Every finding on record at Westchester Center For Rehabilitation & Nursing

Based on record review, observations and interviews during the Abbreviated Survey (2633933) on 10/21/2025-10/22/2025, the facility did not ensure that the resident's representative was notified timely of an incident for (1) one (Resident #1) of (3) three residents reviewed for Abuse. Specifically, on 09/27/2025 Resident #1 had an episode of aggressive altercation with staff resulting in the need for Resident #1 to be sent out for psychiatric evaluation. The resident's representative was not informed of the incident until they visited and were informed by the resident who was visibly upset about the incident. The finding is:The facility's policy titled, Notification of Changes, last revised on 08/2024, documented it is the policy to notify the resident/designated representative when there is an accident/incident involving the resident. Resident #1 was admitted with diagnoses including dementia, legally blind and cellulitis. The admission Minimum Data Set (an assessment tool) dated 09/07/2025 documented the resident had severely impaired cognition. The resident was independent with eating and required partial assistance with activities of daily living. The resident had documented behaviors on 1-3 days in the assessment lookback period. The Accident and Incident report dated 09/27/2025 documented the family was notified, but did not include a date or time. A review of the electronic medical record revealed that the complainant was listed as the primary contact. A review of a Grievance Form dated 09/29/2025 documented the resident's family expressed concern they were not notified that the resident had an event during the time of 9/27/2025. They were only made aware of this incident by the resident when they came to visit in the morning 09/27/2025. The investigation noted the supervisor was counseled for not contacting the family in a timely manner regarding the incident and was reeducated regarding family notification. During an interview on 10/21/2025 at 12:21 PM, the family member stated when they arrived at Resident #1 in the room on 9/27/2025 the resident was visibly upset. They asked their family member why they were upset, and they stated they asked Certified Nurse #1 to keep the door open, and Certified Nurse Aide #1 said no. The family member stated they were informed by Registered Nurse Supervisor #7 that Resident #1 swung a chair and hit the wall early that morning. The family member stated they also expressed to the interdisciplinary during a meeting on 09/29/2025 that they were not notified about the incident on 09/27/2025. The administrator advised them they would investigate why they were not called. During an interview with on 10/22/2025 at 11:40 AM, the Registered Nurse Supervisor #2 stated around 6:00 AM the Registered Nurse #3(Medication Nurse) asked them to come to unit 2. Upon arrival they saw. Certified Nurse Aide #1 sitting outside Resident #1's room, and the resident was sitting on the bed. Certified Nurse Aide #1 pointed out indentations in the wall. They had asked the resident what happened, and the resident stated they hit the wall, they were sorry and would not do it again. An Incident report was completed at the end of the shift. They stated they believe they had reached out to the family around 8:00 AM, but do not recall if they left a message. They stated they did not call immediately because the resident was assessed and was fine. They were called by the facility later that week and asked why they did not notify the family of the incident. They were counseled and reeducated by the facility about the need for timely family notification. During an interview on 10/21/2025 at 12:15PM, the Assistant Director of Nursing stated they attended the meeting on Monday 09/29/2025 where the family expressed concern over not being notified regarding the event on 09/27/2025. They wanted to know what happened during the event of 09/27/2025 before consenting to send the resident out for a psychiatric evaluation. The family requested an investigation as to why they were not notified. An Investigation was completed the supervisor was educated on ensuring timely family notification when an incident occurs. During an interview on 10/21/2025 at 1:27 PM, Social Worker # 6 stated they were made aware on Monday, 09/29/2025 that the resident's family wanted to have a meeting about the incident that occurred on Saturday, 09/27/2025. During the meeting, the family questioned why they were not notified of the incident. The Administrator advised them the facility would investigate the occurrence. A grievance was initiated as to why the family was not called about the incident. During an interview on 10/22/2025 at 9:30 AM, the Administrator stated that they attended the interdisciplinary meeting on 09/29/2025 regarding Resident #1 and the behaviors that staff felt required the resident to be further evaluated. The family was present at the meeting. The family expressed concern regarding the lack of communication and that they were not notified of the incident that occurred on 09/27/2025. The family informed them they found out about the incident from the resident when they came to visit in the morning. The administrator stated they initiated a grievance, and the investigation/grievance found the family was not notified timely of the incident. The nursing supervisor was counseled and reeducated regarding the need to ensure the family was notified after an incident. 10 NYCRR 415.3(f)(2)(ii)(a)

Based on observation and interview conducted during the recertification survey 1/22/25-1/29/25 the facility did not ensure that garbage was contained and disposed of in an appropriate manner. Specifically, the trash compactor had food spilling out of it and the recycled boxes were not maintained within the dumpster. Findings include: An inspection of the dumpster and trash compactor area was conducted on 01/29/25 at 3:24 PM and revealed the dumpster to have the lid open with card bard boxes littered out of the dumpster and onto the ground around the dumpster including up to five feet away from the dumpster. The compactor was observed to have an approximate area of three (3) feet by four (4) feet of food and debris spilling out. A clear plastic bag hanging over the side of the opening of the compactor and what appeared to be various vegetables, rice, paper and plastic food and beverage containers were littered on the ground. When interviewed on 1/29/25 at 3:30 PM, the Food Service Director stated it should not look that way. The boxes should have been broken down and put inside of recycle dumpster. They stated food service workers were trained on how to work the compactor and if garbage falls out, it should be cleaned up immediately. 10 NYCRR 415.14 (h)

Based on record review and interviews conducted during the Recertification and Abbreviated surveys (NY00337247)) from 01/22/25 to 01/29/25, the facility did not ensure that there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, 1. Upon review of the nursing staffing schedule from 12/22/24-1/29/25, for multiple days, on all three shifts of staffing for each unit, the facility did not provide adequate staffing to meet the needs of the residents, and as per their Facility Assessment, 2. On multiple dates during the night shift on the 2 South Unit, there were only two Certified Nurse Aides scheduled which was not consistent with the Facility assessment that documented that there should be a minimum of three certified nurse aides. Also, on multiple dates during the day shift on the 2 South Unit, there were only three Certified Nurse Aides scheduled which was not consistent with the Facility assessment that documented that there should be a minimum of four Certified Nurse Aides 3. On, 1/23/25 during the Resident Council meeting, multiple residents verbalized concerns about staffing, the number of call outs and floating Certified Nurse Aides, and how the units are staffed below minimum with certified nurse aides. The findings are: The facility policy titled Sufficient Staffing last revised on 7/1/23 documented that the facility will provide sufficient staffing to meet needed care and services for their resident population on a 24-hour basis. The Facility assessment dated [DATE] documented the following requirements for staffing: One Registered Nurse, one Licensed Practical Nurse, and four Certified Nursing Assistants on all four units (2 South, 2 North, 3 South, 3 North) from 7 am-PM, one Registered Nurse, one Licensed Practical Nurse, and four Certified Nursing Assistants on all four units from PM-1, and one Registered Nurse, one Licensed Practical Nurse, and three Certified Nursing Assistants on all four units from 1-7 am. Upon review of the staffing schedule dated 12/23/24 and 1/18/25, on the 11-PM shift, there were only 2 certified nurse aides working on unit 2 south. Upon review of the staffing schedule dated 12/29/24 and 1/5/25 on the 11-PM shift, there were only 2 certified nurse aides working on unit 3 North. During an interview on 01/22/25 at 10:39 AM, Certified Nurse Aide #1 stated they worked short of staff mostly on the weekends. Certified Nurse Aide #1 stated when they worked with 4 certified nurse aides, they each got approximately 15 residents, and sometimes it was hard to get to the residents on time and the residents had to wait a while, making it difficult to do a good job when working short. During a Resident Council meeting on 1/23/25 at 10:43 AM, eleven residents were in attendance, including the President and [NAME] President, and multiple residents verbalized concerns about staffing. The Resident Council President stated staffing numbers were low and staff worked with below minimum number of Certified Nurse Aides. They believe this to be due to call outs from overworked and floating Certified Nurse Aides. Residents stated they need more Certified Nurse Aides to distribute meal trays for hot meals and assist with feeding. During an interview on 01/29/25 at 8:29 AM, the Staffing Coordinator stated they were unaware the facility assessment indicated the minimum amount of certified nurse aides that could work on the night shift was 3. The Staffing Coordinator stated that although it was difficult and the units were heavy, the units could operate with only 2 certified nurse aides. The Staffing Coordinator reviewed the schedules for 12/23/24, 12/29/24, 1/5/25, and 1/18/25, and confirmed that as per the facility assessment, the units were inadequately staff and did not meet the minimum requirements for staffing. During an interview on 01/29/25 at 9:13 AM, the Administrator stated that that the facility assessment was updated on 8/8/24 and the staffing was entered in error. The Administrator stated that they update the facility assessment annually and review it quarterly at the Quality Assurance and Performance Improvement (QAPI) meetings. During an interview on 01/29/25 at 9:17 AM, the Director of Nursing Stated the facility assessment should be reflecting the minimum staffing for each unit on the night shift, should be 2 certified nurse aides. They stated 2 certified nurse aides on the night shift was enough to care for the residents. The Director of Nursing stated that they tried to put an extra certified nurse aide on 2 North because of the acuity of the unit. 51214 2. During an interview on 01/23/25 at 11:09 AM, Resident #1 stated that there have been times when there is not enough staff, and they must wait for care or can't get out of bed because of it. Night and weekend staffing was described as the worst. They were able to provide three dates when the Certified Nursing Assistant staffing was very short: 8/27/2023, 1/7/2024, and 7/6/24. In addition, they stated there were only 2 Certified Nursing Assistants on an overnight shift last week. The staffing sheets documented that there were only two Certified Nursing Assistants on the 11 PM-7 AM shift on 1/6/24, 1/7/24, 7/5/24, and 1/18/25. There were only three Certified Nursing Assistants on the 7 AM-3 PM shift on 8/26/23 and 8/27/23. During an interview on 01/29/25 at 04:21 PM, the Staffing Coordinator stated that the staffing PAR levels are determined by the maximum number of residents on each unit. Stated that the minimum number of Certified Nursing Assistants on the 11pm-7 am shift is 2, but they aim for 3. Stated they were not aware that this conflicted with the facility assessment. Stated that weekends are more often short compared to weekdays. Stated they do have two Certified Nursing Assistants at times on some of the units for the overnight shift. 10NYCRR 415.13(a)(1)(i-iii) 51902

