Every finding on record at United Hebrew Geriatric Center

Based on record reviews, interviews, and observations conducted during an abbreviated (2968858) survey, the facility did not ensure that a resident was free from abuse. This was evident for 1 (Resident #1) of 3 residents sampled for abuse. Specifically, Certified Nursing Assistant #1 is seen in video footage dated 03/26/2026 hitting the back of Resident #1's head.The facility policy #276 for abuse prevention last reviewed January 2025 documented that it was their policy to ensure all residents were free from abuse, neglect, misappropriation of resident property and exploitation. Resident #1 was admitted [DATE] with diagnoses which included unspecified dementia, unspecified severity, with other behavioral disturbance. An admission minimum data set (an assessment tool) dated 11/27/2025 documented the resident had a brief interview of mental status score of 4, indicating severe cognitive impairment. Resident #1 had behaviors of wandering and rejection of care that occur 1 (one) to 3 (three) days and impairment on both sides of the upper and lower extremities. Resident #1 used a wheelchair for locomotion.On 04/09/2026 surveyors reviewed the footage of the video provided by the facility and observed the following:The video dated 26/03/2026 (March 26, 2026) at time stamp 10:58:40 shows Resident #1 in their wheelchair sitting in the main day room area and Certified Nurse Assistant #1 is pushing the wheelchair and seems to be moving other wheelchairs around and then Resident #1 reaches both their arms up over their head and behind them in what appears to be an attempt to touch Certified Nurse Assistant #1, and at time stamp 10:58:44 Certified Nursing Assistant #1 is seen striking the back of the head of Resident #1.Review of the investigative summary dated 03/30/2026 documented that on 03/26/2026 at 10:58 am on the video footage Certified Nurse Assistant #1 was observed moving residents in their wheelchairs towards the entrance of the dayroom near the nursing station desk. Resident #1 is in their wheelchair and seemed to be wheeling themselves towards the entrance. Certified Nurse Assistant #1 then appears to be redirecting Resident #1. Certified Nurse Assistant #1 pushed the back of Resident #1's wheelchair towards the nursing station. Resident #1 appeared to have resisted the movement of their wheelchair and reached with both of their hands backward as if trying to reach Certified Nurse Assistant #1. Certified Nurse Assistant #1 leaned backward avoiding the resident's hands and immediately was seen using their right hand to hit the back of Resident #1's head. During an interview on 04/09/2026 at 1:40 PM Environmental Service Worker #1 stated that while mopping the floor they could see into the main day room area and they heard a commotion, and they looked up and they could hear that Certified Nurse Assistant #1 was telling Resident #1 to put your feet up and then they saw Certified Nurse Assistant #1 pop Resident #1 on their head. They asked the nurse that was near them if they saw what occurred, and the nurse stated no. During this interview it was revealed that there was no further discussion between Environmental Service Worker #1 and the nurse, and Environmental Service Worker #1 did not report this incident to anyone else in the facility until Monday morning 03/30/2026, when they informed the Director of Nursing. During an interview on 04/10/2026 at 3:13pm the Director of Nursing confirmed that they were informed by Environmental Service Worker #1 on Monday 03/30/2026 of the incident that occurred several days prior on 02/26/2026. They further stated that they then reviewed the staffing for the day in question and determined that the staff member was currently working on the unit. The Director of Nursing had a staff member tell Certified Nurse Assistant #1 to leave the unit and report to the office, and they informed Certified Nurse Assistant #1 that they were being suspended pending further investigation. The Director of Nursing and other administrative staff reviewed the video footage from the date and time that was provided by Environmental Service Worker #1, and they saw that Certified Nurse Assistant #1 hit Resident #1 on the back of their head. NYCRR 415.4(b)(1)(i)

Based on observation, record review, and interviews conducted during an abbreviated survey (2968858), the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or 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, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and law enforcement) in accordance with State law through established procedures. This was evident in one out of three residents reviewed for abuse (Resident #1). Specifically, an alleged incident of abuse involving Resident #1 was reported to facility staff on 03/26/2026 and the facility did not report the allegation of abuse to the Department of Health or law enforcement until 03/30/2026.Review of the facility's abuse prevention and reporting policy #276 last reviewed/revised 1/2025 documented on page 10 that it was the policy of the facility that abuse allegations are reported per Federal and State Law. Allegations will be reported within required timeframes to the NYSDOH. Further breakdown of the policy noted under letter d) indicated when should abuse be reported, immediately but not later than 2 hours if the alleged violation involves abuse or results in serious bodily injury. On page 13 the policy further documented under subheading staff-resident abuse, that all allegations/occurrences of all types of staff-to-resident abuse must be reported to the Administrator and to other officials.Resident # 1 was admitted to the facility on 11/2025 with diagnoses that included, but were not limited to, dementia with other behavioral disturbances, hypertension, and chronic kidney disease. An admission minimum data set (an assessment tool) dated 11/27/2025 documented the resident had a brief interview of mental status score of 4, indicating severe cognitive impairment. Resident #1 had behaviors of wandering and rejection of care that occur 1 to 3 days per week and impairment on both sides of the upper and lower extremities. Resident # 1 used a wheelchair for locomotion.On 04/09/2026 surveyors reviewed the footage of the video provided by the facility and observed the following:Video dated 26/03/2026 (March 26, 2026) at time stamp 10:58:40 Resident #1 is in their wheelchair sitting in the main day room area and Certified Nurse Assistant #1 is pushing the wheelchair and seems to be moving other wheelchairs around and then Resident #1 reaches both their arms up over their head and behind them in what appears to be an attempt to touch Certified Nurse Assistant #1, and at time stamp 10:58:44 Certified Nursing Assistant #1 is seen striking the back of the head of Resident #1.Review of the investigative summary dated 03/30/2026 documented that on 03/26/2026 at 10:58 am on the video footage Certified Nurse Assistant #1 was observed moving residents in their wheelchairs towards the entrance of the dayroom near the nursing station desk. Resident #1 is in their wheelchair and seemed to be wheeling themself towards the entrance. Certified Nurse Assistant #1 then appears to be redirecting Resident #1. Certified Nurse Assistant #1 pushed the back of Resident #1's wheelchair towards the nursing station. Resident #1 appeared to have resisted the movement of their wheelchair and reached with both of their hands backward as if trying to reach Certified Nurse Assistant #1. Certified Nurse Assistant #1 leaned backward avoiding Resident #1's hands and immediately was seen using their right hand to hit the back of Resident #1's head. Review of the staffing schedule for Certified Nurse Assistant #1 revealed that they worked the day shift (7:00am to 3:00pm) on 03/26/2026 and returned for their next scheduled day shift on 03/30/2026 and they worked on that day until they were notified by the Director of Nursing that they were suspended pending further investigation. During an interview on 04/09/2026 at 1:40 PM Environmental Service Worker #1 stated that while mopping the floor they could see into the main day room area and they heard a commotion, and they looked up and they could hear that Certified Nurse Assistant #1 was telling Resident #1 to put your feet up and then they saw Certified Nurse Assistant #1 pop Resident #1 on their head. They asked the nurse, subsequently identified as Licensed Practical Nurse #1, that was near them, if they saw what occurred, and the nurse stated no. During this interview it was revealed that there was not much more discussion, and Environmental Service Worker #1 did not report this incident to anyone else in the facility until Monday 03/30/2026, when they arrived in the morning and informed the Director of Nursing. During an interview on 04/09/2026 at 3:00 PM Licensed Practical Nurse #1 stated that Resident #1 is mainly Spanish speaking and that when they first came to the unit, they were quiet, but after some time there have been some changes. Licensed Practical Nurse #1 stated Resident #1 is now speaking Spanish more, has behaviors where they are wheeling around and getting up and going even though they are unstable, they have had falls, and they get mad when you redirect them. Licensed Practical Nurse #1 stated that Resident #1 does not like the noise in the day room and they get angry and very mad about noise. Licensed Practical Nurse #1 stated that on the day in question Environmental Service Worker #1 was talking and then they said hey did you see that person hit Resident #1. Licensed Practical Nurse #1 stated that they understood that Certified Nurse Assistant #1 and Environmental Service Worker #1 were not on good terms with each other. Licensed Practical Nurse #1 stated that knowing that caused them to doubt what they were told and affected their response. Licensed Practical Nurse #1 stated that they know that even if they do not believe something they are supposed to report, I did not report that is my failure. Licensed Practical Nurse #1 stated that they are not aware of any other residents ever complaining about the care they received from Certified Nurse Assistant #1.During an interview on 04/10/2026 at 3:13 PM the Director of Nursing confirmed that they were informed by Environmental Service Worker #1 on Monday 03/30/2026 of the incident that occurred several days prior on 03/26/2026. They further stated that they then reviewed the staffing for the day in question and determined that Certified Nurse Assistant #1 as currently working on the unit. The Director of Nursing had a staff member tell Certified Nurse Assistant #1 to leave the unit and report to the office, and they (the Director of Nursing) informed Certified Nurse Assistant #1 that they were being suspended pending further investigation. The Director of Nursing and other administrative staff reviewed the video footage from the date and time that was provided by Environmental Service Worker #1, and they saw that Certified Nurse Assistant #1 hit Resident #1 on the back of their head. NYCRR 415.4 (b)(2)

Based on record review, and interviews during an abbreviated survey (2968858), the facility did not ensure a comprehensive care plan was developed and implemented to maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (1) of three (3) residents reviewed for abuse. Specifically, Resident #1 had severe cognitive impairment and was involved in a documented incident on 03/26/2026 where abuse occurred and an abuse care plan was not initiated. Review of the facility policy #2-214 comprehensive person-centered care plan dated 1/2023 documented that a comprehensive person-centered care plan is developed for each resident to include measurable goals, objectives and timeframe to meet the resident's medical, nursing, rehabilitation, psycho-social, cultural and nutritional needs. These needs are identified from the IDC (interdisciplinary care) team assessment.Review of the facility's abuse prevention and reporting policy dated 2/2016 and reviewed/revised 1/2025 documented the interdisciplinary team identifies resident risk factors and plans for protecting resident's rights as part of the individualized, comprehensive care planning process. On going assessment, care planning for appropriate intervention and monitoring of resident's needs and behaviors which might lead to conflict, or neglect are conducted. A care plan must be developed to meet the residents' needs and behavioral symptoms and implement measures to protect the alleged victims and others.Resident #1 was admitted to the facility on 11/2025 with diagnoses that included, but were not limited to, dementia with other behavioral disturbances, hypertension, and chronic kidney disease.An admission minimum data set (an assessment tool) dated 11/27/2025 documented Resident #1 had a brief interview of mental status score of 4, indicating severe cognitive impairment. Resident #1 had behaviors of wandering and rejection of care that occurred 1 to 3 days a week and impairment on both sides of the upper and lower extremities. Resident #1 used a wheelchair for locomotion.Review of facility's investigative summary dated 03/30/2026 documented on 03/26/2026 at 10:58 am on the video footage, Certified Nurse Aide #1 was observed moving residents in their wheelchairs towards the entrance of the dayroom near the nurse's station desk. Resident #1 was in their wheelchair seen wheeling themself towards the entrance. Certified Nurse Aide #1 appeared to be redirecting Resident #1. Certified Nurse Aide #1 pushed the back of Resident #1's wheelchair toward the nurse's station. Resident #1 appeared to have resisted the movements of their wheelchair and reached with both hands backward as if trying to reach Certified Nurse Aide #1. Certified Nurse Aide #1 leaned backward avoiding the residents' hands and immediately was seen using their hand to hit the back of Resident #1's head. A Review of Resident #1's care plans did not include documented evidence of an abuse care plan for Resident #1 after the incident on 03/26/2026.During an interview with Unit Manager #1 on 04/10/2026 at 12:58pm they stated Resident #1 is Spanish speaking and understands simple English. One of their triggers is to leave the day room to go to the bathroom. It is not easy for someone in the day room to assist with toileting them because they are watching the whole group in the day room. They have not observed Resident #1 to be physically aggressive, but they do hear them raise their voice when they want to leave the dayroom. Resident #1 does have a behavior care plan with interventions that include quiet areas to express needs and to resolve behavior issues, redirection, toileting scheduled every 2-4 hours and as requested, diversional mobility, recreation therapy, and they will call the son if the resident is having behaviors. The resident is on weekly behavioral notes. There should be an abuse care plan put in place after an incident. There was an update to the behavior care plan after the incident to reflect an added intervention, but other than that they did not see anything else. They do not know of any other residents in the facility having an abuse care plan. This was the first time they had an issue with abuse in the facility. Unit Manager #1 stated they can see where not having an abuse care plan could be an issue.During an interview with the Director of Nursing on 04/10/2026 at 3:12pm they stated in nursing it is the Registered Nurse that initiates, updates, and revises the care plan, such as, on admission, when there is significant change, episodes, with minimum data set assessments that trigger, and following quarterly and annual assessments. Director of Nursing stated that in the facility's historical records they found that a risk for abuse care plan was initiated after incidents, and since identifying that, Registered Nurse #1 initiated a risk for abuse care plan for Resident #1. Director of Nursing also stated that residents with dementia and combative behaviors can be at higher risk for abuse. NYCRR 415.11(c)(1)

