Every finding on record at Triboro Center for Rehabilitation and Nursing

Based on observation, record review, and interviews conducted during survey, the facility failed to ensure that residents are free from resident-to-resident abuse. This was evident for two (2) out of five (5) residents (Resident #1 and Resident #2) sampled. Specifically, on 04/17/2026 at 2:30 PM, Resident #1 unscrewed the handle from a mechanical lift and used it to strike Resident #2 on the left side of the head. Resident #2 was assessed and observed with a four (4)-centimeter raised area to the left side of the head as well as a 0.4-centimeter open area on the pad of the left index finger. Emergency Medical Services (911) was called and Resident #2 was transferred to the emergency room for evaluation and returned to the facility on [DATE]. Resident #1 was transferred to the emergency room for psychiatric evaluation and returned to the facility with no new orders. Resident #1 and Resident #2 were placed on separate floors. This resulted in actual harm to Resident #2 that was not Immediate Jeopardy.The findings are: The facility's policy titled Behavior-Resident to Resident Altercation, dated 07/2020 documented it is the policy of the facility to provide the highest quality of care to our residents, by providing staff with the most efficient, resident-centered procedures for the care of our residents per Federal and State Regulations. This includes, but is not limited to, Resident-to-Resident altercations including all forms of abuse, including resident-to-resident abuse must be reported immediately to the Nursing Supervisor, the Director of Nursing Services and the Administrator. The facility's Policy titled, Abuse, dated 07/18/2025 documented the facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including but not limited to staff, family, friends and residents of the facility. The facility prohibits any exploitation of the mentally and physically disabled residents in the facility. The facility has designed and implemented processes which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property.Resident #1 was admitted to the facility with diagnoses of major depressive disorder, anxiety and acquired absence of the left leg above knee (surgical removal of the leg).The Minimum Data Set (a resident assessment tool) dated 03/20/2026, documented Resident #1 has moderately impaired cognition. Resident #1 uses wheelchair to move around. A review of the Comprehensive Care Plan for Resident-to-Resident Altercation dated 12/03/2025, documented interventions that included administer medication as ordered, monitor behavior and document. Notify medical doctor of inappropriate behavior. Resident-to Resident Care Plan for Altercation was updated on 04/17/2026 to include room change to private room on different floor and offer diversional activity to deter residents.A nursing progress note dated 04/17/2026 at 4:32 PM by Assistant Director of Nursing #1, documented called to the unit to intervene in resident-to-resident altercation. Staff members reported that Resident #1 hit Resident #2 with a metal object in the head. Resident #1 reported that they thought Resident #2 was going through their stuff that is why they hit Resident #2.Resident #1 was transferred to the hospital for psychiatric evaluation and returned with no new orders. Review of a psychiatric progress note dated 04/23/2026 at 5:45 PM, documented Resident #1 seen at bedside for psychiatric re-evaluation and medication management after an altercation with roommate. Will consider adjusting their psychotropic medication. The facility's investigation dated 04/17/2026, documented on 04/17/2026 at 2:30 PM Resident #1 struck Resident #2 on the left side of the head with the handle from the mechanical lift which they unscrewed. Resident #2 sustained a four (4)-centimeter raised area to the left side of the head as well as a 0.4-centimeter open area to the pad of the left index finger. Staff members intervened and separated both residents. Local law enforcement was called and responded. Resident #1 and Resident #2 were transferred to the hospital for evaluation and returned to the facility. Resident #1 (aggressor) was transferred to another unit in a private room. Resident #2Resident #2 was admitted to the facility with diagnoses of diabetes (high level of sugar in the blood), chronic obstructive pulmonary disease (damaged lung with poor air flow), and benign prostatic hyperplasia (enlarged prostate gland).A Minimum Data Set, dated [DATE], documented Resident #2 has intact cognition. Resident #2 uses a wheelchair to move around. A review of the Comprehensive Care plan for Resident-to-Resident Altercation dated 04/17/2026 documented interventions that included monitor behavior and document, psychosocial support and separate resident from the aggressor. A review of the Comprehensive Care plan for Impaired Skin Integrity Abrasion, bruise to head dated 04/28/2026, documented interventions that included prevent resident from scratching and keep hands and body parts from excessive moisture, keep fingernails short.Review of the Hospital record dated 04/17/2026, documented Resident #2 reported they were hit on the head by another resident unprovoked. Swelling with minimal bleeding noted to Resident #2's scalp on left side of the head and an injury to left index finger. No sutures were required. A computer tomography (CT) scan dated 04/17/2026 indicated the results were negative for fracture. There was no documented evidence of new orders from the hospital.A review of a nursing progress note dated 04/17/2026 at 3:19 PM by Assistant Director of Nursing #1 documented Resident #2 was noted with a raised area to the left side of their head with moderate amount of bleeding and their left index finger was noted with a small amount of blood and a 0.4-centimeter open area. Resident #2 was transferred to hospital for evaluation. Review of the physician's order dated 04/27/2026 Tramadol Hydrochloride give one tablet by mouth every six hours as needed for pain for two days. Review of a psychiatric progress note dated 04/23/2026 at 5:49 PM, documented Resident #2 was seen at the bedside for a follow-up assessment after Resident #2 had an altercation with their roommate. Resident #2 is alert and awake, doing well, noted to be calm. Denied pain at this time, no flash back of the incident reported. During an interview on 04/28/2026 at 11:28 AM, Resident #1 stated Resident #2 was in their room and kept coming over to their side. Resident #1 stated on 04/17/2026, when they came out their room, they saw the mechanical lift in the alcove. Resident #1 stated they unscrewed the handle of the mechanical lift and used it to hit Resident #2 when Resident #2 came out of their room.During an interview on 04/28/2026 at 10:48 AM, Resident #2 stated on 04/17/2026, when they came out of their room, Resident #1 approached them and hit them several times on their head and their left index finger unprovoked. Resident #2 stated they feel safe now because Resident #1 was removed from the unit and they do not see Resident #1 anymore. During an interview on 04/28/2026 at 10:00 AM, Housekeeper #1 stated on 04/17/2026 at approximately 2:30 PM when they were sitting in the hallway, they heard another staff member say look. Housekeeper #1 stated when they looked up, they observed Resident #1 hitting Resident #2 several times with the handle from the mechanical lift. During interview with Licensed Practical Nurse #1 and Certified Nursing Assistant #1 on 04/28/2026, they stated they were sitting at the nursing station when they heard Housekeeper #1 calling out for help. They stated when they looked down the hallway, they observed Resident #1 hitting Resident #2 with the mechanical lift handle and they immediately separated both residents.During an interview on 04/29/2026 at 10:30 AM, Licensed Mental Health Counselor #1 stated after their session with Resident #2 on 04/17/2026 and on 04/20/2026 there was no evidence of psychosocial harm. Resident #2 stated they were feeling safe in the facility.During an interview on 04/29/2026 at 10:21 AM, Assistant Director of Nursing #1 stated on 04/17/2026 the unit manager notified them about the incident. Assistant Director of Nursing #1 stated they went to the unit and observed Resident #2 sitting in their wheelchair outside of their room. Assistant Director of Nursing #1 stated Resident #2 reported that Resident #1 struck them in the head for no reason. Assistant Director of Nursing #1 stated Resident #2 was observed with a raised area to the left side of the head and discoloration to left index finger. Assistant Director of Nursing #1 stated Medical Doctor #1 arrived on the unit and examined Resident #2. Assistant Director of Nursing #1 stated Emergency Medical Services was called and responded along with law enforcement. Assistant Director of Nursing #1 stated both residents were separated and transferred to the hospital.During an interview on 04/30/2026 at 2:46 PM, Medical Director #1 stated on 04/17/2026, they were called regarding an altercation between two of their residents. Medical Doctor #1 stated they went to the unit and Resident #2 was sitting in their wheelchair. Medical Doctor #1 stated Resident #2 reported Resident #1 hit them unprovoked. Medical Doctor #1 stated Resident #2 was observed with some bleeding from their head and swelling on the left side of the head. Medical Doctor #1 stated Resident #2 was transferred to the hospital for computer tomography scan (CT) of the head and the results were negative for fracture. Medical Doctor #1 stated the residents were seen by psychiatry. During an interview on 04/30/2026 at 3:04 PM, the Administrator stated they were notified by the Director of Nursing that there was a resident-to resident altercation and both residents were transferred to the hospital for evaluation. The Administrator stated the incident was reported to the Department of Health and the police were called immediately. The Administrator stated that maintenance checked on all Hoyer lifts (mechanic lift) to ensure that they are in good working condition and that no residents can unscrew or interfere with the mechanical lift. The Administrator stated that all staff were instructed to place the mechanical lift in a locked area. The Administrator stated staff members were re-educated on abuse, neglect and mistreatment and frequent rounding to ensure residents' safety. The Administrator stated Resident #1 was transferred to another unit in a private room. 10 New York Codes, Rules, and Regulations 415.4(b)(1)(i)

Number of residents sampled: 6Number of residents cited: 1 Based on record review and interviews, the facility failed to ensure each resident was free from chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms. This was evident for one (1) of six (6) residents (Resident #425) reviewed for Unnecessary Meds, Chemical Restraints/Psychotropic Meds, and Med Regimen Review, out of 38 sampled residents investigated. Specifically, Resident #425 was administered psychotropic drugs without an appropriate diagnosis, there was no documentation of behaviors to support the ongoing use of psychotropic medications, and there was no evidence of monitoring for effectiveness or side effects.The findings are:The facility policy and procedure titled Psychotropic Medication dated 10/2024, last revised 04/28/2025 state psychotropic medications may be prescribed for and administered to residents in accordance with current standards of practice and State and Federal Regulations to promote and/or maintain the resident's highest practicable mental, physical, and psychosocial well-being.Resident #425 was admitted with diagnoses that included Non-Alzheimer's Dementia, Depression, and Bipolar Disorder.The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #425 has severe impairment in cognition, had no potential indicators of Psychosis, and no presence of behavioral symptoms documented. The Minimum Data Set assessment also documented that Resident #425 was taking antipsychotic medication with an indication noted, a gradual dose reduction had not been attempted, and the physician had not documented Gradual Dose Reduction as clinically contraindicated.The Physician's order dated 12/23/2025 documented Seroquel 125 milligrams orally at bedtime for dementia with behavioral disturbance. A care plan titled Behavior dated 10/22/2025 and updated 12/15/2025 documented Resident exhibits behavior symptoms such as hoarding food in drawers, urinating in the dustbin, on the floor in the room and refusing care /showers. Interventions included attempt to establish a daily routine, check for toileting need, provide toileting/incontinence care as indicated, determine the cause of the behavior and maintain residents' safety, and re- approach resident for care/toileting/medication administration/treatments and other needs when resident is more agreeable. The Monitoring/Evaluation notes dated 12/15/2025 documented the appropriate department has been notified to please add extra snacks for Resident #425 throughout the day. There were no other behavior monitoring/evaluation notes documented in Resident #425 clinical record to indicate escalation of behavior and/or effectiveness of interventions in place.A care plan titled Dementia dated 09/19/2025 documented resident has impaired cognition related to Dementia. Interventions included engage the resident to participate in simple, structured activities, keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion, and monitor/document /report to nurse and medical provider any changes in cognitive function. The Monitoring/Evaluation notes did not include documented evidence of the effectiveness of interventions being provided. A care plan titled Psychoactive Medications dated 09/19/2025 documented resident uses psychoactive medications related to diagnosis of Depression. Interventions included give medications ordered by physician, monitor/document side effects and effectiveness, and monitor/record occurrence of target behavior symptoms and document per facility protocol. The Monitoring/Evaluation notes did not include documented evidence Resident #425 was monitored for behavior and effectiveness of psychotropic medications. The Physician's order dated 12/23/2025 documented Seroquel 125 milligrams orally at bedtime for dementia with behavioral disturbance. The Psychiatric Comprehensive Consult dated 09/26/2025 documented Resident #425 was seen for initial assessment for psychiatric evaluation and medication management. Resident #425 was noted alert, awake, and doing well, reported good sleep and appetite. The consult also documented Resident #425 has diagnoses of Major Depressive Disorder, and Dementia without behavioral disturbance. The consult further documented follow up should occur in 3 months and as needed, and staff was to monitor mood and behavior and document accordingly.The Psychiatric Comprehensive Consult dated 11/07/2025 documented Resident #425 was seen for follow up assessment for psychiatric evaluation and medication management. Resident alert, awake, doing well and noted calm. The recommendations were to continue Seroquel 125 milligrams by mouth at bedtime and non-pharmacological interventions. The consult further documented follow up should occur in 3 months and as needed, and staff was to monitor mood and behavior and document accordingly.The Psychiatric Comprehensive Consult dated 12/29/2025 documented Resident #425 was seen for follow up assessment for psychiatric evaluation and medication management and resident was alert, awake, not doing well on current medication, noted to be irritable with disorganized behaviors. The consult also documented staff reported poor sleep and medications would be adjusted. Start Trazodone 25 milligrams by mouth every 12 hours, increase Seroquel to 150 milligrams by mouth at bedtime, and non-pharmacological interventions. The consult further documented follow up should occur in 3 months and as needed, and staff was to monitor mood and behavior and document accordingly. There was no documented evidence of behaviors to support ongoing use of psychotropic medication for Resident #425, or evidence that the effectiveness or side effects of resident's psychotropic medications was monitored or documented.A complaint was submitted by Resident #425's family member in October 2025 which stated they had concerns that Resident #425 had never been diagnosed with Bipolar disorder and was receiving psychotropic medications while having a diagnosis of Dementia. The family also stated Resident #425 has a Dementia diagnosis and can have aggressive behavior as a result and they were seen by a psychiatrist in the community and was not prescribed medication for their behavior. The family further stated they visit regularly and have not observed Resident #425 with aggressive or violent behaviors and think the medication will only worsen Resident #425's condition. The family also stated they had not been informed that Resident #425 was being started on this medication.During an interview on 03/08/2026 at 01:15 pm, the Complainant stated that they had been talking to Resident #425's primary physician at the facility to stop certain medications prescribed due to the increased risk for residents with a diagnosis of dementia. The Complainant also stated the medications were not discontinued until they called 911 in January 2026 and had Resident #425 transferred back to the hospital and then placed in another nursing home. During an interview on 03/12/2026 at 10:54 AM, Certified Nursing Assistant #1 stated that they were not directly assigned to Resident #425, but they never observed Resident #425 with any aggressive behavior on the unit. Certified Nursing Assistant #1 also stated that due to dementia sometimes Resident #425 had could not find their room and was always re-directed. Certified Nursing Assistant #1 further stated Resident #425 used to attend recreation activities on the unit and would eat meals in the dining room with other residents.On 03/12/2026 at 11:05 AM, Certified Nursing Assistant #2 was interviewed and stated they were assigned to Resident #425 for about a month and assisted them with Activities of Daily Living. Certified Nursing Assistant #2 also stated Resident #425 would sometimes refuse shower sand get agitated when being encouraged to take shower, so sometimes additional staff would be needed to assist, or the resident's family would come to assist with the shower.During an interview on 03/12/2026 at 12:28 PM, Licensed Practical Nurse #1 stated Resident #425 sometimes refused to shower on regular basis, but with encouragement would agree to take it when the staff returned later. Licensed Practical Nurse #1 also stated that they could not recollect seeing Resident #425 with any other abnormal behavior, and no staff reported any aggressive behavior to them during Resident's #425 stay in the facility.On 03/12/2026 at 12:33 PM, Registered Nurse #1 was interviewed and stated Resident #425 was admitted from the hospital in September 2025 with Seroquel 150milligrams at bedtime, which was continued by the psychiatrist on 09/26/2025, and on 11/07/2025, it was reduced the Seroquel to 125 milligrams for major depressive disorder/adjustment disorder. Registered Nurse #1 also stated the indication of Seroquel was not documented at the hospital. Registered Nurse #1 further stated Resident #425 was observed and monitored by the staff, was refusing care most of the time and would be aggressive when being encouraged by staff and sometimes when the family was present. Registered Nurse #1 stated that they were not on duty when Resident's medication was reduced and could not explain why the reduction was not documented and updated in the resident's care plan when the medication was decreased.On 03/13/2026 at 9:47 AM, the Psychiatrist was interviewed and stated Resident #425 was discharged from the hospital on Seroquel 150 milligrams at bedtime, was seen for initial assessment, based on hospital discharge record reviewed, Resident #425 was apparently sent from home to the hospital with 150 milligrams of Seroquel, and their child had expressed that Resident #425 could not be handled at home due to behavior problem. The Psychiatrist also stated that the hospital records documented that Resident #425 was well managed with Seroquel 150 milligrams, and a recommendation was given to continue on that same dose in the nursing home to avoid deterioration. The Psychiatrist further stated that during a follow up visit in November, Resident #425 was noted to be doing well, so Seroquel was decreased to 125 milligrams at bedtime. During the follow-up visit in December, staff reported that Resident #425 was having increased behavior and poor sleep, recommendation given to start Trazodone 25 milligrams every 12 hours, and Seroquel increased to 150 milligrams at bedtime and Resident was to be re-evaluated in January but was transferred back to the hospital. The Psychiatrist stated that they are aware of the black box warning, and they usually do Gradual Dose Reduction and give alternative medication, but Resident #425's behavior was very aggressive, and the only medication that helped was Seroquel, so they felt compelled to continue the same medication. The Psychiatrist also stated other medication was tried at the hospital and Resident #425 was only able to be managed on Seroquel, and they did not think it would be good to take them off the medication as they had been stabilized on that medication. On 03/13/2026 at 12:06 PM, the Medical Director was interviewed and stated that Resident #425 was discharged with a high dose of Seroquel 150 milligrams and titrated to 125 milligrams at the nursing home. The Medical Director also stated that the indication was mistakenly documented as only for dementia on the Physician's order. The Medical Director further stated that based on the psychiatry evaluation, Resident #425 also had a diagnosis of Major Depressive Disorder, and other psychotic behavior that should have been indicated on the order. The Medical Director stated that it would not be wise to reduce Resident's Seroquel from 150 milligrams that they were receiving on admission they need to monitor resident further before considering gradual dose reduction. The Medical Director also stated that staff were not properly documenting resident's behaviors, but they cannot just stop the medication that a resident has been taking prior admission.On 03/13/2026 at 12:58 PM, the Director of Nursing was interviewed and stated that the Seroquel was being given for bipolar disorder, but the diagnosis was wrongly selected when the orders were entered. The Director of Nursing was not able to explain why there was no documented evidence of monitoring Resident 425's behavior or the effectiveness of the psychotropic medication being given.On 03/13/2026, between 9:00 AM and 12:30 PM, two (2) attempts were made to speak with Resident #425's primary physician which were both unsuccessful. 10 New York Code, Rules and Regulations 415.3(d)(1)(vii)

