparent dressing to seal foal to wound, cut small hole on film and apply Vac tube connector. Cover with dry protective dressing and connect tube to suction container connector on machine. The order was transcribed in the Treatment Administration Record to document completion during 7:00 AM to 3:00 PM shift. The order was discontinued on 02/26/2025. The Treatment Administration Record from 01/01/2025 to 02/26/2025 revealed wound treatment was left blank on 01/10/2025, documented not administered endorsed to PM nurse manager on 01/11/2025, and not administered out of room/off unit on 01/23/2025. The Nursing Progress Notes from 01/01/2025 to 02/26/2025 did not contain any documentation related to wound treatment on 01/10/2025, 01/11/2025, and 01/23/2025. On 05/06/2025 at 11:01 AM, Registered Nurse #6 stated Resident #640 was admitted with a surgical wound after undergoing amputation and has daily wound treatment ordered. Registered Nurse #6 also stated that Resident #640's wound treatment was done during day shift. Registered Nurse #6 further stated that Resident #640 is very compliant with their care and treatment, and they did not know of any refusal of care or treatment. On 05/06/2025 at 10:58 AM, Registered Nurse #5 stated Resident #640 was admitted here last year after undergoing amputation and they do not know of any refusals of wound treatment. Registered Nurse #5 also stated that they were the manager on duty on 01/10/2025 and 01/23/2025 but they could not recall why there was no documentation related to Resident #640's treatment. Registered Nurse #5 further stated that unit nurses are responsible to complete treatments and document in the record when completed. Registered Nurse #5 stated they can assign the treatment to next shift nurse, and it could be documented in the progress notes. However, Registered Nurse #5 could not confirm if treatment was completed since there was no documentation in the medical record for Resident #640. On 05/06/2025 at 03:53 PM, the Assistant Director of Nursing stated that upon interviewing staff and reviewing the medical record, Resident #640 received treatments on 01/10/2025 and 01/23/2025. The Assistant Director of Nursing also stated that the assigned nurses did not document completion in the Treatment Administration Record, as they were newly hired and missed the treatment documentation. The Assistant Director of Nursing further stated the nurses were counseled and educated to ensure treatments are being documented in the medical record. On 05/06/2025 at 03:13 PM, the Director of Nursing stated Resident #640 has a history of refusing treatments and any refusal is documented in the medical record. The Director of Nursing also stated that they could not confirm if Resident #640 refused treatment on 01/10/2025 and 01/23/2025. 10 NYCRR 415.22(a)(1-4)

The New York State Complaint Intake Summary (#NY00351324) dated 01/10/2025, documented that a family representative stated that they witnessed a mouse running in the resident's room, and also saw a roach on the resident's sandwich. On 04/30/2025 at 12:56 PM, in room [ROOM NUMBER] P East, a sticky fly trap was observed on the bedside table with multiple flies stuck to the fly trapper. An interview was conducted with the resident who resided in room [ROOM NUMBER] P who stated that there are flies everywhere in the room, and when they have complained about it, all the facility does is to replace the sticky fly trap. On 04/30/2025 at 01:08 PM, the resident who resided in room [ROOM NUMBER] East stated that they have seen cockroaches and mice in the room, and they informed staff but could not recall if the exterminator had been to their room. During an interview on 04/30/2025 at 12:44 PM, family representative of the resident in room [ROOM NUMBER] East, stated that flies are everywhere and there are roaches and mice. The family representative further stated that the flies never go away, and they had never seen an exterminator coming to the room. The pest-control service reports were reviewed on 05/01/2025 and revealed that the facility was treated for flies and mice. On 05/06/2025 at 02:36 PM, the Director of Environmental Services stated pest problems were far worse in 2024, and they believe it is much improved since last year. The Director of Environmental Services also stated that they have a better pest control program currently and that staff have been working to ensure that pests are not visible in the rooms/units. The Director of Environmental Services further stated that resident reports of pest sightings have been reduced and that the facility's program to control pests has been effective, and progress is ongoing. The Director of Environmental Services stated they have direct contact with the company's exterminators so they will call immediately when pest sightings are notified. The Director of Environmental Services also stated that they accompany the exterminator when they are in the building to ensure the treatment is done. On 05/06/2025 at 02:52 PM, the Administrator stated that they identified pest problems previously, so it was discussed and planned as a part of a Quality Assurance project. The Administrator also stated that the pest control company was changed, increased treatment frequency with enhanced chemical treatments was implemented and they pest control rounding was initiated last year. The Administrator further stated that the facility also educated residents/family members about proper food storage to less attract pests in the rooms/units by sending educational fliers to residents and educational postings on the units. The Administrator stated they have been seeing a decreased number of pest sightings this year. 10 NYCRR: 415.29(j)(5) On 04/29/2025 at 12:20 PM, Resident #635 who resided in room [ROOM NUMBER] West, was interviewed and stated they observed mice in their room coming from under the heater daily during the nighttime hours. On 05/06/2025 at 11:55 AM, Resident #488 who resided in room [ROOM NUMBER] West, was interviewed and stated they observed a mouse that came out from under their heater during the nighttime. They reported this to the engineering department and the mouse was recently found dead in the heating unit. On 05/06/2025 at 11:56 AM, Resident #55 who resided in room [ROOM NUMBER] [NAME] , was interviewed and stated they observed a mouse every night that comes in their room from the hallway and tries to go in their closet. The last time they saw the mouse was last night. On 05/06/2025 at 10:08 AM, Certified Nursing Assistant #12 was interviewed and stated a mouse frequently comes out of a vent in room [ROOM NUMBER] West. They smelled a foul odor recently and called maintenance who found a dead mouse in the heater. A review of the Unit 8 [NAME] Pest Control Service Record indicated that the following pest sightings were reported on Unit 8 West: droppings on 02/11/2025, a rat on 02/20/2025, and a mouse sound on 04/07/2025. A review of the Unit 8 [NAME] Service Inspection Reports documented that the pest management company provided pest management services to Unit 8 [NAME] on 04/01/2025, 04/18/2025, 04/22/2025, 04/25/2025, 04/29/2025, and 05/06/2025. The Service Reports documented products applied included insect monitors, gel bait for ants and cockroaches, and glue boards for rodents. On 05/06/2025 at 10:47 AM, the Director of Environmental Services was interviewed and stated they did not receive a report regarding mice sightings in room [ROOM NUMBER] West. They were aware of mice sightings in room [ROOM NUMBER] [NAME] which was recently treated by the pest control company. The Director of Environmental Services stated that the pest control company comes on Tuesdays and Fridays and that they also have a facility staff member who looks for holes and then reports to plant operations so they can be sealed. The Director of Environmental Services further stated the exterminator will be informed to inspect and do preventative treatment in rooms 824 [NAME] and 854 West. On 05/06/2025 at 4:00 PM, the Administrator was interviewed and stated the facility changed the Pest Control Company and believe that their current Pest Control Management is effective now. Also, their Quality Assurance and Performance Improvement program revealed a marked reduction in sightings. The Administrator further stated the facility provided residents and their family members boxes to store food which are self-closing and seal. Based on observations, interviews, and record review conducted during Recertification and Complaint (NY#00351324) Survey from 04/29/2025 to 05/06/2025, the facility did not ensure that an effective pest control program was maintained so that facility is free of pests. This was evident on 4 resident's units (Unit 7 East, 8 East, 8 [NAME] and 9 East). Specifically, there were multiple reports of pest sightings and rodent activity in resident rooms/units. The findings are: The facility's policy and procedure titled Pest Management revised 12/6/2024 stated that the facility is to contract with a licensed Exterminator for pest management and standard pest control. During the interview on 04/29/2025 at 02:05 PM, the resident who resided in Room in 703 East stated the facility has had pest problems since they were admitted in last August 2024. The resident who resided in Room in 703 East also stated there have been less pest sightings, but they are still seen throughout the facility. On 05/06/2025 at 11:01 AM, Registered Nurse #6, who worked on Unit 7 East, stated that residents and their representatives reported pest sighting sometime last week. Registered Nurse #6 also stated that any report of pests are documented in the unit pest control log, and the pest control company will then address the pest concerns when they are in the facility. Registered Nurse #6 further stated they do not know when the pest control is done or when the last pest treatment was done. On 05/06/2025 at 11:15 AM, Certified Nursing Assistant #8, who worked on Unit 7 East, stated they observed roaches in one of the resident's room last week and a resident complained of mouse in their room. Certified Nursing Assistant #8 also stated that staff tries to keep resident's rooms clean for the most part, but pests have still been visible on the unit. Certified Nursing Assistant #8 further stated that pests have been a problem on the unit since they started working on the unit. On 05/06/2025 at 10:58 AM, Registered Nurse #5, who worked on Unit 8 East, stated pest control treatments are done twice a week, putting glue traps near radiators, and spraying harsh chemicals for more severe cases. Registered Nurse #5 also stated that they have been working at the facility for less than a year, so they do not know how long this issue has been occurring. On 05/06/2025 at 12:17 PM, Licensed Practical Nurse #4, who worked on Unit 8 East, stated that nursing staff reported seeing roaches in resident's room recently, so they documented the sighting in the unit pest control log. On 05/06/2025 at 01:08 PM, the Director of Plant Operations stated there were reports of pest sightings in resident's rooms/units. The facility has a pest control program with a company who does routine visits to the facility to address the concerns. The Director of Plant Operations also stated that any pest concerns are addressed by the Director of Environmental Services, so they do not know the details of the pest control program.

Based on observations, interviews and record reviews conducted during the Recertification survey from 04/29/2025 to 05/06/2025, the facility did not ensure that a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding. This was evident in 1 (Resident #106) of 1 resident of reviewed for Tube Feeding. Specifically, tube feedings were not appropriately labelled with the resident's name, the flow rate, the time, and the date of the administration for Resident #106. The findings are: Resident #106 was admitted to the facility with diagnoses that included Cerebral Infarction with Aphasia, and Dysphagia. On 04/29/2025 at 11:46 AM, Resident #106 was observed in bed with their tube feeding running. The formula container was running as ordered by the physician but was not labeled with the resident's name, the flow rate, the time, and the date of the administration. On 05/05/2025 at 8:42 AM, Resident #106 was observed lying on their side in bed with the tube feeding running. The formula container was not labeled with the resident's name, the flow rate, the time, and the date of the administration. On 05/05/2025 at 8:30 AM, Licensed Practical Nurse #1 was interviewed and stated that Resident #106 was usually already receiving their tube feeding when they arrived on the unit. Licensed Practical Nurse #1 also stated that since they generally work the night shift, they do not start the feedings which are the responsibility of the nurse who sets up the feeding. Licensed Practical Nurse #1 further stated that the formula bottle is supposed to be labeled with the resident's name and staff are to check the medical order before starting the feed to make sure the resident is receiving the prescribed formula. On 05/06/2025 at 12:12 PM, the Director of Nursing was interviewed and stated that the dietary department usually places a sticker on each formula container with the resident's name. The Director of Nursing also stated that if there is no sticker, the nurse is responsible for checking the order and placing the resident's name and other information on the container. 10 NYCRR 415.12(g)(1-7)