Based on record review and interview the facility did not ensure a Notice of Medicare Non-Coverage is given by the facility to all Medicare beneficiaries at least two days before the termination of services for one (1) of three (3) residents (Resident #194) reviewed for Beneficiary Notification. Specifically, there was no documented evidence that Resident #194 and/or their representative received and signed a two (2) day Notice of Medicare Non-Coverage before termination of services. The findings include: Resident #194 was admitted with diagnoses including unspecified dementia, atherosclerotic heart disease and unspecified atrial fibrillation. The 09/10/2025 admission Minimum Data Set (an assessment tool) documented Resident #194 had severe cognitive impairment, received 100 minutes of occupational therapy and 130 minutes of physical therapy. The 10/20/2025 Notice of Discharge/Transfer documented Resident #194 would be discharged on 10/24/2025.The Beneficiary Protection Notification Review form documented by the former social worker revealed Resident #194's last covered day of Medicare Part A Services was 10/23/2025 and the facility/provider-initiated discharge from Medicare Part A Services when benefit days were not exhausted. There was no documented evidence that Resident #194 and/or their representative received and signed a Notice of Non-Coverage for Medicare Part A Services two (2) days prior to end of services.Resident #194 was discharged from the facility on 10/24/2025.During an interview on 12/09/2025 at 12:11 PM, the Director of Social Work stated there was a meeting to discuss Resident #194's discharge date and the family wanted the resident to go home. They stated that a signed Notice of Medicare Non-Coverage could not be found for Resident #194. 10 NYCRR 415.3 (g)

Based on observation, interview and record review the facility did not ensure that drugs and biologicals were maintained in accordance with current professional standards for storage, labeling and expiration dates during review of medication storage on two (2) of four (4) units. Specifically, 1) observation of the fourth-floor medication cart revealed one (1) insulin pen with no open date and one (1) insulin pen with no patient label and no open date. The fifth-floor medication cart revealed two (2) insulin pens which had not been discarded within 28 days after opening as per the manufacture's recommendation, and 2) a physician ordered Trelegy Ellipta (inhaler) was left in Resident #155's room on the bedside table. The findings include: 1) The 8/2020 policy titled Administration Procedures for All Medications documented when opening a multidose container, place the date on the container. During observation on 12/02/2025 at 10:51 AM, the medication cart on unit 4 Skalet revealed one Lantus Solostar insulin pen labeled with Resident # 5's name which had no open date and one Admelog insulin pen with no resident name label and no open date. During a 12/02/2025 at 10:51 AM interview, Registered Nurse #8 stated whoever opened the insulin pen was responsible for writing the date the insulin was opened. They stated insulin pens were viable for 28 days after they were opened. During a 12/02/2025 at 11:33 AM interview, Registered Nurse/Charge Nurse #9 stated sometime the nurses forget to date insulin pens when they open them. They further stated a pharmacy consultant audited carts and medication pass with the nurses. During observation on 12/02/2025 from 12:33 PM -12:37 PM, the medication carts on the 5 Skalet unit revealed one Lantus Solostar insulin pen with Resident #169's' name which had an open date of 10/24/2025 and had not been discarded within 28 days as per the manufacture's recommendation, and one Lantus Solostar insulin pen with Resident #127 's name which had an open date of 10/27/2025 and had not been discarded within 28 days as per the manufacture's recommendation. During a 12/09/2025 at 10:48 AM interview, the Director of Nursing stated there was no excuse for the insulin pens not having a date to indicate when they were opened, and insulin pens should be discarded 28 days after opened per pharmacy recommendations. They stated nurses should check open dates before they administer insulin. During a 12/09/2025 at 11:09 AM interview, the Infection Preventionist stated they had a lesson plan that covered when an insulin pen was opened, it should be labeled with an open date. They stated the education had been provided once since they started at the facility and there was a skills test upon orientation which was to be reviewed yearly. 2) Resident #155 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease, and respiratory failure. The 06/21/2023 physician order documented Trelegy Ellipta 100-62.5-25MCG powder, inhale one (1) puff daily at 10 AM (self-administration) The 06/19/2024 and 06/21/2024 document titled Resident Participation Agreement for Self-Administration of Medication Program signed by Resident #155, Registered Nurse Unit Manager #17, Nurse Practitioner and Medical Doctor #2, documented when the medication was not in their possession, they agreed to store the medication in the locked closet/drawer in their room. The 10/15/2025 Annual Minimum Data Set (resident assessment) documented Resident #155 was cognitively intact. The 11/04/2025 comprehensive care plan titled Resident Wishes to Self-Administer Medication documented assess the resident for competency and re-evaluate as needed. During observations and interviews on 12/02/2025 at 11:44 AM and 12:52 PM, Resident #155 was sitting in a wheelchair in their room. A Trelegy Ellipta inhaler was lying on Resident #155's over-bed table. Resident #155 stated that they took one (1) puff once daily. Resident #155 was unable to state how long the inhaler had been in the room. During observation on 12/02/2025 at 02:11 PM, Resident #155 was awake while lying in bed. A Trelegy Ellipta inhaler was lying on Resident #155's over-bed table. During an interview on 12/03/2025 at 01:17 PM, Licensed Practical Nurse #16 stated the inhaler which was already in Resident #155's room, was set up by them so that Resident #155 could self-administer the inhaler. They stated they then left the room. Licensed Practical Nurse #16 stated when they returned to the room, Resident #155 told them they self-administered their inhaler. Licensed Practical Nurse #16 stated they left the inhaler in Resident #155's room and were not aware that the inhaler should be locked in a drawer or cabinet. Licensed Practical Nurse #16 stated they were not aware of whether the room had a locked drawer to store the inhaler. During an interview on 12/05/2025 at 12:00 PM, Registered Nurse Manager #17 stated they were not aware the inhaler should be locked in a drawer or cabinet and had not educated the nurses on securing the inhaler. Registered Nurse Manager #17 stated that Resident #155 was evaluated for self-administration in June 2023 and was re-evaluated annually by Medical Doctor #2 and Nurse Practitioner. They reviewed the facility's self-administration program and reviewed the self-administration agreement, and stated that according to the agreement, the medication must be stored in a locked drawer or locked box in the resident's room. Registered Nurse Manager #17 stated Resident #155 did not have a locked drawer in their room, therefore the medication should have been stored in the medication cart. 10NYCRR 415.18(d) (e) (1-4)

Based on observation, record review and interview during the recertification survey (10/2/23-10/6/23) the facility did not ensure that staff maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, two Certified Nurse Aides (CNAs) were observed not using Personal Protective Equipment (PPE) while assisting a resident that was on contact precautions and when CNAs exited the resident room, did not perform proper hand hygiene. The findings are: The Facility policy for Transmission Based Precautions dated 8/30/2022 documents signage outside the resident's room will be posted to communicate precautions to all healthcare personnel. Signage for Contact Isolation and verbal communication between staff can enhance compliance to minimize transmission of infection. Wear a gown and gloves for all interactions that may involve contact with the resident and their environment. The facility policy for Hand Hygiene dated March 2017 documents wash hands with soap and water if there is exposure to clostridium difficile (C.diff, bacteria). 1) Resident #336 had diagnoses including fracture of right femur, enterocolitis due to C. diff and urinary retention. Physician orders dated 9/23/23 documented the resident was on contact precautions for clostridium difficile infection. An observation was made on 10/2/23 at 9:18 AM of CNA #2 who was in Resident #336 room leaning on the foot of the bed with hands on the sheets and came out of the resident's room not wearing gloves or gown and did not wash hands but instead reached for alcohol based hand sanitizer. During an interview with CNA #2 10/02/23 at 09:19 AM they stated they did not realize the resident was on isolation because the resident was not on their usual assignment. CNA #2 stated they was not aware they needed to wash with soap and water but was aware there were instructions on the sign outside the resident's door and should have checked with the nurse. An observation was made 10/02/23 at 09:22AM of CNA#3 in Resident #336 room without gown and gloves and hands were observed touching resident items near the resident's bed. During an interview 10/2/23 at 09:22AM, CNA#3 stated they just came in to say a quick hello and was not aware they needed to wear a gown but did see the sign outside the door. CNA#3 stated she did get report from the nurse but did not know about the gown and gloves, or that they needed to use soap and water to wash hands. During an interview 10/06/23 at 11:53 AM, the Director of Nursing (DON) they stated staff needed to follow the instructions on the sign for residents in contact isolation rooms, and nurses should have been informing staff about these rooms. The DON stated C.diff had spores that were everywhere in the room so staff needed to wear gowns, and they thought all staff knew the precautions. 10NYCRR 415.19(b)(1)(4)