Based on interview and record review during the recertification survey from 1/22/2025 to 1/29/2025, the facility did not ensure a surety bond was purchased to assure the security of all personal funds of residents deposited with the facility. This was evident for 106 residents with Personal Needs Accounts during review of Personal Funds. Specifically, the facility's Surety Bond for $250,000, was less than the sum total of 106 resident personal needs accounts maintained by the facility in the amount of $278,452.49. The findings are: The facility's Continuation Certificate issued by their indemnity insurance company documented a bond for was in force for any loss occurring from 11/1/2024 to 11/1/2025 that did not exceed $250,000. The Continuation Certificate was signed and dated 8/6/2024. The facility Resident Personal Needs Account Ledger documented the sum total of 106 resident accunts managed by the facility was $278,452.49. There was no documented evidence the facility's surety bond was sufficient to cover the entire amount of resident's funds managed by the facility. On 1/29/2025 at 4:04 PM, the Administrator was interviewed and stated the facility's Business Office determined the amount of the surety bond secured by the facility to cover any potential losses to resident funds managed by the facility. The Administrator stated they were not aware the resident funds managed by the facility was greater than the facility's $250,000 surety bond. 10 NYCRR 415.26(h)(5)(v)

Based on observations and interview conducted during the recertification survey 1/22/25 to 1/29/25, the facility did not post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent New York State Department of Health (NYSDOH) survey. Specifically, the survey team did not observe survey results posted anywhere in the facility. In addition, members of the Resident Council were interviewed and reported that they did not know where the survey report was posted or accessible for residents to review. Findings include: The facility policy Clinical Manual - Social Services Manual revised 11/2024 documented: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident right to Examine Survey Results. Related to the Posting of Survey Results documents that it is the policy to post the most recent New York State Department of Health (NYSDOH) survey results, and the plan of correction, as per federal and state requirements. Place readily accessible is a place (such as a lobby or other area frequented by most residents, visitors or other individuals) where individuals wishing to examine survey results do not have to ask to see them. During an initial tour of the facility on 01/22/25 at 11:40 AM a notification was observed posted in the lobby and the elevator stating survey results were available for anyone to view. (There was no documented location for the survey results to be found.) On 1/23/25 at 10:43 AM, a resident council meeting was held with eleven (11) members of the Resident Council including the Resident Council President and [NAME] President. The residents were unaware of where to find the previous NYSDOH inspection survey results. On 1/24/25 03:04 PM it was observed that there was no state survey results available at the front desk. When interviewed Security Guard #43, working the front desk, was asked for assistance in locating the state survey. They stated it was usually on the front table by the entry, however they were unable to locate it. An interview was conducted with the Administrator on 1/24/25 At 3:05 PM. The Administrator looked for the survey results binder on the front table by the entry and was unable to locate it. Administrator proceeded to look in other offices near the lobby. They stated they did not know what happened to the binder with the survey results, it was supposed to be on the front table by the entry and it was the Administrator's responsibility. 415.3(d)(1)(vi)

Based on observations, record review and interviews conducted during the Recertification survey from 01/22/2025 to 01/27/2025, the facility did not ensure that 3(Residents #226, #333, and #96) of 3 Residents reviewed for Respiratory Care was provided with such care, consistent with the professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, 1. Resident #226 who had a Physicians order for Oxygen to be administered via nasal cannula at 2 liters per minute, was observed multiple times with the Oxygen rate not consistent with the Physicians' order, and with the tubing disconnected from the Oxygen concentrator. 2. Resident #333 who had a Physicians orders for Oxygen to be administered via nasal cannula at 2 liters per minute, was observed multiple times with the Oxygen rate not consistent with the Physicians' order, and the facility did not address the Ear, Nose, and Throat recommendations to give Resident #333 humidified oxygen until 2 days after return from the appointment. 3. Resident #96 had a Physicians' order to change the oxygen cannula and filter weekly, label and date the tubing weekly, and there were multiple observations of the Physicians' orders not being followed. The findings are: The facility policy titled Oxygen Administration last revised on 6/2023 documented that Oxygen therapy will be administered by Licensed Nurses with a Physician's Order to provide a resident with sufficient oxygen to their blood and tissues. Oxygen equipment will be checked daily for correct flow and concentration and correct set-up of equipment. 1. Resident #226 was admitted on [DATE] with diagnoses including asthma, hypertension, and hyperlipidemia. The 12/23/24 Admission Assessment Minimum Data Set documented Resident #226 had severely impaired cognition, had a diagnosis of asthma, and received continuous oxygen therapy. The 12/17/24 Physician order documented Resident #226 was to receive continuous Oxygen Via a Nasal Cannula Rate at 2 liters per minute. The Ineffective Airway Clearance/Oxygen Care Plan date 1/20/25 documented that Resident #226 was to receive Breathing Oxygen therapy at 2 Liters per minute via nasal cannula. Interventions included to monitor oxygen saturation. On 1/22/25 at 2:09 PM, Resident #226 was observed in bed on Oxygen via nasal cannula set to 3.5 liters per minute. On 1/23/25 at 9:58 AM, Resident #226 was observed in bed with oxygen at 3 liters per minute and oxygen tube was disconnected from the concentrator. On 1/23/25 at 10:17 AM, Resident #226 was observed in bed on Oxygen via nasal cannula set to 3 liters per minute, tubing was on the floor and not connected to the concentrator. Resident #226 was observed to be breathing deep and gargling. During an interview on 1/23/25 at 10:19 AM, Registered Nurse #2 stated nurses were responsible for ensuring the oxygen was connected to the resident and the concentrator, functioning properly, and the oxygen flow rate was set as per Physician order. Registered Nurse #2 stated the oxygen tubing should not be on floor, and that it should be connected to the concentrator and the resident. Registered Nurse #2 went and got fresh tubing, connecting the tubing to Resident #226 and the concentrator, lowered the flow rate from 3 liters per minute to 2 liters per minutes, and applied the pulse oximeter to Resident #226's finger. When first applied, the Oxygen saturation level started at 89%, and gradually went up to 94% on 2 liters per minute. During an interview on 1/29/25 at 9:33 AM, the Director of Nursing stated that nurses should have been doing rounds and to ensure that oxygen was plugged in and functioning. They stated nurses should have checked to see if the oxygen tubing was connected to the concentrator and administered as per physician order. 2. Resident #333 was admitted on [DATE] with diagnoses including heart failure, peripheral vascular disease, and chronic kidney disease. The 1/23/25 Admission Minimum Date Set documented Resident #333 had intact cognition and was receiving continuous Oxygen therapy. The 1/22/25 Physician orders documented Resident #333 was to receive continuous Oxygen via nasal cannula rate at 2 liters per minute every day and on every shift, and hold 1/24/25-1/26/25. The 1/24/25 Physician order documented Resident #333 was to receive a trial of continuous Oxygen via nasal cannula 1.5 liters per minute, every day, on every shift for 2 days. On 1/22/25 at 10:46 AM, Resident #333 was observed in bed on oxygen set at 3 liters per minute via nasal cannula. When interviewed during the observation, Resident #333 stated they needed oxygen to breathe. On 1/24/25 at 9:35 AM , Resident #333 was observed in bed and Oxygen was at 3L/min via nasal cannula. During an interview on 1/24/25 at 9:45 AM, Registered Nurse #4 stated Resident #333's Oxygen was set to 3 liters per minute and should have been set at 2 liters per minute. They stated they did rounds and did not check Resident #333's oxygen and assumed it was set to the appropriate rate. Registered Nurse #4 stated they were responsible for ensuring that the oxygen was set at the correct rate, and they signed for the oxygen and confirmed via Physician orders in the Electronic Health Record that it should have been set to 2 liters per minute. During an interview on 1/24/25 at 9:49 AM, License Practical Nurse Unit Manager #3 stated nurses signed off on oxygen, and were responsible for ensuring the resident was receiving the physician ordered rate. On 1/27/25 at 8:50 AM, Resident #333 was observed with oxygen set at 3 liters per minute via nasal cannula. License Practical Nurse Unit Manager #3 stated the Oxygen rate should have not been set to 3 liters per minute. The Ear, Nose and Throat(ENT) consult for Resident #333, dated 1/27/25, documented recommendations to administer saline mist 3-4 drops x 1, humidification for oxygen, and to follow up in 3-4 weeks. The 1/27/2025 at 4:17 PM nursing progress note by Licensed Practical Nurse Unit Manager #3 documented Resident #333 returned from their appointment with the Ear, Nose, and Throat, and the recommendations were for Resident #333 to receive a Humidifier for Oxygen. The Physician was notified and in agreement with orders, and all orders were entered into Electronic Health Records. On 1/28/25 at 1:49 PM, Resident #333 was observed on oxygen set to 3 liters per minute and had no humidifier. During an interview on 01/28/25 at 1:49 PM, Resident #333's family member stated they requested the Resident to receive an updated oxygen concentrator with a humidifier, and Resident #333 did not receive one. During an interview 1/29/25 at 8:58 AM, Registered Nurse Unit Manager #5 stated Resident #333 went to an outside appointment the Ear, Nose, and Throat(ENT) doctor, and they recommended a humidifier and stated that Resident #333 had not received one as the facility did not have any available. During an interview on 1/29/25 at 9:26 AM, the Director of Nursing stated the nurses were responsible for doing rounds and checking residents on oxygen looking at equipment and the flow rate. The Director of Nursing stated the facility had humidifiers available and Resident #333 should have received one immediately upon return as per Ear, Nose and Throat doctor's recommendation. During an interview on 01/29/25 at 12:32 PM, Medical Doctor #1 stated they were not notified Resident #333 had recommendations from Ear, Nose and Throat doctor from their appointment on 1/27/25 and that they were informed on 1/29/25. Medical Doctor #1 stated that when a resident returned from an outside doctor's appointment with recommendations on the consult, they expected to be immediately notified. Medical Doctor #1 stated Resident #333 could benefit from humidified oxygen due to history of nose bleeds. Medical Doctor #1 stated that Resident #333's family member requested to bring in a humidifier, but maintenance denied it because they did not allow outside electrical equipment. Medical Doctor #1 stated they would order a humidifier as it would help with the resident's breathing and their nosebleeds. 10 NYCRR 415.12

