Based on interview and record review conducted during a Standard survey completed on 5/17/24, the facility did not ensure that a resident has the right to refuse treatment for one (Resident #10) of five residents reviewed for immunizations. Specifically, Resident #10 was administered the pneumococcal vaccine (used to prevent pneumonia) by facility staff without consent. The finding is: The policy and procedure titled Resident Rights dated 10/22 documented the facility will protect and promote the rights of the resident. The policy and procedure documented the resident had the right to accept or refuse care and treatment. Residents have a right to be provided a statement that should they be unable to make their own decisions and be adjudicated incompetent and not be restored to legal capacity, or if a conservator should be appointed for you, these rights and responsibilities shall be exercised by the appointed committee or conservator in a representative capacity. The policy and procedure titled Vaccinations - Patient/Elder revised 9/22 documented residents 65 years or older are assessed for pneumococcal status at time of admission and immunization consent/declination received at that time. The policy and procedure documented prior to vaccination, double check the chart for physician's order, normal baseline temperature, serious reaction to applicable vaccine, and signed consent form. Resident #10 was admitted with diagnoses that included dementia, diabetes mellitus (high blood sugar), and anxiety. The Minimum Data Set (MDS- a resident assessment tool) dated 4/17/24 documented Resident #10 was always understood, always understands, and had moderate cognitive impairment. The Minimum Data Set documented Resident #10 received the pneumococcal vaccine. The Health Care Proxy form dated 9/26/23 documented Resident #10's responsible party was their Health Care Proxy. The Health Care Proxy documented the responsible party would make decisions for Resident #10 when Resident #10 was unable to make their own health care decisions. The Employee/Resident/Inpatient Vaccine Administration Consent/Waiver Form dated 1/26/24 documented verbal declination was obtained via phone with the Health Care Proxy for Influenza (flu), Pneumococcal, Respiratory Syncytial Virus (RSV- a common respiratory virus), Hepatitis B and Covid-19 Vaccines. The form further documented Resident #10 received the Pneumococcal Vaccine on 2/28/24. The History and Physical dated 11/10/23 documented Resident #10 had baseline Alzheimer dementia and was definitely confused. The Physician General Clinic Note dated 2/8/24 documented Resident #10 was pleasantly confused. Review of the Medication Administration History Report dated 2/1/24-2/29/24 documented Resident #10 received the Prevnar 20 (pneumococcal) vaccination on 2/28/24. Review of the Care Plan edited on 4/24/24 documented Resident #10 had advance directives. The Care Plan documented Resident #10's wishes would be honored and the Health Care Proxy was in the chart. During an interview on 5/15/24 at 2:56 PM, Registered Nurse #3 stated they had helped to obtain vaccination consents and declinations from the residents or the residents' responsible party. Registered Nurse #3 stated based on Resident #10's Brief Interview for Mental Status score, they would not be able to make the decision to consent to or decline a vaccination. Registered Nurse #3 stated a verbal declination was obtained from Resident #10's Health Care Proxy by Registered Nurse #2 and cosigned by Registered Nurse #3. Registered Nurse #3 stated Resident #10 received the pneumococcal vaccination after the declination was obtained. Registered Nurse #3 stated Resident #10 should not have received the pneumococcal vaccination because they had the right to refuse the vaccination. During an interview on 5/15/24 at 3:13 PM, the Social Worker stated Resident #10's Health Care Proxy was very involved in their care and made health care decisions for Resident #10. During an interview on 5/15/24 at 3:22 PM, Registered Nurse #2 stated Resident #10 was unable to make their own decisions and that was why they contacted Resident #10's Health Care Proxy. Registered Nurse #2 stated, based on the electronic medication administration record, the Director of Nursing gave the pneumococcal vaccination on 2/28/24. During an interview on 5/15/24 at 3:30 PM, the Director of Nursing stated the consent and declination form was filled out incorrectly. The Director of Nursing stated Resident #10 should not have received the vaccination because the family did not want them to have it. The Director of Nursing stated they signed in two places that Resident #10 received the vaccination. removed. During an interview on 5/16/24 at 9:52 AM, the Medical Director stated it was expected for nurses to follow Resident #10's wishes. During an interview on 5/17/24 at 10:00 AM, the Administrator stated it was expected for nursing to administer or not administer a vaccination based on the consent and declination form. The Administrator stated it was the Director of Nursing's responsibility to make sure consent forms and administering immunizations were done accurately. 10 NYCRR 415.3f(1)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a Standard survey completed on 5/17/24 the facility did not immediately inform resident's representatives of a change in their physical and/or mental status for two (Resident #39 and Resident #28) of three residents reviewed for notification of change. Specifically, Resident #39 was given an intramuscularly injection (IM) of Haldol (antipsychotic medication) 5 milligrams and the family was not notified until after the resident had an adverse reaction to the medication. Additionally, the facility did not notify Resident #28's representative of a reddened area on their coccyx until 6 days later, and there was no documented evidence Resident #28's representative was notified of a stage II pressure area. The findings are: The policy titled Change in Condition dated 2/2021 documented that it was the responsibility of the Registered Nurse or Registered Nurse Supervisor to notify the resident, the physician, and the resident's responsible party, of changes in the resident's medical or mental condition, and document the notification in the medical record. The form titled Your Rights as a Nursing Home Resident in New York State dated 2022, documented that residents had the right to refuse medications, treatments, and chemical restraints. It also documented that the resident's representative had those rights in the instance that the resident was unable to make their own decisions. 1. Resident #39 had diagnoses including unspecified dementia, macular degeneration (loss of the central field of vision), and lung cancer. The Minimum Data Set (a resident assessment tool) dated 2/22/24, documented Resident #39 was severely cognitively impaired and displayed no behaviors. Resident #39's care plan dated 3/6/24, documented the resident was at risk for pain and receiving palliative care (comfort care). Interventions included to monitor for changes in behavior that may be contributed to pain and to monitor. The care plan also documented interventions to maintain family contacts. Resident #39's progress note dated 2/28/24 at 3:00 PM revealed the Director of Nursing documented they were made aware that Resident #39 had become very agitated, restless, and physically aggressive with staff during routine care and rounds. They contacted Nurse Practitioner #1, and a new order was received for Haldol 5 milligrams intramuscularly X 1 dose and every 4 hours as needed. There was no documented evidence the family was notified of the resident's behaviors, or that they were notified of the new order for Haldol prior to its administration. The Prescription Order dated 2/28/24 at 3:13 PM, documented an order for haloperidol lactate (Haldol) 5 milligrams intramuscularly injection, one time and as needed every 4 hours. The order was written for vascular dementia with other behavioral disturbance by the Director of Nursing. Review of the Medication Administration History dated 2/1/24- 2/29/24, revealed Licensed Practical Nurse #4 administered the haloperidol lactate 5 milligrams intramuscularly injection on 2/28/24 at 9:07 PM. Review of Resident #39's progress note dated 2/29/24 at 2:00 PM (documented as late entry on 3/1/24 at 7:27 AM) revealed the Unit Manager Registered Nurse #1 documented they communicated with Nurse Practitioner #1 about the resident's reaction to the Haldol and that the family was aware. During an interview on 5/13/24 at 12:43 PM, Resident #39's representative stated they had not been notified of the resident's behaviors or that Haldol was administered until they came to visit (2/29/24). The representative stated they noticed Resident #39 was not behaving as they normally did; their arms and legs were flailing around, and they were unable to respond or communicate. At that time, the unit manager told them the resident's change was a reaction to the Haldol they had received the night before. During an interview on 5/15/24 at 10:39 AM, Registered Nurse Unit Manager #1 stated when the resident had a change in condition and a new order was received from the provider the receiving nurse (Director of Nursing) should have notified the resident's representative and documented the notifications in the progress notes. During an interview on 5/15/24 at 11:46 AM, the Director of Nursing stated that nursing staff should notify the family before a new medication was given. The Director of Nursing stated that it was important because the family could be aware that the resident had an adverse reaction to the medication in the past, and they have the right to refuse the medication. During an interview on 5/15/24 at 1:21 PM, Nurse Practitioner #1 stated they expected the nursing staff to notify the resident's family or representative prior to giving any new medication. Especially with a medication like Haldol because it was considered a form of chemical restraint. 