Based on observation, interview, and record review during the recertification survey from 10/2/23 to 10/6/23, the facility did not ensure that care was provided in a manner that maintained dignity for 1 of 2 residents (Resident #7) reviewed for catheters. Specifically, Resident #7 urinary catheter drainage bag was not concealed to prevent direct observation of urine by others. The findings are: The facility policy, titled, ' environment that preserves dignity, and contributes to a positive self image' documented it is the policy of the facility to ensure and respect each residence, rights to dignity, and contribute to a positive self image, which included to care for a residence in a manner, and in an environment, that promotes maintenance or enhancement of each residence, quality of life. The facilities policy titled, 'Urine drainage bags' did not include documentation related to privacy covers for the urine drainage bag. Resident #7 had diagnoses included urinary retention, benign prostatic hyperplasia, and obstructive and reflux uropathy. The Minimum Data Set (MDS- a resident assessment tool) dated 8/22/23 documented the resident had severely impaired cognition, the resident required 2-person dependent assistance with toilet use, and had an indwelling urinary catheter. The Activities of Daily Living (ADL) Toileting Care Plan, last updated 9/01/23, documented the resident required total assistance with toilet use and had a suprapubic catheter. Interventions included to provide total assistance of 2 persons for toileting. The Urinary Diversion: Supra Pubic Cather Care Plan last updated 9/01/23, documented the presence of a Foley catheter #24 with 5 cc balloon via supra pubic cystostomy in place due to urinary retention related to enlarged prostate. Interventions included to provide privacy bags-leg bags for the drainage/output and provide catheter care daily. The Certified Nurse Aide (CNA) instructions documentation included Foley catheter care every shift and a privacy bag with date. The physician order dated 8/11/2023 documented a suprapubic catheter French size 24 for a diagnosis of urinary retention related to enlarged prostate, and suprapubic catheter care every shift and as needed. During an observation on 10/03/23 at 11:35 AM, the resident was observed in bed, a urine collection bag was observed hanging from the bed frame with urine observed in the urine collection bag, the bag was uncovered and visible from hallway. During an interview on 10/03/23 at 11: 45 AM, CNA #1 stated they were the primary aide caring for the resident and they washed and dressed the resident earlier in the morning. CNA #1 stated they knew the urine collection bag should have been covered with a dignity bag but they did not see one in the resident's room. CNA #1 stated they should have asked the nurse for a dignity bag. During an interview on 10/03/23 at 11:55 AM, the Licensed Practical Nurse (LPN) #1 stated they never saw dignity bags covering any resident's urine collection bags when residents are in bed. Stated they do not think that urine collection bags need to be covered when residents are in bed. During an interview on 10/03/23 at 12:05 PM, LPN #2 stated that urine collection bags should always be covered even if the resident was in bed, and dignity covers were stored at the nurse's station in the drawer. During an interview on 10/03/23 at 12:20 PM, Registered Nurse Unit Manager (RNUM) # 1 stated: - residents' urine collection bags should always be covered with dignity bags even when residents were in bed. - the aide should have ensured the urine collection bag was covered when they performed care, and they should have asked the nurse if they needed a dignity bag. - the nurse was also responsible for making rounds and checking for placement of dignity bags. During an interview on 10/04/23 at 9:15 AM, the Chief Nursing Officer (CNO) stated it was the policy of the facility to cover urine collection bags when residents were attired and out of bed, but stated that since the resident in question was in a private room, it was unclear whether the urine collection bag should be covered. When asked whether the urine collection bag should be uncovered if it is visible from the unit hallway, the CNO stated that was unclear.

Based on interview, and record review during the recertification survey from 10/2/23 to 10/6/23, it was determined the facility did not ensure an ongoing program of activities was provided to meet the needs and interests of, and support the physical, mental, and psychosocial well-being of the residents, based on the comprehensive assessment and care plan for 1 of 2 residents (Resident #18) reviewed for activities. Specifically, Resident #18 voiced concern about the facility's cuts to their activities programming and how it negatively affected their daily quality of life. The findings are: A facility policy titled, 'Therapeutic Recreation Services', last revised 1/2000, documented, It is the policy of this facility to provide activities that are multi-faceted and reflect each individual resident's needs. Resident #18 was admitted to the facility with diagnoses including but not limited to atrial flutter, spinal stenosis, and major depressive disorder. The 7/14/23 Minimum Data Set (MDS- a resident assessment tool), documented Resident #18 had a Brief Interview of Mental Status of 15 (cognitively intact). Resident #18's comprehensive care plan, originally created 7/30/21, documented the resident enjoyed pottery and art classes, attended resident council meetings, and enjoyed outings such as trips to the dollar store or casino. During a resident council meeting on 10/3/23 at 11:08 AM, Resident #18 stated they had lived at the facility for many years and was concerned about the facility's cuts to activities programming since the pandemic. Resident #18 stated the facility used to provide programming that included cooking classes, trips to shopping centers, the casino, and community events. Resident #18 stated those were the activities that made them feel like a human, and how activities programming was, The medicine provided to the resident's hearts and minds. Resident #18 stated the activities team worked hard but there was not enough staff. Resident #18 stated they brought their concerns to management previously without resolution or improvements. During an interview on 10/4/23 at 10:25 AM, RNUM#1 stated activities had not been the same since the COVID pandemic. RNUM #1 stated the facility used to have an activities aide for each unit but as activities staff left their positions, they were not replaced and the staff remaining in the activities department now cover the entire building. RNUM #1 stated activities used to include bus trips to the casino, Memorial Day celebrations, field trips to community events, and cooking in the kitchen however, they probably did not have these activities anymore due to staffing. During an interview on 10/4/23 at 11:21 AM, the facility's Activities Director stated the resident's concerns were valid. The Activities Director stated they used to have 9 activities staff in the department and an activities staff member was assigned to every floor. The Activities Director stated now they have 2 staff, and sometime 3 staff to cover the entire building. During an interview on 10/4/23 at 11:40 AM, the facility's interim Administrator stated outside trips and additional programming had not restarted since COVID, partially because of staffing issues, and stated it was difficult recruit new people after previous activities staff left their positions. The Administrator stated the facility needed to provide more activities and they have requested to hire additional activities staff. S483.24(c)(1)

Based on observations, interviews and record review during a recertification survey from 10/2/23 to 10/6/23, the facility did not ensure food was served under sanitary conditions for 2 of 12 residents (Residents #335 and #126) . Specifically, registered nurse (RN) #1 did not perform hand hygiene between serving residents while passing out food during a breakfast meal to prevent cross contamination and infection and was wearing gloves to serve meals. Findings include: The facility Hand Hygiene policy revised 9/28/18 documents hand hygiene is the single most effective action in the prevention of transmission of infection. Careful hand hygiene must be performed before and after any direct resident care. During an observation on 10/02/23 at 8:23 AM, RN#1 passed breakfast meal trays to residents on the 2nd floor dining room while wearing gloves. RN#1 took a tray and with gloves on their hands delivered it to Resident #335. While still wearing the same gloves, RN#1 returned to the food supply room next to the serving station and touched the keypad with the gloved finger to place a code to unlock the door and went in, then RN #1 returned to Resident #335 with cold cereal and placed it on the table. RN#1 went to get another tray, received the plate of food and a gloved thumb was observed on the inside of the plate. They went over to Resident #126, touched the resident on the back, then touched meal tray, put a clothes protector on Resident #126, went back to the supply room touching the keypad, got a tea bag for Resident #335 then touched a tray and a banana. Still wearing the same gloves RN#1 touched a resident wrist to check the name band and returned to the food station. RN#1 then pulled up her pants with the gloves still on. During the entire observation, the gloves were not removed, and hand hygiene was not performed. During an interview on 10/02/23 at 8:33 AM, RN#1 stated they were unaware of the number of surfaces they touched and was unsure why they were wearing gloves. RN #1 stated not wearing gloves and using hand sanitizer would have been a better idea. During an interview on 10/06/23 at 11:45 AM with the Director of Nursing (DON) stated staff were not supposed to be wearing gloves while serving food because it could spread germs. The DON stated the new Infection Preventionist (IP) would be starting soon and provide in-servicing. 10NYCRR 415.14(h)

Based on observation, interview, and record review conducted during an abbreviated survey (NY00305602), the facility did not ensure that a Baseline Care Plan was developed and implemented to include the minimum healthcare information necessary to properly care for the immediate needs of the resident to address the resident's combative behaviors during care. This was evident for 1 of 3 residents reviewed for abuse. Specifically, Rehab staff documented on 11/14/22 that Resident #1 was spitting at staff and the behavior was reported to the nurse who reported to the Unit Registered Nurse (RN#1). Behavior and Activities of Daily Living (ADL) care plans were not updated to include interventions to address Resident#1's spitting behavior. The findings are: A review of the facility policy and procedure signed and dated 3/2022 titled, Comprehensive Person-Centered care Planning documented that the Interdisciplinary Team (IDT) initiates and implements the baseline care plan, and the head nurse/charge nurse initiates and implements a nursing care plan to meet resident's care needs upon admission. Resident #1 was admitted to the facility on [DATE] with diagnoses including but not limited to Sepsis, Anxiety Disorder, and Alzheimer's Disease. The Minimum Data Set (MDS, a resident assessment tool) documented the resident's admitted d 11/11/22. The resident's BIMS was documented as 99, severely impaired cognition. The resident exhibited physical and verbal behavioral symptoms directed towards others daily, and other behavioral symptoms not directed towards others 1-3 days. The resident required extensive assistance of 2 staff for bed mobility and dressing and toilet use and hygiene, and extensive assistance of 1 staff for eating. A review of the Baseline Plan of Care dated 11/11/22 documented Resident's Cognition as alert to person, Activities of Daily Living; bed mobility, transfers, toilet use and bathing with assist of 2, dressing, grooming/hygiene with 1 assist. There was no other interventions documented. A review of the ADL Care Plan dated 11/11/22 documented the resident required extensive assist of 2 staff for bathing, extensive assist of 2 staff for bed mobility and dressing and transfers. Resident required extensive assist of 1 staff for personal hygiene and dependent assist of 2 staff for toilet use, set-up with supervision for eating. A review of the Behavior Symptoms Care Plan dated 11/12/22 documented the resident is resistive to care as manifested by hitting, kicking, spitting to staff and verbally abusive, cursing and having accusatory behavior, but did not include interventions. A review of a Nursing Note dated 11/12/22 at 6:25 AM, documented the resident was combative, kicking and swinging while receiving incontinent care with 2-assist. Staff reminded to calmly approach resident and if fighting, to allow time for aggression to subside A review of the Physical Therapy Treatment Encounter Notes dated 11/14/22 documented that Resident #1 was combative and swinging and spitting at the therapist several times and swearing at providers. A review of the Nursing Progress Note dated 11/14/22 at 2:47 PM, written by Licensed Practical Nurse(LPN #1) documented that the resident resisted incontinent care, used derogatory language, kicking and trying to hit staff. 2-person assist maintained, employing calm approach. Review of the ADL Care Plan intervention dated 11/15/22 documented 'explain all procedures prior to initializing'. There was no documentation of interventions to address the resident's specific behaviors Review of Behavior Symptoms Care Plan interventions dated dated 11/15/22. documented, 'redirect negative behaviors, orient to daily routines, explain procedures prior to initiation of tasks'. No intervention was documented to address the resident's behavior of spitting. An interview was conducted on 11/18/22 at 3:30 PM with Physical Therapist (PT#1). PT#1 stated they were assisted with Resident#1's care for the first time on 11/14/22. PT#1 stated they were informed by the CNA#2 and Occupational Therapist (OT) that the resident was combative during care. Resident #1 was kicking, swinging, and spitting. PT#1 stated they reported the resident's behavior on 11/14/22 to the nurse in charge after providing care. An interview was conducted on 11/21/22 at 11:40 AM with the Licensed Practical Nurse (LPN#1). LPN#1 stated that the resident was resistant and combative with care including spitting at staff on 11/14/22 on the day shift, they documented the behaviors in the nursing note and reported to the RN#1. An interview was conducted on 11/21/22 at 11:55 AM with RN#1. RN#1 stated that on 11/14/22 when LPN#1 reported the resident's combative behaviors, they did not update the care plan because they thought the care plan was already updated. RN#1 stated that s/he reported Resident#1's behavior to the ADON who is responsible for the unit. An interview was conducted on 11/21/22 at 1:10 PM with the Assistant Director of Nursing (ADON). The ADON stated that the first encounter with the resident was on 11/14/22 during rounds. Resident #1 was calm in bed, with his feet on the wheelchair. The ADON stated that they asked a CNA#3 why the resident was positioned with feet on wheelchair, and the CNA#3 stated the resident was combative. The ADON assisted CNA#3 to reposition the resident and the resident was cooperative and repositioned himself. The ADON stated they thought the resident was going through a transisitional phase and was getting adjusted to the unit as the resident was admitted on ly 3 days prior. The ADON stated that on the morning of 11/15/22 RN#1 reported that Resident#1was combative, but when RN#1 observed the resident, Resident #1 appeared calm. The ADON stated they updated the Behavior and ADL care plans to reflect the behaviors and added new interventions. The ADON stated s/he felt the interventions were appropriate at that time based on their observations and interactions with the resident. An interview was conducted on 11/21/22 at 11:00AM with the Chief Nursing officer (CNO). The CNO stated that any Registered Nurse (RN) who identifies a change or escalation in behavior should enter appropriate interventions, and the interventions will populate under nursing instructions. The CNO stated that if a Licensed Practical Nurse (LPN) identifies a change or escalation in behavior, they are expected to document and report to the RN. 415.11

