Every finding on record at The Riverside

Based on record review and interviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible and failed to ensure residents received adequate supervision to prevent accidents. This was evident for two out of two residents (Resident #14 and Resident #15). Specifically, 1). On 02/21/2025, Resident #14 was in bed eating breakfast when they were served hot water that had been reheated in the microwave by Certified Nursing Assistant #11. Resident #14 spilled hot water on their right thigh and sustained second degree burns. 2). On 09/22/2025, Certified Nursing Assistant #17 transferred Resident #15 from the bed to the wheelchair without the required assistance of a second staff member as indicated in the care plan. During the transfer, Resident #15's right leg became caught between the wheelchair's leg rest and wheel. As a result, Resident #15 sustained four skin tears (wound that occurs when skin is pulled or stretched) to the right lower leg. This resulted in actual harm to Resident #14 and Resident #15 that was not Immediate Jeopardy. The findings include:1.The facility policy titled Re-heating Food in Microwave last revised 11/09/2023 documented a food thermometer will be kept in a designated area by the microwave with instructions for reheating. The food thermometer will be properly sanitized before each use using an alcohol pad. Allow the alcohol to dry after sanitizing before using to test the food temperature. Food items must be reheated to 165 degrees. Thermometer should be held in food for 15 seconds. Food is to be stirred thoroughly to distribute heat evenly and then allow to sit for 2 minutes prior to serving the patient. Food should temp at 135-140 degrees before serving. Resident #14 had diagnoses of diabetes mellitus (disease in which your blood glucose, or blood sugar levels are too high) and atrial fibrillation (an irregular heart rhythm that starts in your heart's upper chambers).The Minimum Data Set (a resident assessment tool) dated 12/10/2024 documented that Resident #14 had intact cognition, required setup assistance with most activities of daily living, and had impairment in range of motion of both upper extremities.The Kardex (a resident care summary that instructs certified nursing assistants how to provide care) documented Resident #14 received set up or clean up assistance for eating on 02/21/2025. A review of medical orders from 02/21/2025 through 03/13/2025 revealed orders for Acetaminophen (medication used to relieve mild to moderate pain and reduce fever) oral tablet 500 milligrams give two tablets by mouth every 12 hours for pain to right thigh, Silver Sulfadiazine Cream (Silvadene -topical medication used to prevent and treat wound infections, particularly in patients with second and third degree burns) 1% apply to right thigh topically and Bacitracin ointment (a topical antibiotic used to prevent and treat minor bacterial skin infections) and then secondary abdominal pad every day and as needed every night shift for second degree burn.The Medication Administration Record dated February 2025 reflected Resident #14 experienced pain and received Acetaminophen [PHONE NUMBER] milligrams for pain with a pain score of two to four, three times on the day of the incident 02/21/2025 and then every 12 hours from 02/21/2025 to 02/28/2025.A nurse's progress note dated 02/21/2025 at 9:05 AM by Assistant Director of Nursing #3 documented Resident #14 spilled hot water on their right thigh while reaching over their breakfast tray. An area of erythema (redness of the skin caused by increased blood flow to superficial capillaries) noted to right thigh and tender to touch. Physician was made aware and ordered to cleanse area with normal saline and apply Silvadene cream and leave open to air every day and as needed. Acetaminophen 500 milligrams two tabs stat and every 12 hours for five days. Physical Therapy consult also ordered for a specialty cup. Resident representative was notified.A physician progress note dated 02/22/2025 documented Resident #14 spilled hot water on their right thigh while reaching over their breakfast tray yesterday. Resident complaining of pain with a scale of three out of 10. Assessment: burn, erythema, and small fluid filled blister. Resident to continue with Silver Sulfadiazine 1% Cream apply to right thigh topically one time a day and Acetaminophen oral tablet 500 milligrams, give two tablets by mouth every 12 hours for pain to right thigh.Review of the facility Incident Investigation Report dated 02/21/2025 documented Resident #14 accidentally spilled hot coffee on their right thigh during breakfast. Resident #14 stated that they had reached over their tray and were moving it and they knocked over the cup onto their right thigh. The facility investigation documented Certified Nursing Assistant #11 heated a cup of water in the microwave for 30 seconds and placed the cup on Resident #14's tray. Resident #14 then reached over the tray and the water spilled on their right thigh. Resident #14 was wearing a nightgown which had absorbed the water. The clothing was immediately removed by the licensed nurse, and the area was assessed. There were no injuries observed at time of incident. The facility's summary of investigation concluded there is no credible evidence to support that the incident was caused by abuse, neglect or mistreatment.On 07/20/2026 at 1:29 PM, Resident #14 was interviewed and stated that they picked up a plastic mug from the meal tray, causing hot water that had been reheated by Certified Nursing Assistant #11 to spill onto their leg. Resident #14 also stated that the affected area was painful and subsequently developed a blister, which has since healed. On 07/22/2026 at 4:03 PM, Certified Nursing Assistant #11 was interviewed by telephone and stated that they do not recall this incident. Certified Nursing Assistant #11 explained that the usual procedure for reheating hot water for a resident is to place the cup in the microwave for one to two seconds and then place it on the resident's tray. Certified Nursing Assistant #11 also stated that a thermometer is located near the microwave. Certified Nursing Assistant #11 did not answer whether they used the thermometer to check the temperature of the hot water after reheatingOn 07/23/2026 at 11:33 AM, Assistant Director of Nursing #4, who also serves as the Wound Care Nurse, was interviewed and stated the nurse on the unit notified them that Resident #14 had spilled hot water onto their right thigh. They responded and interviewed the resident who stated that while reaching for the tray in front of them they accidentally knocked over the cup causing the hot water to spill onto their thigh. Assistant Director of Nursing #4 assessed the affected area and observed erythema and tenderness to palpation, with no blistering or open areas present at the initial assessment. Upon reassessment at approximately 4:00 PM the same day, the Assistant Director of Nursing #4 observed a small fluid filled blister. The physician was notified, and orders were received for the application of Silvadene cream and a one-time dose of extra strength acetaminophen. Assistant Director of Nursing #4 further stated that Resident #14 was monitored by the facility's wound care team which included the wound care physician, rehabilitation staff, dietitian, and nursing staff. Assistant Director of Nursing #4 stated that the 2nd degree burn gradually decreased in size and ultimately healed completely.On 07/27/2026 at 3:44 PM, the Director of Nursing was interviewed and stated that Assistant Director of Nursing #4 informed them that Resident #14 sustained a superficial burn to one of their legs after accidentally spilling hot water that had been provided for their tea bag. The Director of Nursing stated that Certified Nursing Assistant #11 should have followed the facility's posted microwave reheating guidelines and should have checked the temperature of the liquid before serving it to Resident #14. The Director of Nursing stated that all staff received in-service education both before and after the incident regarding the proper procedures for reheating and serving hot liquids.On 07/29/2026 at 9:53 AM, the Wound Care Physician was interviewed by telephone and stated that they serve as the facility's wound care consultant and visit the facility weekly. Based on the presence of a blister, healthy pink tissue, the Wound Care Physician stated that Resident #14 sustained a second-degree burn. The Wound Care Physician did not recall whether Resident #14 had fragile skin or if they reported pain related to the injury. They stated that the typical treatment for this type of burn is Silvadene cream, which helps prevent infection and provides a soothing effect.On 08/03/2026 at 1:15 PM, the Administrator was interviewed and stated that reheating guidelines were posted in the pantry areas prior to the incident. The Administrator stated that staff, including Certified Nursing Assistant #11, had received in-service education in November 2023 on proper reheating procedures before the incident and that Certified Nursing Assistant #11 received re-education before being reinstated. The Administrator stated there are thermometers in each pantry near the microwave. 2). The facility policy titled Activity of Daily Living Support with revision on 10/07/2025 documented interventions to improve a resident's functional abilities or minimize functional decline are in accordance with the resident's needs, preferences, stated goals, and recognized standards of practice. The resident's responses to interventions are monitored, evaluated, and revised as appropriate.Resident #15 had diagnoses of Alzheimer's disease (a progressive brain disease that causes memory loss and cognitive decline) and osteoporosis (a disease that causes bones to become weak, brittle, and more likely to break).The Minimum Data Set, dated [DATE] documented that Resident #15 had severely impaired cognition and was dependent on staff for all activities of daily living.The Comprehensive Care Plan dated 07/21/2025 documented Resident #15 requires substantial, maximal assistance of two staff for chair to bed and bed to chair transfers.The Kardex Report as of 09/22/2025 documented Resident #15 requires substantial, maximal assistance of two staff for chair to bed transfers and bed to chair transfers.A nurse's progress note dated 09/22/2025 at 12:07 PM by Assistant Director of Nursing #3 documented Resident #15 was assessed following a reported transfer incident. Assessment revealed multiple skin tears to the right lower extremity measuring 3.0 centimeters by 2.0 centimeters by 0.1 centimeter, 2.0 centimeters by 2.0 centimeters by 0.1 centimeter, 2.0 centimeters by 2.0 centimeters by 0.1 centimeter, and 1.0 centimeter by 1.0 centimeter by 0.1 centimeter. A small amount of bleeding was noted. According to Certified Nursing Assistant #17, while transferring Resident #15 from the bed to the wheelchair, the resident's lower extremity became caught in the wheelchair frame, resulting in the injuries. The physician was notified and provided orders to apply Bacitracin to the affected areas and to obtain stat (immediate) x-rays of the right tibia (larger of the two lower leg bones commonly called the shinbone), fibula-(the smaller bone of the lower leg, located alongside the tibia, that helps support the ankle), and ankle. Resident #15's representative was notified of the incident.A physician's progress note dated 09/22/2025 documented that Resident #15 was seen for a follow-up evaluation related to right lower extremity pain. The physician was informed by nursing staff that the resident's right leg became positioned between the leg rest and wheelchair frame. It was unclear how the resident's leg became lodged in that position. Engineering was contacted to remove the leg rest, allowing the resident's leg to be safely released. Assessment revealed skin excoriations (superficial wounds to the top layer of the skin) to the lower right extremity, which were attributed to Resident #15's attempts to free the leg. A stat X-ray of the lower right extremity was ordered. Additional orders include application of bacitracin to the right shin and covering the affected area. The wound care nurse is to evaluate the injury.The wound care consultant assessment note, dated 09/24/2026, documented a skin tear to the right shin measuring 9.8 centimeters in length by 6.5 centimeters in width by 0.1 centimeters in depth (four wounds measured as one). The wound care consultant recommended application of a Xeroform dressing (a sterile non-stick gauze dressing coated with petrolatum jelly and a mild antiseptic) daily and as needed. The wound and peri-wound area to be cleansed with normal saline prior to application of the dressing.Review of the facility Incident Investigative Report dated 09/22/2025 documented Certified Nursing Assistant #17 was transferring Resident #15 from the bed to the wheelchair without the required assistance of another staff member. Resident #15's foot had become caught in the wheelchair frame and Certified Nursing Assistant #17 immediately called for assistance. Licensed Practical Nurse #5 reported being summoned to Resident #15's room to assist. Licensed Practical Nurse #5 stated the facility engineer was contacted to loosen the wheelchair leg rest, allowing the resident's leg to be safely released. As a result of Resident #15 attempting to free their leg, they sustained four skin tears to the right lower extremity. Resident #15 reported mild pain and was administered Tylenol, which was effective in relieving the pain. The physician was notified of the incident and evaluated Resident #15. A stat x-ray of the right lower extremity was ordered, and a treatment regimen for the skin tears was initiated with follow up by the wound care team. The stat x-rays of the right tibia, fibula, and ankle revealed no evidence of fracture. Certified Nursing Assistant #17 was immediately removed from the schedule. The root cause analysis determined Certified Nursing Assistant #17 did not fully adhere to Resident #15's care plan by transferring the resident without the required assistance of a second staff person.On 07/23/2026 at 9:45 AM and 1:25 PM, attempts to reach Certified Nursing Assistant #17 for an interview were unsuccessful.On 07/27/2026 at 11:41 AM, Licensed Practical Nurse #5 was interviewed and stated they were called to Resident #15's room, where they observed Certified Nursing Assistant #17 with Resident #15, whose leg was caught in the wheelchair. Licensed Practical Nurse #5 stated it was unclear how the incident occurred. When they asked Certified Nursing Assistant #17 what happened, they were unable to provide an explanation of how Resident #15's leg became stuck in the wheelchair. Licensed Practical Nurse #5 contacted the maintenance department to evaluate the wheelchair and loosen the mechanism. Three staff members then assisted Resident #15 by stabilizing the resident's right leg while carefully backing the resident out of the wheelchair and transferring Resident #15 back to bed. Assistant Director of Nursing #3 was notified, assessed the resident, and assisted with cleaning and wrapping resident's wounds. Licensed Practical Nurse #5 stated Resident #15 required a two-person assist for transfers and personal care according to the care plan. Licensed Practical Nurse #5 stated Certified Nursing Assistant #17 was removed from the unit following the incident, and they have not seen them since that time.On 07/27/2026 at 12:13 PM, Assistant Director of Nursing #3 was interviewed and stated they were called to assess Resident #15 after the resident's right leg became caught between the wheelchair frame and the leg rest during a transfer. Assistant Director of Nursing #3 stated that upon entering the resident's room, Certified Nursing Assistant #17 and Licensed Practical Nurse #5 were present, and Resident #15 had already been returned to bed. Assistant Director of Nursing #3 stated they assessed Resident #15 and observed a skin tear to the right lower leg, which was not extensive. First aid was provided, the physician was notified, and orders were obtained for wound care and an x-ray. The x-ray was negative, and Resident #15 was followed by the wound care physician and wound care nurse until the skin tear healed. During the post incident interview, Certified Nursing Assistant #17 reported that while transferring Resident #15 alone, their leg became stuck in the wheelchair during the transfer. Assistant Director of Nursing #3 also stated that Resident #15's care plan specified the resident required a two-person transfer. Assistant Director of Nursing #3 further stated that Certified Nursing Assistant #17 was immediately removed from the schedule and suspended pending the outcome of the facility's investigation. Upon completion of the investigation, attempts were made to contact Certified Nursing Assistant #17, however, they did not return the calls and did not return to employment at the facility. Assistant Director of Nursing #3 stated nursing staff are educated to review and follow each resident's care plan, including transfer assistance requirements, during orientation, annually, and as needed.On 07/27/2026 at 3:32 PM, the Director of Nursing was interviewed and stated that Certified Nursing Assistant #17 was required to have a second staff member present when transferring Resident #15, as specified in the resident's care plan and Kardex report. The Director of Nursing also stated that Certified Nursing Assistant #17 did not provide an explanation for transferring Resident #15 without the required assistance. The Director of Nursing stated that following the incident, Resident #15 underwent an x-ray of the right lower leg, which was negative for injury. Resident #15 sustained skin tears that were treated with wound care and subsequently healed. The Director of Nursing stated that nursing staff conduct random clinical rounds and managers routinely observe resident care to monitor compliance with care plans. Certified Nursing Assistant #17 was immediately removed from the work schedule and suspended pending the investigation. The Director of Nursing stated the facility's intent was to terminate Certified Nursing Assistant #17; however, staff were unable to contact them following the investigation.On 07/29/2026 at 9:28 AM, Physician #1 was interviewed by telephone and stated Resident #15's right leg became caught in the wheelchair near the leg rest. As the resident attempted to remove their leg, a small skin tear to the right shin occurred. Physician #1 stated that an x-ray of the right lower leg was ordered, and the results were negative. Bacitracin was prescribed for treatment of the skin tear. Physical therapy was consulted to evaluate the wheelchair and determine whether a different wheelchair was needed. Resident #15 was also evaluated by the wound care team, and the small skin tear to the right shin subsequently healed.On 07/30/2026 at 1:17 PM, the Administrator was interviewed and stated that Certified Nursing Assistant #17 had received in-service education regarding following each resident's plan of care prior to the incident. The Administrator stated that Resident #15 required a two-person transfer and that nursing staff had been instructed to follow Resident #15's plan of care during all transfers. The Administrator further stated that Certified Nursing Assistant #17 transferred Resident #15 without the required two-person transfer assistance as instructed in the plan of care.During an interview by telephone on 08/04/2026 at 2:12 PM, the Medical Director stated that their responsibilities include oversight of clinical care and ensuring compliance with regulatory requirements. They attend morning meetings and when concerns arise, they contact the primary physician on the unit. The Medical Director stated they are typically notified by nursing staff and also communicate with the primary physician to ensure the resident is evaluated. The Medical Director also stated the facility conducts monthly Quality Assurance and Performance Improvement meetings and medical board meetings to assess residents' clinical status and identify areas for improvement. Regarding incidents such as burns, the Medical Director stated that they review and sign off on all accident and incident reports, thoroughly review the reports and findings, and communicate findings to the Director of Nursing, Administrator, and Assistant Administrator. The Medical Director stated that when concerns are identified, they promptly contact the attending physician to discuss the case, review findings, and provide recommendations during morning meetings. 10 New York Code, Rules and Regulation 415.12(h)(2)