2. Resident #523 was admitted to the facility with diagnoses including Alzheimer's Disease, Insomnia, Diabetes and Spontaneous Ecchymoses. The Quarterly Minimum Data Set (a resident assessment tool) dated 11/04/2024 documented that Resident #523 as severely cognitively impaired but requiring only supervision or set up for all Activities of Daily Living. A Medical note dated 01/28/2025 at 1:07 PM states that Resident #523 was seen for multiple scratches and ecchymoses to the upper extremities and left breast. Resident #523 was unable to provide any relevant history in view of their cognitive deficits. The scratches were located on their left hand, left elbow, right wrist and mid forehead, and there were two large ecchymoses on the lateral and medial side of the left breast with a central abrasion. The physician ordered bacitracin for the scratches and x-rays of the hands and elbow, which were negative. A Nursing note dated 01/28/2025 at 12:11 PM, stated that Resident #523 was noted with scratches to the right wrist, left hand and elbow, and was observed to have long nails which were immediately trimmed. The resident's family member was notified and requested transfer to the hospital for follow up. An Accident and Incident Report and written statements dated 01/27/2025 and 01/28/2025 were gathered from six staff members, none of whom witnessed or heard any falls or commotions on the unit. The Administrative Summary dated 02/05/2025 stated that surveillance video was reviewed at the time and revealed no encounters with other residents or aggressive contacts with staff, so the facility concluded that there was no cause to believe any abuse had taken place. There was no documented evidence that injuries of unknown origin for Resident #523 were reported. On 05/06/2025 at 8:56 AM, Licensed Practical Nurse #3 was interviewed and stated that Resident #523 had been residing on their unit prior to the alleged incident. Licensed Practical Nurse #3 also stated that the Resident #523 had not had any witnessed falls or any altercations with others while they were on the unit, and so they did not know what happened to cause the injury. On 05/06/2025 at 11:47 AM, the Director of Nursing was interviewed and stated that the facility's policy is to investigate the resident's clinical baseline prior to reporting an alleged incident. If the facility finds it has reasonable cause to suspect that a purposeful act might have caused the injury, it would have been reported. The Director of Nursing further stated that the injury had a clinical baseline consistent with the resident's diagnosis of spontaneous ecchymoses, which the facility interpreted as an injury of known, not unknown origin and therefore there was no need to report it. 10 NYCRR 415.4(b)(1)(i) Based on record review, and staff interviews during the Recertification and Complaint (NY#00362652, NY#00371137) Survey conducted from 04/29/2025 to 05/06/2025, 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 for 2 (Resident #201 and Resident #523) out of 6 residents reviewed for Accidents out of 38 total sampled residents. Specifically, 1) the facility did not report an incident when Resident #201 was noted with swelling and ecchymosis on left forearm/upper arm, an injury of unknown origin, to the New York State Department of Health, and 2) the facility did not report an incident where multiple scratches and ecchymoses noted to the upper extremities and on the left breast of Resident #523. The findings are: The facility's policy and procedure titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property revised 10/13/2023 documented injuries of unknown source are reported per Federal and State Law. 1. Resident #201 was admitted to the facility with diagnosis that included Diabetes Mellitus, Alzheimer's Disease, and Hypertension. The Significant Change in Status Minimum Data Set assessment dated [DATE] documented Resident #201 had severely impaired cognition. The Accident/Incident Report dated 11/21/2024 documented that on 11/21/2024 at 6:30 PM, Resident #201 was noted with skin discoloration to left upper arm and swollen hand. Resident #201 was unable to explain the occurrence/injury. Resident's representative was at bedside. Nursing supervisor and physician were notified. The Medical Note dated 11/22/2024 documented Resident #201 was examined for swelling and ecchymosis on left forearm, and upper arm. Resident is nonverbal, started screaming/agitated when touched the arm. Ordered x ray of left forearm, upper arm and to continue pain assessment. The Radiology Report dated 11/22/2024 documented Resident #201's left humerus x-ray revealed evidence of fracture involving humeral head and neck displacement of fracture fragments. The Accident/Incident Investigation completed on 11/28/2024 concluded that based on clinical observation, chart review and staff interviews, there is no cause to believe Resident #201's fracture with humeral head and neck displacement was a result of any abuse, neglect or mistreatment. There was no documented evidence the facility reported Resident #201's injury of unknown source, resulting in major injury, to the New York State Department of Health. On 05/06/2025 at 03:09 PM, the Director of Nursing stated that Resident #201 has a diagnosis of osteoporosis and is at a higher risk for fracture. The Director of Nursing also stated that Resident #201's injury was consistent with diagnosis and was not from an unknown origin, therefore, it was not reported to the New York State Department of Health.

2. The New York State Complaint Intake Summary (#NY00351324) dated 01/14/2025 documented that a family representative stated that the residents' rooms were left with crumbs and garbage on the floor, and the Administrator was notified about their concerns and nothing was done about it. On 04/30/2025 at 01:08 PM, in room [ROOM NUMBER] on Unit 9 East, paper towels and old tissues of a brownish color were observed on the floor. Two trash cans by the bedside were nearly full of trash. The resident who resided in room [ROOM NUMBER] stated that the housekeeping staff do not come to clean very often, and they only come in one or two times a week. On 05/01/2025 at 11:37 AM, an interview was conducted with Housekeeper #1 who stated that they work five days a week on several units and come to work on Unit 9 East about three times a week. Housekeeper #1 also stated that they were not sure if someone else came to clean the room after them. Housekeeper #1 concluded that the last time they worked on Unit 9 East was this past Sunday April 27th, 2025. On 05/01/2025 at 11:47 AM, an interview was conducted with Certified Nursing Assistant #13 who was regularly assigned to the resident in room [ROOM NUMBER]. Certified Nursing Assistant #13 stated they did not notice that the room was not clean, and if they had noticed the room was not clean they would have informed the housekeeping staff. On 05/01/2025 at 12:00 PM, an interview was conducted with Registered Nurse #10, who stated that they have not seen any unclean rooms. Registered Nurse #10 also stated that no resident had reported to them room concerns, but some residents did complain of roaches and flies and the exterminator comes almost every day to treat the units. Registered Nurse #10 also stated they were not aware that room [ROOM NUMBER] was not clean. On 05/06/2025 at 01:08 PM, the Director of Plant Operations stated that any equipment repair is submitted via an online work request, and they will also receive request by telephone or email for any urgent repair request. The Director of Plant Operations also stated that they are responsible for maintenance of common areas, corridors, and building structures, including the rooms, and they also replace the radiator filter every six months and change the motor as needed. The Director of Plant Operations further stated that they do unit rounding twice a week on a total of four units per week to identify any area of concerns. The Director of Plant Operations stated they did not identify the concerns found on unit 8 East during their environmental round. On 05/06/2025 at 02:36 PM, the Director of Environmental Services stated housekeeping staff tasks are to empty the garbage, sweep and mop the floors, dust/wipe furniture, and supply toiletries in all the resident's rooms daily. The Director of Environmental Services also stated windowsills, window shields, and metal radiator grills are cleaned or wiped daily by housekeeping staff. The Director of Environmental Services further stated they do round on all the units daily to ensure staff are doing their assigned tasks. However, they were not aware of these problems on the unit. On 05/06/2025 at 02:52 PM, the Administrator stated the Director of Environmental Services and Director of Plant Operations do environmental rounds twice weekly to identify any concerns, but the Administrator does not recall any of these concerns being reported to them. 10 NYCRR 415.12(h)(2) Based on observations and interviews conducted during the Recertification and Abbreviated survey Complaints (NY#00351324 ) from 04/29/2025 to 05/06/2025, the facility did not ensure the residents' right to a safe, clean and comfortable environment. This was evident on 2 (Unit 8 East and Unit 9 East) out of 20 resident units. Specifically, resident rooms were not cleaned and furniture not maintained in good repair, and in a homelike manner. The findings are: The facility's policy and procedure titled Maintenance of Building, Resident's Rooms and Common Areas reviewed 01/2025 stated that the facility is to ensure the physical environment including resident's rooms, common areas, and building systems is maintained in a clean, safe, and fully functional condition through timely and efficient maintenance practices. 1. During multiple observations on Unit 8 East from 04/29/2025 at 11:23 AM to 05/01/2025 at 12:55 PM, the following were observed but not limited to: In room [ROOM NUMBER] B, there was peeling/broken nonslip stickers on the floor, dust and dirt build up noted on the radiator and metal vent grill. In room [ROOM NUMBER] P, there was dust and dirt build upon the radiator and vent grill, peeling paint and orange and brown stained window ledge and window shades splashed with brown stains, and a broken handle on the drawer next to the bed. In room [ROOM NUMBER] P, there were mismatched floor tiles which had brown stains, peeling and broken nonslip stickers on the floor, radiator which was dusty and had built up dirt, and a window shade with brown stains. In room [ROOM NUMBER] F, there was dust and dirt build up on the radiator, peeling nonslip stickers on the floor, the bathroom door has a lower quarter-half chipped showing wooden material, window shades with dark stains, a hole on the wall above closet A, mismatched floor tiles with brown stains, room door with peeling paint and scruff marks, a nebulizer placed on a dusty surface, and a visibly smudged table stand next to the television. In room [ROOM NUMBER] B, there was a buildup of dust and dirt build on the radiator and vent grill and peeling nonslip stickers on the floor. In multiple rooms, hallways, and areas near the elevators there were walls with scratches and scruff marks, areas with peeling wall paper, damaged baseboards, window shades with brown stain, stained floors and mismatching tiles, and dust and dirt built up on radiators and the vent grills. Review of Maintenance Logbook for 8 East from 4/1/2025 to 4/29/2025 did not contain requests for any of the above observations.