Based on record reviews and interviews conducted during an abbreviated survey (NY00305602), the facility did not report alleged violations involving abuse within the prescribed timeframes to the New York State Department of Health (NYS DOH) for 1 of 3 residents (Resident #1) reviewed for Abuse. Specifically, the Physical Therapist (PT#1) reported to the Registerd Nurse in Charge (RN#1) on 11/15/22 that they witnessed a Certified Nurse Aide (CNA#1) put a wet washcloth in the Resident #1 mouth during care. PT#1 documented the incident on the PT Treatment Encounter Note on 11/15/22. RN#1 stated they reported the incident to the Assistant Director of Nursing (ADON) on 11/15/22. The facility did not report the incident to NYSDOH until 11/16/22. The findings are: A review of the facility policy and procedure signed and dated 10/18/22 titled, Resident Abuse, Neglect, Mistreatment, and Exploitation documented the facility ensures residents are free from abuse, neglect, misappropriation of resident property, and exploitation and complies with federal, state guidelines and complies with NYS DOH Office of Long-Term Care Incident Reporting Manual. Resident #1 was admitted to the facility on [DATE] with diagnoses including but not limited to Sepsis, Anxiety Disorder, and Alzheimer's Disease. The Minimum Data Set (MDS, a resident assessment tool) documented that the resident had severe cognition impairment and required extensive assistance of 2 staff for bed mobility, dressing, toilet use and hygiene, and extensive assistance of 1 staff for eating. A review of the Physical Therapist's (PT #1) Physical Therapy Treatment Encounter Note in the Electronic Medical Record (EMR) dated 11/15/22 at 04:35:12 PM, documented that they assisted CNA #1 in changing and washing the resident. Resident#1 demonstrated intense combativeness striking and spitting at both providers. PT#1 sustained a small lac on right nose due to reisdent's agitation. Resident #1 spat at CNA #1 and CNA #1 put a wet rag in resident's mouth stating, 'I outta wash your mouth out' and pushed his head to the side and reported to the Registered Charge Nurse and Director of Rehab (DOR) as this was unnecessary and abusive. A review of the RN #1's undated statement documented that on 11/15/22 at around 11:15 am, PT #1 approached them in the nursing office and stated that during care CNA #1 put a washcloth in Resident#1's mouth because the resident was spitting and that made PT #1 uncomfortable. An interview was conducted on 11/18/22 at 1:55 PM with the Assistant Director of Nursing (ADON). The ADON stated that on 11/15/22 the Registered Charge Nurse reported PT#1's concerns regarding the resident spitting and combative behavior, and that CNA #1 blocked the resident ' s mouth with a washcloth. RN #1 requested face shields for the staff to use for protection. A review of the facility Accident/Incident Report dated 11/16/22 documented that on 11/16/22 at approximately 8:30 AM, the PT#1 reported to the DOR that s/he witnessed CNA#1 yesterday at approximately 11:00 AM, put a wet towel into Resident #1's mouth and said 'I outta wash your mouth out' and push the resident's face and right shoulder. A review of the facility investigation dated 11/16/22, completed 11/21/22, documented the investigation was not initiated until a day after the Physical Therapist reported their concerns to the Registered Charge Nurse on 11/15/22 and the Registered Charge Nurse reported to the ADON on 11/15/22. The investigation included a summary of the incident and staff statements. The PT written statement on the PT encounter form documented that during Activities of Daily Living (ADL) care on 11/15/22 at approximately 11:00AM, the resident was combative and CNA#1 put a washcloth in the resident ' s mouth. On 11/18/22 at 9:00 AM, an interview was conducted with the facility Administrator. They stated they were made aware of the incident by the Director of Rehab on 11/16/22 and reported to the NYS DOH the same day. They stated PT#1 reported to RN#1 on 11/15/22 that the resident had scratched him/her. PT#1 repored to the DOR on 11/16/22 that CNA#1 was abusive and DOR reported to them. The Administartor stated CNA#1 was suspended immediately and interviewed by the DON on 11/16/22. 483.12 ( c ) (1)

Based on record review and interviews during an Abbreviated Survey (NY00305602), it cannot be ensured that the facility thoroughly investigated an incident to rule out abuse neglect, exploitation, or mistreatment for 1 of 3 residents reviewed. Specifically, the Physical Therapist (PT #1) documented they reported to the Registered Nurse Charge Nurse (RN#1) on 11/15/22 that they witnessed the Certified Nursing Assistant (CNA#1) put a wet washcloth in the resident's mouth and stated 'I outta wash your mouth out' and pushed his/her head to the side. There was no documented evidence that the facility thoroughly investigated the allegation when it was reported to the RN#1 by PT #1 on 11/15/22 or when it was reported to the Assistant Director of Nursing (ADON) by the RN#1 on 11/15/22, until the following day. The findings are: A review of the facility policy and procedure signed and dated 10/18/2022 titled, Resident Abuse, Neglect, Mistreatment, and Exploitation documented the facility ensures residents are free from abuse, neglect, misappropriation of resident property, and exploitation including by screening prospective employees training staff upon hire and annually, conduct continuing education throughout the year, instructing staff how to handle difficult residents and how to report circumstances surrounding any act they may have committed in their care that could be interpreted as an act of abuse, exploitation, mistreatment, or neglect, complies with federal, state, local and Omnibus Budget Reconciliation Act (OBRA) guidelines, and complies with NYS DOH Office of Long Term Care Incident reporting Manual and NYS DOH Law 2803-d. Resident #1 was admitted to the facility on [DATE] with diagnoses including but not limited to Sepsis, Anxiety Disorder, and Alzheimer's Disease. The Minimum Data Set (MDS, a resident assessment tool) documented the resident had severely impaired cognition and required extensive assistance of 2 staff for bed mobility and dressing and toilet use and hygiene. The Minimum Data Set (MDS, a resident assessment tool) documented the resident's admitted d 11/11/22. The resident's BIMS was documented as 99 with severely impaired cognition. The resident exhibited physical and verbal behavioral symptoms directed towards others daily, and other behavioral symptoms not directed towards others 1-3 days. The resident required extensive assistance of 2 staff for bed mobility and dressing and toilet use and hygiene, and extensive assistance of 1 staff for eating. A review of the Physical Therapist's (PT #1) 'Physical Therapy Treatment Encounter Note in the Electronic Medical Record (EMR) dated 11/15/22 at 04:35:12 PM, documented that they assisted CNA #1 in changing and washing the resident. Resident#1 demonstrated intense combativeness striking and spitting at both providers. PT#1 sustained a small lac on right nose due to resident's agitation. Resident #1 spat at CNA #1 and CNA #1 put a wet rag in resident's mouth stating 'I outta wash your mouth out' and pushed his head to the side and reported to the Registered Charge Nurse and Director of Rehab (DOR) as this was unnecessary and abusive. A review of the RN #1's undated statement documented that on 11/15/22 at around 11:15 am, PT #1 approached them in the nursing office and stated that during care CNA #1 put a washcloth in the mouth because the resident was spitting and that made PT #1 uncomfortable. A review of the facility Accident/Incident Report dated 11/16/22 documented that on 11/16/22 at approximately 8:30 AM, the PT reported to the DOR that s/he witnessed CNA#1 yesterday at approximately 11:00 AM, put a wet towel into Resident #1's mouth during care and said 'I outta wash your mouth out' and push the resident's face and right shoulder. A review of the facility investigation dated 11/16/22, completed 11/21/22, documented the investigation was not initiated until a day after PT #1 reported their concerns to the RN#1 on 11/15/22 and the RN#1 reported to the DON on 11/15/22. The investigation included a summary of the incident and staff statements. PT#1's statement documented that during Activities of Daily Living (ADL) care on 11/15/22 at approximately 11:00AM, the resident was combative, and CNA#1 put a washcloth in the resident ' s mouth. On 11/18/22 at 9:00 AM, an interview was conducted with the facility Administrator. They stated they were made aware of the incident by the Director of Rehab on 11/16/22 and reported to the NYS DOH the same day. They stated PT#1 reported to RN#1 on 11/15/22 that the resident had scratched him. PT#1 reported to the DOR on 11/16/22 that the CNA#1 was abusive and DOR reported Pt#1's account to them. The Administrator stated CNA#1 was suspended immediately and interviewed by the DON on 11/16/22. On 11/18/22 at 12:00 PM, an interview was conducted with PT #1. PT #1 stated they felt CNA #1 was inappropriate by putting the washcloth to the resident ' s mouth, but didn't know if it was abuse. PT#1stated that when they wrote abuse in their statement, they meant inappropriate . PT #1 stated they told the charge nurse that the incident made them uncomfortable, and CNA#1 should not work directly with the resident on 11/15/22 after the incident occurred. PT#1 stated they told the Rehab Director the following morning, and s/he took a written statement. On 11/18/22 at 1:30 PM, an interview was conducted with the RN charge nurse (RN #1). RN#1 stated PT#1 reported their concerns on 11/15/22 before lunch, the RN didn't realize that PT#1 was concerned about abuse. The RN stated they thought CNA#1 was blocking the resident's spitting with the washcloth. RN#1 stated their concern was that PT#1 reported they've been scratched by Resident#1 causing an open area on PT#1's nose. RN#1 stated they reported the spitting and combativeness to the Assistant Director of Nursing (ADON) and that PT#1 was not comfortable with CNA#1 caring for the resident. RN#1 got face shields for the staff. protection. CNA#1 was removed immediately from the resident's care and the next day, the CNA#1 was switched to another unit. RN#1 stated they were in-serviced and is frequently re-in-serviced on abuse prevention and reporting, and has no concerns about CNA#1. An interview was conducted with the ADON on 11/18/22 at 1:55 PM. The ADON stated that on 11/15/22 the Registered Nurse Charge Nurse (RN#1) reported PT#1's concerns regarding Resident#1 ' s spitting and combative behavior, and that CNA#1 blocked the resident ' s mouth with a washcloth, and that they were getting face shields for the staff to use. A follow-up interview was conducted on 12/22/22 at 2:00 PM with RN#1. RN#1 stated that when PT#1 reported his/her concerns on 11/15/22, s/he, (the RN), did not perceive the concern as abuse RN#1 stated they thought that CNA#1 was using the washcloth to block the resident's spit. RN#1 stated that their usual process when someone reports a concern is to check the resident immediately for any signs or symptoms of injury or abuse, reassign staff as needed and report to the RN supervisor. RN#1 stated they reported the account by PT#1 to the ADON that CNA#1 put the washcloth in front of the resident's mouth. RN#1 informed the ADON that they checked the resident, and was bringing face shields to the unit for staff protection. 483.12 (c) (2)

