Based on observation, interview, and record review conducted during a Standard survey completed on 12/18/23, the facility did not ensure the resident's right to personal privacy during medical treatments for one (Resident #62) of one resident reviewed. Specifically, the Podiatrist completed Resident #62's exam and treatment in a common area in the presence of other residents. The finding is: The policy and procedure titled Residents' Rights revised 11/2014 documented the facility respects residents' rights in providing care. All residents are afforded their right to a dignified existence, self-determination, respect, full recognition of their individuality, consideration and privacy in treatment and personal care for personal needs and communications with and access to persons and services inside and outside of the facility. The facility shall protect and promote the rights of each resident and shall encourage and assist each resident in the fullest exercise of these rights. The policy and procedure titled Podiatry dated 2/2019 documented all podiatry treatments are rendered in the resident's room (unless otherwise arranged for specific reason). Resident #62 had diagnoses including dementia, hypertension, and depression. The Minimum Data Set - (a resident assessment tool) dated 9/29/23 documented Resident #62 had moderate cognitive impairments, was understood, and understands. The Minimum Data Set documented no behaviors. The Certified Nursing Assistant Care Guide (guide used by staff to provide care) dated 12/18/23 documented Resident #62 was a one assist with a rolling walker for ambulation and transfers. The Comprehensive Care Plan revised 8/1/23 documented Resident #62 required podiatry visits as needed for long thick nails. The podiatry schedule documented Resident #62 had nailcare services on 12/15/23. During an observation on 12/15/23 at 9:48 AM in the D Wing Team 2 common area with other residents present, the Podiatrist knelt on one knee next to Resident #62's recliner, placed a barrier pad on the floor, removed Resident #62's socks and filed the bottom of Resident #62's feet over the barrier pad. The Podiatrist then clipped Resident #62's toenails on both feet and then replaced the socks on Resident #62's feet. The Podiatry Progress Note dated 12/15/23 documented Resident #62 was seen and examined for podiatry services. Aseptic debridement was performed for hypertrophic (thick), dystrophic (discolored, thickened, deformed), and trimmed all toenails without complications. During a telephone interview on 12/15/23 at 3:49 PM, the Podiatrist stated they filed Resident #62's feet and clipped their toenails while seated in a recliner in the D wing common area. The Podiatrist stated they did not take Resident #62 back to their room or request assistance from the nursing staff as it would have been a hassle due to their behavior. The Podiatrist stated they treated Resident #62 without providing privacy and stated, It was easier to cut the nails while Resident #62 was in the recliner, than to not have cut them at all. During an interview on 12/18/23 at 9:58 AM, Licensed Practical Nurse #11, Unit Coordinator stated they saw the Podiatrist just as they were finishing Resident #62 treatment on 12/15/23. Licensed Practical Nurse #11, Unit Coordinator stated cutting nails was personal care that should be done behind closed doors for privacy and dignity. Not everyone wants to see feet being worked on, in their living room. Cutting nails should be done in private, and was disrespectful to the resident. During an interview on 12/18/23 at 12:14 PM, the Director of Nursing stated, completing nail care in the common areas on the units was unacceptable. The Podiatrist should have brought the resident back to their room, or had staff do it, to provide privacy to the resident. 10NYCRR 415.3 (d) (1)(ii)

Based on observation, interview, and record review conducted during a Complaint investigation (Complaint #NY00324906) completed during the Standard survey on 12/18/23, the facility did not ensure the resident's right to be free from verbal abuse and neglect for one (Resident #134) of four residents reviewed. Specifically, on 9/26/23 Resident #134 reported Certified Nursing Assistant #11 yelled, swore at them, took their call light away and threw it at the wall. The finding is: The policy and procedure titled Resident Abuse: Investigation and Reporting dated 1/23, documented it is the facility's policy to prohibit and assure the residents' rights to be free from verbal abuse, physical abuse, sexual abuse, neglect, exploitation, mistreatment, and misappropriation of resident property. The policy and procedure documented that verbal abuse is defined as the use of language that willfully includes disparaging and derogatory terms to the resident. The policy and procedure documented that neglect is defined as is failure of employees to provide goods and services to a resident necessary to avoid harm, pain, mental anguish, or emotional distress. Resident #134 had diagnoses including cerebral infarction with hemiplegia (weakness) and language deficits, gastrointestinal hemorrhage, and difficulty walking. The Minimum Data Set (a resident assessment tool) dated 9/4/23 documented Resident #134 had intact cognition, was understood, and understands. The comprehensive care plan dated 9/18/23 documented Resident #134 required assistance with activities of daily living related to cerebral vascular accident (CVA, stroke). Interventions included that Resident #134 was non ambulatory, an extensive assist of one staff member for bed mobility and an extensive assist of two staff members with a platform walker for transfers. Review of the untitled facility investigation provided by and signed by the Administrator documented that on 9/26/23 while Physical Therapist #3 was working with Resident #134 a report was made of potential verbal abuse. It was reported that a Certified Nursing Assistant was rough, used vulgar language and threw items at the wall in Resident #134 room over the weekend. The investigation documented that interview with Resident #134 revealed the item that was thrown was a call bell and the call bell logs were reviewed. The investigation documented that review of the call light logs on 9/23/23 revealed no call bell was used for the 11:00 PM to 7:00 AM shift and on 9/24/23 limited call bell use for the 11:00 PM - 7:00 AM. The investigation documented the conclusion was the complaint was substantiated based on identifiers provided by Resident #134 and limited call bell use on the dates of 9/23/23 and 9/24/23. Review of an employee statement dated 9/26/23 signed by Physical Therapist #3 revealed that while asking Resident #134 during a therapy treatment how they were doing using the platform walker the resident stated the staff do not have patience for them. The employee statement documented that Resident #134 stated a Certified Nursing Assistant yelled, God damn it and hurry the hell up during care. The statement documented that Resident #134 stated that a staff member was rough and threw things at their wall. Review of an employee statement dated 9/26/23 signed by the Director of Social Work and Registered Nurse #5 documented that Resident #134 stated that a Certified Nursing Assistant that was caring for them treated them like dirt, swore at them, grabbed the call bell from them and threw it against the wall. The statement documented that the resident did not want to say anything, was afraid and that the Certified Nursing Assistant would be able to find out where Resident #134 lived. The statement documented that Resident #134 stated the situation occurred probably on Sunday night. Review of an email dated 9/29/23 at 1:14 PM sent to the Director of Nursing received from Certified Nursing Assistant #11 documented that Certified Nursing Assistant #11 statement was that they were unaware of anything out of the ordinary as far as my care for residents on the nights on 9/23/23 and 9/24/23 for rooms 123-130. Review of the call light log for Resident #134 revealed on: -9/23/23 from 8:47 PM until 9/24/23 at 7:45 AM the call bell was not activated. -9/25/23 from 1:28 AM until 6:51 AM the call bell was not activated. Review of the untitled Unit A Certified Nursing Assistant room assignment sheets Certified Nursing Assistant #11 was assigned to Resident #134 on 9/23/23 and 9/24/23 for the 11:00 PM-7:00 AM shift. During an interview on 12/13/23 at 9:33 AM, Resident #134 stated that they felt they were in an abusive situation with a Certified Nursing Assistant. Resident #134 stated that while they were getting into bed at night a Certified Nursing Assistant was rough with them, took their call bell away and threw it at the wall. Resident #134 stated they were concerned the staff member was abusive to other residents. During an interview on 12/15/23 at 11:52 AM, Resident #134's Health Care Proxy stated Resident #134 informed them of a Certified Nursing Assistant lost their patience with Resident #134 while caring for them. Resident #134 Health Care Proxy stated that Resident #134 was upset and irritated because a Certified Nursing Assistant took their call bell away, threw it at the wall and did not want to care for them. Resident #134's Health Care Proxy stated they felt the situation was abusive because of the vulnerability of Resident #134. During a telephone interview on 12/15/23 at 1:47 PM, Certified Nursing Assistant #11 stated that they worked A unit team #3 on 9/23/23 into 9/24/23 and 9/24/23 into 9/25/23. Certified Nursing Assistant #11 stated that they were angry that they had team #3 two days in a row because team #3 care that was required was heavy. During an interview on 12/15/23 at 1:18 PM, the Director of Social Work stated that Resident #134 was afraid, and that Resident #134 thought the staff member would find out where they lived and harm them. The Director of Social Work stated that per Resident #134 interview, neglect and verbal abuse occurred and that all residents have the right to remain free from abuse. During an interview on 12/18/23 at 8:45 AM, Physical Therapist #3 stated that during a therapy treatment on 9/26/23 they asked Resident #134 how they were doing transitioning to the platform walker. Physical Therapist #3 stated that Resident #134 reported that the night before a Certified Nursing Assistant did not have patience with them, yelled at them to hurry the hell up and threw items at the wall. Physical Therapist #3 stated that Resident #134 reported that they were afraid to tell anyone, and they appeared to be uncomfortable with the situation. Physical Therapist #3 stated they told Register Nurse #5 immediately because they consider the situation an allegation of abuse and that all residents should be safe from abuse. During an interview on 12/18/23 at 8:58 AM, Register Nurse #5 (Unit manager of A wing) stated they reported the situation to the Director of Nursing and the Administrator. Register Nurse #5 stated that removing the call light from Resident #134 was neglect because they could not call for help when needed and swearing at Resident #134 was a form of verbal abuse. During an interview on 12/18/23 at 10:34 AM, the Director of Nursing stated that their conclusion to their investigation was that abuse occurred and that every resident has a right to remain free from abuse, neglect, and mistreatment. During an interview on 12/18/23 at 12:54 PM, the Administrator stated their conclusion was neglect and verbal abuse occurred based on review of the call bell log report, Resident #134's statement and a second statement given from a different resident. 10 NYCRR 415.4 (b)(1)(ii)

