**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) The facility's Hazardous Area, Devices, and Equipment policy last reviewed on 1/2024 documented a hazard is defined as anything in the environment that has the potential to cause injury or illness. The policy identified hazards including sharp objects that are accessible to vulnerable residents. The policy further documented that any element of the resident environment that has the potential to cause injury and is accessible to a vulnerable resident is considered hazardous. Resident #165 was admitted with diagnoses including Bipolar Disorder, Schizophrenia, and Major Depressive Disorder. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 14, indicating the resident was cognitively intact. The Minimum Data Set documented the resident had potential indicators for Hallucinations (a false perception of objects or events involving your senses: sight, sound, smell, touch, and taste). The Minimum Data Set documented the resident used a manual wheelchair and walker for mobility and could walk 150 feet with supervision. A Comprehensive Care Plan titled Behavior Symptoms initiated on 1/06/2024 and revised on 9/23/2024, documented interventions that included 15-minute monitoring for suicidal ideation initiated on 1/06/2024 and modifying the environment to reduce episodes of negative behavior and risk for falls or injury. A nursing progress note, written by Registered Nurse Unit Supervisor #2, dated 6/04/2024 documented Resident #165 was exhibiting behavioral symptoms such as repeated movements and wandering. The resident complained of hearing voices to hurt themselves but had no plan. The physician's order dated 6/04/2024 documented to monitor Resident #165 every 15 minutes for Suicidal Ideation. The Psychiatry Consult note dated 6/05/2024 documented Resident #165 had a history of Depression and Schizophrenia. Resident #165 reported auditory Hallucinations (hearing voices that were not there). The nursing progress note, written by Registered Nurse Unit Supervisor #2, dated 6/07/2024 documented Resident #165 complained of hearing voices and could not control the voices in their head anymore. The resident reported they have a plan to kill themselves. The resident was transferred to the hospital. The medical progress note, written by Physician's Assistant #1, dated 6/07/2024 documented Resident #165 was seen for a weekly follow-up and for continued monitoring of chronic and acute conditions including Suicidal Ideation. The resident was sent to the hospital for Suicidal Ideation. The hospital Discharge summary dated [DATE] documented Resident #165 was seen in the emergency room for Psychiatric evaluation for Suicidal Ideation. A review of the medical record from 6/07/2024 to 9/19/2024 indicated no behaviors of Suicidal ideation or a plan for self-harm. A review of the 15-minute monitoring sheets from 8/22/2024 to 09/23/2024 documented that staff monitored the resident every 15 minutes. Resident #165 was observed sleeping in their bed on 9/17/2024 at 10:28 AM. A disposable shaving razor was observed at the sink in the resident's room. During an interview on 9/19/2024 at 9:34 AM, Resident #165 was in their room lying in bed and stated they just had breakfast, enjoyed the breakfast, and had no concerns with the facility. During an observation on 9/23/2024 at 10:47 AM, Resident #165 was observed sleeping in their bed. A disposable shaving razor was observed at the sink in the resident's room. During an interview on 9/23/2024 at 10:48 AM, Certified Nursing Assistant #4 stated they were the assigned Certified Nursing Assistant for Resident #165, and the razor that was observed in Resident #165's room belonged to the resident's roommate. Certified Nursing Assistant #4 stated the disposable shaving razor should not be left in the resident's room. Certified Nursing Assistant #4 then removed the disposable shaving razor from the resident's room. During an interview on 9/23/2024 at 10:49 AM, Registered Nurse Supervisor #2 stated Resident #165 was on every 15-minute monitoring for suicidal ideation and should not have access to the disposable shaving razor. During an interview on 9/23/2024 at 11:36 AM, Psychiatrist #1 stated Resident #165 should not have access to a razor because in the past Resident #165 had expressed thoughts of self-harm. During an additional interview on 9/24/2024 at 10:29 AM, Registered Nurse Supervisor #2 stated Resident #165 has not been verbalizing thoughts of suicidal ideation since their return from the hospital in June 2024. Resident #165 is monitored every 15 minutes for a history of auditory hallucinations. During an additional interview on 9/24/2024 at 10:58 AM, Certified Nursing Assistant #4 stated the resident has been much more pleasant since they