Based on interview, and record review conducted during an abbreviated survey (NY00305602), the facility did not ensure that 1 out of 3 sampled residents (Resident #1) was free from abuse and mistreatment. Specifically, on 11/15/22 Physical Therapist (PT#1) reported to Registered Nurse in Charge (RN#1) that while providing care, a Certified Nursing Assistant (CNA #1) put a wet rag in the mouth of Resident #1 as the resident became combative. During the facility's investigation, it was reported by CNA #1 that PT #1 held Resident #1 down by his/her hand and foot during care as the resident became increasingly combative. The findings are: The Facility Policy and Procedure titled, Resident Abuse, Neglect, Mistreatment, and Exploitation signed and dated 10/18/22 documented the facility ensures residents are free from abuse, neglect, misappropriation of resident property, and exploitation Resident #1 was admitted to the facility on [DATE] with diagnoses including but not limited to Sepsis, Anxiety Disorder, and Alzheimer's Disease. The Minimum Data Set (MDS, a resident assessment tool) documented the resident had severely impaired cognition and required extensive assistance of 2 staff for bed mobility and dressing and toilet use and hygiene, and extensive assistance of 1 staff for eating. The Physical Therapy (PT#1) Treatment Encounter Note in the resident's Electronic Medical Record (EMR) dated 11/15/22 at 04:35:12 PM was reviewed. PT#1 documented, Assisted CNA #1 in changing and washing the patient. Resident #1 demonstrated intense combativeness striking and spitting at both providers. Writer suffered a small lac on right nose due resident's agitation. During changing, Resident #1 spat at CNA #1 and CNA #1 put a wet rag in patient's mouth stating, 'I outta wash your mouth out' and pushed his/her head to the side. Reported this to nurse in charge as this was unnecessary and abusive. A review of a statement written by the Charge Nurse (RN #1) which was undated revealed PT #1 reported that during care CNA #1 put a washcloth in the mouth of Resident #1. RN #1 also wrote that they went to Resident's room to assess resident and found Resident #1 in the dining room. RN #1 documented that the resident did not verbalize discomfort and had no physical signs of being abused. A review of PT #1's handwritten statement dated 11/16/22 documented while working with CNA #1, the resident was verbally and physically combative with staff as they attempted to get him undressed and cleaned. While cleaning the resident, CNA #1 was spit on by the resident. CNA #1 then dunked a washcloth in water and put it in Resident #1's mouth stating, 'we outta wash your mouth out' then pushed the patient's face and right shoulder. Incident occurred 11/15/22 at approximately 11 am. A review of facility statement dated 11/16/22 written by the Director of Rehab (DOR) documented that PT #1 reported an incident involving a resident that occurred during care on 11/15/22 at approximately 8:30am. PT #1 stated that s/he witnessed something CNA #1 did when they provided care to a resident who was combative, spitting and scratching during care. PT #1 reported that CNA #1 put a wet washcloth in Resident #1's mouth and told him, 'We ought to clean your mouth out'. CNA #1 also pushed resident's face and shoulder. PT #1 stated they reported the incident to the charge nurse. DOR stated they reported the account by PT #1 to the Chief Operations for Nursing. Review of CNA #1's undated statement, documented that CNA #1 was assigned to care for Resident #1 on 11/15/22. CNA #1 and PT #1 entered Resident #1's room around 10:30 am. CNA #1 wrote that they introduced themselves to the resident and the Resident #1 did not answer. PT #1 took off the covers, CNA #1 got a basin of water, soap, washcloth and told the resident that they will be providing care to get him/her up and dressed. Resident #1 pushed the table with the basin away. PT #1 held down the resident's hand and foot on the bed and they took turns removing the resident's gown and briefs. Resident #1 kicked PT #1. PT #1 held resident's foot and hand and they washed the resident. Resident kicked, hit, spit bit and called them names. CNA #1 documented that they wiped resident's face with washcloth and did not put washcloth in Resident #1's mouth. CNA #1 documented they do not recall pushing Resident #1 because the resident was fighting and moving all over. A review of the facility Accident/Incident Report dated 11/16/22 documented that on 11/16/22 at approximately 8:30 AM, PT #1 reported to the DOR that they witnessed a CNA yesterday put a wet towel into Resident #1's mouth and say, 'I outta wash your mouth out' and push the resident's face and right shoulder. The incident occurred at approximately 11:00 AM on 11/15/22 when they were providing care to Resident #1. During an interview on 11/18/2022 at 12:00 PM, PT#1 stated that on 11/15/2022 in the late morning, they assisted CNA #1 to wash, dress and transfer Resident #1 to his wheelchair. PT #1 stated the resident was already spitting and swinging at both providers while CNA #1 was washing the resident. PT #1 stated that CNA #1 took a washcloth, put it into the basin of water, and put it to the resident ' s mouth and said to the resident 'we outta wash your mouth out '. PT #1 stated they assumed some of the washcloth got inside the resident ' s mouth. PT #1 said CNA #1 held the washcloth on the Resident#1's mouth for less than one second, pushed the resident ' s face and shoulder and said, 'this resident shouldn't be here 'and walked away. PT #1 stated they felt the CNA #1 was inappropriate putting the washcloth to the resident ' s mouth but didn't know if it was abuse. PT #1 stated they told the charge nurse about the incident on 11/15/22, that the interaction made them uncomfortable and recommended that CNA #1 should not work with the Resident #1. PT #1 stated that when they wrote abuse in their statement, they meant inappropriate PT #1 stated they had prior experience working with combative, confused residents in other Skilled Nursing Facility (SNF). Incident was reported to the DOR the following morning. During an interview 11/18/22 at 12:50 PM, the DOR stated PT #1 came to report to them on 11/16/22 at 8:30 AM that something made them uncomfortable when they worked with CNA#1 on 11/15/22. The DOR stated that PT #1 reported that CNA #1 put a wet washcloth in Resident #1's mouth and told the resident, 'we ought to clean your mouth out' and pushed the side of the resident's face and shoulder. PT #1 stated they reported the incident to the charge nurse right after the incident occurred. During a follow-up interview on 11/22/22 at 9:55AM, CNA #1 stated that on 11/15/22, while PT #1 took off the resident's gown, CNA #1 explained to Resident #1 that they were going to wash them. Resident #1 was spitting, kicking, and screaming during the wash and the resident had a lot of spit on his/her face. CNA #1 stated they explained to the resident that they were going to clean the spit off their face with a washcloth. CNA #1 stated that after washing the resident's face, they went to the bathroom to wash the spit off their hands. CNA #1 stated that if a resident isn't ready to get up, they tell the nurse and re-approach later. Residents are not forced to get up if they don't want to. The CNA stated that they did not put the washcloth in the resident's mouth. They stated, I wouldn't do that, I'm not crazy! CNA #1 further stated that the resident has teeth and would have bitten their fingers. There is no documented evidence that CNA#1 reported the residents' behavior to a nurse. During a follow-up interview on 12/22/22 at 2:00 PM, RN #1 stated that when PT #1 reported their concerns on 11/15/22, RN #1 did not perceive the report as abuse. RN #1 stated they thought that CNA #1 was using the washcloth to block the resident's spit. RN #1 explained that the usual process when someone reports an issue or concern is to check the resident immediately for any signs or symptoms of injury or abuse, reassign staff as needed and then report to the RN supervisor. RN #1 stated they reported the incident to the ADON. RN #1 informed the ADON that they checked the resident, and the resident had no injuries. RN #1 requested face shield for the staff to protect them. A follow-up phone interview was conducted with CNA #1 on 12/22/22 at 2:35 PM. CNA #1 stated that when they entered the room with PT #1, they explained to the resident what they were going to do and placed the basin on the table. The resident started kicking and hitting and pushed the table with the basin away. CNA #1 stated they were not sure why the resident behaved that way, perhaps the resident did not want to be bothered at that time. CNA #1 stated that they feel that when Resident #1 was resistant to care they should have reapproached later although PT #1 said they needed to perform the rehab and that their time was limited. Resident #1 was slotted for that time. CNA #1 stated that PT #1 held down the resident's hand and foot while the resident was lying on his side so they could not kick and hit while they were being washed. CNA #1 stated that they feel they should have left the room and allowed Resident #1 to rest and re-approach later. PT #1 wanted the care completed. CNA #1 stated they didn't report anything to the charge nurse because they thought the charge nurse already knew about the resident's behaviors. CNA #1 stated that they were in-serviced on abuse prohibition/dementia care. In the training they were taught to reapproach any resident refusing care or is combative. When resident refuses care they should not perform the care but rather report to the nurse and reapproach later. During an interview on 12/23/22 at 9:50 AM with the Staff Educator(SE), they stated that CNA #1 was up to date on trainings including Abuse, Dementia, Resident Rights, and Behaviors. SE stated the facility does not manage the training for the rehab department and referred the surveyor to the Rehab Director. During a follow up interview with DOR on 12/23/22 at 11:10 AM, the DOR stated that PT #1 was a contracted staff, and contract staff complete a checklist of skills provided by their agency. The DOR stated that therapy training includes how to treat residents who frequently present with combative behaviors and confusion. The DOR stated that new hires receive oral explanations including to take each patient situation as it presents and modify the treatment plan as needed. The DOR stated if a resident was in danger of injuring themself by kicking or hitting it would be appropriate for the therapist to put hands on the resident to prevent them from injuring themselves. The DOR stated the first thing to do with a resident who is resistant is to try to calm them down, but if that is ineffective, the resident should be left alone and re-approached later. The DOR stated that in this investigation, it is difficult to determine if PT #1 should have stopped care without having been an eyewitness. The DOR stated that the therapist has flexibility in their daily schedule. Therapists have a daily list of residents to provide therapy and they can decide who to do first based on which resident is ready. The therapist can reapproach a resident who is not ready to participate in therapy. 483.12 (a) (1)

Based on record review and interview conducted during a recertification survey, the facility did not ensure that for 1 of 2 residents (#180) reviewed for hospitalization that the resident or her representative were given timely written notification of the bed hold policy before transfer in a language and manner they could understand. The findings are: Resident #180 was admitted on [DATE]. Her [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS - a resident assessment and screening tool) dated 12/21/2018 indicated that Resident #180 is cognitively intact. Review of a 3/15/2019 nursing note showed that Resident #180 was transferred to the emergency room and admitted with a [DIAGNOSES REDACTED]. Resident #180 was subsequently discharged from the hospital and returned to the facility on [DATE]. Review of the medical record and interview with the Director of Social Work on 6/13/2019 at 2:15 PM showed no evidence that the resident or her representative had received timely written notification of the facility's bed hold policy prior to her hospital admission. 415.3(h)(4)(i)(a)

