**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident # 444 was admitted to the facility with diagnosis including Respiratory failure with hypoxia, Heart failure, and COPD (chronic obstructive pulmonary disease). The admission Minimum Date Set 3.0 (MDS) dated [DATE] documented Resident # 444 had intact cognition (BIMS score 15) and only Resident #444 participated in the assessment. On 06/01/23 at 11:08 AM, Resident #444 was interviewed and stated they had been admitted to the facility for about 1 month (5/11/23) and did not recall they were invited to any care plan meeting. Resident #444 also stated they made decisions for themselves. The MDS 3.0 Schedules and CCP documented Resident #444's CCP was scheduled for 5/31/23. The Interdisciplinary Care Conference Record/CCP Meeting dated 5/31/23 had no documentation of Resident #444's or their designated representative's signature to indicate their attendance of the care plan meeting. There was no documented evidence in the electronic medical record (EMR) or hard copy chart that Resident # 444 and/or their designated representative was invited to attend or refused to attend the care plan meeting held on 5/31/23. On 06/05/23 at 03:18 PM, the Social Worker (SW) # 2 was interviewed and stated they were responsible for inviting residents and/or their designated representatives to the care plan meetings after receiving the CCP schedule from the MDS department. The SW # 2 also stated the residents and/or their designated representatives were invited to all care plan meetings including initial, quarterly, annual, significant change, or as needed. The SW # 2 further stated the care plan meeting was an opportunity and right for the residents and their designated representative to participate in the development and implementation of their person-centered plan of care and establishing the expected goals and outcomes of care. The SW # 2 stated they documented the invitation to the care plan meeting in the electronic medical record under social services. The SW # 2 was not able to find any documented evidence in the EMR or hard copy chart that Resident # 444 and/or their designated representative was invited to, attended, or refused to attend the care plan meeting held on 5/31/23. The SW # 2 stated they might have forgotten to document the invitation in the EMR. On 06/05/23 at 04:12 PM, the Director of Social Services (DSS) was interviewed and stated the social worker was responsible for inviting residents and their designated representatives to all the care plan meetings. They should documented the invitation in the medical record. The DSS checked Resident #444's medical record and was not able to find any documented evidence that Resident #444 and/or their designated representative were invited to the care plan meeting on 5/31/2023. The DSS also stated they were not able to explain the reason Resident #444 and/or their designated representative was not invited to the care plan meeting on 5/31/2023. The DSS further stated it was an error if Resident # 444 and/or their designated representative were not invited to the care plan meeting as a resident should be given the opportunity to participate in their own care plan development and set up the goals. 483.10 (c) (2-3) Based on record review and interviews conducted during the Recertification survey from 6/1/23 through 6/8/23, the facility did not ensure that each resident or resident representative was offered the opportunity to participate in the review of their Comprehensive Care Plan s (CCP). This was evident for 2 out of 4 residents reviewed for care planning out of a sample of 38 residents. (Resident #54 and Resident #444). Specifically, Resident #54 and Resident # 444 were not invited to participate in their care plan meeting. The findings are: The facility policy titled Comprehensive Care Planning (CCP) with no effective date and last updated in September 2022 documented the CCP will be prepared by the interdisciplinary team that includes the input from the resident when appropriate and the resident's family or legal representative. It also documented the Social Work Department staff will make a phone call and/or mail a letter of invitation to the designated representative prior to the meeting to invite them to participate. It further documented the resident will be verbally notified of the meeting at least 48 hours in advance, and again on the day of the meeting by both Social Services and Nursing Staff. 1) Resident #54 was admitted with the diagnoses that include Urinary Retention and Osteomyelitis. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] identified Resident #54's cognition as intact with a Brief Interview for Mental status score of 15. An initial Interdisciplinary Care Conference Record/CCP Meeting note dated 2/14/23 documented that Resident #54 can participate in the CCP meeting. However, there were no documented evidence that the resident was invited or participated in the care plan meeting. A Quarterly Interdisciplinary Care Conference Record/CCP Meeting note dated 5/2/23 documented that Resident #54 can participate in the care plan meeting. However, there was no documented evidence that Resident #54 participated in the CCP meeting. On 6/7/23 at 10:00 AM an interview was conducted with Resident #54. Resident #54 stated that they were not invited to the care plan meeting and has never attended the meeting. On 6/6/23 at 4:06 PM, an interview was conducted with Social Worker #3 (SW #3). SW # 3 stated that they invite residents who have capacity to the care plan meeting. Residents' family representatives are invited if the resident has no capacity. Resident #54 was invited to the initial and quarterly care plan meeting, but they did not document if the resident attended the meeting. They should have documented it in the chart. On 6/8/23 at 9:54 AM, an interview was conducted with the Director of Social Services (DSS). The DSS stated the social worker is supposed to invite the residents and family representatives to the CCP meetings. They are supposed to document that the resident is invited and if they refuse to come. The social worker should have documented if the resident participated or did not participate. On 6/7/23 at 9:25 AM an interview was conducted with the Director of Nursing (DNS). The DNS stated that the social worker is supposed to invite the family representatives and/or the resident either by letter or phone and document that is done in all care plan meeting notes. They should have invited Resident #54 to the care plan meeting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification and Complaint survey, the facility did not ensure that residents are informed and provided written information concerning their right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. This includes a written description of the facility's policies to implement advance directives and applicable State law. This was evident for 3 of 3 residents reviewed for Advance directive out of 35 sample residents (Residents #23, #121, and #229). Specifically, the facility failed to discuss and provide information concerning the resident's right and option to formulate an advance directive for newly admitted resident. The findings are: The facility Policy and Procedures titled Advance Directives dated June 2009, last revised August 2022, documented that the facility will conform to all applicable laws and regulatory agencies requirement while maintaining a program that ensures residents wishes regarding self-determination. 