Based on observation, record review, and interviews during an abbreviated survey (NY00356446), the facility did not ensure that each resident received adequate supervision to prevent an elopement. This was evident for one (1) out of four (4) residents (Resident #2) sampled for elopement. Specifically, the facility Elopement/Unauthorized Leave Incident Report dated 10/04/2024 documented that the surveillance video footage showed at 11:09 AM on 10/04/2024 Resident #2 exited the unit unsupervised. At 11:15 AM, the East COVID entrance door alarm was activated, and Security Officer #3 deactivated the alarm. The investigation documented that it was confirmed at 11:47 AM Resident #2 was missing. Resident #2 was located by the police and was taken to the emergency roiagnom on [DATE] without injury. The findings include: A Policy and Procedure titled Elopement and Unsafe Wandering Policy reviewed 10/04/2024 documented an elopement occurs when a resident leaves the premises or a safe area without authorization (i.e. an order for discharge or leave of absence) and/or any necessary supervision to do so. A Policy and Procedure titled Resident Safety and Security desk Operations reviewed date of 04/2024 documented monitor resident exits and ensure Out on Pass documentation is complete and residents are properly escorted. Prevent unauthorized resident undetected exit of building or unescorted departures. Monitor resident movement through entrances and exits. Prevent unauthorized exits, especially for residents with cognitive impairments. Immediately report any high-risk exit seeking residents to the director of security. Surveillance and Monitoring documented regularly check Closed Circuit Television to secure high-risk or sensitive areas throughout the facility. Resident #2 admitted to the facility with diagnoses including Dementia, Schizophrenia Disorder, and Anxiety Disorder. The Minimum Data Set (an assessment tool) dated 10/04/2024 documented Resident #2 was moderately impaired (decisions poor; cues/supervision required). Resident #2 ambulated with supervision or touching assistance. An Elopement Risk assessment dated [DATE] documented Resident #2 was identified at risk for elopement. Resident #2 had exhibited exit seeking behavior, restlessness, agitation, and verbalized desire to leave the facility. A Wandering/Elopement Risk Care Plan dated 10/02/2024 documented to provide visual monitoring of Resident #2's location every hour and alert staff regarding Resident #1's behavior. An Hourly Visual Check Monitoring form dated on 10/04/2024 documented other for Resident #2's location from 9:00 AM - 10:00 AM and from 10:00 AM - 11:00 AM. An Accident/Incident Investigation Report dated 10/04/2024 at 11:49 AM, documented Resident #2 was observed by the elevator approaching the nursing station. At approximately at 11:15 AM, the East lobby alarm was activated with full search of security and staff conducted headcount. At 11:47 AM, Resident #2 was not visible on the unit. Security and the Assistant Director of Nursing were notified. Code Orange (elopement code) was activated at 11:49 AM. Review of the facility Elopement/Unauthorized Leave Incident Report dated 10/04/2024, documented Timeline of Events (from Security Department). At 11:09 AM, Resident #2 exited the unit without authorization. At 11:15 AM, Security Officer #3 deactivated the triggered Code Alert box at the East COVID doors. At 11:21 AM, Security Officer #4 notified the Director of Security of triggered alarm. At 11:24 AM, the Director of Security contacted Associate Director of Nursing to initiate a full facility count. At 11:47 AM, Associate Director of Nursing confirmed that Resident #2 was missing. At 11:49 AM, Code Orange was announced. At 11:51 AM, Incident Command Center was activated. At 11:55 AM, Director of Security contacted local law enforcement. At 1:43 PM, Code Orange remained in effect until local law enforcement located Resident #2. At 1:58 PM, a notification was received via WhatsApp group chat that Resident #2 was found walking on the highway and was taken to the emergency room at approximately 1:40 PM by the police. A nursing progress note dated 10/07/22024 at 9:48 AM (late entry for 10/04/2024) by Unit Manager #1 documented Resident #2 left the facility unauthorized on 10/04/2024. Resident #2 was picked up by an ambulance and was sent to hospital. Resident #2 was discharged home from hospital with their spouse. During an interview on 04/07/2024 at 12:00 PM, Resident #2's assigned Certified Nursing Assistant #3 who worked on 10/04/2024 on the 7:00 AM to 3:00PM shift, stated they were in the hallway documenting in sigma kiosk when Resident #2 returned from their appointment and was left at the nursing station (does not recall the time). Certified Nursing Assistant #3 stated they provided Resident #2 with a wheelchair and brought them back to their room. Certified Nursing Assistant #3 stated Resident #2 did not attempt to exit the facility and did not exhibit any behavior problem on 10/04/2024. Certified Nursing Assistant #3 stated that they monitored Resident #2, and prior to them leaving for their break at 11:00 AM, they notified Registered Nurse #1 and other Certified Nursing Assistants on the unit that they were leaving the unit. Certified Nursing Assistant #3 stated when they returned from their break, the staff were searching for Resident #2. Certified Nursing Assistant #3 stated everyone knew Resident #2 was on visual monitoring for wandering behavior. During an interview on 04/07/2025 at 12:29 PM, Registered Nurse #1 who worked on 10/04/2024 on the 7:00 AM to 3:00 PM shift stated Resident #2 did not exhibit any behaviors that would indicate they wanted to leave the facility. Registered Nurse #1 stated they gave Resident #2 their medications at 10:00 AM and Resident #2 verbalized that they did not need anything when they were asked. Registered Nurse #1 stated Resident #2 was ambulatory; walked around on the unit; and was being monitored for wandering behavior. Registered Nurse #1 stated Resident #2 had a wander guard in place on their right ankle that was functional. Registered Nurse #1 stated that the wander guard placement and functionality is documented in the Treatment Administration Record. Registered Nurse #1 stated that one of the staff members (does not recall name) asked them for Resident #2 (don't recall time) and they checked the off-unit logbook and Resident #2 was not at therapy. Registered Nurse #1 stated they instructed the staff members to search the unit and notify Unit Manager #1 if Resident #2 was not located. Registered Nurse #1 stated they do not recall the exact time, but that it was after 11:00 AM that they were unable to locate Resident #2 and Code Orange was activated. Registered Nurse #1 stated that none of the staff saw Resident #2 exited the unit via the elevator (Cab #3) located on the side of the nursing station. Registered Nurse #1 stated they did not hear the elevator alarm on the unit. An attempt was made to contact Security Officer #3 multiple times on 04/08/2025 but was unsuccessful. A letter was sent via certified mail on 04/08/2025 with no response to date. During a telephone interview on 04/08/2025 at 12:13 PM, Unit Manager #1 stated they conducted rounds and the unit (does not recall time) and spoke with Resident #2's roommate, Resident #2 was not in their room during rounds. Unit Manager #1 stated Resident #2 was on hourly visual monitoring. Unit Manager #1 stated Code Orange was announced at approximately 11:49 AM and staff conducted headcounts on all the units. Unit Manager #1 stated all staff on the unit reported they did not hear any of the alarms (exit doors and elevators) sounding on the unit. Unit Manager #1 stated they don't have any explanation as to how Resident #2 was able to leave the unit unsupervised. Unit Manager #1 stated that staff must punched in a code on the keypad before using the exit doors otherwise, the door will alarm. During an interview on 04/07/2025 at 2:00 PM, Associate Director of Nursing stated the Director of Security notified them on 10/04/2024 at approximately 11:24 AM that the alarm went off in the East lobby main entrance at approximately 11:15 AM. The Associate Director of Nursing stated at approximately 11:47 AM, Unit Manager #1 reported to them that Resident #2 was not on the unit and that a search had been completed. The Associate Director of Nursing stated that Code Orange was activated at 11:49 AM. The Associate Director of Nursing stated that the searched was extended to neighboring area, staff was sent to different areas, hospitals were called, and the police was notified. The Associate Director of Nursing stated the hospital called the facility on 10/04/2024 at 1:58 PM and reported Resident #2 was brought into the emergency department by the police at 1:40 PM. The Associate Director of Nursing stated they went to the hospital and Resident #2 was there with their spouse and the police. The Associate Director of Nursing stated Resident #2 was assessed in the emergency department with no visible injuries. The Associate Director of Nursing stated Resident #2 was discharged from the emergency room to their home with their spouse. The Associate Director of Nursing stated Resident #2's wander guard was removed and tested in the facility and was found to be functional when the elevators wander guard alarms activated. The Associate Director of Nursing stated they don't know why the alarm on the elevator didn't active when Resident #2 entered the elevator. The Associate Director of Nursing stated they reviewed the video footage dated 10/04/2024 at 11:07 AM and Resident #2 went by the side elevator (cab #3) of nursing station and exited the elevator without sounding the alarm. The Associate Director of Nursing stated that the video footage showed three staff members were at the nursing station on the unit at the time, but they did not notice Resident #2 going to the elevator. The Associate Director of Nursing stated when a resident wearing a wander guard stands in front of the elevator, the elevator wander guard alarm will activate, and the elevator will not move unless a staff enters a code to deactivate the alarm. The Associate Director of Nursing stated Resident #2 was last seen at 11:15 AM prior to exiting the East lobby in the COVID entrance door. The Associate Director of Nursing stated Security Guard Officer #3 was not aware Resident #2 exited the facility. The Associate Director of Nursing stated after Resident #2 activated the wander guard alarm in the East lobby entrance door that leads to the street, Security Guard Officer #3 got up, checked inside the lobby, looked around the door outside, then deactivated the alarm. The Associate Director of Nursing stated Security Officer #3 did not follow facility policy protocol. Security Officer #3 should not have deactivated the alarm and should have immediately notified the Director of Security. The Associate Director of Nursing stated they investigation concluded that abuse or neglect did not occur because Resident #2 was on hourly visual monitoring and had a wander guard in place. During a telephone interview on 04/16/2025 at 12:10 PM, Security Officer #4 stated they worked on 10/04/2024 on the 7:30 AM-3:30 PM shift. Security Officer #4 stated that they were in the process of relieving Security Officer #3 when they heard an alarm sounding from the East lobby side of the COVID entrance, but the alarm stopped once they approached the lobby. Security Officer #4 stated they asked Security Officer #3 about the alarming door at the COVID entrance and Security Officer #3 told them that they reset the alarm. Security Officer #4 stated they notified the Director of Security that the exit door alarm was activated. Security Officer #4 stated they were not aware that a resident was missing unit they were notified by nursing and Code Orange activated. Security Officer #4 stated it was the Director of Security who reviewed the camera on 10/04/2024 (does not recall the time). During an interview on 04/07/2025 at 11:40 AM the Director of Security stated they were notified by Security Officer #4 that the alarm in the East lobby side by the COVID entrance door was triggered. The Director of Security stated that Security Officer #3 should have investigated the interior and exterior perimeter to ascertain why the alarm was triggered and notify them. The Director of Security stated that Security Officer #3 just deactivated the alarm without checking if a resident exited the facility. The Director of Security stated there are always three Security Officers on duty on each shift. The Director of Security stated they reviewed the video footage, and a timeline was made. The Director of Security stated the Security Officer #3 received in service on elopement prevention prior the incident. During an interview on 04/07/2025 at 2:30 PM the Administrator stated they were notified of the incident on 10/04/2024 at 11:50 AM by the Associate Director of Nursing and the Director of Security. The Administrator stated they were informed that the alarm system did not malfunction, but that the code alert sensor in the elevator had less sensitivity. The Administrator stated that they had to increase the audible decibels and covered the sensors in the elevator to increase the alarm sound. They also stated when a resident wearing a wander guard enters the elevator the alarm will automatically signal to the Life Safety Committee via group text to alert them of the activation of the alarm. This will prevent future occurrence of elopement. The Administrator stated in the East lobby entrance the alarm was activated and sounded, but Security Officer #3 did not go around the perimeter and they did not find out why the system alarmed. Security Officer #3 did not follow the policy protocol and just deactivated the alarm without calling the Director of Security. The Administrator stated to prevent reoccurrence, the Command Center had an After- Action Report/Improvement Plan on 10/04/2024 and completed it on 10/05/2024. 10NYCRR415.12(h)(2)