Number of residents sampled: 2Number of residents cited: 1 Based on interviews and record review, the facility failed to ensure all alleged violations involving abuse were reported immediately to the New York State Department of Health but not later than 2 hours after the alleged occurrence. This was evident for one (1) of two (2) residents (Resident #426) reviewed for Abuse out of 38 total sampled residents. Specifically, Resident #426 sustained an unwitnessed injury to the upper right eyelid which they could not explain, which was not reported to Department of Health. The findings are: The facility policy titled Abuse Prevention dated 07/18/2025 stated the facility must report alleged violations related to mistreatment, exploitation, neglect, or abuse including injuries of unknown source and misappropriation of resident property and report the results of all investigations to all the proper authorities within prescribed timeframes. The policy also stated alleged violations involving abuse, neglect, exploitation mistreatment are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. Resident #426 had diagnoses that included Alzheimer's disease, Cognitive Communication Deficit, and Depression. The Minimum Data Set assessment dated [DATE] documented Resident # 426 had severely impaired cognition, required partial assistance of one (1) person to assist with Activities of Daily Living. The Investigation Form dated 11/26/2025 documented that at 8:15 AM Certified Nurse Assistant #3 observed Resident #426 with redness on right upper eyelid and when interviewed Resident #426 stated they fell. The form also documented that Resident #426 later stated they did not know what happened. The Accident/Incident Statement Form completed by Licensed Practical Nurse #3 documented that they were called by the Certified Nursing Assistant to evaluated Resident #426 who was observed with a bump over their right eye. The statement documented that Resident #426 stated they fell, however they were not able to state how and when they fell. On 03/13/2026 at 12:38 PM, the Director of Nursing was interviewed and stated investigation of the redness on the resident's right upper eyelid was done and since Resident #426 stated at first they had fallen, the facility concluded the injury came from the fall. The Director of Nursing also stated Resident #426 is confused and cannot fully state what happened. The Director of Nursing further stated the injury to Resident #246's right eye was not reported to Department of Health since the facility had already completed their investigation. 10 New York Code, Rules and Regulations 415.4(b)(2)

Number of residents sampled: 6Number of residents cited: 1 Based on record review and interviews, the facility failed to ensure that a resident's comprehensive care plan was reviewed and revised to accurately reflect the needs of the resident and in response to current interventions. This was evident for one (1) of six (6) residents (Resident #425) reviewed for Unnecessary Meds, Chemical Restraints/Psychotropic Meds, and Med Regimen Review, out of 38 sampled residents. Specifically, there was no documented evidence that Resident #425's comprehensive care plan for psychoactive medications was reviewed and revised after medications were adjusted. The findings are:The facility policy and procedure titled Care Plans-Comprehensive dated 10/2015, last revised 08/02/2024 stated assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.Resident #425 was admitted to the facility with diagnoses that included Non-Alzheimer's Dementia, Depression, and Bipolar Disorder.The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #425 has severe impairment in cognition, had no potential indicators of Psychosis, and no presence of behavioral symptoms documented. The Minimum Data Set assessment also documented that Resident #425 was taking antipsychotic medication with an indication noted, a gradual dose reduction had not been attempted, and the physician had not documented Gradual Dose Reduction as clinically contraindicated.A care plan titled Dementia dated 09/19/2025 documented resident has impaired cognition related to Dementia. Interventions included engage the resident to participate in simple, structured activities, keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion, and monitor/document /report to nurse and medical provider any changes in cognitive function. The Monitoring/Evaluation notes did not include documented evidence of the effectiveness of interventions being provided. A care plan titled Psychoactive Medications dated 09/19/2025 documented resident uses psychoactive medications related to diagnosis of Depression. Interventions included give medications ordered by physician, monitor/document side effects and effectiveness, and monitor/record occurrence of target behavior symptoms and document per facility protocol. The Monitoring/Evaluation notes did not include documented evidence Resident #425 was monitored for behavior and effectiveness of psychotropic medications. Physician's order dated: 12/23/2025 documented: - Seroquel 125 mg PO at bedtime for The Physician's order dated: 12/23/2025 documented Seroquel 125 milligrams orally at bedtime for dementia with behavioral disturbance. The Psychiatric Comprehensive Consult dated 09/26/2025 documented Resident #425 was seen for initial assessment for psychiatric evaluation and medication management. Resident #425 was noted alert, awake, and doing well, reported good sleep and appetite. The consult also documented Resident #425 has diagnoses of Major Depressive Disorder, and Dementia without behavioral disturbance. The consult further documented follow up should occur in 3 months and as needed, and staff was to monitor mood and behavior and document accordingly.The Psychiatric Comprehensive Consult dated 11/07/2025 documented Resident #425 was seen for follow up assessment for psychiatric evaluation and medication management. Resident alert, awake, doing well and noted calm. The recommendations were to continue Seroquel 125 milligrams by mouth at bedtime and non-pharmacological interventions. The consult further documented follow up should occur in 3 months and as needed, and staff was to monitor mood and behavior and document accordingly.The Psychiatric Comprehensive Consult dated 12/29/2025 documented Resident #425 was seen for follow up assessment for psychiatric evaluation and medication management and resident was alert, awake, not doing well on current medication, noted to be irritable with disorganized behaviors. The consult also documented staff reported poor sleep and medications would be adjusted. Start Trazodone 25 milligrams by mouth every 12 hours, increase Seroquel to 150 milligrams by mouth at bedtime, and non-pharmacological interventions. The consult further documented follow up should occur in 3 months and as needed, and staff was to monitor mood and behavior and document accordingly. There was no documented evidence comprehensive care plans for Resident #425 reflected monitoring for effectiveness of medication or monitoring of mood or behavior problems and was revised after medications were adjusted.On 03/12/2026 at 12:33 PM, Registered Nurse #1 was interviewed and stated Resident #425 was admitted from the hospital in September 2025 with Seroquel 150milligrams at bedtime, which was continued by the psychiatrist on 09/26/2025, and on 11/07/2025, it was reduced to Seroquel 125 milligrams for major depressive disorder/adjustment disorder. Registered Nurse #1 also stated that they were not on duty when Resident's medication was reduced and could not explain why the reduction was not documented and updated in the resident's care plan when the medication was decreased.On 03/13/2026 at 12:58 PM, the Director of Nursing was interviewed and stated that the Registered Nurse and the supervisors are expected to review and update the residents' comprehensive care plans whenever there is any change in residents' conditions. The Director of Nursing also stated that they noticed that there have been some challenges with residents' comprehensive care plans, and there is on-going review of residents' comprehensive care plans by interdisciplinary committee members to ensure that all necessary care plans are in place and appropriately reviewed. 10 New York Code, Rules and Regulations 415.11(c)(2)(i-iii).

Number of Residents sampled: 5Number of Residents cited: 1 Based on observation, record review, and interviews, the facility failed to ensure a resident received adequate supervision to prevent an accident. This was evident for one (1) of five (5) residents (Resident #269) reviewed for Accidents out of 38 sampled residents. Specifically, Resident #269 was provided with one person assistance instead of two-person assistance during care on 09/12/2025. Certified Nursing Assistant #4 attempted to turn Resident #269 onto their right side at which time Resident #269 rolled off the bed sustaining a left parietal (area in the skull) hematoma (a collection of clotted blood outside a blood vessel that may occur due to injury or disease) with a laceration and right upper face skin excoriation (damage to the surface of the skin). The findings include:The facility policy titled Accident-Incidents last revised 06/02/2024 stated it is the policy of the facility to monitor and evaluate all the occurrences of accidents or incidents or adverse events occurring on the facility's premises which is not consistent with the routine operation of the facility or care of the residents. These occurrences must be evaluated and investigated. The team will review the investigation, and continue, if necessary, discuss and determine from the investigation the root causes, make recommendations for additional intervention, education and conclude the investigation.Resident #269 was admitted with diagnoses that included Hemiplegia (one-sided paralysis or weakness), Aphasia (a language condition that affects a person's ability to communicate), and Diabetes Mellitus.The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #269 was moderately cognitively impaired, had impairment on one side of upper extremity and impairment on both sides of lower extremities. The Minimum Data Set assessment also documented that Resident #269 was dependent on staff for toileting, upper and lower body dressing, required substantial assistance of staff for rolling left and right, and was frequently incontinent of bowel and bladder. The Visual/Bedside Kardex Report dated 08/28/2025, 09/04/2025, 09/11/2025 and 09/12/2025 documented substantial assist of one staff for rolling left/right. The Nursing Progress note dated 09/12/2025 documented that nursing became aware of fall incident on 09/12/2025 at 5:20 PM. Upon arrival Resident #269 was found on the floor face down, noted with left parietal hematoma with laceration and right upper face skin excoriation, with Certified Nursing Assistant #4 by Resident #269's side. The note also documented Certified Nursing Assistant #4, stated that while care was being given to Resident #269, Certified Nursing Assistant #4 was attempting to turn Resident #269 to the right side. Resident #269 attempted to hold on to the metal part of the bed with their left side. However Resident #269 reached out too far and accidentally rolled off the bed on to the floor headfirst. The Physical Therapy PT Therapy Progress Report form dated 08/15/2025 documented rolling left/right in bed as of 07/30/2025 and 08/15/2025 was total dependence without attempts to initiate.The Physical Therapy PT Recert, Progress Report & Updated Therapy Plan dated 08/25/2025 documented rolling left/right in bed, with a baseline date 7/28/2025 and previous date 8/13/2025, was total dependence with attempts to initiate. The section of the form titled Comments documented Resident #269 is able to initiate rolling but requires at least two persons in order to complete rolling. The form also documented Resident #269 will continue to benefit from verbal cues for task sequencing to prevent falls and injury.The Physical Therapy PT Therapy Progress Report form dated 09/04/2025 Physical therapy progress report documented with rolling left/right in bed, with a baseline date of 7/28/2025, previous date of 8/22/2025, and current date of 9/4/2025, was total dependence with attempts to initiate. The section of the form titled Comments documented that Resident #269 is able to initiate rolling but requires at least two persons in order to complete rolling. The form also documented continued use of verbal cues for task sequencing is recommended to reduce the risk of falls and injury.On 03/08/2026 at 12:02 PM, Resident #269's sibling was interviewed and stated that Resident #269 had a fall last year in which they were dropped from the bed as one staff was assisting with care at that time instead of two. On 03/08/2026 at 12:24 PM, the Complainant was interviewed and stated Resident #269 has history of multiple strokes, is paralyzed from the waist down, and has limited mobility in the left arm and left leg. The Complainant also stated that on 09/12/2025 as Resident #269 was being changed, they received one person assistance instead of two-person assistance and Certified Nursing Assistant was in the process of changing Resident #269 and attempted to turn Resident #269 during care, at which time Resident #269 ended up getting flipped off the bed. The Complainant further stated that this issue of only one (1) staff assistance instead of two (2) staff assistance during care was addressed previously with the facility. Complainant stated that they along with resident's sibling had previously informed the facility that Resident #269 needed two (2) person assistance for care prior to the fall.On 03/11/2026 at 10:30 AM, Occupational Therapist #1 was interviewed and stated Resident #269 was on a course of physical therapy and occupational therapy from 07/28/2025 to 09/17/2025. Occupational Therapist #1 also stated that when a resident is on therapy, there is an ongoing communication between the Rehabilitation department and the nursing manager and staff on the floor throughout the course of therapy. Occupational Therapist #1 further stated that as per the therapy progress report, rolling to the left/right as of 09/04/2025 required two (2) person assistance to ensure safety, which should have been carried over as it posed a safety and fall risk.On 03/11/2026 at 12:23 PM, the Director of Nursing Services was interviewed and stated that this incident was previously investigated, and Resident #269 was noted to be one person assistance for bed mobility so there was no care plan violation at that time. The State Surveyor then reviewed the physical therapy progress notes dated 09/04/2025 which included the comment that Resident #269 requires at least two persons in order to complete rolling with the Director of Nursing Services. The Director of Nursing Services stated they would have to review this and could not offer an explanation at this time as to why that recommendation was not followed.On 03/12/2026 at 11:26 AM, a follow-up interview was conducted with the Director of Nursing Services who stated the mechanism for communicating between disciplines at the time of incident was via a hard copy document that was passed from the therapist to the nursing manager who would update the resident tasks. The Director of Nursing Services also stated they had reviewed the record and could only locate a note from Rehabilitation to nursing in May 2025 recommending a change from two person assistance to one person assistance and could locate no additional documentation of any other subsequent change. The Director of Nursing Services further stated they were not sure if a change was even done as there was nothing uploaded in the chart and a hard copy could not be located. The Director of Nursing services stated the process was changed in the electronic medical record to allow therapists to directly update tasks. The Director of Nursing Services could not offer an explanation as to what happened with the communication between therapists and nursing staff when Resident #269 was identified as needing two person assistance to complete rolling from left to right and right to left. The Director of Nursing Services further stated that it is important recommendations are carried over because the level of care provided is based on the residents needs and it is important to avoid situations in which accidents happen as in this case Resident #269 fell about a week later.On 03/12/2026 at 3:47 PM, the Director of Rehabilitation was interviewed and stated that as of January 2026, there was a change in the system where therapists can directly enter tasks. The Director of Rehabilitation also stated that prior to that, the Rehabilitation department would pass a slip of paper to inform the nurse managers of the resident's status, and the tasks would then be placed based on the therapist recommendation and the nursing managers assessment. The Director of Rehabilitation further stated that the section that states rolling left assesses residents' ability to roll from left to right and from right to left. The therapy note stated that Resident 269 is in need of two (2) person assistance for rolling was current as of 09/04/2025 and the level of assistance should have been conveyed from Rehabilitation to nursing at that time. The Director of Rehabilitation stated that the task which stated one person assistance for rolling left/right should have been updated to two person assistance at that time even though Resident #269 was not yet discharged from the therapy program. The Director of Rehabilitation also stated they are not sure what happened in the process and could not say if nursing was made aware or if the recommendation went unheeded. The Director of Rehabilitation further stated that there was no documented evidence to show what occurred during that time.On 03/13/2026 at 12:04 PM, the Assistant Director of Nursing #2 was interviewed and stated that the Resident Task list can be updated during the course of therapy if a decline is noted. The Assistant Director of Nursing #2 also stated that if a decline is noted, nursing should be notified and tasks updated accordingly as if it is not properly addressed or picked up in a timely manner, a delay in treatment could occur. 10 New York Code, Rules and Regulations 415.12 (h)(2)

Based on observation, record review, and interviews conducted during the recertification survey from 2/21/2024 through 2/28/2024, the facility did not ensure reasonable accommodation of a resident's needs and preferences. This was evident for 1 (Resident #46) of 38 sampled residents. Specifically, Resident #46 was unable to transfer out of bed because the facility did not have a functioning bariatric Hoyer (mechanical) lifter. The findings are: The facility policy titled Quality of Life/Accommodation of Needs dated 10/2023 documented the resident's individual needs and preferences will be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. Resident #46 was admitted with the diagnoses that include Heart Failure and Diabetes Mellitus. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #45 was cognitively intact. On 2/21/2024 at 1:02 PM, Resident #46 was interviewed and stated they were unable to transfer out of bed and unable to take showers for approximately 6 weeks because the facility's bariatric Hoyer lifter was broken. Resident #46 stated they wanted to get out of bed and preferred to take showers. On 2/21/2024 at 1:06 PM, 2/22/2024 at 11:24 AM, and 2/23/2024 at 10:43 AM, Resident #46 was observed lying in bed. The Task List Report dated 12/18/2023 documented Resident #46 required a mechanical lift to transfer out of bed, for toileting, and for showering. On 2/26/2024 at 3:32 PM, Certified Nursing Assistant #1 was interviewed and stated they used a bariatric Hoyer lifter to transfer Resident #46 out of bed. The bariatric Hoyer lifter broke and was removed from the unit to be repaired. On 2/27/2024 at 11:49 AM, Certified Nursing Assistant #2 was interviewed and stated Resident #46 has not been transferred out of bed for approximately 1 month because the bariatric Hoyer lifter was broken and has not been repaired. Management was aware the Hoyer lifter was broken. Certified Nursing Assistant #2 stated Resident #46 was scheduled for showers twice weekly, but they did not know the last time Resident #46 was received a shower because Resident #46 could not be transferred out of bed. On 2/28/2024 at 10:46 AM, Licensed Practical Nurse #4 was interviewed and stated that Resident #46 required a bariatric Hoyer lifter and the unit's standard Hoyer lifter was too light to transfer the resident out of bed. Resident #46 used to come out of bed to go to physical therapy until the bariatric Hoyer lifter broke. 02/28/2024 at 2:29 PM, the Acting Director of Nursing was interviewed and stated the bariatric Hoyer lifter was removed from Resident #46's unit but staff were aware the facility had another bariatric Hoyer lifter on another unit. On 2/28/2024 at 1:22 PM, the Administrator was interviewed and stated they were aware the bariatric Hoyer lifter was removed from Resident #46's unit for repairs but could not recall when the Hoyer lifter broke. 10 NYCRR 415.5(e)(1)