1) Resident #23 was admitted to the facility 03/27/2003, with diagnoses that included coronary artery disease (CAD), Cerebrovascular accident (CVA), Non-Alzheimer's Dementia. The Significant Change in Status Minimum Data Set 3.0 (MDS) dated [DATE] documented the resident had moderately impaired cognition, clear speech, made self understood, and understood others. The MDS also documented the resident participated in the assessment, and no family or significant other participated in the resident's assessment. On 06/02/23 at 09:48 AM, Resident #23 was interviewed and stated they have been in the facility for a long time, and nobody has had any discussion with them about Advance Directive since admission. The Comprehensive Care Plan (CCP) for Advance Directives dated 3/4/23, updated 5/3/23 documented that Resident #23 has a Designated Representative. The interventions included: Social Worker will review choices and options about Advance Directives on quarterly basis The CCP Evaluation note dated 3/4/23 documented that the resident's designated Representative remain in effect and the Plan of Care (POC) would be continued. The CCP Evaluation note dated 5/31/23 documented that there have been no changes requested at this time and to continue the POC. There was no documented evidence that Advance Directives (AD) were discussed with the Resident #23 or their designated representative, and no AD were noted in the medical record. 2) Resident #121 was initially admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses that included Non-Alzheimer's Dementia, Seizure Disorder, and Schizophrenia. The admission Minimum Data Set (MDS) dated [DATE] documented the resident had severe impairment in cognition with long and short-term memory problems. The MDS documented the resident is sometimes understood and had clear speech. The MDS also documented that Resident #121 participated in assessment and had no family or significant other. The admission Minimum Data Set (MDS) dated [DATE] documented the resident had severe impairment in cognition with long and short-term memory problems. The MDS documented the resident is sometimes understood had clear speech. The MDS also documented Resident #121 participated in the assessment and had no family or significant other. On 06/02/23 at 10:49 AM, no documented evidence of Advance Directives noted in resident's chart. Resident was interviewed and stated that he/she cannot remember any staff discussed Advance Directive with him/her. There was no documented evidence that Advance Directives has been discussed with the resident or their designated representative in the medical record, and there were no AD noted in the medical record. 3) Resident #229 was admitted to the facility 03/02/2023, with diagnoses that included Hypertension, Cerebrovascular Accident (CVA), and Seizure Disorder. The admission Minimum Data Set (MDS) dated [DATE] documented the resident had severe impairment in cognition with long and short-term memory problems. On 06/07/23 at 11:31 AM, an interview was conducted with the Resident #229's family member. The family member stated that no staff has ever discussed advance directive with them. The CCP for Advance directives dated 3/3/23 documented the resident has a designated representative. The CCP goals included: Resident will be able to make informed decisions about advanced directives; Respect advance directive. The interventions included: - Social worker will review choices and options about Advance Directives. The CCP for Advance directives Quarterly Note dated 5/30/23 documented that the resident's designated representative remains in effect. There was no documented evidence in the medical record that Advance Directives were discussed with the designated representative. On 06/05/23 at 11:49 AM, an interview was conducted with RN #1. RN #1 stated that when a resident is admitted , the Social Worker (SW) discusses the Advance Directives with the resident and the family and is to be documented in the Social Services Progress note in the resident's charts. RN also stated that resident's Advance Directive is discussed during the resident's CCP meeting, and the care plan on Advance Directive is expected to be updated by the SW to indicate the status of resident's Advance directive discussed with the resident/resident's family. On 06/07/23 at 11:34 AM, an interview was conducted with Registered Nurse Supervisor (RNS #3). RNS #3 stated that the Advance directive is the responsibility of the SW, unless if the resident's family notify the admission Nurse of their wishes for the resident's AD, which the admission nurse will communicate to the Social Services to follow up with necessary paperwork. If the resident comes in with the DNR or Full Code paper, the admission nurse will document and inform the SW to follow up. If there is no Advance Directive for DNR/DNI, resident will be Full code pending SW discussion with the family. On 06/07/23 at 12:08 PM, an interview was conducted with the Social Worker (SW#1). SW #1 stated: Upon admission, initial assessment is completed, if resident is able to make decision, all the options of Advance Directive is discussed, if residents are not able to make the decision, and they don't have any upon admission, Advance Directive is not discussed with family member unless they have Health Care proxy. SW #1 stated that this will be documented in the initial notes. SW stated that if resident that is unable to make decision is admitted without DNR/DNI, resident will be treated as full code if there is no Healthcare Proxy for the resident. SW stated that they did not discuss the advance Directives with the family member/designated representative with the residents' designated representatives because they are not the Health Care Proxy. On 06/07/23 at 12:20 PM, an interview was conducted with the Director of Social Services (DSS). DSS stated that when residents are admitted , the Social Service discuss Advance Directive with the resident if they are alert and oriented, if resident is unable to make decision, it is discussed with the family members or designated representatives. They discuss DNR/DNI, life sustaining treatment options available when newly admitted , and also review it with them during the quarterly meeting. DSS stated that the discussion is supposed to be documented in the resident charts during initial assessment and during quarterly review. DSS stated that they were surprised that Advance Directives were not being discussed with the resident/residents' designated representative; and they are not aware that it is not being documented in the resident's charts. On 06/07/23 at 12:40 PM, an interview was conducted with the Director of Nursing (DON). DON stated that when residents are admitted , the social worker will discuss options of Advance Directives with the resident or the family member, if resident comes with Advance directives, the doctor will be notified and will be ordered, if there is none upon admission, the doctor and the social worker will discuss the advance directives with the family, which should be documented in the residents' chart. DON stated that they are not aware that this is not being done. 415.3 (e) (2)(iii).