Based on observation, record review and interviews conducted during an abbreviated survey (Case NY 00324036), the facility did not ensure the resident's right to be free from physical abuse by nursing home staff. This was evident for one out of six residents (Resident #1) sampled for abuse. Specifically, on 09/15/23 at 12:30 PM, Resident #1 stated Certified Nursing Assistant (CNA) #1 punched them twice in the nose after they refused personal care. Nurse Manager (RM) #1 assessed Resident #1 and observed that the nose was bleeding with slight swelling, and seem shifted to the left. Emergency Medical Services (911) and the Attending Doctor was called. CNA #1 was removed from the nursing unit. At 1:55 PM, Resident #1 was transferred to the Hospital emergency room . The findings are: The Facility's Policy/Procedure for Abuse/Neglect/Exploitation/ Mistreatment and Misappropriation reviewed 01/19/23, documented the State defined abuse as inappropriate physical contact with a resident of a residential health care facility, while the resident is under the supervision of the facility, which harms or is likely to harm the resident. To comply with the State Regulation this facility has zero tolerance for abuse. Resident #1 was initially admitted to the facility with Diagnoses which included Fracture of Femur and HIV, was readmitted to the facility on [DATE] after a total hip replacement. A Minimum Data Set (MDS - an assessment tool used to determine level of care required) dated 08/11/23, documented Resident #1 was cognitively intact and required two persons to assist with bed mobility. The facility's Incident Report dated 09/15/23, documented Resident #1 was observed with nose bleeding. A statement from CNA #1 documented that they were not assigned to Resident #1 but was asked by CNA #2 who was assigned, to assist with providing care to Resident #1. CNA #2 went out of the room to get towels and linens and on returning saw Resident #1's nose was bleeding and Resident #1stated that CNA #1 punched them twice on the nose. Resident #1 was assessed by the Nurse Manager and the Attending Physician. There were swelling, laceration, misalignment of the nose, and complaint of nose pain. First aid was given. The family were informed and 911 was activated. Resident #1 was transferred to hospital emergency room for further evaluation. A Care Plan (CP) Activity Report documented on 08/11/23, that a Potential Risk for Abuse CP was initiated on admission. The intervention included staff monitoring and support. The CP for Abuse was updated on 09/15/23 and documented that an actual abuse occurred. The Attending Physician Transfer note dated 09/15/23, documented that the Physician was informed at about 12:30 PM that Resident #1 was yelling that their nose was broken and painful. A physical examination documented that the nose was noted to be misshaped at the bridge with a one cm small laceration linear on right side slanting toward midline in the superior aspect. There was a very mild amount of fresh blood and swelling. During a telephone interview on 09/25/23 at 1:44 PM, CNA #1 stated they worked the 7AM to 3 PM shift on 09/15/23 and was not assigned to Resident #1. They went to assist the assigned CNA #2 who went to get towels. During that time, CNA#1 was trying to help Resident #1 to move up in the bed when Resident #1 tried to hit them, CNA #1 blocked the hit with the right arm and the resident's nose collided with their elbow and the nose started bleeding. The nurse and supervisor were called and came to the room. The CNAs did not start to provide care when this happen, and they were not aware that Resident #1 was a two person assist. CNA #1 said that they were removed from the floor, 911 was called and that they were locked up for some hours. and was given a letter from the precinct and told to stay away from the nursing home. During a telephone interview on 09/25/23 at 2:01 PM, CNA #2 stated they were assigned to Resident #1 and was preparing to give care to Resident #1 when CNA#1 came to the room. They told CNA#1 that Resident #1 was a two person assist and to stay in room as CNA#2 stepped out to get towels. When they return to the room CNA #1 told them that there was an incident. Resident #1 had some bleeding on the nose. CNA # 1 told CNA #2 that the Resident #1 tried to hit them, and they (CNA# 1) blocked the hit with their arm and the resident's nose hit their elbow. During an interview on 09/25/23 at 1:19 PM, Nurse Manager (RM) #1 stated that Resident #1 gets agitated during care since the total hip replacement and had issues with pain. Oxycodone was ordered and given. On 09/15/23, RM #1 stated that they assess Resident #1 and saw a small nosebleed, with slight swelling of the nose which seemed to be shifted to the left. First aid treatment was applied, The Medical doctor (MD) #1 was notified and 911 was called. CNA #1 was removed from the nursing unit. On 09/15/23 at 12:54 PM, Law enforcement arrived with included six Police Officers. The Police Officers interviewed CNA #1 and Resident #1. At 1: 50 PM, CNA #1 was escorted out of the facility. At 1:55 PM, Resident #1 was transferred to the emergency room . During an interview on 09/25/23 at 5:18 PM, the Medical Director stated that they were informed on 09/15/22, by the Attending MD #1 that Resident #1 was transferred to the hospital for possible nose injury. During a follow up telephone interview on 09/27/23 at 11:00 AM, the Medical Director stated that Resident #1's hip pain was managed with medication and that Resident #1 had a history of Chronic Bilateral nasal bone fracture associated with deformity that was confirmed on a Cat Scan of the head and face done on 12/26/21. On 09/15/23, the Cat Scan was repeated and showed no new evidence of fractures in any of the facial bones, however there was still chronic bilateral nasal bone fracture when compared to scan of 12/2021. The sinuses are clear, and the orbits are unremarkable. The misshaped nose bridge is old based on the Ct Scan report. Resident #1 was discharged from the hospital on 09/22/23 with a diagnosis of Nose injury. During a telephone interview on 10/10/23 at 1:48 PM with the Associate Director of Nursing (ADON) who conducted the investigation, stated that CNA #2 did not actually see Resident #1 being hit, CNA #2 was just outside the resident's door where the linen cart was and heard the Resident #1 scream, went into the room and noticed some bleeding from Resident #1' s nose. 10 NYCRR 415.4(b)(1)(i)

Based on observation, record review, and interviews conducted during the Recertification survey of 5/9/23 to 5/16/23, the facility did not ensure that person-centered care plans (CCP) with measurable goals, time frames and interventions were developed to address a resident's medical needs. This was evident for 2 (Resident #351 and #232) of 39 total sampled residents. Specifically, 1) a CCP related to tracheostomy care was not developed for Resident #351, and 2) a CCP related to oxygen use was not developed for Resident #232. The findings are: The facility policy titled Person-Centered Care Planning - Comprehensive Care Plan effective October 2017, reviewed 4/28/23, states the facility must develop and implement a person-centered care plan for each resident consistent with the resident's rights that include measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs that are identified in their assessment. 1. Resident #351 had diagnoses of kidney transplant and tracheostomy status. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #351 had mild cognitive impairment and a tracheostomy. On 5/11/23 at 11:42 AM, Resident #351 was interviewed and stated they don't need the oxygen anymore. The tracheostomy is closing. The Medical Doctor (MD) Orders dated 3/7/23 documented Resident #351 receive trach stoma care. There was no documented evidence a CCP related to tracheostomy care was developed for Resident #351. An interview was conducted on 5/15/23 at 4:51 PM, with Registered Nurse Manager (RNM) #5, who stated the RN is responsible to initiate and update care plans. Residents requiring tracheostomy care should have CCP related to tracheostomy care in their medical record. The RN reviews the new admission or readmission history to determine CCPs to initiated or reactivate. 2. Resident #232 had diagnoses of dementia and sepsis. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #232's cognition was severely impaired and resident receives oxygen therapy. The Medical Doctor (MD) orders dated 5/3/23 documented an order for Resident #232 to receive oxygen inhalation continuous via nasal cannula at 2 liters per minute every shift, have oxygen saturation monitored every shift, and be reported to the MD if their oxygen saturation is below 88%. An MD note dated 5/05/2023 documented Resident #232 was hypoxic, had pneumonia, and was started on supplemental oxygen. Nursing Notes dated 5/11/23, 5/7/23, and 5/5/23 documented Resident #232 refused to use oxygen. There was no documented evidence a CCP related to oxygen use was developed for the resident. An interview was conducted on 5/12/23 at 11:28 AM with Registered Nurse Manager (RNM) #1 who stated Resident #232's oxygen saturation is checked every shift. The RNMs initiate CCP Resident #232 should have a CCP related to oxygen use in place. RNM #1 reviewed Resident #232's medical record and was unable to provide documentation of a CCP related to oxygen use. An interview was conducted on 5/15/23 at 5:04 PM with the [NAME] President of Clinical Services (VPCS) who stated care planning is done upon admission and readmission. The MDS assessment is reviewed and the CCPs are updated. All CCPs are reviewed during the interdisciplinary care plan meeting. 415.11 (c)(1)

Based on observation, record review, and interviews conducted during the Recertification survey from 5/09/2023 through 5/16/2023, the facility did not ensure Comprehensive Care Plans (CCP) were reviewed and revised after each assessment. This was evident for 2 (Residents #87 and #351) of 39 sampled residents. Specifically, (1) the care plan for Tube Feeding was not reviewed for Resident #87, and 2) the care plan for abuse was not revised for Resident #351. The findings are: The policy and procedure titled Person-Centered Care Planning-Comprehensive Care Plan, last revised 4/28/2023, documented each person-centered care plan is reviewed by the interdisciplinary team (IDT) on a quarterly, annual, and as needed basis. Documentation in the Electronic Medical record (EMR) should reflect results of the IDT meetings including the discussion of any changes to the resident's plan of care. 1) Resident #87 had diagnoses which included Cerebral Infarction, Hemiplegia, and Aphagia. On 05/16/23 at 10:21 AM, Resident #87 was observed in bed with a feeding tube in place. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] Resident #87 was severely cognitively impaired and received nutrition via a feeding tube. The CCP related to tube feeding, initiated 1/05/2021 and last reviewed 5/26/2022, documented that Resident #87 will be adequately nourished and hydrated via feeding tube. A Physician's order dated 1/17/2023 and renewed 4/20/2023 documented Resident #87 received enteral feeds. There was no documented evidence the CCP related to Resident #87's tube feeding was not reviewed and revised upon MDS assessments dated 8/24/22, 11/22/22, and 2/22/23. During an interview on 5/16/2023 at 12:05 PM, the Registered Nurse Supervisor (RNS) stated care plans are updated quarterly, annually, and after any significant change. The Dietician is supposed to update the CCP related to tube feeding. During an interview on 5/16/2023 at 1:49 PM, the Dietician stated they made a mistake by not updating Resident #87's tube feeding CCP and the CCP should have been reviewed and updated upon each MDS assessment. 45349 2) Resident #351 had diagnoses of kidney transplant and tracheostomy status. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #351 had mild cognitive impairment and a tracheostomy. A CCP titled Abuse, effective date 12/25/22, documented a goal for Resident #351 to be free of abuse. The CCP was last updated 12/27/22. There was no documented evidence the CCP related to abuse prevention for Resident #351 was reviewed and revised upon each MDS assessment. An interview was conducted on 5/15/23 at 4:51 PM with Registered Nurse Manager (RNM) #5, who stated the RN is responsible to initiate and update care plans. The other disciplines also do their area. RNM #5 stated that for a readmission, they go through the history and reactivate, review the goals and interventions. They document the review in the note's sections of the care plan. An interview was conducted on 5/12/23 at 11:53 AM with the MDS Senior Manager (MDS-SM) who stated that the unit nurse is responsible for the care plans. The MDS department monitors care plans that are linked to the MDS. An interview was conducted on 5/15/23 at 5:04 PM with the VP of Clinical Services (VPCS) with regard to the policy and procedure for care planning. The VPCS stated that when a resident comes to the facility, admission, or readmission, they do a baseline care plan and then comprehensive care planning. They follow the MDS assessment for review and updates. The Social Workers are doing follow up/audits to make sure the care plans are in place, even nursing care plans and will review during the care plan meeting. 415.11(c)(2)(i-iii)

Based on observation, record review and interviews conducted during the Recertification survey from 5/9/23 to 5/16/23, the facility did not ensure a resident received treatment and care in accordance with professional standards of practice. This was evident for 1 (Resident #385) of 4 residents reviewed for Positioning/Mobility, out of a sample of 39 residents. Specifically, Resident #385 was observed on several occasions, without bilateral elevating leg rests as per physician's order. The findings are: The facility policy titled Turning/Positioning/Devices, last revised 04/28/23, documented that the general guidelines include that the interdisciplinary team will assess residents that need to be placed on positioning devices. The facility's policy titled Rehabilitation Services last revised 08/03/22 documented physician must order a therapy evaluation and an evaluation /plan of treatment must be completed by a qualified therapist, prior to initiating therapy to establish a patient-centric individualized plan of care. Resident #385 had diagnoses of dementia and peripheral vascular disease. On 05/09/23 at 12:01 PM, 05/11/23 at 08:33 AM, 05/12/23 at 01:02 PM, 05/12/23 at 03:23 PM, Resident #385 was observed in their wheelchair without bilateral elevating legrests in place. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented Resident #385 had severely impaired cognition and used a wheelchair. The Physician's order renewed 05/02/23 documented Resident #385 use a wheelchair with bilateral elevating legrests. On 05/12/23 at 03:24 PM, Certified Nursing Assistant (CNA) #3 was interviewed and stated Resident #385 does not have wheelchair legrests and legrests are not used because sometimes the other residents crash into them and fall. On 05/12/23 at 03:30 PM, Registered Nurse (RN) #2 was interviewed and stated Resident #385 does not use legrests and they do not know the reason the legrests were not applied to the resident's wheelchair. Rehab ordered the leg rests based on their evaluation and the resident's need for the leg rests. RN #2 then answered that Resident #385 refused to have the legrests. RN #2 was unable to provide documented evidence Resident #385 refused to have legrests applied to their wheelchair. On 05/12/23 at 03:55 PM, the Rehab Director was interviewed and stated Resident #385 was assessed 2/10/23 and the order for the resident to have bilateral legrests was continued so that the resident can push themselves in the wheelchair. On 05/15/23, at 05:42 PM, the Director of Nursing (DON) was interviewed and stated Rehab is responsible for providing residents with a wheelchair legrests. If legrests are ordered, the resident should be using them. 415.12