2. Resident #28 had diagnoses including Alzheimer's disease, stroke, and type II diabetes mellitus. The Minimum Data Set, dated [DATE], documented the resident was severely cognitively impaired, and was at risk for developing pressure areas. Resident #28's care plan dated 9/12/22, documented the resident was at risk for altered skin integrity related to a history of pressure areas, incontinence of bowel and bladder, and dementia. Review of Resident #28's progress note dated 8/24/23 revealed the Director of Nursing documented that a Stage 2 open ulcer (shallow ulcer cause by pressure) was noted on the resident's left buttock that measured 0.5 centimeters by 0.3 centimeters. The ulcer was cleansed with wound wash skin prep applied (a liquid film forming a protective barrier on a patient's skin to help reduce friction from removing adhesive dressings), and covered with a foam border dressing. There was no documented evidence the resident representative was notified of the development of the stage 2 pressure ulcer. Review of Resident #28's progress note dated 8/30/23 revealed Registered Nurse Unit Manager #1 documented they assessed resident's left buttock, and the area was resolved. They also assessed the coccyx and found no open area; skin was peeling; apply [NAME] (Calmoseptine- a moisture barrier cream to prevent skin irritation from urine and feces) three times a day and as needed. Review of Resident #28's progress notes dated 9/7/23 revealed Licensed Practical Nurse #2 documented that patient had redness in coccyx area, cleaned area, and foam border dressing applied. There was no documented evidence the resident representative was made aware of the redness and the need to start a treatment. Review of Resident #28's progress notes dated 12/19/23 revealed Licensed Practical Nurse #1 documented that resident continues with open area on coccyx; Calmoseptine applied, unit manager aware and will continue to monitor. There was no documented evidence the resident representative was made aware of the skin concerns. Review of the Physician Order Report - Treatments flow sheet dated 9/12/22 to 2/28/24 documented the following: 9/12/22 - skin checks weekly on shower days. 7/28/23 - remove lidocaine patch from back. 8/11/23 - Calmoseptine to buttocks as needed per shift. 12/20/23 - oxygen to at 2 liters via nasal canula as needed. 2/28/24 - apply Calmoseptine to right and left buttock, cover with foam border dressing once a day. Review of the View Care Conference - Care Conference Information dated 9/13/23 revealed no evidence the family was notified of the reddened area. During an interview on 5/16/24 at 10:09 AM, the Medical Director stated they would expect the nurses to contact them to notify them of any open area. During an interview on 5/16/24 at 10:45 AM, Licensed Practical Nurse #1 stated they do not recall being told about the reddened area on the resident's coccyx by Licensed Practical Nurse #2 who worked the night shift before them. They stated they would document they contacted the family or the physician about the reddened area. During an interview on 5/16/24 at 11:08 AM, Registered Nurse Unit Manager #1 stated they expect the Licensed Practical Nurses to tell them about any skin conditions. They stated they would have documented in progress notes about contacting the family and the Medical Director for any skin issues. During an interview on 5/16/24 at 12:02 PM, the Director of Nursing stated the physician should be notified about any open area on the resident, because Resident #28's coccyx was a chronic pressure area, they would not have notified the family. They stated family should be notified about any change in condition within 24 hours. They also stated that it should be documented in progress notes that family was notified. The Director of Nursing reviewed the medical record and stated the family attended the care conference meeting on 9/13/23, and may have been notified at that time of skin concerns. During an interview on 5/17/24 at 9:05 AM, Licensed Practical Nurse #2 stated they should have contacted a Registered Nurse to assess the reddened area. They stated if the area wasn't followed up on by the morning shift nurse, they should have contacted the Registered Nurse on their next shift. During an interview on 5/17/24 at 9:19 AM, Registered Nurse Unit Manager #2 stated if there was not a registered nurse available in long term care, they expected the Licensed Practical Nurses to call the Medical Care Unit to get a Registered Nurse to assess any skin areas. They stated they expect their nurses to document in progress notes they contacted the Registered Nurse or Supervisor to assess a skin area. During an interview on 5/17/24 at 10:05 AM, the Administrator stated they expected nursing staff to notify family, and the physician of any change in condition, or any new treatment or medication. 415.3 (e)(2)(ii)(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a Complaint (NY00325631) investigation conducted during a Standard Survey completed on 5/17/24, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice for two (Resident #28 and #39) of fifteen residents reviewed for quality of care. Specifically, there was no Registered Nurse assessment for a resident with a reddened area on their coccyx, and there was no order obtained from the physician for treatment of a Stage 2 (a shallow wound that affects the skin and the tissue below it) pressure ulcer (#28). Additionally, there was no evidence of a Registered Nurse assessment for a resident who experienced a change in their behavior, received an antipsychotic medication and after the resident had an adverse reaction to the medication (Resident #39). The findings are: The policy titled Skin - Pressure Ulcer/Injury Treatment dated 10/05, documented that an assessment by a Registered Nurse included: the date assessed, measurements including length, width, and depth, stage of ulcer if appropriate, the location and type of wound. The policy titled Standard Physician Orders dated 6/23/11, documented that telephone or verbal orders for Long Term Care residents may be accepted by a licensed nurse and must be countersigned by a physician within 48 hours. The undated facility job description for a Licensed Practical Nurse, documented that the Licensed Practical Nurse was to provide nursing care under the guidance of a Registered Nurse, must be able to document in the patient's records, and identify appropriate nursing interventions. The undated facility job description for a Registered Nurse, it documented that the Registered Nurse assures the delivery of safe, comprehensive, effective, appropriate nursing care including resident assessments, documentation, and medication administration. 1. Resident #28 was admitted to the facility with Alzheimer's disease, stroke, and type 2 diabetes mellitus. Review of the Minimum Data Set (a resident assessment tool) dated 9/3/23 documented the resident was severely cognitively impaired. Further review of the Minimum Data Set documented the resident was at risk for developing pressure areas. The resident's Care Plan dated 9/12/22, documented the resident was at risk for altered skin integrity related to a history of pressure areas, incontinent bowel and bladder, and dementia. Review of the chronological nursing progress notes dated 8/1/23 to 12/27/23 documented the following: 8/24/23 - The Director of Nursing wrote that a Stage 2 open area was noted on the resident's left buttock measuring 0.5 centimeters by 0.3 centimeters, area was cleansed with wound wash with skin prep (protective barrier) and covered with a foam border dressing. 8/30/23 - Registered Nurse Unit Manager #1 wrote that assessed resident's left buttock and area resolved; also assessed the coccyx and found no open area; skin is peeling; apply [NAME] (calmoseptine- a moisture barrier cream to prevent skin irritation from urine and feces) three times a day and as needed. 9/7/23 - Licensed Practical Nurse #2 wrote that patient has redness in coccyx area, cleaned area, and foam border dressing applied. 12/19/23 - Licensed Practical Nurse #1 wrote that resident continues with open area on coccyx; Calmoseptine applied, unit manager aware and will continue to monitor. There was no documented evidence that there was a registered nurse assessment regarding the reddened area to the resident's coccyx 9/7/23, and there was evidence of a registered nurse assessment on 12/19/23 of the open area on the resident's coccyx. Review of the chronological Physician Order Report - Treatments flow sheet dated 9/12/22 to 2/28/24 documented the following: 9/12/22 - skin checks weekly on shower days. 7/28/23 - remove lidocaine patch from back. 8/11/23 - Calmoseptine to buttocks as needed per shift. 12/20/23 - oxygen to at 2 liters via nasal canula as needed. 