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview conducted during the Recertification/Complaint survey from 6/1/23 to 6/8/23, the facility did not ensure that the resident and their representatives were provided with a written summary of the baseline care plan. This was evident for 1 of 3 residents reviewed for Advance Directive out of a sample of 35 residents. (Resident #229). The finding is: The facility policy and procedure titled Comprehensive Care Planning - Baseline Care Plans dated September 2022 documented: .The facility must provide the resident and their representative with a summary of the baseline care plan that includes but not limited to: The initial goals of the resident; A summary of the resident's medication and dietary instructions; Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; Any updated information based on the details of the comprehensive care plan, as necessary. Resident #229 was admitted to the facility with diagnoses that included Hypertension, Gastroesophageal Reflux Disease, Cerebrovascular Accident (CVA), Seizure Disorder. The admission Minimum Data Set (MDS) dated [DATE] documented the resident had severe impairment in cognition with long and short-term memory problems and is total dependence of staff for all activities of daily living. The MDS also documented that resident's family or significant other participated in the assessment. Review of the Resident's medical record contained no documented evidence that a copy of the baseline care plan had been provided to the resident's designated representative. On 06/07/23 at 11:31 AM, an interview was conducted with the resident's representative who stated that they were not given a written summary about the baseline care plan. On 06/05/23 at 11:49 AM, an interview was conducted with the Charge Nurse (RN #1). RN #1 stated that after the completion of the baseline care plan, the Social Services department is responsible for giving out all the necessary paperwork, including the summary of the baseline care plan to the resident/resident's family. RN #1 also stated that they were not sure if, and when the copy of the Baseline care plan was given to the resident's family. On 06/07/23 at 12:08 PM, an interview was conducted with the Social Worker (SW) #1 who stated that they do not give a copy of the baseline Care Plan Summary to the family member unless they request it. On 06/07/23 at 12:20 PM, an interview was conducted with the Director of Social Services (DSS) who stated that the baseline care plan is completed by all interdisciplinary team (IDT) members within 48 hours of resident's admission, and a copy is supposed to be given to resident's family member if the resident is not able to make decision. On 06/07/23 at 01:15 PM, the Director of Nursing (DON) was interviewed and stated that they make sure that the baseline care plan was completed within 48 hours of admission, signed, and kept in the resident's file. The DON also stated that IDT members are always informed to ensure that a copy of the summary is given to the resident and/or to the family members. The DON further stated that they were surprised that this was not being done. 415.11 (c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Recertification Survey from 6/1/23 to 6/8/23, the facility did not ensure a comprehensive care plan (CCP) was reviewed and revised to reflect changes in the resident's care. This was evident for 1 (Resident #444) of 2 residents reviewed for Respiratory out of 38 total sampled residents. Specifically, Resident #444's CCP was not reviewed and revised to reflect that Resident #444 was receiving oxygen therapy. The findings are: The facility policy titled Comprehensive Care Planning (CCP) with no effective date and last updated in September 2022 documented the CCP will be kept current by all disciplines on an ongoing basis. It also documented each discipline will be responsible for updating the care plan and alerting the team that a new problem has been identified. Resident #444 was admitted to the facility with diagnosis including Respiratory failure with hypoxia, Heart failure, and Chronic Obstructive Pulmonary Disease) The admission Minimum Date Set 3.0 (MDS) dated [DATE] documented Resident #444 had intact cognition, was on oxygen therapy, and only Resident #444 participated in the assessment. On 06/01/23 at 11:08 AM, Resident #444 was interviewed and stated they were on oxygen at all times before and after current admission to the facility. On 06/01/23 11:12 AM, 06/02/23 at 12:20 PM, 06/05/23 at 02:22 PM, 06/06/23 at 10:19 AM, 06/07/23 at 12:00 PM, 06/08/23 at 09:51 AM, and on other occasions during the survey, Resident #444 was observed receiving oxygen through nasal cannula from the oxygen delivery setting on the wall. Patient Orders dated 5/12/23 documented Oxygen via Nasal Cannula at 3 Liters per minute. Telephone order dated 5/20/23 documented give O2 2lt (liters) via nasal cannula. The CCP related to COPD/Respiratory initiated 5/11/23 documented Resident #444 had COPD and interventions included to observe for signs of acute respiratory distress, monitor for side effects of respiratory treatments, and administer respiratory treatment of Breo Ellipta. There was no documented evidence that the care plan had been updated to reflect that resident was placed on oxygen therapy. On 06/05/23 at 02:51 PM, Certified Nursing Assistant (CNA) #5 was interviewed and stated Resident #444 was alert and oriented and had been on oxygen all the time since they were admitted the unit. On 06/05/23 at 03:37 PM, the Clinical Nurse Manager (CNM) #1 was interviewed and stated the RNs on the unit were responsible for creating, reviewing, and updating the care plans for residents after the MDS assessments and as needed. CNM #1 also stated they remembered they called the physician to obtain the oxygen order for Resident #444 after their admission to the facility and the oxygen order was not discontinued. CNM #1 stated it was their error for not updating the care plan of COPD to reflect oxygen use for Resident #444. On 06/05/23 at 03:56 PM, the Director of Nursing (DON) was interviewed and stated all the RNs on the unit were responsible for updating the care plan if needed. The DON also stated the oxygen use had to be included in the care plan if a resident had oxygen therapy. The DON stated they were not familiar with Resident #444 and was not aware Resident #444 was on oxygen therapy. The DON also stated they were not able to explain why the oxygen use was not included in the care plan for Resident #444. 