Based on interviews and record review, the facility failed to ensure that an alleged violation involving neglect was reported to the New York State Department of Health within the acceptable timeframe, and that the results of all investigations were reported to the State Survey Agency within five working days of the incident. This was evident for one resident (Resident #14) out of one resident reviewed for Accidents. Specifically, an alleged violation for Resident #14 was not reported within 2 hours, and the facility did not submit a follow-up investigation report within five (5) working days of the incident.The findings include:The facility policy titled Abuse Reporting and Investigating reviewed 03/03/2023 documented all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. The administrator, or his/her designee, provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five working days of the occurrence of the incident.Resident #14 had diagnoses which included diabetes mellitus (disease in which your blood glucose, or blood sugar levels are too high) and paroxysmal atrial fibrillation (an irregular heart rhythm that starts in your heart's upper chambers).The Minimum Data Set (a resident assessment tool) dated 12/10/2024 documented that Resident #14 had intact cognition and required setup or supervision with most activities of daily living and had impairment of both upper extremities.A nurse's progress note dated 02/21/2025 at 9:05 AM, documented Resident #14 spilled hot water on their right thigh while reaching over their breakfast tray. An area of erythema (abnormal redness of the skin) was noted to their right thigh and was tender to touch. The physician was made aware and ordered to cleanse area with normal saline and apply Silvadene cream and leave open to air every day and as needed. Acetaminophen 500 milligrams two tabs stat and every 12 hours for five days.The facility Incident Report initiated 02/21/2025 documented on 02/21/2025 at 9:00 AM Resident #14 accidentally spilled hot water on their right thigh during breakfast. Resident #14 stated that they had reached over their tray and was moving the hot water and they knocked over the cup spilling the water onto their right thigh. The facility investigation documented Certified Nursing Assistant #11 heated water in the microwave for 30 seconds and placed on Resident #14's tray. Resident #14 then reached over the tray and the water spilled on their right thigh. Resident #14 was wearing a nightgown which had absorbed the water. The clothing was immediately removed by the licensed nurse, and the area was assessed. There were no injuries observed at time of incident. The facility's summary of investigation concluded there is no credible evidence to support that the incident was caused by abuse, neglect or mistreatment. The investigation was completed and signed on 03/01/2025 by the Assistant Director of Nursing #1.A confirmation email from New York State Department of Health documented the facility submitted the incident to the New York State Department of Health on 02/21/2025 at 4:26 PM, more than two hours after the incident occurred.A webform Nursing Home Investigative Report showed that the facility submitted the follow-up investigation report to the New York State Department of Health on 03/01/2025 at 11:30 AM, more than five days after the incident occurred. On 07/27/2026 at 3:44 PM, the Director of Nursing was interviewed and stated that the incident was not reported timely because the blister on Resident #14's right thigh was not present immediately following the incident and was identified at a later time. The Director of Nursing further stated that they were unsure why the follow-up investigation report was not submitted within the required five-day timeframe. The Director of Nursing further stated that the report should have been submitted within five days of the incident.On 08/03/2026 at 1:27 PM, the Administrator was interviewed by telephone and stated they did not believe the incident met the criteria for reporting within two hours. The initial assessment did not identify any blistering. When the blister was observed later that day the incident was then reported to the department of health. The Administrator further stated that submissions of the five-day investigation reports have not previously been an issue. However, the Administrator was unable to explain why the five-day investigation report was not submitted within the required timeframe. 10 New York Code Rules and Regulation 415.4(b)(2)

Based on record review and interviews, the facility failed to ensure that all allegations of abuse were thoroughly investigated. This was evident for one resident (Resident #29) out of 17 residents reviewed for Abuse. Specifically, on 03/10/2026, Resident #29 alleged that the assigned Certified Nursing Assistant was rough while assisting with turning and providing perineal care and there was no evidence the allegation was thoroughly investigated.The findings include:The facility policy titled Abuse Reporting and Investigating reviewed 03/03/2023 documented all reports of resident abuse are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. The investigator consults daily with the administrator concerning the progress/findings of the investigation. Upon conclusion of the investigation, the investigator records the findings of the investigation on approved documentation forms and provides the completed documentation to the administrator.Resident #29 had diagnoses which included Alzheimer's disease (a type of dementia that affects memory, thinking, and behavior), psychotic disorder (a mental disorder that causes abnormal thinking and perceptions), and hemiplegia (a paralysis that affects only one side of the body).The Minimum Data Set (a resident assessment tool) dated 01/25/2026 documented that Resident #29 had moderately impaired cognition, had no physical or verbal behavioral symptoms directed towards others, and had not rejected care. The Minimum Data Set also documented Resident #29 required supervision with rolling left and right and moderate assistance with toileting hygiene.A nurse's progress notes dated 03/10/2026 at 7:00 AM by Registered Nurse #8 who is also the supervisor documented that Resident #29 complained the assigned aide was rough while turning and providing perineal care. Resident #29 also alleged that the aide struck them on the lip with a hard object. Assessment revealed no visible injury to the lips. The Assistant Director of Nursing and the Director of Nursing were notified.A psychiatry progress note dated 03/11/2026 at 5:21 PM documented Resident #29 was seen earlier today as requested by the team for a significant issue of alleged abuse. Resident #29 stated that the night nurse came at 3:00 AM to change them and they cleaned their private parts roughly and turned them around in bed in a rough way. Resident #29 stated this happens every single night. Resident #29 started crying and also stated they have epilepsy and should not be woken up in the middle of the night. The facility incident report initiated 03/10/2026 documented on 03/10/2026 at 7:00 AM Resident #29 complained the assigned aide was rough while turning and providing perineal care. Resident #29 also alleged that the aide struck them on the lip with a hard object. Registered Nurse #8 assessed Resident #29's lip and there was no discoloration, no indurated area, no redness, and no swelling noted. Resident #29 also reported to the psychiatrist after the alleged incident that the night nurse came at 3:00 AM to change them and they cleaned their private parts and turned them around in bed roughly. The facility's summary of investigation concluded there is no credible evidence to substantiate that abuse, neglect, or mistreatment occurred.Review of the facilities investigative report and staff written statements revealed no documented evidence that Resident #29's allegation of receiving rough perineal care and being handled roughly during repositioning was investigated. On 07/24/2026 at 2:39 PM, Licensed Practical Nurse #6 was interviewed by telephone and stated that while they were giving medications on the unit, Certified Nursing Assistant #23 informed them that they had been handing Resident #29 the call bell and bed remote. As Resident #29 turned, the call bell inadvertently made contact with Resident #29's mouth. Licensed Practical Nurse #6 stated that the incident was immediately reported to Registered Nurse #8 who is also the supervisor. Licensed Practical Nurse #6 further stated that Resident #29 never complained that their private areas had been cleaned roughly.On 07/24/2026 at 2:50 PM, Registered Nurse #8 who is also the supervisor was interviewed by telephone and stated Licensed Practical Nurse #6 informed them that Resident #29 alleged Certified Nursing Assistant #23 had hit them. Registered Nurse #8 stated they immediately assessed Resident #29, interviewed both Resident #29 and Certified Nursing Assistant #23, and promptly notified the Director of Nursing. The facility initiated an investigation and contacted 911. Registered Nurse #8 stated that their assessment revealed no visible injuries and Resident #29 denied pain. Resident #29 reported that Certified Nursing Assistant #23 was providing routine morning care when they accidently hit their face with their hand. Registered Nurse #8 further stated that they did not recall receiving any complaints from Resident #29 that they had been washed roughly in their private area.On 07/24/2026 at 3:13 PM, Certified Nursing Assistant #23 was interviewed and stated they provided care to Resident #29, including washing them and placing clean sheets underneath Resident #23 after care was completed. Certified Nursing Assistant #23 stated they picked up the call bell from the floor and handed it to Resident #29. Certified Nursing Assistant # 23 stated that when Resident #29 turned their face, the call bell struck the resident's mouth. Certified Nursing Assistant # 23 reported no injury occurred and that the incident was accidental. Certified Nursing Assistant #23 also stated they notified Licensed Practical Nurse #6, who then contacted Registered Nurse #8. Certified Nursing Assistant #23 denied handling Resident #29 roughly and stated Resident #29 never complained about receiving rough care. Certified Nursing Assistant #23 further stated that Resident #29 frequently told them they did a good job providing care.On 07/27/2026 at 1:33 PM, Assistant Director of Nursing #2 was interviewed and stated they were notified by Registered Nurse #8 that Resident #29 had made an allegation that Certified Nursing Assistant #23 hit Resident #29 on their lip with their hand. Certified Nursing Assistant #23 was immediately removed from resident care, and 911 had been contacted. Resident #29 remained at the facility and was not transported to the hospital. Registered Nurse #8 assessed Resident #29 and obtained written statements from the staff members involved and the Director of Social Service interviewed residents who had received care from Certified Nursing Assistant #23. Assistant Director of Nursing #2 further stated Resident #29 did not report that care had been provided in a rough manner and they only reported that Certified Nursing Assistant #23 hit them on their lip with the call bell.On 07/27/2026 at 4:01 PM, the Director of Nursing was interviewed and stated Certified Nursing Assistant #23 reported the call bell accidently struck Resident #29's lip. The Director of Nursing stated there was no injury noted, including no pain, redness, or swelling. The Director of Nursing stated the facility's investigation focused only on the reported lip injury because Resident #29 rambles on about so many issues.On 08/03/2026 at 12:55 PM, the Administrator was interviewed by telephone and stated that when Resident #29 made the allegation, the resident only reported being hit on the lip. The Administrator further stated they find it hard to imagine that due diligence was not completed for all aspects of the investigation, as the facility consistently conducts thorough investigations.On 08/04/2026 at 12:37 PM, Physician #2 was interviewed by telephone and stated they have been involved in Resident #29's care for several years. Resident #29 has a baseline cognitive deficit and an intellectual disability. Physician #2 also stated it is possible that the facility reported the allegation involving Resident #29 being handled roughly during care, including rough cleaning of their private area. Physician #2 further stated that they did not perform an examination of Resident #29's perineal area. Physician #2 stated that when Resident #29 is asked how they are doing, they frequently jump from one topic or story to another. Resident #29 has a history of chronic stories and previously claimed to have had 20 certified nursing assistants terminated. Physician #2 also stated that this situation has been ongoing for some time and is not the first time of resident making accusatory complaints. Physician #2 stated they were informed by the facility that two staff members are required to enter Resident #29's room and to provide care.10 New York Code Rules and Regulation 415.4(b)(3)

Based on record review and interviews, the facility failed to ensure a resident received treatment and services in accordance with professional standards of practice and their comprehensive person-centered care plan. This was evident for one resident (Resident #29) of 17 residents reviewed for Abuse. Specifically, Resident #29's Kardex and Certified Nursing Assistant Documentation Survey Report documented that two staff members were required to provide all care. However, on 03/20/2026 Certified Nursing Assistant #23 provided care to Resident #29 without a second staff member.The findings include:The facility policy titled Activity of Daily Living Support with revision on 10/07/2025 documented interventions to improve a resident's functional abilities or minimize functional decline are in accordance with the resident's needs, preferences, stated goals, and recognized standards of practice. The resident's responses to interventions are monitored, evaluated, and revised as appropriate.Resident #29 had diagnoses which included Alzheimer's disease (a type of dementia that affects memory, thinking, and behavior), psychotic disorder (a mental disorder that causes abnormal thinking and perceptions), and hemiplegia (a paralysis that affects only one side of the body).The Minimum Data Set (a resident assessment tool) dated 01/25/2026 documented that Resident #29 had moderately impaired cognition, had no physical or verbal behavioral symptoms directed towards others, and had not rejected care. The Minimum Data Set also documented Resident #29 required supervision with rolling left and right and moderate assistance with toileting hygiene.The Kardex Report as of 03/10/2026 documented Resident #29 is a two person for care due to accusatory behaviors.The Certified Nursing Assistant Documentation Survey Report documented Resident #29 received two persons for care on 03/10/2026.The facility incident report initiated 03/10/2026 documented on 03/10/2026 at 7:00 AM Resident #29 complained the assigned aide was rough while turning and providing perineal care. Resident #29 also alleged that the aide struck them on the lip with a hard object. Registered Nurse #8 assessed Resident #29's lip and there was no discoloration, no indurated area, no redness, and no swelling noted. Resident #29 also reported to the psychiatrist after the alleged incident that the night nurse came at 3:00 AM to change them and they cleaned their private parts and turned them around in bed roughly. Certified Nursing Assistant #23 did not provide a valid explanation for failing to obtain assistance from Licensed Practical Nurse #6 before providing care. The facility's summary of investigation concluded there is no credible evidence to substantiate that abuse, neglect, or mistreatment occurred.On 07/27/2026 at 1:33 PM, Assistant Director of Nursing #2 was interviewed and stated Resident #29 required two-person assistance because they expressed accusatory behaviors. Assistant Director of Nursing #2 also stated that when a resident is placed on a two-person assist for care, staff on the unit are informed, and the unit manager reinforces the intervention. Assistant Director of Nursing #2 further stated that staff increase their attention to residents with documented behaviors, and at the beginning of each shift, certified nursing assistants receive report from the floor nurse or unit manager and are instructed to review the Kardex before providing care to residents.On 07/27/2026 at 2:50 PM, Licensed Practical Nurse #6 was interviewed and stated Resident #29 is a two-person assist for care due to accusatory behaviors. Licensed Practical Nurse #6 also stated they did not know why Certified Nursing Assistant #23 provided care independently and did not ask them Certified Nursing Assistant #23 why they did not ask for assistance with Resident #29.On 07/27/2026 at 2:53 PM, Certified Nursing Assistant #23 was interviewed and stated Resident #29 required two-person assistance for care and that, at times, a nurse accompanied them when providing care. Certified Nursing Assistant #23 also stated that on the day of the incident, they did not ask the nurse to assist them before providing care to Resident #29. Certified Nursing Assistant #23 further stated Resident #29 was pleasant and able to turn during care. Certified Nursing Assistant #23 acknowledged being informed by other staff prior to the incident that Resident #29 required two-person assist for care.On 07/27/2026 at 4:01 PM, the Director of Nursing was interviewed and stated that Resident #29 required two-person assistance for care due to a history of accusatory behaviors and Certified Nursing Assistant #23 was suspended pending the outcome of the investigation.On 08/03/2026 at 12:55 PM, the Administrator was interviewed by telephone and stated Resident #29 required two-person assistance for care and that Certified Nursing Assistant #23 should have obtained assistance before providing care, in accordance with Resident #29's plan of care. 10 New York Code Rules and Regulation 415.12

Based on record review and interviews conducted during the Recertification survey from 11/13/2024 to 11/20/2024, the facility did not ensure that, to the extent practicable, the resident or resident representative participated in the development, review, and revision of the comprehensive care plan. Specifically, the care planning meeting was not held at the time-of-day Resident #55 was available to participate. This was evident in 1 out of 3 residents reviewed for Care Plans out of 39 residents. (Resident #55) The Finds include: The facility policy and procedure titled Comprehensive Care Plans, with the last revised date of 10/01/2024, documented that the Resident/Representative is encouraged to participate in development and amendment the comprehensive care plans. The Social Worker/Designee will notify the resident and the responsible party of the care plan conference date and time. Every effort will be made to schedule care plan meetings at the best time of the day for the resident/representative. Resident #55 was admitted to the facility with diagnoses that include Diabetes Mellitus and End Stage Renal Disease. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #55's cognition intact with a Brief Interview of Mental Status score of 13. On 11/14/2024 at 9:17 AM, Resident # 55 was interviewed and stated, they informed me about the meeting, but I could not go. I am not around on Mondays when they have a meeting. They try to do it early, but I leave at 8:30 AM for dialysis and return at 4:00 PM. Care Plan note dated 03/15/2024 at 9:46 AM documented the upcoming care plan meeting for 03/18/2024. Resident # 55 stated that they have dialysis and would like to reschedule. The writer will follow up with the assigned social worker. The Care Plan meeting note dated 03/18/2024 at 11:53 AM has no documented evidence that Resident # 55 participated in the care plan meeting. Care Plan note dated 04/26/2024 at 10:32 AM documented the upcoming care plan meeting is scheduled for 04/29/2024. Resident # 55 stated that they have dialysis and would like to reschedule. The writer will follow up with the assigned social worker. The care plan meeting note dated 04/29/2024 at 1:20 PM has no documented evidence that Resident # 55 participated in the care plan meeting. Care Plan note dated 07/26/2024 at 1:14 PM documented the upcoming care plan meeting for 07/29/2024. The Admission/Discharge Planner went to see Resident #55 at the bedside. The resident was alert and stated that they had dialysis on the day of the care plan meeting. The writer will follow up with the assigned social worker. The Care Plan meeting note dated 07/30/2024 at 5:31 PM has no documented evidence that Resident # 55 participated in the care plan meeting. Care Plan note dated 10/25/2024 at 7:32 PM documented an upcoming care plan meeting is scheduled for 10/28/2024. The Discharge Planner went to see Resident # 55 at their bedside. The resident agreed with the care plan meeting. The writer advised the team to come to the resident's room for the care plan meeting, and the resident verbalized understanding. The Care Plan note dated 10/29/2024 at 5:35 PM has no documented evidence that Resident #55 participated in the care plan meeting. On 11/18/2024 at 12:18 PM, Social Worker #2 was interviewed and stated that Resident # 55 was invited to the care plan meeting but could not attend because of dialysis. Last week, we scheduled the care plan meeting for a different day when the resident was not in dialysis. There should have been an exception for the resident's care plan meeting to be scheduled on a different day. We should be able to make time for the resident to attend their care plan meeting. The team gives the resident an update after the meeting. On 11/20/2024 at 9:26 AM, the Discharge Planner was interviewed and stated they did the care plan meeting invitation. A few times, Resident #55 said that they had dialysis on the scheduled care plan meeting day. The Social Worker was informed that the resident had dialysis on the day of the care plan meeting. The Social Worker said, Okay, we will gather with the team to meet with the resident. On 11/20/2024 at 11:06 AM, a follow-up interview was conducted with Social Worker #2. Social Worker #2 stated that they were aware that Resident #55 would not be available to attend the care plan meeting because the resident had a dialysis appointment. The care plan meeting was not rescheduled. The Discharge Planner informed me that the resident would not be available, but we still went on with the meeting. On 11/19/2024, at 3:04 PM, the Director of Social Services was interviewed and stated, that Resident # 55 was on dialysis, so the resident could not participate in the care plan meeting. We just recognized this and changed the day of the care plan meeting. Resident #55 care plan meeting is held on Mondays, and the resident goes for dialysis on Mondays. It is the schedule for the floor. It was an error, and we have corrected it. On 11/20/2024 at 1:16 PM, the Director of Nursing was interviewed and stated that alert residents are invited to care plan meetings. We should have coordinated the time that is convenient for the resident. We should have coordinated the care plan meeting on a non-dialysis day. The resident goes for dialysis every Monday. It should not be the same day; they should have changed the meeting date. 10 NYCRR 415.11(c)(2)(i-iii)