2/28/24 - apply Calmoseptine to right and left buttock, cover with foam border dressing once a day. There was no evidence a physician's order was obtained on 8/24/23 for the Stage 2 pressure ulcer on the resident's left buttocks to include the use of skin prep and dry foam dressing; the discontinuation and the initiation of applying Calmoseptine three times daily and as needed on 8/30/23; and there was no evidence there was a physician's order on 9/7/23 to add the foam dressing. During an interview on 5/16/24 at 10:09 AM, the Medical Director, they stated they expected the nurses to contact them to obtain an order for a foam border dressing and any treatment for any open area on a resident. They stated they expected the registered nurses to assess any open area on a resident. During an interview on 5/16/24 at 10:45 AM, Licensed Practical Nurse #1 stated an order from the physician's was needed for any dressing and treatment. During an interview on 5/16/24 at 11:08 AM, Registered Nurse Unit Manager #1 stated they expected the Licensed Practical Nurses to get a registered nurse to assess all skin issues. They stated that if it was after the day shift ended and there were no Registered Nurses in the skilled nursing facility, the Licensed Practical Nurses were to go to the Medical Care Unit or call the Medical Care Unit to find a Registered Nurse to assess any skin concerns. hey stated they would expect the Licensed Practical Nurses to write a progress note and document they contacted a Registered Nurse to complete the assessment. They stated that a foam border dressing and any skin treatment needed an order from a physician. During an interview on 5/16/24 at 12:02 PM, the Director of Nursing stated the physician should be notified about any open areas on a resident. The Director of Nursing stated that any foam border dressing for an open area required an order from the physician. They stated they thought they obtained an order for the Stage 2 on 8/24/23, then verified that the order was not on the Physician Order Report - Treatment flow sheet. During an interview on 5/17/24 at 9:05 AM, Licensed Practical Nurse #2, they stated that they should have contacted a Registered Nurse to assess the reddened area on the resident. They stated if the area wasn't followed up on by the morning shift nurse, they should have contacted the Registered Nurse on their next shift. During an interview on 5/17/24 at 9:19 AM, Registered Nurse Unit Manager #2, they expected any of the Licensed Practical Nurses to call the Medical Care Unit to get a Registered Nurse to assess any skin concerns. They stated they expect their nurses to document in progress notes that they contacted the Registered Nurse or Supervisor to assess a skin area. 2. Resident #39 had diagnoses including unspecified dementia, macular degeneration (loss of the central field of vision), and lung cancer. The Minimum Data Set, dated [DATE], documented Resident #39 was severely cognitively impaired, and displayed no behaviors. Resident #39's Care Plan dated 3/6/24, documented resident was at risk for pain due to diagnosis of cancer and admitted on palliative care (comfort care). Further review of the Care Plan documented monitor for changes in behavior that may be contributed to pain and monitor for verbal and non-verbal signs of pain. Review of Resident #39's progress note dated 2/28/24 at 3:00 PM revealed the Director of Nursing documented they were made aware that Resident #39 was becoming very agitated, restless, and physically aggressive with staff during routine care and rounds. They contacted Nurse Practitioner #1, and a new order was received for Haldol 5 milligrams intramuscular X 1. There was no evidence a Registered Nurse or the Director of Nursing completed a comprehensive resident assessment of the resident's condition/status when the resident experienced a change in their behavior. The Prescription Order dated 2/28/24 at 3:13 PM, documented an order for haloperidol lactate (Haldol) 5 milligrams intramuscularly injection, one time and as needed every 4 hours. The order was written for vascular dementia with other behavioral disturbance by the Director of Nursing. Review of the Medication Administration History dated 2/1/24- 2/29/24, revealed Licensed Practical Nurse #4 administered the haloperidol lactate 5 milligrams intramuscularly injection on 2/28/24 at 9:07 PM. Review of Resident #39's progress note dated 2/29/24 at 2:00 PM (late entry on 3/1/24 at 7:27 AM) revealed the Unit Manager Registered Nurse #1 documented they communicated with Nurse Practitioner #1 about the resident's reaction to the Haldol. There was no evidence a comprehensive resident assessment was completed by a Registered Nurse when the resident experienced an adverse reaction to the Haldol. During an interview on 5/16/24 at 9:40 AM, the Medical Director stated if a resident was having a change in condition or a reaction to a medication, they would expect the Registered Nurse to document a complete assessment. The provider might not be able to come into the facility so they would trust the nurse's assessment, make recommendations, or give orders. During an interview on 5/16/24 at 11:40 AM, the Director of Nursing stated when a resident has a change in condition or a reaction to a medication, a thorough physical assessment should be documented in the resident's progress note by the Registered Nurse. They stated that the progress note dated 2/28/24 at 3:00 PM did not contain a thorough physical assessment of Resident #39. The Director of Nursing also stated that the progress note dated 2/29/24 at 2:00 PM did not contain a thorough physical assessment of Resident #39. During an interview on 5/17/24 at 10:05 AM, the Administrator stated that as a standard of practice a thorough registered nurse assessment should be completed and documented for any change in a resident's condition. 10 NYCRR 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a complaint investigation (NY00296464) completed during a Standard survey started 9/18/22 and completed 9/22/22, the facility did not ensure the resident's rights to be free from abuse for three (Resident #19, 24 and 31) of four residents reviewed for abuse. Specifically, it was determined CNA #3 was verbally abusive to three residents during care. The findings are: The policy titled Resident Abuse Investigation dated issue 9/21/2022 documented it is the policy of the facility to investigate incidents that may involve resident abuse. The Nursing Home Administrator is responsible for ensuring the safety and wellbeing of the residents. All staff are trained on the definition, identification, and responsibility to report suspected abuse. Staff are encouraged to contact the nursing home administrator to in the event there is an incident. The nursing home administrator will gather information including accident/incident reports and witness statements if available. Based on the type of abuse reported the administrator may request a resident being assessed by nurse, social worker, or appropriate clinical professional to determine if the resident suffered emotional or physical injury. Based on the initial findings a timely incident form will be completed and submitted via the (name of state incident reporting system) by the administrator. If the suspected abuser is an employee, the he or she may be suspended or terminated from employment depending on the state of the investigation. The policy titled Abuse- Identification and Reporting date revised 2/19 documented the facility recognizes each elder has the right to be free for all types of abuse including, verbal, sexual, physical, mental abuse, corporal punishment, and involuntary seclusion. 1. Resident #31 has diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting left dominant side, benign prostatic hyperplasia (BPH- enlargement of the prostate), and type 2 diabetes mellitus. The Minimum Data Set (MDS- a resident assessment tool) dated 5/18/2022 documented Resident #31 was understood, understands and cognitively intact. Review of the Comprehensive Care Plan last reviewed/ revised date 4/21/22 documented Resident #31 was at risk for alteration in elimination related to bowel incontinence at times. Approaches included to toilet the resident every 2-4 hours and per request, and wears briefs or pull ups AAT (at all times). During an observation on 9/19/22 at 8:20 AM Resident #31 was sitting in the hallway outside their room in a wheelchair with the door to their room shut behind them. Resident appeared comfortable and calm. During an interview on 9/19/22 at 8:22 AM, Resident #31 stated I had an issue with one of the CNAs. It was CNA #3. I had a medical problem at the time, and I accidentally had a bowel movement in my pants. CNA #3 stated to me, I can't believe you (explicit word) yourself. I told CNA #3 I did not appreciate that attitude and under no terms will I be sworn at. I told another CNA about it, and they reported it to the Social Worker, who came and spoke to me about the incident. I was then told that CNA #3 will no longer be working on my unit, and I haven't seen them since. At the time I was so embarrassed and ashamed. I now feel comfortable and safe because they no longer work on the unit. Review of the interdisciplinary Progress notes between 5/24/22 through 5/28/22 revealed there was no documentation regarding the incident or any assessment of the resident or contact with the physician regarding the incident. 