Based on observation, interview, and record review conducted during a Complaint investigation (Complaint #NY00325623) during the Standard survey completed on 12/18/23, the facility did not ensure that all residents were free from physical restraints for the purpose of discipline or convenience, and that are not required to treat the resident's medical symptoms for one (Resident #113) of one resident reviewed for physical restraints. Specifically, on 10/8/23 a wet floor sign was placed behind the rear wheels of Resident #113's wheelchair to prevent them from moving freely. The finding is: The policy and procedure titled Restraints dated 10/2022 documented the facility creates and maintains an environment that fosters minimal use of restraints. A physical restraint is any manual method of physical/mechanical devices, material or equipment attached or adjacent to the resident's body that the resident cannot remove easily, which restricts freedom of movement or normal access to one's body. Physical restraints will not be ordered or used: for staff convenience; for purpose of discipline or as a substitute for direct care, activities, and other services. Resident #113 had diagnoses which included cognitive communication deficit, unspecified dementia, and neuromuscular dysfunction of bladder (nerves and muscles of bladder don't work well together). The Minimum Data Set (a resident assessment tool) dated 9/28/23 documented Resident #113 understood, understands, had moderate cognitive impairment and displayed physical and verbal behaviors 4 to 6 days. The Minimum Data Set documented physical restraints weren't used. The comprehensive care plan revised on 9/25/23, documented Resident #113 had the potential for a communication problem related to diagnosis of cognitive communication deficit. Interventions included to anticipate and meet their needs, allow adequate time to respond, do not rush, request clarification from the resident to ensure understanding, use simple, brief, consistent words/cues. Additionally, Resident #113 had was at risk for falls related to confusion and generalized muscle weakness. Interventions included to offer the recliner when in the common area, physical therapy to evaluate and treat as ordered or as needed. The comprehensive care plan did not document the use of restraints. Review of an email dated 10/9/23 at 12:09 PM sent by the Administrator documented Nursing Home Facility Incident Report Successfully Submitted. Per Dietary Aides #1 and #2, Resident #113 was present in the dining room for breakfast on 10/8. Resident #113 attempted to leave the dining room several times, staff members were able to bring Resident #113 back to the room. Unknown staff members placed a collapsible wet floor sign behind Resident #113's wheelchair to block their exit from the dining room table. Resident #113 was then unable to leave the dining room table with the signs behind their wheelchair. Recreation of the described event indicates that a wheelchair would not be able to move backward if wet floor signs were placed behind the wheels unless significant force was used to wheel over. Interviews with Dietary Aides #1 and #2 completed to identify staff members involved in activity. Staff to be educated on restraints and residents right to refuse. Review of typed phone conversation with Licensed Practical Nurse #7 dated 10/9/23 signed by the Director of Nursing, documented an incident occurred with Resident #113 in the dining room on Sunday, 10/8/23. Licensed Practical Nurse #7 stated that on 10/8/23, they were encouraging Resident #113 to eat in the dining room during breakfast. Resident #113 was given their tray and then began moving their wheelchair backwards, which ran into Licensed Practical Nurse #7's foot. Licensed Practical Nurse #7 stated they put wet floor signs under Resident #113's large wheelchair wheels to attempt to keep them at the table so they could be motivated to eat. Licensed Practical Nurse #7 stated that Resident #113 was able to roll over the signs without difficulty. Additionally, the Director of Nursing documented Licensed Practical Nurse #7 was counseled regarding resident's rights, and that placing items behind a wheelchair were considered restraints and were against policy. During several observations on 12/14/23 and 12/15/23 between 8:46 AM and 1:20 PM, Resident #113 was in their wheelchair in the dining room or in the common area. Resident #113 was not observed to self-propel their wheelchair and did not display any verbal or physical behaviors. During a telephone interview on 12/14/23 at 3:45 PM, Dietary Aide #1 stated on 10/8/23 they were getting breakfast ready at the servery in the dining room and observed Resident #113 leaving their table. Unknown nursing staff kept telling Resident #113 to stay there (at the table in the dining room). Dietary Aide #1 stated their co-worker, Dietary Aide #2, stated to them they placed a sign under Resident #113's wheels. Dietary Aide #1 stated when they turned around, they observed the sign under Resident #113's wheelchair wheels and did not see who placed it there or how long the sign was in place. Dietary Aide #1 stated they reported the incident on 10/9/23 after saying something to someone else who told them they should report the incident because it was technically abuse. Dietary Aide #1 stated they felt the situation was ridiculous and that staff should have allowed Resident #113 to leave the dining room if they didn't want to eat. Dietary Aide #1 stated at the time this occurred they didn't think it was a form of abuse, but now they know it was. During a telephone interview on 12/14/23 at 3:56 PM, Dietary Aide #2 stated they were serving residents breakfast in the dining room and heard Resident #113 state to staff that they weren't hungry as they were trying to leave the dining room. Dietary Aide #2 stated a staff member then took and placed a wet mop sign under Resident #113's rear wheelchair wheel. Dietary Aide #2 stated Resident #113 was trying to wheel over it but would get stuck on it and wasn't able to move any further. Dietary Aide #2 stated Resident #113 seemed aggravated, very upset, raising their voice trying to get staff to listen to what they were saying. Dietary Aide #2 felt this was abuse, because other residents were able to come and go but staff were preventing Resident #113 from leaving. Dietary Aide #2 stated they didn't think about reporting the incident to their supervisor and didn't know what nurse to report it to. Dietary Aide #2 stated they should have reported it right away so something could have been done sooner if possible. During a telephone interview on 12/14/23 at 4:18 PM, Licensed Practical Nurse #7 stated Resident #113 was uncooperative and wanted to leave the facility the morning of 10/8/23. Licensed Practical Nurse #7 stated that Licensed Practical Nurse #8 asked them to keep Resident #113 in the dining room. Licensed Practical Nurse #7 stated Resident #113 wasn't having it, they wanted to go, Resident #113 was upset, verbally abusive and didn't want to cooperate with staying in the dining room. Licensed Practical Nurse #7 stated approximately 15 minutes before the meal was served, Resident #113 was in and out of dining room. Licensed Practical Nurse #7 stated before Resident #113's breakfast tray came, they placed the sign behind the back wheels of Resident #113's wheelchair, as they wanted to try and keep Resident #113 in the dining room so they could keep an eye on them but wasn't successful. Licensed Practical Nurse #7 stated Resident #113 rolled over the sign, Licensed Practical Nurse #7's foot, and left the dining room. Licensed Practical Nurse #7 stated they were trying to keep Resident #113 safe and attempted to prevent Resident #113 from leaving the dining room. Licensed Practical Nurse #7 stated they wouldn't want this done to their family member because it was their right to move around freely as desired and it's their home. Licensed Practical Nurse #7 stated they received education over the phone from Director of Nursing and Administrator and understands this could be considered a restraint and that it was wrong. During a telephone interview on 12/14/23 at 4:40 PM, Licensed Practical Nurse #8 stated they weren't fully aware of what occurred with Resident #113 on 10/8/23. Licensed Practical Nurse #8 stated Resident #113 was a handful and was exit seeking that morning and asked co-worked, Licensed Practical Nurse #7, to keep an eye on Resident #113. Licensed Practical nurse #8 stated they did not witness Resident #113 being restrained by a wet floor sign. Licensed Practical Nurse #8 stated that placing a wet floor sign behind a resident's wheelchair would be considered a restraint because the resident wouldn't be able to move freely, and Resident #113 would not be able to move the wet floor sign. During an interview on 12/18/23 at 12:58 PM, the Director of Nursing stated they spoke with Licensed Practical Nurse #7 over the phone and counseled them. The Director of Nursing stated they couldn't remember the conclusion to the Facility Reported Investigation regarding Resident #113, that the Administrator completed it. The Director of Nursing stated the Licensed Practical Nurse #7 should not have placed the wet floor sign behind Resident #113's wheelchair because it was a form of a restraint. During an interview on 12/18/23 at 3:07 PM, the Administrator stated they concluded the incident with Resident #113 was unsubstantiated. The Administrator stated they recreated the scenario, and they (the Administrator) were able to roll back over a wet floor sign in a wheelchair. The Administrator stated the floor sign could have been a restraint if Resident #113 wasn't able to roll over it and if they knew Resident #113 wasn't able to move their wheelchair over the floor sign, the incident would have been substantiated as a form of abuse rising to a level of deficient practice with disciplinary action. The plan of correction was for everybody involved to be in-serviced on resident rights and restraints. The Administrator stated this was completed, however the signature sheet couldn't be found. 