Based on observation, record review and staff interviews conducted during an Abbreviated Survey (NY 326) on 01/18/2021, the facility did not ensure that pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) were provided to meet the needs of each resident. This was evident for 1 out of 6 residents sampled (Resident #1). 1) Specifically, from 11/09/2021 through 11/16/2021, Resident #1 did not receive his/her medication, [MEDICATION(S)] XL (Antidepressant) 300 milligrams (mg) daily. 2) Additional, from 12/12/2021 through 12/13/2021 and 12/29/2021, Resident #1 did not receive [MEDICATION(S)] XL 300mg daily. Staff interviews revealed that the medication was not in stock and was not available for Resident #1. Findings are: Resident #1 was initially admitted to the facility on [DATE] with diagnoses including Depression, Anxiety, and Opioid Dependence. Resident #1 was also admitted on [MEDICATION(S)] Maintenance. The Minimum Data Set (MDS, a resident assessment tool) dated 10/17/2021 documented that Resident #1 had a Brief Interview for Mental Status (BIMS, use to determine attention, orientation, and ability to recall information) score of 15/15, associated with intact cognition. The facility's Policy entitled Medication Administration dated 12/2021 documented: Medications shall be administered according to established schedules. Medications will be documented in the facility Electronic Health Record (EHR). Documentation discrepancies which are unacceptable in Electronic Medication Administration Record (EMAR) include: awaiting medication delivery, medication not available. Nurses must inform nurse manager/nurse supervisor and document. The Medical Doctor (MD) or Nurse Practitioner (NP) must be informed of the status of medication or current medication issue and document; reschedule the medication as per MD or NP orders when informed. A [CONDITION(S)] Drug Use Care Plan effective 05/26/2021 documented etiology: Anxiety as evidence by history of agitation and being short tempered. The interventions included: administer medications as ordered, assess effectiveness of medication, evaluate for reduction of medication dose, and assess behavioral pattern. A Proof of Delivery Packing Slip dated 10/18/2021 documented that [MEDICATION(S)] HCL tab 300 mg ([MEDICATION(S)] XL 300 mg), quantity 30 tablets was delivered on 10/18/2021 at 7:17 PM. RNS #1's name was printed on the packaging slip next to signed by and a horizontal line was drawn below signature. A Physician's Order dated 11/05/2021 at 10:12 AM documented: [MEDICATION(S)] XL 300 mg 24-hour tablet, extended release, give 1 tablet (300 mg) by oral route once daily (OD) in the morning for Major Depressive Disorder and Generalized Anxiety Disorder. The Electronic Medication Administration Record (EMAR) dated 11/01/2021 through 11/30/2021, revealed that [MEDICATION(S)] XL 300 milligrams (mg) 24-hour tablet, extended release, once a day was not administered to Resident #1 on 11/09/2021 (pending delivery), on 11/10/2021 (refused), on 11/11/2021 (Other), on 11/12/2021 (awaiting delivery), on 11/13/2021 (Other), on 11/14/2021 (Other), on 11/15/2021 (refused) and on 11/16/2021 (Other). A Proof of Delivery Packing Slip dated 11/16/2021 documented [MEDICATION(S)] HCL tab 300 mg ([MEDICATION(S)] XL 300 mg), quantity 30 tablets delivered on 11/16/2021 at 7:25 PM. A staff signature observed on the slip indicating that the medication was delivered and accepted by facility staff. The EMAR dated 12/01/2021 through 12/31/2021, revealed that Resident #1 did not receive [MEDICATION(S)] XL 300mg orally once a day on 12/12/2021,12/13/2021 and 12/29/2021. The EMAR documentations revealed: on 12/12/2021 (Other: medication reordered from pharmacy), on 12/13/2021 (refused) and on 12/29/2021 (Other: waiting delivery). A Proof of Delivery Packing Slip dated 12/13/2021 documented [MEDICATION(S)] HCL tab 300 mg ([MEDICATION(S)] XL 300 mg), quantity 30 tablets delivered on 12/13/2021 at 7:12 PM. RNS #1's initial was observed on the slip indicating that the medication was delivered and aaccepted by facility staff. A Psychiatry Consult Report dated 12/20/2021 at 1:22 PM documented that Resident #1 had a History of Depression and Anxiety and was referred for Psychiatry follow up evaluation. Resident #1's Psychiatric medications included [MEDICATION(S)] XL 300mg orally daily. Diagnoses: [CONDITION(S)] Disorder, Opioid Dependence and Generalized Anxiety. Recommendation made to continue the current medications and treatment, as the risks for changes outweighed the benefits. During an interview on 01/18/2022 at 10:30AM, Resident #1 stated that he/she did not receive the [MEDICATION(S)] XL 300mg for five days in November 2021 and two days in December 2021. Resident #1 stated that the nurses did not give him/her an explanation as to why he/she was not receiving the [MEDICATION(S)] and when the medication would become available. Resident #1 stated that he/she did not report the issues to the Nursing Supervisor or Social Work. Resident #1 stated I just wanted the staff to give me a reason for the missing medications. During an interview on 01/18/2022 at 10:45 AM, Licensed Practical Nurse (LPN #1) stated that he/she reordered the [MEDICATION(S)] XL 300mg for Resident #1 in the EMAR and called the pharmacy for the refill. LPN #1 stated that he/she reordered the medications on 11/10/2021 and expected the medications to be delivered the same day. LPN #1 stated that he/she notified the Medical Doctor (MD) on 11/10/2021 and was told to call the pharmacy. LPN #1 stated that pharmacy representative informed LPN #1 that the [MEDICATION(S)] XL was in the next delivery. LPN #1 stated that he/she reordered the medication again and called the pharmacy on 11/11/2021. LPN #1 stated that the medication blister packs had a month supply of medications to last until the next refill. During an interview on 01/18/2022 at 11:00 AM, MD #1 stated that he/she might have received a call from the nurses on missed medications dates indicated, but like every call they make for unavailability of medications he/she tells the nurses to call and follow up with the pharmacy to deliver. MD #1 stated that he/she evaluated Resident #1. MD #1 stated Resident #1 did not have any negative effects from the missed doses of [MEDICATION(S)] XL 300 mg by mouth daily. MD #1 stated that Resident #1 was receiving other [CONDITION(S)] medications and [MEDICATION(S)]. During an interview on 1/18/2022 at 2:00PM, Registered Nurse (RN) #1 stated that medications must be sent for refills when it is on the blue line or seven days remaining in the EMAR. The Pharmacy fills medication refills for 30-day supply unless they send medications for only five days. During an interview on 01/18/2022 at 2:30 PM, Pharmacist #1 stated that the pharmacy refilled monthly medication when they received the Doctor's Monthly Orders every 28 days. The facility staff must generate an order so they can refill the medication. Pharmacist #1 stated that the MD's orders were received, refilled, and delivered on 10/18/2021, 11/16/2021 and 12/13/2021. Medication discrepancy such as not available is not a pharmacy issue because they send refills for 30 days. Pharmacist #1 also stated that they monitored accuracy and timely delivery of medications by ensuring that they follow-up with any warning they receive from their system. During an interview on 1/18/2022 at 4:00 PM and, the Director of Nursing (DON) stated that when the pharmacy is unable to do a refill or medication is not available, nurses must report to the supervisor to address pharmacy issues. The DON stated that the nurses should not indicate awaiting delivery, they must call the MD for further orders. The DON stated that the administration times can be changed in the EMAR to accommodate when the medication would be available. The DON stated that he/she was not made aware that Resident #1 had missed the [MEDICATION(S)] XL medication several times. During subsequent interview on 02/10/2022 at 1:24PM, LPN #1 stated that he/she informed the Registered Nurse Supervisor (RNS) that Resident #1's [MEDICATION(S)] XL medication was not available, but that he/she could not recall which RNS he/she spoke to and what he/she was instructed to do. LPN #1 stated that he/she did not inform the MD that the [MEDICATION(S)] XL medication was still not available on 11/11/2021 and from 11/13/2021 through 11/16/2021. During an interview on 02/10/2022 at 2:20 PM, Pharmacist #2 stated that on 10/18/2021, 11/16/2021 and 12/13/2021, 30 [MEDICATION(S)] 300 mg XL tablets were dispensed each time for Resident #1. Pharmacist #2 further stated that a facility staff signed for medications delivered from the pharmacy. Pharmacist #2 also stated that whenever a request for medication refill is received too soon, a warning in the pharmacy system would say that it was too soon for the prescription refill. During a subsequent interview on 02/10/2022 at 3:32 PM, the DON also stated that medications were delivered to the units and the units nurses signed for medications. The DON said that Resident #1 had no outward effects from not receiving the missing [MEDICATION(S)] XL medications. The DON further said that an investigation was done and concluded that 30 days' supply of medications were not received from the pharmacy. During an interview on 02/10/2022 at 4:15 PM, the Medical Director stated that he/she did not recall being notified of Resident #1's missing [MEDICATION(S)] XL medication doses in 11/2021 and12/2021. The Medical Director stated that if the MD is informed of a resident missing any medication, firstly, the MD should confer with the nursing team. The Medical Director stated that he/she would be notified if needed. Secondly, the MD should find out if the resident has any harm from missing the medication doses. The Medical Director said that in situations, the MD could have communicated with the pharmacy regarding dispensing of the missing medication and the MD could have also ordered a replacement with similar medication. During an interview on 02/14/2022 at 10:48 AM, MD #1 stated that he/she evaluated Resident #1 when a New York State Department of Health surveyor was at the facility. MD #1 further stated that if a nurse informed him/her that a resident did not have a specific medication and the pharmacy refused to refill the medication, MD #1 would call the pharmacy himself/herself. During a follow up interview on 03/08/2022 at 11:30 AM, Pharmacist #2 stated that as per the packing slip proof of delivery for Resident #1's [MEDICATION(S)] 300 mg XL, 30 tablets were delivered to the facility on [DATE] at 7:17 PM. Pharmacist #2 also stated that there was no facility staff signature on the delivery slip. Pharmacist #2 said RNS #1's name was printed, and a line was drawn across the signature area. Pharmacist # 2 was not sure why there was a line instead of RNS #1's signature. During a follow up interview on 03/09/2022 at 1:05 PM, LPN #1 stated that residents' medications are delivered from the pharmacy during the evening and night shifts. LPN #1 said that he/she did not receive any medications for Resident #1 during the day shift. LPN #1 said that he/she worked during the evening shift at times and received residents' medications from the pharmacy delivery person. LPN #1 also said that he/she did not have to check the medications. LPN #1 stated that the Nursing Supervisor signed for medications deliveries. Prior to the beginning of the COVID-19 pandemic, the unit nurses had to check the medications to see if they matched what was documented on the packing slip. LPN #1 stated that the facility only saved the top part of the medication blister pack cards with the prescription information. The bottom portion of blister pack cards which showed how many medications are administered to the resident, are discarded. During an interview on 03/09/2022 at 3:48 PM, Registered Nurse Supervisor #1 (RNS #1) stated that during the COVID-19 Pandemic, RNS #1 signed for medications deliveries at the front desk. RNS #1 stated that he/she received medications from the pharmacy delivery person in October 2021 and December 2021. RNS #1 said that he/she did not check to see if the medications were correct. RNS #1 stated that he/she took the medications to the residents' units and gave to the nurses. RNS #1 stated that he/she only checked narcotics deliveries to see if they were correct. RNS #1 also said that medications are now delivered to the units by the pharmacy delivery person. During a follow up interview on 03/09/2022 at 4:30 PM, the DON stated that the nurses do not count medications delivered from the pharmacy; only narcotics are counted. The DON stated that he/she ran a report which revealed that multiple requests were made for the [MEDICATION(S)] XL refills. The DON stated that the procedure for when a medication was unavailable, the nurses were to request the medication refill, call the pharmacy and call the Physician. If the medication was not available by the next delivery, escalate to the Nursing Supervisor. The DON stated that the nurses are licensed and responsible for administering medications as per Physicians Orders. The DON stated that the nurses received in-service on requesting medications refills, informing the Physician and Nursing Supervisors when medications are not available. 415.18(a)