2. Resident #24 has diagnoses including encephalopathy (disease of both brain and spine), cirrhosis of the liver, and depressive episodes. The MDS dated [DATE] documented Resident #24 was understood, understands and cognitively intact. Review of the Comprehensive Care Plan last reviewed/ revised date 7/13/22 documented Resident #24 has impaired ADL (activities of daily living)/ self-care ability and physical function related to muscle weakness. Approach for dressing is limited with one assist. During an interview on 9/18/22 at 1:35 PM, Resident #24 stated several months ago CNA #3 made me go to bed and get up on their time not my time and was very nasty about it. CNA #3 was also nasty and did the same thing to my roommate Resident #19. I reported it to the Social Worker, and they spoke to me regarding the incident. I was told that CNA #3 no longer works here. I feel safe with the staff who work with me now. When situations like this arise, I know who to go to if things need to be addressed. Review of interdisciplinary Progress Notes dated between 5/20/22 to 5/30/22 revealed there was no documentation regarding the incident, any assessment of the resident and there was no contact with the physician regarding the incident. 3. Resident #19 has diagnoses including fracture of left femur, Down syndrome, and unspecified behavioral syndromes associated with psychological disturbances and physical factors. The MDS dated [DATE] documented Resident #19 was sometimes understood, sometimes understands and severely cognitively impaired. Review of the Comprehensive Care Plan last reviewed/ revised date 7/6/22 documented no problem, goal or approaches for ensuring a safe environment for a resident who was severely cognitively impaired with a diagnosis of Down syndrome. During an observation on 9/18/2022 at 2:07 PM Resident #19 was in the dining room sitting up in a Geri chair (specialized chair) visiting with their sister. Resident #19 was unable to verbally communicate with their sister but was responding to their questions by looking at them and smiling. Resident #19 appeared to be comfortable. Throughout the survey during multiple intermittent observations revealed Resident #19 appeared to be comfortable with no signs of agitation. Review of interdisciplinary Progress Notes from 5/23/22 to 5/26/22 revealed there was no documentation regarding the incident or any assessment of the resident, contact with the physician and contacting the family regarding the allegation. Review of the Automated Complaint Tracking System (ACTS) completed by the Administrator with the date/time of occurrence of 5/24/2022 at 11:17 AM and submitted by facility 5/24/2022 at 2:34 PM documented yes there was reasonable cause to believe that abuse, neglect, or mistreatment occurred. Overview: I received an email from Licensed Practical Nurse (LPN) #1 Unit Manager that LPN #2 reported multiple residents on the third floor with complaints against Certified Nurse Aide (CNA) #3. LPN #2 called me due to Resident #31 and Resident #24 had verbalized the complaints against CNA #3. Resident #31 stated CNA #3 got mad that I was incontinent of stool, and I didn't want to report them because they will be meaner to me. Resident #24 stated CNA #3 tried to tell me at 3:30 AM I had to get up and get dressed for the day. Then CNA #3 dragged Resident #19 up and dressed them at 3:30 AM. CNA #3 said to me they didn't care if I liked it or not and then they yelled at Resident #19. It is likely that CNA #3 violated residents' rights and was verbally abusive to multiple residents. The Social Worker is interviewing all residents on the floor to determine the scope of the situation. CNA #3 was called immediately upon receipt of the complaint. They were suspended indefinitely and will be terminated upon completion of the investigation at 1:15 PM. Their next shift would have been at 10:00 PM this evening. Social Work is interviewing and counseling the affected residents. The investigation is ongoing until all residents on that floor are interviewed. Review of the untitled Director of Social Work interviews ( part of facility investigation) dated 5/24/2022 documented this social worker interviewed Resident #24 in the privacy of their room to discuss a complaint they had with CNA #3. They reported that for some time now CNA #3 was coming into the room anywhere between 3:30 AM and 4:00 AM to get them up and dressed for the day. CNA #3 would have them dress and then lay back in bed and turn their lights off. They reported CNA #3 did this to their roommate Resident #19 as well. (Resident #19 is unable to be interviewed due to cognitive impairment). Resident #24 reported they finally had enough and told CNA #3 they did not want to do this any longer. Resident #24 reported CNA #3 stood at the end of their bed with gloves on their hands and would slap their hands telling them Come on let's go. Resident #31 was interviewed in the privacy of their room to discuss their complaint they had with CNA #3. They reported CNA #3 was in their room Monday night as they had been incontinent of bowel. Resident #31 reported CNA #3 said, I can't believe you are grown man and (explicit word stated) yourself. Resident #31 reported they were embarrassed, felt disrespected and was afraid to say anything. Two other residents were interviewed and reported no issues with CNA #3. During an interview on 9/21/22 at 9:43 AM, the Director of Social Work stated I remember the incident vaguely. I do remember interviewing Resident # 31 and Resident #24. Resident #24 was talking about CNA #3 coming in their room very early in the morning to get them dressed and then was put back to bed. Resident #24 made a comment that this was also happening to their roommate Resident #19. I was unable to interview Resident #19 because of their cognitive status. When I interviewed Resident #31, they told me what had happened and what CNA #3 said to them, and it was a harsh statement, and it is not what we feel to be appropriate to say to a resident as it is demeaning and possibly borderline verbal abuse. In a further interview on 9/22/22 at 8:41 AM the Director of Social Work stated I am really just responsible for interviewing residents in these situations. I do not do any conclusions on the investigations. I felt with Resident #31 the language was inappropriate and should be looked into by the Administrator who would be the one to decide if it was truly abuse. The Administrator would be the one to write up the final conclusions on investigations. During an interview on 9/21/22 at 10:49 AM, LPN #2 stated Resident #24 told them that CNA #3 yelled at them and Resident #19 and that they did not like the way they were spoken too and that they were too stern with the residents. In addition, CNA #3 stood at the ends of their beds clapping their hands together and telling them to hurry up. Resident #31 reported that they were incontinent, and CNA #5 was not nice about it and made demeaning comments to them. During an interview on 9/21/22 at 1:26 PM the Administrator stated, the Director of Social Work basically did the complaint. I submitted the report to the state and fired the employee (CNA #3). My conclusion was that CNA #3 was inappropriate with the residents involved. In my opinion once I reviewed the investigation, I believe abuse did occur. During an interview on 9/22/22 at 8:17 AM, the Acting Director of Nursing (DON) stated they were not involved in this investigation, but they would consider this incident a form of abuse. 415.4(b)(1)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during a complaint investigation (NY00296464) completed on a Standard survey started 9/18/22 and completed 9/22/22, the facility did not ensure that all alleged violations including abuse are reported immediately, but not later than 2-hours after the allegation is made to the appropriate officials (including the State Survey Agency). Four (Resident #3, 19, 24, and 31) of four residents reviewed for abuse were involved in incidents either not reported or not reported timely to the New York State (NYS) Department of Health (DOH) as required. Specifically, resident to resident altercation (#3 and 31) and allegations of verbal abuse (#19, 24 and 31). The findings are: The policy titled Resident Abuse Investigation dated issue 9/21/2022 documented it is the policy of the facility to investigate incidents that may involve resident abuse. All staff are trained on the definition, identification, and responsibility to report suspected abuse. Staff are encouraged to contact the nursing home administrator to in the event there is an incident. Based on the type of abuse reported the administrator may request a resident being assessed by nurse, social worker, or appropriate clinical professional to determine if the resident suffered emotional or physical injury. Based on the initial findings a timely incident form will be completed and submitted via the (name of states incident reporting system) by the administrator. 1. Resident #31 has diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting left dominant side, benign prostatic hyperplasia (BPH- enlargement of the prostate), and type 2 diabetes mellitus. The Minimum Data Set (MDS- a resident assessment tool) dated 5/18/2022 documented Resident #31 was understood, understands and cognitively intact. Review of the Comprehensive Care Plan last reviewed/ revised date 4/21/22 documented Resident #31 was at risk for alteration in elimination related to bowel incontinence at times. Approaches included to toilet the resident every 2-4 hours and per request, and wears briefs or pull ups AAT (at all times). 