10 NYCRR 415.4(2)(iv)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard survey completed on 12/18/23, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #15) of three residents reviewed. Specifically, Certified Nursing Assistant #8 did not provide/utilize a rolling walker during a transfer per the plan of care and the resident fell. The finding is: The policy and procedure titled Resident Accident and Incident Report and Follow up Investigation revised 6/2022 defined Accident as an unintentional or unexpected occurrence that is undesirable or unfortunate and did result in, or might have resulted in, injury, damage, harm, or loss. The facility could not provide a policy and procedure for care plan implementation. Resident #15 had diagnoses which included urinary tract infection (UTI), weakness, and hypertension (HTN, high blood pressure). The Minimum Data Set (a resident assessment tool) dated 10/16/23 documented Resident #15 had severe cognitive impairment, was understood, and understands. The Minimum Data Set documented the resident transferred with a walker and was dependent on staff for bed/chair to chair transfers. The undated closet care plan (guide used by staff to provide care) documented Resident #15 required moderate assistance from one staff member with a rolling walker for bed/chair to chair transfers. The comprehensive care plan dated 11/27/23 documented Resident #15 had a fall on 11/27/23 which resulted in an injury that included a hematoma (collection of blood under the skin) to the top of Resident #15's head. The new planned intervention included cleaning the floor of ants. During an observation and interview on 12/12/23 at 10:20 AM, Resident #15 had bilateral (both) periorbital (around the eyes) and forehead ecchymosis (bruising) and was sitting in their room in a recliner. Resident #15 stated they fell the other day, landed face first on the floor and hit the left side of their face on the walker that was in front of the dresser. The untitled facility incident report dated 11/27/23 documented a witnessed fall at 1:57 PM. Certified Nursing Assistant #8 transferred Resident #15 and during the transfer Resident #15 was staring at the ground due to ants being all over the floor. Resident #15 leaned forward, began to fall. Certified Nursing Assistant #8 attempted to stop Resident #15 from falling and ended up falling over with Resident #15. Resident #15 sustained a hematoma to the top of the scalp. Under the Predisposing Situation Factors section of the facility incident report the box indicating none was checked. The box for using wheeled walker was left blank. The unsigned and dated 11/27/23 employee statement from Certified Nursing Assistant #8 documented as they were transferring Resident #15 to their chair for lunch Resident #15 was focused on the ants on the floor, leaned forward towards the ants and fell to the floor. Certified Nursing Assistant #8 tried preventing Resident #15 from falling and fell with Resident #15. During an interview on 12/14/23 at 1:15 PM, Certified Nursing Assistant #8 stated on 11/27/23 at 11:50 AM they transferred Resident #15 from their recliner to their wheelchair for lunch. Resident #15 kept their head down and was focused on ants on the floor and fell. Certified Nursing Assistant #8 stated they tried to stop the fall instead they fell with Resident #15 and yelled for help. During an interview on 12/14/23 at 1:30 PM, Certified Nursing Assistant #8 stated a rolling walker was documented on Resident #15's closet care plan. The rolling walker was in front of the dresser and was not used when Resident #15 fell on [DATE]. Certified Nursing Assistant #8 stated, Just because a rolling walker was on the closet care plan, didn't mean we had to use them all the time, only when the resident requested to use it. On 11/27/23 at 11:50 AM Resident #15 fell forward, hit their head on the rolling walker, landed face down and smacked their head on the rolling walker. Certified Nursing Assistant #8 stated they should have reviewed Resident #15's closet care plan. Rolling walkers were used for support and could have prevented the fall on 11/27/23. During an interview on 12/15/23 at 10:42 AM, Physical Therapist #2 would have expected staff to review the closet care prior to entering a resident's room. Rolling walkers were expected to be used when documented on the closet care plan for safety and stability. Gait belts were assistive devices worn around the waist. They were used for safe transfers, assisting with sitting and standing and used while walking. Gait belts were to be held onto by the staff during transfers and not assisting residents from under their arms. Lifting someone from under their arms could cause subluxation (dislocation). During an interview on 12/18/23 at 9:04 AM, Physical Therapist #1 stated Certified Nursing Assistants were expected to read the closet care plans before giving care. Resident #15 was kyphotic (hunchback), making it difficult to raise their head. The rolling walker was the safest means of transfer for Resident #15 and should have been used. The rolling walker could have prevented Resident #15's fall on 11/27/23, but I cannot say for certain. During an interview on 12/18/23 at 9:10 AM, the Director of Physical Therapy stated closet care plans were reviewed prior to providing care. Resident #15 should have had the rolling walker positioned in front of them. Certified Nursing Assistant #8 should have had Resident #15 hold onto the walker, Certified Nursing Assistant #8 should have had ahold of the gait belt and the rolling walker, guided the buttocks, and backed up Resident #15 to a seated position. Lifting on Resident #15's arm could cause damage. The rolling walker should have been used as specified on the closet care plan and potentially prevented the fall on the floor on 11/27/23. During an interview on 12/18/23 at 10:02AM, Licensed Practical Nurse #11 Unit Coordinator stated the rolling walker helped with Resident #15's balance. Certified Nursing Assistant #8 should have provided Resident #15 their rolling walker after reviewing the closet care plan and could have prevented the fall on 11/27/23. During an interview on 12/18/23 at 12:02 PM, the Director of Nursing, stated that they would expect the staff to review the closet care plan prior to care. It was unacceptable not to use a rolling walker. Certified Nursing Assistant #8 could have prevented Resident #15 from falling perhaps if the rolling walker was used. During an interview on 12/18/23 at 1:21 PM, the Administrator stated the rolling walker would have given Resident #15 and Certified Nursing Assistant #8 more control therefore could have prevented Resident #15 from falling forward and sustaining a hematoma. 10 NYCRR 415.2 (h) (1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a Standard survey completed 12/18/23, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, to help prevent the development and transmission of communicable diseases and infections for three (Residents #31, #95, and #116) of three residents reviewed for airborne and droplet precautions. Specifically, staff did not wear appropriate personal protective equipment, including gowns, gloves, eye protection and N95 (respirator, not resistant to oil- based aerosols, 95 efficiency) masks prior to entering COVID-19 (Coronavirus Disease 2019) positive resident's rooms. Additionally, Resident #116's door lacked airborne/droplet precaution instructions to put on a N95 mask before entering the room. The findings are: The policy and procedure titled Airborne Precautions last revised 12/2021, documented the purpose of airborne precautions was to reduce the risk of airborne transmission of infectious agents. The precautions applied to patients/residents known or suspected to have infections transmitted by the airborne route, including but not limited to pulmonary tuberculosis, varicella, COVID-19 (Coronavirus Disease 2019), and measles. All staff, directly or indirectly involved in resident/patient care are responsible for following airborne precautions in conjunction with standard precautions. Major emphasis included the following: N95 or equivalent for persons who must share air space with an infected resident/patient. The policy and procedure titled Droplet Precautions, last revised 12/21, documented it was the responsibility of the Infection Control Nurse or designees to initiate and ensure that droplet precautions were properly implemented. All staff, directly or indirectly involved in resident/patient care were responsible for following droplet precautions in conjunction with standard precautions. Droplet precautions apply to any patient/resident known or suspected to have infections transmitted by infectious droplets, including but not limited to Coronavirus Disease 2019 (COVID-19). Review of an untitled facility document dated of 12/14/23, identified by the Registered Nurse/Assistant Director of Nursing/Infection Preventionist as the resident COVID-19 (Coronavirus Disease 2019) positive list, documented Resident #116 had a positive rapid test on 12/9/23, Resident #95 had positive rapid test on 12/12/23, and Resident #31 had positive rapid test on 12/14/23. 