Based upon interview and record review conducted during the recertification survey, the facility did not ensure that each resident received proper treatment and assistive devices to maintain hearing ability. This was evident for 1 of 38 residents reviewed. (Residents#109). The findings are: Resident #109 was admitted on [DATE] with [DIAGNOSES REDACTED]. The annual MDS (minimum data set-a resident assessment tool) dated 10/23/18 documented the resident was cognitively intact, had minimal difficulty hearing, used a hearing aid or other hearing appliance, made himself understood, and understood others. Subsequent quarterly MDS assessments on 12/22/18, 3/6/19 and 4/14/19 all documented that the resident had minimal difficulty hearing, used a hearing aid or other hearing appliance, made himself understood, and understood others. The comprehensive care plan (CCP) for communication dated 12/10/16 documented the following; resident had adequate hearing with use of left hearing aid; left hearing aid sent out for repair; usually understands others. No date was given for when the hearing aide was sent out. Care Plan progress notes dated 2/25/17 to 3/21/19 did not address the left hearing aid. An Ear, Nose and Throat (ENT) consult dated 1/25/2018 documented poor hearing. An Audiology consult dated 7/19/18 documented the resident's left hearing aid was broken. An ENT consult dated 9/27/18 documented the resident's left hearing aid was broken. During a tour of the unit on 6/06/19 at 12:00 PM the resident declined an interview. The resident's son was present and reported the resident's left hearing aid was taken last (MONTH) for repair and was not returned. He further stated the resident was deaf in his right ear and had fifty percent hearing in his left ear. In an interview conducted on 6/12/19 at 9:45 am the resident reported that he is deaf in his right ear and his hearing had been worsening in his left ear. He stated someone took his left ear hearing aid for repair over a year ago and he would like his hearing aid back. The interview was conducted in a small, quiet room free from extraneous sounds with only the resident and surveyor present. During the interview the resident requested to be spoken to from his left side and asked that several questions be repeated. 415.12(3)(b)

Based on observation, record review and interview conducted during an abbreviated survey (NY# 5), the facility did not ensure that nurse aides demonstrated competency to provide safe care and respond to individual needs as identified in the assessment and care plan for 1 of 3 residents (Resident #1) reviewed for accidents. Specifically, Resident #1 was able to stand and required the assistance of one person to transfer from her wheelchair to bed. Nurse aides found that the resident could not stand. The nurse aides used a mechanical device (Sara Lift) to transfer the resident without notifying a nurse of the change in the resident's condition or seeking guidance for how to safely transfer the resident. The findings are: Resident #1 has [DIAGNOSES REDACTED]. The Annual MDS (Minimum Data Set, a resident assessment and screening tool) dated 4/27/18 revealed that the resident was moderately cognitively impaired, required extensive assistance of 1 person with transfer and walking and used a wheelchair and walker. The comprehensive care plan (CCP) on ADLs (Activities of Daily Living), specifically with transfer, was initiated on 4/21/15. The CCP had a goal that the resident would be transferred safely. The interventions to achieve this goal included to ensure safe transfer technique with staff, monitor for any change in status, provide extensive assist of 1 staff with transfer. According to the Accident/Incident Investigation Report Form dated and signed by an RN Supervisor (RNS) on 9/2/18, the RNS assessed the resident in bed on 9/2/18 at 6:30AM with reported swelling, redness, pain on right elbow. Resident unable to report what happened. Noted restricted range of motion on her right arm, grimaces with attempt to lift the arm. She was provided with pain medication, kept in bed, area was immobilized. X-ray report shows highly displaced and angulated acute right distal humeral fracture, generalized high grade [MEDICAL CONDITION]. She was sent to emergency room for evaluation and treatment. The facility summary of investigation revealed: At approximately 6:30AM on 9/2/18, the assigned night shift CNA #1 was providing care to Resident #1 and noted swelling and redness and Resident #1 complained of mild pain to the right elbow. CNA #1 informed LPN #1 who observed Resident #1's right elbow. LPN #1 informed the RN supervisor who assessed Resident #1 and noted redness, swelling of right arm. Resident #1 complained of pain upon palpation, skin warm to touch and not able to do range of motion on the right arm. MD was notified. Stat x-ray of the right elbow was done and it showed highly displaced and highly angulated acute right distal humeral fracture, generalized high grade [MEDICAL CONDITION]. MD was informed and examined Resident #1 and ordered transfer to hospital. Investigation was initiated. The ADON interviewed CNA #2 who was assigned to Resident #1 on the 3-11 shift on 9/1/18 and CNA #3, who was assisting CNA #2 to transfer Resident #1 from wheelchair to bed. According to CNA #2, on 9/2/18 around 7:30PM, she and CNA #3 were trying to transfer Resident #1 from the wheelchair to bed but apparently Resident #1 could not stand up. Both CNAs thought that it would be safer for them to use the Sara lift to transfer Resident #1 from wheelchair to bed without informing the nurse. According to both CNAs Resident #1 did not hit anything during transfer and did not complain of any pain after completion of care. Reenactment of the transfer with the use of the Sara lift by CNA #2 and CNA #3 was done by the ADON. The facility concluded that after careful review of staff statements, interviews, review of the CNA Accountability Record, comprehensive care plan and the [DIAGNOSES REDACTED].#1's right distal humeral fracture occurred in the course of usual care as stated in the Physician's Progress Notes. CNA #2 was interviewed on 2/8/19 at 1:55PM. She stated that she was assigned to Resident #1 on 9/1/18 on the 3-11 shift. About 7:30PM, she needed help to transfer her and CNA #3 assisted. They were trying to transfer the resident from the wheelchair to bed but she was not standing. They didn't want her to fall and for her safety, she said to try and use the Sara lift. They then transferred Resident #1 from the wheelchair to bed without notifying the nurse. Both CNAs went back at around 9 to 10PM and changed Resident #1's diaper. She wasn't complaining of pain, she was comfortable. CNA #3 was interviewed on 2/8/19 at 2:12PM. She stated that on 9/2/18, she helped CNA #2 with Resident #1's PM care. They tried to stand her up to transfer her from the wheelchair to bed but she would not stand up. CNA #2 said that they would use the Sara lift for Resident #1's safety. They didn't want her to fall. They didn't notify the nurse that they were using the Sara lift. Between 10PM to 10:30PM, CNA #3 and CNA #2 changed Resident #1's diaper and left her on her side. She said that Resident #1 did not complain of any pain and they didn't see anything on her arm. 415.26(c)(1)(iv)

Based on observation and interview conducted during a recertification survey, the facility did not ensure that foods were stored and served under sanitary conditions. Specifically, (1.) frozen ground meat placed in the refrigerator for thawing was not cooked in a timely manner, (2.) 1 of 7 nourishment unit refrigerators did not contain a thermometer, and (3.) a Certified Nurse Aide (CNA) did not use a barrier to handle sandwiches served to Resident #255 during two lunch meals. The findings are: 1. An initial inspection of the kitchen was conducted in the morning of 10/19/17. A pack of ground beef labeled 10/14/17 was observed in the walk-in refrigerator. The head cook was interviewed at that time and stated that on 10/14/17, the ground beef, weighing 8 pounds, was removed from the freezer and was placed in the walk-in refrigerator to be thawed. The head cook was asked as to what was the facility's policy for how long this item should be left in the refrigerator and stated that it should be used within three days. The US Department of Agriculture (USDA) website on food safety relating to ground beef stated that thawed ground beef should be used within 2 days. The ground beef would have been thawed by 10/16/17 and should have been used by 10/18/17. 2. During an observation in the afternoon of 10/20/17, 1 of 7 nourishment unit refrigerators in use on Unit 4K did not have a thermometer. (Refrigerators in use are to be equipped with working thermometers.) The Unit Manager was not available for interview at that time. The Unit Clerk was interviewed at about 3:15 PM on the same date and stated that she will inform maintenance that there is no thermometer in the refrigerator. 3. During the lunch meal on Unit 2K, a CNA was observed to set up the meal tray for Resident #255. The CNA used her bare hands to pick up half of the sandwich and placed it in one of the resident's hands. Another meal observation was done at lunch time on 10/23/17. The same CNA was observed to unwrap the sandwich for Resident #255. Using her bare hands, the CNA picked up the sandwich and gave it to the resident. The CNA was interviewed at that time and was asked as to the proper way of handling the resident's food. In response, the CNA asked the surveyor in return as to what she should do after she was observed using her bare hands in handling the resident's sandwich. The Unit Registered Nurse Manager was then interviewed following interview with the CNA and stated that the CNA should not have used her bare hands. 415.14(h)