Based on record review and interviews conducted during the Recertification Survey from 1/22/25-1/29/25, the facility did not ensure certified nurse aide performance reviews were completed at least once every 12 months for 4 (#'s 14, 25, 32, and 33) of 5 Certified Nurse Aides reviewed for certified nurse aide performance reviews. The findings are: The facility policy titled Competencies revised 06/2023 documented that the facility will conduct job related competencies based upon the Facility Assessment and on employee job description/evaluation. The facility will provide education required for Nurse Aides of 12 hours per year for re certification. Competencies will be conducted by return demonstration method. Written testing may be completed in conjunction with the return demonstration. Upon review of for Certified Nurse Aide #14's performance review dated 9/27/24, there was no documented evidence that it was signed/dated by employee, immediate supervisor, department head, and dated by Human Resources. Upon review of for Certified Nurse Aide #25's performance review dated 1/13/24, there was no documented evidence that it was signed by department head, reviewed, dated by Human Resources. Upon review of for Certified Nurse Aide #32's performance review dated 1/20/24, there was no documented evidence that it was signed/dated by the department head and dated by Human Resources. Upon review of for Certified Nurse Aide #33's performance review with an incomplete date, there was no documented evidence that it was signed/dated by employee, immediate supervisor, department head, and dated by Human Resources. During an interview on 01/28/25 at 04:56 PM, the Staffing Educator stated performance reviews should be done annually, and that all the staff performance reviews should be signed by the employee, supervisor, department head, and the Human Resource Director, and that if the performance review is not signed by all people on the form to sign, the form is not complete and not acceptable. During an interview on 01/28/25 at 05:36 PM, the Human Resource Director stated that after staff performance reviews are completed and signed, the completed document must be given to Human Resource to date so that it can be filed in the employee file. The Human Resource director stated that the performance reviews for Certified Nurse Aides #'s 14, 25, 32, and 33 were incomplete and were still in the Staff Education office because of the turnover of staff and had not made it into their office. During an interview on 01/29/25 at 09:17 AM, the Director of Nursing stated that performance reviews are done annually, and they should be filled out and signed by the employee, supervisors, department heads, and given to the Human Resource Director to be filed. During an interview on 01/29/25 at 05:48 PM, Certified Nurse Aide #29 stated they been employed at the facility for over 5 years and have never been given a performance review. 10NYCRR 83.35(d)(7)

Based on observations and interviews conducted during the recertification survey from [DATE]-[DATE], the facility did not ensure that food was stored in accordance with professional standards for food service safety. Specifically, food items were not properly sealed and dated in the kitchen walk in refrigerator, freezer, dry storage, and unit panty refrigerator; outdated food was not disposed of when expired; and food was not served at appropriate temperature. Findings include: The facility policy Receivable and Storage Policy revised on ,d+[DATE] documented: Ensure all foods are securely covered, dated, and labeled. The facility policy Food and Nutrition Services revised on [DATE] documented: Meals will be provided in a timely manner so that hot foods are served hot and cold foods are served cold. The facility policy Food From Home - Procurement reviewed on ,d+[DATE] documented: It is the policy of this facility to provide safe and sanitary storage, handling, and consumption of all foods including those brought to residents by family and other visitors. The initial inspection of the kitchen was conducted with the Food Service Director on [DATE] at 9:57 AM and the following was observed: - In the walk-in refrigerator, cottage cheese in individual serving cups with no label and no date, shredded cheese was not sealed, and an individual portion of milk with no date. - In the freezer, tator tots with no label and no date, green beans not sealed, frozen beef with no date. - In the dry storage area, a plastic jug of opened salsa (needed to be refrigerator), chicken base not sealed, and an open base of rice not sealed. The Food Service Director was interviewed during the observation and stated that all items should be labeled, dated, and sealed and did not know why this was not done. During the initial inspection of the kitchen on [DATE] at 9:57 AM the observation of two boxes of expired individual packages of BBQ sauce in the dry storage, dated ,d+[DATE] and ,d+[DATE]. The Food Service Director stated the packages should have been discarded. During inspection of unit pantry refrigerators on [DATE] at 8:50 AM, Unit 3 South had applesauce in cups with no date; Unit 2 North and 2 South had ice packs stored in the freezer. When interviewed on [DATE] at 4:40 PM, the Director of Nursing and Assistance Director of Nursing stated it was the responsibility of the nursing staff to maintain the unit pantry refrigerators, including recording temperatures. They did not know why ice packs were stored in the freezer. During a temperature test tray check on [DATE] at 12:54 PM, with the Food Service Director, the carton of milk was found to have a temperature of 59 degrees Fahrenheit . The Food Service Director had no explanation of why the milk temperature was so high. 10 NYCRR 415.14 (h)

Based on record reviews and interviews conducted during the recertification survey from 1/22/25-1/29/25, the facility did not ensure that the Certified Nurse Aides were provided the required 12 hours of training and annual in-services on dementia care management and resident abuse prevention, to ensure safe delivery of care. Specifically, the facility was unable to provide documented evidence that 5 (#'s 14, 25, 32, 33, and 34) of 5 Certified Nurse Aides reviewed for Nurse Aide training, were provided 12 hours of mandatory training. The findings are: The facility policy titled Sufficient Staffing last revised on 7/1/23 documented that the facility will ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. During an interview on 01/29/25 at 10:11 AM, the Staffing Educator was unable to provide documented evidence that 12 hours of training and annual in-services were completed for Certified Nurse Aides #'s 14, 25, 32, 33, and 34. Multiple requests given from 1/28/25 11/29/25 asking for the competencies and the staffing coordinator was unable to provide the requested documents(competencies). The Staffing Educator stated that they started working in the facility at the end of May 2024 and that when came they became employed at the facility, things were unorganized, and they are still trying to get things in order. During an interview on 01/29/25 at 05:05 PM, the Administrator stated that the Staffing Educator should have been able to provide the required in-services and that not providing required documents is unacceptable, and that there is no excuse as to why the in-services was not organized and readily available because the Staffing Educator has been employed in the facility since May/June or 2024. 10 NYCRR 415.26 (c)(1)(iv)

Based on interviews and record review during the recertification survey from 1/22-1/29/2025, the facility did not ensure that residents' financial records were available to the residents through quarterly statements for 1 of 4 residents reviewed for personal funds. Specifically, Resident #92 was not aware that they had any personal funds and the facility financial office was not able to provide proof that the resident received quarterly statements. Findings include: Facility Policy titled Resident's Funds last reviewed 10/2024 documented 24/7 access to funds, maintaining and managing resident accounts, and process for accessing funds. It did not document a process for providing residents with quarterly statements. Resident #92 had diagnoses including Diabetes Mellitus, End Stage Renal Disease, and Non-Alzheimer's Dementia. The Quarterly Minimum Data Set, dated [DATE] documented the resident had moderately impaired cognition, and the resident and family participated in goal setting. During an interview on 1/23/25 at 9:47AM, Resident #92 denied having any money or receiving any financial statements. On 01/23/25 at 4:00PM Resident #92's Fund Ledger for 1/1/24-12/31/24 was provided for review. It was documented that Resident #92's funds were managed by the facility and funds were in their account. During an interview on 1/29/25 at 10:36 AM, the Fiscal Manager stated they handled resident personal fund accounts and residents that were alert and oriented were hand delivered quarterly statements. They stated Resident #92 received quarterly statements, but they were unable to provide documented evidence that the statements were received. They stated they save the quarterly batch of statements that were distributed to residents on their computer, but they could not provide evidence of who received their statements. They stated Resident #92 had not inquired about money or statements, and they did not recall them coming for funds during banking hours. According to their financial statement, Resident #92 received services for the barber, but they did not have to request those funds as they were automatically deducted from their account to cover the expense. The Fiscal Manager was uncertain if Resident #92 was aware that they were paying for those services out of their personal funds. Stated that they would follow up with Resident #92 to ensure that they were aware of their funds and review their statement with them. 10NYCRR415.26(h)(5)(i)