1. Resident #116 had diagnoses including heart failure, dementia, and benign prostatic hyperplasia (BPH, enlarged prostate gland). The Minimum Data Set (a resident assessment tool) dated 11/17/23 documented Resident #116 was understood, sometimes understands, and had severe cognitive impairment. During an observation on 12/12/23 at 11:28 AM, Resident #116's room door was closed, a three-drawer bin was outside the room that contained personal protective equipment including gloves, gowns, surgical masks, eye shields, and N95 masks. A laminated droplet precaution sign was posted on the door. The sign documented families and other visitors were to follow precautions for common conditions including seasonal Influenza, Pertussis (Whooping Cough), Bacterial Meningitis, and Mumps. COVID-19 (Coronavirus Disease 2019) was not listed on the sign. Personal protective equipment was to be put on in this order: wash or sanitize hands, gown, mask (the sign did not list the specific type of mask to be worn), eye cover and gloves. Additionally, during this observation, Licensed Practical Nurse #4 was wearing a surgical mask, donned (put on) a gown, gloves, and entered Resident #116's room without donning a N95 mask and eye protection. 2. Resident #95 had diagnoses including COVID-19 (Coronavirus Disease 2019), congestive heart failure (heart condition), and chronic obstructive pulmonary disease (COPD, group of lung diseases that block airflow). The Minimum Data Set, dated [DATE] documented Resident #95 usually understands, was usually understood, and had moderate cognitive impairment. During an observation on 12/13/23 at 10:23 AM, Resident #95's room door was closed and had a white Airborne/Droplet Precautions sign posted stating, only essential personnel were to enter the room and a fit tested N95 mask was required before entering the room. Staff must wash their hands, put on a gown, N95 mask, goggles or face shield, and gloves. Remove all personal protective equipment before exiting the room, wash hands and place your surgical mask on outside the room. During an observation on 12/13/23 from 12:02 PM to 12:20 PM, Resident #95 was in their room, in bed, and had an occasional loose, wet cough. Resident #95 stated they were very thirsty, and the call bell was turned on. At 12:12 PM, Resident Aide #1 entered Resident #95's room not wearing a gown, gloves, or eye protection, and had a N95 mask incorrectly applied/positioned over a surgical mask on their face. Resident Aide #1 touched the blanket on the bed, was in direct contact while they covered Resident #95 with the blanket and turned off the call bell without wearing gloves. Resident Aide #1 exited the room without sanitizing/washing their hands carrying Resident #95's water pitcher. At 12:20 PM Resident Aide #1 was outside Resident #95's room and stated to Occupational Therapist #1, no one ever told me I needed to wear this. The Occupational Therapist #1 stated to Resident Aide #1, it's on door prior to entering. During an observation and interview on 12/13/23 at 12:21 PM, Occupational Therapist #1 stated the sign posted on the door told staff what personal protective equipment was required prior to entering a COVID-19 (Coronavirus Disease 2019) positive room. Occupational Therapist #1 stated it was important to have personal protective equipment on prior to entering the room because once they were in the room they were exposed to airborne pathogens. Occupational Therapist #1 stated they could become sick if they didn't wear the appropriate personal protective equipment and they wouldn't be protecting the resident either. During an observation on 12/14/23 at 10:59 AM, Licensed Practical Nurse #6 entered Resident #95's room carrying a medication cup and a spoon in their hand wearing only a surgical mask and no other personal protective equipment. The door was left opened and Licensed Practical Nurse #6 leaned forward toward Resident #95, within 3 feet, to speak to Resident #95. During an interview on 12/14/23 at 11:02 AM, after they exited Resident #95's room, Licensed Practical Nurse #6 stated Resident #95 was on COVID-19 (Coronavirus Disease 2019) precautions and they only needed to gown up and apply a COVID mask (N95) if they were going to be in contact with a resident. Licensed Practical Nurse #6 stated they did not read the sign posted on the door, and they should have because Resident #95 had COVID-19 (Coronavirus Disease 2019). Licensed Practical Nurse #6 stated they didn't know why the precaution signs on Resident #116 and Resident #95's doors were different. Licensed Practical Nurse #6 stated both Resident #116 and #95 had COVID-19 (Coronavirus Disease 2019) and the precaution signs should be the same. During an interview at 11:56 AM, Licensed Practical Nurse #6 stated they probably should have worn personal protective equipment, including a N95 mask because they were in a resident's room that was on airborne precautions. During an interview on 12/15/23 at 11:07 AM, Resident Aide #1 stated if they saw a precaution sign on a resident door, they would read it and follow it. Resident Aide #1 stated they would wear personal protective equipment according to sign before entering the room. Resident Aide #1 stated to be honest they were a little confused, not clear on what I was reading prior to entering Resident #95's room on 12/13/23 at 12:12 PM. Resident Aide #1 stated they should have read the sign, asked a nurse if they didn't understand it because personal protective equipment protects them, and they should make sure they were following the policy. 3. Resident #31 had diagnoses including Alzheimer's disease, COVID-19 (Coronavirus Disease 2019), and anxiety disorder. The Minimum Data Set, dated [DATE] documented Resident #31 usually understands, was usually understood, and had severe cognitive impairment. During an observation on 12/15/23 at 9:43 AM, Licensed Practical Nurse #4 entered Resident #31's room without a N95 mask on. The sign posted on the resident's door documented a N95 mask was required. During an interview on 12/15/23 at 11:44 AM, Licensed Practical Nurse #4 stated they were aware of which residents were on precautions through report, rooms had bins inside/outside the door, and usually had a sign stating what personal protective equipment to wear in the room. Licensed Practical Nurse #4 stated they knew Resident #31 was on COVID-19 (Coronavirus Disease 2019) precautions and knew what personal protective equipment was required, I'm a professional Licensed Practical Nurse, been dealing with COVID (Coronavirus Disease) since it came out and it's on the door. Licensed Practical Nurse #4 stated that they did not need a N95 mask if they had a face shield on. Licensed Practical Nurse #4 stated the sign stated they needed N95, they probably got flustered and didn't wear the N95 but they should have. Licensed Practical Nurse #4 stated it was important to follow precaution signs to protect themselves, other residents, and families. During an interview on 12/14/23 at 11:09 AM, Licensed Practical Nurse #3, Unit Coordinator, stated they had three COVID-19 (Coronavirus Disease 2019) positive residents on their unit. Licensed Practical Nurse #3 stated upon entering and providing care, full personal protective equipment (gown, gloves, N95 mask covered with surgical mask and face shield) were to be worn. Licensed Practical Nurse #3, stated a N95 mask was required upon entering a COVID-19 (Coronavirus Disease 2019) positive room no matter what. Licensed Practical Nurse #3 stated personal protective equipment was important to prevent the spread of COVID-19 (Coronavirus Disease 2019) to other residents and staff. Licensed Practical nurse #3 stated the precaution signs on Resident #95 and Resident #116's doors were different because one sign was older and the other was newly made. Licensed Practical Nurse #3 stated both signs should indicate the use of a N95 mask as they were COVID-19 (Coronavirus Disease 2019) rooms. During an interview on 12/14/23 at 12:12 PM, Registered Nurse/Assistant Director of Nursing/Infection Preventionist stated an airborne/droplet precaution sign should be posted on COVID-19 (Coronavirus Disease 2019) positive room doors. The Registered Nurse/Assistant Director of Nursing/Infection Preventionist stated proper precaution signage was needed to let the staff know exactly what personal protective equipment to wear to prevent the spread of infectious disease. Registered Nurse/Assistant Director of Nursing/Infection Preventionist stated staff were required to wear a N95 mask upon entering a COVID-19 (Coronavirus Disease 2019) room. During an interview on 12/18/23 at 12:58 PM, the Director of Nursing stated COVID-19 (Coronavirus Disease 2019) positive residents have airborne/droplet precautions signs on their doors. The Director of Nursing stated they expected the staff to be wearing full personal protective equipment, including a N95 mask prior to entering the room. The Director of Nursing stated it was important for the proper precaution sign to be posted so staff knew what they were supposed to do, and so families knew what to wear when entering a precaution room. 10 NYCRR 415.19 (a) (1-2)