415.11(c)(2)(i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification survey from 6/1/23 through 6/8/23, the facility did not ensure a resident with an indwelling Foley catheter was provided care consistent with professional standards of practice. Specifically, a resident was observed several times with an indwelling Foley catheter without a Medical Doctor's Order (MDO). This was evident in 1 of the 1 residents reviewed for urinary catheter out of 38 sample residents. (Residents # 105). The findings include: The facility policy and procedure titled Urinary Catheterization dated 9/2022 documented that urinary catheter should be placed under the direction of a physician's order-catheter change monthly and as needed by a licensed nurse. Resident #105 was admitted to the facility with a diagnosis of Urinary Tract Infection and Manic Depression. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had an indwelling catheter. On 6/1/23 at 10:38 AM, 6/2/23 at 10:49 AM, 6/5/23 at 9:36 AM, and 6/6/23 at 9:14 AM Resident #105 was observed in bed with a Foley catheter drainage bag attached to the left side of the bed. An Elimination/Genitourinary Care Plan initiated on 2/13/23 documented that Resident # 105 has an indwelling catheter. A Medical Doctor Order (MDO) dated 5/11/23 to 6/7/23 did not contain an order for Foley catheter insertion or care. A Urology Consult Note dated 5/9/23 at 11:40 AM documented that Resident #105 was seen and examined, and a Foley catheter was seen in the urinary bladder. A care plan note dated 5/11/23 documented to continue with the plan of care. Foley is in place and intact. A Nurse's progress note dated 5/11/23 documented an indwelling Foley catheter in place with clear urine output. A Nurse's Progress Note dated 5/13/23 at 11:54 PM documented Foley intact/patent. A Certified Nursing Assistant (CNA) Accountability Record dated 5/15/23 through 6/7/23 documented that Resident #105 has a catheter. On 6/8/23 at 12:52 PM, an interview was conducted with Licensed Practical Nurse (LPN) #1 who stated that Resident #105 was admitted with a Foley catheter and the Foley catheter is changed every 30 days. LPN #1 also stated there is no active order for the Foley catheter and that there was an order before, but it fell off. On 6/8/23 at 1:11 PM, an interview was conducted with Clinical Nurse Manager (CNM) #1 who stated that Resident #105 had been on the floor for a while and was admitted with a Foley catheter for Benign Prostatic Hyperplasia (BPH). CNM #1 also stated that the Foley catheter is changed every month, and there is supposed to be an order for the Foley catheter, and the nurses are responsible for picking up the orders. CNM #1 further stated that they did not know why there was no order in the computer for the catheter. On 6/8/23 at 2:14 PM, an interview was conducted with the Director of Nursing (DNS) who stated that Resident #105 was admitted from the hospital with the Foley catheter, and as per the doctor, the Foley cannot be discontinued because of the resident's history of BPH. The DNS further stated that there should have been an order in place and the nurses and doctors are responsible for ensuring that the orders are in. 415.12(d)

Based on record review and staff interviews during the Recertification and Complaint survey, the facility did not ensure that a surety bond or similar protection with the amount equal to at least the current total amount of resident's funds. Specifically, the surety bond held by the facility did not cover the total amount of resident personal funds deposited with the facility. This was evident for 111 residents with personal funds out of 238 residents in the facility. The findings are: On 6/7/23 at 10:16am, the Finance Manager presented a surety bond in the amount of $150,000 with an effective date of 5/4/2009. The finance ledger dated 6/7/2023 with residents funds amount documented the current total amount of resident's funds was $257,687.53. The facility did not ensure that the value of the surety bond covered funds currently held in all residents accounts. On 6/7/23 at 12:54pm, the Finance Manager stated the amount of the surety bond was established in 2007. The Finance Manager stated there is an additional $90,000 in a CD (certificate of deposit), totaling the amount of surety at $240,000. The Finance Manager reported since COVID residents have had extra money coming in so it increased the total amount of residents funds. The Finance Manager reported the facility has never reviewed the surety bond since it was established in 2007. 415.26(h)(5)(v)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.)Resident #82 was admitted [DATE] with diagnoses of Subdural Hematoma and Dementia with Behavioral Disturbance. The resident had no diagnosis of schizophrenia or bipolar disorder but was admitted with an order for Divalproex 250 mg twice a day for mood disorder and an order for Citalopram 10 mg daily for depression. The Behavioral Problem Care Plan initiated 02/27/2023 documented Resident #82 was verbally abusive. The care plan was updated 05/27/2023 and documented there had been no behavioral issues for the past 2 quarters. The Mood State Care Plan initiated 03/06/2023 documented Resident #82 had depression. The care plan was reviewed 05/29/2023 with a note stating that the resident's mood had been stable for the past 2 quarters A Drug Regimen Review (DRR) dated 02/2023 recommended to attempt to reduce the dosages of Citalopram and Depakote. The recommendations were repeated in 05/2023 but were not acted upon by the unit physician. Resident #82 was seen by the psychiatrist for initial evaluation on 04/29/2023. The psychiatrist noted that the resident had noticeable memory deficits but was coherent, calm, and cooperative, with stable mood, had been compliant with medications and had no behavioral disturbances. However, psychiatrist recommended to continue the Divalproex and Citalopram without Gradual Dose Reduction (GDR). There was no documented evidence a GDR was performed for Resident #82' prescribed antipsychotic medication. On 06/06/2023 at 10:44 AM, the Attending Physician (AP) #1 was interviewed and stated that the physician prescribes psychotropic medications based on the psychiatrist's recommendations. In the case of Resident # 82, they did not respond to the pharmacist's recommendations to reduce the dose of the resident's psychotropic medications because the resident was stable on their current medications, and they did not want the resident to relapse. On 06/07/2023 at 11:56 AM, the Medical Director was interviewed and stated that the facility remains committed to doing GDRs on psychotropic medications wherever possible. The Medical Director stated that they would communicate with the psychiatrists and encourage them to revisit GDRs when they are appropriate. On 06/07/2023 at 12:33 PM, the Pharmacy Director was interviewed and stated the physician chooses not to act, however, the pharmacist has no recourse other than to continue to remind them. 483.45(e)(1) 483.45(e)(2) Based on observation, record reviews, and staff interviews conducted during the Recertification survey from 6/1/23 through 6/8/23, the facility did not ensure that Gradual Dose Reduction (GDR) was attempted for a prescribed psychotropic medication. This was evident in 2 (Resident #113 and #82) of 5 residents reviewed for Unnecessary Medication out of a sample of 38 residents. Specifically, 1) Resident #113 had a diagnosis of dementia and was prescribed and administered Risperidone for agitation with no GDR attempted, and 2) Resident # 82 had a diagnosis of dementia and was prescribed Divalproex and Citalopram without a GDR attempt. The findings are: The facility policy titled Psychopharmacological Drugs/Chemical Restraints revised August 2022 documented that the policy is to ensure that all residents maintained on psychopharmacological medication are on the lowest dosage of drug to achieve effects and are reviewed on a regular basis to evaluate need for continued use. 1.) Resident # 113 was admitted to the facility with diagnoses that included Diabetes Mellitus, Dementia and Depression. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #113 was moderately cognitively impaired, displayed no psychosis or behavioral symptoms, and received antipsychotic medication 7 out of 7 days prior to the assessment. No gradual dose reduction (GDR) had been attempted, and GDR had not been documented as clinically contraindicated. On 6/5/23 at 9:29 AM, Resident #113 was observed sleeping in their room. On 6/6/23 at 8:21 AM and 12:25 PM, and 6/7/23 at 2:43 PM, Resident #113 was observed out of bed and in their wheelchair. The Comprehensive Care Plan (CCP) related to psychotropic drug use, initiated 8/10/22 and last revised 4/24/23, documented Resident #113 received Risperidone 0.5mg at bedtime for agitation. The Psychiatry Consult dated 01/26/2023 documented the reason for Resident #113's consult was neurocognitive disorder with mood problems. Resident #113 was hospitalized for hyperglycemia and their presentation was suspected secondary to delirium/altered mental status from hyperglycemia versus worsening dementia. Resident #113 was cooperative, had cognition within normal limits, and had a low risk level for violence. The primary psychiatric diagnosis was documented as dementia with mood disturbance. The consult documented a recommendation for Resident #113 to continue with Namenda 5mg twice daily, Risperidone .5mg at bedtime for dementia with mood disorder, and Melatonin 5mg at 6 PM for insomnia. A Drug Regimen Review (DRR) note dated 2/2023 documented please attempt to reduce the dose of Risperidone 0.5 mg oral at bedtime (started on 8/11/22). The Primary Medical Doctor (PMD) documented their response 3/28/23 that Resident #113's symptoms were controlled with the current dose. The Psychiatry Consult for Resident #113, dated 3/24/23, documented problems addressed in the note included depression, dementia, Hyperlipidemia, and hypertension. Resident #113 was oriented to person, place, and time, was listening to the radio, smiled appropriately, was in a good mood, and reported being in contact with their family. Resident #113 denied depressive, delusional, manic, and paranoid symptoms and was stable on the current regimen. Psychiatry Consult dated 4/30/23 documented Resident #113 had no reported violence, cognition within normal limits, insight within normal limits, was cooperative, and denied suicidal ideation. The consult documented the reason for the consult was neurocognitive disorder, problems addressed included Resident #113's dementia with mood disorder, and the recommendation was to continue with Memantine 5mg twice daily for dementia, Risperidone .5mg daily for mood disorder, and Melatonin 5mg at 6 PM. A DRR note dated 5/2023 documented to attempt to reduce the dose of Risperidone 0.5 mg orally at bedtime (started on 8/11/22). The PMD documented their response 6/5/23 that Resident #113 was prescribed the required dose for their symptoms. Nursing Note dated 5/22/23 documented Resident #113 was found seated on the floor in front of their bed at 7:02 AM. Resident #113 reported they were trying to move from the bed to the wheelchair. Continue to monitor. The Medical Doctor Order (MDO) 5/30/23 documented Resident #113's order to receive Risperidone 0.5 mg at bedtime for agitation would stop after 32 days. The Medication Administration Record (MAR) from 5/1/23 to 6/7/23 documented that Risperidone 0.5 mg was administered daily at bedtime. There was no documented evidence a GDR of Resident #113's Risperidone .5mg was attempted despite Resident #113 displaying appropriate behaviors and stable cognition. On 6/5/23 at 3:41 PM, an interview was conducted with Certified Nursing Assistant (CNA) # 3 who stated that Resident #113 does not exhibit behaviors. The resident does not get agitated and is very cooperative. On 06/06/23 at 08:22 AM, an interview was conducted with Licensed Practical Nurse (LPN) #2 who stated that Resident #113 has no behaviors The resident is always gentle and calm. Resident #113 sleeps at night and does not get agitated. On 06/06/23 at 12:16 PM, an interview was conducted with Clinical Nurse Manager (CNM) #1 who stated that Resident #113 does not exhibit agitation. They like to listen to the radio and play music loudly. Resident #113 interacts well with everyone. Resident #113 is on Risperidone 0.5 mg at bedtime for Agitation. The Psychiatrist sees the resident. On 06/06/23 at 12:24 PM, an interview was conducted with Attending Physician (AP) #1 who stated that Resident #113 is on Risperidone 0.5 mg at bedtime for Agitation, which was started on 8/11/22. There have not been any recent falls, so the medication is working well. They cannot taper the Risperidone, even though the pharmacist recommended tapering the medication, because it is helping the resident. AP #1 does not want Resident #113 to fall and sustain a head injury. Though there is a black box warning for the use of Risperidone, the benefits outweigh the risk, and AP #1 will not taper the medication. On 06/06/23 at 12:40 PM, an interview was conducted with the Psychiatrist who stated that Resident #113 has neurocognitive disorder and behavior problems. Resident #113 was started on a low dose of Risperidone, and the plan is to try to reduce it. There has not been any GDR since admission. Resident #113 is on a small dose, and it is tough to do a GDR. The Psychiatrist does not feel comfortable taking Resident #113 totally off of Risperidone. The resident is getting a little better. There is a black box warning, but the resident is on a lower dose.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews conducted during re-certification survey, the facility did not report an alleged incident of resident-to-resident sexual abuse was reported to the New York State Department of Health (NYSDOH) within 2 hours. Specifically, the Certified Nursing Assistant (CNA #1) reported that she observed Resident #23 and Resident #38 (a cognitively impaired resident) engaged in inappropriate sexual behavior in the dining room. The facility did not report this allegation of resident-to-resident abuse to NYSDOH. This was evident for 2 of 3 residents sampled for abuse (Resident #23 and Resident # 38). The findings include: The facility's policy and procedure titled Abuse Prevention Protocol with a revised date 01/22/2020 states that an investigator is trained to report incident to NYSDOH Long Term Care bureau when there is reasonable cause for patient abuse without necessarily completing internal investigation. The policy further states that the federal regulations require reporting of alleged abuse, neglect, or mistreatment within five days of incident. Resident #23 was admitted with diagnoses which include Hypertension, Cerebrovascular