Based on record review and interviews conducted during the recertification survey from 2/21/2024 to 2/28/2024, the facility did not ensure a resident's financial records were made available through quarterly statements. This was evident for 1 (Resident #247) of 38 total sampled residents. Specifically, Resident #247 did not receive their quarterly Resident Fund Statements in writing within 30 days of the end of the quarter. The findings are: The facility policy titled Resident Funds Account dated 8/2023 documented the resident, designated representative, or legal representative will be provided, at least quarterly, with a statement showing the account balance, funds deposited and withdrawn, and interest accrued. Resident #247 had diagnoses of hypertension and heart failure. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #247 had mild cognitive impairment. On 2/21/2024 at 10:03 AM and 2/27/2024 at 11:11 AM, Resident #247 was interviewed and stated they did not receive quarterly statements in writing for their resident fund account. Resident #247 stated they were asked to sign the quarterly statements but were not given a copy. The Resident Fund Statement dated from 9/30/2023 to 12/29/2023 documented Resident #247's signature acknowledging they received the quarterly statement on 2/20/2024. On 2/28/2024 at 11:24 AM, the Finance Coordinator was interviewed and stated they reviewed quarterly Resident Fund Statements with residents who had cognitive capacity to understand their account information. The Finance Coordinator stated they only provided the residents with a written copy of their statement if the resident specifically asked for a copy. Resident #247 was asked to sign their quarterly Resident Fund Statement but was not provided with a copy. The Finance Coordinator stated they were unaware residents were supposed to receive written copies of their statements. On 2/28/2024 at 1:11 PM, the Administrator was interviewed and stated the Finance Coordinator provided residents with a copy of their quarterly account statements upon request because some residents did not want a copy and would throw the statement away. 10 NYCRR 415.26(h)(5)(i)

Based on the record review and interviews conducted during the recertification and abbreviated (NY00328119 and NY00323553) survey from 2/21/2024 to 2/28/2024, the facility did not ensure alleged violations involving abuse were reported to the New York State Department of Health immediately, but no later than 2 hours, after the allegation was made, and the investigation conclusion was reported within 5 working days of the alleged violation. This was evident for 3 (Resident #81, #456, and #293) of 38 total sampled residents. Specifically, 1) the investigation conclusion for a resident-to-resident altercation involving Resident #81 and #456 was not reported to the New York State Department of Health within 5 days of occurrence, and 2) Resident #293's allegation they were verbally abused by Licensed Practical Nurse #2 was not reported to the New York State Department of Health. The findings are: The facility policy titled Abuse dated 2/2023 documented reporting of suspected or alleged resident abuse or mistreatment will be made to the appropriate state agency immediately, but no later than 2 hours, after the identification of the allegation. Investigation findings are reported to the state survey and certification agency within five days of completion. 1) The facility Incident Report initiated 11/15/2023 documented Resident #81 alleged Resident #456 hit them with a wheelchair at 1:05 AM, resulting in a head laceration and subsequent hospitalization for Resident #81. The Director of Nursing documented the conclusion of the investigation on 1/20/2024 that abuse did not occur. The Aspen Complaint Tracking System report dated 11/15/2023 at 2:04 AM documented the facility reported the altercation between Resident #81 and #456 to the New York State Department of Health. There was no documented evidence the facility reported the investigation results of the altercation between Resident #81 and #456 within 5 working days of 11/15/2023. On 2/28/2024 at 1:46 PM, the Director of Nursing was interviewed and stated this incident involving Resident #81 and Resident #456 occurred on 11/15/23 at 1 AM and was submitted to the NYS DOH at 2 AM which was within the required timeframe. The facility then investigated the case to conclude there was no evidence to support that any abuse occurred. Director of Nursing stated once the investigation is completed, the results are submitted to the NYS DOH within 5 working days. However, they were not able to explain if the results of this investigation were ever submitted to NYS DOH. 48876 2) Resident #293 had diagnoses of diabetes mellitus and coronary artery disease. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #293 was cognitively intact. During an interview on 2/22/2024 at 11:07 AM, Resident #293 stated, in 9/2023, Licensed Practical Nurse #2 became frustrated after 2 unsuccessful attempts to obtain enough blood from Resident #293's fingerstick to test their blood glucose levels. Licensed Practical Nurse #2 told Resident #293 I hope your sugar goes up to 500 and you have a heart attack and die. It's your fault you're like this, having only 1 leg, and left the resident's room to retrieve another lancet to attempt a 3rd fingerstick on Resident #293. Licensed Practical Nurse #2 returned to Resident #293's room and the resident refused the fingerstick and told Licensed Practical Nurse #2 to leave their room. Resident #293 stated they reported the incident to Registered Nurse #1 that same evening and Registered Nurse #2 the next day. Resident #293 was informed Licensed Practical Nurse #2 was moved to work on another resident unit. Resident #293 then reported the alleged violation to the New York State Department of Health. A Social Work Note dated 9/8/2023 documented Resident #293 had a complaint and Social Worker #4 provided the resident with a Grievance Form. A Grievance Form dated 9/8/2023 documented Resident #293 reported to Social Worker #4 that Licensed Practical Nurse #2 became upset when they couldn't obtain a blood sample from a fingerstick to test the resident's blood glucose level twice. Licensed Practical Nurse #2 yelled and cursed at Resident #293, telling the resident it was their fault Licensed Practical Nurse #2 couldn't get the blood sample and their fault they were in this condition. There was no documented evidence Resident #293's allegation of verbal abuse by Licensed Practical Nurse #2 was reported to the New York State Department of Health within 2 hours of the resident's report of the allegation. On 2/23/2024 at 8:57 AM, Registered Nurse #2 was interviewed and stated they spoke with Resident #293 about their verbal abuse allegation involving Licensed Practical Nurse #2 two days after the occurrence. Registered Nurse #2 was told by Resident #293 that the resident already reported the incident to Registered Nurse #1. Registered Nurse #2 stated they did not initiate an investigation, did not report the allegation to the New York State Department of Health, told Resident #293 that Licensed Practical Nurse #2 no longer worked on their unit, and contacted Social Worker #4 so Resident #293 could file a grievance. On 02/23/2024 at 10:49 AM, Social Worker #4 was interviewed and stated Resident #293's Grievance Form was forwarded to the Director of Nursing and the Director of Social Work to determine whether further investigation was needed. Social Worker #4 did not further investigate the allegation because the Grievance Form did not document that further investigation was necessary and the Director of Social Work did not direct them to follow up with Resident #293. Social Worker #4 stated they did not report Resident #293's allegation of verbal abuse to the New York State Department of Health because the Director of Nursing and Director of Social Work were responsible for abuse allegation reporting. On 02/23/2024 at 3:18 PM, the Director of Social Work was interviewed and stated they notified Resident #293 that Licensed Practical Nurse #2 would be reassigned and would not return to their unit. The Director of Social Work stated they were unaware they were responsible for reporting allegations of abuse to the New York State Department of Health and was unable to provide documented evidence of the facility's response to Resident #293's allegation of verbal abuse. On 02/26/2024 at 12:24 PM, the Administrator was interviewed and stated all facility staff were mandated to report allegations and suspicion of abuse. The former Director of Nursing employed at the facility 9/2023 was the facility's abuse coordinator and signs of abuse were immediately reported to them. 10 NYCRR 415.4(b)(2)

Based on record review and interviews conducted during the Recertification and Abbreviated (NY00323553) Survey from 02/21/2024 to 02/28/2024, the facility did not ensure an allegation of abuse was thoroughly investigated. This was evident for 1 (Resident #293) of 38 total sampled residents. Specifically, an investigation of Resident #293's allegation of verbal abuse against Licensed Practical Nurse #2 was not completed. The findings are: The facility policy titled Abuse dated 2/2023 documented allegations of suspected abuse shall be promptly and thoroughly investigated by facility management with witness statements from staff, residents, visitors, and family members who may be interviewable and may have information regarding the allegation. Resident #293 had diagnoses of diabetes mellitus and coronary artery disease. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #293 was cognitively intact. During an interview on 2/22/2024 at 11:07 AM, Resident #293 stated, in 9/2023, Licensed Practical Nurse #2 became frustrated after 2 unsuccessful attempts to obtain enough blood from Resident #293's fingerstick to test their blood glucose levels. Licensed Practical Nurse #2 told Resident #293 I hope your sugar goes up to 500 and you have a heart attack and die. It's your fault you're like this, having only 1 leg, and left the resident's room to retrieve another lancet to attempt a 3rd fingerstick on Resident #293. Licensed Practical Nurse #2 returned to Resident #293's room and the resident refused the fingerstick and told Licensed Practical Nurse #2 to leave their room. Resident #293 stated they reported the incident to Registered Nurse #1 that same evening and Registered Nurse #2 the next day. Resident #293 was informed Licensed Practical Nurse #2 was moved to work on another resident unit. Resident #293 then reported the alleged violation to the New York State Department of Health. A Social Work Note dated 9/8/2023 documented Resident #293 had a complaint and Social Worker #4 provided the resident with a Grievance Form. A Grievance Form dated 9/8/2023 documented Resident #293 reported to Social Worker #4 that Licensed Practical Nurse #2 became upset when they couldn't obtain a blood sample from a fingerstick to test the resident's blood glucose level twice. Licensed Practical Nurse #2 yelled and cursed at Resident #293, telling the resident it was their fault Licensed Practical Nurse #2 couldn't get the blood sample and their fault they were in this condition. There was no documented evidence Resident #293's allegation of verbal abuse against Licensed Practical Nurse #2 was thoroughly investigated. On 2/23/2024 at 8:57 AM, Registered Nurse #2 was interviewed and stated they spoke with Resident #293 about their verbal abuse allegation involving Licensed Practical Nurse #2 two days after the occurrence. Registered Nurse #2 was told by Resident #293 that the resident already reported the incident to Registered Nurse #1. Registered Nurse #2 stated they did not initiate an investigation, told Resident #293 that Licensed Practical Nurse #2 no longer worked on their unit, and contacted Social Worker #4 so Resident #293 could file a grievance. On 02/23/2024 at 10:49 AM, Social Worker #4 was interviewed and stated Resident #293's Grievance Form dated 9/8/2023 was forwarded to the Director of Nursing and the Director of Social Work to determine whether further investigation was needed. Social Worker #4 did not further investigate the resident's abuse allegation because the Grievance Form did not document that further investigation was necessary and the Director of Social Work did not direct them to follow up with Resident #293. On 02/23/2024 at 3:18 PM, the Director of Social Work was interviewed and stated they notified Resident #293 that Licensed Practical Nurse #2 would be reassigned and would not return to their unit. The Director of Social Work stated they met with the resident to ensure they were satisfied with the outcome of the grievance investigation, but was unable to provide documented evidence Resident #293's abuse allegation was investigated, including witness statements and a conclusion to the investigation. On 02/26/2024 at 12:24 PM, the Administrator was interviewed and stated all facility staff were mandated to report allegations and suspicion of abuse. The former Director of Nursing employed at the facility 9/2023 was the facility's abuse coordinator and received reports from staff immediately following abuse allegation or suspicion. The Administrator was not aware of Resident #293's allegation of verbal abuse against Licensed Practical Nurse #2. 10 NYCRR 415.4(b)(3)

Based on record review and interviews conducted during the recertification and complaint (NY00331431) survey from 2/21/2024 to 2/28/2024, the facility did not ensure a person-centered comprehensive care plan was developed and implemented to meet a resident's needs. This was evident for 1 (Resident #113) of 38 total sampled residents. Specifically, a comprehensive care plan related to pain was not developed to address Resident #113's chronic pain. The findings include: The facility policy titled Care Plan-Comprehensive dated 10/2023, documented a comprehensive care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Resident #113 had diagnoses of Hypertension and Arthritis. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #113 had moderately impaired cognition. A Medical Doctor's Order dated 1/3/2024 documented Resident #113 was ordered acetaminophen 650 mg every 6 hours as needed for pain. The Comprehensive Care Plan related to alteration in comfort initiated 1/3/2024 documented Resident #113 had a diagnosis of arthritis. There was no documented evidence the Comprehensive Care Plan was developed with interventions to address Resident #113's risk for pain. On 2/28/2024 at 10:18 AM, Registered Nurse #3 was interviewed and stated that the admission nurse initiated the care plan related to Resident #113's pain on 1/3/2024. Resident #113 was assessed for pain every morning. Registered Nurse #3 stated they were responsible for developing care plans with interventions but was unable to explain the reason Resident #113's care plan did not include interventions. On 2/28/2024 at 2:46 PM, the Acting Director of Nursing was interviewed and stated the nurse managers were responsible for reviewing care plans within 5 days of a resident's admission to update the care plans depending upon the admission assessment. The care plan related to Resident #113's pain was initiated upon admission, but the team did not realize that interventions were not in place. 10 NYCRR 415.11(c)(1)

Based on observation, record review, and interviews conducted during the Recertification survey from 2/21/2024 to 2/28/2024, the facility did not ensure an activities program was provided to meet the interests of and support the physical, mental, and psychosocial well-being of the residents. This was evident for 1 (Resident #57) of 5 residents reviewed for Activities out of 38 total sampled residents. Specifically, Resident #57 was not engaged in meaningful activity programs in accordance with their preferences and needs. The findings are: The facility policy titled Recreation Programming dated 12/2023 based on comprehensive assessment, individualized care plan, and the preferences of each resident, an ongoing program of recreational services to support residents in their choice of activities were provided. The recreational programs/activities were designed to meet the interest of and support each resident's physical, cognitive, social, emotional, psychosocial, and spiritual wellbeing. Resident #57 had diagnoses of Dementia and Cerebral Infarction. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #57 was severely cognitively impaired. The annual assessment dated [DATE] documented Resident #57 was severely cognitively impaired, and their activity preferences included listening to music, pet therapy, keeping up with the news, getting fresh air when the weather was good, reading books, newspapers, and magazines, and interacting with groups of people. On 2/21/2024 from 10:45 AM to 11:21 AM, Resident #57 was observed sitting in their wheelchair at the nursing station. There were no ongoing activities on the unit and Recreation Leader present. There were 7 other residents seated by the nursing station and they were not engaged in an activity program or interaction. The February Activity Calendar for the unit posted next to the elevator documented Strolling Library at 10:30 AM. On 2/22/2024 from 10:37 AM to 11:15 AM, Resident #57 was observed self-propelling their wheelchair in circles on the unit. No activity program or Recreation Aide was observed on the unit. The February Activity Calendar documented Painting at 10:30AM. were happening on the unit for the day. On 2/23/2024 at 10:10 AM, Resident #57 was observed sitting alone in the floor dining room without any stimulation, interaction, or ongoing activity program. The Comprehensive Care Plan related to recreation initiated 1/25/2022 documented Resident #57's interests included listening to music, socializing with peers, and tabletop games. Interventions included to provide the resident with a monthly calendar and daily schedule of events and assist the resident in finding programs of interest. The Recreation assessment dated [DATE] documented Resident #57 enjoyed listening to music, reading chronicles, watching television, pet therapy visits, and observing activity programs. The Recreation Leader would provide Resident #57 with assistance as needed. The Activity Log from 2/1/2024 to 2/23/2024 documented Resident #57 participated in dance and movement and table/cognitive games on 2/16/2024, 1 out of 24 days. There was no documented evidence Resident #57 was engaged in an ongoing to meet their interests and needs. On 2/27/2024 at 11:12 AM, Certified Nursing Assistant #9 was interviewed and stated Resident #57 liked participating in group activities. Recreation staff did not offer Resident #57 activities or assist Resident #57 to any social events or other activity programs. On 2/27/2024 at 10:54 AM, Licensed Practical Nurse #6 was interviewed and stated activity programs occurred in the main auditorium, not on the unit. Cognitively intact and independent residents participated in the activity programs in the auditorium. The activity programs on the unit were inconsistent and intermittent. Resident #57 was active and enjoyed socializing, dancing, and listening to music. Resident #57 would participate in activities on the unit if they were provided. On 2/23/2024 at 11:32 AM, Recreation Leader #1 was interviewed and stated they were newly hired and had worked in the facility for a few weeks. Activities were scheduled to take place on Resident #57's unit from Monday to Friday from 9:45 AM to 11:30 AM and 1 PM to 5 PM. Activities included painting, bowling, scripture reading, watching movies, trivia, drawing and decorating, music, board games, and bingo. Recreation Leader #1 stated Resident #57 liked to be around people and would benefit from social events. Recreation Leader #1 was unaware how residents were made aware of daily activities and stated they did not provide activities with any bed-bound residents. On 2/26/2024 at 12:01 PM, the Recreation Director stated there Resident #57's unit did not have a Recreation Leader since 10/2023. No other recreation staff were assigned to cover the unit until Recreation Leader #1 was hired a few weeks ago. Recreation staff were responsible for visiting residents on the unit daily from 10 AM to 10:30 AM and inviting them to activity events for the day. Activities occurred on the unit from 10:30 AM to 12 PM and 2:30 PM to 5 PM. The Recreation Director stated they did not know the reason Resident #57 was not invited to or provided with activities on their unit. 10 NYCRR 415.5(f)(1)