Based on interview and record review conducted during a Standard survey completed 12/18/23, the facility did not implement an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for one (Resident #131) of two residents reviewed. Specifically, Resident #131 received Macrodantin (an antibiotic) since 5/23/23 for urinary tract infection prophylaxis (prevention) without documented evidence to support its continued use, appropriate indications for continued use, and lack of monitoring and tracking of its use. Additionally, no rationale regarding prophylactic antibiotic use was given by the physician/prescriber on the medication regimen review dated 7/29/23. The finding is: Review of the policy and procedure titled Antibiotic Stewardship Policy revised 12/2022, documented the facility will develop an Antibiotic Stewardship program that promotes appropriate use of antibiotics for quality of care, successful resident outcomes and reduction of potential adverse consequences related to antibiotic use. Antibiotic Stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. This can be accomplished through improving antibiotic prescribing, administration and management practices thus reducing inappropriate use to ensure that residents receive the right antibiotic for the right indication, dose, and duration. The Infection Preventionist will track antibiotic use and monitor adherence to evidence-based criteria, including documentation related to antibiotic selection and use, tracking antibiotics used to review patterns of use and determination of the impact of the antibiotic stewardship interventions, monitoring for clinical outcomes and provide reports related to monitoring antibiotic usage and resistance data to the QA Committee. Review of the policy and procedure titled Resident/Employee Infection Surveillance Program revised 8/2021 documented the program provides a means to identify the incidence and prevalence of infections within the facility and maintain relevant statistical data. It was the responsibility of the Infection Control Nurse to maintain the Resident/Employee Infection Control Program. Review of the policy and procedure titled Infection Tracking revised 6/2021 documented effective measures were developed to prevent, identify, and control infections acquired or brought into the long-term care facility from the community for the purpose of producing early, uniform identification and reporting. Facility will follow McGeer's criteria (infection surveillance checklist) for tracking urinary tract infections. Prophylactic antibiotics will be reviewed by Medical Doctor/pharmacy consultant. 1. Resident #131 diagnoses included neuromuscular dysfunction of bladder (nerves and muscles of bladder don't work well together), urinary tract infection, and benign prostatic hyperplasia (BPH, noncancerous enlargement of the prostate gland) without lower urinary tract symptoms. The Minimum Data Set (resident assessment tool) dated 10/12/23 documented Resident #131 had severe cognitive impairment, had an indwelling catheter (tube inserted into the bladder to drain urine), and used antibiotic medication. The comprehensive care plan revised 5/25/23, documented Resident #131 was on antibiotic therapy Levaquin (antibiotic) related to a current infection (urinary tract infection), and Macrodantin for urinary tract infection prophylaxis. Interventions included to administer antibiotic medications as ordered by the physician, monitor/document side effects and effectiveness every shift. Review of Resident #131's Order Summary Report from 4/10/23 to 12/16/23 documented an active physician order for Macrodantin oral capsule 50 milligrams, give 1 capsule by mouth in the morning for urinary prophylaxis with a start date of 5/27/23 and there was no stop date. Additionally, Resident #131 received Levofloxacin (antibiotic) 500 milligrams by mouth in the evening for a urinary tract infection for 7 days from 5/19/23-5/26/23; Amoxicillin (antibiotic) 500 milligrams by mouth every 8 hours for occlusal trauma (dental damage) for 7 days from 7/8/23-7/15/23; Ciprofloxacin (antibiotic) 500 milligrams by mouth every morning and at bedtime for a urinary tract infection for five days from 7/21/23-7/26/23; Amoxicillin 500 milligrams by mouth every 8 hours for tooth infection for 7 days from 10/6/23-10/13/23; Macrobid (antibiotic) 100 milligrams by mouth two times a day for urinary tract infection for 5 days from 11/17/23-11/22/23; Obtain urinalysis/culture and sensitivity one time only completed 11/19/23; Ertapenem Sodium (antibiotic) 1 gram inject intramuscularly one time only for urinary tract infection until 12/4/23; Ciprofloxacin 500 milligrams by mouth every morning and at bedtime for urinary tract infection for 5 days from 12/4/23-12/9/23; Ceftriaxone Sodium (antibiotic) inject 1 gram intramuscular in the evening for infection for 5 days from 12/5/23-12/10/23. Review of the Monthly Infection Tracking Form from May 2023 through November 2023 did not list or monitor and track Macrodantin 50 milligrams daily for urinary tract infection prophylaxis for Resident #131. Additionally, the Amoxicillin Resident #131 received from 7/8/23-7/15/23, 10/6/23-10/13/23 and the Macrobid received from 11/17/23-11/22/23 were not documented or tracked on the Monthly Infection Tracking Form. Review of Lab Results Report documented Urine Culture results as followed: -Collection Date: 5/17/23, Reported Date: 5/19/23, documented abnormal results and resistance to Nitrofurantoin (Macrodantin) -Collection Date: 7/19/23, Reported Date: 7/21/23, documented abnormal results and resistance to Ciprofloxacin (Cipro) -Collection Date: 11/20/23, Reported Date: 11/23/23, documented abnormal results with two microorganisms present, only one of the microorganisms was sensitive to Nitrofurantoin -Collection Date: 12/1/23, Reported Date: 12/4/23, documented abnormal results and resistance to Nitrofurantoin Outside consults for Resident #131 did not contain a consultation from a Urologist. Review of Medication Administration Record from May 2023 through December 2023 documented Resident #131 received Macrodantin 50 milligrams daily for urinary tract prophylaxis starting 5/27/23 through 12/16/23, except from 11/18/23-11/22/23, while the resident received Macrobid 100 milligrams twice a day for a urinary tract infection for five days. Review of the Consultant Pharmacist Review: Behavioral (medication regimen review) dated 7/29/23, revealed a recommendation to document periodic support and monitoring for prophylactic antibiotic use for compliance purposes. The Medical Doctor #2 signed this form on an unknown date, that they disagreed with this recommendation and no rationale was documented as to why they disagreed. Review of GP (General Practitioner) Progress Note dated 5/17/23 at 12:47 PM, Nurse Practitioner #1 documented Resident #131 had a past medical of history of urinary tract infection, an indwelling catheter secondary to retention, and they were going to start prophylactic Macrodantin and cranberry due to the indwelling catheter. The plan was to start Macrobid 100 milligrams twice a day for 5 days for urinary tract infection, cranberry caps 425 milligrams twice a day for prophy, and to start Macrodantin 50 milligrams daily once the Macrobid was completed. No further Nurse Practitioner notes addressed the use of the prophylactic antibiotic. Review of Medical Doctor/Nurse Practitioner/Physician Assistant Progress Notes dated 7/18/23 through 11/30/23 revealed no documentation that the resident received a prophylactic antibiotic and no documented rationale for the continued use of the antibiotic. Review of Resident #131's nursing Progress Notes 5/15/23 through 12/16/23 did not document/monitor the use of the prophylactic antibiotic. During an interview on 12/15/23 at 4:37 PM, Registered Nurse/Assistant Director of Nursing/Infection Preventionist stated they tracked antibiotic use for the facility but didn't track prophy antibiotic use because it didn't need to be tracked. Registered Nurse/Assistant Director of Nursing/Infection Preventionist stated per the McGeer's criteria they did not need to track prophylactic antibiotics on their antibiotic tracking report. They stated they did not know how many residents in the facility were on a prophylactic antibiotic and it was up to the doctor to decide if a prophylactic antibiotic should be stopped/discontinued. Additionally, they stated antibiotics should have reason for being recommended. They stated every morning they pull up the dashboard in the electronic medical record system and look to see who was started on an antibiotic, why and if it meets McGeer criteria. They compare their monthly report with the pharmacy report. During an interview on 12/18/23 at 10:16 AM, Registered Nurse/Assistant Director of Nursing/Infection Preventionist stated it doesn't state in the McGeer criteria that they have to track prophylactic antibiotics. They stated prophylactic antibiotics were reviewed by the medical doctor and pharmacy consultant. During an interview on 12/18/23 at 12:16 PM, Registered Nurse #5, Unit Coordinator, stated not all residents with indwelling catheters received prophylactic antibiotics. They stated improper use of antibiotics could cause gastrointestinal issues and antibiotic resistance. During an interview on 12/18/23 at 11:30 AM, Pharmacist #2 stated with excessive use of antibiotics, antibiotic resistance can occur, and an infection can get more out of control. During an interview on 12/18/23 at 11:55 AM, Consultant Pharmacist #1 stated that prophylactic antibiotic use was a provider's clinical decision. The Consultant Pharmacist stated they tried to get rid of prophylactic antibiotics, but they got a lot of pushback from doctors. All antibiotics were required to be tracked with a rationale and a duration needed to be included. The Consultant Pharmacist stated continued use of antibiotics could lead to overgrowth of non-susceptible organisms, lack of efficacy over time, blood dyscrasias (disease or disorder of the blood) and antibiotic resistance. During an interview on 12/18/23 at 1:00 PM, the Director of Nursing stated they expected antibiotics to be tracked for any acute infections and for the McGeer's criteria to be followed. The Director of Nursing stated they would hope the medical providers would document an explanation for use of all antibiotics. The Director of Nursing stated that if residents received prolonged antibiotics, the medication could end up not doing the resident any good, and the resident could build resistance to antibiotics. The Director of Nursing stated there should be a rationale, as well as a note documented if the provider disagrees with a Medication Regime Review. During an interview on 12/18/23 at 1:53 PM, Nurse Practitioner #1 stated recurrent urinary tract infections would be the only reason they would prescribe someone on a prophylactic antibiotic. Nurse Practitioner #1 stated a resident having an indwelling catheter was not an appropriate indication for the use of a prophylactic antibiotic. Additionally, Nurse Practitioner #1 stated dual/duplicate antibiotic therapy should be avoided and they would expect a prophylactic antibiotic to be held until new antibiotic was completed. During telephone interview on 12/18/23 at 2:07 PM, Medical Doctor #2 stated they usually wrote a note in the electronic medical record upon reviewing medication regime reviews. Medical Doctor #2 stated it is subjective on whether to use prophylactic antibiotics. They stated use of prophylactic antibiotic was to prevent Resident #131 from getting more urinary tract infections. Medical Doctor #2 stated they were sure the facility tracked antibiotic use and would know if there were any side effects. 