2. Resident #24 had diagnoses including encephalopathy (disease of both brain and spine), cirrhosis of the liver, and depressive episodes. The MDS dated [DATE] documented Resident #24 was understood, understands and cognitively intact. Review of the Comprehensive Care Plan last reviewed/ revised date 7/13/22 documented resident has impaired ADL (activities of daily living)/ self-care ability and physical function related to muscle weakness. Approach for dressing is limited with one assist. 3. Resident #19 had diagnoses including fracture of left femur, Down syndrome, and unspecified behavioral syndromes associated with psychological disturbances and physical factors. The MDS dated [DATE] documented Resident #19 was sometimes understood, sometimes understands and severely cognitively impaired. Review of the Comprehensive Care Plan last reviewed/ revised date 7/6/22 documented no problem, goal or approaches for ensuring a safe environment for a resident who was severely cognitively impaired with a diagnosis of Down syndrome. 4. Resident #3 has diagnoses including unspecified dementia with behavioral disturbance, fibromyalgia (disorder characterized by widespread musculoskeletal pain and fatigue), and post-traumatic stress disorder (PTSD). The MDS dated [DATE] documented Resident #3 was understood, understands and severely cognitively impaired. Review of Comprehensive Care Plan last reviewed/revised 8/12/22 documented Resident #3 was at risk for alteration in mood and behavior related to diagnosis of dementia, PTSD, and depression. Often wanders into other elders' rooms without being invited. Resident #3 is at risk for elopement due to Dementia with wandering behaviors. a.) Review of the Customer Service Opportunity for Improvement report signed by the Director of Social Work dated 7/5/22 documented occurrence date as 7/5/22, no time documented. Resident #31 reported to Licensed Practical Nurse (LPN) #2 the back of their neck hurts because Resident #3 keeps patting them on the back of their neck. This social worker interviewed Resident #31 and they reported the same thing. The social worker asked when does this happen and Resident #31 reported every morning when they are in the hall outside of their room waiting to go back to the room after breakfast and during any activity program. Resident #31 also reported they do not like the other elder and stated, I was very close to grabbing Resident #3 by the neck and punching them. This social worker explained physical altercations should be avoided and they should allow staff to intervene. Review of the NYS DOH Automated Complaint Tracking System (ACTS) Facility Summary between 6/4/22 and 9/12/22 revealed that no report had been filed regarding the alleged resident to resident altercation on 7/5/22. b.) Review of the untitled Director of Social Work interviews (part of facility investigation) dated 5/24/2022 documented this social worker interviewed Resident #24 in the privacy of their room to discuss a complaint they had with CNA #3. They reported that for some time now CNA #3 was coming into the room anywhere between 3:30 AM and 4:00 AM to get them up and dressed for the day. CNA #3 would have them dress and then lay back in bed and turn their lights off. They reported CNA #3 did this to their roommate Resident #19 as well. (Resident #19 is unable to be interviewed due to cognitive impairment). Resident #24 reported they finally had enough and told CNA #3 they did not want to do this any longer. Resident #24 reported CNA #3 stood at the end of their bed with gloves on their hands and would slap their hands telling them Come on let's go. Resident #31 was interviewed in the privacy of their room to discuss their complaint they had with CNA #3. They reported CNA #3 was in their room Monday night as they had been incontinent of bowel. Resident #31 reported CNA #3 said, I can't believe you are grown man and (explicit word stated) yourself. Resident #31 reported they were embarrassed, felt disrespected and was afraid to say anything. Two other residents were interviewed and reported no issues with CNA #3. Review of the Automated Complaint Tracking System (ACTS) completed by the Administrator with the date/time of occurrence of 5/24/2022 at 11:17 AM and submitted by facility 5/24/2022 at 2:34 PM for allegations of resident verbal or mental abuse for Residents #19, 24 and 31. During an interview on 9/22/22 at 8:17 AM, the Acting Director of Nursing stated, I do not know what the reporting regulations are for the state and CMS (Centers for Medicare & Medicaid Services). The Administrator takes care of the reporting. During an interview on 9/22/22 at 11:02 AM, the Administrator stated the incident involving Resident #3 and Resident #31 was not reported to the state. Additionally, the incident with Resident #19, 24 and 31 was not reported within the two hours because I fired the CNA #3 and felt there was no immediate threat anymore to the three residents. I am familiar with the reporting rules on abuse and am familiar with the 2-hour rule. 415.4(b)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a complaint investigation (NY00296464) completed on a Standard survey started 9/18/22 and completed 9/22/22, the facility did not have evidence that all alleged violations of abuse were thoroughly investigated for four (Residents #3, 19, 24, and 31) of four residents reviewed. Specifically, there was a lack of a thorough investigation to include nursing assessments, interviews with staff and other potential victims into alleged verbal abuse by a certified nursing assistant (CNA) (Residents #19, 24, and 31) and into a resident-to-resident confrontation (Residents #3 and 31). The findings are: The policy titled Resident Abuse Investigation dated issue 9/21/2022 documented it is the policy of the facility to investigate incidents that may involve resident abuse. The Nursing Home Administrator is responsible for ensuring the safety and wellbeing of the residents. All staff are trained on the definition, identification, and responsibility to report suspected abuse. Staff are encouraged to contact the nursing home administrator to in the event there is an incident. The nursing home administrator will gather information including accident/incident reports and witness statements if available. Based on the type of abuse reported the administrator may request a resident being assessed by nurse, social worker, or appropriate clinical professional to determine if the resident suffered emotional or physical injury. Based on the initial findings a timely incident form will be completed and submitted via the Health Commerce System by the administrator. If the suspected abuser is an employee, the he or she may be suspended or terminated from employment depending on the state of the investigation. The policy titled Abuse-Identification and Reporting date revised 2/19 documented the facility recognizes each elder has the right to be free for all types of abuse including, verbal, sexual, physical, mental abuse, corporal punishment, and involuntary seclusion. 1. Resident #31 has diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting left dominant side, benign prostatic hyperplasia (BPH- enlargement of the prostate), and type 2 diabetes mellitus. The Minimum Data Set (MDS- a resident assessment tool) dated 5/18/2022 documented Resident #31 was understood, understands and cognitively intact. Review of the Comprehensive Care Plan last reviewed/ revised date 4/21/22 documented Resident #31 was at risk for alteration in elimination related to bowel incontinence at times. Approaches included to toilet the resident every 2-4 hours and per request, and wears briefs or pull ups AAT (at all times). Review of the interdisciplinary Progress notes between 5/24/22 through 5/28/22 revealed there was no documentation regarding the incident, any assessment of the resident or contact with the physician regarding the incident. Review of the Progress Notes from 7/4/22 to 7/10/22 had no documentation of the physician being contacted regarding the incident with Resident #3. 2. Resident #24 has diagnoses including encephalopathy (disease of both brain and spine), cirrhosis of the liver, and depressive episodes. The MDS dated [DATE] documented Resident #24 was understood, understands and cognitively intact. Review of the Comprehensive Care Plan last reviewed/ revised date 7/13/22 documented Resident #24 has impaired ADL (activities of daily living)/ self-care ability and physical function related to muscle weakness. Approach for dressing is limited with one assist. Review of interdisciplinary Progress Notes dated between 5/20/22 to 5/30/22 revealed there was no documentation regarding the incident or any assessment of the resident and contact with the physician regarding the incident. 