returned from the hospital and has not expressed thoughts of hurting self. During an interview on 9/24/2024 at 1:25 PM, the Director of Nursing Services stated that no razors should have been kept in any resident's room. Resident #165 had the potential to self-harm. 10 NYCRR 415.12(h)(1)(2) Based on observations, record review, and interviews during the Recertification Survey initiated on 9/17/2024 and completed on 9/25/2024, the facility did not ensure that each resident received adequate supervision to prevent accidents and the resident environment remained as free of accident hazards as is possible. This was identified for two (Resident #51 and Resident #165) of ten residents reviewed for Accidents. Specifically, 1) Resident #51 had a history of falls and wandering behavior and the Comprehensive Care Plan directed staff to place the resident in a supervised area when awake. Resident #51 was left unsupervised in the hallway on 7/24/2024 at 1:10 AM and was found on the floor with injuries to the right side of their forehead and mouth. Subsequently, the resident was transferred to the hospital and was diagnosed with Traumatic Subdural Hemorrhage (brain bleed) and a Cervical Fracture (spine). 2) Resident #165, with a history of Suicidal Ideation was observed with an unattended disposable shaving razor in their room. This resulted in actual harm to Resident #51 that is not Immediate Jeopardy. The findings are: 1) The Falls Prevention Policy and Procedure last updated in January 2024 documented that as part of the initial assessment, the interdisciplinary team will help identify the individuals with a history of falls and risk factors for subsequent falling. The staff, with the support of the attending Physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, Activities of Daily Living (ADL) capabilities, activity tolerance, continence, and cognition. The staff and attending Physician will collaborate to identify fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. Resident #51 had diagnoses that included Dementia, Insomnia, and Hypertension. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severely impaired cognitive skills for daily decision-making. The Minimum Data Set documented that the resident needed partial/moderate assistance of one person to walk 10 feet. The Minimum Data Set documented that the resident had a history of falling and had no behaviors. The Fall Risk Evaluation dated 2/11/2024 documented a score of 21 indicating the resident was a high risk for falls. The Comprehensive Care Plan for Falls initiated on 1/22/2023, updated 1/24/2024, documented interventions to place the resident in a supervised area when awake and monitor the resident every 15 minutes for frequent falls Updated 1/22/2024, documented provide redirection and encourage the resident to utilize one-person assistance for ambulation with a rolling walker for safe ambulation and for fall prevention. The Comprehensive Care Plan for Behaviors dated 2/2/2023 documented the resident had potential risks for exhibiting behavior symptoms such as verbally aggressive/abusive, physically aggressive/abusive, and wandering behavior related to cognitive impairment secondary to Dementia. The interventions included administering medications, distracting the resident from wandering and modifying the environment to reduce episodes of negative behavior and risk for falls or injury. There was no documented evidence the current Certified Nursing Assistant [NAME] (care instructions for Certified Nursing Assistants) did not include interventions indicated in the Comprehensive Care Plan to place the resident in a supervised area when out of bed. The Nursing Progress Note dated 7/24/2024 at 6:53 AM, by the Registered Nurse Supervisor #6, documented that the resident was observed sitting on the floor hallway around 1:10 AM. The resident had a bump on the right side of their forehead and a swollen upper lip with blood inside their mouth. The resident denied pain and the range of motion (ROM) was within normal limits. The resident stated, I am going home. The resident's Physician was called and ordered to transfer the resident to the emergency room for a head Computed Tomography (CT) scan. The Occurrence Report/Investigation dated 7/31/2024 documented Certified Nursing Assistant #3, who was assigned to the resident, reported that while they attended to another resident, Resident #51 got up (from their wheelchair) and fell to their right side in the hallway. The investigation concluded that the resident was confused, had a history of Dementia, Depression, poor sleeping patterns, and needed constant reminders. The resident was non-compliant with the use of their call bell and ambulated without assistance at times despite redirection. The resident was to