10 NYCRR 415.12(l)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during a complaint investigation (Complaint #NY00274853) completed on a Standard survey conducted from 5/23/22 through 5/31/22, the facility did not ensure that all alleged violations including abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin, are reported immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse, to the appropriate official (including the State Survey Agency). Four (Residents #16, 22, 60, and 109) of four residents reviewed for reporting of alleged violations of abuse were involved in incidents not reported timely to the New York State (NYS) Department of Health (DOH) as required. Specifically, resident to resident altercations (#16, 22, 60, and 109) and injury of unknown origin (#60). The findings are: A facility policy titled Resident Abuse: Investigation and Reporting revised 9/2020 documented Federal and State regulations require the facility to report alleged violations of mistreatment, neglect, and abuse, including injuries of unknown origin. It shall be the policy of this facility to prohibit and assure the resident's right to be free from verbal, physical, or sexual abuse, exploitation, mistreatment, neglect, and misappropriation of resident property. Report to the NYS DOH all instances where there is sufficient evidence for a prudent person to believe that above abuses identified has occurred. The policy documented the individual must have acted deliberately, not that he/she must have intended to inflict injury or harm. 1. Resident #22 was admitted to the facility with diagnoses which included dementia, hypertension (HTN-high blood pressure), and depression. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 4/22/21 revealed the resident had severe cognitive impairment, sometimes understood, and sometimes understands. Review of the Comprehensive Care Plan (CCP) dated 11/16/21 documented physical behaviors towards other residents. The plan included to administer medications as ordered; analyze times of day, triggers and document interventions used to de-escalate behaviors. The CCP further documented fragile skin with anticoagulant use and to monitor for increased bruising. Review of the [NAME] (guide used by staff to provide care) dated 4/16/21 revealed resident #22 ambulated independently without any assistive device. 2. Resident #60 was admitted to the facility with diagnoses which included dementia, HTN, and hyperlipidemia (elevated fat levels in the blood). Review of the MDS dated [DATE] revealed the resident had moderate cognitive impairment, usually understood, and usually understands. Review of the CCP dated 12/3/21 documented resident #60 ambulated independently with a rolling walker. Review of the [NAME] dated 4/16/21 revealed resident #60 transferred independently with a rolling walker. a.) Review of the facility Accident/Incident Report dated 4/16/21 revealed at 6:00 PM, resident #22 hit resident #60 on the left arm with a hairbrush. The residents were separated. Review of the Health Electronic Response Data System (HERDS) Nursing Home Incident Form revealed the Administrator reported the alleged abuse to the DOH on 4/19/21 at 4:16 PM. During an interview on 5/25/22 at 2:01 PM the Registered Nurse (RN) #1, Supervisor stated they reported the resident-to-resident altercation to the Director of Nursing (DON), immediately after the incident occurred on 4/16/21 and was aware the of the State Agency required 2-hour reporting timeframe. The DON notified the Administrator. The Administrator would report alleged abuse to the DOH. b.) Review of the facility Accident/Incident Report dated 3/28/22 documented at 7:30 AM resident #22 had a small abrasion with a bruise of unknown origin on their left upper extremity. Review of the HERDS Nursing Home Incident Reporting System revealed the facility did not report the bruise of unknown origin noted to resident #22's left arm on 3/28/22 to the DOH as required. During an interview on 5/26/22 at 9:40AM the RN #2, Unit Coordinator stated an investigation included employee statements to determine the root cause of the bruise to resident #22's left arm. RN#2 stated they were unable to recall reporting the bruise to the DON or reviewing the incident report in morning report with the Interdisciplinary Team (IDT). The DON or Administrator would be responsible for reporting a bruise of unknown origin to the State Agency within 2 hours after being notified. During an interview on 5/26/22 at 4:10 PM the DON stated an investigation was initiated of the resident-to-resident altercation on 4/16/21. The DON concluded that resident #22 had no intent to hit resident #60 with the hairbrush due to dementia. Therefore, the Administrator didn't report the resident-to-resident altercation to the State Agency until three days later. The DON further stated the facility followed the 2016 Incident Reporting Manual for guidance and was not familiar with the most current guidance. The resident-to-resident altercation on 4/16/21 and bruise of unknown origin on 3/28/22 should have been reported by the Administrator within 2 hours to the State Agency according to the State Operations Manual and were not. During an interview on 5/26/22 at 4:30 PM the Administrator stated the facility followed the 2016 Incident Reporting Manual as a guidance tool and was unaware of the most current guidance in the State Operations Manual (SOM). The Administrator further stated the resident-to-resident altercation between resident #22 and resident #60 and the bruise of unknown origin for resident #60 on 3/28/22 should have been reported within 2 hours to the State Agency and were not. Ultimately, I'm the one who is responsible. 3. Resident #109 was admitted with diagnoses including dementia, diabetes, and depression. The MDS dated [DATE] documented the resident was cognitively intact. and no physical or verbal behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, threatening, screaming, or cursing at others). Review of the CCP dated 2/18/22 documented the resident is noted to easily agitate others at times. Three noted resident to resident encounters. Interventions included educate resident on proper behavior towards others. If reasonable, discuss behavior and explain why inappropriate and/or unacceptable. Resident given the option to change rooms and wanted to. Keep resident away from another resident who they had the negative encounter with. Redirect at times of agitation. Review of the [NAME] dated 1/7/22 documented staff to encourage and maintain that resident is kept away from another resident (#16). 4. Resident #16 was admitted with diagnoses including Parkinson's (tremors and rigidity of movement) disease, dementia, and diabetes. The MDS dated [DATE] documented the resident was severely cognitively impaired. Additionally, the MDS documented physical and verbal behavioral symptoms directed towards others on one to three days in the seven day look back. The MDS further documented the identified symptoms put the resident and others at significant risk for physical injury, and significantly intruded on the privacy or activity of others. Review of the CCP dated 2/18/22 documented history of aggression/threatening behavior towards staff and peers. Two resident to resident altercations, with history of wandering into other rooms. Interventions included monitor resident's behavior and keep distance between themselves and other stated resident (#109) on 2/15 into morning of 2/16/22. Caregivers to provide opportunity for positive interaction, attention. Stop and talk with resident when passing by. Continue psych med review for aggressive behaviors toward staff and peers. Medication review and room change due to peer-to-peer altercation. Provide distraction. Additionally, the CCP documented potential to be verbally/physically aggressive towards staff and peers at times with refusal of care related to dementia. Interventions included analyze of key times, places, circumstances, triggers, and what de-escalates. Review of the [NAME] dated 1/7/22 documented staff to encourage and attempt to maintain resident is kept away from another resident (#109). Review of the facility Accident/Incident Report dated 1/6/22 documented at 11:45 PM Resident #16 struck another resident (#109). Resident #109 was sitting in their wheelchair (w/c) in common area waiting for a snack from nurse. Resident #16 approached resident #109 and grabbed the w/c. Argument started, resident #16 struck resident #109 on back two times, one witnessed by nurse. Staff separated. Resident #109 version of incident documented I want to deck resident #16, just let me at them. Resident #16 version of incident documented You're a bunch of liars and resident #16 became verbally abusive and threatened physical abuse. During an interview on 5/23/22 at 11:44 AM resident #109 stated resident #16 on D Unit, about six months ago, hit me with a yellow floor sign and I punched them in the face. I moved to this unit. I was sick of them (Resident #16) always beating up on me. On 5/27/22 at 11:06 AM, resident #109 stated resident #16 came in my room, all the time, and would walk by and give me the shaking fist and I would say go on, get out of here. Why should I have to move to please Resident #16? Why should I have to change my room? I liked my room on D Unit, but I decided to give it a try and I like it down here on B Unit. I wasn't afraid of Resident #109. Review of the Complaint/Incident Tracking System Report (software that logs and tracks nursing home complaints) revealed the incident was not reported to the NYS DOH as required. During an interview on 5/27/22 at 6:55 AM, Licensed Practical Nurse (LPN) #3 stated they witnessed resident #16 hit resident #109, with an open hand, to the back. It was a resident-to-resident altercation. Resident #109 was in the common area waiting for a snack and resident #16 grabbed resident #109's w/c. Resident #109 got angry. Resident #16 slapped with an open hand. LPN #3 stated they didn't think resident #16 meant to hurt resident #109, I think resident #16 just wanted to hit resident #109 because they were next to them. I guess it would be resident to resident abuse because they came in contact with each other. This should have been reported to the NYS DOH. LPN #3 stated they notified the Nursing Supervisor, on duty, and they would have been responsible to notify the DON. During interview on 5/27/22 at 7:29 AM, LPN #4 stated they were the Supervisor on 1/7/22. LPN #4 stated Registered Nurse (RN) #4 assessed both residents. LPN #4 stated