Based on observation, interview and record review conducted during an abbreviated survey (Complaint #NY 782), the facility failed to ensure that Certified Nurse Aides (CNAs) demonstrated competency in skills and techniques necessary to meet special needs and prevent abuse for one of six residents with dementia and dysphagia (swallowing disorder) who was totally dependent on others to provide all aspects of care (Resident #1). Specifically, monitoring and supervision was not performed effectively to ensure that training for abuse prevention, ADL (activities of daily living) care and assistance to feed were properly implemented. Six CNAs failed to provide care in accordance with the Resident #1's assessment, physician's orders [REDACTED]. This resulted in immediate jeopardy and substandard quality of care affecting Resident #1 with [DIAGNOSES REDACTED].#2, #3, #4, #5 and #6). The findings are: Cross references: F226 - Freedom from Abuse = K F282 - Care provided by qualified persons in accordance with the plan of care = D F490 - Effective Administration. Resident well-being = K Signed attendance sheets submitted by the facility revealed that Abuse education was provided during orientation and subsequently for Certified Nurse Aides (CNA) #1 - #6 on various dates between 9/25/09 and 7/7/17. The facility policy for Abuse Prevention Program dated 5/20/10 documented that the facility has zero tolerance for abuse. The policy states under the section for Prevention that, DON/Supervisor/Head Nurse/Charge Nurse 1. Supervises staff to identify inappropriate behaviors such as, but not limited to: Derogatory language, Rough handling, Ignoring resident while giving care, . Inappropriate tone of voice, Disrespectful attitude. The section for Protection included the statement that Supervisory/Personnel/All Departments 1. Makes rounds to observe staff performance and intervenes as appropriate. And Nursing 1. Assures appropriate care is rendered to residents on all tours. According to the facility policy on Thickened Liquids Used for Dysphagia dated June 2011, to ensure the safety of swallowing in Residents with Dysphagia (swallowing disorder) the Licensed Nurse/CNA administers in accordance with the physician's orders [REDACTED]. The facility policy for Feeding the Resident (Dependent Eating) dated December 1999 stated under Responsibility for Licensed Nurse/Certified Nursing Attendant Do not force the resident to eat. Give liquids slowly. The facility policy for Resident Dining and Food Set-Up dated June 1998 included under Responsibility for Certified Nursing Assistant Feeding resident Requiring Extensive Assistance to Feed resident slowly with fork or spoon filled only half full. Never rush the resident through his meals. Do not use force feed. The policy also stated The necessary nursing oversight will be provided to insure safe meal completion. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Annual Minimum Data Set (MDS; a resident assessment tool) dated 7/27/17, the resident had severely impaired cognition, severely impaired vision, rarely or never had the ability to be understood or to understand others and was unable to speak. This MDS indicated that the resident had functional limitation in range of motion including both upper extremities with impairment involving the shoulders, elbows, wrists and hands. The resident required total assistance of one person for eating and did not demonstrate rejection of care. A Speech Pathologist Progress Note dated 3/16/16 documented the resident requires upright positioning when feeding in bed, slow rate and small bolus presentation as well watching for swallow. Resident continues to be at risk for aspiration. The Speech Therapy Plan of Care dated 6/15/16 and the Care Plan Activity Report of 7/15/16 documented that the resident had signs of oropharyngeal dysphagia (difficulty swallowing), tended to sit with her head leaning down and would require one hand placed against her forehead to assist with bringing her head to a more midline position. The documented plan was to provide a slow feeding rate and small bolus with the use of a teaspoon. The Resident Nursing Instruction (a care guide which provides CNAs information regarding the type and level of care to provide the resident), initiated on 2/1/15 and revised on 7/22/16, documented that the resident required total assistance of one person for eating. The same form further documented that during feeding the CNA should gently tilt the resident's head up with their hand on the resident's forehead to facilitate feeding, and that the resident was to be fed slowly with small amounts on spoon. According to a lesson plan and sign-in sheets for Continuation of Care for Resident #1, charge nurses provided in-service education to nursing staff on 7/22/16 and 7/27/16. This education included instructions to feed the resident slowly with small amounts on spoon and watch for swallowing prior to giving more food. Sign-in sheets were signed by CNA #1 and CNA #4. There was no documented evidence that this education was provided to CNAs #2, #3, #5 and #6. According to the Dysphagia In-Service document, the Speech Pathologist provided in-services to LPNs, RNs and CNAs regarding feeding residents with dysphagia on 12/6/16, including CNA #5. There was no documented evidence that CNAs #1, #2, #3, #4 or #6 received the in-service education. The facility did not provide documented evidence, upon request, for competency evaluation of CNAs related to provision of care for activities of daily living (ADLs) and feeding residents with dysphagia. The Physician order [REDACTED]. The resident was observed seated in a tilted wheelchair in the dining room during the lunch meal on 8/17/17. The resident's head was tilted with a forward neck posture and upper extremities were flexed. The resident was hand-fed and demonstrated no participation in the activity of eating other than to move her mouth and swallow. A family member was interviewed on 8/17/17 at 12:00 PM. During this interview, the family member provided a video recording that was viewed at that time by the surveyor and the family member. The video recording revealed multiple, individual episodes of physical and emotional abuse to Resident #1 while in bed during assistance to eat and provision of care by six CNAs (CNAs #1, #2, #3, #4, #5 and #6). Abusive treatment of [REDACTED]. The video also revealed multiple episodes of failure to utilize techniques to assist the resident to eat according to physician's orders [REDACTED]. CNAs were not observed to gently tilt the residents head, slowly feed the resident small amounts on a spoon and/or watch for the resident to swallow. The video recording was subsequently reviewed by facility administrative staff on 8/17/17 at 8:30 PM and involved CNAs between 8/18/17 at 8:30 AM and 8/21/17 at 2:15 PM. The Chief Nursing Officer was interviewed on 8/18/17 at 2:20 PM and stated that what he saw in the video was not acceptable and it was abuse, mistreatment, rough handling and forceful feeding. He also stated that he realized that the staff need more training and the management need to do more supervision and monitoring. The Assistant Administrator was interviewed on 8/18/17 at 2:58 pm and stated that what she saw in the video was abuse in feeding, rough handling, physical abuse, forceful feeding, and that she will ensure to have more supervision and monitoring to prevent abuse. The Administrator was interviewed on 8/18/17 at 3:00 PM and stated that staff were not implementing what they were taught and nurses were not following up with abuse prevention. She stated that supervision was not effective and that possibly the nurses were not recognizing abuse. The Administrator also stated that abuse training was done on-line at orientation time, then in person and followed by monthly in-service. The Administrator stated that the facility needed to do better supervision and monitoring. Eighteen CNAs were randomly interviewed on the day and evening shifts between 8/18/17 and 8/22/17 and stated that they received training on abuse. Fifteen of the eighteen CNAs reported that no supervision and no one monitors the way they provide care or assistance with feeding. Residents #2, #3, #4, #5 and #6 were identified by facility staff as requiring honey-thickened consistency liquids and feeding by teaspoon. According to care plan documents, these residents also required total assistance to eat. The facility removed the immediate jeopardy on 8/23/17 by conducting inservice education of staff regarding abuse prevention during feeding and activities of daily living (ADL) care, monitoring of residents who are being fed by the CNAs, dysphagia and aspiration, safe feeding techniques, and following CNA accountability as stated in the plan of care. The interim plan also included that each unit will have an assigned leadership staff member who will be supervising, observing, monitoring and evaluating with appropriate feedback and actions seven days a week. 415.26(c)(1)(iv)

Based on observation, interview and record review during an abbreviated survey (Complaint #NY 782), the facility failed to implement policies and procedures to prohibit and prevent resident abuse. Specifically, on-line in-service education for abuse prevention was provided for staff without effective follow-up to ensure understanding and compliance. The facility failed to supervise staff to identify abuse, intervene to ensure that residents were protected from abuse and mistreatment and ensure that all allegations of abuse were immediately reported to the administrator of the facility. Video evidence revealed repeated physically and emotionally abusive treatment of [REDACTED].#1) with dementia and dysphagia (swallowing disorder), who was totally dependent on staff to provide all aspects of activities of daily living, by six Certified Nurse Aides (CNAs) during assistance to eat and provision of care. On one occasion, a Registered Nurse (RN) observed an episode of abusive treatment of [REDACTED]. The facility's failure to prevent, identify, intervene and report abuse resulted in immediate jeopardy and substandard quality of care affecting Resident #1 with the potential to affect five additional residents with swallowing difficulty who require total assistance with care and feeding (Residents #2, #3, #4, #5, and #6) and all other residents in the facility. Cross References: F282: Care provided by qualified persons in accordance with the plan of care = D F490: Effective Administration/ Resident Well- Being = K F498: Proficiency of Nurse Aides = K The findings are: The facility policy for Abuse Prevention Program dated 5/20/10 documented that the facility has zero tolerance for abuse. The policy states under the section for Training that, Upon hire, the employee attends organizational orientation at which time the facility's abuse prevention program and all policies related to abuse are covered. The section for Prevention states that, Nursing/All Departments Assess staff competency annually. In-services staff on appropriate interaction/handling of residents to include, but is not limited to, appropriate language, tone of voice and touch. DON/Supervisor/Head Nurse/Charge Nurse 1. Supervises staff to identify inappropriate behaviors such as, but not limited to: Derogatory language, Rough handling, Ignoring resident while giving care, Inappropriate tone of voice, Disrespectful attitude. The section for Protection included the statement that Supervisory/Personnel/All Departments 1. Makes rounds to observe staff performance and intervenes as appropriate. And Nursing 1. Assures appropriate care is rendered to residents on all tours. The facility policy for Reporting of Abuse dated April 2014 revealed that any staff member who discovers any allegations of abuse must report to the Vice President of Nursing and appropriate department heads immediately upon discovery of the abuse. According to signed attendance sheets submitted by the facility, Abuse education was provided during orientation and subsequently on various dates including for Certified Nurse Aide (CNA) #1 on 9/25/09 , 12/21/13, 10/11/14, 1/17/15, and 3/25/17; CNA #2 on 10/14/14, 6/30/15, and 7/7/17; CNA #3 on 12/5/13, 8/21/14, 12/17/14, 9/24/15, and 6/1/17; CNA #4 on 11/10/09, 1/16/14, 11/10/14, 12/22/14 and 9/19/15; CNA #5 on 12/12/13, 8/5/14, 12/30/14, 10/9/15, and 1/24/17; CNA #6 on 12/1/15, and 4/22/17; and RN #1 on 7/7/17. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. According to the Annual Minimum Data Set (MDS; a resident assessment tool) dated 7/27/17, the resident had severely impaired cognition, severely impaired vision, rarely or never had the ability to be understood or to understand others and was unable to speak. This MDS indicated that the resident had functional limitation in range of motion to upper and lower extremities on both sides with impairment involving the shoulders, elbows, wrists, hands, hips, knees and feet. The resident required total assistance of two persons with bed mobility, toilet use and personal hygiene, and required total assistance of one person for dressing and eating and did not demonstrate rejection of care. The Resident Nursing Instruction (a care guide which provided CNAs information regarding the type and level of care to provide the resident), initiated on 2/1/15 and revised on 7/22/16, documented that the resident required total assistance with one person for eating and total assistance of two persons with bed mobility. The same form further documented that during feeding the CNA should gently tilt the resident's head up with their hand on the resident's forehead to facilitate feeding, and that the resident was to be fed slowly with small amounts on spoon. The resident was observed seated in a tilted wheelchair in the dining room during the lunch meal on 8/17/17. The resident's head was tilted with a forward neck posture and upper extremities were flexed. The resident was hand-fed and demonstrated no participation in the activity of eating other than to move her mouth and swallow. A family member was interviewed on 8/17/17 at 12:00 PM. During this interview, the family member provided a video recording that was viewed at that time by the surveyor and the family member. The video recording revealed multiple, individual episodes of physical and emotional abuse to Resident #1 while in bed during assistance to eat and provision of care by six CNAs (CNA #1 - CNA #6). Abusive treatment of [REDACTED]. shut: CNA #1: - forcefully pushed the resident's head back while pressing her forehead. - fed the resident heaping/overfull spoonful of food rapidly and forcefully. Food spilled from the spoon and from the resident's mouth onto her chin and lower jaw in large volumes. CNA #1 scooped food from the resident's chin and face and refed this food back into the resident's mouth rapidly and forcefully without waiting for the resident to swallow. The resident grimaced and coughed during the meal. - unwrapped and ate bread while she was feeding the resident. - pinched the resident's nose for at least 16 seconds while CNA #1 put a cup to the resident's mouth. - pulled roughly on both of the resident's legs while turning and positioning her unassisted by a second caregiver during two episodes of provision of care. - threw a cloth over the resident's face, then roughly wiped her mouth, nose, eyes, then nose again and then mouth again in a continually rough manner. CNA #2: - fed the resident forcefully while dipping the spoon into a cup that she held in the same hand that she used to hold the resident's forehead for positioning. Scooped food roughly from chin and refed. Used the spoon to force the resident's mouth open. - provided positioning care to the resident unassisted and pulled the resident's leg roughly, pushed forcefully on the resident's face, picked the resident up several inches from the surface of the bed and dropped her roughly back to the bed. - handled the resident roughly while turning and positioning in bed unassisted on two further occasions. - cleaned the resident's face in a rough manner. The resident grimaced twice and expressed a fearful look during the care. CNA #3 - provided care to the resident unassisted and pulled the resident to position in bed in a rough manner. CNA #4 - on two occasions, forced a tablespoon heaped with food into the resident's mouth. Used the spoon to pry open the resident's mouth. Scooped food from chin and refed. CNA #5: - wiped the resident's face in a rough manner. CNA #6: - forcefully fed the resident and pushed back the resident's head roughly during feeding. Scooped food from chin and refed. Used spoon to open mouth. RN #1 walked into the resident's room while CNA #6 was feeding the resident and witnessed CNA#6 feeding and handling the resident in a rough manner. RN #1 did not intervene to protect the resident in the above episode. The video recording was viewed, with family member consent, on 8/17/17 at 8:30 PM with facility administrative staff that included the Assistant Administrator, Chief Nursing Officer, Director of Nursing, Assistant Director of Nursing/evening shift RN (Registered Nurse) Supervisor, and night shift RN Supervisor. The administrative staff then immediately identified the involved staff members, specifically, four day shift CNAs, two evening shift CNAs and one RN from the day shift. The above administrative staff members were interviewed and reported no prior knowledge of abuse and mistreatment of [REDACTED]. The night shift RN Supervisor was interviewed on 8/18/17 at 1:35 PM and stated that what she saw in the video was very disturbing, absolute abuse and mistreatment. She further stated that she will be more vigilant in supervision and monitoring of the staff during care. This RN was interviewed again on 8/21/17 at 10:00 AM and stated that the nurses were supposed to supervise and monitor the CNAs to protect the residents from abuse and she now realized that it was not done properly. The Infection Control Nurse, who was in charge of staff development, was interviewed on 8/18/17 at 1:50 PM and stated that all facility staff get mandatory on-line in-service education for abuse prevention on a yearly basis. In addition, he stated that nursing staff are in-serviced by Nursing Supervisors as needed. He stated that there was no specific designee responsible for in-servicing and following up. The Director of Nursing, Assistant Directors of Nursing, Assistant Administrator, Nursing Supervisors and himself did in-services. He further stated that he did not assess competencies for the nursing staff; the Nursing Supervisors were responsible for competency evaluation. He stated that documentation of competency evaluation was kept in the nursing office in a binder. Upon request, he did not locate and provide the records. The Director of Nursing was interviewed on 8/18/17 at 2:00 PM and stated that she was shocked and numb after watching the video. She further stated she could define the actions of the CNAs as that of abuse, mistreatment, forceful feeding and rough handling. When asked what she did to ensure that residents were protected from abuse, she stated that there should have been close supervision and better monitoring to protect the residents from abuse. The Assistant Director of Nursing/evening shift Nursing Supervisor was interviewed on 8/18/17 at 2:15 PM and stated that she couldn't believe what she saw in the video. She also stated it was abuse, neglect, mistreatment, rough handling and forceful feeding. She stated that it was horrible. During a subsequent interview on 8/21/17 at 11:00 AM, she stated that she was upset to see the abuse that happened and realized that she should have instructed the evening nurses to do more rounds and monitor the CNAs during care and feeding. The Chief Nursing Officer was interviewed on 8/18/17 at 2:20 PM and stated that what he saw in the video was not acceptable and it was abuse, mistreatment, rough handling and forceful feeding. He also stated that he realized that the staff needed more training and that management needed to do more supervision and monitoring. During a subsequent interview on 8/22/17 at 10 AM, he stated that the management staff should have made more rounds to monitor the CNAs. The Assistant Administrator was interviewed on 8/18/17 at 2:58 PM and stated that what she saw in the video was deplorable, embarrassing, abuse in feeding, rough handling, physical abuse and forceful feeding. She further stated that the management should have provided more monitoring and supervision to prevent abuse. The Administrator was interviewed on 8/18/17 at 3:00 PM and stated that she was working in the facility for the last [AGE] years and nothing like this happened before. She further stated that she trusted her staff and she realized now that she can't trust them anymore. During this interview, she was offered to watch the video recording, which she declined and stated that her administrative team watched it and that was enough. She further stated that she couldn't say anything further about the abuse that happened in the facility because she didn't watch the video recording. The Administrator also stated that abuse training was done on-line at orientation time, then in person and followed by monthly in-service. Staff were not implementing what they were taught. Nurses were not following up with abuse prevention. The Administrator stated that the supervision was not effective and that the facility needed to do better supervision and monitoring. The following CNAs and RN observed in the video recording viewed the recording and were interviewed: CNA #1 (evening shift) was interviewed on 8/18/17 at 8:30 AM and stated that she realized that the spoon was overfilled with food and she was forcefully feeding the resident. CNA #1 did not provide any comments when she was asked about pinching the resident's nose while feeding the resident from a cup. RN #1 (day shift) was interviewed on 8/18/17 at 11:36 AM and stated that she was the medication nurse, so she never gets time to supervise the CNAs. She further stated that she went into the resident's room while CNA #6 was feeding to let the CNA know that another resident needed assistance. After watching the video, RN #1 stated she realized that the CNA was feeding the resident forcefully and she should have taken action by reporting her observation immediately. CNA #6 (day shift) was interviewed on 8/18/17 at 12:10 PM and stated that she was fast in feeding the resident and she knew that she was supposed to feed the resident slowly. CNA #5 (day shift) was interviewed on 8/18/17 at 12:20 PM and stated that she didn't realize that she was being rough in cleaning the resident's face and using the dirty towel to clean the resident's eyes. She also stated that she had force fed the resident before and was sorry about it. CNA #3 (evening shift) was interviewed on 8/18/17 at 12:30 PM and stated that she was rough in handling the resident and she was sorry for her mistake. CNA #4 (day shift) was interviewed on 8/19/17 at 11:40 AM and stated that she realized after watching the video that she was trying to open the resident's mouth with the spoon that was overfilled with food. She stated she felt bad for forcing the food. She also stated that she felt bad because once she cleaned the resident's face roughly with a clothing protector and sometimes the resident coughed during feeding. CNA #2 (day shift) was interviewed on 8/21/17 at 2:15 PM and stated that she knew she did not feed properly. She stated further that she should have positioned the resident properly and held her head gently. CNA #2 also stated that she wouldn't do to her mother what she did to the resident. Eighteen CNAs were randomly interviewed on the day and evening shifts between 8/18/17 and 8/22/17 and stated that they received training on abuse. Fifteen of the eighteen CNAs reported that there was no supervision and no one monitors the way they provide care or assistance with feeding. Residents #2 - #6 were identified by facility staff as requiring honey-thickened consistency liquids and feeding by teaspoon. According to care plan documents, these residents also required total assistance to eat. The facility removed the immediate jeopardy on 8/23/17 by conducting inservice education of staff regarding abuse prevention during feeding and activities of daily living (ADL) care, monitoring of residents who are being fed by the CNAs, dysphagia and aspiration, safe feeding techniques, and following CNA accountability as stated in the plan of care. The interim plan also included that each unit will have an assigned leadership staff member who will be supervising, observing, monitoring and evaluating with appropriate feedback and actions seven days a week. 415.4(b)