Resident #392 Based on record review and interviews conducted during the Recertification and Abbreviated (NY00338415) Survey from 11/13/2024 to 11/20/2024, the facility failed to ensure that a resident was free from physical abuse. This was evident in 1 (Resident #392) of 7 residents reviewed for abuse out of 39 total sampled residents. Specifically, on 04/06/2024 at approximately 06:30 AM, a video recording device in Resident #392's room recorded Certified Nursing Assistant #12 grabbing and hitting Resident #392 on the hands and arms. The findings are: The facility policy titled Abuse Reporting with a revision date of 09/26/2024 documented that the facility will not condone resident abuse by anyone, including staff members, other residents, consultants, volunteers, and staff of other agencies serving the resident, resident representatives, family members, legal guardians, sponsors, friends, or other individuals. The Incident Report dated 04/07/2024 documented that on 04/07/2024 at approximately 11:45 AM, Resident #392's wife reported to Assistant Director of Nursing #1 that they had placed a video recording device in Resident #392's room. Resident #392's wife reported that they had reviewed footage from the recording device and observed Certified Nursing Assistant #12 roughly handling Resident #392 on 04/06/2024 at approximately 06:30 AM. The Incident Report documents that Assistant Director #1 reviewed the footage and confirmed that Certified Nursing Assistant #12 rough handled Resident #392 on 04/06/2024 at approximately 06:30 AM. Following review of the footage, Assistant Director of Nursing #1 assessed Resident #392. Resident #392 did not show signs of distress or being in pain. Resident #392 was observed to have purplish discolorations on: the right dorsal hand measuring 1 cm x 1cm, the left hand measuring 1.2 cm x 1cm, and the right arm measuring 0.5 cm x 0.5 cm. The skin remained intact with no swelling or edema observed. The Incident Report concluded that the rough handling of Resident #392 by Certified Nursing Assistant #12 was consistent with abuse. The Employee Disciplinary Notice dated 04/08/2024 documents that Certified Nursing Assistant #12 was terminated on 04/08/2024 related to the physical abuse incident against Resident #392 on 04/06/2024. The Employee Disciplinary Notice documented that Certified Nursing Assistant #12 refused to provide the facility with a statement related to the incident. The surveyor made multiple attempts to reach Certified Nursing Assistant #12 via phone for a between 11/13/2024 and 11/20/2024 but was unable to reach Certified Nursing Assistant #12. Resident #392 had diagnoses including Non-Alzheimer's Dementia, muscle weakness, and speech and language deficits following Cerebrovascular disease. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #392 had severely impaired cognition. A Comprehensive Care Plan dated 08/29/2023 and revised on 10/01/2024 documented that Resident #392 was at risk for abuse related to cognitive impairment and dependence on others for activities of daily living care. The facility interventions documented were to provide one to one visits with the resident, investigate all allegations of abuse promptly, and assess the resident for signs and symptoms of abuse such as bruising, behavior changes, weight loss, and changes in psychosocial status, and to report any signs to appropriate resources. A Psychiatry Progress Note dated 04/08/2024 documented that Resident #392 was evaluated by Psychiatry following the abuse incident on 04/06/2024. The Psychiatry note documented that Resident #392 was confused, smiling, and in no apparent distress. Resident #392 was unable to provide information related to the incident or interactions with staff. On 11/19/2024 at 02:24 PM, Assistant Director of Nursing #1 was interviewed and stated that they received the initial abuse allegation from Resident #392's wife. They stated that they reviewed the video footage of the incident which showed that Certified Nursing Assistant #12 had handled Resident #392 roughly. They stated that following the review of the footage, they notified the facility's doctor, the Director of Nursing, the Administrator, and the New York Police Department. Assistant Director of Nursing #1 stated that they assessed the resident and observed purplish discolorations on Resident #392's right hand, left hand, and right arm. Assistant Director of Nursing #1 stated that the Director of Nursing then took over the investigation to report it to the Department of Health and to discipline Certified Nursing Assistant #12. On 11/19/2024 at 11:08 AM, the Director of Nursing was interviewed and stated that the Assistant Director of Nursing #1 received the allegation of Certified Nursing Assistant #12 abusing Resident #392 by Resident 392's wife on 04/07/2024. Assistant Director of Nursing #1 assessed the resident and notified the Director of Nursing of the incident. The New York Police Department was notified of the incident and Resident #392's wife declined to press charges against Certified Nursing Assistant #12. Certified Nursing Assistant #12 was not in the facility when the facility became aware of the incident. Certified Nursing Assistant #12 was removed from the schedule and reported to the facility on [DATE] to be interviewed by the Director of Nursing regarding the reported incident. The Director of Nursing stated that Certified Nursing Assistant #12 stated that they had been trying to provide care to Resident #392 and that the resident fought against her. The Director of Nursing stated that they showed Certified Nursing Assistant #12 the video footage of the incident and Certified Nursing Assistant #12 refused to provide a written statement related to the incident. The Director of Nursing stated that Certified Nursing Assistant #12 was then terminated, and that their actions violated the facility's abuse prevention policies. On 11/20/2024 at 12:10 PM, the Administrator was interviewed and stated that they were informed by the Director of Nursing of the abuse investigation related to Resident #392 and Certified Nursing Assistant #12. They stated that the Director of Nursing completed the investigation and reported it to the Department of Health. The Administrator stated that the abuse incident should not have occurred but that they felt like the facility did a good job in completing the ensuing investigation. 10 NYCRR 415.4(b)(1)(i)

Based on observations, interviews, and record reviews conducted during the Recertification Survey from 11/13/2024 to 11/20/2024, the facility did not ensure that a person-centered Comprehensive Care Plan was developed and implemented to meet the resident's goals, and address the resident's medical, physical, mental, and psychosocial needs. Specifically, 1) Resident # 100 who had diagnosis of Dementia had no care plan in to address a Dementia diagnosis. 2) Resident # 186 receiving an Anti-depressant and Opioids had no care plan in place. This was evident of two of 5 residents investigated for Unnecessary Medications out of a sample of 39 residents (Resident #100 and Resident #186). The findings are: The facility policy and procedure titled Comprehensive Care Planning, with the last revised date of 10/1/2024, documented that the facility will develop a comprehensive, person-centered care for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental and physiological needs which are identified in the comprehensive assessment and lead to the resident's highest obtainable level of independence. 1) Resident #100 was admitted to the facility with diagnoses that include Cerebrovascular accident, Non-Alzheimer's Dementia, Depression, and History of Falling. The Admission Minimum Data Set assessment dated [DATE] documented Resident #100's cognition as severely impaired with a Brief Interview for Mental Status score of 3. The Minimum Data Set further documented the resident has a diagnosis of Non-Alzheimer's Dementia. Physician's Progress Note Late Entry dated 10/30/2024 00:00 documented Chief complaint for Psychiatric evaluation follow up. Brief Interview for Mental Status score of 3 on 9/12/24. Patient is a [AGE] year-old. Chart Reviewed, case discussed with staff. No current behavioral problems reported. Patient denied current symptoms of depression. Psych medications include Lexapro 15 mg daily. Physicians Encounter Progress Note dated 10/27/2024 at 01:00 documented resident is a [AGE] year-old patient with Past medical History of Depression, Hypertension and Dementia. A Nursing Progress Note dated 10/24/2024 at 15:54, documented Resident alert and oriented times one. Resident status post fall and resident remains stable with no new complains or signs of discomfort, no delayed symptoms, bruises, skin tear. Continue monitoring for any status changes. Social Service Progress Note dated 9/12/2024 at 10:04AM documented the Social Services Evaluation was completed for resident. Reason for Evaluation: Advance Directives in Place: Full Code. Communication: Primary Language: Primary Language: English. Speech Pattern: Clear speech. Ability to Express Ideas and Wants: Understood. Understanding Verbal Content: Understands. Brief Interview for Mental Status : 3.0 Severe Impairment. Mild Depression. A Social Services Admission/Re-admission Progress Note dated 9/12/2024 at 11:49AM, documented Late Entry: Resident is a [AGE] year-old admitted to the Riverside Rehab from Mount [NAME] St. [NAME] on 9-11-24 with the diagnoses of Closed displaced intertro-chanteric fracture of right femur, Dementia. Resident scored 3 on the Brief Interview for Mental Status and resident's mood appears stable. A review of Resident #100's medical records revealed no documented evidence that a comprehensive care plan with interventions for Resident #100's Dementia diagnosis was initiated and implemented. On 11/20/24 at 09:40 AM, The Director of Nursing was interviewed and stated, initiating Care Plans depends on the specific Care Team responsible. The Director of Nursing stated for cognitive impairment residents the Social work department is responsible for initiating the care plan, because they complete the resident Brief Interview for Mental Status and depending on the score received, the Social Worker will be alerted on the cognition of the resident. The Director of Nursing stated the Department Head of Social Work is responsible for monitoring if that the care plans are implemented based on the resident triggers and plan of care. The Director of Nursing also stated all the care teams are responsible for completing the care plans and the expectation is that this is done on admission, quarterly, annually, and episodic and as needed. The Director of Nursing added was not sure what happened in this case. On 11/20/24 at 09:24 AM, the Director of Director of Social Work was interviewed and stated the Social Work Department is responsive for initiating the Cognitive Impairment Care plan for residents with Dementia and low Brief Interview for Mental Status scores. The Director of Social Work stated when a resident is admitted to the facility the Social Worker assessed the resident and based on the resident's Brief Interview for Mental Status score the care plan is initiated. The Director of Social Work stated based on the resident's Brief Interview for Mental Status a Cognitive Impairment Care plan should be implemented. The Director of Social Work also stated, I monitor that the Care plans are in place by conducting audits and reviewing all care plans for new admission. The Director of Social Work did not state what happened with this resident's care plans and or if the resident care plan was audited. The Director of ocial Work added, this was just an oversite. On 11/19/24 at 10:39 AM, Social Worker #1 was interviewed and stated, Social Service is responsible for initiating the Cognitively Impaired Dementia Care Plans. Social Worker #1 stated the resident who is cognitively impaired was admitted on the 14th floor and not sure if the care plan for Dementia/Cognitively impairment was initiated or not. Social Worker #1 stated, care plans differ from floor to floor, and every care plan looks different. Social Worker #1 stated I will go and review the resident's record and will get back to Surveyor about the care plan. On 11/19/24 at 10:57 AM Social Worker #1 returned to speak with Surveyor and stated, the resident is cognitively impaired with Brief Interview for Mental Status score of 3. They have communication issues and have a diagnosis of Dementia. Social Worker #1 also stated the initiating of the care plan was an oversite, and added I am not sure what happened but will put the care plan in place. 50894 2. Resident #186 had diagnoses including Multiple Sclerosis, Depression, and a Right Femur Fracture. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #186 was cognitively intact. Review of the Hospital Discharge Summary dated 06/03/2024 documented that Resident #186 was discharged from the hospital to the facility with an order for Oxycodone 5 mg every 4 hours as needed for pain. Review of the Order Recap Report dated 06/01/2024 through 06/30/2024 documented that from 06/10/2024 to 06/17/2024, Resident #186 had an order for Oxycodone HCl 5 mg to be taken every 4 hours as needed for pain. This order was renewed on 06/19/2024 and ended on 06/26/2024. Review of the Medication Review Report dated 07/01/2024 through 11/19/2024 documented that this order for Oxycodone was renewed on 07/09/2024. The Medication Review Report also documented that Resident #186 had orders to receive Oxycodone HCl 5 mg every 12 hours for pain placed on 09/16/2024, 10/30/2024, and 11/13/2024. Review of Psychiatry Progress Note dated 06/18/2024 documented that Resident #186 reported signs and symptoms of clinical depression and was recommended to start Citalopram Hydrobromide 10 mg daily. Review of the Medication Review Report dated 07/01/2024 through 11/19/2024 documented that an order was placed for Resident #186 to receive Citalopram Hydrobromide 10 mg daily for depression on 06/20/2024. This order was renewed on 07/07/2024 and remained active as of 11/19/2024. Review of the November 2024 Medication Administration Record documented that Resident #186 received Oxycodone HCl 5 mg every 12 hours and Citalopram Hydrobromide 10 mg daily as ordered between 11/01/2024 and 11/19/2024. Review of Resident #186's medical record revealed no documented evidence that comprehensive care plans related to Oxycodone usage or Citalopram usage were created or implemented. On 11/18/2024 at 02:27 PM, Registered Nurse Manager #6 was interviewed and stated that residents on opioid medications and antidepressant medications are supposed to have care plans created specifically to address those medications. The care plans would include information related to the medication's purpose and potential side effects of the medication. Registered Nurse Manager #6 stated that the nurse manager on duty at the time of the first order being placed would be responsible for creating the care plan. Registered Nurse Manager #6 was unable to provide an explanation for why care plans for Oxycodone HCl and Citalopram were not created for Resident #186. On 11/19/2024 at 11:08 AM, the Director of Nursing was interviewed and stated that residents on opioid medications and antidepressant medications should have care plans in place related to those medications. They stated that the nurse manager on the unit would be responsible for creating the care plans. The Director of Nursing was unable to provide an explanation for why care plans for Oxycodone HCl and Citalopram were not created for Resident #186. 10 NYCRR 415.11(c)(1)

Based on observation, record review, and interviews conducted during the recertification survey from 11/13/2024 to 11/20/2024, the facility did not ensure an ongoing activities program was provided to meet the resident's interest and support the resident's physical, mental, and psychosocial well-being. This was evident in 2 (Resident #247 and 384) of 4 residents reviewed for Activities out of 39 sampled residents. Specifically, Residents #247 and 384, who reside in the Memory Care (Dementia) unit, were not provided with activities that met the residents' preferences and cognitive abilities. The findings are: The facility's policy and procedure titled Activity, with the last revised date of 10/22/2024, documented that group activities are available. The activities calendar is completed and maintained to inform residents, families, and staff of the activity opportunities available. The November 2024 Activities calendar for the 11th floor was posted in the dining room. Activities from 11/13/2024 through 11/20/2024 are as follows: On 11/13/2024, Riverside news at 9:30 AM all units, Riverside cafe 10:30 AM select units, one to one music therapy 12:30 PM, drive-in snack cart at 1:30 PM on the 11th floor, Classic hour at 4:00 PM, Live music at 6:30 PM on the 11th floor. On 11/14/2024, Riverside news at 9:30 AM for all units, Doll therapy at 10:00 AM, birthday party at 2:30 PM on 11th floor. On 11/15/2024, Riverside news at 9:30 AM all units, painting and the price is right 11:00 AM, and virtual reality at 1:30 PM on select units. On 11/16/2024, Riverside news at 9:30 AM all units, one to one Affirmation at 10:30 AM all units, ball toss, selected units at 11:00 AM, Activities rolling cart at 2:30 PM all units, Manicure selected units at 4:00 PM. On 11/17/2024, Riverside news at 9:30 AM all units, 1 1 Affirmation at 10:30 AM all units, ball toss, selected units at 11:00 AM, Activities rolling cart at 2:30 PM all units, Manicure selected units at 4:00 PM. On 11/18/2024, Riverside News at 9:30 AM, all units On 11/19/2024, Riverside News at 9:30 AM for all units, doll therapy at 10:00 AM for all units, Riverside Cafe at 10:30 PM for select units, balloon games at 2:20 PM, 1:1 sensory stimulation at 3:30 PM On 11/20/2024, Riverside news at 9:30 AM for all units, Riverside Cafe at 10:30 AM for select units,1:1 music therapy at 12:30 PM, drive-in snack cart on the 11th floor, and Live music at 6:30 PM on the 11th floor. 1. Resident #247 was admitted with diagnoses that include Hypertension and Alzheimer's Disease. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #247's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of 6. The annual minimum data set assessment dated [DATE] documented that according to Resident #247's family, it is very important for the resident to do their favorite activities, and somewhat important to have books and newspapers to read and listen to music. On 11/14/2024, at 10:47 AM, Resident # 247 was observed out of bed in the dining room. The television was on, and the resident's head was on the table. There were no ongoing activities. At 11:34 AM, the resident was observed sleeping in the dining room, with a daily chronicle in front of the resident and other residents. The television was on, and no other activities were noted. On 11/15/2024 at 2:43 PM, Resident # 247 was observed out of bed in a wheelchair in their room with the television on. There were no supplies for independent use in the resident's room. The Comprehensive Care Plan related to Activities initiated on 09/16/2022 documented Resident #247's interest in attending recreational programs and being independent in leisure while not involved in any structured group programs. The interventions include offering supplies for independent use and providing la carte-type activities. Resident #247's activities attendance record dated 11/05/2024 to 11/16/2024 documented that the resident was active in eight activities. The attendance record shows no activities offered on 11/08/2024 through 11/11/2024. 2. Resident # was admitted to the facility with diagnoses that include Cerebrovascular Accident (CVA) and Alzheimer's Dementia. The Minimum Data Set assessment dated [DATE] documented Resident # 384 cognition as severely impaired with a Brief Interview for Mental Status score of 3. The annual minimum data set assessment dated [DATE] documented that it is very important for the resident to have books, newspapers, and magazines to read, listen to music, keep up with the news, do things with groups, do favorite activities, and participate in religious services or practices. On 11/13/2024 at 11:14 AM, Resident #384 was observed in the dining room with other residents, with the television on. There were no one-on-one or group activities. On 11/14/2024 at 11:34 AM, Resident #384 was observed in the dining room with 20 other residents, with the television on and the Price is Right playing. The daily chronicle was in front of the residents. No one-on-one or group activities were noted. On 11/15/2024, at 10:42 AM, Resident #384 was observed in the dining room with 15 other residents, with no ongoing activities. The television was on. On 11/20/2024 at 10:49 AM, Resident #384 was observed coloring in the dining room. There were other residents observed coloring in groups. On 11/20/2024 at 10:50 AM, Resident #384 was interviewed and stated that they like coloring but do not do it because they do not have anything like that. They started doing this today, and this is my first time doing this. I usually come and eat, sit, and watch television. The Comprehensive care Plan related to Activities initiated on 05/03/2024 documented that the resident or family or significant other stated that it is very important for the Resident #384 to have books, newspapers, and magazines to read, listen to music, keep up with the news, and do things with groups of people. The interventions documented include providing 1:1 visit, sensory stimulation, monthly calendars, supplies/materials as needed, reminders. Resident #384's Activities attendance record dated 11/05/2024 to 11/19/2024 documented that the Resident #384 was active in 18 activities and declined one. The attendance record shows no activities on 11/7, 11/8, 11/9, 11/11, 11/12 and 11/17/24. On 11/19/2024 at 11:03 AM, Certified Nursing Assistant #5 was interviewed and stated that sometimes Resident #247 goes to the dining room and play dominos. An activity staff comes daily, either in the morning or the evening, and does activities with the residents. At times, I sing with the residents to entertain them. On 11/19/2024 at 11:17 AM, Certified Nursing Assistant #6 was interviewed and stated that all the residents had to be out of bed and stay in the dining room. We take turns watching the residents every hour. Sometimes, we play Bingo with the residents, play music, and dance with them. On 11/19/2024 at 11:23 AM, the Recreation Director was interviewed and stated that the activity aide for the floor was off today. The aide does color, nail painting, and cognitive games daily. We do not have activity when the aide is off. The Certified Nursing Assistants play games with the residents when the assigned aide is not on duty. There is a plastic container with games in the dining room. The Recreation Aide distributes reading materials to the residents in the morning and does 1:1 room visits. Some residents like to watch television, which is a form of activity. They watch shows such as The Price is Right. On 11/20/2024 at 12:37 PM, Certified Nursing Assistant #4 was interviewed and stated that Resident #384 is independent and participates in activities when there are any. The resident likes to paint and sing. The recreation staff come and do nails or plays games with the residents for about an hour, then leave. The recreation staff comes and goes back and forth. The residents watch television in the dining room. On 11/20/2024 at 10:35 AM, Licensed Practical Nurse #2 was interviewed and stated, at times they sing to the residents. The resident stays in the dining room, sleeps, and watches television when there are no activities. There are no ongoing activities all the time. On 11/20/2024 at 12:13 pm, the Recreation Therapist was interviewed and stated, they are responsible for the 11th-floor activities and do paperwork such as documentation, progress notes, attendance, and care planning meetings. Thursday, I did painting with four residents in the morning for 45 minutes at 11 am. I do one-to-one therapy with those who cannot paint. I did two residents' nails on Friday, but the rest declined. I also transport residents to and off the unit programs, which can take about three and a half hours. There is no coverage when I am off. We do arts and crafts and word searches and puzzles for about an hour. There are a lot of cognitively impaired residents, and I do music with them. On 11/20/2024 at 1:21 PM, the Director of Nursing was interviewed and stated that they make rounds on the unit in the morning. Sometimes, I see activities going on the 11th floor. The Certified Nursing Assistants play music for the residents. They have rolling carts and riverside news. They have games that they play with them. It was brought to our attention yesterday that there are no ongoing activities on the unit. We had a meeting to do something immediately. We will improve the activities in the units. 10NYCRR 415.5(f)(1)