they notified the DON immediately. Any resident-to-resident situations are taken care of immediately. There is a two-hour window, but I notify the DON or whoever is on call right away. I am expected to notify my superior and they report to the DOH, that is what I know. During interview on 5/31/22 at 10:54 AM, LPN #5 Unit Coordinator (UC) stated they were aware of the resident-to-resident altercation because it was discussed at morning meeting the following day. LPN #4 stated the expectation is that supervision is notified of any incident, and they would be responsible to notify, administration, so they are aware of the resident-to-resident altercation. It's immediate. During interview on 5/31/22 at 11:08 AM the DON stated the incident was investigated and discussed to rule in or out abuse. Resident #109 usually stayed in their room but came out for snacks. Resident #16 usually sits in the common area near their room and is very territorial of that area. We thought there was no intent, resident #16 was startled, it was isolated. If staff calls me for something like this we start the investigation and I call the Administrator. The Administrator does all the reporting to the DOH, at this time. There have been discussions about opening up reporting access to other staff. During interview on 5/31/22 at 11:44 AM the Administrator stated the incident should have been reported to NYS DOH. We considered this incident isolated and were following the 2016 Incident Reporting Manual, which I have learned is outdated. Now that I know that all allegations are to be reported, this should have been reported. 415.4(b)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review conducted during the Standard survey completed on 8/13/19, the facility did not treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for one (Resident #193) of one resident reviewed for dignity. Specifically, Resident #193 reported a medical provider asked personal health related questions in the dining room, during mealtime, with other residents and visitors present, that were embarrassing. The finding is: 1. Resident #193 was admitted to the facility on [DATE] with diagnoses which include left femur (long thigh bone) fracture s/p (status post) reduction and internal fixation (surgery to stabilize broken bone), hyperlipidemia (high levels of fat particles in the blood), and hypertension (high blood pressure). The care plan initiated on 8/5/19 documented the resident was alert and oriented x 3 (person, place, time) with memory intact. He was able to make his needs known and is independent with decision making. Review of History and Physical, signed and dated 8/6/19 by MD (Doctor of Medicine) #2 included Resident #193 was seen and examined by MD #2 on 8/6/19. In addition, upon physical exam, MD #2 documented the resident was AAOx3 (awake, alert, and oriented to person, place, or time). Additionally, the MD documented upon interview he reported initially he did have some hematuria (blood in urine) but it was improving, had some intermittent dizziness and reported having loose bowel movements. During a medication administration observation on 8/8/19 at 8:22 AM, with Licensed Practical Nurse (LPN) #2 present, Resident #193 stated, I was having dinner with my wife and another couple when one of the doctors came into the dining room and started to discuss my medical issues, my intestinal and stomach issues. The other couple got up and left the table. It made me feel awkward. It was a violation of privacy and dignity. She didn't even introduce herself. I told the social worker; she said she was going to report this up so administration can look into it, but no one ever got back to me. During an interview on 8/13/19 at 9:48 AM, the Director of Social Work stated, Resident #193 had concerns about a provider discussing issues with him in the dining room. He did not go into detail. I told him I would talk to supervising staff and I informed the DON. During an interview on 8/13/19 at 11:39 AM, the Assistant Food Service Director stated, sometimes the providers will come into the main dining room. They don't usually like to disturb meal service but if they have questions, they will come an speak to residents. During an interview on 8/13/19 at 11:43 AM Certified Nurse Aide (CNA) stated, I have seen the MD's and NP's (Nurse Practitioner) come and talk to people in the dining room. During an interview on 8/13/19 at 11:48 AM, Rehab Aide #1 stated, I have seen providers in the main dining room at meal times, not during the meal, but before and after meals speaking with the residents. During an interview on 8/13/19 at 1:36 PM, MD #2 stated, I did have conversations in main dining room (with Resident #193), but I can't remember the details. I don't remember, I might have, I might not have, spoken about intestinal issues and diarrhea. I don't want to say if I can't really remember. During an interview on 8/13/19 at 12:27 PM the Administrator stated, Providers would not conduct a visit in the main dining room. I would expect they meet with the patient in their room and if a semi-private room to pull the curtain. We also have an office (on the unit) that can be used for private conversations. 415.5(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 8/13/19 the facility did not ensure that residents who use psychotic drugs receive gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for one (Resident #103) of four residents reviewed for antipsychotic medications. Resident #103 received Risperidone (Risperdal, an antipsychotic medication) 0.25 mg (milligrams) QOD (every other day) from 3/21/19 to 6/3/19 for dementing illness associated behavioral symptoms. On 6/3/19 Risperidone was increased to 0.25 mg QD (daily) lacking supporting behavioral documentation and diagnosis for its continued use. The findings are: Review of the policy titled Psychoactive Medication Use and Behavior Assessment/ Reassessment dated [DATE] revealed each resident will receive and will be provided the necessary behavioral health care and services to obtain or maintain in the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Any resident who exhibits behaviors or who is on psychoactive medication will be assessed utilizing the BMARC (Behavioral Modification Administration Review Committee) forms. Behavior problems such as: Behavior which endangers the Resident or other Residents; Resistance to care/ refusal; Difficulties dealing with people and coping in the facility such as verbal outbursts; and behavior relating to specific diagnosis of psychiatric disorders which impair the Resident's ability to function at his/ her highest level. 1. Resident #103 was admitted on [DATE] and had diagnoses that included unspecified dementia without and with behavioral disturbances, unspecified psychosis not due to substance or known physiological condition and major depressive disorder. The Minimum Data Set (MDS, a resident assessment tool) dated 7/12/19 revealed the resident was severely cognitively impaired and is usually understood and usually understands. Section N: documented the resident received antipsychotic medications during the last seven days and on a routine basis only. GDR was attempted 3/21/19 and GDR has not been documented by a physician as clinically contraindicated. The comprehensive care plan initiated 3/28/19 documented the resident was currently prescribed medications for DX (diagnosis) dementia and psychosis. Interventions included to administer psychotropic medications as ordered by physician; monitor for side effects and effectiveness every shift; allow calming choices/ non-pharm logical interventions including- coloring books, expressing her thoughts and feelings to staff and family, some music, organizing her room, visit table mates; consult with pharmacy, physician to consider dosage reduction when clinically appropriate at least quarterly; discuss with physician/ family regarding ongoing need for use of medication. Review behaviors/ interventions and alternate therapies attempted and their effectiveness as per facility policy; educate resident/ family/ caregivers about risks, benefits and the side effects and/or toxic symptoms of medications. During an observation and interview on 8/6/19 at 9:55 AM, Resident #103 was in her room in her wheel chair straightening her room. The resident was very appropriate with her answers. Additionally, she was calm and showed no signs of any type of behavior. During an observation on 8/8/19 at 10:10 AM Resident #103 was in her room wiping down her wheelchair and straightening up her room. Surveyor spoke with the resident at that time. Resident showed no signs of behaviors. During of intermittent observations between on 8/12/19 and 8/13/19 between 8:00 AM and 2:00 PM resident stayed mainly in her room. The resident did not display any behaviors. Review of the Medication Review Report signed by the physician on 7/2/19 revealed the following order Risperidone Tablet 0/.25 mg - give one tablet by mouth at bedtime for Psychosis. Review of the Medication Review Report signed by the physician 5/7/19 revealed discontinue Risperidone and monitor behavior. Review of the Order Recap Report dated 8/12/19 revealed Resident #103 revealed the following orders: - Risperidone 0.25 mg- give 1 tablet by mouth at bedtime for dementia start date 8/14/18 end date 1/7/19. - Risperidone 0.25 mg- give 1 tablet by mouth at bedtime for anxiety start date 1/7/19 end date 1/9/19. - Risperidone 0.25 mg- give 1 tablet by mouth at bedtime for dementing illness associated behavioral symptoms start date 1/9/19 end date 3/21/19. - Risperidone 0.25 mg- give 1 tablet by mouth at bedtime every other day for dementing illness associated behavioral symptoms start date 3/21/19 end date 6/3/19. - Risperidone 0.25 mg- give 1 tablet by mouth at bedtime for depression start date 6/3/19 end date 6/25/19. - Risperidone 0.25 mg- give 1 tablet by mouth at bedtime for psychosis start date 6/25/19. Review of the Medication Administration Record date August 1, 2018 through August 11, 2019 revealed resident received the following: - Risperidone 0.25 mg- give 1 tablet by mouth at bedtime from 8/1/18 to 3/21/19. - Risperidone 0.25 mg- give 1 tablet by mouth at bedtime every other day from 3/21/19 to 6/3/19. - Risperidone 0.25 mg- give 1 tablet by mouth at bedtime from 6/3/19 to 8/11/19. Review of the Nursing Progress Notes between 3/3/19 through 8/12/19 