Based on observation, interview, and record review during the Recertification survey from 01/22/2025 through 01/29/2025, the facility did not ensure residents had the right to a dignified dining experience for 2 of 35 residents (Residents #168, #14) reviewed for dignity while dining. Specifically, facility staff were observed standing over Residents #168 and #14 while assisting the residents with their meals. The findings include: The facility policy titled Feeding the resident last date reviewed 9/2023, documented the facility staff will sit while feeding resident, no standing while feeding for those residents requiring feeding assistance, unless necessary. Staff should be at eye level with the resident while feeding. 1. Resident #168 was admitted to the facility with diagnoses including Diabetes Mellitus, non-Alzheimer dementia, and malnutrition. The 11/28/24 Quarterly Minimum Data Set Assessment (a resident assessment tool) documented Resident #168 had moderately impaired cognition and needed supervision assistance with eating. During an observation on 1/22/25 at 12:50 PM, in Resident #168's room, the resident was in the bed and Certified Nurse Aide #21 was observed standing over the resident while feeding them their lunch meal. During an interview on 01/22/25 at 1:03 PM, Certified Nurse Aide #21 they stated they assisted the resident with lunch. They stated they were standing and feeding the resident because the resident's bed was in the lowest position and they thought if they raised the bed it would not be stable and start moving. They stated they stood while feeding this resident, but they usually sat when they assisted residents with meals. 2. Resident #14 was observed at breakfast on 1/29/25 at 8:49 AM. The resident was in bed with the meal tray on the bedside table and Registered Nurse #27 standing over the resident while feeding them their meal. During an interview on 1/29/25 at 8:54 AM, Registered Nurse #27 stated the resident was assisted with meals because resident was blind and unable to feed themselves. Registered Nurse #27 reported the resident ate well when fed by staff. When asked about protocol for assisting with feeding they stated they knew to sit when feeding in the dining room, but did not realize it was needed for feeding a resident in bed in their room. Registered Nurse #27 obtained a chair and continued to feed Resident #14 while seated. 10 NYCRR 415.5 (d) (1)(i) 51902

Based on observation, interview, and record review conducted during the recertification survey from 1/22/2025 to 1/29/2025, the facility did not ensure a resident's right to reside and receive services in the facility with reasonable accommodation of their needs and preferences. This was evident for 1 (Resident #167) of 7 residents reviewed for Environment. Specifically, Resident #167's wheelchair was unable to maneuver around their bed preventing Resident #167 from being able to access and use their own bathroom. The findings are: The facility policy titled Resident Rights dated 11/2024 documented a resident has the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. Resident #167 had diagnoses of postherpetic polyneuropathy and chronic obstructive pulmonary disease. Minimum Data Set 3.0 assessment dated [DATE] documented Resident #167 was cognitively intact. The Comprehensive Care Plan related to activity of daily living function - mobility devices initiated 6/3/2024 documented Resident #167 was out of bed to 24-inch bariatric wheelchair, required contact guard assist with toilet transfers, ambulated with rolling walker for 10 feet with contact guard assist. Last reviewed 8/28/2024 without changes. The Urogynecology Consult dated 9/19/2024 documented recommendations for Resident #167 to have a private room with an accessible bathroom to facilitate mobility and improve toileting. Physician Orders dated 11/8/2024 documented Resident #167 was ordered to be out of bed to a bariatric reclining wheelchair with roho cushion with 1 assist daily. On 1/23/2025 at 10:48 AM, Resident #167 attended a Resident Council Meeting and stated their 24-inch wheelchair was unable to maneuver around their room enough to unable Resident #167 to use their own bathroom. Resident #167 stated they had to wheel themselves to the shower room with a bathroom down the hall but there is only a curtain to provide them privacy. Resident #167 stated there have been occasions where staff and other residents slid open the curtain not knowing they were there. Resident #167 stated they preferred to use the bathroom in their own room and communicated this preference to several staff members without resolution. On 1/25/2025 at 6:13 PM, Resident #167 was observed in their shared bedroom in a 24-inch wheelchair. The bathroom door was located near the foot of and in between the 2 hospital beds in the room. Resident #167 wheeled their chair towards the foot of their bed and the space in between the bed and wall was too narrow for Resident #167 to pass, preventing them form accessing their bathroom. There was no documented evidence Resident #167 was provided with reasonable accommodations to access and use the bathroom in their room. On 1/29/2025 at 3:51 PM, the Administrator was interviewed and stated they previously had multiple conversations with Resident #167 regarding the resident's inability to access the bathroom in their room. Resident #167 reported to the Administrator that they could not maneuver their wheelchair in their room adequately to fit through their bathroom doorway. This resulted in Resident #167 wheeling themselves down the hallway to the unit's shower room when they had to use the bathroom. The Administrator stated Resident #167 was offered a room change but there was no documented evidence of efforts or interventions to reasonably accommodate Resident #167's preference to use the bathroom in their room. 10 NYCRR 415.5(e)(1)

Based on observation, interview, and record review conducted during the recertification and abbreviated (NY00352407) from 1/22/2025 to 1/29/2025, the facility did not ensure a resident's right to receive written notice, including the reason for the change, before the resident's room was changed. This was evident for 1 (Resident #10) of 7 residents reviewed for Choices. Specifically, Resident #10's Health Care Agent did not receive written notice of or explanation for the resident's room change on 10/11/2024. The findings are: The facility policy titled Transfers - Room Changes dated 4/11/2024 documented the facility will inform the resident and/or resident representative of the room change both verbally and written, including the reason for the change, the effective date of the change and the location of the change. Resident #10 had diagnoses of Alzheimer's disease and cerebral infarction with right hemiplegia and hemiparesis. Minimum Data Set 3.0 assessment dated [DATE] documented Resident #10 was severely cognitively impaired. Census Activity dated 10/11/2024 documented Resident #10 had a room change. Social Work Note dated 10/11/2024 documented Resident #10's room was changed due to medical necessity and a message was left for the resident's Health Care Agent. There was no documented evidence Resident #10's Health Care Agent was provided written notice and explanation for the resident's room change on 10/11/2024. On 1/22/2025 at 12:54 PM, Resident #10's Health Care Agent was interviewed and stated Resident #10's room was changed, and they were not provided with an opportunity to refuse the room change, given prior notification of the room change, or given a reason for the room change. \/On 1/29/2025 at 12:03 PM, the Director of Social Work was interviewed and stated Resident #10 was moved due to medical necessity and a voicemail was left for the Health Care Agent. The Director of Social Work did not confirm whether the Resident #10's Health Care Agent received the voicemail or agreed with the room change prior to moving the resident to another room. On 1/29/2025 at 3:51 PM, the Administrator was interviewed and stated residents and families were informed prior to a room change occurring due to another resident's medical necessity. 10 NYCRR 415.3(g)(3)

Based on interview and record review conducted during the recertification and abbreviated (NY00344201) from 1/22/2025 to 1/29/2025, the facility did not ensure a resident's right to manage their financial affairs. This was evident for 1 (Resident #182) of 3 residents during Personal Funds review. Specifically, the facility diverted Resident #182's income to a personal needs account managed by the facility without informing the resident's court-appointed Legal Guardian. The findings are: The facility policy titled Resident Rights dated 11/2024 documented residents had the right to manage their personal funds. Resident #182 had diagnoses of unspecified dementia and schizoaffectove disorder. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #182 was severely cognitively impaired, the resident and their family participated in the assessment, the resident's family provided discharge status information, and did not document that Resident #182 had a Legal Guardian. The Admission Agreement dated 10/26/2022 documented the undersigned agreed to pay the net available monthly income for Resident #182, a Medicaid recipient, to the facility by the 6th day of each month or to arrange for the income payor to send the monthly income directly to the facility. The Admission Agreement was signed by Resident #182's Legal Guardian. Addendum VI of the Admission Agreement documented the undersigned would agree to arrange for direct payment of the resident's monthly income to the facility. There was no documented evidence Resident #182's Legal Guardian signed Addendum VI or agreed with changing Resident #182's income recipient or address. A Supreme Court Oath and Designation dated 4/14/2023 documented the appointment of Resident #182's Legal Guardian as the guardian of the resident's person and property. The Comprehensive Care Plan related to Advance Directives initiated 11/1/2022 was updated by the Director of Social Work on 5/24/2024 and documented Resident #182's Legal Guardian provided documentation the court appointed them Legal Guardian of Resident #182's person and property. The Aspen Complaint Tracking System Intake dated 6/4/2024 documented an allegation the facility changed Resident #182's income recipient without notifying the resident's Legal Guardian. The facility's Accounts Receivable Ledger for Resident #182 documented net available monthly income credits to Resident #182's account on 6/11/2024, 7/1/2024, and 8/6/2024. The facility's Resident Funds Ledger documented $50 personal needs allowance credits to Resident #182's account on 6/11/2024, 7/1/2024, and 8/6/2024. A Social Security Administration notification addressed to the facility on [DATE] documented the facility was removed as Resident #182's representative payee and would no longer receive the resident's monthly income. There was no documented evidence the facility obtained written authorization from Resident #182's Legal Guardian prior to depositing income with the facility and opening a personal needs account for the resident. On 1/29/2025 at 12:03 PM, the Director of Social Work was interviewed and stated they received a copy of court documents from Resident #182's Legal Guardian in 5/2024 and updated the resident's medical record to reflect Resident #182 had a court-appointed indicate the court appointed Legal Guardian of person and property. On 1/29/2025 at 11:16 AM and 5:42 PM, the Fiscal Manager was interviewed and stated they were responsible for overseeing resident funds accounts. After reviewing Resident #182's deposits in 6/2024, 7/2024, and 8/2024, the Fiscal Manager stated the Business Office applied to become the representative payee (recipient) of Resident #182's monthly income check in 6/2024 upon Medicaid approval and determination of the resident's net available monthly income amount to be paid to the facility. Resident #182 was cognitively impaired and unable to participate in financial discussions or decisions. The Fiscal Manager stated they were not aware Resident #182 had a Legal Guardian responsible for financial decisions until 9/2024 when they received a notification from the Social Security Administration informing the facility they were no longer representative payee for the resident. The Fiscal Manager stated they did not attempt to contact any next of kin listed on Resident #182's facesheet and did not have any communication with the resident's Legal Guardian prior to or after the facility became representative payee for the resident. On 1/29/2025 at 4:15 PM, the Administrator was interviewed and stated they were not aware of any financial concerns related to Resident #182's net available monthly income or personal funds account with the facility. 10 NYCRR 415.26(h)(5)