3. Resident #19 has diagnoses including fracture of left femur, Down syndrome, and unspecified behavioral syndromes associated with psychological disturbances and physical factors. The MDS dated [DATE] documented Resident #19 was sometimes understood, sometimes understands and severely cognitively impaired. Review of the Comprehensive Care Plan last reviewed/revised date 7/6/22 documented no problem, goal or approaches for ensuring a safe environment for a resident who was severely cognitively impaired with a diagnosis of Down syndrome. Review of the interdisciplinary Progress Notes from 5/23/22 to 5/26/22 revealed there was no documentation regarding the incident, or an RN assessment of the Resident 19, contact with the physician and contacting the family regarding the allegation. In addition, there was no documentation of monitoring the resident's status for possible psychologic affects. 4. Resident #3 has diagnoses including unspecified dementia with behavioral disturbance, fibromyalgia (disorder characterized by widespread musculoskeletal pain and fatigue), and post-traumatic stress disorder (PTSD). The MDS dated [DATE] documented Resident #3 was understood, understands and severely cognitively impaired. Review of the Comprehensive Care Plan last reviewed/revised 8/12/22 documented Resident #3 was at risk for alteration in mood and behavior related to diagnosis of dementia, PTSD, and depression. Often wanders into other elders' rooms without being invited. Resident #3 was at risk for elopement due to dementia with wandering behaviors. Review of the interdisciplinary Progress Notes from 7/4/22 to 7/10/22 had no documentation regarding the incident on 7/5/22 or contact with the physician regarding the incident. a. Review of the Automated Complaint Tracking System (ACTS) completed by the Administrator with the date/time of occurrence of 5/24/2022 at 11:17 AM and submitted by facility 5/24/2022 at 2:34 PM documented yes there is reasonable cause to believe that abuse, neglect, or mistreatment occurred. Overview: I received an email from Licensed Practical Nurse (LPN) #1 Unit Manager that LPN #2 reported multiple residents on the third floor with complaints against Certified Nurse Aide (CNA) #3. LPN #2 called me due to Resident #31 and Resident #24 had verbalized the complaints against CNA #3. Resident #31 stated CNA #3 got mad that I was incontinent of stool, and I didn't want to report them because they will be meaner to me. Resident #24 stated CNA #3 tried to tell me at 3:30 AM I had to get up and get dressed for the day. Then CNA #3 dragged Resident #19 up and dressed them at 3:30 AM. CNA #3 said to me they didn't care if I liked it or not and then they yelled at Resident #19. It is likely that CNA #3 violated residents' rights and was verbally abusive to multiple residents. The Social Worker is interviewing all residents on the floor to determine the scope of the situation. CNA #3 was called immediately upon receipt of the complaint. They were suspended indefinitely and will be terminated upon completion of the investigation at 1:15 PM. Their next shift would have been at 10:00 PM this evening. Social Work is interviewing and counseling the affected residents. The investigation is ongoing until all residents on that floor are interviewed. Review of the untitled Director of Social Work interviews (within facility investigation) dated 5/24/2022 documented this social worker interviewed Resident #24 in the privacy of their room to discuss a complaint they had with CNA #3. They reported that for some time now CNA #3 was coming into the room anywhere between 3:30 AM and 4:00 AM to get them up and dressed for the day. CNA #3 would have them dress and then lay back in bed and turn their lights off. They reported CNA #3 did this to their roommate Resident #19 as well. (Resident #19 is unable to be interviewed due to cognitive impairment). Resident #24 reported they finally had enough and told CNA #3 they did not want to do this any longer. Resident #24 reported CNA #3 stood at the end of their bed with gloves on their hands and would slap their hands telling them Come on let's go. Resident #31 was interviewed in the privacy of their room to discuss their complaint they had with CNA #3. They reported CNA #3 was in their room Monday night as they had been incontinent of bowel. Resident #31 reported CNA #3 said, I can't believe you are grown man and (explicit word stated) yourself. Resident #31 reported they were embarrassed, felt disrespected and was afraid to say anything. Two other residents were interviewed and reported no issues with CNA #3. During an interview on 9/21/22 at 9:43 AM the Director of Social Work stated, I remember the incident vaguely. I do remember interviewing Resident # 31 and Resident #24. Resident #24 was talking about CNA #3 coming in their room very early in the morning to get them dressed and then was put back to bed. Resident #24 made a comment that this was also happening to their roommate Resident #19. I was unable to interview Resident #19 because of their cognitive status but probably should have contacted the family to see if they had noticed any changes in mental status and informing them of the allegation but felt the sister would have contacted them if there was an issue. When I interviewed Resident #31, they told me what had happened and what CNA #3 said to them, and it was a harsh statement, and it is not what we feel to be appropriate to say to a resident as it is demeaning and possibly borderline verbal abuse. The Social Worker stated they only interviewed two other residents but thinks that these residents were not even on CNA #3's assignment and staff interviews would have been done by the Administrator. During an interview on 9/21/22 at 1:26 PM, the Administrator stated the Director of Social Work basically did the complaint investigation and they submitted the report to the state. The Administrator stated, I felt we did not need to do further investigation or interviewing of other staff members because we fired the employee involved. During a telephone interview on 9/21/22 at 4:11 PM, RN #3 stated typically, we go to the social worker with this type of incident, and they do a full interview with the residents and then would do a report on it. Someone who was cognitively impaired I would take a look at. Yes, I would contact the resident's representative if they were cognitively impaired. Any form of abuse I would contact the doctor and do a full assessment on. During an interview on 9/22/22 at 8:17 AM, the Acting Director of Nursing (DON) stated they were not involved in this investigation, but they would expect their staff to interview other staff members who worked with this employee to see if they have heard anything and knew anything about this incident. Would also expect interviews to be completed with other residents to see if they were potential victims. Because Resident #19 isn't cognitively able to express what happen they would expect the staff to contact the family regarding any changes they may have seen with the resident and to inform the family of the allegation. Also, staff should be contacting the physician for all three residents about the allegation and the findings. b. Review of the Customer Service Opportunity for Improvement report signed by the Director of Social Work dated 7/5/22 documented occurrence date as 7/5/22, no time noted. Resident #31 reported to Licensed Practical Nurse (LPN) #2 the back of their neck hurts because Resident #3 keeps patting them on the back of their neck. This social worker interviewed Resident #31 and they reported the same thing. The social worker asked when does this happen and Resident #31 reported every morning when they are in the hall outside of their room waiting to go back to the room after breakfast and during any activity program. Resident #31 also reported they do not like the other elder and stated, I was very close to grabbing Resident #3 by the neck and punching them. This social worker explained physical altercations should be avoided and they should allow staff to intervene. Review of the Progress Note completed by RN #3 dated 7/5/22 documented Resident #31 reported neck pain after they stated another resident touched their back. Social worker spoke with Resident #31 at their bedside. RN #3 asked the resident to point exactly where it hurt, and the resident pointed to the base of their neck. RN assessment revealed no abnormalities of the neck. No redness/ swelling/ bruising was noted. Resident #31 was able to move their neck in all directions/ had full range of motion without any signs of difficulty/ discomfort. No tenderness to palpation. The resident wishes to continue to receive Tylenol (a medication to help relieve pain). During a telephone interview on 9/21/22 at 4:11 PM, RN #3 stated typically we go to the social worker with this, and they would do the interviews with the residents. An RN assessment was completed on Resident #31 and no red marks were found on their neck. The doctor was not contacted, and I did not interview other staff. During an interview on 9/22/22 at 8:45 AM, the Director of Social Work stated they did speak to Resident #31 about Resident #3 patting them on the neck and that it started to hurt. They stated they offered Resident #31 a room change to the second floor but that they declined. Other residents were not interviewed regarding this incident. During an interview on 9/22/22 at 8:03 AM, the Administrator stated the incident between Resident #3 and Resident #31 was not really a resident to resident because there was no harm. We did not interview other residents that Residents #3 has patted on the back to see if they were bothered by it or even possible hurt them, and we did not interview staff regarding Resident #3 and their wandering and behaviors because I didn't think it could have been abuse and both residents have rights. Further interview at 11:03 AM the Administrator stated, I guess I could have done a better investigation. During an interview on 9/22/22 at 8:17 AM, the Acting DON stated they would expect their staff to interview other staff members and residents to see if they were having similar issues with Resident #3. They would have expected the physician to be called. 415.4(b)(3)