Based on observations, interviews and record reviews conducted during an abbreviated survey (NY00289287), the facility did not ensure that a resident was free from physical abuse. This was evident in 1 out of 3 residents sampled for abuse (Resident #1). Specifically, Resident #1 was observed with a small cut and blood above the right eyebrow by Certified Nursing Assistant (CNA) #6 on 01/08/22 on the morning shift. Resident #1 reported that CNA #1 hit them with a towel during care on the night shift. Resident #1 was transferred to the hospital for a Computerized Tomography (CT) Scan of the head that was negative. Resident #1's plan of care documented that 2-persons are required to provide personal hygiene care. CNA #1 provided care to Resident #1 without assistance on 01/08/22. The findings are: The facility's Policy and Procedure titled Abuse, Neglect, Exploitation, and Misappropriating Prevention Program last reviewed 03/15/21, states that Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal mental, sexual or physical abuse, and physical or chemical restraint not required to treatment the resident's symptoms. The policy also documented that to establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive, or emotional problems. Resident #1 was admitted to facility with diagnoses including Dementia, Psychotic Disorder, and Depressive. The Minimum Data Sets (MDS, a resident assessment tool) dated 10/30/21 documented that Resident #1 had moderately impaired cognition. The Resident required extensive assistance of 2 people for bed mobility, personal hygiene, and toileting. Section E documented that rejection of care occurred on 1-3 days. An at Risk for Potential Abuse Care Plan initiated on 11/04/2018 documented that Resident #1 will not experience any form of abuse or neglect through review date. The Care Plan was updated on 01/08/2022 to reflect on the abuse allegation. The interventions included wound consult, offering padded side rails, assessing The Resident for signs and symptoms of abuse, follow up with social services and investigate all allegations of abuse. Provide support to ensure the Resident is free from abuse. An Activity of Daily Living (ADLs) Comprehensive Care Plan (CCP) related to refusal of care, changing of adult brief even when wet was implemented on 11/22/19 with interventions for staff to provide emotional support and encouragement for Resident to get out of bed at least two times a week. A Task List Report (CNAs instructions) dated 08/20/21 documented that Resident #1 requires 2 persons assist when providing care. The CNA Kardex report dated 12/31/21, under Behavior/Mood documented that when the Resident becomes agitated, staff to intervene before agitation escalates, guide away from source of distress; engage calmly in conversation; if Resident #1 response is aggressive, staff to walk calmly away and approach later. Under Bathing and Personal Hygiene documented that Resident #1 requires extensive assist of one staff. Transfer documented on 01/22/19, under turning and positioning, that the Resident requires two staff assist for ADLs (Activity of Daily Living). There were no instructions for staff to immediately report the Resident's behavior to the nurse. A Nursing Progress Note dated 01/08/2022 at 8:42 AM documented that when the day shift CNA #6 went to Resident #1 to give care, the Resident stated that the night CNA #1 had hurt them. A small cut with some blood above the Resident's right eyebrow was observed. CNA #1 stated that the Resident attempted to pull a towel away from them which caused the Resident to hit themself. The area was noted with some edema. The cut was cleansed and treated with bacitracin and the supervisor was notified. The supervisor notified the Director of Nursing Services (DON), who notified 911, family member and unit the physician. The Resident was sent to the emergency room (ER) for further evaluation. The Resident was returned to the facility after undergoing a Computerized Tomography (CT) Scan of the head which was negative. A facility Alleged Abuse Report dated 01/08/2022 documented that at about 4:25 AM Resident #1 was observed with a small, opened area to the right side of the forehead with edema. The Resident stated that they were hit with a towel by CNA #1. Statements were gathered from 2 Licensed Practical Nurses (LPN) and 6 CNAs. CNA #1 stated that the Resident became suddenly combative during a brief change after agreeing to be changed and then had blood on their forehead. The facility's conclusion of the investigation documented that CNA #1 did not follow Resident #1's plan of care for 2 people to provide care. Also documented was that CNA #1 could not give a consistent account of how Resident #1 sustained the injury. On 02/09/23 at 3:41 PM, CNA #1 was interviewed and stated that they had worked at the facility since 2011 but only worked with Resident #1, once, on 01/08/2022. CNA #1 stated that Resident #1 was soiled and that they were trying to persuade Resident #1 to be washed and changed, but Resident #1 was combative. CNA #1 stated that Resident #1 tried to grab the towel and CNA #1 let go of the towel. CNA #1 stated that Resident #1 must have hit themselves when CNA #1 let go of the towel. CNA #1 stated that they were not aware that Resident #1 required 2 people for care. On 02/09/2023 at 4:30 PM, the Assistant Director of Nursing (ADON) was interviewed and stated that Resident #1 was refusing to be changed but the CNA felt it would be negligent to leave the Resident wet and soiled. However, the protocol is that when a resident is a 2 person assist, there must be 2 CNAs to provide all care, and when a resident refuses care, the supervisor must be alerted. The ADON stated that in the incident of 01/08/22, CNA #1 did not adhere to the protocol for a 2 person assist and was terminated. The facility emphasized that 2 persons must always be present during care. 10 NYCRR 483,12(a)(1)

Based on observations, interviews and record reviews conducted during an abbreviated survey (NY00289287), the facility did not ensure that a resident was free from physical restraint. This was evident in 1 out of 3 residents sampled (Resident #1). Specifically, two Certified Nursing Assistants (CNA #2 & CNA #3) physically restrained Resident #1, by holding down the Resident's wrists, during incontinent care on 07/28/22. Resident #1 was observed on 07/29/22 with discoloration to the left wrist, medial forearm, and the right wrist. Resident #1 reported on 07/29/22 that two CNAs held their arms down. The findings are: The facility Policy and Procedure on Restraints revised on 02/22/21, states that restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. It documented that when the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented. It defines physical restraints as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Resident #1 was admitted to facility with diagnoses including Dementia, Psychotic Disorder, and Depressive. The MDS dated [DATE] documented that Resident #1 had intact cognition. Section G documented that Resident #1 required extensive assistance of more than 2 people with bed mobility, toileting, and personal hygiene. Section E documented that rejection of care occurred on 4-6 days. A Task List Report (CNAs instructions) dated 08/20/21 documented that Resident #1 requires 2 persons assist during care on all shifts. The CNA Kardex report dated 06/30/22, under Behavior/Mood documented that when the Resident becomes agitated, staff to intervene before agitation escalates, guide away from source of distress; engage calmly in conversation; if Resident #1 response is aggressive, staff to walk calmly away and approach later. Resident Care dated 05/2022, documented that if the resident resists ADLs (Activity of Daily Living), staff are to reassure the resident, leave and return 5-10 minutes later and try again. There were no instructions for staff to immediately report the Resident's behavior to the nurse. A Therapy Note dated 07/29/22 documented that the unit nurse phoned the Physical Therapist (PT) to discuss a discoloration on Resident #1's left hand. On assessment, a discoloration was observed on Resident #1's left wrist area and medial forearm as well as the right wrist. The Resident reported that on the previous night two CNAs had held their arms down while changing their brief. 911 was activated and STAT x-rays were ordered which showed a fracture of the left distal radius, age indeterminate. A plan was made to send the Resident to the hospital for evaluation, but the Resident's family stated that the injury was not new and preferred that they remain in the facility due to the threat of COVID exposure. The wrist was Ace wrapped. A Radiology Report result dated 07/31/22 documented that multiple views of the left wrist showed no acute fractures or dislocation. Moderate osteoarthritis is seen in the joint spaces. Diffuse osteopenia is present. The facility Summary of Investigation undated, documented that on 07/29/22 at approximately 3:20 PM, the Registered Nurse Manager (RNM) #1 was notified by a CNA Alleged Abuse Report dated 07/29/2022 documented that the Resident said that the that Resident #1 had discoloration on their left wrist. The Resident was interviewed and stated that two people held their hand last night during care. Resident #1 was unsure of the exact time but stated that it was dark outside. The Medical Doctor (MD) noted thin skin to bilateral upper extremities with mild swelling to the left wrist (radial aspect). Resident #1 denied pain during the visit but endorsed that their left wrist was hurting. A STAT x-ray was ordered and as needed pain medication. It is documented that the Resident is cognitively intact. It is documented that the x-ray results of the right wrist documented fracture to distal Radius - age indeterminate. There is no soft tissue swelling. Multiple vies of the right hand demonstrate no acute fracture of dislocation. X-ray results of the left wrist documented no acute fracture of dislocation of the left hand. Moderate osteoarthritis is seen in the joint spaces. Diffuse osteopenia is present. There is no soft tissue swelling. The facility concluded that the CNAs held Resident #1's hand down and did not notify the nurse that Resident #1 refused care. An undated statement from the Social Worker (SW) documented that Resident #1 reported to the Nurse Manager and the SW that one CNA was pushing their hand down on the rail while another CNA was washing the Resident with a towel. It is documented that the Resident reported that the incident happened at 11:00 PM on the night before (07/28/22). It is also documented that Resident #1 stated that at 05:00 AM, another CNA gave them ice to put on the left hand since the hand was hurting. CNA #2 provided a statement to the facility dated 07/28/22. The statement documented that CNA #2 was assigned to Resident #1 on 07/28/22. It documented that Resident #1 refused to be changed multiple times throughout the evening. CNA #2 approached the Resident towards the end of the shift and wake up the Resident because the Resident was covered in coffee and the bed was soiled with urine. CNA #2 stated that they informed Resident #1 that they needed to be changed and that Resident #1 started to yell and refused care. CNA #2 stated that they called CNA #3 to assist them as the Resident was extremely combative and was yelling derogatory terms at the CNAs. CNA #2 documented that the Resident was trying to hit them, and CNA #3 took the lead and held the Resident's wrist done to prevent the Resident from hitting them. CNA #3 provided a written statement to the facility dated 07/28/22. The statement documented that CNA #3 assisted CNA #2 with providing care to Resident #1. It documented that Resident #1 was very combative with the CNAs by swinging their arms and attempting to bite the CNAs. CNA #3 documented that they completed care and left the Resident screaming at them. On 02/09/2023 at 4:30 PM, the ADON was interviewed and stated that Resident #1 was refusing to be changed but the CNAs felt it would be negligent to leave the Resident wet and soiled. The ADON also stated that the two CNAs were unfamiliar to Resident #1 and did not alert their supervisor that the resident was agitated during care which the Resident had refused. The ADON stated that CNA #2 and CNA #3 took it upon themselves to ignore the Resident's wishes, violated the protocol and restrained the Resident. 10 NYCRR 483.12

Based on observations, record review, and interviews conducted during the Recertification survey from [DATE] to [DATE], the facility did not ensure food was prepared, distributed, and served in accordance with professional standards for food service safety to prevent foodborne illness. This was observed during Kitchen observation. Specifically, (1) the Speech Language Pathologist (SLP) did not perform hand hygiene while feeding lunch to Resident #436, 2) expired pureed banana was observed in the emergency food supply, and 3) sandwiches from the tray line was not held within acceptable parameters, at or below 41 degrees Fahrenheit (F), to prevent foodborne illness. The findings are: The facility policy titled Food Storage last reviewed [DATE] documented old stock is always used first (first in - first out method). Date markings to indicate the date or day by which ready to eat. The facility policy titled Food Temperatures last reviewed [DATE] documented all cold foods items will be transported and delivered to maintain temperatures at or below 41 F. The facility policy titled Hand Hygiene last reviewed [DATE] documented appropriate 20-second handwashing must be performed before and after resident contact, after handling used linens, after contact with resident mucous membranes, bodily fluids, or excretions. 1) On [DATE] at 01:07 PM, the SLP was observed taking a lunch tray to Resident #436's room while the resident was in bed. The SLP placed the tray down, donned gloves, and began adjusting the bed sheet on Resident #436's lap. The SLP removed 1 pillow and adjusted another pillow from beneath the resident's head. The SLP placed an apron on Resident #436 and began to feed the resident food items from the lunch tray. The SLP did not change their gloves or perform hand hygiene before feeding Resident #436. On [DATE] at 12:09 PM, the SLP was interviewed and stated they typically would not wear gloves, but gloves were used when repositioning Resident #436. The SLP did not want to cross contaminate and is usually more conscious of hand hygiene. 2) On [DATE] at 08:41 AM, a tour was conducted of the Emergency Food storage area and following observation was made there was 5 boxes containing (16 cups of 4 ounce containers per box) of pureed banana with [DATE] expiration date (total of 320 ounces of pureed banana). On [DATE] at 10:14 AM, the Dietary Storeroom Clerk (DSC) was interviewed and stated they oversee organizing the emergency food storeroom. The storeroom is inventoried every 3 months and the Food Service Supervisor (FSS) notifies the DSC which items must be rotated based on first-in first-out (FIFO) method. The DSC's last walk through was ,d+[DATE]. On [DATE] at 10:22 AM, the FSS was interviewed and stated they look at the emergency food storeroom every 3 months with the DSC and last rotated items in ,d+[DATE] to ,d+[DATE]. Items in the emergency supply are rotated as needed. 3) On [DATE] at 11:31 AM, tray line observation was conducted in the Kitchen. An egg salad sandwich pulled from the tray was held at a temperature of 55.3 F, above acceptable parameter of 41 F or below. On [DATE] at 11:37 AM, tray line temperature of a tuna sandwich was 43.5 F. On [DATE] at 12:01 PM, the Dietary Aide (DA) was interviewed and stated that they were responsible for making the egg salad sandwiches. The sandwiches should be held at 40 F by the time the DA is done making them. On [DATE] at 11:40 AM, the Food Service Supervisor (FSS) was interviewed and stated that the sandwich will be discarded, and the DA will remake them. The holding temperature should not be over 40 F. The sandwiches should be ,d+[DATE] F. On [DATE] at 11:43 AM, the Director of Food Services (DFS) was interviewed and stated they review the temperature logs for sandwiches monthly and report their findings to the Quality Assurance Committee. Sandwiches can be very challenging to keep at 41 F or less. 415.14 (h)

Based on observation, record review and interview conducted during the recertification survey, the facility did not maintain an effective pest control program so the facility is free of pests and rodents. This was evident for 3 (Units 2, 6, and 10) of 12 residential units. Specifically, there were multiple observations of mice and insects throughout resident rooms and common areas on Units 2, 6, and 10. The finding is: The facility policy titled Pest Control last revised 09/09/2022 documented the facility will maintain an ongoing pest control program to ensure that the building is kept free of insects and rodents. Treatment of the facility for pest and insect control is performed on a weekly basis with more frequent treatment as needed. The Exterminator will review the Pest Control Log (PCL) on a weekly basis or as needed and indicate in the log the location of application, the pesticide used, and date of visit. On 02/14/2023 at 12:32 PM and 02/16/2023 at 10:57 AM, room [ROOM NUMBER] on Unit 2 was observed with a cockroach approximately 1 inch in length crawling out of the top drawer of a resident's dresser. Resident #16 stated they have seen a mouse in their room. On 02/14/2023 at 04:04 PM, a mouse approximately 4 inches in length was observed running behind a storage bin and approximately 9 black ants were crawling on the floor in room [ROOM NUMBER]. On 02/15/2023 at 11:05 AM, a mouse was observed on Unit 2 running across the hall from the Nursing Station and squeezing under the Storage Closet door. On 02/16/2023 at 09:53 AM, 02/17/2023 at 10:51 AM, and 02/21/2023 at 04:53 PM, room [ROOM NUMBER] on Unit 6 was observed with black flies near the trash can and mouse droppings under a chair. On 02/17/23 at 12:08 PM, a mouse was observed running across the floor of room [ROOM NUMBER] on Unit 10 and passing under a resident's wheelchair. The Unit 2 PCL documented room [ROOM NUMBER] was observed with a mouse on 02/09/2023 and with a mouse and roaches on 02/15/2023. Various observations of mice on Unit 2 were documented 1/4/23, 1/14/23, 1/23/23, 1/25/23, 1/30/23, and 2/2/23. The Unit 10 PCL documented a mouse was observed in room [ROOM NUMBER] on 02/06/2023. Various mouse sightings were documented on 01/03/2023, 01/18/2023, 1/20/2023, 01/24/2023, 2/6/2023, 2/7/2023, and 2/9/2023 documented recent mice sightings. The Pest Control Service Inspection Report dated 2/09/2023 documented Unit was treated for mice and did not document inspection details. The Pest Control Service Inspection Report dated 1/25/2023 documented better food storage was recommended. On 02/17/2023 at 12:30 PM, Licensed Practical Nurse (LPN) # 4 was interviewed and stated they saw a rat 3 months ago on Unit 10. The Exterminator comes to the facility to take care of the pests and documents in the PCL. On 02/17/2023 at 10:24 AM, Unit 10 Housekeeper #2 stated they have noticed mice, report it by writing it in the PCL, and have not noticed roaches or flies. Housekeeper #2 stated they have seen Exterminator 10-15 times in the last month on the units. On 02/22/2023 at 11:30 AM, the 10th floor Registered Nurse (RN) #4 was interviewed and stated they occasionally see mice on the unit and last saw a mouse a few months ago. They write their concerns in the PCL. On 02/22/2023 at 11:47 AM, the Unit 6 Housekeeper #3 was interviewed and stated they have not noticed pests on the unit but has noticed mouse droppings in room [ROOM NUMBER] and thought it was dust. On 02/22/2023 at 01:19 PM, the Assistant Director of Nursing (ADON) #2 was interviewed and stated they have seen a roach on Unit 2 in the past and the Exterminator comes twice a week. On 02/22/2023 at 01:46 PM, the Director of Environmental Services (DES) was interviewed and stated the Exterminator comes 3 times a week and does rounds with the Director of Maintenance (DM). There have not been any reports of ants, occasional reports of flies, and rare reports of roaches. There have been complaints of mice throughout the building. Hoarding and family bringing in food are factors. The DES meets with Housekeeping twice a week about paying attention to open food containers when cleaning. The DM was unavailable for an interview throughout the survey. On 02/22/2023 at 01:57 PM, the Exterminator was contacted and did not partake in an interview. 415.(5) (h)(1)