Based on observation, record review, and interviews conducted during the recertification survey from 2/21/2024 to 2/28/2024, the facility did not ensure a resident was given psychotropic medication to treat a specific condition as diagnosed and documented in the clinical record. This was evident for 1 (Resident #213) of 5 residents reviewed for unnecessary medication out of 38 total sampled residents. Specifically, Resident #213 was not provided with nonpharmacological interventions to address behavior and was prescribed psychotropic medication without an appropriate diagnosis. The findings are: The facility policy titled Antipsychotic Medication Use dated 6/21/2023 documented residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The Attending Physician and other staff will gather and document information to clarify the resident's behavior mood, function, medical condition, specific symptoms, and risk to the resident. Resident #213 had diagnoses of non-Alzheimer's dementia and depression. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #213 was severely cognitively impaired, had no hallucinations or delusions, and did not display inappropriate behaviors. The Comprehensive Care Plan related to behavior symptoms initiated 8/2/2022 documented Resident #213 exhibited public urination, property destruction, pulling clothing out of drawers and closets, smearing feces, refusing medication, verbal and physical aggression, instigating behaviors, and delusions. Interventions initiated on 8/2/2022 documented to modify the environment to reduce episodes of negative behavior, psychiatric evaluation, to document all behaviors, to provide the resident with activities, and to determine the cause of resident behavior. The Psychiatry Consults dated 2/27/2023, 5/11/2023, and 9/19/2023 documented Resident #213 had a history of depression, anxiety, dementia, insomnia, and was not prescribed psychotropic medication. Resident #213 did not display psychotic symptoms, anxiety, or agitation. The Psychiatrist recommended monitoring Resident #213 without prescribing psychotropic medication. There was no documented evidence Resident #213 displayed inappropriate behavior from 9/19/2023 to 10/16/2023. Nursing Note dated 10/16/2023 documented Resident #213 had a room change due to roommate incompatibility. Nursing Note dated 10/17/2023 documented Resident #213 was found asleep in another resident's bed, was confused, and was redirected using a nonpharmacological approach. Resident #213 was better after nonpharmacological intervention. The Attending Physician Note dated 10/17/2023 documented Resident #213 was had a clinical assessment with focus on dementia with behavioral disturbances and roommate altercations. Psychiatry consult was requested. The plan was to continue redirection and reorientation. The Attending Physician Note dated 10/18/2023 documented Resident #213 was evaluated by Psychiatry on 10/16/2023 and Resident #213 was ordered to start receiving Trazodone 25 mg twice daily for depression and Seroquel 25 mg daily for depression. There was no documented evidence Resident #213 was evaluated by the Psychiatrist on 10/16/2023. Physician's Orders dated 10/23/2023 documented Resident #213 was ordered to receive Trazodone 25 mg twice daily for depression and Seroquel 25 mg daily for depression. The Psychiatry Consult dated 11/3/2023 documented Resident #213 should continue Trazodone and Seroquel for delusions, hallucinations, and worsening mood. Staff were able to redirect Resident #213 since the resident started on psychotropic medication. The Medication Administration Record from October 2023 to February 2024 documented Resident #213 received Seroquel 25mg 1 tablet once daily and Trazodone 25mg 1 tablet twice daily. The Comprehensive Care Plan related to psychoactive medication use initiated 11/19/2023 documented Resident #213 had depression, psychotic disorder, and anxiety. Interventions included to monitor and record occurrence of target behavior symptoms like verbal/physical aggression, psychosis, delusions, and to monitor and document side effects and effectiveness of the medication ordered by physician. There was no documented evidence Resident #213 was provided with nonpharmacological interventions to address behaviors prior to psychotropic medication initiation. There was no documented evidence nonpharmacological interventions attempted with Resident #213 were ineffective. There was no documented evidence Seroquel was ordered for an appropriately diagnosed condition. On 2/28/2024 at 10:50 AM, Licensed Practical Nurse #8 was interviewed and stated Resident #213 became agitated one day and became verbally aggressive towards their roommate. Resident #213 could not be redirected and was started on psychotropic medication. Resident #213 had episodes of agitation twice weekly and was easily redirected. Licensed Practical Nurse #8 was unable to provide documented evidence of Resident #213's behaviors or implemented nonpharmacological interventions. On 2/28/2024 at 2:21 PM, Attending Physician #1 was interviewed and stated Resident #213 had dementia and insomnia and displayed agitation and destructive behaviors. The Attending Physician #1 was unable to provide documented evidence of Resident #213's behaviors or symptoms related to psychosis and stated the Psychiatrist recommended the resident start psychotropic medication for psychosis. On 2/28/2024 at 5:12 PM, the Psychiatrist was interviewed and stated Resident #213 had dementia, depression, and anxiety. Resident #213 exhibited agitation and mood swings but was easily redirected. Resident #213 was started on Seroquel and Trazodone for increased agitation that could not be redirected. The Psychiatrist stated Seroquel was approved for treatment of bipolar disorder and schizophrenia. Resident #213 did not have a diagnosis of bipolar disorder or schizophrenia. The Psychiatrist stated they were unaware what nonpharmacological interventions were attempted prior to initiation of psychotropic medication. 10 NYCRR 415.12(l)(2)(i)

Based on observation, record review and interviews during an abbreviated survey (NY003030413), the facility failed to ensure that a resident environment remained as free from accident hazards as was possible, and that each resident received adequate supervision and assistance devices to prevent accidents. This was evident in 1 out of 3 residents sampled (Resident #1). Specifically, on [DATE] at 12:00 AM, Resident #1 was observed by Certified Nursing Assistant #1 (CNA #1) lying on a bedside floor mat with their head by the bottom portion of the bedframe. Between 1:00 AM and 2:00 AM, Resident #1 had blood on the palms of their hands and was seen scratching their back of head on the sharp portion of the bedframe. CNA #2 informed License Practical Nurse #1 (LPN #1) that Resident #1 had a nickel size wound at the back of their head. LPN #1 informed Registered Nurse Supervisor #1 (RNS #1) that Resident #1 had a known behavior of sleeping on the floor mats and had self-inflicted skin scratching behavior. RNS #1 did not conduct a physical assessment, neurological check, or monitor Residents #1' s vital signs. There was no documented evidence or care plans that Resident #1 slept on the floormat or had self-inflicting scratching behaviors. The Medical Doctor (M.D.) was not informed that Resident #1 had a wound to the head, which were not assessed or treated. On [DATE], at 05:15 AM, Resident #1 had no pulse and was unresponsive. LPN #1 called the Emergency Medical Services Number (911) and initiated Cardiopulmonary Resuscitation (CPR). At 06:00 AM, The Emergency Medical Services (EMS) Providers arrived at the facility and were unable to resuscitate Resident #1. The EMS Report Summary documented that Resident #1 had a bleeding laceration at the back of their head and was pronounced deceased at 06:36 AM. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy. The findings are A facility policy entitled Falls Management and Prevention, revised on ,d+[DATE], documented that, a fall is an unintentional change in position coming to rest on the ground, floor, or onto the next lower surface (onto bed, chair, or bedside mat). The policy/procedure stated that a fall risk will be completed for all residents, initially on admission, readmission, and significant change. After an identified fall, vital signs, neurological status, changes in cognition should be assessed by the nurse. If a resident had fallen, or were found on the ground, a complete head-to-toe assessment must be performed, and the physician contacted. Resident #1 was admitted to the facility with diagnoses which included, non-Alzheimer's dementia, Anxiety disorder, Anemia and Cancer. The Minimum Data Set 3.0 (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of ,d+[DATE]. Resident #1's cognition were severely impaired. Resident #1 required two people for extensive assistance in bed mobility, physical lifting, turning, and positioning. Resident #1 were wheelchair bound. A Fall Risk Evaluation dated [DATE], score Resident #1 at 18 indicating that Resident #1 were a high risk for falls. A behavioral monitoring tool dated [DATE], documented that Resident #1 did not display any behaviors. No interventions were needed. Resident #1 were not on a scheduled monitoring and rounding frequency. A Quarterly Review for falls dated [DATE], documented that Resident #1 had no falls over the past three months, was confined to a chair, had no orthostatic hypotension, and was unable to stand independently. The Interventions was to place floor mats next to the bed. A Fall Risk Care plan dated [DATE], documented that Resident #1 were high risk for falls related to dementia, confusion, history of an actual fall in July of 2021, and immobility. The interventions were to anticipate and meet Resident #1's needs, non-skid socks, and place floor mats next to bed. The Fall Risk Care plan did not include visual monitoring, Resident #1 were on a standard two-hour general monitoring that were designed for all residents. There were no documented evidence of increase monitoring after Resident #1 were seen on the floor mat and no indications as to how Resident #1 ended up on the floor mat. There were no documentation to place the bed in the lowest position. A medical record review revealed that there was no documentation to reflect that Resident #1 preferred to or had a habit of sleeping on the floor mat. There was no documented evidence of care plans with interventions for Resident #1 to sleep on the floormat. The Facility Investigation Report which included written statements from the staff was initiated by the Director of Nursing (DNS) on [DATE], documented that on [DATE] at 12:00 AM, Resident #1 were seen lying on the floor mat with their head by the bottom portion of the bedframe. Resident #1 was left on the floor as directed by LPN #1, who stated that Resident #1 had a behavior of sleeping on the floor. Resident #1 was later seen with blood on their palms between 1 AM and 2 AM. The RNS #1 came to the floor and were informed by the LPN #1 that Resident #1 had a sleeping on the floor mat behavior and a history of self-injurious behaviors. CNA #2 reported seeing Resident #1 scratching the back of the head on a sharp portion of the bedframe. CNA #2. reported that Resident #1 had a nickel sized wound to the back of their head. The Facility investigation dated [DATE], concluded that Resident #1 did not have a physical assessment or neurological checks with vital signs completed by either LPN #1 or RNS #1. On [DATE] at 05:00 AM, Resident #1 was non-responsive when staff attempted to do am hygiene and CPR was initiated. EMS arrived and eventually pronounced Resident # 1 deceased at 6:36 AM. Postmortem care were completed by CNA #1 and CNA #2 and Resident #1's body were transferred to the facility morgue in the basement. On [DATE] at 8:15 PM, the funeral home arrived and discovered a wound on the resident's head and a large amount of blood. The body was taken by the funeral home to the medical examiner and the Resident #1's cause of death has not been determined. The Facility's investigation report documented that the investigation was inconclusive for the origin of the head injury because the RNS #1 and the LPN #1 failed to complete a full body assessment of Resident #1 that was lying on the floor mat next to the bed. A Nursing Progress Note written by LPN #1 dated [DATE] at 2:19 AM, documented that the Date/Time of the actual observation was [DATE] at 12:00 AM. Resident #1 was observed with blood on the palms of their hands lying on the floor mat. Upon observation, scratches that were old and new were seen all over Resident #1's body. RNS #1 on duty was made aware. A Nursing Progress Note written by LPN #1 dated [DATE] at 8:07 AM, documented that they were called by the CNA #1 at 5:45 AM, stated that while in the process of providing care, Resident #1 were unresponsive. Resident #1's vital signs were monitored, and the resident's blood pressure was ,d+[DATE], pulse was 40 to 20. An immediate code and CPR were initiated. RNS #1 were notified, and they called 911. At 6:36 AM, Resident #1 was pronounced deceased by EMS. A medical record review dated [DATE] and [DATE] revealed that there was no documented evidence that RNS #1 did a physical assessment, neurological check, or monitored Residents #1' s vital signs. Resident #1 head were not examined or treated when Resident #1 were seen on the floormat with the head near to the bedframe. During interviews on [DATE] at 1:09 PM and at 3:00 PM, LPN #1 stated that on [DATE] at 11:30 PM, Resident #1 was in bed, awake, and breathing normally, with floor mats on both sides of the bed and the bed and in the lowest position. On [DATE] at approximately 12:00 AM, CNA #1 came to the desk and reported that Resident #1 was on the floor mat. LPN #1 said they went to room and saw Resident #1 lying on floor mat. They stated that they left the room immediately to call the RNS #1, and CNA #1 stayed with the resident. LPN #1 stated that RNS #1 came to the unit between 1:30 AM and 2:00 AM. RNS #1 saw Resident #1 lying on the floor in their room but did not examine Resident #1. LPN #1 stated it was normal behavior for Residents #1 to sleep on floor mat. During an interview on [DATE] at 2:19 PM, CNA # 2 stated that on [DATE] at 12:00 AM, Resident #1 was seen lying on a floor mat on the floor. Resident #1 was seen with nickel-sized wound to the back of their head. Resident #1 's head was on the sharp portion of the bed frame. CNA #2 informed LPN #1 that Resident #1's head was on the bed frame and a wound were seen at back of the head. LPN #1 told CNA #2 to leave Resident #1 alone. During an interview on [DATE] at 4:42 PM, CNA #1 stated that on ,d+[DATE]/ 2022 at 12:00 AM, Resident #1 was seen lying on a floor mat with their head against the frame of the bed. LPN #1 was informed, and they called the RNS #1. RNS #1 instructed LPN #1 and CNA #1 to leave Resident #1 on the floor and place a pillow under Resident #1 's head. CNA #1 stated that they placed the pillow under Resident #1 's head and did not see any signs of bleeding or injuries on Resident #1's head. During interview on [DATE] at 12:00 PM, RNS #1 stated LPN #1 called and reported that Resident #1 were on the floor but like to sleep on the floormat, as this was the normal behavior for Resident #1. RNS #1 stated that they went to Resident #1's room at approx. 1:30 to 2: 00 AM, and found Resident #1 on the floor mat, awake, and alert. RNS #1 stated they instructed the CNAs to push the bed away from Resident #1, move the side table away, and place pillows against the side of the bed and to keep an eye on Resident #1. RNS #1 stated that they did not perform a head-to-toe assessment. During an interview on [DATE] at 6:00 PM, the Director of Nursing (DNS) stated that LPN #1 and RNS #1 did not follow the facility's policy and procedure on falls and failed to assess the Resident #1, after finding Resident #1 on the floor. The DNS stated that the RNS #1, and LPN #1 was on suspension pending the outcome of the investigation. The DNS stated that on [DATE], the facility started to in serviced of all staff on falls prevention, policy & procedure on falls, assessments, neglect, and abuse reporting. The in-services are ongoing. During a follow up interview on [DATE] at 12: 30 PM, RNS #1 stated that they did not check Resident #1's Comprehensive Care Plan to verify if Resident #1's behavior of sleeping on the floor was addressed. RNS #1 stated that they did not do a head-to-toe assessment of Resident #1 when they saw Resident #1 on the floor mat. RNS #1 stated that they observed Resident #1 lying on their side with their body including legs on the floor mat. During interview on [DATE] at 6:15 PM, the M.D, stated that they were not called when Resident #1 was on the floormat and that on [DATE], they found out that Resident #1 expired. The M.D. stated that Resident #1 was assessed monthly, and that their head was normal, there was no skin infections, and there were no wounds noted on any part of the resident's body. The M.D stated that Resident #1 did not have any behavior problems and that the staff have never mentioned that Resident #1 had a behavior of sleeping on floor. The M.D. stated that Resident #1 was followed closely due to their medical condition and was last seen and evaluated on [DATE]. During a telephone interview on [DATE] at 2:50 PM, EMS personnel #1 stated that on [DATE] at 6:00 AM, Resident #1 was unresponsive in bed with a lot of blood on the pillow that was under their head. EMS stated it was hard to tell which part of the resident's head had the wound because the resident had a lot of hair. The EMS stated that the Resident's head was immediately wrapped with a bandage to slow the bleeding as they performed cardio-pulmonary resuscitation. The EMS stated that no staff members were available to discuss Resident #1' s medical condition. The EMS said they informed their Lieutenant that the resident had a head injury. EMS #1 said that the Medics were given the greenlight by medical control to pronounce Resident #1 deceased at 6:36 AM. 10 NYCRR: 415.12(h)(1)(2)