Based on observation, interview, and record review conducted during the Standard survey started on 9/18/22 and completed 9/22/22, the facility did not ensure appropriate use, entrapment risk assessment, and maintenance of bed rails for one (Resident #25) of one resident reviewed for bed rail use. Specifically, the facility did not follow manufacturer's instructions on proper use of a bed rail, did not perform an entrapment risk assessment prior to installing a bariatric portable bed rail to the adjustable hospital bed frame, and did not implement a routine monitoring system to protect residents from entrapment risk when using bed rails. The finding is: The facility policy and procedure (P&P) titled Side Rail Safety - Environmental Safety Side Rail Assessment and Maintenance Side Rail Safety Assessment dated 1/2022, documented a Registered Nurse (RN) will complete documentation on the Environmental Safety Side Rail Assessment which will include mental status, mood state, medical diagnoses, elimination, falls history, visual impairment, mobility, medications (sedative/hypnotic, antidepressant, psychotropic, diuretic, antihypertensive), and total score. Additionally, the maintenance staff/designee will complete documentation on the Maintenance Side Rail Safety Assessment which includes measurements of seven (7) potentially hazardous zones to the resident. The product description of the bariatric portable bed rail, provided by the Maintenance Technician, documented the bed rail was not intended for use on adjustable beds. The bariatric bed manufacturers User Manual documented the bed had an adjustable frame, adjustable height, adjustable head, and adjustable foot of bed. Additionally, the use of bed accessories by other manufacturers have not been tested by the manufacturer. Use of non-manufacturer bed accessories may result in injury or death. Use only manufacturer rails, mattresses, bed extenders and other accessories with bed products. 1. Resident #25 had diagnoses including schizophrenia, hypertension, and diabetes mellitus. The Minimum Data Set (MDS - resident assessment tool) dated 7/5/22 documented the resident was cognitively intact, required extensive assistance of two people for bed mobility, total assistance of two people for transfers, and bed rails were used daily. Additionally, the MDS documented the resident received antipsychotic, antidepressant, diuretic, and opioid medications daily. During observations on 9/18/22 at 1:54 PM and 9/19/22 at 10:45AM, a single portable bed rail was attached to the right side of Resident #25's adjustable bed. The bed rail was attached loosely to the bed frame and was able to be moved 3 to 4 inches away from the mattress. The facility Event Form dated 6/26/22 documented Resident #25 fell out of bed at 3:00AM and the intervention to prevent reoccurrence was to place a grab bar to the right side of the bed. The comprehensive care plan documented Resident #25 utilized a grab bar on right side of their bed to assist with repositioning (start date 7/1/22). The goal was to maintain their ability to participate with bed mobility and approaches included the risks and benefits were explained and acknowledged. The facility Side Rail Consent form signed and dated 7/5/22 by Resident #25, documented Resident #25 was informed of alternatives to the right side grab bar and the potential benefits and risks of use. During a telephone interview on 9/22/22 at 9:42 AM, the bed manufacturer Customer Service Representative stated the manufacturer did not recommend using other manufacturers products with theirs secondary to other manufacturers products were not tested for compatibility. During an interview on 9/22/22 at 10:27 AM, the Acting Director of Nursing (DON) stated they expected the maintenance department to ensure the installed bed rail was compatible with the bed frame. The DON stated the bed rails should be checked periodically but was unsure of the timeframe. During an interview on 9/22/22 at 10:32 AM, the Director of Maintenance stated they received a request to install the bed rail on Residents #25's bed and the rail was installed. Additionally, the Director of Maintenance stated they did not ensure the bed rail was compatible with the bed frame and maintenance did not perform any safety checks/inspections on the bed rail. During an interview on 9/22/22 at 10:46 AM, the Administrator stated they did not consider the bed rail a siderail, but an assist bar for mobility and any device installed on a resident's bed should be assessed. During an interview on 9/22/22 at 11:21 AM, Licensed Practical Nurse (LPN) #1/ MDS Coordinator stated the bed rail was installed by maintenance to the right side of Resident #25's bed. LPN #1 stated an Environmental Safety Side Rail Assessment was not performed prior to bed rail placement. 415.12(h)(1)

Based on interview and record review conducted during the Standard survey started on 9/18/22 and completed 9/22/22, the facility did not maintain an infection prevention and control program to ensure the health and safety of residents to help prevent the transmission of COVID-19. Specifically, the facility had no documented evidence that one (Certified Nursing Assistant (CNA) #2) of three staff reviewed for COVID-19 testing, whom were not up to date with their COVID-19 vaccinations, were tested for COVID-19 as required. The finding is: The Centers for Medicare and Medicaid Services (CMS) QSO 20-38-NH revised 3/10/22 documented that staff who are not up to date with their COVID-19 vaccinations needed to be tested at a minimum once a week when the COVID-19 community transmission level was at moderate (yellow) and at minimum twice a week when the COVID-19 community transmission level is at high (red). The QSO documented up to date meant a person had received all recommended COVID-19 vaccines, including any booster doses when eligible. The facility policy and procedure (P&P) titled COVID-19 Outbreak & Testing Requirements for Staff, Residents, and Patients dated 8/22 documented the facility will follow the most current guidelines and recommendations of the Centers for Disease Control and Prevention (CDC), CMS, and/or New York State Department of Health (NYS DOH) for the testing of patients, residents, and staff. Routine testing will be performed on all COVID-19 Medical Exempt staff, staff who have not completed their primary COVID-19 vaccination series, and staff who are not up to date with COVID-19 vaccination booster. The County Level Timeseries Data for New York report documented Allegany County had a substantial level of community COVID-19 transmission from 8/14/22-8/20/22 and had a high level of community transmission of COVID-19 from 8/28/22 through 9/21/22. The facility Request for Medical Immunization Exemption Form - COVID-19 Vaccination signed and dated by a medical provider on 2/15/22, documented CNA #2 was granted a medical exemption for the COVID-19 vaccination. The untitled, undated employee timecard documented CNA #2 worked: 4 days (8/14/22, 8/16/22, 8/18/22, 8/19/22) during the week of 8/14/22-8/20/22 3 days (8/28/22, 9/1/22, 9/2/22) during the week of 8/28/22-9/3/22 3 days (9/13/22, 9/15/22, 9/16/22) during the week of 9/11/22-9/17/22 2 days (9/19/22, 9/20/22) during the week of 9/18/22-9/21/22 The facility was unable to provide documented evidence CNA #2 had been tested for COVID-19 for the weeks of 8/14/22-8/20/22, 8/28/22-9/3/22, 9/11/22-9/17/22, and 9/18/22-9/21/22. During an interview on 9/22/22 at 7:59 AM, Registered Nurse (RN) #2 Infection Preventionist (IP) stated they check the county level transmission daily on the CDC website. The IP stated the county was at a moderate level and the facility policy was to test all staff not up to date on COVID-19 vaccinations twice weekly. Additionally, the IP stated they were aware CNA #2 was noncompliant with COVID-19 testing and has discussed the problem several times with administration. During a telephone interview on 9/22/22 at 8:26 AM, CNA #2 stated they were aware of the facility COVID-19 testing regulation and that they had not been compliant with the regulation. The CNA stated they were unsure how to be tested for COVID-19 outside of the facility COVID-19 testing schedule. During an interview on 9/22/22 at 8:26 AM, the Administrator stated they were unaware CNA #2 was non- complaint with COVID-19 testing and apparently there was a fault in the system. 415.19