Based on interviews and record review conducted during the Recertification and Complaint survey (NY00299038) Survey from 02/14/2023 to 02/22/2023, the facility did not ensure alleged violations involving abuse were reported to the New York State Department of Health (NYSDOH) immediately, but not later than 2 hours after the allegations were made. This was evident for 1 (Resident #293) of 3 residents reviewed for Abuse. Specifically, an allegation of abuse involving Resident #293 was not reported to the NYSDOH within 2 hours of the allegation being made. The findings are: The facility policy titled Abuse Reporting last reviewed 08/28/2022 documented if resident abuse or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to the state law. Immediately is defined as (a) within two hours of an allegation involving abuse or result in serious bodily injury; or (b) within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Resident #293 had diagnoses of vascular dementia and anxiety. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #293 was severely cognitively impaired. The facility Incident Report dated 7/13/2022 documented Resident #293 had two red areas (.4 cm X .4 cm) to their left upper extremity and reported being manhandled by staff at approximately 3 PM. The Health Emergency Reporting Data System (HERDS) report (NY00299038) dated 07/13/2022 documented the facility reported Resident #293's allegation to the NYSDOH at 6:28 PM, more than 2 hours after the allegation was made. On 02/21/2023 at 12:50 PM, Registered Nurse (RN) #3 was interviewed and stated abuse needs to be reported right away. RN #3 notified Assistant Director of Nursing (ADON) #2 and Director of Nursing (DON) when RN #3 became aware of the allegation of abuse involving Resident #293. On 02/21/2023 at 02:51 PM, ADON #2 was interviewed and stated they reported the incident involving Resident #293 to the DON within 1 hour of receiving the report. ADON #2 has the ability to report allegations of abuse to the NYSDOH. On 02/22/2023 at 02:13 PM, the DON was interviewed and stated RN #3 informed the DON of the incident involving Resident #293. Allegations of abuse must be reported to the NYSDOH within 4 hours of occurrence. 415.4(b)(1)(i)

Based on record review and interviews conducted during the recertification and complaint survey (NY00308262) from 2/14/23 to 2/22/23, the facility did not ensure a resident was free of significant medication errors. This was evident for 1 (Resident #761) of 40 total sampled residents. Specifically, Resident #761 did not receive their anticoagulant (AC), Xarelto, in accordance with Medical Doctor Order (MDO). The findings are: The facility's policy titled Medication Administration last reviewed 9/27/22 documented medications must be administered in accordance with the orders. If a medication is unavailable from the pharmacy for the scheduled time, the E-Box or First Dose Machine. If the medication is not available in the E-Box or First Dose Machine for the scheduled time, the Practitioner will be contacted for further instructions. Resident #761 was admitted to facility on 12/23/22 with diagnoses which included atrial fibrillation and cerebral infarction. Aspen Complaint Tracking System intake dated 1/9/23 documented complainant emailed and reported Resident #761 did not receive Xarelto according to MDO during their stay in the facility. The Baseline Care Plan (BCP) dated 12/23/22 documented Resident #761 was cognitively intact. MDO dated 12/23/22 documented Resident #761 was ordered to receive Xarelto 15 mg once daily for blood thinning with start date of 12/24/22. The Physician Note dated 12/23/22 documented Resident #761 was seen for admission evaluation and current medication included Xarelto 15mg once daily. The Medication Administration Record (MAR) from 12/24/22 through 12/27/22 documented the number 9 with notation Other/See Nurse Notes in 4 of 4 opportunities for Resident #761 to receive Xarelto 15mg. Nursing Note dated 12/27/22 documented Resident #761 left the facility against medical advice at 11:34 AM. The Pharmacy Delivery Manifest documented MDO for #761 to receive Xarelto 15mg once daily was transcribed 12/23/22 at 10:03 PM and delivered to the facility 12/27/22 at 8:53 PM. There was no documented evidence Resident #761 was administered Xarelto 15mg daily in accordance with MDO. On 2/17/23 at 3:02 PM, Licensed Practical Nurse (LPN) #2 was interviewed and stated they worked the day shift on 12/24/22, 12/25/22, and 12/27/22 and did not remember if Resident #761 received their Xarelto on those days. LPN #2 stated they documented Other/See Nurse Notes on the Resident #761's MAR next to Xarelto, and this could indicate the medication was not available to be administered. On 2/22/23 at 09:26 AM, the Pharmacy Director was interviewed and stated Xarelto order was electronically transcribed to the pharmacy on 12/23/22 at 10:03 PM and delivered to the facility on [DATE] at 8:53 PM. There was a delay in the pharmacy dispensing Xarelto for Resident #761 and the pharmacist who received the order did not follow procedure to alert the nurse that Xarelto was out of stock. When a medication is out of stock, the pharmacist is required to notify the nurse that the medication is available in the facility's emergency supply First Dose Machine and is also responsible to arrange delivery of the medication with a local back up pharmacy. Xarelto was available in the facility's First Dose Machine. On 2/22/23 at 10:26 AM, Medical Doctor (MD) #2 was interviewed and stated they admitted Resident #761 to the facility and were not informed Xarelto was out of stock so an alternative could be ordered. This medication should have been continued from the hospital until it was discontinued by an MD. On 2/22/23 at 1:18 PM, the Director of Nursing Services (DNS) was interviewed and stated the pharmacy emails the nursing administration when a medication is out of stock and the MD is notified so an alternative medication can be ordered. The facility pharmacy did not notify the facility that Xarelto 15mg for Resident #761 was out of stock. Xarelto 10mg is available in the First Dose Machine and the nursing supervisor could have requested to retrieve the medication. There was no Xarelto dispensed from the First Dose Machine for Resident #761. 415.18(a-d).

Based on record review and interviews conducted during the recertification and complaint (NY00308262) survey from 2/14/23 to 2/22/23, the facility did not ensure a resident was provided pharmaceutical services to meet their needs. This was evident for 1 (Resident #761) of 40 total sampled residents. Specifically, the pharmacy did not dispense an anticoagulant (AC), Xarelto, to the facility in accordance with Medical Doctor Order (MDO) for Resident #761. The findings are: The facility's policy titled Medication Administration last reviewed 9/27/22 documented medications must be administered in accordance with the orders. If a medication is unavailable from the pharmacy for the scheduled time, the E-Box or First Dose Machine. If the medication is not available in the E-Box or First Dose Machine for the scheduled time, the Practitioner will be contacted for further instructions. Resident #761 was admitted to facility on 12/23/22 with diagnoses which included atrial fibrillation and cerebral infarction. Aspen Complaint Tracking System intake dated 1/9/23 documented complainant emailed and reported Resident #761 did not receive Xarelto according to MDO during their stay in the facility. The Baseline Care Plan (BCP) dated 12/23/22 documented Resident #761 was cognitively intact. MDO dated 12/23/22 documented Resident #761 was ordered to receive Xarelto 15 mg once daily for blood thinning with start date of 12/24/22. The Physician Note dated 12/23/22 documented Resident #761 was seen for admission evaluation and current medication included Xarelto 15mg once daily. The Medication Administration Record (MAR) from 12/24/22 through 12/27/22 documented the number 9 with notation Other/See Nurse Notes in 4 of 4 opportunities for Resident #761 to receive Xarelto 15mg. Nursing Note dated 12/27/22 documented Resident #761 left the facility against medical advice at 11:34 AM. The Pharmacy Delivery Manifest documented MDO for #761 to receive Xarelto 15mg once daily was transcribed 12/23/22 at 10:03 PM and delivered to the facility 12/27/22 at 8:53 PM. There was no documented evidence the pharmacy dispensed Xarelto 15mg for Resident #761 in accordance with MDO. On 2/17/23 at 3:02 PM, Licensed Practical Nurse (LPN) #2 was interviewed and stated they worked the day shift on 12/24/22, 12/25/22, and 12/27/22 and did not remember if Resident #761 received their Xarelto on those days. LPN #2 stated they documented Other/See Nurse Notes on the Resident #761's MAR next to Xarelto, and this could indicate the medication was not available to be administered. On 2/22/23 at 09:26 AM, the Pharmacy Director was interviewed and stated Xarelto order was electronically transcribed to the pharmacy on 12/23/22 at 10:03 PM and delivered to the facility on [DATE] at 8:53 PM. There was a delay in the pharmacy dispensing Xarelto for Resident #761 and the pharmacist who received the order did not follow procedure to alert the nurse that Xarelto was out of stock. When a medication is out of stock, the pharmacist is required to notify the nurse that the medication is available in the facility's emergency supply First Dose Machine and is also responsible to arrange delivery of the medication with a local back up pharmacy. Xarelto was available in the facility's First Dose Machine. On 2/22/23 at 10:26 AM, Medical Doctor (MD) #2 was interviewed and stated they admitted Resident #761 to the facility and were not informed Xarelto was out of stock so an alternative could be ordered. This medication should have been continued from the hospital until it was discontinued by an MD. On 2/22/23 at 1:18 PM, the Director of Nursing Services (DNS) was interviewed and stated the pharmacy emails the nursing administration when a medication is out of stock and the MD is notified so an alternative medication can be ordered. The facility pharmacy did not notify the facility that Xarelto 15mg for Resident #761 was out of stock. Xarelto 10mg is available in the First Dose Machine and the nursing supervisor could have requested to retrieve the medication. There was no Xarelto dispensed from the First Dose Machine for Resident #761. 415.18(a-d).

Based on observation, interview, and record review conducted during the recertification survey from 2/14/23 to 2/22/23, the facility did not ensure a resident was seen by a physician every 60 days. This was evident for 1 (Resident #282) of 40 total sampled residents. Specifically, Resident #282 did not have a Medical Doctor (MD) visit within 60 days of their last MD visit. The findings are: The facility policy Physician (MD) Services and MD Visits date 10/20/22 documented the MD will respond to notification of and will assess and manage acute and significant changes in resident condition. The attending physician must visit patients at least every 60 days. The Agreement for Hospice Care dated 6/13/2017 documented the Hospice Interdisciplinary Group (IDG) will communicate with the skilled nursing facility's attending Physician (MD) as needed to coordinate hospice care of the resident. Resident #282 had diagnoses of dementia and hypertension. The minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #282 was severely cognitively impaired and received Hospice care within the last 14 days. Medical Doctor Order (MDO) dated 2/11/2022 documented Resident #282 was ordered to receive Hospice care. MD Monthly Note dated 12/1/22 documented Resident #282 is on Hospice and continue management per Hospice. Hospice Collaboration Note dated 12/16/22 documented Hospice Registered Nurse (RN) informed the resident's spouse; Resident #282 will be discharged from Hospice due to extended prognosis. Hospice Collaboration Note dated 12/21/22 documented Hospice RN spoke with the facility nurse about Resident #282 being discharged from Hospice on 12/22/22. Care Plan Meeting Note for significant change dated 1/31/23 documented Social Worker (SW) #1, the nurse manager, and dietician were present at the meeting and Resident #282 graduated from Hospice 12/22/22. MDO dated 1/31/23 documented Hospice care for Resident #282 was discontinued. There was no documented evidence the MD assessed Resident #282 and their total plan of care within 60 days of their last MD visit, 12/1/22. On 02/22/23 at 08:56 AM, the Hospice MD was interviewed and stated they cannot recall direct communication with the Resident #282's attending physician, MD #1. The hospice nurse usually coordinates with the facility. On 02/22/23 at 10:47 AM, Assistant Director of Nursing (ADON) #1 was interviewed and stated they were unable to find documentation of communication with MD #1 re: Resident #282's discharge from Hospice 12/22/22. On 02/22/23 at 12:46 PM, the Director of Nursing (DON) was interviewed and stated the MD should reassess and reevaluate a resident once they are removed from Hospice services. On 02/22/23 at 11:40 AM, MD #1 was interviewed and stated the facility has a contract with a Hospice agency. If the resident is under the Hospice umbrella, then Hospice becomes their primary care provider and MD #1 addresses acute issues. MD #1 stated they limited their monthly visits of Resident #282 when the resident was placed on Hospice so the resident's wife would not get billed privately for their visit. Resident #282 was discharged from Hospice 12/2022 and is back under MD #1's care. MD #1 was made aware Hospice was being discontinued when the Resident had their Care Plan Meeting (1/31/23). Resident #282 was last seen by MD #1 in 11/2022. MD #1 sees Resident #282 every couple of weeks but does not write notes. A note would be written if there is anything concerning resident care, if there is an acute change, or if conducting a regular visit. MD #1 stated there are MDs that do not document but it does not mean they are not seeing the residents. 415.15(b)(2)(ii)

Based on observation, record review, and interviews conducted during the Recertification survey from 2/14/2022 to 2/22/2022, the facility did not ensure a resident with respiratory care was provided such care consistent with professional standards of practice. This was evident for 1 (Resident #55) of 2 residents reviewed for respiratory care out of 40 sampled residents. Specifically, Resident #55 was observed receiving oxygen via Nasal Cannula (NC) without a Medical Doctor's Order (MDO). The findings are: The facility policy titled Oxygen Administration revised 4/22/2022 documented Clinical Staff will provide therapy in accordance with the guidelines to ensure safe oxygen administration and responsibilities of the Licensed Nurse include adjust flow of oxygen at the rate ordered by the Physician. Resident #55 had diagnoses of Pneumonia (PNA) and Vascular dementia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #55 had severely impaired cognition and received oxygen therapy. On 2/15/2023 at 10:00 AM and 12:50 PM, Resident #55 was observed receiving oxygen via NC at 2 liters per minute (LPM). with Oxygen in use at 2 liters per minute via NC. The Comprehensive Care Plan (CCP) related to Resident #55's risk of aspiration initiated 2/13/18 and 3/10/22 documented Oxygen via NC without defined LPM. The Treatment Administration Record (TAR) dated 2/01/2023 to 2/15/2023 did not document Resident #55 used oxygen via NC. There was no documented evidence an MDO was placed for Resident #55 to receive oxygen via NC. On 2/17/2023 at 10:53 AM, an interview was conducted with the Registered Nurse (RN) #4 who stated Resident #55 has an MDO to use oxygen as needed. After reviewing Resident #55's medical record, RN #4 stated the resident's oxygen MDO was discontinued 12/10/22. RN #4 was unable to provide an explanation for oxygen use without an MDO and was unable to explain how the flow rate of 2 LPM was determined. On 2/22/2023 at 1:28 PM an interview was conducted with the Director of Nursing (DON) who stated the physician should have been contacted to obtain an MDO for oxygen and the flow rate. The TAR would then reflect the MDO and the nurses sign that the oxygen therapy is being administered according to MDO. 415.12(k)(6)