Based on observations, record reviews and interviews conducted during the recertification survey from 1/22/25-1/29/25, the facility did not ensure the development and implementation of comprehensive person-centered care plans to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents (Resident #333) reviewed for Respiratory Care. Specifically, Resident #333 was receiving continuous Oxygen, and the facility was unable to provided documented evidence that a Respiratory/Oxygen Care Plan was in place. The findings are: The facility policy titled Care Planning Process and Care Conference last revised on 7/2023 documented that the facility will develop a comprehensive, resident centered care plan for each resident/patient. Care plan development, renewal and revision will be based upon the results of the resident assessment. The care plan is a working tool that provides a profile of the needs of the individual resident/patient; the resident/patient care plan will be available for use by staff caring for the resident. Resident #333 was admitted on [DATE] with diagnoses including but not limited to heart failure, peripheral vascular disease, and chronic kidney disease. The 1/23/25 Admission Minimum Date Set documented that Resident #333 had intact cognition and was receiving continuous Oxygen therapy. The 1/22/25 Physicians orders documented that Resident #333 was to receive continuous Oxygen via nasal cannula rate at 2 liters per minute every day and on every shift and to hold 1/24/25-1/26/25. The 1/24/25 Physicians order documented that Resident #333 was to receive a trial of continuous Oxygen via nasal cannula 1.5 liters per minute, every day, on every shift for 2 days. Upon review of care plans, there were no documented evidence that Resident #333 had an Oxygen therapy care plan in place. During an interview on 01/29/25 at 8:58 AM, Registered Nurse Unit Manager #5 stated that they were responsible for creating resident care plans and there should have been a Care Plan in place for Resident #333's Oxygen therapy. During an interview on 1/29/25 at 9:26 AM , the Director of Nursing stated Resident #333 was admitted on Oxygen and a Care Plan for Oxygen should have been created by the admission nurse. 10 NYCRR 415.11(c)(1)

Based on interviews and record review during the recertification survey from 1/22-1/29/24 the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 4 residents (Resident #92) reviewed for insulin. Specifically, Resident #92's insulin order had a dicrepency and the order was not being followed as written. Findings include: Resident #92 had diagnoses including Diabetes Mellitus, End Stage Renal Disease, and Seizure Disorder. The Quarterly Minimum Data Set (assessment tool) dated 11/13/2024 documented Resident #92 with moderate cognitive impairment. Medications received included hypoglycemic and injections on 3 days. The Comprehensive Care Plan for Diabetes Mellitus dated 12/3/24 documented the resident would be free of observable signs and symptoms of hyperglycemia and hypoglycemia. Interventions included administering medications as ordered and monitoring for signs and symptoms of hyperglycemia and hypoglycemia. A Physician order dated 12/18/24 documented Humalog Kwik Pen (U-100) Insulin 100unit/ml subcutaneous, inject 1 unit by subcutaneous route 3 times per day for diabetes. A sliding scale was also part of the order and documented the following parameters: for a blood sugar of 151-200 2 units, 201-250 4 units, 251-300 6 units, 301-350 8 units, 351-400 10 units of Humalog administered. If blood sugar greater than 400 or below 60 call the physician. During an interview on 1/23/25 at 9:55 AM, Resident #92 stated they did not get any shots when asked about insulin administration. Pharmacy Reviews completed every month for the last year documented no irregularities or recommendations for Resident #92's medication orders. During an interview on 1/27/25 at 10:33 AM, Licensed Practical Nurse #12 stated that when they were assigned as Resident #92's medication nurse, they followed the sliding scale, they did not administer one unit of Humalog in addition to the sliding scale as indicated in the order. During an interview on 1/27/25 at 10:40 AM, Registered Nurse Unit Manager #5 stated that Resident #92 was not receiving one unit of Humalog in addition to the sliding scale for insulin coverage. The order was not entered correctly, and they would have the order corrected. The order should have been the sliding scale without the one unit of insulin. A Physician order dated 1/27/25, documented Humalog Kwik Pen (U-100) Insulin 100 unit/ml subcutaneous route 3 times per day at 6:30am, 11:30am, 4:30pm. A sliding scale was also part of the order and documented the following parameters: for a blood sugar of 151-200 2 units, 201-250 4 units, 251-300 6 units, 301-350 8 units, 351-400 10 units of Humalog administered. If blood sugar greater than 400 or below 60 call the physician. During a telephone interview on 1/28/25 at 9:55 AM, Licensed Practical Nurse #40 stated they did not administer one unit of insulin in addition to the sliding scale when they were assigned as Resident #92's medication nurse in the days prior to 1/27/25. They follow the sliding scale only. They only administered insulin if Resident #92's sugar was above 151 as the sliding scale indicated. During a telephone interview on 1/28/25 at 10:15 AM, Licensed Practical Nurse #16 stated they did not administer any insulin to Resident #92 when they were assigned as their medication nurse on 1/25/24. They stated they followed the sliding scale for coverage. The stated that they were oriented to always follow the sliding scale and did not administer 1 unit of insulin as the resident blood sugar was 110. During an interview with the Director of Nursing on 1/28/25 at 11:30 AM, they confirmed an entry error for Resident #92's Humalog order. They stated that the sliding scale was to be followed for the Humalog order, an additional one unit should not be administered on top of the sliding scale. During an interview on 1/28/25 at 11:35AM, Nurse Practitioner #35 and Medical Doctor #2 stated the order for Resident #92's Humalog Insulin was to follow the sliding scale, an additional one unit of insulin should not be administered on top of the sliding scale. They stated the order was not entered correctly. During an interview on 1/29/25 at 4:14PM the Pharmacy Consultant stated that one unit of Humalog in addition to the sliding scale may be an appropriate order if determined as such by the Physician, but it depended on the patient's condition. 10NYCRR 415.12

Based on observation, record review and interview during the recertification survey conducted from [DATE] to [DATE], the facility did not ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards, including expiration dates when applicable for 2 of 2 medication storage rooms, and 1 of 4 med carts reviewed. This was evident for 2 (Medication Storage Rooms 3 South Unit and 2 North Unit) of 2 medication storage rooms and 1 of 4 medication carts observed. Specifically, the 3 South Unit and 2 North Unit Medication Storage Rooms had an expired box of hydrocolloid wound dressing and an expired box of safety needle, the 3 South Unit medication cart contained an open and undated 32 ounce bottle of supplement. The findings are: The facility policy titled Medication Storage last reviewed on ,d+[DATE] documented the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. During an observation of 3 South Unit Medication Storage Room on [DATE] at 10:18 AM accompanied by Licensed Practical Nurse #23, revealed a box of hydrocolloid wound dressing exoderm satin with expiration date ,d+[DATE], and safety infusion set shw,d+[DATE]Y with expiration date [DATE]. When interviewed at the time of observation, Licensed Practical Nurse #23 stated they were responsible for checking medication storage room supplies including expiration dates on a weekly basis. They stated any expired supplies need to be removed from storage and discarded. During an observation of 3 South Unit medication cart on [DATE] at 10:43 AM with Licensed Practical Nurse #24, an open and undated 32 ounce bottle of collagen and whey protein was found. When interviewed at the time of observation, Licensed Practical Nurse #24 stated once the stock medication or supplements were opened they needed to be dated and discarded within 60 days. Licensed Practical Nurse #24 was not able to find a date on the bottle and did not know why the bottle was not dated. During an observation of 2 North Unit Medication Storage Room on [DATE] at 1:08 PM accompanied by Licensed Practical Nurse #3, a box of safety needles with expiration date [DATE] was observed. When interviewed during the observation, Licensed Practical Nurse #3 stated once medication or treatment supply expired it must be discarded right away in a biohazard room. They did not know why the safety needle supply with expired date was kept in the infusion box of medical storage room. 10 NYCRR 415.18 (e)