remain on close monitoring, and for the staff to not leave the resident unattended and maintain safety visual checks. During an interview on 9/20/2024 at 11:35 AM, Certified Nursing Assistant #3 stated when they came on duty for their 11:00 PM-7:00 AM shift on 7/24/2024 (their shift started on 7/23/2024), Resident #51 was already seated in the hallway in their wheelchair. Certified Nursing Assistant #3 stated Resident #51 was agitated and wanted to go home. Resident #51 had packed a bag using a pillowcase in which the resident had put their belongings. Certified Nursing Assistant #3 stated that Resident #51 had a history of getting up from their wheelchair and going to the bathroom without assistance if they were left alone. Certified Nursing Assistant #3 stated they sat with the resident in the hallway because someone had to be there to watch the resident. Certified Nursing Assistant #3 stated they had to leave Resident #51 in the hallway to help Certified Nursing Assistant #9 with another resident in a room. Certified Nursing Assistant #3 stated they did not expect Resident #51 to get up from their wheelchair by the time they got back from helping Certified Nursing Assistant #9 in a room with another resident. During an additional interview on 9/23/2024 at 12:00 PM, Certified Nursing Assistant #3 stated they left Resident #51 in the hallway to help another Certified Nursing Assistant #9 break up a fight between two residents in their room. Certified Nursing Assistant #3 stated Licensed Practical Nurse #10 also got up from the Nurse's Station and went into the same room, leaving Resident #51 alone in the hallway. Certified Nursing Assistant #3 stated they heard a noise in the hallway, ran out of the room, and saw Resident #51 lying on the floor. Licensed Practical Nurse #10 was unavailable for an interview. During an interview on 9/24/2024 at 12:55 PM, the Assistant Director of Nursing Services/Risk Manager stated the resident always has to stay in someone's line of vision because you could not tell when the resident would get up so you would have to be able to see the resident. The Assistant Director of Nursing Services/Risk Manager stated Resident #51 fell on 7/24/2024 at 1:10 AM during the night when Certified Nursing Assistant #3 left Resident #51 in the hallway to assist another Certified Nursing Assistant #9. The Assistant Director of Nursing Services/Risk Manager stated that Certified Nursing Assistant #3 should have called for help so they could have stayed with Resident #51 while someone else went to help the other Certified Nursing Assistant #9. The Assistant Director of Nursing Services/Risk Manager stated the resident's care plan was not followed and Certified Nursing Assistant #3 should have stayed with Resident #51. During an interview on 9/24/2024 at 1:23 PM, the Director of Nursing Services stated there was a break in the resident's plan of care. Certified Nursing Assistant #3 or Licensed Practical Nurse #10 should not have left Resident #51 alone in the hallway. During an interview on 9/24/2024 at 1:50 PM, the Medical Director stated that someone should have at least been there, some responsible party, to stay with the resident. Both the Certified Nursing Assistant and Licensed Practical Nurse should not have left the resident alone. A responsible party should have relieved the individual watching the resident, unless it was an emergency or urgent situation, such as a resident having a cardiac arrest.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the Recertification Survey and Abbreviated Survey (NY00305185) initiated on 3/22/2023 and completed on 3/30/2023, the facility did not ensure each resident was free from abuse, neglect, misappropriation of resident property, and exploitation. This was identified for one (Resident #140) of two residents reviewed for Resident-to-Resident Abuse. Specifically, on 11/8/2022, Resident #326, with intact cognition, verbalized that they are going to hit Resident #140 if the resident went to their room again. Soon after the verbal threat, Resident #326 went to Resident #140's room and was observed hitting Resident #140 in the head. Subsequently, Resident #140 was transferred to the hospital and was diagnosed with a left orbital (eye) skull fracture and bruising to the head. This resulted in actual harm to Resident #140 that is not Immediate Jeopardy. The finding is: The facility's policy titled, Abuse Prevention Program/Abuse and Neglect-Clinical Protocol/Abuse Investigation and Reporting, last reviewed 1/2023, documented that residents have a right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The facility defined Physical abuse as the use of physical force that may result in bodily injury, physical pain, or impairment. Physical abuse includes but is