Based on observation, record review, and interviews conducted during the Recertification survey from 2/14/2023 to 2/22/2023, the facility did not ensure residents with limited range of motion (ROM) received appropriate treatment and services to prevent further decrease in ROM. This was evident in 2 (Resident #55 and #334) of 3 residents reviewed for Positioning/Mobility. Specifically, 1) Resident #55 was observed without a right flex hand splint (RFHS) and left hand roll (LHR) in place per Medical Doctor's Order (MDO), and 2) Resident #334 was observed with inconsistent application of bilateral hand carrots (BHC) and bilateral elbow splints (BES). The physician's orders, care plan, and Certified Nursing Assistant instructions were not updated with the recent recommendations of Occupational Therapy on 1/25/23 for the BHC to be worn 4 hours on and 4 hours off and BES not applicable because the resident did not tolerate them. Resident #344 complained of discomfort caused by the BES during observations. The findings are: The facility policy titled Adaptive Assistive Devices revised 5/25/2021 documented residents will be provided with adaptive equipment as prescribed by the physician. 1) Resident #55 had diagnoses of Polyosteoarthritis and Vascular dementia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #55 had severely impaired cognition, required total assistance of two people to perform Activities of Daily Living (ADL), and did not receive splinting assistance. On 2/15/2023 at 10:00 AM and 12:50 PM, Resident #55 was observed bed without RFHS in place. The LHR was observed in place. On 2/16/2023 at 9:18 AM and 2/17/2023 at 9:47AM, Resident #55 was observed in bed without a RFHS and LHR in place. The MDO dated 10/06/2022 and last renewed 1/30/2023 documented Resident #55 should always wear LHR and RFHS with removal for hygiene and skin checks. The Occupational Therapy (OT) Discharge Summary dated 1/3/23 documented the primary caregivers were educated on skin checks and the splinting/orthotic schedule for Resident #55. Certified Nursing Assistant (CNA) Tasks for the month of February 2023 documented Resident #55 should wear a LHR when out of bed with removal during ADL, skin checks, and ROM. Resident #55 should wear a RFHS from breakfast to lunch with removal for ADLs, skin checks and ROM. On 2/17/2023 at 10:15 AM an interview was conducted with CNA #4 who stated Resident #55 normally has a RFHS and LHR applied to their hands. CNAs remove the devices during care and skin checks. The CNA Tasks provide CNAs with instructions re: how to apply devices to residents. The nurse and therapist performed personal hygiene on Resident #55 today and CNA #4 stated they did not apply the RFHS and LHR to the resident yet. On 2/17/2023 at 10:53 AM, Registered Nurse (RN) #4 stated they provided care to Resident #55 today and Resident #55 does not wear RFHS and LHR while in bed as per CNA Task instruction. After reviewing Resident #55's medical record, RN #4 stated they were unable to explain the discrepancy between the MDO and the CNA Task instruction. On 2/21/2023 at 10:59 AM an interview was conducted with the Director of Rehabilitation (DOR) who stated the MDO is correct, and Resident #55 should always wear the RFHS and LHR and removed for hygiene and skin checks. The Rehab Department (Rehab) is responsible for inservicing CNAs and nurses on devices, updating the CNA Task menus, and updating the comprehensive care plan (CCP). The CNA Task instructions were not correct. On 2/23/2023 at 1:28 PM, the Director of Nursing (DON) was interviewed and stated Rehab recommends a device order, the nurse confirms the order with Rehab, and the MD writes a MDO for the device. Rehab updates the CNA Tasks with device instructions. Nursing and Rehab make rounds to ensure residents are wearing devices appropriately and per MDO. 42101 2) Resident #344 had diagnoses of spinal stenosis of the cervical region and generalized muscle weakness. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #344 was severely cognitively impaired, required extensive assistance for Activities of Daily Living (ADL), had limited ROM in bilateral upper and lower extremities, and did not receive assistance with splinting devices. On 02/14/2023 at 11:16 AM, Resident #344 was observed sitting in a reclining wheelchair with BES and a knee separator in place. BHC were not in use. Resident #344 complained of pain/discomfort caused by the devices. On 02/14/2023 at 04:51 PM, Resident #344 was observed sitting in a reclining wheelchair with BHC laying on the seat of the wheelchair by their legs. Resident #344 was wearing bilateral elbow extension splints and a knee separator. Resident #344 complained that their arms were hurting. On 02/15/2023 at 11:06 AM, 11:57 AM and 12:26 PM, Resident #344 was observed sitting in a reclining wheelchair wearing the knee separator. There were no BHC or BES in place. On 02/16/2023 at 12:57 PM, Resident #344 was observed sitting in a reclining wheelchair wearing a knee separator. The BHC were placed on the seat by their legs, and no BES was in place. On 02/16/23 03:02 PM, Resident #344 was observed sitting in a reclining wheelchair without BES in place. Resident #344 was wearing bilateral hand carrots and a knee separator. The Comprehensive Care Plan (CCP) related to ADLs initiated 10/19/2020 and last revised 1/31/23 included the following interventions: bilateral elbow extension splints to be worn OOB in order to decrease risk of contractures (initiated 9/10/21) and 1/31/2023 bilateral carrot splints to be worn at all times to decrease risk for further contracture with removal for skin checks/hygiene (initiated 1/31/23). The CCP related to arthritis dated 1/23/2023 documented Resident #344 used supportive devices such as splints recommended by Occupational Therapy (OT). The MDO dated 8/12/2021 documented Resident #344 knee separator to be worn when out of bed (OOB). The MDO, initiated 09/10/2021, documented Resident #344 should always wear BES when out of bed to decrease the risk of contracture. The CCP for generalized muscle weakness dated 1/5/2023 documented Resident #344 had decreased tolerance of splint and stiffness in arms and legs resulting in a need for skilled PT services. The Occupational Therapy (OT) Discharge Summary dated 1/26/2023 documented Resident #344 did not meet thier goal to wear BES for 3 hours. As of 1/18/23, Resident #344 could only tolerate the elbow splints less than 30 minutes, and as of 1/25/23, the elbow splints were deemed not applicable. Resident #344 did not meet their goal to wear bilateral carrot splints for 8 hours. As of 1/25/23, they could tolerate the bilateral carrot splints for 4.5 hours. The recommendations for orthotic mangement were to wear bilateral carrot splints on a schedule of 4 hours on and 4 hours off. The MDO, initiated 01/31/2023, documented Resident #344 should wear BHC at all times with removal for hygiene and skin checks. The CNA Accountability Record dated January 2023 and February 2023 documented instructions for bilateral carrot splints to be worn at all times in order to decrease risk for further contracture remove for skin checks/hygiene and bilateral elbow extension splints to be worn out of bed (OOB) in order to decrease risk of contractures. There was no documented evidence the CCP, Physician's Orders, and the CNA instructions were updated with the application schedule for the bilateral hand carrots and the lack of recommendation for bilateral elbow splints due to intolerance as recommended by OT upon discharge from restorative therapy. The Certified Nursing Assistant (CNA) Document Survey Report from 2/01/23 through 2/17/23 did not document CNA signatures confirming the application of the BHC for 4 out of 51 opportunities and the BES for 6 out of 51 opportunities. There was no documented evidence Resident #344 refused to wear their BES or BHC. When the resident was discharged from therapy there is no documentation that their care plans and orders were updated to reflect their level of function at therapy discharge. During an interview on 02/21/2023 at 02:57 PM, CNA # 5 stated Resident #344 wears BHC and is supposed to have a BES but refuses to wear the device. CNA #5 tells the nurse everyday Resident #344 refuses to wear the BES and documents it in the medical record when any resident refuses to wear a device. CNA #5 did not know the schedule for Resident #344 to wear the BES. Resident #344 screamed when the therapist tried to put the device on them. CNA #5 stated Resident #344 needs therapy on their arms because they are contracted. During an interview on 02/22/2023 at 01:05 PM, Licensed Practical Nurse (LPN) #5 stated Resident #344 uses BHC splints, BES, and leg separatoers. The therapist and CNA apply the devices to the resident. LPN #5 was not aware Resident #344 refused to wear their BES or BHC. LPN#5 stated that the devices should be in place when the resident is awake and out of bed to prevent additional contractures. When they do rounds, they check to make sure the devices are in place. On 02/22/2023 at 02:06 PM, the Occupational Therapist (OT) was interviewed and stated Resident #344 was discharged from therapy 3 weeks ago, and is doing well with the BHC. The OT stated they tried hand rolls with Resident #344 during therapy, but they could only tolerate them for 4 hours due to pain. The elbow splint was recommended for Resident #344 because Resident #344 was uncomfortable when stretching out their elbow in therapy. The BHC and BES should be applied to the resident daily secondary to contracture and to promote potential functional use in the future with removal for hygiene. The OT was not aware the resident refused to wear the devices. On 02/22/2023 at 01:21 PM, Assistant Director of Nursing (ADON) #2 was interviewed and stated the CNA informs the ADON when Resident #344 does not wear their devices. The CNA informed ADON #2 that Resident #344 was refusing to wear their devices today. On 2/23/2023 at 1:28 PM, the Director of Nursing (DON) was interviewed and stated Rehab recommends a device order, the nurse confirms the order with Rehab, and the MD writes a MDO for the device. Rehab updates the CNA Tasks with device instructions. Nursing and Rehab make rounds to ensure residents are wearing devices appropriately and per MDO. 415.12(e)(2)

Based on record review and interviews conducted during the Recertification and Complaint (NY00306631) Survey from 2/14/23 to 2/22/23, the facility did not ensure a resident's Comprehensive Care Plan (CCP) was reviewed and revised to reflect a change in the resident's status. This was evident for 2 (Resident # 18 and #184) of 40 sampled residents. Specifically, the CCP related to abuse prevention was not reviewed and revised for Resident #18 and #184 following their involvement in a resident-to-resident altercation. The findings are: The facility policy titled CCPs effective 01/29/13 and reviewed 10/12/22 documented that care plan conferences will be scheduled by the care plan team as needed to address changes in the resident condition. The facility Investigation Summary dated 12/9/22 documented interventions to address the resident-to-resident altercation involving Resident #18 and #184 included keeping the residents at least arm's length distance apart during activities involving musical instruments and exploring musical instruments with a soft outer layer. 1) Resident #184 had diagnoses of Alzheimer's Disease and major depressive disorder. The MDS assessment dated [DATE] documented Resident #184 was severely cognitively impaired. The CCP related to abuse victim risk, initiated 5/23/21, documented interventions including ensuring Resident #184 was free from abuse or neglect. The CCP related to activities, initiated 5/17/22, documented Resident #184 should be encouraged to participate in recreational programs. A Nursing Note dated 12/7/22 documented Resident #18 struck Resident #184 on the forehead with a wooden musical instrument during an activity held in the Activity Room. Staff immediately intervened and separated the residents. There was no doumented evidence the CCP for Resident #184 was updated after the altercation on 12/7/22. 2) Resident # 18 had diagnoses of dementia and major depression. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident # 18 was severely cognitively impaired. The CCP related to abuse victim risk, initiated 2/4/21, included the intervention to assess Resident #18 for abuse and neglect. The CCP related to activities, initiated 10/16/20, documented Resident #18 should sit near peers and socialization was encouraged. There was no documented evidence CCP for Residents #18 was reviewed and revised following the resident-to-resident altercation on 12/7/22. During an interview on 02/21/23 at 11:36 AM, the Recreation Therapist (RT) stated nursing did not add any interventions to Resident #18's and #184's CCP following their resident-to-resident altercation. During an interview on 02/21/23 at 11:54 AM, the Director of Therapeutic Recreation (DTR) stated Recreation staff were instructed not to use musical instruments any longer. The DTR and the RT ensure the activity CCP is updated quarterly. Interventions should have been added to the activity CCP for Resident #18 and #184 following their incident in the Activity Room. During an interview on 2/21/23 at 11:02 AM, the Assistant Director of Nursing (ADON) #1 stated Resident #18 and Resident #184 were involved in an incident, and the intervention implemented was to separate the residents during activities. In addition, staff were instructed not to use hard instruments during musical activities. ADON #1 stated they were responsible for updating the residents' CCPs, but the interventions were not included on the CCPs related to abuse as they should have been During an interview on 02/21/23 at 3:26 PM, the Director of Nursing (DON) stated they discussed not using hard instruments with the DTR to prevent further incidents. Staff also ensure Resident #18, and Resident #184 are not sitting close together during recreational activities. The new interventions should have been on the CCPs related to abuse and activities for Resident #18 and Resident #184. The nursing and activity departments are responsible for updating the CCPs. 415.11(c)(2) (i-iii)

Based on record review and interviews conducted during a Recertification and Complaint (NY00308262) Survey from 02/14/2023 to 02/22/2023, the facility did not ensure a Baseline Care Plan (BCP) was developed, implemented, and provided to the resident and resident representative (RR). This was evident for 2 (Resident #612 and #761) of 40 sampled residents. Specifically, 1) the RR of Resident #612 was not provided with a copy of the BCP upon completion, and 2) the BCP for Resident #761 did not include the resident's anticoagulant therapy. The findings are: The facility policy titled BCP last reviewed 10/13/2022 documented the facility will develop and implement a BCP that must include physician orders. 1.) Resident #612 had diagnoses of dementia and hypertension. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #612 was severely cognitively impaired and the family or significant other participated in the assessment. The BCP initiated for Resident #612 on 02/03/2023 was completed and signed by the interdisciplinary team (IDT) on 02/04/2023. The BCP was not signed by Resident #612 or the RR. There was no documented evidence Resident #612's RR was provided with a copy of the BCP upon completion. On 02/17/2023 at 10:00 AM, an interview was conducted with Social Worker (SW) #2 who stated the BCP is completed for new residents within 48 hours of admission to the facility. The BCP is given to the RR during the initial care plan meeting, 21 days after admission. The BCP was not given to the RR of Resident #612 because the resident did not have their initial care plan meeting yet. On 02/21/23 at 3:07 PM, the Director of Social Services (DSS) was interviewed and stated the BCP is completed within 48 hours of a resident's admission to the facility. Once the BCP is completed, the unit SW should provide a copy to the resident or RR and document that it was given in the record. The BCP is supposed to be given to the resident or RR before the initial care plan meeting. The BCP should have been given to Resident #612's RR, and this was not done. 44842 2. Resident #761 was admitted to the facility on [DATE] with diagnoses of atrial fibrillation and cerebral infarction. The BCP dated 12/23/22 documented Resident #761 was cognitively intact and was not receiving anticoagulants. A PO dated 12/23/22 documented an order for Resident #761 to receive Xarelto 15 mg once daily, an anticoagulant, for blood thinning. During an interview on 02/22/23 at 9:07 AM, Registered Nurse (RN) #2 stated they were responsible for completing Resident #761's BCP. Resident #761 was taking Xarelto which is a blood thinner. RN #2 stated anticoagulant use should have been documented on Resident #761's BCP. On 02/22/23 at 1:18 PM, the Director of Nursing (DON) was interviewed and stated a resident's BCP should reflect the medications listed on the admitting PO. Resident #761 was taking Xarelto, and anticoagulant use should have reflected on the BCP. 415.11(c)