Based on observation, record review, and interviews during an abbreviated survey (NY00303413), the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. A head-to-toe comprehensive assessment was not performed, on a resident that was found on the floor. This was evident for 1 out of 3 residents sampled for quality of care (Resident #1). Specifically, on [DATE] at 12:00 AM, Resident #1 was observed by Certified Nursing Assistant #1 (CNA #1) lying on a bedside floor mat with their head by the bottom portion of the bedframe. Between 1:00 AM and 2:00 AM, Resident #1 had blood on the palms of their hands and was seen scratching their back of head on the sharp portion of the bedframe. CNA #2 informed License Practical Nurse #1 (LPN #1) that Resident #1 had a nickel size wound at the back of their head. LPN #1 informed Registered Nurse Supervisor #1 (RNS #1) that Resident #1 had a known behavior of sleeping on the floor mats and had self-inflicted skin scratching behavior. RNS #1 did not conduct a physical assessment, neurological check, or monitor Residents #1' s vital signs. There were no documented evidence or care plans that Resident #1 slept on the floormat or had self-inflicting scratching behaviors. The Medical Doctor (M.D.) was not informed that Resident #1 had a wound to the head, which were not assessed or treated. On [DATE], at 05:15 AM, Resident #1 had no pulse and was unresponsive. LPN #1 called the Emergency Medical Services Number (911) and initiated Cardiopulmonary Resuscitation (CPR). At 06:00 AM, The Emergency Medical Services (EMS) Providers arrived at the facility and were unable to resuscitate Resident #1. The EMS Report Summary documented that Resident #1 had a bleeding laceration at the back of their head and was pronounced deceased on [DATE] at 06:36 AM. The findings are: Resident #1 was admitted to the facility with diagnoses which including, Non-Alzheimer's Dementia, Anxiety disorder, Anemia and Cancer. The Minimum Data Set 3.0 Assessment (MDS) dated [DATE], documented that Resident #1 had a Brief Interview for Mental Status (BIMS) score of two indicating severely impaired cognition. Resident #1 required extensive assistance of two persons for bed mobility, physical lifting, turning, positioning, and was wheelchair bound. A Fall Risk Evaluation dated [DATE], score Resident #1 at 18 indicating that Resident #1 were a high risk for falls. A behavioral monitoring tool dated [DATE], documented that Resident #1 did not display any behaviors. No interventions were needed. Resident #1 were not on a scheduled monitoring and rounding frequency. A Quarterly Review for falls dated [DATE], documented that Resident #1 had no falls over the past three months, was confined to a chair, had no orthostatic hypotension, and was unable to stand independently. The Interventions was to place floor mats next to the bed. A Fall Risk Care plan dated [DATE], documented that Resident #1 were high risk for falls related to dementia, confusion, history of an actual fall in July of 2021, and immobility. The interventions were to anticipate and meet Resident #1's needs, non-skid socks, and place floor mats next to bed. The Fall Risk Care plan did not include visual monitoring, Resident #1 were on a standard two-hour general monitoring that were designed for all residents. There was no documented evidence of increase monitoring after Resident #1 were seen on the floor mat and no indications as to how Resident #1 ended up on the floor mat. There were no documentations to place the bed in the lowest position. A medical record review revealed that there was no documentation to reflect that Resident #1 preferred to or had a habit of sleeping on the floor mat. There was no documented evidence of care plans with interventions for Resident #1 to sleep on the floormat. The Facility Investigation Report which included written statements from the staff was initiated by the Director of Nursing (DNS) on [DATE], documented that on [DATE] at 12:00 AM, Resident #1 were seen lying on the floor mat with their head by the bottom portion of the bedframe. Resident #1 was left on the floor as directed by LPN #1, who stated that Resident #1 had a behavior of sleeping on the floor. Resident #1 was later seen with blood on their palms between 1 AM and 2 AM. The RNS #1 came to the floor and were informed by the LPN #1 that Resident #1 had a sleeping on the floor mat behavior and a history of self-injurious behaviors. CNA #2 reported seeing Resident #1 scratching the back of the head on a sharp portion of the bedframe. CNA #2. reported that Resident #1 had a nickel sized wound to the back of their head. The Facility investigation dated [DATE], concluded that Resident #1 did not have a physical assessment or neurological checks with vital signs completed by either LPN #1 or RNS #1. On [DATE] at 05:00 AM, Resident #1 was non-responsive when staff attempted to do am hygiene and CPR was initiated. EMS arrived and eventually pronounced Resident # 1 deceased at 6:36 AM. Postmortem care were completed by CNA #1 and CNA #2 and Resident #1's body were transferred to the facility morgue in the basement. On [DATE] at 8:15 PM, the funeral home arrived and discovered a wound on the resident's head and a large amount of blood. The body was taken by the funeral home to the medical examiner and the Resident #1's cause of death has not been determined. The Facility's investigation report documented that the investigation was inconclusive for the origin of the head injury because the RNS #1 and the LPN #1 failed to complete a full body assessment of Resident #1 that was lying on the floor mat next to the bed. A nursing progress note written by LPN #1 dated [DATE] at 2:19 AM, documented that Resident #1 was observed with blood on the palms of their hands, and had old and new scratches are all over their body. RNS #1 was informed. A progress note dated [DATE] at 8:14 AM, written by the LPN #1 documented called by CNA #1 at 5:45 AM, that while providing care, Resident #1 became unresponsive. Their vital signs were monitored, and B/P(blood-pressure) was ,d+[DATE], Pulse was 40 to 20. CPR was initiated and RNS #1 was notified and 911 called. The EMS Providers took over CPR and at 6:36 AM, Resident #1 was pronounced deceased . A Nursing Supervisor's note dated [DATE] at 6:43 AM, documented by the RNS that the writer was called to unit and informed that Resident #1 was unresponsive, CPR was started by the facility staff, and the Emergency Medical Number (911) was called. The EMS team took over and provided CPR and other interventions. Resident #1's next-of-kin was called and informed. EMS pronounced Resident #1 deceased at 6:36 AM. A Physician Monthly Physical Assessments Notes from [DATE], to [DATE], documented that Resident #1' s head was normal, there were no cuts, or open areas to the head or on any part of the body. A medical record review from [DATE], revealed that the medical doctor was not informed that Resident #1 was found on floor and sustained an injury to their head. A Medical record reviewed from [DATE] to [DATE], revealed that there was no documented evidence that RNS #1or LPN #1 assessed the resident's vital signs, performed a head-to-toe examination of Resident #1, nor evaluated neurological status after CNA #2 reported noting wound on back of resident's head. An EMS documentation titled Prehospital Care Report Summary by the FDNY (Fire Department of New York) and EMS dated [DATE] at 06:00:56 AM, documented that upon arrival on scene, the resident had no heartbeat, was pulseless, pupils were fixed, had a laceration to back of head that was bleeding. Resuscitative measures could not revive the resident and was pronounced deceased at 6:36 AM. During interviews on [DATE] at 1:09 PM and at 3:00 PM, LPN #1 stated that on [DATE] at 11:30 PM, Resident #1 was in bed, awake, and breathing normally, with floor mats on both sides of the bed and the bed was in the lowest position. On [DATE] at approximately 12:00 AM, CNA #1 came to desk and reported that Resident #1 was on the floor mat. LPN #1 said she/he went to room and saw Resident #1 lying on floor mat. They stated that they left the room immediately to call the RNS #1, while CNA #1 stayed with the resident. LPN #1 stated that RNS #1 came to the unit between 1:30 AM and 2:00 AM, saw Resident #1 lying on the floor in their room but did not examine Resident #1. LPN #1 said it was normal behavior for Residents #1 to sleep on floor mat. LPN #1 also said the behavior of sleeping on the floormat was not documented in the care plan or in the nursing notes. The LPN #1 stated that Resident #1 have tendency to self-inflict injury and observed Resident #1 with scratch marks on the body with blood on their palms. LPN #1 said resident's behavior of self-inflicting injury was not documented in the resident's care plan. During interview on [DATE] at 2:19 PM, CNA #2, stated that on [DATE] at approximately 12 AM, Resident #1 was seen lying face up on floor mat, trying to scratch their head on piece of metal at foot of bed. LPN #1 was called. The RNS #1 and LPN #1 went to the room said it was Resident #1 's usual behavior to sleep on floor mat, and just leave him/her there. CNA #2 said she/he inform LPN #1 that Resident #1 have a wound on back of their head and need to be covered, but LPN #1 said to leave Resident #1 alone. CNA #2 stated at approximately 5:00 AM, they went with CNA #1 to Resident #1's room to give care, as they lift Resident #1 off the floor to put back to bed, they noted Resident #1 was cold, and unresponsive. CNA #2 said they checked the pulse on right hand and there was no pulse, CNA #1 checked for breathing and resident was not breathing. CNA #2 said they informed LPN #1 that Resident #1 was unresponsive, that the nurse came to room with blood-pressure machine and checked blood pressure on resident's right arm and called a code. CNA #1 started chest compression. During an interview [DATE] at 4:42 PM, CNA #1 stated that he/she took care of Resident #1, that on [DATE], at approximately 12:00 AM, Resident #1 was lying on the floor mat and head towards foot of the bedframe. CNA #1 said they informed LPN #1 who came to the room and saw resident lying on the floor mat. CNA #1 stated the LPN #1 went to call the RNS #1. CNA #1 stated that LPN #1 RNS #1 came to Resident #1's room, and neither nurse examined Resident #1. CNA #1 stated the RNS #1 told them to push bed away, push the nightstand away from the resident, place pillows against the side of the bed so resident will not injure self against bed rail and leave the resident on the floormat and keep an eye on the resident. CNA #1 said he/she lifted Resident #1's head and place a pillow under resident's head, rolled sheets together, place under the resident's feet so resident #1's legs will not touch the floor. CNA #1 stated he/she did not see any blood on Resident #1's head, there was no blood on the floor or on the bed frame. CNA #1 said he/she was unaware if CNA #2 went back in the room to check resident's head, and at no time did the CNA #2 reported to CNA #1 they saw a wound on the head of the resident. CNA #1 said they made rounds at 3:30 AM and the resident #1 was still on floormat alert and breathing fine. CNA #1 said they went to resident #1's room to give morning care at 5:00 AM, and as they lifted Resident #1 off the floor with CNA #2, they noted that the resident was cold and unresponsive, had no pulse and was not breathing. LPN #1 was called came to the room with a blood-pressure machine, checked resident's blood-pressure. CNA #1 said they started chest compression on Resident #1, the EMS came at approximately 5:55 AM and they took over the chest compression. During interview on [DATE] at 12 PM, RNS #1 stated LPN #1 called and reported that Resident #1 was on the floor. RNS #1 stated that LPN #1 reported that Resident #1 like to sleep on the floormat, as this was the normal behavior for Resident # 1. RNS #1 stated that she/he went to the Resident #1's room and found Resident #1 on the floor mat, awake, and alert. RNS #1 stated the LPN #1 and CNA #2 informed them of scratches on Resident #1's legs, lifted the gown up, saw old scratches on both legs and thigh, that there was no active bleeding and no blood on Resident #1's palm. RNS #1 stated that they did not perform a head-to-toe assessment but instructed the CNAs to push the bed away from Resident #1, move the side table away, and place pillows against the side of the bed and to keep an eye on Resident #1. RNS #1 denied LPN #1 informed she/he that Resident #1 had self-inflicts injuries. During an interview on [DATE] at 6:00 PM, the Director of Nursing (DNS) stated it is unknown how Resident #1 sustained a head injury, that it was the funeral home attendant that informed the facility that the deceased had a cut on the head that was bleeding. The DNS said that the funeral home attendant removed the resident's body, and they were unable to view or confirm the injury on the head of the deceased . The DNS stated LPN #1 and RNS #1 acted on their own accord, failed to follow the facility's policy and procedure that stated, residents found on the ground must receive a head-to-toe physical assessment. The DNS stated that the RNS #1, and LPN #1 are currently on suspension pending the outcome of the investigation. The DNS stated that the facility stated to in serviced staff on falls, policy and procedure on falls, assessments, neglect, abuse reporting on [DATE]. During a follow up interview on [DATE] at 12: 30 PM, RNS #1 stated that they did not check Resident #1's Comprehensive Care Plan to verify if Resident #1's behavior of sleeping on the floor was addressed. RNS #1 stated that he/she did not do a head-to-toe assessment of Resident #1 when he/she saw Resident #1 on the floor mat. RNS # 1 stated that he/she observed Resident #1 lying on their side with their body including legs on the floor mat. During interview on [DATE] at 6:15 PM, the M.D, stated that he/she was not called when Resident #1 was on the floormat, on [DATE], he/she found out that Resident #1 was deceased . The M.D. stated that Resident #1 was assessed monthly, and that their head was normal, there were no skin infection, and no wound were noted on any part of the Resident #1's body. The M.D stated that Resident #1 did not have any behavior problems and that the staff have never mentioned that Resident #1's tended to sleep on floor. The M.D. stated that Resident #1 was followed closely due to the medical condition and was last seen and evaluated on [DATE]. During a telephone interview on [DATE] at 2:50 PM, EMS personnel #1 stated that on [DATE] at 6:00 AM, on arrival at the facility, Resident #1 was in bed with a lot of blood on the pillow under their head. They stated that it was hard to tell which part of the head had the wound as Resident #1 had a lot of hair. Resident #1's head was immediately wrapped with bandage to slow the bleeding as they performed cardio-pulmonary resuscitation. No staff members were available to discuss Resident #1' s medical condition. Their Lieutenant was informed that Resident #1 had a head injury. EMS #1 said that the Medics was given the greenlight by medical control to pronounce Resident #1 deceased at 6:36 AM. 10 NYCRR: 415.12

Based on observation, interviews and record review conducted during an abbreviated survey (NY 754), the facility did not ensure that a resident receive treatment and care in accordance with professional standards of practice and the residents' choices. This was evident in 1 of 3 residents sampled (Resident #1). Specifically, Resident #1's Hospital Discharge Summary dated 04/21/2021 documented that Resident #1 to follow up with Neurosurgery Consult Clinic. Record review revealed that Resident #1 missed the appointment on 12/01/2021 and the facility did not reschedule the appointment. The findings include: Review of the facility's Policy and Procedure entitled Physician-Consultations revised 01/2022 documented: Nursing shall coordinate all resident referrals including emergency or specialized services as ordered by medical provider. Referrals for medical services must be based on physician evaluation of resident need and a related physician order. After receiving a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Attempts to secure an appointment with the necessary agency will continue until an appointment is received. Residents who are admitted with appointments that have been scheduled prior to admission will have transportation and escort arrangements made by the transportation coordinator. Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14/15, indicating intact cognition. The resident required extensive assistance of 2 persons with most areas of his/her Activities of Daily Living (ADL) tasks. A Review of the Hospital Discharge Summary dated 04/21/2021 documented: Magnetic Resonance Imaging (MRI) of the cervical spine done 04/14/2021 showed [CONDITION(S)] Disc Disease with the worst level at Cervical 5 (C5)-C6 where there is severe central canal stenosis and moderate cord compression. Neurosurgery consulted; patient refused surgery at this time. Discussed surgical and conservative options with patient. Please follow up in Neurosurgery clinic on Wednesday clinic from 12:30 PM-3:30 PM (address and telephone number provided). Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Physician's Progress Note dated 09/22/2021 at 4:10 PM documented that hospital MRI of the cervical spine showed [CONDITION(S)] disc, severe central canal stenosis and moderate cord compression. Abnormal signal within the [NAME] and medulla oblongata. [MEDICATION(S)] and [MEDICATION(S)] were discontinued due to continual lethargy with improvement in mental status after discontinuance. Awake, alert, missed Neurosurgery appointment. Requested another appointment. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Nursing Progress Note dated 12/01/2021 at 3:45 PM documented that Resident #1 was scheduled for Neurosurgery Clinic appointment at 12:00 PM with 11:00 AM pick up. The resident was ready for appointment and staff were about to transfer the resident to wheelchair, but the resident refused. Resident #1 stated that he/she will not go unless he/she goes with a stretcher. As per transportation, arrangements were made for wheelchair, was unable to attain a stretcher at this time. Review of a Physician's Progress Note dated 12/02/2021 at 6:57 PM documented that Resident #1 missed Neurosurgery appointment again, requested another appointment. Record review revealed that a new appointment was not scheduled for Resident #1 after the resident missed the appointment on 12/01/2021. On 07/20/2022, surveyor received an email, a hand-written Appointment Information sheet, from the facility. The hand-written appointment sheet documented that an appointment was scheduled for Resident #1 on 03/17/2022, to be transported via stretcher. During an interview on 05/18/2022 at 3:55 PM, the Assistant Director of Nursing (ADON) stated that the facility had challenges getting Neurosurgery Clinic appointment for Resident #1 due to the pandemic. The ADON stated that the facility had issues with Resident #1's Insurance not wanting to pay for an ambulance. The ADON stated that the facility had arranged ambulette service but Resident #1 said the wheelchair could not fit in the ambulette. The ADON stated that the facility will schedule in house Neurology Consult for Resident #1. During an interview on 05/18/2022 at 4:00 PM, Resident #1 stated that the facility was not scheduling and making appropriate transportation arrangements for him/her to go to clinic appointments in the community. Resident #1 stated that the facility had made an appointment for him/her to be transported to Neurosurgery Clinic, but his/her wheelchair was too large and could not fit in the ambulette. Resident #1 stated that the clinic appointment and pick up was last year. Resident #1 stated that since he/she missed the appointment 12/2021, no one has gotten back to him/her regarding a new appointment. During an interview on 06/21/2022 at 3:16 PM, Resident #1's Attending Physician stated that he/she was Resident #1's Physician since Resident #1 was admitted to the facility. The Attending Physician stated that Neurosurgery Clinic appointment was made for Resident #1 in September but Resident #1 refused. The Attending Physician stated that in the meanwhile he/she ensured that Resident #1 was followed by the Physiatrist monthly and Resident #1 was also referred for Physical and Occupational Therapies. The Attending Physician stated that Resident #1 was seen by the in-house Neurologist last week. During a follow up interview on 07/20/2022 at 4:15 PM, Resident #1's Attending Physician stated that he/she reviewed the Neurologist Note dated 06/20/2022 and the Neurologist recommended that Resident #1 should go to Neurology Clinic in the community. During a follow up interview on 07/20/2022 at 1:00 PM, the Transportation Coordinator stated that ambulance transportation was arranged for Resident #1 to go to Neurosurgery Clinic on 03/17/2022 but the ambulance company cancelled the trip. The Transportation Coordinator stated that an appointment was made for Resident #1 to go to Neurosurgery Clinic on 06/02/2022 (after surveyor's on-site visit) but the ambulance arrived at the facility too late for the appointment. The Transportation Coordinator stated that the appointment was rescheduled for 08/05/2022. During an interview on 07/20/2022, the Director of Nursing (DON) stated that the facility had issues getting Resident #1's Neurosurgery Clinic appointment due to the COVID-19 pandemic. The DON stated that the facility made appointment for Resident #1 to go to the Neurosurgery Clinic on 12/01/2021 but Resident #1 refused to go by ambulette and requested an ambulance. The DON stated that the facility made an appointment for Resident #1 to go the Neurosurgery Clinic in March 2022 by stretcher, but the ambulance company did not have a provider (the DON clarified driver). The DON stated that another appointment was scheduled on 06/02/2022 but the ambulance arrived at the facility at 4:00 PM, past the appointment time. 415.12