Based on observation, record review and interview conducted during the recertification survey from 1/22/25 through 1/29/25, the facility did not ensure that staff maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for 1 of 3 residents reviewed for transmission-based precautions; and 2 of 10 staff reviewed for influenza vaccinations. Specifically, 1) Resident #483 was on Enhanced barrier Precautions and staff was observed providing care without wearing proper protective equipment. 2) Licensed Practical Nurse #17 and Certified Nurse Aide #15 did not receive the influenza vaccine and were observed not wearing a mask. Findings include: 1. The facility policy titled General Infection Transmission- Based Precautions revised date 1/1/2024 documented the use of transmission-based precautions (isolation precautions) to manage specific, highly transmissible, or epidemiologically important pathogens with mode of transmission related to contact, droplet, and airborne. The goal of the facility is to provide a safe and sanitary environment for residents, visitors, and staff. Transmission- based precautions is discontinued by a physician. Resident #483 was admitted with diagnoses including Parkinson's disease, Diabetes Mellitus, and Pressure ulcer sacral region Stage 3. 12/14/2024 Care plan on Enhanced Barrier Precautions documented Risk for Infection. The goal was the resident would remain free from signs and symptoms of infection. Interventions included to wear gown and gloves during high contact resident care activity. The Minimum Data Set assessment dated [DATE] documented Resident #483 was severely cognitively impaired, dependent on all staff for all cares, always incontinent of urine and bowel, not on toileting schedule, and had a sacral ulcer stage 3 present on admission. The 1/11/ 2025 Physician orders documented the resident was on enhanced barrier precautions. On 01/27/2025 at 11:00 AM, during observational rounds, Certified Nursing Aide #36 was observed providing care to Resident #483. Certified Nursing Aide #36 did not wear the proper personal protective equipment. Certified Nursing Aide #36 did not wear a gown during incontinence care and dressing. Certified Nursing Aide #36 transferred Resident #483 from bed to wheelchair. Certified Nursing Aide #36 was interviewed and stated that they were aware of the sign posted outside resident #483 room that indicated the resident was on enhanced barrier precaution. Certified Nursing Aide #36 stated they were supposed to put on a gown and gloves when providing care. Certified Nursing Aide #36 did not give an explanation why she did not put on a gown during care. When interview on 01/27/25 at 11:06 AM, Licensed Practical Nurse #38 stated that Resident #483 was on enhanced barrier precautions due to a pressure ulcer. They stated that staff were supposed to put on gown, gloves, and mask during care. Interview on 01/27/25 at 11:17 AM with Registered Nurse Unit Manager #39, they stated that staff were aware they needed to wear Personal Protective Equipment during care of residents on enhance barrier precaution. Registered Nurse Unit Manager #39 stated that Certified Nursing Aide #36 should have been wearing a gown during care of Resident #483. 2. The facility policy titled Influenza Vaccines revised date 9/2024 documented, to prevent transmission of influenza viruses and other infectious agent in healthcare settings, including in long-term care facilities requires an approach of influenza vaccinations, and infection prevention and control measures. Employees will be offered the influenza vaccine at no charge, employees refusing the vaccine, may be required to wear masks in resident care areas throughout the influenza season. During an observation on 1/27/25 at 4:49 PM, Certified Nurse Aide #15 entered a resident room on unit 2N. When interviewed at the time of observation, Certified Nurse Aide #15 stated she was not vaccinated for influenza. They stated they knew they were supposed to be wearing a mask and did earlier, but they went outside and forgot to put it back on before caring for the resident. During on observation on 1/27/2025 at 4:54 PM, Licensed Practical Nurse #17 was giving medication to the residents in a room on Unit 3 South. They were not wearing a face mask and did not have the facility's sticker on their badge indicating they receive the influenza vaccine. When interviewed at the time of observation, Licensed Practical Nurse #17 stated they had not received the influenza vaccine, and they had never taken the Influenza vaccine. Licensed Practical Nurse #17 stated they did not fill out a declination form for refusal of the influenza vaccination and was not told they needed to wear a mask if they did not have the influenza vaccination. During an interview on 1/29/25 at 11:19 AM, the Human Resources Director stated the facility offered Covid, Influenza and pneumococcal vaccinations. New hires were made aware as part of their on- boarding and other staff were also made aware. They stated the staff could refuse the influenza vaccine but must wear a mask during influenza season following a refusal. During an interview on 1/29/25 at 11:38 AM, the Nurse Educator stated the staff immunization record were documented on a tracker. An observation of the staff tracker, but many of the staff did not have their signatures that education was provided for influenza. 10 NYCRR 415.19 (a) (1-3) 50816 Resident #483 was admitted with diagnoses including Parkinson's ds, type 2 Diabetes Mellitus, Pressure ulcer sacral region stage 3. 12/14/24 Physician's order documented Enhanced Barrier Precaution. 12/14/2024 Care plan on Enhanced Barrier Precautions documented Risk for Infection. Goal Resident will remain +free from signs and symptoms of infection. Interventions included maintain enhanced use gown and gloves during high contact resident care activity. 12/15/2024 Care plan on Skin Integrity Sacral documented Goal Pressure will show healing process as evidenced by decrease in size and stage of pressure ulcer. Resident's pressure ulcer will not show increase in size or stage. Wound will be free of signs and symptoms of infection. Interventions included apply local treatment as ordered by MD. assess for pain, effectiveness of pain medication, perform wound care rounds weekly, provide pressure relieving devices as appropriate, weekly wound measurements and prn 12/16/24 Minimum Data Set (an assessment tool) documented resident was severe cognitively impaired, dependent on all staff for all cares, always incontinent of urine and bowel, at risk of developing pressure ulcers, had a sacral ulcer stage 3 present on admission. 1/11/ 2025 Physician orders documented to include cleanse sacral area with NS then apply Zinc, On 01/27/2025 at 11:00am Certified Nursing Assistant # 36 was observed providing care to Resident # 483 without proper personal protective equipment. Certified Nursing Assistant # 36 did not wear a gown during incontinence care, dressing and transferred Resident#483 from bed to wheelchair. Certified Nursing Assistant #36 was interviewed and stated that they are aware of the sign posted outside resident # 483 room that indicated resident was on enhanced barrier precaution. Certified Nursing Assistant # 36 stated if a resident is on enhanced barrier precaution they are supposed to put on a gown and gloves during care. Certified Nursing Assistant # 36 did not give an explanation why she did not put on a gown during care. Certified Nursing Assistant #36 stated they did not follow enhanced barrier precaution during care. Interview on 01/27/25 at 11:06 AM with Licensed Practical Nurse # 38, they stated that Resident # 483 is on enhanced barrier precautions because she has pressure ulcer. They stated that staff are supposed to put on gown, gloves, mask, during care. Interview on 01/27/25 at 11:17 AM with Registered Nurse Unit Manager # 39, they stated that staff are aware to wear Personal Protective Equipment during care of residents on enhance barrier precaution. Registered Nurse Unit Manager # 39 stated that Certified Nursing Assistant # 36 should have put on a gown during care of Resident # 483. Interview on 01/27/25 at 11:21 AM - 11:23 am with Director of Nursing, they stated they have educated staff on infection control and enhanced barrier precaution. Certified Nursing Assistant # 36 did not follow enhanced barrier precaution and should have put on a gown during care of Resident # 483.

Based on record review and interviews during the Recertification and Abbreviated (NY#00336657) surveys from 1/22/2025 to 1/29/2025, the facility did not ensure a resident's designated representative had the right to be informed in advance, by the physician or other practitioner or professional, of treatment options and to choose the alternative or option they preferred for 1 (Resident # 233) of 2 residents reviewed for resident rights. Specifically, the facility administered Donepezil (a medication for dementia) to Resident #233 and the resident representative had requested the medication to not be given. Findings include: Resident # 233 was admitted with diagnoses including dementia, chronic obstructive pulmonary disease and gastroesophageal reflux disease. The facility's policy and procedure titled Resident Rights, revised 11/2024, documented the resident rights to be notified of his or her medical condition and of any changes in his or her condition; A resident has the right to be informed in advance, by the physician or other Practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option they prefer. The 7/24/2023 care plan, updated on 8/22/2023, documented the resident had Cognitive Loss/Dementia and the goal was Resident #233 would remain at their current level of cognitive functioning. Interventions included to communicate with the resident, family and staff regarding the resident's capabilities and needs. The 8/1/2023 Minimum Data Set (an assessment tool) documented the resident had severe cognitive impairment. The 02/23/2024 Neurology consult documented the reason for the consult was Alzheimer's disease with a recommendation to consider a trial of Donepezil 5 milligrams at bedtime for cognitive support. The 02/23/2024 Physician progress note documented the resident was seen by the neurologist, and they agreed with the neurology consult. The plan was to consider a trial of Donepezil 5 milligrams for cognitive support for Alzheimer's disease. The 02/23/2024 Physician order documented to administer Donepezil 5 milligrams tablet, give 2 tablets once daily in the evening at 6:00 PM for Alzheimer's disease. The 02/23/2024 at 4:02 PM nursing progress note documented Resident #233 was seen and assessed by the Neurologist and the Neurologist recommended to a consider trial of Donepezil 5 milligram at bedtime daily for cognitive support. The Attending Physician was contacted and in agreement with the plan of care. The resident representative was called and educated on the recommended medication and verbalized they did not want the medication given to the resident yet. The physician was made aware, and no new orders were given. The 02/26/24 at 7:52 nursing progress note documented resident's resident representative was contacted and asked if they agreed with the Neurologist recommendation for Donepezil and verbalized, they wanted more time to decide. The physician was made aware, and no new orders were given. The Medication Administration Record documented Resident #233 received Donepezil 5 milligram tablet daily from 02/28/2024 to 03/17/ 2024. The 3/11/2024 Physician progress note documented Resident #233 was seen and examined for monthly evaluation and medications included Donepezil 5 milligram tablet. The 3/18/2024 Nurse Practitioner progress note documented they reviewed medications with resident representative, and they declined the medication Donepezil. This was discussed with the Physician and nursing and Donepezil was discontinued. When interviewed on 1/28/2025 at 4:19 PM, the Director of Nursing stated the facility protocol was to notify the family designated representative of any changes in medications. When interviewed on 1/29/2025 at 9:54 AM, the Nurse Practitioner stated they spoke with the resident representative on 3/18/2025 review the medications and they requested the Donepezil to be discontinued. The Nurse Practitioner stated the medication should have been discontinued when resident's representative did not want it given. When interviewed on 1/29/2025 at 6:41 PM, the Director of Nursing stated they did not know why the Donepezil medication was administered. 415.3(c)(1)(iii)