Accident and Dementia. The Minimum Data Set (MDS) dated [DATE] documented Resident #23 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 13 out of 15. An Occurrence Reporting Form dated 08/15/2020 documented that Resident #23 was involved in sexually inappropriate behavior with another resident. A Nurse's Progress Note dated 08/16/2020 at 3:09 PM documented that Resident #23 is day 2 post sexually inappropriate behavior. A Psychosomatic Medicine Note dated 08/16/2020 documented the Psychiatrist saw Resident #23 after the incident. It is documented that the staff reported that Resident #23 and Resident #38 were found to be engaged in sexual activity in the dining room, where Resident #38 was masturbating Resident #23. It is documented that Resident #23 stated that it was unsolicited, but he likes it. The Psychiatry Note did not document Resident #23's decision-making capacity or ability to consent to a sexual relationship. A Social Work Note dated 08/17/2020 at 10:54 AM documented that on 08/15/2020, Resident #23 reportedly had Resident #38's face on his crotch area. It is documented that the social worker met with Resident #23 and he stated that no such thing happened. Resident #23 was counseled and encouraged to refrain from interacting with Resident #38. A Resident Safety care plan initiated on 08/16/2020 documented that Resident #23 is at risk for abuse as evidenced by provocative behavior towards other residents. The interventions included close observation and protect resident from further harm. Resident # 38 was admitted to the facility on [DATE] with diagnoses which include Coronary Artery Disease, Diabetes Mellitus, and Dementia. The MDS dated [DATE] documented Resident #38 had moderately impaired with a BIMS score of 8 out of 15. An Occurrence Reporting Form dated 08/15/2020 documented that a CNA reported that Resident #38 was observed engaging in sexually inappropriate behavior in the dining room. A Psychosomatic Medicine Note dated 08/16/2020 documented that Resident #38 engaged in sexual behavior with Resident #23. It is documented that Resident #38 was found masturbating Resident #23 in the dining room. The Psychiatry Note did not document Resident #38's decision-making capacity or ability to consent to sexual behavior. A Resident Safety care plan initiated on 08/16/2020 documented that Resident #38 is at risk for abuse as evidenced by provocative behavior towards other residents. The interventions included close observation, room change, change seating arrangement in the dining room and provide emotional support. A care plan notes dated 08/17/2020 documented that Resident #38 was found exhibiting inappropriate behavior towards Resident #23. The facility investigation report dated 08/17/2020 concluded that the act was consensual. There was no documented evidence that this allegation of potential sexual abuse was reported to the NYS Department of Health within 2 hours pending outcome of an investigation. On 10/27/2020, CNA #1 was interviewed. She stated that she was assigned to the day room to monitor the residents. There were six residents seated 6 feet apart. She went to the pantry to get something, and was inside the pantry for about 2 to 3 minutes. When she came out, Resident #38 and Resident #23 were seated next to each other, and Resident #38 had Resident #23's penis in her hand. She immediately moved Resident #38 to a different table and reported it to the nurse. On 10/27/2020 at 4:47 PM, Social Worker #1 (SW #1) was interviewed. She stated that she was informed that Resident #38 had inappropriate behavior with Resident #23 in the dining room. She interviewed Resident #38, and she admitted that she touched Resident #23 inappropriately. On 10/27/2020, at 4:55 PM, the Registered Nurse Supervisor was interviewed. She stated that the nurse called her to the floor after dinner and told her that Resident #38 had inappropriate behavior with Resident #23, and Resident #38 was holding Resident #23's penis. She assessed both residents, and they were fine. She informed the Assistant Director of Nursing. The RN Supervisor stated that she did not initiate an incident report. She said that she did not think about the incident report because Resident #38 has the capacity to make decisions. She asked Resident #38 what happened, and the resident laughed. Resident #38 did not mention that it was consensual. On 10/27/2020 at 5:05 PM, SW #2 was interviewed. She stated that she met with Resident #23, and the resident denied the alleged inappropriate behavior. She said that Resident #23 has Dementia and does not have 100% capacity to make decisions. On 10/28/2020 at 3:03 PM, the Director of Nursing was interviewed. She stated that she was made aware of the incident the same day, and Resident #38 was moved to another room for supervision. She said that Resident #38 told her that they were attracted to each other, and things got out of hand. She said that the team concluded that the behavior was consensual. The DNS noted that she did not believe that it was reportable because the residents said it was consensual. She said that reflecting at the incident now, it could have been reported to the Department of Health. 415.4(b)(1)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) The facility policy and procedure titled Abuse Prevention Protocol revised on 1/20/2020 documents that All incidents which could involve abuse, neglect or mistreatment are reviewed through internal investigation process initiated by the nursing supervisor by completing the investigation of alleged abuse form and are to be completed within 24-72 hours. The investigative process should include a Description of allegations, complaint, injury, description of residents risk factors, environmental factors, physician findings, list of staff involved in the resident care, summary of findings, plan of correction, notification of family, administrator, NYSDOH. The facility policy and procedure titled Complaint Grievance Policy and Procedure revised September 2020 documents that if a resident wishes to file a greivance any staff member may provide the form to the resident and assist in filling it out if needed. This complaint form is then given to the appropriate supervisor who then gives it to the Resident Advocate/Director of Social Work who initiates an investigation which must be completed within five business days, when possible. Response to the complainant must be made within 5 business days of receipt of complaint in writing. If an alleged abuse is suspected, the Director of Social Work will bring it to the Abuse Prevention/Occurrence Review Committee meeting for further action. The Committee will contact the Dept. of Health when necessary. The Resident Advocate/Director of Social Work will maintain a log, complete quarterly reports and submits to the executive director. The report incudes: summary, trends., potential problems, recommendations Resident #63 was a resident with diagnoses which include stroke, aphasia, and nontraumatic intracerebral hemorrhage The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident #63 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 13 out of 15. On 10/22/20 at 10:58 AM, Resident #63 was