Based on observation, record review, and staff interviews during the Recertification/Complaint survey, the facility did not ensure that infection prevention control practices were followed to help prevent the spread, development, and transmission of communicable diseases and infections. Specifically, (1) Residents' respiratory care equipment was not properly covered to prevent contamination and possible spread of infections to the residents. (2) The facility-specific water management plan for Legionella was missing required components the following components: (a) a site-specific water management plan that described the water distribution system, (b) a sampling plan for the potable water system and (c) a sampling plan for the cooling tower. In addition, the plan was not reviewed and/or revised within the last year. This was evident for 3 of 3 residents reviewed for respiratory care out of 38 sampled residents (Resident #s 24, 191, and 367) and the Water Management Plan reviewe for Infection Control. The findings are: 1) The facility's Policy and Procedure titled [CONDITION(S)] care dated 10/2014, last revised on 08/2021 documented that tracheotomy care has identical goals: to ensure airway patency by keeping the tube free of [MEDICATION(S)] buildup, to maintain [MEDICATION(S)] membrane and skin integrity, to prevent infection, and to provide psychological support .Aseptic technique must be used during cleaning and sterilization of reusable [CONDITION(S)] tubes, during all dressing changes, and during [CONDITION(S)] tube changes, either reusable or disposable. Gloves must be used on both hands during any or all manipulation of the [CONDITION(S)]. Sterile gloves must be used during aseptic procedures. Resident #24 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set 3.0 (MDS), Assessment Reference Date (ARD) 10/06/2021 documented the resident had moderate impairment in cognition, clear speech, made self understood and understood others. The MDS also documented the resident required extensive assistance of staff for most Activities of Daily Living. The Comprehensive Care Plan (CCP) for Respiratory dated 9/29/2021 documented that resident has an alteration in respiratory system related to Acute respiratory failure, Requires nebulizer treatment, and Tracheotomy care. Goals included: - Resident will receive adequate oxygenation as evidenced by resident's acceptable pulse oximetry level through the review date; Resident will receive effective treatments as evidenced by no SOB or bronco spasm through the review date; Resident will exhibit no signs of respiratory distress through the review date. Interventions included: - Administer treatments (nebulizer) & medications per MD orders. Observe for s/s of poor airway clearance and gas exchange. (SOB, coughing, skin color changes). Observe stoma site/ secretions for s/s of infection report same to MD. Provide O2 per MD orders. Maintain/change tubing per protocol. Provide tracheotomy care daily and PRN using aseptic technique. Suction secretions per MD orders and as needed (via [CONDITION(S)], orally or nasopharyngeal). The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [CONDITION(S)] collar FIO2 40% as tolerated every shift for SOB. Oral Suctioning every shift for Respiratory Therapist and as needed. Change inner cannula Q shift and prn every shift. [MEDICATION(S)] Aerosol Solution 108 (90 Base) MCG/ACT 2 puff via [CONDITION(S)] every 6 hours for SOB. [MEDICATION(S)] HFA Aerosol Solution 17 MCG/ACT ([MEDICATION(S)] HFA) 2 puff via [CONDITION(S)] every 6 hours for SOB. On 01/18/22 at 12:13 PM, Resident #24 was observed in the room sitting on the bed. An uncovered and undated [CONDITION(S)] oxygen mask was on the overbed table. Resident #24 stated that the oxygen mask is used during the night and taken off during the day. Resident #24 stated they did know when the tubing was changed. On 01/19/22 at 08:34 AM, Resident #24 was observed in bed sleeping with oxygen is in use via [CONDITION(S)] collar. On 01/19/22 at 09:07 AM, Resident #24 was observed in bed, awake with no oxygen in use. The oxygen mask was noted placed on the nightstand, uncovered. On 01/20/22, between 9:10 AM and 12:19 PM, the resident's oxygen mask was observed uncovered and placed on the night stand next to the resident's urinal. The same was observed on 01/21/22, between 8:50 AM and 11:14 AM. On 01/21/22 at 10:45 AM, Resident #24 was interviewed. Resident #24 stated they could not recall being given a bag to keep the oxygen mask in. Resident stated that the mask is taken off when not in use during the day and placed on the table. On 01/21/22 at 11:02 AM, an interview was conducted with the Certified Nursing Assistant (CNA #3). CNA #3 stated that Resident #24 used to be totally dependent on staff for all Activities of Daily Living, but now, the resident able to do things independently. CNA #3 also stated the resident uses oxygen at night. CNA #2 further stated that whenever the resident's oxygen mask is noted on the table during rounds, it is placed in the plastic bag. CNA#3 stated that they did not realize that the mask was placed on the table uncovered. On 01/21/22 at 11:14 AM, the RN Unit Manager, (RN #2), was interviewed and shown the resident's oxygen mask placed on top of the nightstand beside the urinal. RN #2 stated that the mask is supposed to be kept in a bag, and RN #2 was not aware that Resident #24 was placing it on the table. 2) Resident #191 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . [CONDITION(S)], [CONDITION(S)], Gastroesophageal Reflux Disease, [CONDITION(S)], [CONDITION(S)], Respiratory failure. The Admission Minimum Data Set 3.0 (MDS), Assessment Reference Date (ARD) 10/25/2021, documented the resident had severe impairment in cognition with long and short-term memory problems. The MDS documented the resident was totally dependent on staff for all Activities of Daily Living. The Comprehensive Care Plan (CCP) for Respiratory dated 10/18/2021 documented that resident has alteration in spontaneous ventilation R/T Respiratory failure/arrest. The CCP interventions included: Administer treatments (nebulizer) & medications per MD orders. Maintain vent settings per MD and respiratory therapist. Moisten airway by humidifier HS or continuously. Observe for s/s of poor airway clearance and gas exchange. (SOB, coughing, skin color changes.) Observe secretions color, consistency and odor, report abnormalities to MD. Provide tracheotomy care daily and PRN using aseptic technique. Suction secretions per MD orders and as needed (via [CONDITION(S)], orally or nasopharyngeal). The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 01/19/22 at 09:15 AM, Resident #191 was observed in bed. A uncovered Yankeur Suction tubing catheter was noted dangling from resident's overbed table next to the suction cup. On 01/20/22 at 09:57 AM, the resident was observed. Resident #191 took the Yankeur from the overbed table to suction self orally and placed the catheter back on the table. On 01/20/22, between 08:47 AM and 12:20 PM, the Yankeur suction catheter was observed placed on the suction pump on top of the overbed table. On 01/21/22, between 08:24 AM and 10:45 AM, theYankeur suction catheter was observed placed on overbed table. On 01/21/22 at 10:34 AM, an interview was conducted with the Certified Nursing Assistant (CNA #2). The CNA stated that they have seen the resident use the suction tube to self-suction and place the tubing back on the table. CNA #2 stated that the Therapist gives out the Yankeur to the resident when they are giving [CONDITION(S)] care, and they are not sure where the Yankeur is supposed to be kept. 3) Resident #367 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set 3.0 (MDS), Assessment Reference Date (ARD) 12/28/2021, documented the resident had moderate impairment in cognition. The residsent was able understand others and make self understood. The MDS also documented the resident required extensive assistance of staff for most Activities of daily Living. The Comprehensive Care Plan (CCP) for Mechanical Ventilation dated 12/22/2021 documented that resident has Alteration in spontaneous ventilation R/T Disease process intermittent Asthma and acute respiratory failure on vent. Goals included: - Resident will have no complications from ventilator therapy occur through the review date; Resident will not demonstrate any signs and symptoms of infection through the review date. Interventions included: - Administer treatments (nebulizer) & medications per MD orders. Maintain vent settings per MD and respiratory therapist. Observe for s/s of poor airway clearance and gas exchange. (SOB, coughing, skin color changes). Observe secretions color, consistency and odor, report abnormalities to MD. Observe stoma site/ secretions for s/s of infection report same to MD. Provide tracheotomy care daily and PRN using aseptic technique. Suction secretions per MD orders and as needed (via [CONDITION(S)], orally or nasopharyngeal). Assess for relief. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 01/18/22 at 11:59 AM, Resident #367 was observed in bed holding a Yankeur suction catheter tube. Resident #367 occasionally placed it on the overbed table or on top of the bed sheet. On 01/19/22 at 09:05 AM, the resident was observed in bed sleeping, An uncovered Yankeur suction catheter was noted dangling from the bed pointing to the floor. On 01/20/22 between 08:45 AM and 12:30 PM, resident was observed in bed with a Yankaur Suction catheter placed on the bed cover sheet On 01/21/22 at 08:25 AM, the resident was observed in bed sleeping with an uncovered Yankaur Suction catheter, resting on their left. On 01/21/22 at 10:40 AM, an interview was conducted with CNA #1. The CNA stated that Resident #367 is able to suction self orally, and usually holds on to the suction tubing. CNA #1 stated that they are only assigned to the resident today and was not aware the resident was placing the tubing on top of the bedsheet. On 01/21/22 at 10:47 AM, an interview was conducted with the Respiratory Therapist (RT). The RT stated that some of the agency per diem respiratory therapists have been noted to be giving out Yankeur suction catheters to the residents uncovered most of the time. The RT stated not keeping the tube covered is an infection control problem. The RT stated that whenever they see the yankeur suction catheter uncovered, it is replaced and placed in a plastic bag. The RT further stated that the floating RT will be educated to ensure that residents' tubing are properly protected. On 01/21/22 at 11:25 AM, RN manager, RN #2, was interviewed. RN #2 stated that the oral suction tubing is supposed to be kept in the bag to prevent infection. On 01/21/22 at 02:56 PM, an interview was conducted with the Infection Prevention Control Person (RN/ICP). RN/ICP stated that daily round is done every shift by the Director of Nursing (DON), and the Nurse Managers, to ensure that proper infection control protocol is followed by the staff. RN/ICP stated that they have not been noticing the Suction tubing being placed uncovered in the resident's room. RN/ICP further stated that all staff including the Nurse Managers will be given re-in-service to prevent further occurrence, and more rounds will be done to ensure compliance. On 01/25/22 at 10:39 AM, an interview was conducted with the DON. DON stated that the facility has been very thorough in ensuring that infection prevention control protocol is strictly followed by all staff, especially with the prevailing COVID-19 Pandemic. DON stated that rounds are frequently made on the units to ensure compliance. DON further stated that they are very surprised that such breach in infection prevention control have been noticed on the unit because all the past, the facility has had no such deficiency. DON stated that immediate action has been taken to correct the situation and prevent further occurrence. 4) The facility-specific water management plan for Legionella was missing required components including but not limited to (a) a site-specific water management plan that described the water distribution system, (b) a sampling plan for the potable water system and (c) a sampling plan for the cooling tower. In addition, (d) the plan was not documented as having been reviewed and/or revised within the last year. (a) Record review of two facility legionella water management plans (one for the potable water system, and one for the cooling tower, together as the plan) both titled, Management and Maintenance Plan for Local Law 77 revealed the plan lacked the required component of a description of the facility-specific water distribution system. In an interview on 1/25/2022 at 5:08 PM, the Administrator stated the Director of Engineering was charged with maintaining the facility's water management plan. In an interview on 1/25/2022 at 1:16 PM, the Director of Engineering stated the water management plan was last reviewed sometime last year but could not recall when. They further stated that the water management plan would not include the water distribution system within the building because that was domestic water and the facility utilized condenser water for the potable system. They additionally stated that the distribution system for the condenser water was not described within the plan, but that they were aware of the water system layout within the facility by memory. Record review of the facility's water management plan revealed it lacked required components of a Legionella sampling plan for (b) the potable water system and for (c) the cooling tower, including but not limited to specific monitoring sites; frequency at which each monitored site is evaluated; and policies and procedures for personnel, new staff or an outside consultant to identify specific sampling locations for the facility staff and consultants when performing sampling and maintenance activities. In an interview on 1/25/2022 at 1:15 PM, the Director of Engineering confirmed that there was no sampling plan for either the potable water system or for the cooling tower within the plan. They additionally stated that water samples were collected and analyzed by a laboratory. (d) Record review of the facility's water management plan revealed it was not documented as having been reviewed and/or updated within the last year. In an interview on 1/25/2022 at 1:17 PM, the Director of Engineering stated the water management plan was last reviewed sometime last year but could not recall when and did not document the review. 415.19(a)(b) (1-3)

Based on observation, staff interview, and record review conducted during the Recertification Survey conducted 1/18/22 to 1/25/22, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety. Specifically, (1) food was stored in refrigerator/freezer without proper labeling, dating, and covers/sealing, (2) proper refrigerator/freezer temperatures were not maintained, (3) week-old prepared food was not discarded, (4) staff were not practicing appropriate hand hygiene and glove use during food preparation activities to prevent cross-contamination. This was evident for the Kitchen Observation Facility Task. The findings are: The Food Storage Policy revised 2/25/2021, documented: Food will be stored in an area that is clean, dry and free from contaminants. Food will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination. All containers must be legible and accurately labeled and dated. Refrigeration temperatures should be thermostatically controlled to maintain food temperatures at or below 41 degrees F and freezer temperatures to keep food frozen solid. All refrigerator units will be kept clean and in good working condition at all times. All foods should be covered, labeled and dated. All freezer units will be kept clean and in good working condition at all times. All foods should be covered, labeled and dated. Safe thawing: frozen meat, poultry, and fish should be defrosted in a refrigerator for 24 to 48 hours and should be used immediately after thawing. On 01/18/22 at 09:56 AM, an open bag of chicken fingers, with a dried-out appearance, was observed in walk-in freezer #4, without a date on the open bag; a pan of spinach with a metal lid was observed in walk-in refrigerator #1 without a label or date. The walk-in freezer section of box #1 was at a temperature of 10 degrees F (Fahrenheit). Walk-in refrigerator #2, 8 rolls of ground beef and a bag of chicken were observed thawing in a bucket on top of a box of chicken. No dates for delivery or pull dates (date taken out of the freezer) was observed. An uncovered pan of unidentified food was observed in the freezer section of refrigerator #2. Refrigerator unit # 3 had a rack with cakes dated 1/11/22 and peach cobbler dated 1/12/22. The refrigerator temperature was 50F; the freezer did not have an inside thermometer. The outside thermometer read 15F. On 1/24/22 at 8:45 am, walk-in box #3 refrigerator was observed. There was a pan of raw, sliced onions without a date. Walk-in box #3 freezer contained a box with an open bag of onion rings inside. The product was exposed, and there was no open date on the bag. The Cook was observed going into walk-in box #3 wearing gloves. The Cook exited the refrigeration unit still wearing gloves, returned to cooking station and began panning out waffles. The Cook did not remove the gloves and wash hands prior to working with the waffles. Walk-in box #2 refrigerator was observed with an open box of fish. The bag inside was open with fish exposed, and there was no open date on the bag. The pull date (date taken from the freezer and transfered to the refrigerator) was posted on the wall, on a plain piece of paper, above was 1/16/22. An interview with the FSD was conducted on 01/18/22 at 09:56 AM during initial tour of the kitchen. The FSD did not have an issue with the temperatures as the food was frozen solid. Regarding proper temps, FSD aware that it should be zero degrees for a freezer. An interview with the Cook was done on 01/24/22 08:48 AM with regard to the proper procedures for infection control, hand washing, and food handling. The Cook stated before prepping food, hands should be washed with soap and water prior to donning gloves. The Cook did not realize that he/she had not taken off gloves and washed hands prior to starting work on waffles. The Dietary Supervisor was interviewed on 01/24/22 at 08:45 AM regarding storage of food items. The Supervisor stated everything should be dated. 415.14(h)

Based on observations, record review, and staff interviews conducted during the Recertification/Complaint survey, (1) the facility did not ensure that the Comprehensive Care Plan (CCP) was reviewed after each assessment or revised with changes in the resident's condition. Specifically, the CCP was not reviewed and revised after a resident with fragile skin sustained a skin tear. (2) The facility did not ensure that Resident or Resident's representative was offered the opportunity to participate in the revision and/or review of the comprehensive care plan. Specifically, cognitively intact residents were not invited to quarterly care plan meetings. This was evident for 1 of 7 residents reviewed for Accident, (Resident #493) and 1 of 2 residents reviewed for care plan meeting (Resident #64), out of 38 sampled residents. The findings are: The facility Policy on Care Plans - Comprehensive dated ,d+[DATE], last revised ,d+[DATE] documented A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .Each resident's care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to participate in the planning process .Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan .Assessments of the residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. (1) Resident #493 admitted to the facility [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set 3.0 (MDS) assessment, Assessment Reference Date (ARD) [DATE], documented that the resident had moderately impaired cognition - decisions poor, cues/supervision required; the resident had clear speech with distinct intelligible words, made self understood, and understands others. The MDS also documented the resident was totally dependent on staff for most Activities of daily Living. The Comprehensive Care Plan (CCP) for Skin Integrity initiated [DATE], last revised [DATE] documented that resident was at risk for impaired skin integrity related to fragile skin. The CCP goal was for the residents's skin to remain intact. Interventions included: Avoid mechanical trauma - Constrictive shoes, cutting and trimming corns and calluses, adhesive tapes, improper shaving, and vigorous massage. Report to MD any signs of deterioration or significant change to area of impairment. Apply protective/preventative skin care. The Comprehensive Care Plan (CCP) for Skin Integrity initiated [DATE], last revised [DATE] documented that resident had impaired skin integrity related to multiple bruises to bilateral upper extremities. Goals included: resident's impaired skin area will show signs of improvement/healing during the review period, with interventions including Apply treatment as per order; Monitor/document/report to MD PRN of any sign or symptoms of infection. A Nursing Note dated [DATE] documented: Called to assess resident who was noted lying supine in bed with a skin tear to Right antecubital area of hand. Resident had a name band on the hand, and it appears that the friction caused by the band on the hand that was crossed on her chest caused an alteration in skin integrity to both arms. Resident skin is paper thin, and the slightest irritation causes the skin to tear. Also noted a smaller skin tear on Left hand. Slight bleeding noted to both sites. No swelling observed or s/s of pain or discomfort. NP (Nurse Practitioner) notified and ordered [MEDICATION(S)] to site 2x daily. Unable to contact Nephew. Notified Niece. There was no documented evidence the CCP for Skin Integrity was reviewed and revised with new interventions when the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE] at 02:42 PM, an interview was conducted with the Registered Nurse Supervisor (RN #1). RN #1 stated that resident was on their unit before resident expired. RN #1 also stated that resident was frail with very fragile skin, like paper. RN #1 stated the resident's skin was prone to tear without any pressure and was previously noted with few episodes of skin tear which were documented in the progress notes. RN #1 further stated the Nurse Manager/RN Supervisor is responsible for updating the care plan. RN #1 stated they thought the resident's skin integrity care plan was updated for the previous skin tear noted on [DATE]. On [DATE] at 01:00 PM an interview was conducted with the Assistant Director of Nursing (ADON). ADON stated that resident was assessed on [DATE] after the reported incident, noted with some skin tear on the left arm, which could be related to resident's chronic fragile skin. ADON further stated that the resident's skin integrity Care Plan was supposed to be updated, and they did not know it was not updated. On [DATE] at 10:39 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that RN on the unit is supposed to initiate and update the resident's Comprehensive Care Plan, the Nurse Manger and the RN supervisors are supposed to check for the proper documentation on care plan initiation and update and make the needed corrections are noted. DON also stated that they know that the resident is at high risk for skin tear, but they are not aware that the resident's care plan for Skin Integrity were not updated as the impairment in resident's skin assessments were observed. (2) The facility policy titled Care Planning - Interdisciplinary Team created ,d+[DATE] and last updated ,d+[DATE] documented it is the facility's policy that the resident, the resident's family and/or the resident's legal representative/guardian or surrogate are invited and encouraged to participate in the development of and revisions to the resident's care plan. An IDT (Interdisciplinary team) meeting V.3 note will be completed in the EHR (Electronic Health Record) after care plan meeting is completed. Resident #64 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission minimum data set (MDS) dated [DATE] documented that the resident had intact cognition. The baseline care plan was created on [DATE]. Review of the progress notes [DATE]-[DATE] revealed no documented evidence that the resident and/or resident's family had been invited to an initial care plan meeting. There was documented evidence that a quarterly care plan meeting had been held. A progress note dated [DATE] documented a quarterly care plan meeting was held for the resident. The note does not document that the resident was invited or attended the quarterly care plan meeting. The medical record did not have any documented evidence that the resident and/or resident's representative was invited to or or attended this quarterly care plan meeting. On [DATE] at 9:35 AM the resident was interviewed about participation in care planning. The resident stated that they were not aware of care plannings or the care plan process. This writer explained what the care plan process is to the resident and he stated that he did not attend a care plan meeting when he was first admitted or since admissin. Resident stated that they were only aware that next week they were supposed to go back to doctor to look at their feet and that's the extent of it. On [DATE] at 11:45 AM the Social Worker (SW #1) for the unit was interviewed. SW #1 stated care planning meetings are held once a week on Tuesdays. Social Work discusses the social and emotional well-being and and answers any questions that the family/resident may have with regards to their wellness at the care plan meeting. Social work calls the family members to set up the meeting. Each discipline charts on their own portion of the meeting. Social Work documents care plan attendance or declination via an attestation form. The resident's guardian or family member signs off on the attestation form as well. There are two forms in the medical record, one is an invite, and the other one is an attestation form. On [DATE] at 11:37 AM SW #1 was interviewed again. SW #1 stated that another social worker (SW #2), who is no longer at the facility, was assigned to Resident #64 at the time of the care plan meeting. SW #1 stated Resident #64 was not invited to the initial care plan meeting by SW #2, and it was an oversight. SW #1 stated that they had the resident sign today for an upcoming care plan meeting and had the resident's mother agree to participate by phone as well. On [DATE] at 12:12 PM the Director of Social Work (DSW) was interviewed. The DSW states that SW #2 was assigned to the resident upon admission. The DSW stated Social Work receives a care plan meeting schedule from the MDS Coordinator. The SW coordinates the care plan meetings and invites the residents who are alert and oriented. Families are invited to the care plan meeting via mail, and they may also be called. The family usally attends via phone. A lot of times resident won't come, but that's usually documented. Care plan attendees are documented in the EMR (Electronic Medical Record). The DSW states the SW explains the care planning process and care plan meeting date upon admission to the resident and family. An invitation letter is also sent. A lot of times, the resident will forget ther [NAME] a meeting, but the invitation should be documented in the EMR. SW #2 may have been overwhelmed, and the lack of invitation was an oversight. 415.11(c) (1)