Based on observations, interviews and record review conducted during an abbreviated survey (NY00341327, NY00358946), the facility did not provide adequate supervision/monitoring to prevent accidents for 2 of 6 residents (Resident #3 & #10) reviewed. Specifically, (1) Resident #3 who had a history of suicidal attempts and cut their left wrist sustaining a laceration that was unwitnessed by staff on 05/04/2024 was placed on 1:1 monitoring following the incident had no documented 1:1 monitoring. Resident #3 was found by Certified Nurse Aide with blood on his gown and on the floor on 5/5/2024 and was transferred to the hospital for further evaluation. The investigative summary concluded Resident #3 used a pointed pencil to harm self; (2) Resident #10 who had severe cognition impairment and had history of multiple falls sustained a head injury from an unwitnessed fall on 10/09/2024 and was transferred to the hospital for further evaluation Resident #10 had falls with no injury on 02/18/2024, 04/09/2024, 04/22/2024, 06/05/2024, 08/25/2024, and 10/07/2024 but there was no documented evidence of appropriate care plan interventions to prevent further falls and had no Physical Therapy Evaluation and Occupational Therapy Evaluation after each fall. Findings include: The Facility Policy titled Incident and investigation of accidents hazards, supervision and assistive devices last revised on 7/31/2024 documented an avoidable accident means an accident occurred because the facility failed to identify environmental hazards and assess individual residents risk of an accident, including the need for supervision and /or assistive devices; to analyze the hazards/risks and eliminate them or if not possible, identify and implement measures to reduce the hazard risks, implements measures including adequate supervision and assistive devices, consistent with a resident's needs to reduce accidents and monitor for the effectiveness of the interventions and modify care plan as necessary. Resident #3 had diagnoses including Major Depressive Disorder, Colostomy Complication, Essential Hypertension and Morbid Obesity. The Quarterly Minimum Data Set (MDS, an assessment tool) dated 6/13/2024 documented the resident had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 15/15, associated with intact cognition (00-7 severe impairment, 08-12 moderate impairment and 13-15 cognitively intact). The comprehensive care plan initiated 02/23/2024 documented that Resident #3 was at risk for harm and had a goal to maintain clutter free environment and staff will continue 30-minute rounding to ensure safety. Interventions included to conduct environmental rounds every shift. Facility Incident/Accident Investigation dated 05/04/2024 documented Resident #3 as alert and oriented with a Brief Interview for Mental Status of 15. Resident #3 reported they were trying to open a canned drink and accidentally cut themselves on the left wrist. Resident #3 refused hospital transfer despite the presence of paramedics. Wound dressed, physician and family notified. Resident #3 was encouraged to call for assistance. Nursing Progress Note dated 5/4/2024 documented that around 4:20 PM, Certified Nurse Aide reported they noted a skin laceration on Resident #3's left wrist area. The writer attended immediately to observe a resident with a cut on the left wrist. According to resident, they stated they were trying to open a can and accidentally cut their left wrist sustaining a laceration on the left wrist. Physician ordered transfer to the hospital and when the ambulance arrived, Resident #3 refused to go to hospital. Physician notified of Resident #3 refusal to go to hospital. Physician ordered Augmentin for Left Wrist Laceration and Left Wrist Laceration area cleaned with normal saline and bacitracin applied with dry dressing. Resident #3 is on 30-minute monitoring and staff continue to watch the resident closely, call bell within reach. Resident #3 advised to call staff for anything they needed. Facility Incident/Accident Investigation dated 5/5/2024 documented Resident #3 was observed using a pencil to harm themselves. Resident was sent out immediately to the hospital. Review of Resident #3 Electronic Monitoring Record (EMR) revealed no 30-minute monitoring for 5/4/2024 through 5/5/2024. During an interview conducted on 1/8/24 at 11:26 AM, Certified Nurse Aide #1 stated they were assigned to Resident #3 on 5/5/2024 and was working with another resident when the nurse informed them that Resident #3 had cut themself. Certified Nurse Aide #1 stated they left Resident #1 with the nursing staff to care for the other resident. Certified Nurse Aide #1 denied knowing any interventions in place for Resident #3 regarding close monitoring or that the resident had suicidal history. During an interview conducted on 1/8/2025 at 11:47 AM, Certified Nurse Aide #2 stated when they came into work on 5/5/2024 they were informed that there had been an incident with Resident #3 cutting themself the day before. Certified Nurse Aide #2 stated it was reported that no one knew what they had cut themself with. Certified Nurse Aide #2 stated they suggested they put Resident #3 on 30-minute monitoring, and they also went and scanned the room for safety. Certified Nurse Aide #2 stated there was a pair of scissors present and they notified the supervisor. Certified Nurse Aide #2 stated the supervisor removed the scissors and Resident #3 was upset stating they needed the scissors for their colostomy care. Certified Nurse Aide #2 stated they told them they would have to remove the scissors or call the Director of Nursing and Resident #3 let them remove the scissors. Certified Nurse Aide #2 stated later in the day they heard the nurse scream and ran to the resident room. Certified Nurse Aide #2 stated they grabbed a clean blanket and held it on Resident #3's wound. Certified Nurse Aide #2 stated Resident #3 was fighting and being resistant with the care and continued to state that they wanted to die. Certified Nurse Aide #2 stated 911 was called and the resident was sent out to the hospital. Certified Nurse Aide #2 denied knowing of any interventions in place for Resident #3 regarding monitoring or suicidal history prior to 5/5/2024. During an interview on 1/8/2025 at 12:58 PM, the Nursing Supervisor#1 stated they were notified by staff that a Resident #3 was bleeding on 5/4/2024, and they went to assess. Nursing Supervisor #1 stated Resident #3 reported they were trying to open a can drink and sustained an injury but Resident #3 was bleeding from the wrist and their injury was not consistent with the story they were reporting. Nursing Supervisor #1 stated after the assessment they looked to see if there was anything in the room that the resident could use to harm themself but did not find anything. Nursing Supervisor #1 stated they called 911 and Resident #3 refused to go to the hospital. Nursing Supervisor #1 stated the Director of Nursing was notified and they were instructed to place Resident #3 on 1 to 1 monitoring. Nursing Supervisor #1 stated they placed Resident #3 on every 15-minute monitoring instead. Nursing Supervisor #1 stated such monitoring is usually documented on a form. Nursing Supervisor #1 stated they were not aware of Resident #3's suicidal history until after the incident when they read through their chart. During an interview on 1/8/2025 at 12:51 PM, Certified Nurse Aide #3 stated they were handing out trays on 5/4/2024 and when they opened the door to Resident #3's room they saw blood on the floor. Certified Nurse Aide #3 stated they followed the trail and saw blood all over, so they asked Resident #3 what had happened. Certified Nurse Aide #3 stated Resident #3 stated nothing happened and that they were trying to open a can and sustained an injury. Certified Nurse Aide #3 stated they notified the nurse. Certified Nurse Aide #3 stated they questioned Resident #3 asking them if they were trying to open a can, how did they cut themself on the wrist. The injury was not consistent with the story Resident #3 was reporting. The facility wanted to send the resident out to the hospital, but the resident refused. Prior to the incident, the only complaint the resident had was about the food, otherwise the Resident #3 was fine. Certified Nurse Aide #3 denied any knowledge of Resident #3 having behaviors or been placed on close monitoring. During an interview on 1/8/2025 at 2:45 PM, the Director of Nursing stated they were unable to locate every 30 Minute Monitoring for Resident #3 on 5/4/2024 & Every Shift Monitoring from 2/22/2025 to 5/4/2025. During an interview conducted on 1/8/2025 at 3:10 PM, the Director of Nursing stated they were not employed at the time of Resident #3's admission, but they expect monitoring to be done and documented when put in place. During an interview conducted on 1/8/2025 at 3:29 PM, the Administrator stated their expectation would be for monitoring to be done when put in place. However, they did not expect for monitoring to be documented. The Administrator stated they would expect for monitoring to be more of keeping a close eye on the resident. Resident #10 had diagnoses including but not limited to lack of coordination, dementia, and transient cerebral ischemic attacks. Resident #10 was residing in the facility's locked dementia unit. A Minimum Data Set, dated dated dated [DATE] documented a Brief Interview for Mental Status assessment score of 4/15 associated with severe cognition impairment. Resident #10 required supervision while walking with a walker and supervision with meal set-up, bathing, dressing, and bed mobility. Resident #10 had a wander/elopement alarm on. Resident #10 had one fall without an injury. The Discharge MDS dated [DATE] documented that Resident #10 had 3 falls- one with an injury and 2 falls without an injury. Review of the Accident/Incident Report dated 10/9/2024 revealed that on 10/9/2024 at around 8:00 AM Resident #10 was found on the floor outside the bathroom in their room with bleeding from the head noted. When the resident was assessed, visible bleeding from the head was noted, rolling walker was seen near the bathroom door. 911 was activated. Next of kin was notified of incident and resident's status. Emergency Medical Service arrived immediately, and the resident was transferred out to the hospital. Review of Fall Risk Assessments revealed that Resident #10 was identified as high risk for fall since 1/22/2024 but had no comprehensive care plan in place to prevent falls. Review of the Physical Therapy Evaluation dated 2/12/2024, revealed that Resident #10's balance during transitions and walking was scored as follows: moving from seated to standing position, walking with assistive device, turning around while walking, moving on and off toilet and surface to surface transfer: 2 = not steady, only able to stabilize with human assistance. Review of the Occupational Therapy Evaluation dated 2/12/2024, revealed that Resident #10 scored a total of 24 out of 105, in the Barthel Index Scoring Form (an assessment tool, used to measure the ability to perform basic activities of daily living like bathing, dressing, eating, toileting, chair-to-bed transfers, walking and grooming). A score of 21-60 means severe dependency. Record review facility nursing progress notes revealed Resident #10 had falls with no injury on 02/18/2024, 04/09/2024, 04/22/2024, 06/05/2024, 08/25/2024, and 10/07/2024 but there was no documented evidence of appropriate care plan interventions such as consistent monitoring to prevent further falls Record review revealed that the resident had no Physical Therapy Evaluation and Occupational Therapy Evaluation after fall incidents on 02/18/2024, 04/09/2024, 04/22/2024, 06/05/2024, 08/25/2024, and 10/07/2024. Physical and Occupational therapy evaluations conducted on 8/27/2024 and 10/7/2024 but the functional status evaluation was not documented in the evaluation. During an interview on 1/10/2025, at 3:02pm, with the Director of Nursing (DON), stated, their expectations when a fall occurs are as follows: the accident investigation form needs to be filled out immediately, the physician and family need to notified, the pain, skin and fall assessments need to be done, to obtain physician orders for physical and occupational therapy and for x-rays, we discuss the fall in risk management meetings and the care plan must be updated. To prevent falls, we may ask for one or more of the following physician orders such as room change (near the nurses' station), low bed or baseline pain management. Upon a resident's admission, we check for history of falls or repeated falls. We continue to have care plan meetings and interdisciplinary team meetings with all department directors and with our physician in morning meetings. During an interview was on 1/13/2025, at 3:11pm, with Resident #10's representative who is also the healthcare proxy they stated, every time I attended a care plan meeting with the Director of Social Services, they were told they would move Resident #10 to the room closest to the nurses' station. This was never done. During an interview on 1/21/2025, at 11:42am, the Director of Social Services stated they had no documentation or records about moving Resident #10 to a room closest to the nurses' station. The Director for Social Services stated they did see the family a lot because they visited regularly. Resident #10 was always at the nurses' station because Resident #10 walked around a lot with the walker, Resident was very independent and pleasantly confused but they can get feisty. During an interview of 1/28/2025, at 1:16pm the Physical Therapist stated they only completed the assessment for Resident #10 but did not complete any evaluations because they found that Resident #10 did not have a change in functional status. They performed an assessment and not an evaluation because Resident #10 was still ambulatory and there was no change in the resident's function. The Physical Therapist stated an assessment is just to see if there was a physical change in the resident's function. The assessment is usually completed within 24 hours of the incident/fall. If the physical function is the same after an incident, they just continue with the plan of care. 10NYCRR 415.12(h)(2)