Based on observation, interview and record review conducted during an abbreviated survey (Complaint #NY 782), the Administration failed to ensure that the facility was administered in a manner that enabled it to use its resources effectively and efficiently, to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, facility administration failed to provide oversight and supervision of staff to protect residents from abuse during provision of care and feeding. Evidence revealed repeated physical and emotional abuse by six certified nurse aides (CNAs), during the provision of care and assistance with eating, towards one of six residents reviewed for abuse (Resident #1). This resulted in immediate jeopardy and substandard quality of care affecting Resident #1 and potentially affecting all the residents of the facility. The findings are: Cross references: F226 - Free from Abuse/Involuntary Seclusion = K F282 - Care provided by qualified persons in accordance with the plan of care = D F498 - Proficiency of Nurse Aides = K According to the facility policy for Abuse Prevention Program dated 5/20/10, the facility has zero tolerance for abuse. The section for Protection included the statement that Supervisory/Personnel/All Departments 1. Makes rounds to observe staff performance and intervenes as appropriate. And Nursing 1. Assures appropriate care is rendered to residents on all tours. The facility policy for Resident Dining and Food Set-Up dated June 1998 included under Responsibility for Certified Nursing Assistant Feeding resident Requiring Extensive Assistance to Feed resident slowly with fork or spoon filled only half full. Never rush the resident through his meals. Do not use force feed. The policy also stated The necessary nursing oversight will be provided to insure safe meal completion. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Annual Minimum Data Set (MDS; a resident assessment tool) dated 7/27/17, the resident had severely impaired cognition, severely impaired vision, rarely or never had the ability to be understood or to understand others and was unable to speak. This MDS indicated that the resident had functional limitation in range of motion including both upper extremities with impairment involving the shoulders, elbows, wrists and hands. The resident required total assistance of one person for eating and did not demonstrate rejection of care. Surveyors and representatives of the facility's administrative team, including the Assistant Administrator, Chief Nursing Officer, Director of Nursing, Assistant Director of Nursing/evening shift Registered Nurse (RN) Supervisor and an RN night shift Supervisor, viewed a video recording involving Resident #1, that was provided by a family member of Resident #1, on 8/17/17 at 8:30 PM. The video recording revealed multiple, individual episodes of physical and emotional abuse to Resident #1 while in bed during assistance to eat and provision of care by six CNAs (CNAs #1 - #6). Abusive treatment of [REDACTED]. The video also revealed multiple episodes of failure to utilize techniques to assist the resident to eat according to physician's orders [REDACTED]. CNAs were not observed to gently tilt the residents head, slowly feed the resident small amounts on a spoon and watch for the resident to swallow. The night shift RN Supervisor was interviewed on 8/18/17 at 1:35 PM and on 8/21/17 at 10:00 AM and stated that the nurses were supposed to supervise and monitor the CNAs to protect the residents from abuse and she now realized that it was not done properly. The Director of Nursing was interviewed on 8/18/17 at 2 PM and stated that there should have been close supervision and better monitoring to protect the residents from abuse. The Assistant Director of Nursing/evening shift Nursing Supervisor was interviewed on 8/18/17 at 2:15 PM and stated that she should have instructed the evening nurses to do more rounds and monitor the nurses' aides during care and feeding. The Chief Nursing Officer (CNO) was interviewed on 8/18/17 at 2:20 PM and stated that what he saw in the video was not acceptable and it was abuse, mistreatment, rough handling and forceful feeding. He also stated that he realized that the staff needed more training and the management needed to do more supervision and monitoring. He stated the management should have made more rounds to monitor the nurses' aides. The Assistant Administrator was interviewed on 8/18/17 at 2:58 PM and stated that management should have provided more monitoring and supervision to prevent abuse. The Administrator was interviewed on 8/18/17 at 3:00 PM and stated that she has been working in the facility for last [AGE] years and nothing like this happened before. She was asked what she does to ensure that residents are protected from abuse and she stated that she trusted her staff and she is realizing now that she can't trust them anymore. She stated that training was provided online during orientation, and monthly too. She stated that the CNO provided in-service upon hire. She stated that staff were not implementing what they were taught and nurses were not following up with abuse prevention. She stated that supervision was not effective and that possibly the nurses were not recognizing abuse. During the interview, she was offered to watch the video recording, which she declined and stated her administrative team watched it and that was enough. She also stated that she couldn't say anything further about the abuse that happened in the facility because she didn't watch the video recording. The Administrator also stated that abuse training was done on-line at orientation time, then in person and followed by monthly in-service. Staff were not implementing what they were taught. Nurses were not following up with abuse prevention. The Administrator stated that the supervision was not effective and that the facility needed to do better supervision and monitoring. Residents #2, #3, #4, #5 and #6 were identified by facility staff as requiring honey-thickened consistency liquids and feeding by teaspoon. According to care plan documents, these residents also required total assistance to eat. The facility removed the immediate jeopardy on 8/23/17 by conducting inservice education of staff regarding abuse prevention during feeding and activities of daily living (ADL) care, monitoring of residents who are being fed by the CNAs, dysphagia and aspiration, safe feeding techniques, and following CNA accountability as stated in the plan of care. The interim plan also included that each unit will have an assigned leadership staff member who will be supervising, observing, monitoring and evaluating with appropriate feedback and actions seven days a week. 415.26