Based on observation, interviews and record review conducted during an abbreviated survey (NY00286307) completed on 01/28/2022, the facility did not ensure that all alleged violations involving abuse was reported within 2 hours to the facility Administrator and to New York State Department of Health (NYS DOH). This was evident for 1 out of 3 residents sampled (Resident #1). 1) Specifically, on 11/10/2021 at 12:33am to 1:00am, Security Officer (SO) #1 observed, on security camera, Certified Nursing Assistant (CNA) #1 abusing Resident #1. This was not reported immediately to the Administrator or the Nursing Supervisor that was on duty. 2) The incident was reported to NYS DOH at 11:50pm on 11/10/2021. The Findings are: A facility policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property dated 11/28/2017; last revised 04/23/2019 documented that the facility has zero-tolerance for abuse. The policy documents that allegations of abuse are to be reported immediately, but not later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse. Under section Internal Reporting, it is documented that employees must always report any abuse or suspicion of abuse immediately to the administrator. Resident #1 was initially admitted to the facility on [DATE] with diagnoses including Unspecified Dementia with Behavioral Disturbance, and Major Depressive Disorder. The Minimum Data Set (MDS, a resident assessment tool) dated 09/20/2021 documented that Resident #1 had a Brief Interview of Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) and scored 3/15 associated with severely impaired cognition. Resident #1 required supervision with one-person physical assist for most areas of Activities of Daily Living (ADLs). Review of the facility surveillance video footage, of 2 [NAME] in front of the nursing station, dated 11/10/2021 from 12:33AM to 1:09AM, revealed that CNA #1 grabbed, slapped, punched, and kicked Resident #1 multiple times. CNA #1also held fists up towards and pointed their finger near Resident #1's face. One staff member was visualized walking over to the area where CNA #1 abused Resident #1, however at the time of their arrival, there was no abuse occurring. There was no nurse visualized on the video. A security incident report dated 11/10/2021 documented that Security Officer (SO) #1 noted CNA #1 pushing and kicking Resident #1 at about 12:51 AM on unit [NAME] 2. SO, #1 immediately informed the Security Supervisor (SS). During an interview on 01/19/2022 at 04:58 PM, Security Officer (SO) #1 stated that on 11/10/2021 at about 12:50 AM, he/she happened to notice CNA #1 abusing Resident #1. SO #1 stated that it looked like CNA #1 pushed and possibly kicked Resident #1. SO #1 stated that he/she did not see where CNA #1's foot landed. SO #1 stated that he/she immediately called SS #1 to informed them of the incident but was unable to reach them. SO #1 stated that SS #1 reviewed the video footage at about 03:00 PM. SO #1 stated that he/she did not inform anyone else of the incident. SO #1 stated with a situation like this you need to be 100 percent sure and the only way to be sure is by reviewing the video footage, the only person who has access to the video footage is SS #1. During an interview on 01/25/2022 at 02:28 PM, The Director of Fire Safety, Security, and Telecommunications (DSST) stated that if an SO witnesses or believes to witness any abuse over video monitors, they are to inform the nursing supervisor and the DSST. DSST stated that SO #1 wanted to speak with the DSST and review the video footage before stating that abuse had occurred. The DSST stated that he/she (DDST) reached out to the SO #1, the following morning, but SO #1 did not answer their phone. The DSST stated that he/she finally spoke to SO #1 on 11/10/2021 at about 03:40 PM. The DSST stated at that time, he/she (DSST) immediately went to review the video footage, which confirmed that abuse had taken place. The DSST stated that he/she immediately contacted the [NAME] President of Nursing (VPN) and informed them of the findings. During an interview on 01/28/2022 at 04:08 PM The Director of Nursing (DON) stated that the DSST notified him/her of the video footage of abuse by CNA #1 towards Resident #1 on 11/10/2021, between (about) 03:30 PM and 04:00 PM. The DON stated that the DSST reviewed the video footage then notified him/her that CNA #1 struck Resident #1. The DON stated that he/she did not review the video footage the same day he/she (DON) was notified. The DON stated that they reviewed the video footage the following day. The DON stated that the expectation was for SO #1 to inform an NS even if they suspected abuse. The DON stated this allegation is not required to be reported to state survey agencies within 2 hours of the allegation being made, since there were no significant injuries noted to Resident #1. The DON stated that he/she notified the Administrator shortly after he/she was made aware. During an interview on 01/28/2022 at 04:28 PM, The Administrator stated that the DON notified him/her of the abuse by CNA #1 against Resident #1 a few minutes after the DON was informed. The administrator did not recall exact time. The Administrator stated that he/she reviewed the video footage themselves a day or two after being notified. The Administrator stated that suspicion of abuse must be reported to state survey agencies within 2 hours of forming the suspicion only if it results in serious bodily injury. The Administrator stated that SO #1 should have informed the RNS. 415.4(b)(1)(i)

Based on observation, interviews and record review conducted during an abbreviated survey (NY00286307) on 01/28/2022, the facility failed to ensure that a resident remained free from abuse. This was evident for 1 out of 3 residents sampled (Resident #1). Specifically, on 11/10/2022, the Security Officer (SO) #1 observed on security camera, Certified Nursing Assistant (CNA) #1 physically abused Resident #1. Resident #1 was assessed with linear abrasions to the top of his/her head and scratches to the back of the head. CNA #1 was not removed from the unit immediately. The facility failed to protect Resident #1 from staff abuse. The Findings are: A facility policy entitled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property dated 11/28/2017 and last revised 04/23/2019 documented: The facility has zero-tolerance for abuse. The policy documents how abuse will be prevented by screening employees as well as training employees. The policy documented that abuse prevention will include resident assessment; orientation for residents, representatives, and staff; and supervision of staff. The policy documented that abuse should be reported immediately, but not later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse. A facility investigation dated 11/11/2021 documented that it was discovered that CNA #1 was observed inappropriately handling Resident #1. Resident #1 was noted with linear abrasions to the top of his/her head and to the right posterior shoulder. The right 5th finger appeared swollen. Resident #1 observed to have long, jagged fingernails. Self-infliction cannot be ruled out. Resident #1 was unable to describe how the injuries occurred due to significant cognitive deficits. X-rays of Resident #1's right elbow, hand, and knee ordered, and the Police was called. CNA #1's statement documented that another CNA (#2) was present on the unit. The facility investigation did not contain a statement from CNA #2. A facility investigation addendum dated 11/12/2021 documented that abuse was identified, and that CNA #1 was observed striking and pushing Resident #1 on video footage. Resident #1 was initially admitted to the facility on [DATE] with diagnoses including Unspecified Dementia with Behavioral Disturbance, and Major Depressive Disorder. A Care Plan entitled ABUSE: RESIDENT ABUSE/RESIDENT TO RESIDENT ALTERCATION updated 09/03/2021, documented interventions that to redirect any unacceptable behavior and for staff to provide emotional support. Also documented, no reports of abuse. The care plan was updated post incident. The Minimum Data Set (MDS, a resident assessment tool) dated 09/20/2021 documented that Resident #1 had a Brief Interview of Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) and scored 3/15 associated with severely impaired cognition. Resident #1 required supervision with one-person physical assist for most areas of Activities of Daily Living (ADLs). A nursing progress note dated 11/10/2021 documented that it was reported that Resident #1 may have been mishandled. A Medical Doctor (MD) progress note dated 11/10/2021 documented that Resident #1 may have been mishandled. A full body assessment was performed by nursing. Resident #1 was observed with linear abrasions to the right posterior shoulder and top of his/her head. Resident #1 was not in acute distress. Later in day - Nurse Practitioner assessed resident and noted Right Knee swelling with pain - lidocaine topical patch and Tylenol as needed ordered. A review of a Physician Order dated 11/10/2021 documented Bacitracin 500 unit/gram topical ointment by topical route to Right Shoulder and Scalp, cleanse with normal saline, apply bacitracin, cover with dry dressing daily and as needed. A Physician's Order dated 11/11/2021 documented Apercreme (Lidocaine) 4% topical patch - apply 1 patch by topical route once daily to the right knee. Review of the facility surveillance video footage, of 2 [NAME] in front of the nursing station, dated 11/10/2021 from 12:33AM to 1:09AM, revealed that CNA #1 grabbed, slapped, punched, and kicked Resident #1 multiple times. CNA #1also held fists up towards and pointed their finger near Resident #1's face. One staff member was visualized walking over to the area where CNA #1 abused Resident #1, however at the time of their arrival, there was no abuse occurring. There was no nurse visualized on the video. A security incident report dated 11/10/2021 documented that SO #1 observed CNA #1 pushing and kicking Resident #1 at about 12:51 AM on 2 [NAME] unit. The statement documented that SO #1 immediately informed the Security Supervisor (SS) SS #1. SO #1 observed the incident on security camera. During an interview on 01/19/2022 at 04:49 PM, Certified Nursing Assistant (CNA) #1 stated that Resident #1 was attempting to push a resident in the wheelchair and all they did was prevent this. CNA #1 stated that Resident #1 attempted to come at me and then CNA #1 put their arms up to redirect Resident #1. CNA #1 stated that they then held onto Resident #1's shirt from the back and attempted to redirect them to Resident #1's room. CNA #1 denied kicking, pushing, punching, or placing their hands on Resident #1's head. CNA #1 stated that if you watch the video, you will see that I did not abuse this resident. CNA #1 stated that maybe I did not handle the situation appropriately, but I did not abuse anyone. During an interview on 01/19/2022 at 04:58 PM, Security Officer (SO) #1 stated that on 11/10/2021 at about 12:50 AM, he/she happened to notice CNA #1 abusing Resident #1. SO #1 stated that it looked like CNA #1 pushed and possibly kicked Resident #1. SO #1 stated that he/she did not see where CNA #1's foot landed. SO #1 stated that he/she immediately called SS #1 to informed them of the incident but was unable to reach them. SO #1 stated that SS #1 reviewed the video footage at about 03:00 PM. SO #1 stated that he/she did not inform anyone else of the incident. SO #1 stated with a situation like this you need to be 100 percent sure and the only way to be sure is by reviewing the video footage, the only person who has access to the video footage is SS #1. During an interview on 01/25/2022 at 02:28 PM, The Director of Fire Safety, Security, and Telecommunications (DSST) stated that if an SO witnesses or believes to witness any abuse over video monitors, they are to inform the nursing supervisor and the DSST. The DSST stated that on the night of 11/10/2021, SO #1 called the DSST, who did not answer the phone. The DSST stated that SO #1 did not inform the nursing supervisor of the abuse on the night it occurred. The DSST stated that SO #1 stated that he/she was not certain of what he/she had seen. The DSST stated that SO #1 wanted to speak with the DSST and review the video footage before stating that abuse had occurred. The DSST stated that he/she (DDST) reached out to the SO #1, the following morning, but SO #1 did not answer their phone. The DSST stated that he/she finally spoke to SO #1 on 11/10/2021 at about 03:40 PM. The DSST stated at that time, he/she (DSST) immediately went to review the video footage, which confirmed that abuse had taken place. The DSST stated that he/she immediately contact the [NAME] President of Nursing (VPN) and informed them of the findings. The DSST stated that all SO staff are provided with the same abuse in-services as all other staff. During an interview on 01/28/2022 at 04:08 PM The Director of Nursing (DON) stated that the DSST notified him/her of the video footage of abuse by CNA #1 towards Resident #1 on 11/10/2021. The DON stated that the DSST informed them that after reviewing the video footage, it appeared to the DSST that CNA #1 struck Resident #1. The DON stated that the DSST confirmed this with video review. The DON stated that they did not review the video footage the same day (11/10/2021). The DON stated that they reviewed the footage the following day. During an interview on 01/28/2022 at 04:28 PM, The Administrator stated that the DON called and notified him/her of the abuse by CNA #1 towards Resident #1. The Administrator stated that he/she reviewed the video footage themselves a day or two after being notified of the abuse. During an interview on 02/10/2022 at 03:04 PM, Nursing Supervisor (NS) #1 stated that on 11/09/2021 on the 11PM-7AM shift, there was no nurse on Unit 2 [NAME] and that he/she covered this unit. NS #1 stated that when he/she made rounds and administered medications on the unit, it was quiet. NS #1 stated that there were no observations of staff to resident abuse. NS #1 stated that he/she was never informed of the incident or any issues during that shift. 415.4(b)(1)(i)