not limited to such acts of violence as striking (with or without an object), hitting, beating, pushing, shoving, slapping, kicking, pinching, and burning. Resident #326 (aggressor) was admitted with diagnoses including Bipolar Disorder, Panic Disorder, and Difficulty in Walking. The 8/19/2022 admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The MDS documented that the resident had verbal behavioral symptoms directed toward others and required extensive assistance for bed mobility and transfers. Walking did not occur, and the resident utilized a wheelchair for mobility. The Comprehensive Care Plan (CCP) for Resident #326 titled, Behavior Problems effective 8/12/2022 documented that the resident had behaviors of increased agitation, yelling and was verbally abusive to staff and others, physically abusive toward staff, and was socially inappropriate. A 9/6/2022 entry documented that the resident was overheard talking to a friend on the phone about an incident in another facility and what they would do at the other facility with a gun. Interventions were put in place including close supervision. A Psychiatry consult for Resident #326 dated 9/6/2022 documented diagnoses of Bipolar Disorder, Panic Disorder, and Alcohol Use. The resident was noted with a worsening condition and with mood instability. Recommendations included Quetiapine (an antipsychotic medication) 50 milligrams (mg) twice a day. A review of Resident #326's progress notes from August 2022 to October 2022 revealed on 8/11/2022 Resident #326 made a threat to hit staff. Other documented behaviors in progress notes included agitation, yelling, verbally abusive, harmful to self and others, erratic, voicing suicidal and homicidal ideation, physically aggressive, cursing, disruptive to the whole unit, and slamming the nursing station desk for narcotics (controlled substance). A nursing progress note for Resident #326, written by Licensed Practical Nurse (LPN) #4 (charge nurse), dated 11/8/2022 documented LPN #4 was informed by Certified Nursing Assistant (CNA) #1 that the resident stated, If [Resident #140] goes into my room again, I am going to punch [Resident #140] out. Resident #326 repeated the same statement to LPN #4. LPN #4 notified the nursing supervisor. The nursing progress note documented that CNA #1 yelled out for assistance because Resident #326 was going into Resident #140's room. LPN #4 ran down the hall and saw Resident #326 standing over and punching Resident #140 with a closed fist. LPN #4 jumped in between the two residents and screamed, and then Resident #326 stopped punching Resident #140. Staff responded and a physician was notified. Resident #326 left the unit with the ambulette attendants and three police officers. Resident #326 returned to the facility on [DATE]. A Social Work note for Resident #326 dated 11/9/2022 documented a 30-day transfer-discharge notice issued to Resident #326 due to the resident being a danger to other residents. A review of admission transfer and discharge (ADT) data revealed that Residents #140 and #326 resided across the hallway from each other. Resident #140 (victim) was admitted with diagnoses including Alzheimer's Disease, Hypertension, and Altered Mental Status. The 10/2/2022 Significant Change MDS assessment documented a BIMS score of 4, indicating the resident had severely impaired cognition. The MDS documented that the resident sometimes understands and is sometimes understood. The MDS documented no mood or behavioral issues. The MDS documented that the resident required limited assistance for transfers and walking. A CCP titled Abuse Prevention for Resident #140 dated 10/26/2022 documented that the resident was at risk for victimization related to the diagnosis of Alzheimer's Disease. Interventions included to remove the resident from the area of the aggressor and counsel the resident to avoid contact with the aggressor. A nursing progress note for Resident #140 dated 11/4/2022 documented the resident was observed going into other resident rooms and eating from their food trays. Resident #140 was redirected whenever this behavior was observed. A nursing progress note, written by Registered Nurse (RN) #6, for Resident #140 dated 11/8/2022 documented that at 5:30 PM Resident #140 was assaulted by another resident (Resident #326). Resident #326 left their room and went into Resident #140's room and started punching Resident #140 in the head several times for no reason. Resident #140 was assessed for injury; some swelling was noted. Due to Resident #140's scalp deformity, RN #6 was unable to assess the injury. Physician #4 was made aware of the incident and ordered to transfer Resident #140 to the hospital for head injury evaluation. A nursing progress note dated 11/9/2022 documented that RN #4 