Based on observations, interviews, and record review conducted during the Focused Infection Control Survey and abbreviated survey (#NY 835), the facility did not ensure that residents remained free from abuse. Specifically, a resident with Dementia and a history of physical aggression (Resident #2) was involved in four resident-to-resident altercations after being transferred to a new unit. The facility failed to implement interventions to address the resident's aggressive behaviors and protect other residents on the unit from future altercations. In the third altercation, a resident (Resident #1) sustained a laceration to the crown of the head after Resident #2 hit them with a footrest. After this incident, there was a fourth resident-to-resident altercation with Resident #5. Resident #2 was transferred to the hospital for evaluation and placed on one-to-one (1:1) supervision. This was evident for 2 of 5 residents reviewed for Abuse (Resident #s 1 and 5). The findings are: A facility policy and procedure related to Abuse Reporting dated 2/1/18 documented that facility staff will monitor residents for aggressive behavior towards other residents. Should a resident be observed abusing another resident, or if an allegation has been made, the facility will remove the aggressor, separate the residents, review to identify the cause of behavior, perform a root cause analysis, develop a care plan to prevent the recurrence, and document interventions and their effectiveness. Resident #2, the Aggressor, was admitted to the facility with a [DIAGNOSES REDACTED]. The resident was moved from a 2-bed room on the Memory Care Unit (a specialized Dementia Unit) to a 4-bed room with 3 roommates on a regular long-term care unit on 5/5/20. An A/I investigation dated 5/29/20 documented that the Resident #2 hit Resident #1 in the head with a footrest from a wheelchair without provocation. The Nursing Supervisor was made aware, the care plan was updated, the residents were separated by staff, Resident #2 was placed on 1:1 supervision, [MEDICATION NAME] 1mg IM was administered, family was notified, labs were ordered on [DATE], and Psychiatry/Psychology consults were ordered for both residents. The most recent quarterly MDS dated [DATE] documented the resident had severely impaired cognition, fluctuating inattention, disorganized thinking, and did not display any inappropriate behaviors or wandering behavior. On 6/2/20 at 1:49PM, Resident #2 was observed in bed with a 1:1 Certified Nursing Assistant (CNA #3) present. The resident's bedside dresser was across the room by the window. The dresser drawers were on the floor, broken apart. During the observation, CNA #3 stated that Resident #2 became very agitated, pulled the drawers out of the dresser, and slammed them on the floor, breaking them. CNA #3 moved the dresser away from the resident for safety. CNA #3 explained that the resident wandered around the room, pulled the lunch tray off a roommate's table, and threw it on the floor. The roommate was wheeled out for safety by CNA #3, and the resident was prevented from throwing another roommate's tray. CNA #3 attempted to soothe and calm Resident #2 verbally, but the resident remained agitated. CNA #3 stated Resident #2 approached her in a threatening manner, with fists clenched, and CNA #3 felt threatened. During the incident, Resident #2 also went into the hallway, grabbed a meal tray from the cart, and threw it to the ground. The resident was redirected and returned to the room. CNA #3 stated she did not report this incident to the nurse yet. A Comprehensive Care Plan (CCP) related to Behavior, initiated 12/12/19, documented the resident had a history of [REDACTED]. After moving, the resident had resident-to-resident altercations/allegations on 5/16/20, 5/20/20, 5/29/20, and 6/1/20. Interventions to address the behavior included providing activities of interest, praising improvement, monitoring behavior, intervening as necessary, anticipating needs, separating from other resident post-altercation, redirection, and Psychiatry and Psychology consults. After each altercation on the new unit, the resident was placed on temporary 1:1 safety monitoring or 30-minute monitoring. Once that monitoring was completed, the resident had another altercation. Nursing notes dated 5/8/20 and 5/9/20 documented that the resident was wandering and was an elopement risk. Nursing notes on 5/16/20 documented that the resident continued to attempt to leave the unit. Resident #2 pushed Resident #3 off their wheelchair, causing Resident #3 to fall on the floor. Resident #2 was placed on 1:1 safety monitoring on 5/16/20. An Accident/Incident Investigation (A/I) was initiated on 5/16/20 and completed on 5/21/20. It documented that there was no reasonable cause to believe that abuse had occurred, and Resident #3 was not injured. The recommended interventions for Resident #2 were Psychiatry consult, emotional support, and temporary 1:1 safety monitoring. The facility did not identify this as resident-to-resident abuse. A Physician's (MD) order dated 5/17/19 documented the resident would have 1:1 safety monitoring until 5/19/20, and a Psychiatry consult was ordered. A 1:1 Supervision Documentation Log dated 5/17/20 documented that Resident #2 had several periods of restlessness. There was no documented evidence that the resident's behavior was assessed prior to the discontinuation of 1:1 safety monitoring on 5/19/20. A Psychology note dated 5/18/20 documented that the resident had adjustment issues related to physical and functional decline, behavioral challenges, was cognitively impaired, reclusive, disorganized, and had poor impulse control. The resident also displayed anxiety, hallucinations, disassociation, delusions, and limited insight. Suggested behavioral approaches included listening and providing supportive statements to encourage adjustment, provide positive reinforcement, provide a low-stimulation environment, and provide redirection. Nursing notes dated 5/20/20 documented Resident #4 accused Resident #2 of hitting them with a table, but Resident #2 denied doing so. On 5/20/20, the resident was evaluated by the Psychiatrist as a result of having an incident. Resident #2 went to another resident's room and laid in their bed. The Psychiatrist recommended that cognitive enhancers be discontinued if irritability continues as it may worsen their mood (This recommendation was not followed until 5/27/20). An MD Note dated 5/21/20 documented that Resident #2 was accused of hitting Resident #4 with a table. The MD advised close monitoring due to Resident #2's history of altercations with other residents. MD Orders dated 5/21/20 documented orders for q (every) 30-minute monitoring for wandering from 5/21/20 until 5/27/20. A Nursing Behavior note dated 5/23/20 documented that Resident #2 curses, yells at, and hits staff and cannot be redirected. The resident was observed picking up a chair to hit staff and other residents. Nursing Notes dated 5/24/20 to 5/28/20 documented Resident #2 continued to wander into resident rooms throughout the unit and sleep in other resident beds. On 5/27/20, the MD documented that Resident #2 had a lot of aggressive behaviors lately and was difficult to control. Resident #2 threw water on the floor in another resident's room and turned the water on in a room causing a flood. There was no documented evidence that a wander that the resident's wandering behavior was reassessed or new interventions were implemented prior to the 30-minute monitoring being discontinued on 5/27/20. MD Orders dated 5/27/20 documented the cognitive enhancer, Donepezil 10mg once daily, was discontinued. The Interdisciplinary Team (IDT) was aware of the resident's aggressive history, increased aggression, and increased wandering into other rooms, but the enhanced monitoring was discontinued. There was no CCP or interventions put into place to prevent wandering or to protect other residents from Resident #2 once the temporary enhanced monitoring or 1:1 supervision ended. There was no documented evidence the environment was assessed for potential hazards after Resident #2 was observed and accused of utilizing objects to hurt others. 1) Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 ((MDS) dated [DATE] documented the resident had severely impaired cognition. The resident required extensive assistance of 1 person for bed mobility, transfer, dressing, toileting, and personal hygiene. The resident required limited assistance of 1 person for locomotion on and off the unit. On 6/1/20 at 10:51AM, an observation was made of the 2nd floor. Resident #1 was observed sitting in a wheelchair in the hallway by the nursing station. Resident #1 had multiple visible staples on the crown of the head. A CCP related to Resident #1 being at risk for abuse due to being mentally challenged was initiated on 12/12/18 and updated on 5/29/20, after Resident #1 was hit in the head with a footrest by Resident #2. An intervention dated 5/29/20 documented the resident was to be transferred to the emergency department. A Nursing Note dated 5/29/20 documented that the resident had a laceration to the corona measuring 6cm (centimeters) x .1cm x .4cm following a resident to resident altercation. The resident denied dizziness. Another resident allegedly hit Resident #1 with a footrest causing the injury. The MD was notified. An icepack was applied, Tylenol was administered, next of kin notified, and the resident was transferred to the emergency department for further evaluation and stitches. A Nurse Practitioner (NP) note dated 5/29/20 documented that Resident #1 was reportedly hit by another resident with a footrest. The resident sustained [REDACTED]. The bleeding was stopped, a dressing was applied, and Tylenol was given. An MD note dated 5/29/20 documented that Resident #1 was reportedly hit by another resident in the head which resulted in a bleeding laceration wound on the central occiput (back of the head) measuring 6cm in diameter and 3 mm (millimeters) deep with jagged edges. Resident #1 complained of a headache but denied dizziness. Resident #1 was transferred to the emergency room for a CT scan and wound closure. An Accident/Incident (A/I) investigation for Resident #1, dated 5/29/20, documented that the resident sustained [REDACTED]. The CNA heard the resident scream. Resident #1 was observed sitting in a w/c in their room, and Resident #2 was observed standing in Resident #1's room with a wheelchair footrest in their hand. There was no antecedent for the behavior. Resident #2 was immediately removed from the area and placed on 1:1 supervision. The statement written by the CNA assigned to Resident #2 documented Resident #2 was wandering in the hallway at 1:30 PM. The CNA was picking up meal trays when she heard Resident #1 scream. physician's orders [REDACTED].#2 was placed on temporary 1:1 monitoring every shift for 3 days from Friday to Sunday. This intervention of temporary increased monitoring did not prevent Resident #2 from engaging in resident-to-resident altercations once the monitoring was completed. Two CCPs were initiated for Resident #2 on 5/30/20 related to Physically aggressive behavior and wandering, but these CCPs were created with general interventions that were not individualized. There was no documented evidence that a CCP meeting was held by the IDT to assess the resident's aggression and lack of effectiveness of current techniques applied in order to create resident-centered interventions. The resident also had documented behavior of wandering since 5/8/20 yet the CCP related to wandering was not initiated until 5/30/20. The facility did not address how Resident #2 would be supervised after 5/31/20 to prevent additional resident-to resident abuse. 2) Resident #5 had a [DIAGNOSES REDACTED]. The MDS dated [DATE] documented Resident #5 had intact cognition. On 6/2/20 at 1:21PM, an interview was conducted with Resident #5 who stated that on the morning of 6/1/20, at approximately 7AM, they could not sleep and staff allowed Resident #5 to go to an empty resident bed in another room to pray and rest. Resident #5 sat on the bed facing the door, started praying, and closed her eyes. After a few minutes, Resident #5 felt a blow to the right side of the head. Resident #5 opened her eyes and saw Resident #2 standing by the bed. Resident #2 did not reside in the room where Resident #5 was praying. Resident #2 did not say anything and walked towards the B bed by the window. When Resident #2 went behind the drawn curtain, Resident #5 grabbed their walker and left the room. Resident #5 immediately informed the nurse about the incident and requested to file a police report. When the police arrived, they spoke to Resident #5 about the incident, but the resident is unsure if a report was taken. Resident #5 stated that Resident #2 is a known wanderer on the unit and has wandered into their room on several occasions. One night, Resident #5 awoke at 2AM to find Resident #2 standing over the bed staring at them. Resident #5 was fearful and grabbed the call bell to call the nurse. Resident #2 then left the room. Resident #5 informed nursing staff about Resident #2 wandering into their room, but staff expect the residents on the unit to accept this behavior as normal. Resident #5 was offered a room change after Resident #2 hit her; however, Resident #5 does not want to change rooms. Resident #5 reported feeling uneasy about how easily Resident #2 can enter their room. Resident #5 does not know how to react or what Resident #2 will do if they move or call for help. Resident #2 is unpredictable, and this scares them. A Nursing progress note dated 6/1/20 at 8:39AM, documented that Resident #5 was hit by Resident #2 on the right ear. Resident #5 was praying in room [ROOM NUMBER]A and Resident #2 came into the room and hit Resident #5 on the right ear with a bare hand. She expressed a pain level of 3/10. The medication nurse documented staff looked for Resident #2, but the resident could not be located. An MD note dated 6/1/20 documented that Resident #5 was evaluated following the incident. The resident had no injury. A Comprehensive Care Plan (CCP) related to being at risk for abuse was initiated on 6/1/20 and documented that Resident #5 was to be assessed for bruises, should be reported to appropriate resources, all investigations should be investigated promptly, social service follow-up, provide a safe person to report to, provide assistance with ADLs, provide comfort and reassurance, relocate aggressor or resident as needed. A Nursing note dated 6/2/20 documented that Resident #5 had a bruise noted on the right ear. A Social Service note dated 6/2/20 documented that Resident #5 was offered a room change and declined. Nursing Notes dated 6/1/20 for Resident #2 documented at 9:40AM, Resident #2 was transferred to the hospital for further evaluation, returned to the facility at 3:04PM, and restarted on 1:1 supervision. A 1:1 Supervision Documentation Log for Resident #2, initiated 5/30/20, included documentation of resident's status every 15 minutes while 1:1 supervision was in progress. Resident #2 was often restless, agitated, aggressive, and attempted to get into another resident's bed per documentation of the 1:1 CNA. The log documented the resident received 1:1 supervision from 5/30/20 to 6/1/20 at 9:30 AM when the resident was transferred to the hospital. There was no documented evidence that the resident's behavior was assessed or that new interventions were implemented prior to Resident #2 hitting Resident #5 on 6/1/20. An interview was conducted with CNA #1, the CNA assigned to Resident #2, on 6/1/20 at 11:08AM. She stated that she has been assigned to Resident #2 since Resident #2 was moved to the unit. Resident #2 is cognitively impaired, is known to be combative, and walks around hitting staff and residents. CNA #1 was not working on 5/29/20 when Resident #2 hit Resident #1. The resident was agitated and aggressive this morning towards CNA #1 and threw sheets on the floor. CNA #1 was able to calm the resident down and bring the resident back to bed. At 7:30AM, the nurse manager informed CNA #1 that Resident #2 hit Resident #5. After the incident occurred, the night nurse informed CNA #1 that Resident #2 was on 1:1 supervision overnight and CNA #1 was supposed to continue 1:1 supervision of Resident #2. CNA #1 was unaware of this when she started her shift and did not provide 1:1 supervision. CNA #1 addresses the resident's behavior by encouraging and being nice to the resident. She redirects Resident #2 to because the resident wanders the entire unit and enters other residents' rooms. CNA #1 does not prevent Resident #2 from interacting with residents they had altercations with. The staff cannot keep Resident #2 away from other residents. CNA #1 does not know what causes Resident #2's agitation or what calms the resident down. The CNAs document a resident's behavior using the STOP and WATCH forms on the computer and by telling the nurse. An interview was conducted with Licensed Practical Nurse (LPN) #1, the 2nd floor daytime nurse manager, on 6/1/20 at 11:29AM. LPN #1 stated that the unit has long and short-term residents. Resident #2 was transferred from the 11th floor 4 weeks ago after it became a COVID-dedicated unit. The resident is quiet and sleeps in the daytime but wanders, becomes aggressive without provocation, and is unpredictable after waking up for lunch. Resident #2 picks up items from the nursing station and throws them. When Resident #2 moved from the 11th floor, LPN #1 was provided with a history of the resident's behavior. The resident enjoys listening to music and eating sweets. Resident #2 had 2 radios but broke them. Recreation plays music or guitar for Resident #2 and provides coloring books and magazines. Resident #4, a former roommate, was moved after accusing Resident #2 of hitting them with an overbed table. This incident was unwitnessed. The staff redirect Resident #2 when the resident sleeps in other residents' beds. On Friday, 5/29/20, Resident #2 hit Resident #1 with the leg rest of a wheelchair while Resident #1 was eating lunch in their room. The staff conduct hourly rounds of residents and were unaware that Resident #2 wandered into another resident's room. After Resident #2 hit Resident #1 with the leg rest, Resident #2 was given a stat dose of [MEDICATION NAME] 1mg IM and placed on 1:1 supervision until 6/1/20. The LPN is not involved with determining what interventions are used to address resident's behavior. Resident #1 hit Resident #5 this morning. Resident #5 was sitting in room [ROOM NUMBER] when Resident #2 entered the room and hit Resident #5 on the right ear. Resident #2 does not reside in room [ROOM NUMBER]. Resident #2 was not incited in any resident-to-resident altercations. After each incident, Resident #2 was evaluated by the Psychiatrist and placed on close supervision or 1:1 monitoring. It is not safe for other residents on the unit with Resident #2 there. A follow-up interview was conducted with LPN #1 on 6/2/20 at 2:19PM. She stated the plan to keep other residents safe from Resident #2 after the incident on 5/29/20 was to ensure that all wheelchair leg rests were out of sight and not accessible to Resident #2 when she wanders. On 6/2/20 at 2:01PM, the 2nd floor was observed. There were 3 empty wheelchairs lined up in the hallway along the wall approximately 10 feet from the room of Resident #2. Leg rests were attached to one of the wheelchairs. There were 2 overbed tables and a small empty stool in the hallway, unattended. Detached leg rests left on a regular chair in room [ROOM NUMBER] were visible from the hallway. An interview was conducted with the Director of Recreation (DOR) on 6/2/20 at 10:41AM. Resident #2 has Alzheimer's dementia and used to be on the 11th floor/Memory care unit. The resident displayed aggressive behaviors while on the 11th floor. Recreation staff have reported to the DOR that Resident #2 has a short attention span and becomes aggressive without provocation. An interview was conducted with CNA #3, the CNA assigned to provide Resident #2 with 1:1 supervision, on 6/2/20 at 10:57AM. She stated she is assigned to provide the resident with 1:1 supervision until 3PM. CNA #3 was made aware that the resident had an altercation with another resident on 6/1/20. Resident #2 has been sleeping since CNA #3 came in at 7AM. If the resident becomes agitated or wanders, CNA #3 will redirect the resident. If Resident #2 is unable to calm the resident down, she will inform the supervisor. An interview was conducted with LPN #2, the medication nurse on the 2nd floor, on 6/2/20 at 2:06PM. LPN #2 stated that the Memory care unit on the 11th floor was closed and turned into a COVID-19 dedicated unit. The residents from that unit were transferred to the 2nd floor and have difficulty adjusting. Resident #2 is aggressive and has hit LPN #2. She is unpredictable and needs 1:1 supervision at all times. When residents wander on the unit, the nursing staff redirect them to their rooms and offer music or juice. These interventions do not work with Resident #2. The resident wanders from room to room whenever out of bed and cannot be redirected. The motivation or precipitating factors are unknown. An interview was conducted with CNA #2 on 6/2/20 at 2:23PM. CNA #2 is assigned to Resident #3 and Resident #4. The nursing staff does not prevent Resident #2 from interacting with residents they had altercations with. Resident #2 is known to wander and enters other residents' rooms while staff are giving care. The CNA was not informed of any interventions to address the behavior of Resident #2. On 6/1/20 at 10:26AM and 3:25PM, and 6/2/20 at 3:21PM interviews were conducted with the Director of Nursing (DNS). Resident #2 wanders up and down the hallway and strikes out at other residents and staff. Recreation is involved with the resident, but the resident's attention span is short. Other interventions to address behavior include giving a snack, talking to her calmly, and providing nap time. The first resident to resident altercation on the 2nd floor was on 5/16/20. Resident #2 pulled the wheelchair from Resident #3 causing Resident #3 to fall. Resident #2 was placed on 1:1 monitoring for 2 days and seen by Psychiatry. If the resident is calm, the IDT determines if 1:1 supervision can be discontinued. The second resident-to-resident altercation occurred on 5/21/20 when Resident #4 alleged that Resident #2 hit Resident #4 with an overbed table. Resident #2 was placed on 30-minute checks until 5/27/20. The third altercation occurred on 5/29/20 with Resident #1 and was reported to the NYSDOH. Resident #2 was brought to her room which is less stimulating and placed on a 1:1 supervision for 2 days. Resident #2 became agitated on 6/1/20 and struck Resident #5. Resident #2 was sent to the Psychiatric ER for evaluation and returned to the facility. The IDT will continue 1:1 supervision for now. The DNS did not believe the altercations with Resident #3, #4, or #5 were related to abuse because DNS did not define the actions of Resident #2 as willful. The incident involving Resident #5 is still being investigated. The DNS acknowledged that 1:1 supervision was short term and did not address the resident's ongoing aggressive behaviors. The facility did not conduct an IDT Meeting to discuss resident and devise interventions to address aggressive behaviors. An interview was conducted with the Administrator on 6/2/20 at 4:00PM. He stated the Behavior CCP for Resident #2 should have an intervention that staff are not to leave items around her that she can grab. The Administrator was unable to find the intervention after reviewing the resident's CCPs. 415.4(b)(1)(i)