Based on observations, interviews and record reviews conducted during an abbreviated survey (NY 999) on 10/19/2021, the facility did not ensure that all alleged violations involving, sexual abuse was reported immediately but no later than 2 hours to the New York State Department of Health (NYS DOH). This was evident in 1 out of 3 residents sampled. (Resident #1). Specifically, on 10/16/2021 at approximately 8:00 AM, Certified Nursing Assistant (CNA) #1 reported to facility management that he/she observed Licensed Practical Nurse (LPN) #1 with his/her pants down in Resident #1's room. Resident #1's private area was exposed. The facility reported the alleged incident to NYS DOH on 10/19/2021 at 6:14 PM, after DOH surveyor was onsite. The findings are: Review of the facility's policy and procedure entitled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property last reviewed on 04/23/2018 documented: It is the policy of The Plaza Rehab and Nursing Center that abuse allegations are reported per Federal and State Law. The Plaza will ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than two(2) hours after the allegation is made, if the events that cause the allegation do not 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 or result in serious bodily injury, to the Administrator of The Plaza and to other officials (including to the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long-term care facility) in accordance with state law through established procedures. Resident #1 was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 09/17/2021 identified Resident #1 with a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 14/15, associated with intact cognition. A Facility Investigation dated 10/16/2021 documented that CNA #1 called the facility at approximately 8:00 AM and alleged that he/she heard a noise in Resident #1's room on 10/16/2021 at approximately 5:00 AM while he/she was looking for LPN #1. CNA #1 stated that she went to investigate. CNA #1 reported that he/she observed LPN #1 with his/her pants down and Resident #1's private area was exposed. The report documented that Resident #1 denied any inappropriate contact with LPN #1. Resident #1 reported that he/she and the nurse were fully dressed. Resident #1 also verbalized that LPN #1 was always respectful to him/her and never made him/her feel uncomfortable. It was documented that the cameras and interviews revealed inconsistencies in CNA #1's allegations. The facility concluded there was no reason to believe that resident abuse, neglect, or mistreatment occurred. During an interview on 10/19/2021 at 5:00 PM, CNA #1 stated that he/she observed LPN #1, on 10/16/2021 at 5:00 AM, standing at Resident #1's bedside with his/her pants down. Resident #1 had on a nightgown and was lying in bed with his/her private area exposed. During an interview on10/19/2021 at 4:40 PM, the Vice President of Nursing (VPN) stated that he/she received a call on 10/16/2021 shortly after 8:00 AM from the Assistant Director of Nursing (ADON) regarding the allegation of sexual abuse involving LPN #1 and Resident #1. The VPN stated that the facility did not report the allegation of sexual abuse to the NYS DOH because Resident #1 was alert and oriented and denied the allegation. The VPN further stated that Resident #1 had no fear and articulated a good relationship with LPN #1. The VPN also said that there was no cause to believe that abuse occurred after review of the cameras, interviews and inconsistencies in CNA #1's allegation. During an interview on 10/26/2021 at 11:25 AM, the Administrator stated that he/she became aware of the allegation involving Resident #1 and LPN #1 on 10/16/2021 around 8:00 AM. The Administrator stated that when there is an allegation of abuse in the facility, it must be reported to the Director of Nursing and the Administrator. The Administrator stated if a case was identified as suspicion of a criminal offence, the facility would report it to the NYS DOH within 2 hours. The Administrator added that the allegation of sexual abuse was investigated by the facility and found to be unsubstantiated. The Administrator stated that the allegation was reported to DOH after surveyor was onsite. 415.4 (b) (1)(i)

Based on observation, record review and interviews conducted during an abbreviated survey (Case # NY00273106), the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care. This was evident for 1 out of 3 sampled residents (Resident #1). Specifically, Resident #1 requested to be discharged , but the facility did not develop and implement an effective discharge planning process for Resident #1. The findings Include: The facility's policy and procedure entitled Discharge Planning (undated) documented that the interdisciplinary team will work in collaboration and coordination with the resident to best ensure a successful and appropriate discharge plan. When a resident and/or family request a discharge, the interdisciplinary team will schedule a meeting to assess the safety of a discharge. The Social Worker will continue to assess each resident discharge potential on a quarterly basis, upon readmission from a hospital stay, annually, significant change and document in care plan. The Social Worker will keep the resident and/or family informed of all aspects of discharge planning. Resident #1 was initially admitted to the facility on [DATE], with diagnoses including End Stage Renal Disease on Hemodialysis, Chronic Obstructive Pulmonary Disease, Schizophrenia, and Left Below the Knee Amputation. The Minimum Data Set (MDS, a resident assessment tool) dated 03/18/2021, identified the resident with Brief Interview for Mental Status (BIMS, used to determine attention, orientation and ability to recall information) score of 15/15, indicating that the resident's cognitive status was intact. The resident's Health Care Proxy was listed as a silbling. A Quarterly Care Plan Meeting Report dated 03/10/2020 documented that Resident #1 attended the meeting and that an active discharge plan was in place but no date had been currently set for discharge. A Discharge Planning Care Plan initiated 06/09/2020 stated that Resident #1 had no discharge potential. This care plan was updated on 09/02/2020, 12/09/2020 and 03/18/2021 with notes that Resident #1 continued to have no discharge potential and would remain in the facility for longterm placement. A Significant Change Care Plan Meeting Report dated 06/15/2020 was not attended by the resident, and was documented that Resident #1 was for Longterm Placement. A Psychiatry Consult dated 11/16/2020 documented that Resident #1's insight and judgment were limited and that the resident had the ability to reason and understand adequately but was unable to make decisions regarding health needs or discharge. The Social Worker's Notes from 10/2020 to 12/2020, revealed no documentation regarding Resident #1's desire, assessment, and determination to be discharged to the community. A Psychology Note dated 12/17/2020, documented that Resident #1 expressed sadness and worry concerning the future and the likelihood of long-term care. A Psychology Note dated 01/11/2021, documented that Resident #1 continued to experience emotional distress secondary to limited independence/decline requiring care regimen/facility placement. A Psychology Note dated 01/15/2021, documented that Resident #1 expressed frustration due to continued placement - 'I'm still here! A Nurse Practitioner (NP) Note dated 02/09/2021 documented that Resident #1 has been asking for discharge planning. The MDS (signficant change) dated 02/07/2021, had the same documentation under Q except for Q0600, which documented that referral to the Local Contact Agency had not been made. The MDS dated [DATE], Section Q, documented that Resident #1 participated in the assessment, but Q0300 (Resident's Overall Expectation, to be discharged or to remain in the facility) was left blank. Q0400 documented that the resident's representative preferred not to be asked about discharged at every assessment. Q0500 documented no under the resident's wish to discuss the possibility of discharge. Q0600 documented that referral had been made to Local Contact Agency. Record review revealed there were no IDT discharge meeting held for Resident #1. A Social Work's Note dated 06/04/2021, documented that Resident #1 obtained an application to senior housing in the Bronx which the resident's Health Care Proxy had brought in to the facility. The note stated that the Social Worker would assist the resident #1 to obtaining an identification card which was required for the application process and would provide ongoing emotional support. Record review revealed that Resident #1 expressed several times that they wanted to be discharged . Review of the Social Worker's notes revealed that discharge planning was not implemented for Resident #1. Review of Resident #1's discharge care plan, revealed that Resident #1 was for long-term placement. The MDS revealed that Resident #1 had no desire to be discharged . The MDS note documented that a referral was made to the Local Contact Agency, but there were no follow up notes as to the outcome of the referral. The Discharge Planning Care Plan was updated but made no reference to the Local Contact Agency referral. The care plan also referenced that Resident #1 was for long-term care. There was no assessment done to determine Resident #1's capability to function in the community. During an interview on 06/04/2021 at 11:45 AM, Licensed Practical Nurse #1 (LPN #1) stated that every time they covered Resident #1's unit, the resident expressed wanting to go home. The LPN stated that each time Resident #1 stated a wish to be discharged , staff members would tell the resident to speak with the Social Worker. During an interview on 06/04/2021 at 2:00 PM., the Director of Social Services (DSS) stated that Resident #1's Social Worker (SW) was on leave since May 24th and that there were only 5 SWs to cover 20 units from that time up until now. The DSS stated, We are filling in how we can and are concentrating on crisis intervention and assessments. Discharge planning is completely off the radar for people on long-term units. We are just trying to meet the needs of the day. The DSS stated that Resident #1's assigned SW returned to work on 06/01/2021 and that the SW began working on Resident #1's discharge on 06/02/2021. During an interview on 06/04/2021 at 2:20 PM. with Resident #1, the resident stated that the facility wanted them to stay in the facility permanently. Resident #1 stated that they spoke with everyone including the SW regarding wanting to be discharged . Resident #1 stated that they had money to pay rent and that they understood that they would require a home attendant for many hours. Resident #1 stated that they would like to get an apartment. During an interview on 07/01/2021 at 3:25 PM, the Nurse Practitioner stated that Resident #1 was always saying that the resident wanted to go home. The NP recalled referring the resident to Physical Therapy on 02/09/2021 for further prosthetic training and documenting the resident's wish to be discharged , and stated, I informed the social worker but I don't remember if I documented that. During a follow up interview on 07/01/2021 at 1:50 PM, the Social Worker stated to not have been aware that Resident #1 had been deemed by Psychiatry to have no capacity to make discharge decisions in November 2020. But Social Worker stated to be currently working on transferring the resident to an assisted living facility, not an independent setting. According to the resident, family are supportive of that plan although Social Worker stated to not have spoken to them about it. Social Worker stated that no team assessment was done to check Resident #1's capability to function in the community and Social Worker never spoke with the resident about personal discharge goals, assuming that the resident was longterm because they were on a longterm unit and had never brought the issue up to the social worker. Social Worker stated to have read the Psychology and NP notes in residents' charts but was not aware that the resident had expressed a desire to discharged to the psychologist or to the doctor and stated, It was overlooked. Two attempts were made to reach the Psychologist on 07/06/2021 with no success. 10 NYCCR 415 4 (b)(1)(i)