spoke to the emergency room physician, resident had a Computerized Tomography (CT-a diagnostic imaging exam) scan of the head which indicated a non-displaced left orbital (eye) wall fracture. Due to Resident #140's anatomy of the skull, the resident needed to follow up in a few weeks with an orthopedic surgeon to determine if surgical intervention was needed. Resident #140 was admitted to the hospital. A review of Resident #140's medical record revealed no documented evidence that a follow-up with an Orthopedic Surgeon was completed to determine if surgical intervention is needed. Resident #140 was re-admitted back to the facility on [DATE] and relocated to a different unit. A physician's order dated 11/11/2022 documented to place Resident #140 on every 15-minute monitoring due to Resident #140's wandering behavior into other resident rooms. A CCP for Resident #140 titled Resident-to-Resident Altercation, effective 6/27/2022, documented the resident is a potential victim related to the inability to protect self and inability to walk away from an abuser. A review of the Accident and Incident (A/I) report dated 11/8/2022 at 5:30 PM documented that when Resident #140 was lying in their bed, Resident #326 entered the room and began punching Resident #140 on their head. Resident #326 said they did not want Resident #140 coming into their room and taking their food. The A/I investigation dated 11/8/2022 documented there was no reasonable cause to believe any resident abuse, neglect, or mistreatment occurred. On 3/22/2023 at 1:40 PM Resident #140 was observed lying in bed. The resident was awake; however, spoke minimally. The resident appeared calm and comfortable. The resident's skull appeared deformed and enlarged. During an interview with LPN #4 on 3/24/2023 at 11:47 AM, they stated after they went to speak to Resident #326, LPN #4 went back to the nursing station to call the nursing supervisor and that was when CNA #1 alerted them that Resident #326 was observed wheeling themselves into Resident #140's room. LPN #4 stated they ran down the hallway to intervene and witnessed Resident #326 punching Resident #140 in the head. LPN #4 stated Resident #140 had behaviors of wandering into other resident rooms. LPN #4 stated they were not aware of any incidents between the two residents prior to 11/8/2022. During an interview with CNA #1 on 3/24/2023 at 11:56 AM, they stated they were the assigned CNA for Resident #140 on 11/8/2022. CNA #1 stated Resident #140 always wandered and was on every 15-minute check. CNA #1 stated on 11/8/2022 they were completing room checks and saw Resident #140 sleeping in bed. CNA #1 then went into Resident #326's room, who was lying in bed, and told the CNA that they were going to hit Resident #140 because Resident #140 comes into their room and takes stuff. CNA #1 stated at that point CNA #1 left the room and informed LPN #4. CNA #1 stated they were in the hallway when they saw Resident #326 wheeling into Resident #140's room, CNA #1 yelled for help, and LPN #4 responded. There was no documented evidence provided by the facility that every 15-minute monitoring was being completed for Resident #140 on or prior to 11/8/2022. During an interview with Physician #4 on 3/28/2023 at 9:55 AM, they stated the resident has a hypertrophic (enlargement or overgrowth) skull due to Paget's Disease (bone disease). The physician did not recall if Resident #140 went out for a follow-up appointment regarding the fracture of the left lateral orbit wall. Physician #4 stated Resident #326 was a very aggressive individual, staff provided a lot of redirection to the residents but the redirection cannot be performed 100% of the time. During an interview with the Director of Nursing Services (DNS) on 3/28/2023 at 12:02 PM, they stated Resident #326 went to seek Resident #140; the altercation was not in response to Resident #140 going into Resident #326's room again. The DNS stated that after 11/4/2022 when there was documentation that Resident #140 was wandering and seeking food, the resident was given snacks and monitored when in the hallway. The DNS stated they were not able to provide documented evidence of the hallway monitoring. The DNS stated that every-15-minute monitoring requires a physician's order. Resident #140 was placed on every 15-minute monitoring on 11/11/2022 after the incident on 11/8/2022. The DNS further stated that the 15-minute monitoring would not be documented without a physician's order. The Medical Director was interviewed on 3/29/2023 at 11:55 AM. The Medical Director stated Resident #140 sustained a mild fracture because of the incident. The Medical Director stated that the fracture would heal on its own and that a referral to the Orthopedic Surgeon was not warranted. 10 NYCRR 415.4(b)(1)(i)