Based on observation, record review and interviews during a recertification and abbreviated survey, the facility failed to ensure that the residents' received the necessary treatment and services to promote healing of existing pressure ulcers and to prevent new sores from developing for 2 residents (#206 and # 369) of 4 reviewed for pressure sores. Specifically, for Resident #206, the facility did not: 1) develop a CCP (Comprehensive Care Plan) or Physician orders [REDACTED].# 206) and a right lateral leg pressure sore (Resident #369). This resulted in actual harm to (Residents' # 206 and # 369) that is not Immediate Jeopardy. The finding are: 1) Resident # 206 is a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) 3.0 dated 2/21/14 documented: severely impaired cognition, total assistance with ADL's (Activities of Daily Living) Section M: Skin Conditions documented the resident was at risk for developing a pressure ulcer, and had one stage 2 pressure ulcer. The CAA (Care Area Assessment) documented that pressure ulcer was triggered for care planning. A Nursing note (signed by the RN- Registered Nurse/ Manager) dated 2/14/14 documented that the resident was admitted with a right buttock stage 2 open area measuring 1.5 x 2 cm (centimeters). The Braden Scale dated 2/15/14 documented a score of 13, indicating moderate risk for pressure ulcer development There was no documented evidence that a care plan was developed for the existing stage 2 pressure sore, or for the prevention of additional pressure sores. A nutrition note dated 2/15/14 documented that the resident had a past medical history of [REDACTED]. The re-admission weight on 2/15/13 was 131.7# (pounds); 1/21/13 - 140.2 #; 1/13/13 138.4# and 1/2/13 -142.2 #. The note further documented resident was hand fed by staff and had a stage 2 pressure ulcer to the right buttock. The Dietitian recommended a MV I (Multivitamin) and Vitamin C (to promote wound healing). There was no documented evidence that the multivitamins were ordered by the Physician in a timely manner. The CNA (Certified Nurse Assistant) Documentation Record dated 2/16/14 to 3/6/14 documented redness in the " skin check " section and on 2/18/14 the record documented an open area. Review of the " turning and positioning " section of the CNA Documentation Record revealed blank spaces for 2/14/14 to 2/16/14 ( on the evening shift) and 2/17/14 (on the day shift). A Wound Care Note dated 3/7/14 at 3:50pm documented: Resident seen by wound care team, observed redness on left lower buttock with two stage 2 open areas. One site measured 2.5 cm x 1.5 cm and another site measured 1.0 cm x 0.5 cm. A non-blanchable reddened area measured 4.0 cm x 4.5 cm. Treatment was done as per protocol. MD (Medical Doctor) notified. Wheel chair cushion to be evaluated. There was no documented evidence that the unit nurses provided ongoing assessement and monitoring of the residents skin, including the right buttock stage 2 pressure sore (identified on admission) from 2/14/14 through 3/7/14 or a newly developed left buttock stage 2 pressure sore. physician's orders [REDACTED]. The Consultant Plastic Surgery Note dated 3/12/14 documented: past medical history of [REDACTED]. The stage three- left Ishcial pressure ulcer shows an irregularly bordered ulcer which measures 5.0 cm x 5.5 cm. Recommendation: Foley Catheter, ROHO cushion and local treatment with Santyl and Ca (calcium) Alginate with border gauze. There was no documented evidence that the unit nurses completed thorough skin assessments or identified the presence of the ischeal pressure wound. The Medical Note dated 3/16/14 documented that the Foley cath (catheter) recommendation would have to be approved by the family. Continue with topical care. Cont (continue) with Santyl and Ca Alginate with border gauze . The Plastic Surgery Note dated 3/19/14 documented: " This in-house stage 3 Left Ischial PU measures 3.5 x 4.0 cm with 40% slough. Santyl and Foley recommended. " The Wound Care Note dated 3/20/14 documented that the wound is observed with a dark colored center and reddened peri area. Recommend limited time out of bed, turning and positioning, air mattress and Foley. The Medical Note dated 3/24/14 documented that the son agreed to the placement of the Foley catheter - eight days after the Physician documented the need to obtain the family's approval. Physician orders [REDACTED]. The Plastic Surgery note dated 3/26/14 documented Left Ischial PU (Pressure Ulcer) 5.0 cm x 4.5 cm with 60% adherent slough and drier base with Foley in. Recommend: Santyl and T (Turning) and P (Positioning) as ordered. The Nutrition note dated 4/2/14 documented: Nutrition Wound Note-recommend Prostat, MVI (Multivitamin) , Vit (Vitamin) C, and Zinc. The Wound Care Notes dated 4/2/14 documented Left Ischial was re-assessed stage 3 measuring 5.3 x 3.2 x 0.1 cm, noted to be non-responsive to treatment. Review of the TAR (Treatment Administration Record) revealed blank spaces on 3/31/14 and 4/2/14. The Physician orders [REDACTED]. The Physicians orders dated 4/4/14 documented: Cleanse left Ischium with NS pat dry skin prep peri-wound and apply [MEDICATION NAME] oint and dry dressing -secure with border gauze daily and prn (as needed). The resident was observed on 4/3/14 at 1:30pm, asleep and on 4/4/14 during wound care. On 4/7/14 at 1:19 PM the RN Manager was interviewed regarding the pressure ulcer identified on 3/7/14. She stated that she remembers the wound and that the admission was in the evening, therefore she endorsed the information about the wound to the next shift. She stated that she had not notified the Physician. She added that she should have put in an actual care plan for the existing pressure sore and a preventive care plan for the potential pressure sores. On 4/7/14 at 1:47pm the RD (Registered Dietitian) was interviewed and stated that the recommendations dated 2/15/14 for vitamin supplements were not ordered until 4/2/14 .She stated that she does not know why it was not ordered earlier, that the Dietitians have access to put orders in for Vitamin C , Zinc, Prostat , MVI and Juven. She further stated that she had just starting working for the facility in February and was not able to follow up at that time. On 4/7/14 at 1:55 PM the CNA (Certified Nursing Assistant) was interviewed and stated that she worked with the resident every day, gives her a daily bed bath and recalls that the resident had redness on both sides of her buttocks as well as a hardened, reddened area to the left buttock. On 4/7/14 at PM the MDS Coordinator was interviewed and stated that she completed the initial MDS for skin assessment. She documented that the resident had a stage 2 pressure ulcer on admission and that based on the MDS assessment care plans should have been developed. On 4/7/14 at 2:15pm the primary Physician was interviewed and stated that the nurses are responsible for completing the entire skin exam and that he does not recall looking at the residents buttock on admission 2/14/14. The Physician further stated that he did not recall being informed about recommendations regarding the treatment and vitamins and added that the Dietitian is free to call with recommendations. If the staff does not call me they could communicate via the clip board on the unit. If I didn't document anything about the wound I didn't see it. The Wound care Team Coordinator RN (registered Nurse) was interviewed on 4/7/14 at 2:33pm and stated that the team includes three LPN's (Licensed Practical Nurse), a Wound Doctor and the unit RN Manager. The team conducts weekly rounds, the Wound Doctor makes recommendations, and the Nurse Manager is responsible for calling the unit Physician. The treatment recommendations were not communicated to the Primary Physician in a timely manner and this should have been followed up. There were several miscommunications that occurred in this case. On 4/7/14 at 4:01pm the Wound Care Doctor was interviewed and stated that he follows the residents very close with the wound care team. He did not call the primary Physician directly , his recommendations are mediated through the nurse in Charge. He stated that there has been a change in staff over the past month which may have caused a gap in the follow up. 2) Resident #369 was an [AGE] year old resident admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 dated 11/5/13 documented that the resident ' s cognitive skills were intact. The MDS documented that the resident was at risk for pressure ulcer and had one Stage IV pressure ulcer (sacral) that was present on admission. The Braden Skin assessment dated [DATE] documented that the resident was at high risk for skin breakdown. The Nurse Practitioner (NP)'s progress note dated 8/23/13 documented that the resident was observed with a reopened right heel Stage II pressure area. The physician's order [REDACTED]. A Certified Wound Care Nurse (CWCN) ' s progress note dated 9/27/13 documented that the right heel partial thickness skin loss was observed to be resolved with intact, friable pink skin. The physician ordered to apply A & D ointment to the right lower extremity, including the right foot, cover with clean dressing and secure with kerlix wrap daily. The Vascular Consultation report dated 10/1/13 revealed that the resident was evaluated for the right heel ulcer. The vascular surgeon recommended applying a multi-podus boot to the right foot every AM and PM and continuing with the treatment to the right heel. A CWCN ' s progress note dated 10/10/13 documented that the resident ' s right heel was dry and intact. The Vascular Consultation report dated 10/22/13 documented that the right heel wound was observed to be " very small. " The vascular surgeon recommended continuing with the multi-podus boot and treatment to the heel ulcer. The NP ' s progress note dated 10/24/13 documented that the resident wore the multi-podus boot for the right heel without any discomfort. The Wound Physician ' s progress note dated 10/30/13 documented that the resident was seen with the wound team. The note documented that the right heel had no open wound and that a wrapping treatment was not needed, except for an " EZ-Boot. " A CWCN ' s progress note dated 11/10/13 and 11/23/13 documented that the resident's right heel was dry and intact. The Treatment Administration Record (TAR) for October 2013 to December 2013 documented that the resident's right heel ulcer was treated daily as ordered by the physician. The Certified Nursing Assistant (CNA) skin check sheets for October 2013 to December 2013 documented that the resident 's skin was checked daily. Resident #369 's medical record from 10/1/13 to 12/3/13 had no documented evidence that the resident ' s skin and multi-podus boot were being monitored on an ongoing basis by the licensed nursing staff. The Vascular Consultation report dated 12/3/13 documented that during a routine follow-up visit for the right heel wound, Resident #369 was observed with a right lateral leg ulcer " due to multi-podus boot being too tight." The vascular surgeon recommended discontinuing multi-podus boot and applying Santyl Collgenase to the right leg ulcer. The NP ' s progress notes dated 12/3/13 documented that the vascular surgeon discovered a new unstageable pressure ulcer to the right lateral leg. The pressure ulcer was observed as 4 x 2 cm dark eschar with no drainage. A nurse ' s progress note dated 12/3/13 documented that the nurse manager and wound care nurse discussed with the unit staff on performing skin integrity checks, removing the multi-podus boot when giving care, and reporting any changes to the nurse. The facility ' s Internal Investigative Summary for the right lateral leg ulcer dated 12/3/13 documented that the resident was considered a high risk for pressure ulcers due to Diabetes Mellitus and a history of pressure ulcers. The resident had decreased sensation to the lower extremities due to [MEDICAL CONDITION]. The summary documented " no care plan with preventive measures was in place at the time of the occurrence " and " no preventive measures were being carried out at the time of the occurrence. " The Treatment Administration Record (TAR) for December 2013 and January 2014 documented that the right lateral leg was treated daily with Santyl [MEDICATION NAME]. The Vascular Consultation report dated 1/7/14 documented that the resident ' s right leg ulcer was granulating. The right leg ulcer was sharply debrided by the surgeon. The Vascular Consult Report dated 1/21/14 documented that the right lateral leg pressure related wound was sharply debrided with sharp scissors. The facility ' s Root Cause Analysis dated 1/28/14 documented that the facility failed to monitor the resident ' s skin integrity while a multi-podus boot was in place, which resulted in an alteration in skin integrity. The facility concluded that there is reasonable cause to believe that " quality of care concerns occurred. " The facility ' s policy and procedure for Skin Integrity Alert dated 7/5/05 documented that the CNAs are responsible for reporting any changes in skin integrity to the nurse. The nurse managers are responsible for assessing and ensuring protocols are in place upon being notified of the presence of a wound. The facility ' s policy and procedure did not address maintaining good skin integrity during the use of a splint or other assistive devices. On 2/17/14 at 7:05 PM an interview was conducted with CNA #1. CNA #1 stated that when she gave a bath to the resident during the evening shift, she did not take the multi-podus boot off the resident for the skin check. CNA #1 stated that the nurses told her that the boot did not need to be removed for the bath because the treatment to the right foot had been completed during the day shift. On 2/17/14 at 7:15 PM an interview was conducted with CNA #2. CNA #2 stated that she did not see the right lateral leg ulcer on the resident. She stated that she did not take the multi-podus boot off during skin checks. CNA #2 stated that the nurses took the boot off the resident to check on the skin since the resident wore " a special boot. " On 2/17/14 at 5:50 PM an interview was conducted with the Licensed Practical Nurse (LPN) #4. LPN #4 stated that if there is an order for [REDACTED].#4 stated that she did not notice the right lateral leg ulcer under the multi-podus boot when she administered the treatment to the right heel. On 2/17/14 at 4:45 PM an interview was conducted with LPN #5. LPN #5 stated that during the treatment of [REDACTED]. LPN #5 stated that she would normally check the circulation of the leg for residents with a cast or a boot. LPN #5 stated that she did not check Resident #1 ' s right leg because she was too overwhelmed with all the tasks assigned to her on the unit. On 2/26/14 at 1:10 PM an interview was conducted with LPN #6. LPN #6 stated that when she administered the treatments to the resident ' s right heel, she did not recall seeing the ulcer on the right lateral leg. She stated that the CNAs are responsible for performing skin checks and notifying the nurse if there are any changes. During a subsequent interview with LPN #6 on 4/3/14 at 2:50 PM, she stated that during the treatment to the resident ' s right heel, she did not look at other parts of the leg. She stated that she only concentrated on the right heel area and did not perform a skin assessment of the right leg because there was no order for a skin assessment during the treatment. On 4/4/14 at 3:05 PM an interview was conducted with LPN #10. LPN #10 stated that when she administered treatment to the resident ' s right heel, she did not complete a full skin assessment of the right leg. LPN #10 stated that she only focused on the heel and not the entire leg because there was no order to assess the skin of other areas during the treatment. On 2/17/14 at 4:24 PM an interview was conducted with RN #3. RN #3 stated that he did not notice any problems with the resident ' s right leg until the vascular surgeon discovered the ulcer. RN #3 stated that the nurses are supposed to check residents ' skin during bath times when the CNAs call the nurses. He stated that the nurses do not check the skin unless a treatment is due or the CNAs call during the bath time. On 2/2/14 at 3:45 PM an interview was conducted with the RN Unit Manager (UM). The UM stated that she would expect the licensed nurses to check the resident ' s leg with the multi-podus boot for warmth and color of the extremity during the treatment. The UM stated that the resident ' s record did not have documentation that the licensed nurses checked the skin integrity of the right leg. On 2/27/14 at 2:55 PM an interview was conducted with the Vascular Surgeon (VS). The VS stated that the resident had poor perfusion in the right leg. The VS stated that the resident ' s right heel healed nicely with the multi-podus boot. However, the VS stated that the resident developed a skin breakdown to the right lateral leg as a result of the multi-podus boot putting pressure to the leg. The VS stated that initially the right leg ulcer had 80% eschar. He stated that he sharply debrided the ulcer on multiple occasions. The VS stated that he may have to incorporate the use of artificial skin to the area to close the wound. The VS stated that he did not give the facility ' s nursing staff any special instructions to perform neurovascular status checks to the right leg when the multi-podus boot was applied. He stated that he had assumed that the nursing staff would have followed good standards of practice and checked the right leg with the multi-podus boot for any abnormalities. On 3/27/14 at 5:00 PM an interview was conducted with the Wound Physician (WP). The WP stated that he was not aware of the pressure ulcer on the resident ' s right lateral leg until the ulcer was discovered at an outside clinic appointment. The WP stated that usually the nursing staff would take off the boot and look at the entire leg during treatments, but this " issue with the leg fell through the cracks. " 415.12(c)(1)

Based on interviews and record review during abbreviated survey the facility did not ensure that residents were free from significant medication errors. This was evident in 1 of 3 sampled residents (Resident #1). Due to a typographical error during a medication transcription entry into the electronic medical record, Resident #1 received 100 units of [MEDICATION NAME] Insulin via subcutaneous injection instead of 10 units of [MEDICATION NAME]. The resident was treated with Intravenous Fluids (IVF) and finger stick blood glucose monitoring every three hours for 48 hours. Additionally, the unit nurses did not reconcile the medication orders for Resident #1 on the 4:00PM-12:00AM. This resulted in actual harm that is not Immediate Jeopardy. Complaint # NY 137 The findings include: Resident # 1 was a [AGE] year old originally admitted to the facility on [DATE]. He was transferred to the hospital on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 dated 5/13/11 identified that the resident had moderate impairment in cognition. The nurse ' s notes dated 8/10/11 at 5:36PM documented that the resident was readmitted from the hospital status [REDACTED]. The Registered Nurse Manager (RNM) on the 8:00AM-4:00PM shift documented the resident ' s current condition and that all medical orders were discussed with the Primary Medical Doctor (MD). A review of the resident ' s orders prior to the hospitalization on [DATE], revealed a physician's order [REDACTED]. A Physician ' s telephone order upon readmission, dated 8/10/11 at 5:50PM documented [MEDICATION NAME] 100 unit/ml, inject 100 units via subcutaneous route, once daily at 6:00AM (this was a typographical error). Resident #1 ' s Medication Administration Record (MAR) dated 8/11/11 documented that [MEDICATION NAME] 100units/ml., 100 units was administered by subcutaneous injection to the left arm at 6:00AM. An MD order dated 8/11/10 at 12:19PM discontinued [MEDICATION NAME] 100unit/ml, inject 100 units by subcutaneous route once daily. On 8/11/10 at 1:00PM the MD ordered [MEDICATION NAME] 5% in Water (D5W) Intravenous infuse 80cc/hr for 48 hours and finger stick blood glucose monitoring every 3 hours for 48 hours. The facility policy entitled " Medication and Treatment Administration, " dated 5/1/2009 documented that once a new order is entered into the electronic medical record, the next 3 consecutive shifts over a 24 hour period are responsible for checking the orders. On 8/17/11 at 3:45PM a telephone interview was conducted with RNM # 1. RNM #1 was working on 8/10/11 from 8:00AM - 4:00PM. She stated that Resident #1 returned from the hospital at 3:40PM. RNM #1 stated that she completed the re-admission for Resident #1. She stated that she called the MD on the telephone and reviewed the hospital PRI. RNM # 1 stated that the MD told her to follow the medication orders that were in place prior to the recent hospital transfer. She stated that she double checked the medication history in the electronic medical record and noted [MEDICATION NAME] 10 units subcutaneously. RNM # 1 stated that the interim telephone order was her typing error. She stated that instead of ordering [MEDICATION NAME] 10 units she typed 100 units into the electronic order. On 8/17/11 at 4:50 PM LPN # 2, who was working 4:00PM- 12:00AM on 8/10/11, was interviewed. She stated that the RNM informed her that the resident was readmitted and that all the new orders were in the electronic medication record. She stated that it was part of her duties to check all the new orders. She stated that on 8/10/11, she did not question or check Resident #1' s order for [MEDICATION NAME]. On 8/19/11 at 2:30PM a telephone interview was conducted with LPN # 1, who was working on 8/11/11 12:00AM-8:00AM. He stated that on 8/11/11 at approximately 5:01AM, he was alerted by the electronic medical record that Resident #1 was due for administration of [MEDICATION NAME], 100 units via subcutaneous injection at 6:00AM. LPN # 1 stated that he had never administered [MEDICATION NAME]. He checked the MD order against the MAR and all the medications matched. He stated that he put a question mark next to [MEDICATION NAME] because he thought 100 units was a lot to administer. LPN #1 stated that he checked the vials from the pharmacy and there were 3 vials for a 30 days supply labeled [MEDICATION NAME] 100 units subcutaneously, daily. He stated that he went back to the system to check the previous medications prior to hospitalization , but he was unable to pull out the information. LPN #1 spoke to RNS #1 at approximately 7:45 AM. He asked the RNS about the dosage of [MEDICATION NAME]. He stated that the RNS told him " [MEDICATION NAME] is long acting; it should be okay to give to the resident. " He administered [MEDICATION NAME] 100 units after 8:00AM. On 8/17/11 at 2:45PM a telephone interview was conducted with the RN Supervisor who was working 12:00AM-8:00AM on 8/17/11. He stated that on 8/11/11 at around 7:00AM the unit LPN called him regarding an order for [REDACTED]. The RNS stated that he gave an " okay " to the LPN to administer the insulin. He stated that since he was not familiar Resident #1 he should have double checked the orders. On 8/17/11 at 12:25PM the Primary MD was interviewed. The MD stated that on the date of the resident ' s readmission, he gave the RNM a telephone order to continue all the medications from before the recent hospitalization . The MD stated that the following morning he completed the readmission assessment for the resident. While he was reviewing the resident ' s orders, he noticed the order for [MEDICATION NAME] 100units/ml inject 100 units subcutaneous daily. The MD stated that he checked the MAR and noticed that the insulin was administered at 6:00AM with a dosage of [MEDICATION NAME] 100 units instead of 10 units. The MD stated that he went to evaluate the resident. There were no signs of [DIAGNOSES REDACTED] or adverse reaction noted at that time. At this time he ordered IV Fluids and finger stick blood glucose monitoring. On 8/17/11 at 9:45AM and on 12/6/11 at 10:55AM the Director of Nursing (DON) was interviewed. The DON stated that per policies and procedures all 3 consecutive shifts should check the new order. She stated that the nurse who is on duty is responsible for checking all new orders. 415.12(m)(2)