Based on record review and interviews conducted during an abbreviated survey (Case # NY00273106), the facility did not develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and timeframe to meet a resident's medical, nursing, and mental and psychosocial needs. This was evident for 1 out of 3 sampled residents (Resident #1). Specifically, record review revealed that Resident #1 expressed on multiple occasions and to multiple team members that they wished to be discharged . Record review revealed that Resident #1's discharge care plan was not updated to reflect Resident #1's goals, desire, support persons, capacity and capability to function in the community. The findings are: The facility's policy and procedure entitled Comprehensive Assessment and Care Planning, last revised 09/2018, documented that the interdisciplinary team identifies and prioritizes resident care needs, wishes, strengths, weaknesses and risks to develop an appropriate care plan which includes measurable resident treatment goals, services needed to meet the goals, interventions identified to provide care, evaluation of care and resident responses to care. The facility's policy and procedure entitled Documentation, last revised 11/2020, documented that progress toward the care plan goals or any changes in the resident's medical, physical, functional, or psychosocial condition will be documented in the resident's medical record Resident #1 was initially admitted to the facility on [DATE], with diagnoses including End Stage Renal Disease, Chronic Obstructive Pulmonary Disease, Schizophrenia, and Status Post Left Below the Knee Amputation. The Minimum Data Set (MDS, a resident assessment tool) dated 03/18/2021 identified the resident with Brief Interview for Mental Status (BIMS, used to determine attention, orientation and ability to recall information) score of 15/15, indicating that the resident's cognition was intact. A Discharge Planning Care Plan initiated 06/09/2020, documented that Resident #1 had no discharge potential. The care plan was updated on 09/02/2020, 12/09/2020 and 03/18/2021 with Social worker notes that Resident #1 continued to have no discharge potential and would remain in the facility for longterm placement. During an interview on 06/04/2021 at 11:45 AM, Licensed Practical Nurse #1 (LPN #1) stated that every time they covered Resident #1's unit, the resident expressed wanting to go home. The LPN stated that each time Resident #1 stated a wish to be discharged , staff members would tell the resident #1 to speak with the Social Worker. During an interview on 06/04/2021 at 2:20 PM. with Resident #1, the resident stated that the facility wanted them to stay in the facility permanently. Resident #1 stated that they spoke with everyone including the SW regarding wanting to be discharged . Resident #1 stated that they had money to pay for the rent and that they understood that they would require a home attendant for many hours. Resident #1 stated that they would like to get an apartment. During an interview on 06/04/2021 at 12:35 PM, the Social Worker (SW) stated to have first heard about Resident #1's wish to be discharged on [DATE]nd. The SW stated that on 06/02/2021, Resident #1 had an application for senior housing mailed to a family member and a family member had brought the form to the facility. The SW stated that the Discharge Planning Care Plan was not updated to reflect Resident #1's discharge plans. The SW further stated to see Resident #1 at least once a week but do not usually document the visits. During an interview on 06/04/2021 at 2:00 PM., the Director of Social Services (DSS) stated that Resident #1's Social Worker (SW) was on leave since May 24 th and that there were only 5 SW's to cover 20 units from that time up until now. The DSS stated, We are filling in how we can and are concentrating on crisis intervention and assessments. Discharge planning is completely off the radar for people on long-term units. We are just trying to meet the needs of the day. The DSS stated that Resident #1's assigned SW returned to work on 06/01/2021 and that the SW began working on Resident #1's discharge on 06/02/2021. 10 NYCRR 415. 11 (c)(1)

Based on record review and interviews conducted during an abbreviated survey (Case# NY00273106), the facility did not assure that each resident received an assessment that accurately reflect of the resident's status. This was evident for 1 out of 3 sampled residents (Resident #1). Specifically, the record review revealed that starting in December 2020, Resident #1 spoke to multiple team members about being discharging to the community. The Minimum Data Set (MDS, residents clinical assessment), dated 03/13/2021, Section Q, stated that Resident #1 had been referred to the Local Contact Agency to provided resources for community housing. However, during an interview with the Social Worker, Staff #1, revealed that the referral was not made. The referral was documented in error. The findings Include: The facility's policy and procedure entitled MDS Assessor, last updated 07/2020, states that each individual who completes a portion of the assessment (MDS) must certify the accuracy of that portion of the assessment by: a) dating and signing the assessment (MDS); and b) identifying each section completed. Resident #1 was initially admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease, Chronic Obstructive Pulmonary Disease, Schizophrenia, and Left Below the Knee Amputation. The Minimum Data Set (MDS, a resident assessment tool) dated 03/18/2021, identified Resident #1, with Brief Interview for Mental Status (BIMS, used to determine attention, orientation and ability to recall information) score of 15/15, indicating that the resident's cognitive status was intact. The Significant change MDS dated [DATE], documentated under Section Q that the referral to the Local Contact Agency had not been made. The MDS dated [DATE], Section Q, documented that Resident #1 participated in the assessment, but Q0300 (Resident's Overall Expectation, to be discharged or to remain in the facility) was left blank. Q0400 stated that the resident's representative preferred not to be asked about discharged at every assessment. Q0500 documented no under the resident's wish to discuss the possibility of discharge. Q0600 documented that referral had been made to Local Contact Agency. A Discharge Planning Care Plan initiated 06/09/2020, stated that Resident #1 had no discharge potential. This care plan was updated on 09/02/2020, 12/09/2020 and 03/18/2021 with notes that Resident #1 continued to have no discharge potential and would remain in the facility for long term placement. Record review of the Social Worker's notes from 01/2021 through 03/2021, revealed no documentation indicating that a referral to the local Contact Agency was made. There was no documentation that a dischage plan was being considered for Resident #1 During an interview on 06/04/2021 at 12:35AM, the Social Worker (SW) stated responsible for discharge planning for residents on their assigned units. The SW stated that it was documented that a referral will be done to the Local Contact Agency in Resident #1's MDS on 03/202, but that the referral was not made to any agency and that it was an error. The SW stated that Resident #1 never mentioned wanting to be discharged and was considered by SW to be a long-term resident. During an interview on 07/01/2021 at 10:50 AM, the Director of Nursing stated that the person completing each section of the MDS is responsible for checking the accuracy of that section. The MDS Coordinator compiles the data but does not check it for accuracy. If a mistake was picked up later, a modification of the booklet is done and a reason is documented. But the only person who makes sure the information is accurate is the person actually filling out that particular section. 10 NYCRR 415.11 (a)(b)

Based on observation and staff interviews during a Recertification survey, the facility did not ensure that proper sanitation and food handling practices to prevent the outbreak of foodborne illness was followed. Specifically, the cook did not perform hand hygiene during food preparation, after handling of food with gloved hands and after touching the garbage can. This was evident during the Kitchen Observation facility task. The findings are: The facility policy and procedure titled Sanitation revised 09/17/2020 documented that employees shall thoroughly wash their arms with antibacterial soap and water before starting work, during work to keep them clean. The staff shall handle soiled items in a way to minimize contamination of their hands by using gloves. They should replace the soiled gloves with a clean one when handling clean utensils or food. Use gloves at all time during food preparation. On 10/06/2020 between 09:35 AM and 09:59 AM, Cook #1 was observed wearing a cooks' uniform, a plastic apron and gloves while preparing pasteurized liquid eggs in cartons with milk and butter in metal pans. Cook #1 touched the trash can lid with gloved hands, did not remove gloves or perform hand hygiene and proceeded to whisk the liquid egg mixture. After whisking eggs, gloves were removed, the trash can lid was touched while gloves were being discarded, hands were wiped with a pink cloth which was then placed on the metal table. No hand hygiene was performed. Cook #1 was observed changing gloves on multiple occasions during food preparation without performing hand hygiene. After food preparation food was completed, Cook #1 labeled the prepared food, placed the metal pans on the metal rack then placed in the food preparation refrigerator. The Cook was not observed performing hand hygiene. Cook #1 then wiped the preparation table with a dry sanitizing cloth with bare hands and proceeded to rinse the cloth in the sink where there were four unopened cartons of liquid whole egg. The Cook then drained the water from the sink by releasing the lever, placed the unopened cartons of liquid eggs into a metal pan and placed the pan into the food preparation refrigerator. No hand hygiene was observed. Cook #1 returned to the preparation area, wipe food debris off the counter with his bare hands and placed debris in the trash can. The Cook was not observed performing hand hygiene before donning a new pair of gloves. On 10/06/2020 at 10:01AM, during food preparation Cook #1 disposed of trash and was observed touching the trash can lid on two separate occasions without performing hand hygiene. Cook #1 was observed changing gloves as he prepared pans of frozen turkey sausage. Cook #1 then placed plastic wrap and aluminum foil on pans, removed gloves, and discarded the gloves into a trash can while touching the lid of the trash can. The Cook then used his bare hands to wash the knife used to open the cardboard boxes. Cook #1 then proceeded to wash his hands and then used his bare hands to open the trash can lid to dispose of the used paper towel. The Cook then placed plastic wrap over the top of the metal rack and placed the covered pans of turkey sausage into the refrigerator. The Cook then performed hand hygiene, wiped the food preparation counter with bare hands and cloth which was then placed into the cleaning solution. On 10/06/2020 at 10:59AM, an interview was conducted with Cook #1. Cook #1 stated that he should be washing his hands between any food preparation and he should wash his hand with soap and water for 45 seconds. He stated that sanitizing solution should be used to clean surfaces and he should not have used a dry towel to clean the food preparation table. The Cook also stated that when trash is touched, gloves should be changed. He stated that he should change gloves to protect foods from cross contamination. Cook #1 further stated that what the surveyor observed was not normal practice and he had received an in-service on food safety about 2 months ago. On 10/06/2020 at 11:05AM, an interview was conducted with the Food Service Manager (FSM). The FSM stated that staff are expected to perform hand hygiene when arriving at work and gloves are to be worn after hand hygiene is performed. When handling potentially hazardous foods, gloves should be changed constantly when handling boxed foods and after meat is prepared. The FSM also stated in order to prevent cross contamination, staff should change their gloves and wash hands frequently. Staff working in food production should not be touching the trash can and the porter should remove the trash can cover and set it aside. Staff should also be using sanitizing cloth with the sanitizing solution to clean all food preparation surfaces after use. The FSM further stated that staff had been in serviced on food safety. On 10/06/2020 at 11:15AM, an interview was conducted with the Food Service Director (FSD). The FSD stated hand hygiene should be performed when hands are soiled. Hand hygiene should be done between food production to avoid cross-contamination. Surfaces should be cleaned with all-purpose cleaner and sanitizer. After contact with the trash can staff should wash their hands. 415.14(h)