Based on record review and staff interview conducted during the Recertification and Abbreviated survey (NY 550), the facility did not ensure that each resident was seen by a physician at least once every 30 days for the first 90 days after admission, and at least every 60 days after that. Specifically, there was no documented evidence that a resident was seen by a medical provider (physician, physician assistant, or nurse practitioner) every 30 days for 90 days after admission. This was evident for 1 of 38 sampled residents. (Resident # 444) The Findings include: The facility's policy and procedure, titled Physician Services with revised date 04/2021, states that it is the facility's policy to ensure the medical supervision of residents' care during their stay, orders for immediate care and needs are met by a Physician. The Attending Physician/Nurse Practitioner will perform pertinent and timely medical assessments, prescribe an appropriate medical plan of care, provide adequate information regarding the resident's condition and medical needs, and visit the resident at appropriate intervals. Physicians will maintain regular visits based on regulations and facility policy. The policy further states that it is the responsible of the facility to ensure that another physician supervises the care of residents when the attending physician is unavailable. Resident # 444 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 444 cognition as intact with a Brief Interview for Mental Status score of 15. Resident # 444 was on pain management and received pain medication as needed. A review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 01/21/2022 at 11:25 AM, the Registered Nurse (RN) Manager stated that Resident # 444 main complaint was about pain medications. The resident was on [MEDICATION(S)], and it was ordered for 14 days, and it was renewed after the doctor reassessed the resident. The RN Manager does not know why the Attending Physician, or the Nurse Practitioner did not see Resident # 444. During an interview on 01/24/2022 at 1:03 PM, the Nurse Practitioner (NP) stated that Resident # 444 was evaluated for complaints of pains towards the last day of July. The NP said that notes were done but omitted them in the resident chart. The NP does not know if the Attending Physician saw Resident # 444. Residents are seen monthly if they have any complaints or whatever the nurse's place in the communication book. The resident will be seen evaluated and documented in the chart. During an interview on 01/24/2022 at 3:44 PM, the Medical Director stated the NP saw Resident # 444 and wrote a note, but it did not go through. The Attending Physician and the NP collaborate. There should have been a note when the NP saw Resident # 444. 415.15(b)(2)(ii)

Based on observations, record reviews, and staff interviews conducted during a Recertification survey, the facility did not ensure that the resident's drug regimen was free of unnecessary medications. Specifically, the psychiatrist recommended discontinuing [MEDICATION(S)] for a resident on 12/06/2021. On 01/24/2022, the Medication Administration Record shows that the resident was on [MEDICATION(S)]. There was no documented evidence in the clinical record to support why the resident was still on the [MEDICATION(S)]. This was evident for 1 of 5 residents reviewed for the Unnecessary Medication out of a sample of 38 residents. (Resident # 200). The findings include. The facility policy and procedure titled Physician-Consultants with revised date 08/2021 states that it is the policy of the organization to ensure all residents receives medical care in a timely manner. To ensure appropriate and timely care by specialist physicians a consultant will perform requested evaluation and provide a consultant note or report. The policy further states that the attending physician will consider the appropriateness of the consultant recommendation relative to the resident/patient current condition, risk factors and existing medication regimen. As appropriate the attending physician will approve orders base on the consultant recommendation. The facility's policy and procedure, titled Physician Services with revised date 04/2021, states that it is the facility's policy to ensure the medical supervision of residents' care during their stay, orders for immediate care and needs are met by a Physician. The Attending Physician is required to review all recommendation from any discipline. The physician is not obligated to accept any recommendation but must provide clinical documentation on reasons for not accepting or not accepting said recommendation. Resident # 200 was admitted to the facility on [DATE] with diagnoses which include [CONDITION(S)], Dementia, Hypertension, and [CONDITION(S)]. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #200 had severely impaired cognition with a Brief Interview for Mental Status score of 2 out of 15. Section N of the MDS indicated that Resident # 200 is on Antipsychotic and Antidepressant medication. On 01/20/2022 at 9:43 AM, Resident # 200 was observed calmly resting in bed and talking to him/herself. On 01/21/2022 at 9:19 AM Resident # 200 was observed resting quietly in bed. On 01/24/2022 at 9:05 AM, Resident # 200 was observed sleeping in bed. On 01/25/2022 at 10:12 AM, Resident # 200 was observed resting quietly in bed. A Physician Order dated 11/13/2021 contained [MEDICATION(S)] 2.5 mg by mouth two times a day for Prophylaxis, [MEDICATION(S)] 25 mg, 0.5 tablet at bedtime for depression, and [MEDICATION(S)] 40 mg by mouth one time a day for depression. A Care Plan initiated on 11/13/2021 documented that Resident # 200 uses [CONDITION(S)] medications related to medical diagnosis of depression. A Behavior Note dated 11/26/2021 documented that Resident # 200 target behaviors include increase in self isolation. A Medication Regimen Review Note dated 11/28/2021 at 2: 24 PM documented Medication Regimen Review had a recommendation. A Pharmacist Consultant Note dated 11/28/2021 documented that Resident # 200 is on [MEDICATION(S)] 12.5 mg at bedtime for depression. This low dose appears to be Hypnotic, have a psychiatrist evaluate the use of the medication and dosing and the diagnosis. A Psychiatrist Consult Note dated 12/06/2021 documented no increase in severity of [CONDITION(S)], no increase in anxiety, depression with [MEDICATION(S)], and no fatigue. Resident # 200 is on [MEDICATION(S)] 12.5mg at bedtime and [MEDICATION(S)] 40mg daily. Recommended to discontinue [MEDICATION(S)], continue [MEDICATION(S)], and monitor for increased [CONDITION(S)] and depression. A review of the Physician orders dated 12/06/2021 to 01/24/2022 has no documented evidence that the [MEDICATION(S)] was discontinued. A review of the progress notes dated 12/06/2021 to 01/24/2022 has no documentation regarding why the [MEDICATION(S)] was not discontinued, and there was no documented evidence that the resident displayed any behaviors. A review of the Medication Administration Record dated 12/06/2021 to 01/24/2022 revealed that [MEDICATION(S)] 12.5 mg was administered. During an interview on 01/21/2022 at 12:40 PM, the Certified Nursing Assistant # 4 (CNA #4) stated that Resident # 200 is confused, talks to him/herself, and calls out family members at times. Resident # 200 refuses care at times but is not combative. During an interview on 01/24/2022 at 11:28 AM, the Registered Nurse Manager #3 (RNM #3) stated that Resident # 200 talks to him/herself but has no aggressive behavior. The resident has been on [MEDICATION(S)] 12.5 mg at bedtime since admission. Resident # 200 does not interact with any residents. During an interview on 01/24/2022 at 3:20 PM, the Attending Physician (AP) stated that the resident is on [MEDICATION(S)] for depression. The psychiatrist saw the resident on 12/06/2021 and recommended discontinuing the [MEDICATION(S)]. The AP does not know why the [MEDICATION(S)] was not discontinued. The AP has not seen the consult that was done on 12/06/2021. During a follow-up interview on 01/24/2022 at 3:33 PM, the AP stated that as per the Nurse Practitioner, Resident # 200 has behavior issues, that is why the [MEDICATION(S)] was not discontinued. The AP does not know why there was no note in the resident chart. During an interview on 01/25/2022 at 11:22 AM, the Medical Director (MD) could not tell why Resident # 200 is still on the [MEDICATION(S)]. The MD will discuss with the Attending Physician why Resident # 200 is still on [MEDICATION(S)]. The MD stated that the AP must disagree or agree with the recommendation. Recommendations are acts on a couple of days with documentation in the chart. It does not take a month for them to act on a recommendation. During an interview on 01/25/2022 at 11:30 AM, the Psychiatrist stated that Resident # 200 was seen on 12/06/2021. The resident has no incidence of an increase in [CONDITION(S)], so there was no reason why the resident must be on the [MEDICATION(S)]. Resident # 200 was delusional, that is why the resident was on [MEDICATION(S)]. Resident # 200 is doing well and stable and does not need [MEDICATION(S)]. The [MEDICATION(S)] should be discontinued because Resident # 200 is doing well. During an interview on 01/25/2022 at 12:07 PM, the Director of Nursing (DON) stated that the pharmacy consultant recommended a psychiatry consult for Resident # 200. The Psychiatrist saw the resident on 12/06/2021 and recommended discontinuing the [MEDICATION(S)]. The attending physician can agree or disagree on a psychiatrist's recommendation, but it does not take a month. It only takes a couple of days. 415.15(b)(2)(iii)