Based on record review and interviews during a Recertification and Abbreviated survey (Case #NY 712) conducted from 3/14/22-3/21/22, the facility failed to protect each resident's right to be free from abuse, neglect, exploitation and misappropriation of resident property for 1 (Resident #119) of 5 residents reviewed. Specifically, Resident #58 exhibited abusive behaviors toward staff and Resident #119. The facility did not ensure adequate supervision for each resident knowing Resident#58 had a history unpredictable recurring aggression and resident to resident altercations. As a result, Resident #58 pushed Resident #119, causing Resident #119 to fall and sustain a fracture of the wrist. This resulted in actual harm to Resident #119 that was not immediate jeopardy. . The findings are: Abuse, is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. The facility's Clinical Manual titled Abuse Policy, section Procedure dated 2/8/22, documented identify, correct, and intervene where abuse/neglect and/or mistreatment are more likely to occur. This includes but is not limited to, identification/analysis of: Residents with needs and behaviors which might lead to conflict/neglect. The facility's Clinical Manual titled Abuse Policy, section Protection dated 2/8/22, documented Provide 1:1 monitoring as appropriate. Initiate behavior crisis management intervention, as applicable. Resident#58 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) for Resident#58 dated 4/8/21 documented the resident had a Brief Interview of Mental Status (BIMS) score of 7, a severe impairment in cognition. The assessment indicated no wandering or elopement although resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Abuse & Neglect Comprehensive Care Plan dated 4/2/21 documented Resident#58 is at risk for abuse and neglect related to history of resident-to-resident altercation, agitation on unit, wander guard RLE (right lower extremity), and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Behavioral Symptoms Care Plan dated 4/19/21 documented Resident#58 exhibited regressive behaviors which included resident is difficult to redirect, obsesses about money states people steals her money, rummages through others belonging, verbally disruptive, noisy, screams, alternate brief crying episodes with verbal aggression (verbal abusive behavioral symptoms), cursing staff randomly, making accusations, screaming at others. The care plan also documented resident will exhibit fewer or no inappropriate disruptive behavior. To address behavioral concerns, the following goals were on the care plan: provide protective environment to prevent injuries, provide protection for potentially injurious behavior, and social services intervention. Resident#119 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) for Resident#119 dated 3/25/21 documented the resident had a Brief Interview of Mental Status (BIMS) score of 6, a severe impairment in cognition. No [CONDITION(S)] or behavioral concerns were noted on the assessment resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Nursing Progress Note in the EMR (electronic medical record) documents the following escalating behaviors for Resident #58: 4/17/21 written by (Licensed Practical Nurse) LPN#12: Resident#58 wandering from room to room with their packed belongings. Staff redirected the resident to their room, but they went into another room where resident was sleeping. When staff tried to redirect, Resident#58 picked up a chair and tried to hit staff with it. 4/19/21written by LPN#12: Resident#58 wandering into other residents' rooms. Redirected by staff but resident usually not listening, 6 am resident pacing swiftly in hallway, praying, yelling loudly, and swinging arms. Approached nurse in a threatening manner with hands raised. 4/22/21 written by LPN #12: Resident#58 enters other residents' rooms while care being given to them and refuses to leave. Staff cannot leave because the resident blocks their exit. Aggressive towards staff, yelling and attempting to hit staff. 4/23/21written by LPN#12: Resident#58 grabbed another resident R/W (Roller Walker), preventing them from ambulating. Staff intervened and Resident#58 began screaming and continued to hold the R/W and pleading for resident to stay with them. Resident#58 followed other resident to the resident's room and refused to leave even though resident asked them to leave the room several times. Staff made several attempts to redirect resident to their own room, but they screamed and approached staff aggressively swinging arms wildly. 5/2/21written by LPN#9: Resident#58 was crying, beating on the door and seemed to be praying in a hysterical manner. The physician was contacted, and order received for [MEDICATION(S)] 0.5 ml IM STAT and psych consult for Tuesday. There was no documented evidence in the interdisciplinary notes from 4/1/21 to 5/2/21, that de-escalation for behavioral interventions were implemented or used for Resident #58. Review of Nursing Progress Notes in the EMR document the following 5/5/21written by LPN#12: Resident #58 sitting in their room and talking to another resident. Resident#58 did not want resident to leave the room and followed the other resident to their room. Resident#58 kept talking to resident and not allowing them to sleep. Both residents were ambulating in hallway and talking. Staff kept redirecting and encouraging Resident #58 to go to bed. Resident#58 become agitated when staff tried to redirect them back to their own room and Resident #58 raised their hands at staff. Resident #58 remained in the other resident's room most of the shift. 5/14/21 written by LPN#9: Resident #58 was going back and forth from the dining room into the hallway. At 6:50 PM Resident #58 went to the LPN #9 crying and screaming, suddenly they punched LPN #9 very hard on the right triceps. LPN #9 maneuvered the cart between themselves and resident #58. The resident went into the dining room and returned shortly crying and apologized. 5/15/21 written by LPN#6 Resident#58 attempted to snatch pizza from writer's hand saying they should not eat it because it is poisoned, writer gave pizza to the resident and turned to walk away when suddenly Resident#58 hit writer in the back. 5/25/21 written by LPN #6: Resident#119 was observed lying on their back. Resident#119 head was towards the entrance door and feet were towards the bathroom door. Resident #119 was holding their left hand in their right hand and was crying. Their Left wrist was swollen and appeared as if Resident#119 was in pain. Resident #119 and Resident#58 were arguing. Review of interdisciplinary progress notes from 5/5/21-5/25/21 revealed no documented evidence of interventions used by staff other than redirection to support and address Resident #58 behavioral needs. Review of a facility Accident/Incident Investigation Summary of Investigation dated 5/25/21 documented the following: review of the camera this morning provides an accurate account, and the following were noted: Incident was not witnessed. Resident#119 was wandering in other residents' room prior to the incident. Resident #119 entered Resident #58 room and an argument followed. Resident #119 came out of the room and was gesticulating to resident#58 who was still in the room. Resident#58 came out of the room and the video showed them still arguing. Resident#119 removed the right shoe from their foot and hit resident#58. Resident #58 grabbed the right hand, of Resident #119, took the shoes from them, and threw it away. They continued hitting each other and Resident#58 hit resident#119 with a towel. A few seconds into the altercation resident#58 pushed resident#119 who tumbled and fell backward into room [ROOM NUMBER] which is adjacent to room [ROOM NUMBER]. The entire incident lasted from 17:39:30 to 17:40:23 (About a minute). The conclusion of the of the summary of investigation documented there was no evidence of any attempt for abuse, neglect or mistreatment based on the investigation and documented this was an unfortunate altercation between two dementia residents that resulted in a misfortune for resident#119. A Nursing progress note dated 5/26/21 and written by Registered Nurse (RN#3): Writer went to unit to assess another resident who fell . Observed Resident#58 in very aggressive behavior standing by room [ROOM NUMBER] where the other resident was lying on the floor. Became very agitated and ready to hit when approaching other resident and staff. The physician was notified and gave order to send Resident#58 to the Hospital's psychiatric unit for evaluation. A progress note dated 5/26/21 and written by Social Worker (SW) #1: Resident #119 was transferred to the Hospital for evaluation and returned this morning. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an Interview on 3/18/22 10:44 AM, Certified Nursing Assistant (CNA#4) stated that they were giving care to another resident in their room. They heard a sound, then saw Resident#119 on the floor. They said they called for the nurse. The nurse called the supervisor, and they went to assist Resident #119. CNA#4 stated they did not remember what interventions were in place to manage Resident #58's behaviors. CNA #4 stated, Resident #58 does exhibit behavioral disturbances. CNA#4 stated both residents were separated and moved off the floor immediately following the incident. During an interview on 3/17/22 4:51 PM, Licensed Practical Nurse (LPN#9) stated they were not present at the time of the incident. LPN #9 stated that a CNA alerted them that Resident#119 was on the floor. LPN # 9 stated that Resident #58 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN#9 said that the resident can be verbally abusive and would be redirected to their room. LPN #9 said that there was no order for routine monitoring, but CNAs are responsible for monitoring residents on the unit. If there is an altercation, they are to separate the residents and call the nurse for assistance. During an interview on 3/21/22 at 10:31 AM, Administrator #1 stated that this is not an appropriate setting for Resident #58. The Administrator said it was a bad PRI (Patient Review Instrument, used to assess patients prior to admission to nursing home) to begin with. The administrator stated they accepted placement for Resident #58 despite having some knowledge of the residents' history. The administrator stated they were hesitant about accepting Resident#58 into facility due to concerning behaviors. The Administrator stated that the resident was moved into a private room across from the nurse station. This move was to minimize aggressive behaviors and ensure the safety of others. Administrator stated that redirection and activities work really well for Resident #58. The Administrator stated there were times when the resident was not easily directed. 483.12(1)