interviewed with an interpreter. The resident stated that about 8 days ago, during the 4PM-12:30AM shift, a female Certified Nursing Assistant (CNA) was working and left him out in the hallway until midnight. He further stated that whenever this CNA is working she screams at him, insults him, and calls him stupid. The resident stated that he does not know her name because she does not let anybody see her Identification badge. He further stated that whenever she transfers him, she is rough and hurts him. The resident also stated that whenever this CNA is working, she will not change his diaper and it becomes overfilled. He stated that when she does change the diaper she does not clean him and instead just replaces the old diaper with a new one. The Psychiatrist note dated 10/12/20 documented Resident #63 has had no behavioral disturbances and has been interacting appropriately with staff and peers. The resident was not orientated to time, but the resident had fair insight and judgement with no delusions. The resident had slight memory impairment. A statement given by resident and written by Social Worker #2 dated 10/13/20 documented the Resident stated that about 2 weeks prior at 12:30 AM he was at the dining hall and requested for his meals. The CNA stated to him that he was being annoying and hit him in the head with his wheelchair brakes. The same CNA that hit him, took him to the bathroom without cleaning him. After he used the bathroom, the CNA sat him back in his wheelchair in a soiled diaper. The resident then pleaded to a different CNA (CNA #2) asking if he could clean him after he was done eating, and CNA #2 agreed to do so. The statement further documented that the resident does not want to be alone with this CNA and he would like the mistreatment to stop. The Social Worker documented this statement on a blank piece of paper instead of using a formal grievance form. A Resident Concern Follow-up completed by Director of Nursing (DON) on 10/15/20 documented that no meals are served at 12:30 AM as indicated in the resident's statement. On examination, no visible signs of injury were noted. The follow-up documented: Investigation: Resident is alert but with periods of confusion. The follow up reveals no sign of injury. No complaints of injury or mistreatment were reported to the nursing staff. Resident is primarily cared for by male caregivers. Conclusion: Resident is alert with periods of confusion. It is hard to substantiate physical abuse as the reported information is inconsistent. Plan: Staff to continue to monitor for safety and provide direction as needed. Male caregivers to continue to provide care. There was no evidence that a thorough investigation was completed. There was no documented evidence that a follow-up interview was conducted with the resident. There was no documented evidence that interviews were conducted with the charge nurse, CNAs or any other staff members. There was no documented evidence that attempts were made to identify if there were such a CNA working with the resident. There was no documented evidence that the resident was referred to psych following the allegations made on 10/13/20. A review of CNA assignments dated 10/13/20 through 10/23/20 document the resident was assigned a female CNA for the evening shift (4:00PM-12:30 AM) on 10/15/20, 10/16/20, 10/17/20, 10/18/20, 10/19/20, 10/21/20, 10/22/20, and 10/24/20. There was no documented evidence that the resident was assigned to only male caregivers or that an attempt was made to assign the resident male caregivers. No updates were made to the care plan to reflect that the resident will be assigned male caregivers per the corrective action in the concern follow-up. On 10/27/20 at 3:51 PM, an interview was conducted with the Social Worker (SW #2). SW #2 became the resident's assigned social worker on 10/5/20. Initially on 10/12/20, the resident brought up the issue of being kept in their chair too late during routine rounds. SW#2 stated she spoke to nursing staff about the matter and told her supervisor, who instructed her to take a written testimony from the resident. On 10/13/20, she returned to the resident to conduct an interview and document the statement. During the visit, the resident brought up additional details, alleging verbal and physical abuse. After writing the statement, she provided her supervisor and the Director of Nursing (DON) with a copy. SW #2 stated that during the interview, she looked at the resident and there were no visible injuries. The resident was not able to name the CNA and described the CNA as a dark-skinned female with long hair. SW #2 stated that she was not able to help identify the CNA because she was new t the unit. On 10/26/20 at 4:29 PM, an interview was conducted with the evening Registered Nurse (RN #1)Charge Nurse. The RN stated that she is responsible for creating the evening shift CNA assignments, and she was not aware of any resident that shouldn't be assigned female CNAs. Resident #63 did not report any incidents or express being afraid of any staff members to her. RN #1 stated she was surprised to hear the resident reported an issue becuase she is familiar with the resident and sees the resident every shift. RN#1 further stated that she is not aware of any abuse or neglect allegations made by the resident, and she has never been interviewed for an investigation. The RN#1 further stated that if a resident makes an allegation of abuse, it is reported to the supervisor and an investigation is initiated. Sometimes, depending on what is said, the staff member in question will be suspended during the investigation. She also added that if she was informed of an allegation she would go and examine the patient for any injuries. On 10/27/20 at 4:30 PM, an interview was conducted with the DON. She explained that when an investigation is conducted, she takes all information provided into account. Based on what was presented to her in terms of dates and possible injuries, the information was very inconsistent. The DON explained Resident #63 is alert with periods of confusion. She explained that the resident said the incident happened in the past 2 weeks, but they could not give a date or time. The resident reported being taken into the dining room at 12:30 AM, but the facility does not serve meals at that time. The DON further stated that she examined the resident, and there were no signs of injury. She explained that the resident never brought up any issues to nursing staff, and she did not have any reason to substantiate abuse. The DON further stated that no nurses were notified of the allegation because there was no information to report since the resident could not recall the staff member or the time or date. The DON stated that she did not interview any staff herself, but she believes the social worker did. She also stated that she believes the resident was seen by psych since the incident, but she would have to look and see if psych was notified about these behaviors of making allegations. On 10/28/20 at 3:45 PM a follow-up interview was conducted with the DON. She explained that she went and spoke to the resident herself during her investigation. When asked if she used an interpreter, since the resident is primarily Spanish speaking, she replied on and off. She stated that she was able to communicate with the resident by pointing and making gestures, and the resident knows some English. She explained that she pointed to the resident's wheelchair and pointed to the resident's head and asked the resident if they were hit. The resident told her no he was never hit. The DON stated that she did not document this conversation. When asked if CNA #2, who was metioned by name in the resident's statement, was interviewed, the DON stated that CNA #2 was not interviewed because that CNA works the day shift, and the resident said the incident happened at night. The DON explained that during the investigation process, the corrective measures were to continue to provide male caregivers and monitor for safety. 