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey started 9/18/22 and completed 9/22/22, the facility did not maintain an effective pest control program so that the facility is free of pests and rodents. Specifically, one (Unit 3) of two units were observed to have black houseflies in residents' rooms and in the dining room. This involved Residents #8, 14, 24, 28, and 31. The findings are: The facility policy and procedure titled Facility Pest Control with a revised date of 1/11 documented the purpose was to provide safe effective pest control for the facility. The pest control service is contracted to come once each month, or more often if necessary. During an observation on 9/18/22 at 12:00 PM three flies were flying between Resident #14's bed, pillow, and their person while they were eating. The resident was observed swatting at the flies, and stated the flies were bothersome. During an observation of the 3rd floor dining room on 9/18/22 at 12:15 PM residents were eating their lunch meal and there were multiple common house flies flying around and landing on the residents and their food. During an observation in Resident #24's room on 9/18/22 at 1:41 PM, there were several flies flying around the resident, their face and landing on them. Resident #24 kept swatting the flies away. At that time Resident #24 stated, there were always flies in here and they were always bothering me. My father always said there is one thing on earth we don't need and that is flies. During an observation in Resident #14's room on 9/18/22 at 3:00 PM the resident was lying in their bed sleeping and there were 2-3 flies flying and landing on the resident and their covers. During an observation in Resident #14's room on 9/19/22 at 8:57 AM there were several flies flying around and landing on the resident and their food. At the time of the observation Resident #14 stated there were always flies in their room and that the flies bothered them. The flies usually show up in the afternoon and it started a couple weeks ago. During an observation on 9/19/22 at 8:07 AM in the third-floor dining room there were several flies flying around during the breakfast meal. During the Resident Council meeting on 9/19/22 at 9:48 AM Resident #31 stated there were flies in their room and that were bothersome. Additionally, they stated the third-floor dining room was swarming with flies once the sun comes up. During an observation in Resident #28's room on 9/20/22 at 10:43 AM there were four flies that were flying around and landing on the bed. The room was occupied, but the Resident #28 was not present in the room at the time. At 12:33 PM Resident #28 was in their room lying in bed and there were 4-5 flies flying around and landing on the resident. During an observation on 9/20/22 at 12:36 PM in the third-floor dining room area there were several flies flying around and landing on tables and plates. On 9/20/22 at 1:42 PM while sitting at the 3rd floor nursing station there were multiple flies observed flying around. During an observation of Resident #8's room on 9/20/22 at 1:02 PM approximately 4-5 flies were flying around the room and landing on the resident and their bed. Resident #8 stated, these flies are horrible. They are disgusting. During an observation in Resident #8's room on 9/21/22 at 10:47 AM approximately 3-4 flies were flying around and landing on the over the bed tray table and bed. Review of the Resident Council Minutes dated 9/13/22 documented under housekeeping: Can something be done about the flies in the dining room? Review of the Pest Control Service Report dated 8/27/22 documented large fly program serviced. Glue boards were 50% full. Glue boards replaced. Illuminated light trap bulbs replaced. Replace one bulb in fly light by elevator. During an interview on 9/20/22 at 12:38 PM, the Housekeeper stated there had been flies flying around on the third-floor unit for about 2- 3 weeks. I have seen flies especially in Resident #8's room and in the third-floor dining room. I have told my supervisor (Director of Housekeeping) and I was told to just keep on top of getting rid of the garbage. During an interview on 9/20/22 at 12:47 PM Certified Nurse Aide (CNA) #4 stated, I have noticed the flies have been flying around since last week. They are in the dining room and resident rooms. I did not report it to anyone, but we all have been talking about it. The resident in room [ROOM NUMBER] has asked for a fly swatter because of the flies. During an interview on 9/20/22 at 12:51 PM Licensed Practical Nurse (LPN) #2 stated, I have seen flies flying everywhere. Mostly in the patient rooms and the dining room. I started noticing them probably two weeks ago. I reported the flies to the Maintenance Technician last week who came and then had the Maintenance Supervisor come up and look around, and told me they didn't see anything. I then took them in a room and pulled on the pant leg of a resident's pants and multiple flies flew up and off of them. I asked them what they were going to do about these flies and the response I got was that they did not know. During an interview on 9/20/22 at 1:04 PM, the Director of Housekeeping went to Resident #8's room and made an observation of the flies in the resident's room. There were approximately 4- 5 flies flying around and landing on the resident and their bed. The Director of Housekeeping stated Oh my, I did not know the flies were in the residents room. I only knew they were in the dining room. I was made aware of the flies by the Activities Director via e-mail yesterday as the residents were complaining about flies in the dining room at the resident council meeting on 9/13/22. During an interview on 9/21/22 at 10:25 AM the Acting Director of Nursing (DON) stated, I have not seen flies on the third floor. No one has come to me regarding flies. I would expect staff to report to maintenance and housekeeping immediately if there is an issue with flies. Flies are an infection control risk, and they are just not healthy. During an interview on 9/21/22 at 10:37 AM the Maintenance Supervisor stated, I have not noticed any flies up on the third floor. No one has reported it to me that there have been any issues with flies. I would hope they would tell me, but flies to me is more of a housekeeping issue not maintenance. During an interview on 9/21/22 at 10:43 AM, the Maintenance Technician stated that LPN #2 spoke to them about fly problems about 2 weeks ago, but when they went up to the third floor, they did not see any problems. During an interview on 9/21/22 at 11:54 AM, the Activities Director stated at the resident council meeting held on 9/13/22 in the third-floor dining room it was reported that there was an issue with flies in the that dining room. During the meeting we were all actually swatting at the flies. The Activities Director stated I had reported the issue verbally at a morning meeting either on 9/15/22 or 9/16/22. I sent out an e-mail on 9/20/22 to the Director of Housekeeping and Maintenance because that was the day, I was able to actually sit down and type up the minutes from the meeting. During an interview on 9/21/22 at 11:50 AM, Registered Nurse (RN) #2 Infection Preventionist (IP) stated concerns with having flies would be the bacteria they are carrying is being spread around the facility. Flies can carry all kinds of things. During an interview on 9/21/22 at 1:40 PM, the Administrator stated that yesterday was the first time they had heard about a fly issue. I expect the staff to report it to their supervisor when there are problems like this. That is why I have morning meetings every day. 415.29(j)(5)

Based on interview and record review conducted during the Standard survey started on 9/18/22 and completed on 9/22/22, the facility did not have a designated Registered Nurse (RN) to serve as the Director of Nursing (DON) on a full-time basis. Specifically, the Acting RN Director of Nursing was not designated as the DON from 5/25/2022 through 9/22/22 on a full-time basis. The finding is: The undated facility job description for the DON provided by the Human Resource (HR) Manager documented the DON provides administrative and clinical leadership and direction for nursing practice with 24-hour accountability on her/his nursing units. Assures the delivery of comprehensive, safe and effective nursing care in accordance with the established policies and procedures of the long-term care (LTC) nursing department. The DON is directly responsible for the adequate staffing and scheduling of the nursing personal, oversees the staffing schedule and delegates assignments. Review of the untitled form identified as the Acting DON's time sheet provided by the HR Manager dated 6/25/22 through 9/22/22 revealed there was no documented evidence the Acting DON work full time for the Skilled Nursing Facility (SNF). During an interview on 9/21/22 at 2:07 PM, the Acting DON stated they have been in the Acting DON position since 5/25/22. They also oversee the Medium Care Unit (MCU) in the hospital (a nursing care unit that was lower than the Intensive Care Unit (ICU) but above the standard floor care). The Acting DON stated they work in the MCU approximately seventy percent (70%) of the time and in the SNF approximately 30% of the time. Their job duties for the SNF included attending morning report, reviewing referrals, skin rounds and admissions. During an interview on 9/22/22 at 10:23 AM, the HR Manager stated the Acting DON has been in the position since May and was unsure of the DON's duties in the SNF. The facility had been recruiting but they had no prospects and no one in house was qualified. During an interview on 9/22/22 at 11:41 AM, the Administrator stated the Acting DON was available full time for the SNF, but they have other job duties in the hospital. The Administrator was unsure of how the Acting DON job responsibilities were divided between the SNF and the MCU. The Administrator stated they did not apply for an RN waiver, and they have tried to hire a DON, but the candidates have not worked out. 415.13(b)(1)