revealed there was no documentation regarding any behaviors for Resident #103. Review of Follow Up Question Report for Behavior Symptoms dated 3/1/19 through 7/31/19 revealed there were no behavior symptoms observed. Review of BMARC Committee Follow-up revealed the following: - 4/10/19 Risperidone 0.25 mg recommended to be d/c (discontinued). MD (physician) comments: OK to d/c Risperidone and monitor behavior, signed 4/16/19. - 5/1/19 Risperidone 0.25 mg Recommendations: discontinue of Risperidone. Call Psych to notify. Monitor behavior 30 days. MD comments: d/c Risperidone and monitor behavior. - 6/12/19 Recommendations: Psych MD changed Risperidone on 6/3/19. Please evaluate need for medication to be daily. Patient is asymptomatic at this time. Monitor mood and behavior every shift time 1 month. MD Comments: Monitor behavior and record. - 6/19/19 Recommendations: Clarify indication for Risperidone. MD Comments: change to psychosis. - 7/17/19 Recommendations: Risperidone 0.25 mg every other day for 14 days. Behavior charting. MD comments: discontinue. *Family NOT in agreement * dated 7/17/19. Review of undated Gradual Dose Reduction sheet revealed Risperidone 0.25 mg daily by mouth- resident's family refusing GDR at this time. Resident followed by Psych and prescribed this medication by Psychiatrist. Signed by MD on 5/29/19. Review of undated Gradual Dose Reduction sheet revealed Risperidone 0.25 mg daily by mouth GDR ordered and signed by MD on 7/23/19. Review of the Consultant Pharmacy MRR (Medication Regime Review) revealed there were no recommendations dated 8/31/18; 9/29/18; 10/27/18; 11/29/18; 1/28/19; 2/25/19; 3/30/19; 4/30/19; 5/31/19; 6/30/19. Review of the Consultant Pharmacist Reviews revealed the following: - 12/30/19 This resident is receiving the antipsychotic risperidone but lacks an allowable diagnosis to support its use. Physician/ Prescriber Response: Agree- per Psychiatrist indication is dementing illness with associated behavioral symptoms. Please see my note for DX signed 1/8/19. - 2/6/19 GDR of antipsychotic recommended. - 5/7/19 Staff does not report and has not documented any ongoing behaviors, a GDR trial for risperidone should be attempted periodically as dementia is progressive and resident may not exhibit signs and symptoms of behaviors required to support the use of an antipsychotic. Physician/ Prescriber Response: other- will evaluate at next office appointment scheduled 6-3-19, signed by the Psychiatrist and dated 5/7/19. - 7/28/19 Pharmacy consultant had a phone conversation with resident's son. He related a lifelong HX (history) of behavioral issues including several treatments with ECT (electroconvulsive therapy- procedure in which small electric currents are passed through the brain). He lacked written documentation but voiced concern for any changes in medications that could exacerbate her condition. I reviewed the current medication regimen with him including the benefit/ risk and that there may be options if this therapy is considered inappropriate and resident is stable. Medical will have to continue to monitor and determine if therapy continues to be appropriate. Physician/ Prescriber Response: Agree signed and date 7/30/19 Review of an e-mail sent from the Consultant Pharmacist to the DON (Director of Nursing) dated 7/22/19 revealed: I spoke at length with the son. I feel that it would be very difficult for us to compel any changes at this time and might actually be worse for us in light of pending survey. I think I'd like to take a look at some of the documentation again, take a look at some of her options, get some more documentation of a review of our sense of what detriments there might be to making changes at this time. So, we can hopefully support that and take it from there in other words for now. I think getting rid of it or cutting it down further might actually be a problem and we should think of what documentation supports our position. Review of Physician progress notes revealed the following: - Seen on 3/19/19 under assessments- Dementia with behavior, normal pressure hydrocephalus. Her behavior/ psychosis is managed with current meds. Will continue risperidone and Namenda. - Seen on 5/7/19 under assessment- Dementia with behavior, normal pressure hydrocephalus. Her behavior/ psychosis is stable. Will GDR Risperidone and monitor behavior. Under plan- discontinue Risperidone if OK with Psych consult. - Seen on 7/2/19 under assessment- Dementia with behavior, normal pressure hydrocephalus. Her behavior/ psychosis is stable with current Risperidone. Review of the Psychiatrist consultations revealed the following: - Signed and dated 4/1/19 Clinically improving. Patient has difficulty communicating with only one working hearing aid. Risperidone 0.25 mg Q (daily) PO (by mouth) at HS (hour of sleep) and Zoloft (Sertraline - antidepressant) 50 mg by mouth at AM and 25 mg at HS. Follow-up 6/3/19. Reviewed/ Signed and dated by facility Physician on 4/16/19. - Signed and dated 6/3/19 Sertraline 50 mg Q AM and 25 mg Q HS. Risperdal 0.25 mg PO HS. Her son reports patient noted to have increased confused and moody for a couple of months. Her medication log reflects that patient is getting Risperdal every other night. Administer Risperdal 0.25 mg po HS. Next appointment: 8-12-19 at 2:00 PM. Reviewed/ - Signed and dated by facility Physician on 6/14/19. Note the following Psych Consult was done after the facility was made aware of an issue with proper documentation for the use of an antipsychotic medication. - 8/12/19 Continue Sertraline 50 mg Q AM and 25 mg Q HS. Risperdal 0.25 mg PO HS. Patient has H/O (history of) depression with H/O ECT in 2004, with periods of increased confusion and psychosis, especially when she was not on Risperdal. Small doses of Risperdal needed to keep her stable. Recently dose was reduced to QOD (every other day) and her symptoms got worse with increased agitation, confusion and paranoid thoughts. During an interview on 8/8/19 at 10:09 AM, Resident #103 stated she was doing well. The Surveyor and the resident had a nice conversation. During the interview the resident was calm and displayed no behaviors. During an interview on 8/8/19 at 11:41 AM LPN (Licensed Practical Nurse) #1, Unit Manager stated, The nurses place their behavior charting in the progress note section in the electronic medical records. CNAs (certified nurse aide) record the behaviors in the task part of the electronical medical record. Resident #103 will get antsy and agitated at time, really fast. We will do 1:1 which helps at the time, but for the remainder of that day she still is antsy and agitated. I have not seen any other behaviors. The BMARC has recommended discontinuing the risperidone several times, but the son is so against discontinuing the Risperdal. The resident herself has said to leave her on the medication, but no I do not think she would be able to make that decision. During an interview on 8/8/19 at 12:04 PM, the Rehab Aide/ CNA #1 stated, I will do ROM (range of motion) with her and assist her when needed. Most of the time she is pretty good and will do what you ask her to do. She is never aggressive or has behaviors. She is more confused than anything, sometimes not always. I still try to assist her when she is confused, and she is fine. She is a very sweet lady, she likes her room neat and in a certain way. During an interview on 8/8/19 at 12:24 PM, SW (Social Worker) #1 stated, Resident #103 has periods of weepiness and periods of getting worked up, anxious. I usually talk with her. Sometimes it calms her down. She is a busy body and she likes everything a certain way. She sees the outside Psych and they did not want to change recommendations made by the BMARC. Medication wise I cannot comfortable speak on them. I do attend the BMARC meetings. During an interview on 8/8/19 at 3:11 PM, LPN #1, Unit Manager stated, This order that was written on 5/7/19 to d/c Risperdal and monitor behavior was never ordered and placed in the computer. I do not know why this was never done. If the physician decided he did not want this, we would have written on it and had the physician sign it. I am not sure what to tell you about this order as I was not down here at the time it was written. The unit manager who was here at the time is no longer here. During an interview on 8/8/19 at 2:00 PM, the Pharmacy Consultant stated, We did a GDR from March to June. It was increased back up to everyday because of the psych recommendation. I did make a recommendation in 12/2018 to the physician to consider an appropriate diagnoses/ conditions for the use of the Risperdal which on 6/25/19 it was order for psychosis. I do not know if there was any documentation from nursing reporting this type of behavior. On 5/7/19 I did write a recommendation that staff does not report and has not documented any ongoing behaviors and recommended a GDR trial for risperidone. I do attend the BMARC meetings. At that time the psychologist wanted to wait for the residents next office visit which is when the medication was increased back to daily. I did speak to the son recently regarding the use of these medications in the elderly and explained the goal is to reach the lowest affective dose usage possible. The son explained to me that his mother all her life has been on these types of medications and has gone through ECT (electroconvulsive therapy) three times and does not feel comfortable taking his mother off this medication. Son did state he does not have supporting documentation for this, but I feel that at this time we should leave this residents medication alone. The dose was lowered from March 2019 to June 2019 and the resident did not have any behavior changes, but psych felt we made a mistake by doing this and that is why they increased it back to daily. During a telephone interview on 8/9/19 at 8:57 AM, the Physician stated, I increased the Risperidone back up on 6/3/19 probably because the staff were complaining to me that the resident was having increased behaviors. I did not check the chart for any behavior documentation. It may also have been because of the son. I cannot remember, but families will get mad sometimes and I try to take everything into consideration. I have to listen to both the staff and the families. I rely on the staff a lot because I am only there one day a week. I do follow the BMARC and Pharmacy recommendations. 415.12(1)(2)(i)