415.4(b)(ii) Based on record review and staff interviews conducted during a recertification survey, the facility did not ensure that an allegations of abuse were thoroughly investigated and corrective actions were implemented. Specifically, (1) an allegation of potential resident-to-resident sexual abuse reported by a Certified Nursing Assistant (CNA #1) who observed Resident #23 and Resident #38 (a cognitively impaired resident) engaged in sexually inappropriate behavior was not thoroughly investigated; and (2) a resident's allegations of abuse and neglect were not thoroughly investigated, and the corrective action of having male CNA's assigned was not implemented (Resident #63). This was evident for 3 of 3 residents reviewed for Abuse (Resident #s 23, 38, and 63) for 2 abuse allegations reviewed. The findings include: The facility's policy and procedure titled Abuse Prevention Protocol with a revised date 01/22/2020 documented that the nursing supervisor, department heads or designees are trained to make the initial investigation by documenting the statements of complaints summarizing the situation or events, obtaining appropriate written statement form the staff, and or residents/representatives. 1) Resident #23 was admitted to the facility with diagnoses which include Hypertension, Cerebrovascular Accident and Dementia. The Minimum Data Set (MDS) dated [DATE] documented Resident #23 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 13 out of 15. The Facility's Occurrence Reporting Form dated 08/15/2020 documented that Resident #23 was involved in sexually inappropriate behavior with another resident. The occurrence report was incomplete and had no statements attached from the staff or the residents involved. A Nurse's Progress Note dated 08/16/2020 at 3:09 PM documented that Resident #23 was day 2 post sexually inappropriate behavior. A Psychosomatic Medicine Note dated 08/16/2020 documented that the Psychiatrist saw Resident #23 after the incident. The note documented that the staff reported that Resident #23 and Resident #38 were found engaging in sexual activity in the dining room. Resident #38 was masturbating Resident #23. Resident #23 stated that it was unsolicited, but he likes it. A Social Work Note dated 08/17/2020 at 10:54 AM documented that on 08/15/2020, Resident #23 reportedly had Resident #38's face on his crotch area. The social worker met with Resident #23 and he stated that no such thing happened. Resident #23 was counseled and encouraged to refrain from interacting with Resident #38. A Resident Safety care plan initiated on 08/16/2020 documented that Resident #23 is at risk for abuse as evidenced by provocative behavior towards other residents. The interventions included close observation and protect resident from further harm. Resident #38 was admitted with diagnoses including, Coronary Artery Disease, Diabetes Mellitus, and Dementia. The MDS dated [DATE] documented Resident #38 had moderately impaired cognition with a BIMS score of 8 out of 15. The Facility's Occurrence Reporting Form dated 08/15/2020 documented that CNA #1 reported that Resident #38 was noted engaging in sexually inappropriate behavior in the dining room. The occurrence report was incomplete, and there were no statements from the staff on the unit or the residents involved. A Psychosomatic Medicine Note dated 08/16/2020 documented that Resident #38 engaged in sexually inappropriate behavior with Resident #23. The note documented Resident #38 was found masturbating Resident #23 in the dining room. A Resident Safety care plan initiated on 08/16/2020 documented that Resident #38 was at risk for abuse as evidence by provocative behavior towards other residents. The interventions included close observation, room change, change sitting arrangement in the dining room and provide emotional support. A care plan note dated 08/17/2020 documented that Resident #38 was found exhibiting inappropriate behavior towards Resident #23. The facility investigation report dated 08/17/2020 concluded that the act was consensual. There was no documented evidence that facility conducted a thorough investigation with statements from witnesses and the residents involved to rule out abuse and ensure the actions of the residents was consensual. In addition, there was no documented evidence that the facility evaluated Resident #38 for ability to consent to a sexual relationship or to see if the resident understood their actions. On 10/27/2020, CNA #1 was interviewed. She stated that she was assigned to the day room to monitor the residents. There were six residents seated 6 feet apart. She went to the pantry to get something for about 2-3 minutes. When she came out, Resident #38's wheelchair was close to Resident #23, and Resident #38 had Resident #23's penis in her hand. She immediately moved Resident #38 to a different table and reported it to the nurse. On 10/27/2020 at 4:47 PM, Social Worker #1 (SW #1) was interviewed. She stated that she was informed that Resident #38 had inappropriate behavior with Resident #23 in the dining room. She interviewed Resident #38, and she admitted that she touched Resident #23 inappropriately. On 10/27/2020, at 4:55 PM, the Registered Nurse Supervisor was interviewed. She stated that the nurse called her to the floor after dinner and told her that Resident #38 had inappropriate behavior with Resident #23. Resident #38 was holding Resident #23's penis in her hand. She assessed both residents, and they were fine. She informed the Assistant Director of Nursing. The RN supervisor stated that she did not initiate an incident report. She said that she did not think about the incident report because Resident #38 has the capacity to make decisions. She asked Resident 38 what happened, and the resident laughed. On 10/27/2020 at 5:05 PM, SW #2 was interviewed. She stated that she met with Resident #23, and the resident denied the alleged inappropriate behavior. She said that Resident #23 has Dementia and does not have 100% capacity to make decisions. On 10/28/2020 at 3:03 PM, the Director of Nursing was interviewed. She stated that for incidents like this one, the residents are separated and interviews and statements are taken from the staff. She said that a staff member saw what happened, so they did not collect the statement. The RN supervisor was supposed to document her assessment and initiate the investigation. 415.4(b)(ii)