Based on observation, interviews and record review conducted during an abbreviated survey (Complaint # NY00273858) from 01/04/2021 to 04/06/2021, the facility staff failed to provide adequate supervision to prevent elopement. This was evident in 1 out of 5 residents sampled (Resident #1). Specifically, on 03/30/2021, the facility staff did not escort the resident, who was wearing a wander guard, off the unit to the smoke room. Facility staff deactivated the wander guard alarm on elevator #2 and allowed the resident to go off the unit from the 9th floor. A second facility staff deactivated elevator #2's wander guard alarm allowing the resident to reenter elevator #2. As a result, the resident exited elevator #2 at the basement level at 8:39P.M. Whereupon the resident opened the loading dock exit door and left the facility at 8:42P.M. undetected by facility staff. The loading dock exit door has an alarm that sounded locally until manually disarmed by Security Supervisor at 10:42P.M. Facility had two security staff on duty in the lobby on 03/30/2021 who were unaware that the resident exited the facility and set off the loading dock exit door alarm. Nursing staff on the resident's unit were unaware that the resident left the facility. Code Gray was called at 10:50P.M. The facility located the resident on 04/01/2021 after receiving a call from the hospital emergency room staff. This resulted in Immediate Jeopardy and Substandard Quality of Care with the potential for serious harm to 29 residents' who were at risk for elopement. The findings are: Review of the facility's policy entitled Elopement Risk Prevention and the Management of Missing Person last revised on 09/2018 documented: Facility maintains a process to assess all residents for risk for elopement. The facility will implement prevention strategies for those identified as an elopement risk. The facility will institute measures for resident identified on admission and conduct a missing resident procedure. Disciplines working with residents who are at risk for elopement will take into consideration, alerting other staff member when a resident is left unattended or is away from a secured unit. Environment control: the physical plan is secured with measures such as a functional alarm system for egress, stairwells, interior courtyard safety locks of key-pad entry that restrict access to dangerous areas, restricted window opening, elevator controls door alarm codes are changed routinely to minimize the risk of elopement. The policy did not specify how staff would respond to the alarm system for egress and stairwells. The policy did not mention the loading dock exit door that leads to the street. Review of the facility's Policy titled Smoking Program, last revised 01/2020, documented that the residents at risk for elopement and/or have a Wander Guard are to be escorted to/from the smoke room by staff. Review of the Facility's Accident/Incident Report and Internal Investigation dated 03/31/2021, revealed that on 03/30/2021, at approximately 9:42 P.M., Resident #1 was noted missing from the unit. The resident was last seen at approximately 8:30 P.M. at the elevator requesting to go smoke. Code Gray (Elopement) was initiated. Search of facility was unsuccessful, and 911 was called. The Administrator, Director of Nursing (DNS), and family were notified. On 04/01/2021, the hospital notified the facility that Resident #1 was located at a train station and appeared under the influence. Resident #1 did not require hospital admission and was returned to the facility at approximately 3:00 P.M. The facility determined that while the existing elopement prevention equipment system functioned as expected, the resident exited the facility via the loading dock door. Staff members acted outside of established policy, released the elevator, and disarmed the alarm allowing the resident access to the basement and subsequently the loading dock door where the resident exited the facility. Resident #1 was admitted to the facility on [DATE] with diagnoses that included Alcohol Abuse, Schizophrenia, and Traumatic Brain Injury. The Minimum Data Set (MDS, a resident assessment tool) dated 03/04/2021 documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 4/15, associated with severely impaired cognition. The MDS documented that a Wander Guard was used daily. A Readmission Elopement Risk Evaluation dated 02/25/2021 documented Resident #1 was a low risk for elopement. Review of the Certified Nursing Assistant (CNA) Documentation Survey Report (DSR) dated from 03/01/2021 through 03/30/2021, revealed that Resident #1's wander guard was checked every shift and that the wander guard was present on the 3-11 shift on 03/30/2021 at 6:34P.M The report also documented that the resident required extensive assistance of one person for locomotion off the unit. A Smoking Evaluation form dated 03/19/2021, documented that Resident #1 was a smoker. A Smoking Care Plan initiated on 03/19/2021 revealed that Resident #1 was a smoker. The interventions included educating Resident #1 on the benefits of a smoking cessation program, staff to provide supervision during the designated smoking time and staff to reeducate the resident as needed to the facility smoking rules and policy. There was no intervention documented for staff to escort Resident #1 to and from the smoke room. A Nursing Progress Note dated 03/30/2021 at 10:50 P.M., revealed that during rounds, Resident #1 was not in bed. A search was initiated on the floor and through the building. Code Gray was announced. A picture of the resident was given on every floor as per facility protocol. The search was unsuccessful. The head of security and Police were notified. The facility' Surveillance Video Recording dated 03/30/2021 revealed at 8:38P.M. Resident #1 exited elevator #2 on the 1st floor and walked towards the patio door. Resident #1 walked back to the elevator area and walked into elevator #2 following Rehab #1 (identified by facility). After a few seconds, Rehab Staff #1 exited elevator #2 leaving Resident #1 inside of the elevator. At 8:39 P.M., Resident #1 exited elevator #2 at the basement level. Resident #1 approached the exit door at the loading dock area at 8:42P.M. and pushed on the grab-bar handle of the exit door. After 15 seconds, the door opened. Resident #1 went through the loading dock door (which leads to the street) and made a right turn. The resident was out of camera view at 8:42 P.M. At 10:12P.M., Security Supervisor (SS) was observed on the Surveillance Video Recording at the basement level approaching the loading dock exit door. SS pushed the fire door and the door did not open. After 20 seconds, the SS touched the keypad panel (that was on the wall next to the fire door) with a card that was hanging around their neck and then left the area. At no time did the SS open the fire door and look outside. A Nursing Progress Note dated 03/30/2021 at 10:50 P.M., revealed that during rounds, Resident #1 was not in bed. A search was initiated on the floor and through the building. Code Gray was announced. A picture of the resident was given on every floor as per facility protocol. The search was unsuccessful. The head of security and Police were notified. A Resident Accountability Sheet dated 03/29/2021-03/30/2021, revealed that facility staff performed unit rounds at the beginning of each shift, at mealtime and at the end of each shift. It was documented on 03/30/2021 at 11:00 P.M. that Resident #1 was on the unit. A care plan note dated 03/30/2021 at 10:49P.M., revealed that Resident #1 was noted missing during rounds and a search was initiated throughout the building. It was documented that Resident #1 left the building self-unattended. During interview on 4/1/2021 at 11:00 A.M., the Administrator stated that Resident #1 had not yet been located. The Police and the hospitals were notified. The Administrator stated that the facility staff checked all points where Resident could be, but the resident was not found. The Administrator stated that Resident #1 was at risk for elopement and had a Wander Guard on the wrist. The Administrator stated that the facility consisted of 3 passenger elevators all equipped with Wander Guard alarm system to prevent a resident with a Wander Guard from leaving the unit. The Administrator stated there are no cameras on resident units. The Administrator stated that he/she was not sure if Resident #1 was wearing a Wander Guard at the time of the elopement and was not sure how the resident got off the unit. Staff searched Resident #1's room and the wander guard was not found. The Administrator reported that Resident #1 eloped from the facility through the loading dock exit door located in the basement. Review of the Emergency Department Discharge Record dated 04/01/2021, revealed that Resident #1 was brought to the emergency room by Emergency Medical Service (EMS) at 11:47A.M., after they were found sleeping in the subway. No signs of trauma. Neurovascular intact. The resident admitted that they smoked K2 (synthetic cannabinoids). The resident was noted with the facility bracelet on the left wrist. The hospital social worker notified the facility and was informed that the resident ran away 3 days ago. The facility asked the hospital to transfer the resident back to the facility. The resident was discharged at 1:45 P.M. Resident #1 returned to the facility. Review of the Visual /Bedside Kardex Report, for Resident #1, dated 04/01/2021, documented that Resident #1 had a wander guard bracelet to their left wrist and placement to be checked every shift. Under locomotion off the unit, documented the Resident #1 required supervision and/or set up help. There was no documented instruction for staff to escort Resident #1 to and from the smoking room. An observation of the front desk was conducted on 04/01/2021 at 10:45A.M. Two Security Guards observed on duty. The security desk was positioned in the lobby close to the exit door. To the left of the security's desk, a hallway leads to the elevator area. The elevators are approximately 100 feet away from where the security desk was located, therefore the Security Guards were not able to see the elevators or the residents. When the elevator wander guard alarm was activated and sounded, the Security Guards were not able to hear the alarms from where the security desk was located. A camera and monitoring screen were observed at the security's desk. The Security Guards were able to see the loading dock exit door in the basement level as well as the street. An observation was conducted on at the loading dock area on 04/01/2021 at 11:40 A.M. The loading dock exit door was in the basement area next to a closed rolled gate. A keypad to disarm the door alarm was located on the wall between the rolled gate and the loading dock exit door. The loading dock exit door had a grab-bar handle that allowed the door to open when someone presses on the handle for 15 seconds. The loading dock exit door leads directly to the street. Testing of the egress alarm on the loading dock exit door was done in the presence of the Administrator and the Director of Security, who confirmed that the loading dock exit door alarm sounded locally in the basement and could not be heard on the first floor at the security desk. An observation of the elevators was conducted on 04/01/2021 at 3:30P.M. with the Director of Security. There were three passenger elevators and one kitchen elevator. Testing of the wander guard alarm systems were conducted and observed to be functional. A resident wearing a wander guard triggered the wander guard alarm system in elevator #2 on the 5th floor. The elevator stopped and did not move until a staff respond and remove the resident from the elevator. During an interview on 4/01/2021 at 12:30P.M. and 2:30P.M., The Director of Security (DOS) stated there are two Security Guards on each shift (8-4, 4-12 & 12-8). If an alarm was to be activated, one security would remain at the front desk while the other security checks the alarm. He stated that the Security Guards have camera view on the monitoring screen and that it is the Security Guards responsibility to monitor the cameras. The DOS stated that Resident #1 exited the facility through the loading dock exit door located at the basement. He further stated that the loading dock exit door had an egress alarm that sounded locally, and if the alarm is activated, the Security Guards are unable to hear the alarm from the loading dock area in the basement. The DOS stated that after 8:00 P.M., there is no one in the basement to hear the loading dock exit door alarm. During an interview on 04/01/2021 at 4:49P.M., Licensed Practical Nurse #1 (LPN #1), who worked on 03/31/2021, 3-11 shift, stated that Resident #1 did not verbalize that they wanted to go home. LPN #1 said that she was aware that Resident #1 was at high risk for elopement and that the resident had a wander guard on the left wrist. LPN #1 stated that the wander guard was checked at the beginning of the shift and that Resident #1's wander guard was functional. LPN #1 explained that if a resident wearing a wander guard gets into the elevator, the elevator alarm would be activated, and the elevator would not move. The staff would need to remove the resident from the elevator and deactivate the wander guard alarm using a code or ID card. LPN #1 stated that she made rounds at around 8:30P.M. and Resident #1 was in bed and that she went on break sometime after 8:30 P.M. LPN #1 stated that she returned from her break around 10:00P.M. and CNA #1 reported to her that she made rounds at around 9:40 P.M. and that Resident #1 was not in their room. LPN #1 stated that a search was initiated on the unit and the supervisor was informed. The staff continued searching the floors for Resident #1, but the search was unsuccessful, and Code Grey was called at around 10:50P.M. The head of security, the DNS and the Police were all called. LPN #1 stated that she did not hear the elevator wander guard alarm while she was on the unit. During an interview on 04/01/2021 at 5:00 P.M. and 6:31 P.M., Security Supervisor (SS), who worked on 03/30/2021 4-12 shift and went to the loading dock area to conduct rounds at 10:10 P.M. He stated that he heard a beeping noise while he was in the loading dock area, prior to being informed of missing resident, and went to the loading dock exit door. The keypad had no power and he pushed on the loading dock exit door and the door was locked. The SS stated that he scanned the keypad with his ID card and reset the loading dock exit door alarm. The SS stated that no one goes into the basement after 8:00P.M. The SS stated at approximately 10:40 P.M. while he was at the front desk, a CNA informed him that Resident #1 was missing, and security called Code Grey at 10:50P.M. The SS stated that he did not go back to the loading dock area to check for the resident. He stated that he was aware that the loading dock exit door alarm only sounded locally and could not be heard from the lobby area. The Security Guards was only able to see the loading dock exit door from the camera at the front desk. During an interview on 04/01/2021 at 5:37 P.M., CNA #1 stated that Resident #1 was wearing a wander guard because the resident was at risk for elopement. Resident #1 was served dinner around 5:30 P.M. in their room. CNA #1 also stated that she observed Resident #1 after 6:00P.M. in the hallway on the unit. CNA #1 stated that Resident #1 was not on scheduled visual monitoring, because the resident was wearing a wander guard. She stated that she went on break from 8:00 P.M. to 9:00 P.M. and when she returned to the unit, CNA #2 told her that Resident #1 was not in their room, was not on the floor and that Resident #1 did not return from smoking (CNA#1 could not give specific time of this conversation). CNA #1 stated after she completed her documentation, she went to look for Resident #1 in their room and the resident was not in the room. CNA #1 stated that she told the nurse (not sure what time she notified the nurse) and a search for Resident #1 was started. Resident #1 was not found, and Code Grey was called. CNA #1 stated that she was not aware that Resident #1 should have been escorted to and from the smoke room. During an interview on 04/01/2021 at 5:57P.M., CNA #2 stated that Resident #1 never verbalized that they wanted to go home. Resident #1 was at high risk for elopement and was wearing Wander Guard. Resident #1 was not on any scheduled visual monitoring. CNA #2 stated that she heard the elevator wander guard alarm ringing around 7:50P.M. and Resident #1 was standing outside of the elevator. Elevator #1 opened, and Resident #1 went into the elevator. CNA #2 stated that Resident #1 told her that they wanted to go and smoke. At this same time elevator #2 came, and it began to alarm. CNA #2 stated that she went into elevator #2 and deactivated the alarm. CNA #2 went back into elevator #1 (Resident #1 still inside of elevator #1) to deactivate the elevator and Resident #1 got off elevator #1 and went into elevator #2. The elevator door closed and went up. CNA #2 stated that she knew that Resident #1 was at risk for elopement but was not aware that Resident #1 should have been escorted to the smoke room. CNA #2 said that she used her ID card to deactivate the elevator. CNA #2 stated that she did not see Resident #1 on the unit after 8:30P.M. Both LPN #1 and CNA #1 were on break and returned to the unit after 9:00P.M. CNA #2 said that she told both LPN #1 and CNA #1 that Resident #1 was not in their room and LPN #1 said that it was okay because Resident #1 goes to smoke. CNA #2 also stated that LPN #1 said she thinks Resident #1 went to smoke by him/herself. CNA #2 stated that she was about to go on break after 9:00P.M., and asked CNA #1 again if CNA #1 checked Resident #1's room and if the resident was back. CNA#1 went to check, and Resident #1 was not in their room. CNA #2 stated that they started looking for Resident #1 (CNA does not remember exact time they started searching for the resident). CNA #1 went to the 11th floor and Resident #1 was not found. Everyone was on the unit looking for Resident #1. During an interview on 04/02/2021 at 11:14 A.M., the Smoke Monitor (staff #1) was interviewed. He stated that the smoke room was opened from 9:00 A.M. to 8:00P.M. The last smoker left the smoke room at 7:40P.M. Staff #1 said that the residents do not come into smoke room after 7:40 P.M. He stated Resident #1 had a wander guard, and prior to the elopement, Resident #1 was coming to the smoke room and going back to the unit unescorted. During an interview on 04/02/2021 at 1:12P.M. Resident #1 stated that he/she went outside for a for a walk. Resident #1 stated that they pushed the door and the door opened for them. Resident #1 stated that they took the elevator and went downstairs, and no one followed them. Resident #1 said that being inside of the facility made them claustrophobic. Resident #1 stated that they were homeless and was an outside person who liked to walk around. Resident #1 voiced that the wander guard made the elevator alarm goes off and that they do not remember if the alarm went off when they went for a walk that night. During an interview on 04/02/2021 at 1:50 P.M., Rehab Staff #1 stated that she was leaving from the physical therapy gym after 8:30 P.M., on the first floor, and heard the elevator alarm ringing. The elevator door was opened on the first floor. Rehab #1 stated that she checked, and no one was in the elevator and she went into the elevator and deactivated the elevator alarm. Rehab #1 stated that someone (Resident #1) came behind her very fast and went into the elevator. Rehab #1 stated she checked the resident's face and checked to see if the resident was wearing a wander guard, but she did not see the wander guard because Resident #1 was wearing long sleeve shirt. Rehab #1 also stated that Resident #1 told her that they were going to the 5th floor. During an interview on 04/02/2021 at 3:00 P.M., the DNS stated that she received a call at home around 11:00 P.M. from the Security Guard, the Nursing Supervisor and the Administrator stating that Resident #1 was missing, and she came to the facility. Code Grey was called and a search for Resident #1 was conducted throughout the facility, but Resident #1 was not found. Local Law Enforcement was already in the facility when she arrived. The DNS stated that she called all the hospitals and went to the shelter, but Resident #1 was not located. The DNS stated that the hospital notified the facility on 04/01/2021 around 12:00 P.M. that Resident #1 was in hospital. Resident #1 was readmitted to the facility on [DATE] with no injury. Resident #1 was wearing the original wander guard on their left wrist. The DNS reported that the staff did not follow the facility policy on deactivating the wander guard alarm in the elevators. The staff must escort the resident, who is a smoker and is at risk for elopement, to and from the smoking room. The DNS stated that the Charge Nurse should have put interventions on Resident #1's care plan, that the resident had a wander guard and should be escorted to smoke. The DNS further stated that the CNA Accountability must also reflect instructions to escort the resident with Wander Guard to and from the smoking room. During an interview on 04/05/2021 at 11:46 P.M., Registered Nurse Supervisor #1 (RNS #1) stated at around 10:30P.M. the staff notified her that Resident #1 was missing. RNS #1 stated that she went to security and asked the Security Guards if they had seen any resident passed by and the Security Guards said that they had not seen any resident in the lobby. Staff searched all the floors and Resident #1 was not in the building. The RNS stated that she called the Director of Security and they looked at the computer and found out that Resident #1 went through the loading dock exit door and local law enforcement was called. RNS #1 stated that the staff must accompany the residents, who are at risk for elopement, off the unit to and from the smoke room on the 11th floor. She further stated that the Nursing Supervisors are responsible for monitoring the staff to ensure they are following the policy on escorting the residents with wander guards to and from the smoke room During an interview on 4/6/2021 at 10:20 A.M. Security Guard #1 (SG #1) stated that he was on duty on 03/30/2021 on the 4-11 shift. He stated that he was monitoring the cameras but did not see anyone in the basement near the loading dock exit door at the time Resident #1 eloped. SG #1 stated that if a resident opened the loading dock exit door, he would not have heard the alarm at the security desk because the alarm only sounded locally. SG #1 stated that the Security Supervisor informed him that Resident #1 was missing, and Code Gray was activated at 10:50P.M. During an interview on 04/06/2021 at 11:06 P.M., SG #2 stated that he was on duty on 03/30/2021 on the 4-11 shift. SG #2 stated that he was on break from 8:00P.M. to 9:00P.M. A staff from the 9th floor called him around 10:40P.M. stating that Resident #1 was missing, and he called Code Grey around 10:50P.M. Observations conducted on 04/05/2021 at 12:35P.M. confirmed that all wander guard alarm systems in non-residential areas were operational. All delayed egress alarms were operational. The loading dock exit door alarm was connected to the security area and was audible on the first floor. The wander guard computer monitor at the front desk security station was observed depicting a floor display and wander guard number. Elevator #1, #2 and #3 wander guard alarm systems were operational when a wander guard activated the elevator car door to stay open and an audible alarm sounded. However, all wander guard panels located within all residential floors (5 - 13 floors), were not operational when tested (0 of 9 floors). All doors with delayed egress were operational when tested . During a follow up interview on 04/05/2021 at 5:00P.M. and at 5:50 P.M. the Administrator stated that the entire building is covered by the wander guard system. Security Guards respond to the alarm system from the basement, the 2nd floor and the roof and the nursing staff on the unit responds to the alarm system on the unit. The Administrator stated that the Security Guards test the wander guard system on the resident units daily, using a tester. The nursing staff also checks the functionality and the placement of the wander guards. The Administrator stated there is written documentation of the wander guard. The Administrator stated if a resident goes through the stairwell exit door, the alarm will go off and the staff would have to open the alarming exit door and check if it was a resident. The Administrator stated that he does not know how far the staff would be required to travel to check on the stairwell. Staff also would have to conduct a head count to account for all the residents. In addition, staff would notify the security and the supervisor. During a follow-up interview at 5:50 P.M., the Administrator stated that the corporate office said that the wander guard panels on the residential units (5-13 floors) does not have power and that was intentional. The corporate office also stated that the current alarm system on the exit doors was installed three years ago and it does not have a Wander Guard alarm system. The old wander guard panels on the exit doors on the unit should have been removed but have not. The Administrator also stated that the corporate office stated if there is a fire, everybody must be able to get out of the unit. The Administrator said that the corporate office does not want the residential exit doors on the units to be locked for safety reasons. Immediate Jeopardy (IJ) was identified, declared, and the facility DNS and Reginal Director were notified on 04/02/2021 at 5:33P.M. The survey team declared the immediacy of the IJ had been abated after receiving an acceptable corrective action plan from the facility on 04/02/2021 at 8:50P.M. On 04/06/2021 at 5:30P.M., the survey team declared the IJ was removed as of 04/06/2021 at 1:45 P.M. based on the following corrective actions taken by the facility: 1. On 04/01/2021- The Wander Guard System was upgraded to include a visual indicator on the security monitor when residents with Wander Guards are in non-resident care areas (Basement, Roof, 1st floor and 2nd floor). A monitor was placed at the security desk that alarms and displays a blinking light when a resident with a Wander Guard is in the area. There are always (2) Security personnel on duty. Upon alarm trigger, (1) Security staff will respond to the area and return the resident to his/her unit. Security staff will notify the Nursing Supervisor of a resident being in a non-resident care area. Security Supervisor will check the Wander Guard system daily to ensure the visual indicator to identify residents in non-resident care areas is functional. Daily checks were implemented. 100% of the Security Guards were educated on monitoring and responding to alarms including the opening of doors and the searching of the immediate area and notifying the nursing supervisor. 2. On 04/01/2021, the loading dock exit door alarm was fully connected to the Security desk. An alarm panel was placed in the lobby ceiling. Lights and alarms will sound if the alarm is triggered. There are always (2) Security personnel on duty. Upon alarm trigger, (1) Security staff will respond to the loading dock. The triggered door will be opened, and a search of the immediate surrounding area will be conducted prior to silencing the alarm. 100% of the Security Guards were educated on responding to the triggered loading dock exit door alarm and the searching of the immediate surrounding area prior to silencing the alarm. 3. The Security Guards will check for wander guard placement every shift and functionality daily. This was implemented on 03/30/2021-04/06/2021. 100% of the security guards were educated on ensuring daily checks or Wander Guard and door alarms. 4. The Elopement Prevention policy was revised to include residents with Wander Guards are to be escorted off the unit, as well as changes to Loading Dock alarm and wander guard system. 100% of the staff present in house were educated on the revised policy. Education will continue until all clinical and non-clinical staff have been educated. Per diem and agency staff will be in-serviced upon entry to facility prior to reporting to assigned unit. Residents with Wander Guards will be reviewed weekly to ensure Care Plan is current and interventions accurately reflect resident needs. Implementation of this policy was observed. 5. The Smoking policy was reviewed. No changes were required. The policy indicates residents with wander guards are to be escorted to smoke. 100% of the staff present in house were educated on the smoking policy and the importance and expectation of escorting wander guard residents off unit to smoke in accordance with the smoking policy. Education will continue until all clinical and non-clinical staff have been educated. Per diem and agency staff will be in-serviced upon entry to facility prior to reporting to assigned unit. Nursing supervisor will conduct rounds to ensure staff escort residents wearing wander guards to the smoking area in accordance with policy. The smoking list will be reviewed weekly to ensure residents with Wander Guards are identified and are listed as requiring an escort. Implementation of this policy was observed. 6. On 04/05/2021 Facility revised the Elopement policy to include instructions for staff response to alarm triggers: Elevator Alarm: If alarm sounds, check in the elevator car for residents. Should resident be present and have a Wander Guard, assist resident to exit the elevator car and notify Nurse Manager/Supervisor. 7. Stairwell Door Alarm: If alarm sounds, staff are to do an immediate search of the area for residents. Search one flight of stairs up and one flight of stairs down before clearing alarm. If a resident is present, assist resident away from area and immediately report to Nurse Manager/Supervisor if a resident is not located, immediately report to Nurse Manager/Supervisor for unit headcount of residents. If head count reveals a missing resident, notify security, and activate Code Grey. 8. Exit/Loading Door Alarm: If alarm is triggered it will sound locally and at security desk. Security /Staff are to do an immediate search of the area for residents. Open door and search immediate surrounding external area. If a resident is present, assist resident away from area and immediately report to Nurse Manager/Supervisor. If a resident is not located, immediately report to Nursing Supervisor/Security. A head count will be conducted on all units. If head count reveals a missing resident, activate Code Grey. 9. Non-resident areas- Basement, Roof, 1st floor and 2nd floor: If alarm is triggered it will sound and a visual indicator will show at security. Security /Staff will immediately respond to area and assist resident back to unit/ immediately report to Nurse Manager/Supervisor. If a resident is not located, immediately report to Nursing Supervisor/Security. A head count will be conducted on all units. If head count reveals a missing resident, activate Code Grey. 100% of the staff in house were educated on the revised policy and all changes made. Inservice will continue until all clinical and non-clinical have been in-serviced. Per diem and agency staff will be in-serviced upon entry to facility prior to reporting to assigned unit. 10. The facility implemented education on the revised process. The Surveyors on site conducted interviews with 53 staff members on all shifts including, 19 Nurses, 13 CNAs, 6 Housekeeping, 2 Dietary Aides, 11 Security Guards, 1 Recreation staff, 1 Rehab staff. All persons were knowledgeable of the updated process, responding appropriately to alarms, resident assessments accurately reflecting the [TRUNCATED]